|Year : 2014 | Volume
| Issue : 1 | Page : 40-42
Pulmonary tuberculosis and lepromatous leprosy co-infection in a single individual: A Case report
Satyadeo Choubey, Mukesh Sharma, Bharat Agrawal
Department of Pulmonary Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
|Date of Web Publication||5-Feb-2014|
M5-12, Meghdoot Apartment, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences Campus, Sawangi (Meghe), Wardha - 442 004, Maharashtra
Source of Support: None, Conflict of Interest: None
The concomitant occurrence of the two oldest mycobacterial diseases that is tuberculosis and leprosy in a single individual is not rare but has been infrequently reported. Herein, we report a case of 34-year-old laborer who concomitantly presented with both sputum positive pulmonary tuberculosis and lepromatous leprosy. The diagnosis of the two diseases was made simultaneously, which is again infrequent in literature. The treatment of leprosy warrants screening of individual for tuberculosis because multi-drug therapy for leprosy may lead to acquired drug resistance for rifampicin, which is a mainstem of anti-tubercular therapy.
Keywords: Co-infection, leprosy, tuberculosis
|How to cite this article:|
Choubey S, Sharma M, Agrawal B. Pulmonary tuberculosis and lepromatous leprosy co-infection in a single individual: A Case report. J Assoc Chest Physicians 2014;2:40-2
|How to cite this URL:|
Choubey S, Sharma M, Agrawal B. Pulmonary tuberculosis and lepromatous leprosy co-infection in a single individual: A Case report. J Assoc Chest Physicians [serial online] 2014 [cited 2019 Jan 18];2:40-2. Available from: http://www.jacpjournal.org/text.asp?2014/2/1/40/126512
| Introduction|| |
Both tuberculosis and leprosy are chronic granulomatous disease caused by Mycobacterium tuberculosis and Mycobacterium leprae, respectively. The infrequent occurrence of these two diseases in a single individual is explained by their transmission dynamics that is the higher reproductive rate of tubercular bacilli than the lepra bacilli and the degree of cross immunity they offer in an individual. We report a case of lepromatous leprosy and pulmonary tuberculosis in an individual diagnosed simultaneously, at his first hospital visit.
| Case Report|| |
A 34-year-old male, laborer by occupation was admitted with complaints of muco-purulent cough, fever (typical evening rise) and breathlessness for two months and insidious onset skin lesion over ear lobules, bilateral upper and lower limbs for one and half months. There was no history of hemoptysis, chest pain, and loss of weight or appetite. History did not reveal any major medical or surgical illnesses. He was vegetarian by diet, not addicted to smoking, alcohol or tobacco chewing.
Clinical examination revealed pallor, multiple well to ill-defined erythematous hyperpigmented plaques with exfoliations present over bilateral upper [Figure 1]a and lower limbs [Figure 1]b with few targetoid lesions. There was patchy loss of sensation over the lesions on skin prick test. Temperature sensation decreased in upper limbs while it was intact in lower limbs. Motor examination was normal. Respiratory examination revealed bilateral coarse crackles.
On investigation, hemoglobin was 8.8 gm%, total leukocyte count 15000 per cu mm (polymorphs 87%, lymphocytes 12%), Erythrocyte sedimentation rate - 90 mm in the first hour, Mean corpuscular volume - 83 cu micron, Mean corpuscular hemoglobin - 26.9 picogram, Mean corpuscular hemoglobin concentration - 32.4%. Platelet count was 5.5 lacs per cu mm. Renal and liver function tests were within normal limits. Peripheral smear showed normocytic normochromic picture with increased white blood cells (neutrophilic predominance) and adequate platelets. Slit skin smears from ear lobule, forearm and leg were positive for lepra bacilli. Skin biopsy showed features suggestive of lepromatous leprosy [Figure 2]a and b. Chest X-ray showed right upper zone consolidation with bilateral patchy infiltrates [Figure 3]. Sputum for acid fast bacilli was 3+ positive. Human immunodeficiency virus (HIV) status was negative.
|Figure 1: (a) Erythematous hyper-pigmented plaques with areas of hypopigmentation and exfoliation of skin on right forearm, (b) and in lower limb|
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|Figure 2: (a) Skin biopsy from the lesion on forearm. Group of foamy histiocytes (lepra cells) along with inflammatory cells below epidermis seen in low power field, (b) Same lesion in high power field|
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|Figure 3: Chest radiograph showing right upper zone consolidation with bilateral patchy infiltrates|
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Based on clinical findings and investigations, a diagnosis of sputum positive pulmonary tuberculosis with Hansen's disease was made. He was started on both multidrug therapy and direct observation of drug intake (DOTS) (category 1). Rifampicin was given as per DOTS schedule. He was also given a broad spectrum antibiotics considering superadded infection as revealed by increased total leukocyte count. Patient is under our observation and follow-up and is doing well.
| Discussion|| |
Both leprosy and tuberculosis have been prevalent in India since ancient times with current prevalence rate of active tuberculosis estimated to be 4.0 and 16.0 per thousand bacteriologically and radiologically, respectively and that of leprosy 0.88 per thousand. 
