A 59-year-old male patient was admitted to our university hospital (Botucatu, SP, Brazil) complaining of a perianal suppurative ulcer developed two months before the first medical consultation. He was under therapy with prednisone 40 mg/day for six months due to a presumed diagnosis of a drug reaction. On physical examination, a clean 10-cm diameter phagedenic perianal ulcer (Figure ) and two longitudinal suppurative ulcers on the inguino-crural region were observed. During investigation, and soon after reducing the corticosteroid dose, disseminated erythematous papules and nodules were observed in the upper limbs (Figure ).Histopathology of the perianal ulcer revealed a dense histiocytic dermal infiltrate and a granulomatous inflammatory response with central caseous necrosis (Figure ). Fite-Faraco staining showed a few acid-fast bacilli and the hypothesis of cutaneous tuberculosis was raised. The histopathology of upper limbs papular and nodular lesions showed foamy macrophages with globi of bacilli, suggesting lepromatous leprosy (Figure ). The perianal and inguinal ulcers were considered uncommon manifestations of type 2 leprosy developed when corticosteroid was gradually diminished. The patient was treated as for multibacillary leprosy with multidrug therapy and thalidomide.\nFour weeks later, the patient had fever, weight loss, asthenia and worsening of the perianal ulcer (Figure ), but without erythema nodosum leprosum. With this clinical picture, new investigation was developed. The tuberculin skin test was positive (20 × 20 mm) and culture of M. tuberculosis – using a biopsy sample from the perianal ulcer – on Löwenstein-Jensen medium was positive (Figure ). Polymerase chain reaction (PCR) and DNA analysis from upper limb skin samples were positive for M. leprae (Figure ). With the new information the patient was finally diagnosed as presenting simultaneously lepromatous leprosy – type 2 reaction – and cutaneous tuberculosis expressed by the perianal ulcer. Screening for HIV, HBV or HCV infection as well as lung, renal or colon compromising were negative. Hence, the patient was treated with isoniazid, ethambutol and rifampin for nine months with complete healing of the perianal and inguinal lesions after two months (Figure ). After the tuberculosis treatment, the patient was submitted to additional multidrug therapy for 12 months with dapsone, rifampin and clofazimine with complete cure of leprosy.
A 57-year-old Sinhalese woman presented to the dermatology unit of the National Hospital of Sri Lanka with extensive seborrheic dermatitis and tender facial induration (Fig. ) of 1-year duration. She was a homemaker from an urban area with poor social background. She did not have diabetes or hypertension. She had received a Bacillus Calmette–Guérin (BCG) vaccination. She did not smoke tobacco or drink alcohol. A skin biopsy taken from indurated facial plaque revealed evidence of borderline tuberculoid leprosy with type 1 reaction. She did not have hypopigmented anesthetic patches or thickened peripheral nerves in the rest of her body. She was commenced on multibacillary treatment for leprosy. A year later, she developed fever, loss of appetite, loss of weight, and widespread skin abscesses all over her body. Her body mass index (BMI) was within normal range and the rest of the general examination was normal. A respiratory examination revealed bilateral (B/L) coarse crepitations; a neurological examination was normal. Her erythrocyte sedimentation rate (ESR) remained persistently elevated at more than 120 mm/hour. She had inflammatory shadows in a chest X-ray (CXR). A sputum examination for AFB was positive and GeneXpert confirmed rifampicin resistance. At that time, she revealed a diagnosis of human immunodeficiency virus (HIV) infection and tuberculous lymphadenitis, which was made 5 years back, where she had taken 6-month TB treatment but had defaulted on antiretroviral therapy. During this presentation, her CD4+ count was 57/μL. The rest of the investigations are summarized in Table . There was no contact history of leprosy or TB. She was started on a multidrug treatment regime, which included intravenously administered kanamycin (15 mg/kg per day), orally administered ethambutol (800 mg/day), orally administered levofloxacin (750 mg/day), isoniazid (300 mg/day), orally administered ethionamide (500 mg/day), orally administered cycloserine (750 mg/day), and orally administered pyridoxine (10 mg/day). A repeated split skin smear was negative and she continued with multidrug treatment-multibacillary therapy (dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) for leprosy without rifampicin. Highly active antiretroviral treatment was restarted subsequently. At 6 months she had clinically, hematologically, and radiologically improved.