A 65-year-old non-hypertensive, non-diabetic man presented with history of left sided chest pain associated with productive cough and breathlessness for seven days. There was no history of fever, haemoptysis and exertional increase in breathlessness. The patient was referred to our teaching hospital from Green Pastures Hospital (GPH), a tertiary care referral centre for leprosy. The patient was treated for leprosy with WHO multidrug therapy for multibacillary leprosy. The patient was currently on treatment for ulnar neuritis with prednisolone 30 mg once a day for last three months. There was no past history of tuberculosis as per GPH records or information provided by the patient.\nClinical examination revealed numerous hypopigmented skin lesions varying in size from 2 to 10 centimeters over the trunk. The left ulnar nerve was thickened. There was dullness and decreased breath sounds in the left infrascapular and axillary areas.\nThe laboratory investigations revealed hemoglobin: 14.4 mg/dl; total leukocyte count: 19.5×103; erythrocyte sedimentation rate: 60 mm at the end of first hour; serum creatinine: 1.4 mg/dl; and random blood sugar: 91 mg/dl.\nOne out of three sputum samples tested was positive for acid fast bacilli and the chest radiograph showed loculated pleural effusion suggesting long standing pleural collection in left hemi thorax with infiltrations bilaterally, more on left side.\nA diagnosis of borderline leprosy with concomitant pulmonary tuberculosis was made. The patient was referred to DOTS clinic of our teaching hospital and started on category-I treatment according to the guidelines of national tuberculosis programme of Nepal. The oral prednisolone was subsequently tapered and stopped. The patient's general condition improved and was on regular follow up.
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.