Introduction: which have ulcerated. Skin split smear from 6

Introduction: Leprosy and
tuberculosis (TB) although not uncommon in developing countries, the
concomitant occurrence of both diseases in the same patient is rare. We report a case of 47-year-old man who
presented with pulmonary tuberculosis and lepromatous leprosy coinfection.

Case: A
47- year-old Indonesian man presented with multiple nodules and plaques on his
trunk and limbs for the past one month. Furthermore he gave respiratory
symptoms of productive cough and fever for the past 10 days which was
associated with a loss of appetite. On examination, there were multiple tender
and firm 2 x 2 centimeters nodules on his face, trunk and limbs, some of which
have ulcerated. Skin split smear from 6 sites revealed bacterial index of 4.5
with morphological index of 3.1. Mantoux test on the forearm was positive (14
millimetres induration at 48 hours) and sputum for acid fast bacilli was
positive (1+). Chest radiograph was normal.

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Biopsy
from a nodule on the forearm showed foamy macrophages infiltration
with numerous acid fast bacilli are present within. A
diagnosis of lepromatous leprosy complicated with type 2 reaction and sputum
positive pulmonary tuberculosis was made. He was started on multidrug therapy
(MDT), anti TB treatment and systemic corticosteroids for type II leprae
reaction.. He developed complications of anti-TB induced transaminitis and
dapsone induced hemolysis. Treatment was substituted with second line anti-TB
regime and he was discharged well 27 days later.

Discussion: This case highlights the need to recognise concomitant infection
with tuberculosis and leprosy to avoid leprosy treatment becoming a TB “monotherapy” .The exact interaction
between these mycobacterium infections remains unanswered, molecular studies
indicate that a defect in Toll-like receptor 2 (TLR-2) may blunt the triggering
of host defense mechanism.

Conclusion: The
coinfection of leprosy and pulmonary tuberculosis is uncommon and a high index
of suspicious is necessary for diagnosis.