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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 159-162

Disseminated tuberculosis in association with erythema nodosum leprosum


1 Department of Dermatology, Yenepoya Medical College, Mangalore, Karnataka, India
2 Department of Medicine, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Submission19-Feb-2021
Date of Decision10-Jul-2021
Date of Acceptance20-Jul-2021
Date of Web Publication27-Jun-2022

Correspondence Address:
Dr. Manjunath Mala Shenoy
Department of Dermatology, Yenepoya Medical College, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_17_21

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  Abstract 


Mycobacterial diseases are endemic in India but simultaneous occurrence of tuberculosis and leprosy is rarely reported. We report a case of disseminated tuberculosis in an immunocompromised host due long-standing unsupervised corticosteroid intake with erythema nodosum leprosum (type 2 lepra reaction). The patient presented with generalized erythematous papulonodular skin lesions with malaise and body ache for the past 2 years. Later, he developed fever and testicular pain for which he sought medical advice. The diagnosis was based on the various laboratory and imaging studies supported by demonstration of Mycobacterium tuberculosis and Mycobacterium leprae in sputum and skin smears, respectively. The patient developed hepatitis which led to management challenges, however, the institution of antitubercular and antileprosy therapy in titrating doses resulted in improvement of the patient's condition.

Keywords: Disseminated tuberculosis, erythema nodosum leprosum, immunosuppression, leprosy


How to cite this article:
Raj A, Bhat BS, Hegde SP, Shenoy MM. Disseminated tuberculosis in association with erythema nodosum leprosum. BLDE Univ J Health Sci 2022;7:159-62

How to cite this URL:
Raj A, Bhat BS, Hegde SP, Shenoy MM. Disseminated tuberculosis in association with erythema nodosum leprosum. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Aug 15];7:159-62. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/159/348266



Tuberculosis and leprosy have witnessed geographic endemicity with India showing high prevalence of both diseases. Concomitant tuberculosis and leprosy are an uncommon co-occurrence in patients even in endemic countries like India although there is no suitable explanation for this observation,[1],[2] but there seem to be some antagonism between them. However, this scenario is reported scarce in modern literature with a prevalence of 0.02/100,000 population.[3] It is also believed that this may be due to bacillus Calmette–Guérin vaccine which gives some protection against leprosy.[4] We report a case of concomitant tuberculosis and lepromatous leprosy with erythema nodosum leprosum in a secondary immunosuppressed patient.


  Case Report Top


A 54-year-old male presented with low-grade fever and testicular pain for the past 2 weeks. He also had multiple asymptomatic skin lesions over the trunk, extremities, and face for the past 6 months. He had been intermittently taking over the counter oral prednisolone and diclofenac in varying doses for body ache, malaise, and skin rash for more than 2 years. Low-grade fever was associated with evening rise of temperature and chills and reduced appetite. There was associated nasal stuffiness but no bleeding or altered smell perception. There was no history of cough, breathlessness, numbness of extremities, or hoarseness of voice. There was no history of high-risk behavior or orogenital lesions.

Physical examination revealed pallor, pitting pedal edema with axillary and supraclavicular lymphadenopathy. His vitals were stable except for blood pressure which was persistently below 100/60 mmHg. Multiple erythematous papules, nodules, and plaques distributed over the neck, back, chest, abdomen, extremities, and face were seen on cutaneous examination [Figure 1] and [Figure 2]. Few lesions revealed ulceration and crusting. Bilateral ciliary and supraciliary madarosis were present. Peripheral nerve examination depicted enlarged bilateral supraorbital, radial cutaneous, and ulnar nerves. Sensory, motor, and cranial nerve examination were normal. Right testicular tenderness suggestive of epididymo-orchitis was present. Ocular fundus examination showed choroid tubercles on the left side.
Figure 1: Figure showing multiple nodules of erythema nodosum leprosum over the back

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Figure 2: Erythema nodosum leprosum involving the chest and abdomen with few healed ulcerated lesions

