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 19-year-old male, on treatment for MDR-TB, presented with complaints of localized swelling over face, reddish discoloration of limbs, and hypopigmented patches over body since 1 month. He was on Category IV directly observed treatment, short-course chemotherapy for the last 5½ months on the basis of sputum line probe assay report from Revised National Tuberculosis Control Program (RNTCP) accredited laboratory, which showed M. tuberculosis isolates, resistant to drugs isoniazid and rifampicin. The patient was taking kanamycin, ethionamide, pyrazinamide, ethambutol, levofloxacin, and cycloserine regularly. There was a history of leprosy 6 years back, for which the patient was treated for 6 months. The patient had a history of TB 5 years back which was treated with 9 months of daily regimen antitubercular therapy. Clinical examination revealed hypopigmented, dry, scaly plaque over upper arms [], hypoanesthetic plaque over right palm [], and erythematous plaque over right side cheek and nose []. Respiratory system examination revealed bilateral infraclavicular crepts.\nRoutine investigations were normal. Chest radiograph was suggestive of fibrotic lesions, bilateral upper lobes []. Sputum culture from RNTCP accredited laboratory at 4th month was positive for growth of M. tuberculosis.\nDermatology review was taken for skin lesions. The patient was diagnosed as multibacillary (MB) leprosy and started on multidrug therapy regimen (MB-MDT) consisting of rifampicin 600 mg once monthly, dapsone 100 mg daily, and clofazimine 300 mg once monthly and 50 mg daily. Biopsy of skin lesions was suggestive of mid-borderline leprosy. Two weeks later, the patient presented with increased erythema and pain over the skin lesions and appearance of new lesions []. The patient was diagnosed with Type I lepra reaction and started on analgesics and steroids (prednisolone). Prednisolone was given in the dose of 30 mg/day orally for the first 2 weeks and then gradually tapered over the next 4 weeks. It was thus stopped after a total duration of 6 weeks. MB-MDT was continued as per the National Leprosy Eradication Programme guidelines.\nThus, final diagnosis of MDR-TB with mid-borderline leprosy and Type I lepra reaction was made. Skin lesions markedly improved with treatment []. Patient's subsequent sputum cultures were negative and MDR-TB was thereafter managed as per the RNTCP guidelines.