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CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 1  |  Page : 55-58

Coexistence of lepromatous leprosy, cutaneous tuberculosis and pulmonary tuberculosis: A rare occurrence


1 Department of Dermatology, Mythri Dermatology Experts, Hyderabad, Telangana, India
2 Department of Radiology, GSL Medical College, Rajanagaram, Rajahmundry, Andhra Pradesh, India

Date of Submission05-Jun-2018
Date of Acceptance23-Jul-2018
Date of Web Publication26-Apr-2019

Correspondence Address:
Dr. Sandeep Kodali
Department of Dermatology, Mythri Dermatology Experts, 49b, Sairaj Building, 1st Floor, Above Kotak Mahindra Bank, Beside Mercedes Benz Showroom, Madhapur, Hyderabad - 500 081, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_58_18Case

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  Abstract 


Leprosy and Tuberculosis, the two oldest diseases known to mankind, are chronic, granulomatous infections caused by intracellular, gram–positive, aerobic, acid fast bacilli of the genus Mycobacterium. Their coexistence in the same patient has been uncommonly reported in the literature. We report a concomitant infection of cutaneous tuberculosis in the form of lupus vulgaris and scrofuloderma, leprosy and sputum positive pulmonary tuberculosis in the same patient, which is the first to be reported, to the best of our knowledge. There is a need for screening of patients for TB in patients diagnosed with leprosy to prevent the possibility of rifampicin related drug-resistant TB.

Keywords: Cutaneous tuberculosis, lepromatous leprosy, lupus vulgaris, pulmonary tuberculosis, scrofuloderma


How to cite this article:
Kodali S, Kodali MP. Coexistence of lepromatous leprosy, cutaneous tuberculosis and pulmonary tuberculosis: A rare occurrence. J NTR Univ Health Sci 2019;8:55-8

How to cite this URL:
Kodali S, Kodali MP. Coexistence of lepromatous leprosy, cutaneous tuberculosis and pulmonary tuberculosis: A rare occurrence. J NTR Univ Health Sci [serial online] 2019 [cited 2019 May 26];8:55-8. Available from: http://www.jdrntruhs.org/text.asp?2019/8/1/55/257169




  Introduction Top


Leprosy and Tuberculosis are chronic, granulomatous infections caused by intracellular, gram–positive, aerobic, acid fast bacilli (AFB) of the genus Mycobacterium.[1] Mycobacterium leprae, the causative agent of leprosy, affects the skin and peripheral nerves, shows trophism for Schwann cells and Macrophages.[2] Mycobacterium tuberculosis predominantly affects the lungs (pulmonary tuberculosis–PTB). It can disseminate to or involve other organs (extra–pulmonary tuberculosis–EPTB) including lymph nodes, bones, meninges and skin (cutaneous tuberculosis–CTB).[2],[3] There are multiple presentations of both the diseases depending upon the host's cell mediated immune (CMI) response. The spectrum of CTB ranges from anergic multibacillary (miliary and periorificial forms) to hyperergic paucibacillary forms (lupus vulgaris and verrucous tuberculosis). In leprosy, a similar polarity is observed: paucibacillary tuberculoid leprosy with predominant CMI response; multibacillary lepromatous leprosy (LL) with predominant humoral response; and in between the poles, the borderline forms.[1] Though the coexistence of PTB and leprosy have been reported occasionally in the literature, the association of CTB and leprosy has been reported rarely.[3] We report a rare case of coexistence of LL, CTB in the form of scrofuloderma and lupus vulgaris, and PTB.


  Case Report Top


A 40-year-old male patient presented with multiple, painful, recurrent swellings and ulcers on the side of the neck and axillae since 3 years. They burst spontaneously to discharge pus and heal with puckered scarring in the axillae. Similar lesions appeared on the lower part of neck and upper chest since 1 year, appearing, healing and progressing to the other side, leaving behind a whitish, thick patch with scarring. The activity of the lesions was associated with low grade, intermittent fever with chills. History of generalized decrease in sweating, tingling and numbness over both upper and lower limbs since 1 year and productive cough since 6 months. No history of hypopigmented or erythematous patches was given. On general examination, patient was moderately built and poorly nourished, with pallor and pitting type of pedal oedema extending upto the knee. Cervical, axillary, epitrochlear, inguinal group of lymph nodes were enlarged and firm, some were tender, and few were matted. Vital signs were normal. Cutaneous examination revealed generalized xerosis, fine brownish scaling and wrinkling, sparing face, palms and soles and genitalia with infiltration of the face, involving forehead, eyebrows, ear-lobules, cheeks and nose. Similar, but minimal infiltration was seen over trunk and extremities [Figure 1] and [Figure 2]. Madarosis was also observed. A single, large, atrophic, hypopigmented, well demarcated, scaly plaque having occasional crusts, with scarring at one end and infiltration towards the left side was observed on the anterior surface of the neck and upper chest [Figure 3]. Multiple, tender, non-indurated, ulcers with undermined edges, discharging sinuses and puckered scars were seen in both axillae and in the groin [Figure 4] and [Figure 5]. Erythematous, tender and soft swellings, over the left submandibular region and right shoulder were seen. Patchy loss of sensation over both hands and forearms upto the elbows and both feet and legs upto the knees (Glove and stocking type) was seen. Peripheral nerve examination revealed bilaterally symmetrical, non–tender thickening of almost all the peripheral nerves. Haematological investigation showed moderate anaemia (haemoglobin 7.5 grams with microcytic hypochromic blood picture with occasional ovacytes), ESR was 80 mm, hypoproteinaemia (total serum proteins – 4.9 grams, serum albumin 2.2 grams per 100 mL respectively). HIV and VDRL tests were non–reactive. Slit skin smear for AFB with Ziehl Nelson staining showed AFB with presence of globi and bacillary index was 5+. Mantoux test was positive with indurated area being 15 mm. Chest X-RAY showed multiple heterogenous opacities in bilateral lung fields, cavitary lesion in left upper zone and fibrotic changes in the left lower lobe. Two out of three sputum samples were positive for AFB. For histopathological examination, elliptical biopsy was taken from three different sites, namely from the neck, left forearm and the wall of the sinus tract. Section from the neck [Figure 6] shows hyperkeratosis at places, thinned out epidermis with focal denudation at other places, dermis is diffusely and densely infiltrated by neutrophils, lymphocytes, plasma cells, epithelioid cells and occasional Langhan's giant cells with caseation necrosis along with scattered ill-defined granulomas are present in deeper aspects, the left forearm section [Figure 7] showed thinned out epidermis, dermis reveals discrete and confluent collections of foamy histiocytes, and the walls of the sinus tract showed granulomas with epitheloid giant cells, lymphocytes and plasma cells in the dermis. Based on the clinical, histopathological, radiological and sputum findings, a diagnosis of LL, PTB and CTB in the form of lupus vulgaris and scrofuloderma was made. The patient was put on antitubercular (ATT) and multibacillary multidrug therapy (MB–MDT) for leprosy.
Figure 1: Generalized xerosis, fine brownish scaling and wrinkling