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Complete blood profile showed hemoglobin – 9.3 g/dL, total leukocyte count – 6330 cells per microliter with neutrophil 77.9%, lymphocyte – 8.2%, eosinophil – 1.1%, monocyte – 12.6%, and basophil – 0.2%. Platelet count was 128,000 per microliter and erythrocyte sedimentation rate was 63 mm/h. Liver function test (LFT) revealed total bilirubin as 5 mg/dl, direct bilirubin 4 mg/dl and indirect bilirubin 1 mg/dl, serum glutamic oxaloacetic transaminase was 149 IU/L, and serum glutamic pyruvic transaminase was 89 IU/L. Serum sodium was 124 mmol/L, serum chloride was 90 mmol/L, and serum potassium was 3.5 mmol/L. Renal function test was normal. Serum cortisol was 15 mcg/dl. Alpha-fetoprotein and carcinoembryonic antigen levels were normal. HIV spot test, HBsAg, and  Treponema pallidum Scientific Name Search magglutination assay were negative. He was initially treated with empirical antibiotics and supportive therapy.

Chest X-ray showed reticulonodular opacities in mid and lower zones. Computerized tomography (CT) images of thorax showed innumerous nodules with centrilobular predilection (”tree in bud” appearance) indicating military and endobronchial tuberculosis [Figure 3]. CT abdomen showed hepatomegaly and splenomegaly with multiple small nodules indicating possibly disseminated tuberculosis [Figure 4]. Bone marrow biopsy showed hemophagocytosis and epithelioid cell granulomas. Sputum examination showed acid-fast bacilli suggestive of Mycobacterium tuberculosis. Slit-skin smear examination was positive for Mycobacterium leprae with bacteriological and morphological indices of 4 and 15, respectively. Histopathology from a skin lesion revealed diffuse dermal infiltration of foamy macrophages with extension into the subcutis causing lobular panniculitis suggestive of lepromatous leprosy with erythema nodosum leprosum [Figure 5] and [Figure 6]. Fite Faraco staining revealed M. leprae.
Figure 3: Computerized tomographic image of thorax showing multiple nodules displaying “tree in bud” appearance

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Figure 4: Computerized tomographic image showing hyperdense nodular lesions in liver and spleen

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Figure 5: Histopathology of skin lesions showing granulomatous inflammation with foamy cells extending to subcutis

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Figure 6: Histopathology showing granulomatous inflammation with foam cells, neutrophils associated with features of vasculitis

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Diagnosis of disseminated tuberculosis with lepromatous leprosy with type 2 lepra reaction (erythema nodosum leprosum) was established. Considering the deranged liver function, modified antitubercular treatment (ATT) with streptomycin, ethambutol, and levofloxacin was initiated with caution. Clofazimine was added as a part of antileprosy therapy; dapsone was deferred because of anemia and deranged LFT. Once LFT normalized, rifampicin was introduced at small dose and titrated with LFT monitoring. After about 3 weeks, fixed-dose combination ATT was introduced. After about a month of hospitalization, the patient was discharged following clinical and laboratory improvement.


  Discussion Top


According to the global tuberculosis report 2019, an estimated 10 million people fell ill due to tuberculosis; India accounting for 2.8 million.[5] A total of 208,619 new leprosy cases were registered globally in 2018. India accounted for 135,485 new cases in 2016–2017.[6],[7] Tuberculosis and leprosy are mycobacterial diseases seen in similar geographical areas. They are chronic granulomatous disorders with chief mode of transmission being aerosol route. They also have skin tests determining cell-mediated immunity, namely tuberculin and lepromin tests. Tuberculosis is predominantly a pulmonary disease with many extra-pulmonary manifestations, whereas leprosy predominantly affects the skin and peripheral nervous system. Tuberculosis causes high mortality, especially in late diagnosed cases and in the presence of coinfection with HIV. Leprosy is not a killer disease but sure can causes deformities.

