A 50-year-old Sinhalese man with poorly controlled diabetes mellitus presented with facial infiltration (Fig. ) and erythematous painful nodules over his lower limbs and trunk suggestive of lepromatous leprosy with erythema nodosum leprosum. He was a manual laborer with low BMI. The rest of the general and neurological examination was normal. He had received a BCG vaccination. He did not smoke tobacco and drank alcohol occasionally. A skin biopsy revealed evidence of foamy macrophages with well-developed grenz zone. He was commenced on multidrug treatment-multibacillary treatment for leprosy (dapsone 100 mg/day, clofazimine 50 mg/day and 300 mg/once a month, and rifampicin 600 mg/month) with prednisolone 40 mg daily for type 2 reaction. Twelve months later he developed generalized lymphadenopathy with low-grade evening pyrexia and elevated ESR (80–100 mm/hour). Both Mantoux and QuantiFERON Gold test were positive. A CXR remained persistently normal. He was negative for HIV and diabetes. Basic investigations are given in Table . A lymph node excision biopsy revealed suppurative inflammation with focal foamy histiocytes; a TB culture from the lymph node biopsy later showed growth of AFB. GeneXpert did not reveal rifampicin resistance. Therefore, he was started on TB treatment (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) by the respiratory physician for the treatment of extrapulmonary TB. At 6 months, he had improved clinically and biochemically.
A 59-year-old Sinhalese man presented with nonhealing ulcers and deformities of both upper and lower limbs and indurations of his face (Fig. ) for many years. He was clinically diagnosed to have borderline lepromatous leprosy, which was subsequently confirmed with slit-skin smears and histology. He was a laborer from poor social background and did not have a significant past medical history. He was emaciated with low BMI; a neurological examination did not reveal neuropathy. There was no contact history of leprosy or TB. He had received a BCG vaccination. He did not smoke tobacco and he drank alcohol occasionally. During his initial evaluation he was also found to have high ESR (> 100 mm/hour) with positive Mantoux test (21 mm) and sputum was positive for AFB. A CXR and contrast-enhanced computer tomography scan of his chest revealed the focus of pulmonary TB; bronchoalveolar lavage for TB culture revealed growth of AFB, but GeneXpert did not reveal rifampicin resistance. His HIV status was negative and repeated blood sugar levels remained within normal range. Other basic investigations are given in Table . He was commenced on multibacillary leprosy treatment (dapsone 100 mg/day and clofazimine 50 mg/day and 300 mg/once a month) and subsequently added TB treatment (isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 800 mg/day, and pyrazinamide 1500 mg/day) for 6 months. At 6 months, his ESR came down, sputum was negative for AFB, and skin lesions and ulcers improved.