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Figure 2: Infiltration of the ear lobe

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Figure 3: A single, large, atrophic, hypopigmented, well demarcated, scaly plaque with scarring at one end and infiltration towards the left side on the anterior surface of the neck and upper chest

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Figure 4: Multiple, tender, nonindurated, ulcers with undermined edges, discharging sinuses and puckered scars in both axillae

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Figure 5: Multiple, tender, non-indurated ulcers with undermined edges, discharging sinuses and puckered scars in both axillae

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Figure 6: Hyperkeratosis at places, thinned out epidermis with focal denudation at other places, dermis diffusely anddensely infiltrated by neutrophils, lymphocytes, plasma cells, epitheloid cells and occasional Langhan's giant cells and caseation necrosis with scattered ill-defined granulomas in deeper aspects

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Figure 7: Thinned out epidermis, dermis with discrete and confluent collections of foamy histiocytes

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  Discussion Top


The incidence of concomitant infection (leprosy, CTB) is rare even in endemic population like India. PTB, EPTB and CTB accounts for 70%, 30% and 1.5% of the all TB cases respectively. The reported concomitant infection of PTB and CTB in leprosy is reported to be 2.5% to 7.7% and 3.2% respectively in Indian population.[2],[4]

The exact nature of relationship between leprosy and TB still remains enigmatic. They share common characteristics – Gram positive, intracellular, AFB, Mycobacteria cause chronic granulomatous reactions and host–specific CMI response, which shows a vibrant role in defining the clinical spectrum. They share common antigens, as evidenced by conversion of tuberculin and lepromin intradermal tests after administration of Bacillus Calmette–Guérin vaccine.[4]

An inherent impaired immunity against both mycobacterial organisms has been postulated as the aetiology for dual infection. Leprosy leads to depressed CMI which may either reactivate latent tubercular infection or make the person susceptible to new infection. The incubation period of both the infections differ – few weeks to few months in the case of tuberculosis to few months to years in case of leprosy. The duration between the development of leprosy and TB varied between 2 months to 15 years,[4] as in our case it was about 2 years.

Although an increased incidence of PTB has been observed in patients with leprosy, the converse is not observed. It is postulated that prior infection with PTB has a protective effect against infection with Mycobacterium leprae.[5] In our case, patient's history suggests that EPTB occurred earlier, followed by leprosy and PTB.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

We acknowledge Dr. (Lt. Col.) S. Ramachandra and Dr. Nayeem Sadath Haneef for their great source of inspiration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Trindade MÂ, 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;88:236-40.  Back to cited text no. 1
    
2.
Parise-Fortes MR, Lastória JC, Marques SA, Putinatti MS, Stolf HO, Marques ME, et al. Lepromatous leprosy and perianal tuberculosis: A case report and literature review. J Venom Anim Toxins Incl Trop Dis 2014;20:38.  Back to cited text no. 2
    
3.
Farhana-Quyum, Mashfiqul-Hasan, Ahmed Z. A case of lepromatous leprosy with co-existing tuberculosis verrucosa cutis (TVC). Lepr Rev 2015;86:176-9.  Back to cited text no. 3
    
4.
Arya S, Kushwaha R, Jain S, Bunkar M. Concomitant infection with Mycobacterium leprae and Mycobacterium tuberculosis in an immunocompetent patient: A rare association. Int J Med Public Health 2016;6:50-2.  Back to cited text no. 4
  [Full text]  
5.
Rao GR, Sandhya S, Sridevi M, Amareswar A, Narayana BL; Shantisri. Lupus vulgaris and borderline tuberculoid leprosy: An interesting co-occurrence. Indian J Dermatol Venereol Leprol 2011;77:111.  Back to cited text no. 5
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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