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.
A 50-year-old non-diabetic, non-hypertensive man who had completed treatment for lepromatous leprosy two years back, was admitted at Green Pastures Hospital for type-2 lepra reaction (erythema nodosum leprosum). There was a past history of lepra reactions for which he underwent treatment. Currently the patient was again being treated for the same with prednisolone 30 mg once daily, thalidomide 100 mg twice daily and clofazimine 50 mg once daily. However, information about initial screening of tuberculosis was not available.\nThe patient was referred to our teaching hospital with complaints of fever, productive cough and dyspnoea of three months duration. The patient also complained of pain and distension of abdomen and decreased appetite for three months.\nClinical examination revealed tense abdomen with shifting dullness, respiratory system with bilateral crackles with bronchial breath sounds predominantly in the left infra clavicular area, and skin showed no active lesions of erythema nodosum leprosum. The laboratory investigations revealed hemoglobin: 11.8 mg/dl; total leukocyte count: 5900/mm3; erythrocyte sedimentation rate: 110 mm in first hour; random blood sugar: 109 mg/dl; serum electrolytes, sodium: 135 meq/L and potassium: 3.2 meq/L.\nTwo out of three sputum samples were positive for acid fast bacilli. Chest radiograph showed multiple heterogeneous opacities in bilateral lung fields and a cavitary lesion in left upper zone. A diagnosis of pulmonary tuberculosis and provisional diagnosis of peritoneal tuberculosis were made.\nDermatologist's opinion was sought for the lepra reaction. The patient was advised to stop prednisolone as no active lesions persisted. He was subsequently referred to DOTS clinic and was started on category-I treatment.