Brief history of the Present Illness:
A 72-year-old male physician presented with a history of weight loss, fever, decreased appetite, night sweats, and new cutaneous ulcerations involving his arms, legs, and abdominal wall over a period of 4 weeks. He also reported numbness and paresthesias in the upper and lower extremities and a 3 to 4-week history of cough productive of yellow sputum. He denied hemoptysis.
Past Medical History including allergies:
Multibacillary leprosy 30 years prior, treated with dapsone and rifampin for 1 year
Diabetes mellitus on insulin
Epidemiological history: Originally from Columbia, practiced as an OB-GYN physician in Sincelejo, Sucre (state), Columbia. No pets, no travel history outside of Columbia.
Social history: Married, has 2 daughters
Physical Examination: The patient appeared well. The blood pressure was 160/80 mm Hg, pulse 88 beats per minute, respirations 22 breaths per minute, and temperature 39°C during initial hospitalization. Lungs revealed bibasilar crackles and coarse breath sounds anteriorly. Skin exam revealed multiple ulcerated lesions on the elbows, abdomen, and chest wall with surrounding erythema (please refer to figures 1-3). Neuro exam revealed decreased sensation in the bilateral upper and lower extremities (including temperature, light touch, vibratory, and proprioception) and decreased reflexes in bilateral upper and lower extremities. He also had thickened palpable nerves in the epitrochlear fossae bilaterally and in the neck. The exam was negative for hepatosplenomegaly and cervical, axillary, or submandibular lymphadenopathy. His exam was otherwise normal.
CXR with miliary pattern (please refer to figure 4)
Sputum AFB 3+ smear positive, molecular PCR and culture from sputum positive for M. tuberculosis (susceptible to rifampin, isoniazid, pyrazinamide, ethambutol)
Skin biopsy with high bacillary index and AFB present in perineurium (please refer to figures 5 and 6) and PCR from skin biopsy positive for M. leprae (sent to National Hansen's Disease Program, Carville, Louisiana)
- Rapidly growing mycobacteria (M. fortuitum, M. chelonae, M. abscessus)
2. Other mycobacteria (M. marinum, leprosy, cutaneous tuberculosis)
- Fungal (sporotrichosis, chromoblastomycosis, blastomycosis)
- Bacterial (Nocardia brasiliensis, Staphylococcus aureus)
- Free-living amoeba (Acanthamoeba, Balamuthia)
Diagnostic Procedures and Results:
Histopathological examination of skin biopsies performed demonstrated the occurrence of a type-2 reaction in a patient with previous history of treated multibacillary disease. The patient was also diagnosed with pulmonary tuberculosis.
The patient was initially treated with (RIPE) rifampin, isoniazid, pyrazinamide, ethambutol plus clofazimine 300 mg via monthly directly observed therapy in addition to dapsone 100 mg daily. Sputum cultures remained positive for tuberculosis at 2 months. Pyrazinamide and ethambutol were later discontinued after his AFB smear and sputum PCR converted to negative. Isoniazid is currently being continued for a total of 7 months (with rifampin) to complete tuberculosis treatment. Rifampin, dapsone, and clofazimine are being continued for a minimum of 2 years for treatment of leprosy, with plans to obtain repeat skin biopsy to assess for decreasing bacillary load. He has also received a prednisone taper beginning at 80 mg daily (with close glucose monitoring) later decreased to 20 mg daily for treatment of a type 2 leprosy reaction (erythema nodosum leprosum).
Brief Discussion of Differential/Major Teaching points of case:
Our patient was diagnosed with pulmonary tuberculosis and leprosy relapse versus a late leprosy reaction. Leprosy reactions occur frequently among patients with leprosy at any point, including prior to the initiation of multidrug therapy, during therapy, or even years after completion of therapy, often producing significant neurologic sequelae. This group of patients require long-term clinical monitoring due to the need to continue anti-inflammatory therapy, presence of severe neurologic sequelae, or due to the potential occurrence of late leprosy reactions.
Leprosy remains an important neglected tropical disease in Colombia. As this case illustrates, co-infection of M. leprae with other mycobacterial infections may potentially be a factor in the occurrence of late leprosy reactions, or possibly of clinical relapses of leprosy.1 This case supports the biological plausibility that pulmonary tuberculosis triggered the occurrence of a type 2 leprosy reaction.2 Recent evidence suggests that the occurrence of severe leprosy reactions or severe forms of leprosy including Lucio’s leprosy may be due to co-infection between M. leprae and other mycobacteria including Mycobacterium lepromatosis.3-5 Prospective monitoring of a patient with previously treated leprosy and those with a recent diagnosis may prove useful in elucidating if mycobacterial co-infections have an impact on the severity and spectrum of disease of leprosy.
Final Diagnosis: Mycobacterium leprae and Mycobacterium tuberculosis co-infection
- Sendrasoa FA, Renaivo IM, Raharolahy O, Andrianarison M, Ramarozatova LS, Rapelanoro Rabenja F. Pulmonary tuberculosis and lepromatous leprosy coinfection. Case Rep Dermatol Med. 2015;2015:898410. PMID 26504603.
2. Trindade MA, Miyamoto D, Benard G, Sakai-Valente NY, Vasconcelos Dde M, Naafs B. Leprosy and tuberculosis co-infection: clinical and immunological report of two cases and review of the literature. Am J Trop Med Hyg. 2013;88(2):236-40. PMID 23208884.
3. Rawson TM, Anjum V, Hodgson J, et al. Leprosy and tuberculosis concomitant infection: a poorly understood, age-old relationship. Lepr Rev. 2014:85(4):288-95. PMID 25675653.
4. McIver LJ, Parish ST, Jones SP, Kippin AN, Furlong TJ. Acute glomerulonephritis in a child with multidrug-resistant tuberculosis and multibacillary leprosy. Med J Aust. 2011;195(3):150-2. PMID 21806536.
5. Prasad R, Verma SK, Singh R, Hosmane G. Concomitant pulmonary tuberculosis and borderline leprosy with type-II lepra reaction in single patient. Lung India. 2010;27(1):19-23. PMID 20539766.
Figure 1: Physical finding photo, lesions on bilateral lower extremities
Figure 2: Physical finding photo, lesions on chest wall
Figure 3: Physical finding photo, lesions on right upper extremity
Figure 4: Radiograph, chest x-ray
Figure 5: Biopsy slide, skin biopsy with Fite-Faraco stain
Figure 6: Biopsy slide, skin biopsy with H&E stain
C. Franco-Paredes, None
A. Henao-Martinez, None
A. J. Rodriguez-Morales, None
W. Villamil-Gomez, None