It is rare to observe two diseases coexisting in the same patient. Higher productive rate of tuberculosis bacilli as compared to lepra bacilli and degree of cross immunity within an individual probably prevents both infections occurring simultaneously.[8] They may coexist in patients with malnutrition, diabetes mellitus, and immunosuppressed states.[9] Most of the reported cases of tuberculosis-leprosy coinfection were associated with lepromatous leprosy followed by borderline leprosy.[10] Co-occurrence of type 2 lepra reaction with tuberculosis has been an extreme rarity.[11] Erythema nodosum leprosum, the cutaneous lesions of Type 2 lepra reaction is a Type 3 hypersensitivity reaction indicating an abnormal humoral response. In this case, although the patient was taking steroids at low dose, the chronic use of drug could have resulted in immunosuppression that facilitated the development of two infections as reported by some others.[11],[12] Rifampicin constitutes an important drug in the treatment regimen of both leprosy and tuberculosis.[13] It may be worthwhile to consider screening of all patients of leprosy for tuberculosis to avoid acquired drug resistance to rifampicin due to single-drug therapy.


  Conclusion Top


This case has been reported for the rarity of coexistence of the two mycobacterial diseases and the difficulty in the management of the case due to challenging clinical scenario. Many adversities include long-standing unsupervised oral corticosteroid intake, hepatitis, epididymo-orchitis, and hemophagocytosis in this case of disseminated mycobacterial diseases. This case also highlights the importance of screening patients for tuberculosis before instituting antileprosy therapy in endemic areas.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee HN, Embi CS, Vigeland KM, White CR Jr. Concomitant pulmonary tuberculosis and leprosy. J Am Acad Dermatol 2003;49:755-7.  Back to cited text no. 1
    
2.
Ghosh R, Barua JK, Garg A, Barman BP. Dual Infection with Mycobacterium tuberculosis and Mycobacterium leprae at same site in an immunocompetent patient: An unusual presentation. Indian J Dermatol 2017;62:548.  Back to cited text no. 2
    
3.
Rawson TM, Anjum V, Hodgson J, Rao AK, Murthy K, Rao PS, et al. Leprosy and tuberculosis concomitant infection: A poorly understood, age-old relationship. Lepr Rev 2014;85:288-95.  Back to cited text no. 3
    
4.
Coppola M, van den Eeden SJ, Robbins N, Wilson L, Franken KL, Adams LB, et al. Vaccines for leprosy and tuberculosis: Opportunities for shared research, development, and application. Front Immunol 2018;9:308.  Back to cited text no. 4
    
5.
WHO. Global Tuberculosis Report 2019.WHO. Available from: https://www.who.int/tuberculosis/global-report-2019. [Last accessed on 2020 Apr 07].  Back to cited text no. 5
    
6.
WHO. Newsroom Keyfacts in Leprosy.WHO. Available from: https://www.who.int/news-room/fact-sheets/detail/leprosy. [Last accessed on 2020 Apr 07].  Back to cited text no. 6
    
7.
NLEP. Introduction to Leprosy. National Health Portal. Available from: https://www.nhp.gov.in/disease/skin/lepros. [Last accessed on 2020 Apr 07].  Back to cited text no. 7
    
8.
Prasad R, Verma SK, Singh R, Hosmane G. Concomittant pulmonary tuberculosis and borderline leprosy with type-II lepra reaction in single patient. Lung India 2010;27:19-23.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
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. 9
    
10.
Shetty S, Umakanth S, Manandhar B, Nepali PB. Coinfection of leprosy and tuberculosis. BMJ Case Rep 2018;2018:bcr2017222352.   Back to cited text no. 10
    
11.
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. 11
    
12.
Sreeramareddy CT, Menezes RG, Kishore P. Concomitant age old infections of mankind-Tuberculosis and leprosy: A case report. J Med Case Rep 2007;1:43.  Back to cited text no. 12
    
13.
Choubey S, Sharma M, Agarwal B. Pulmonary tuberculosis and lepromatous leprosy co-infection in a single individual: A case report. J Assoc Chest Physicians 2014;2:40-2.  Back to cited text no. 13
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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