Leprosy, especially the multibacillary, leads to depressed cell mediated immunity which may either reactivate the latent tubercular infection or make the person susceptible for new infection. Defect in Toll-like receptor 2 (TLR-2) may blunt the triggering of host defense mechanism. Reduced inducible chemokine ligand-2 (CCL2) and tumor necrosis factor (TNF)- alpha responses in lepromatous leprosy contribute to unrestricted growth and dissemination of tubercular bacilli. ,
Revich et al., in 1954 reported the association to be maximum in lepromatous leprosy followed by borderline and uncommon in tuberculoid form. Gajwani et al.,  in 1968, Gupta et al.,  in 1971 and Agnihotri MS,  et al., in 1973 reported cases of tuberculoid leprosy with tuberculosis. Kumar B et al.,  in 1982 concluded that tuberculosis can occur during full spectrum of leprosy [Table 1].
Both leprosy and tuberculosis are commonly spread via aerosol.  Incubation period varies from 6 months to 40 years for leprosy and 4 weeks for tuberculosis. Co-infection may have a gap of 2 months to 10-15 years.  Usually leprosy predates tuberculosis but the reverse has also been reported as by Agnihotri MS et al., in 1973. In our case, both the diseases were diagnosed simultaneously.
Tuberculosis has also been reported with the use of gluco-corticosteroids used in the treatment of leprosy primarily in type 1 (reversal) reactions and type 2 and silent neuropathy. In our case the patient was not on steroid or other immunosuppressive therapy neither he had other risk factors in the form of HIV infection, silicosis, diabetes mellitus, gastrectomy, renal failure, organ transplants, or smoking habits. The only precipitating event can be his lower socio-economic status.
Leprosy is usually diagnosed by slit skin smear, nasal smears, and histopathological examinations as well. In present case, both slit skin smear and skin biopsy were positive for leprosy. Tuberculosis in leprosy is usually pulmonary one with sputum positivity in almost 80%  but cases have been reported for extra-pulmonary tuberculosis also.  Radiologically, most of the time it is bilateral infiltrates. In our case, he was sputum positive pulmonary tuberculosis with bilateral infiltrates on chest X-ray.
| Conclusion|| |
Rifampicin is a bactericidal drug and constitutes important drug in the treatment regimen of both leprosy and tuberculosis. So the latter must be screened out in each patient of leprosy to avoid acquired drug resistance to rifampicin due to single drug therapy.
| References|| |
|1.||Prasad R, Verma SK, Sing R, Hosmane G. Concomittant pulmonary tuberculosis and borderline leprosy with type-II lepra reaction in single patient. Lung India 2010;27:19-23. |
|2.||Nigam P, Dubey AL, Dayal SG, Goyal BM, Saxena HN, Samuel KC. The association of leprosy and pulmonary tuberculosis. Lepr India 1979;51:65-73. |
|3.||Hasan Z, Jamil B, Zaidi I, Zafar S, Khan AA, Hussain R. Elevated serum CCL2 concomitant with a reduced mycobacterium-induced response leads to disease dissemination in leprosy. Scand J Immunol 2006;63:241-7. |
|4.||Relvich AL. The treatment of tuberculosis in leprosy patients. Lepr Rev 1954;25:179-86. |
|5.||Gajwani BW, Verma BS, Marwaha RK, Pande RS. Simultaneous infection with M. tuberculosis and M. leprae. J Assoc Physicians India 1968;16:563-4. |
|6.||Gupta MC, Prasad M. Associated infection of pulmonary tuberculosis and leprosy. Indian J Med Sci 1971;25:183-5. |
|7.||Agnihotri MS, Rastogi S, Agarwal RC. Tuberculosis and leprosy. Indian J Tub 1973;20:136-7. |
|8.||Kumar B, Kaur S, Kataria S, Roy SN. Concomitant occurrence of leprosy and tuberculosis-A clinical, bacteriological and radiological evaluation. Lepr India 1982;54:671-6. |
|9.||Srilakshmi MA, Amit H, Jayantilal, Raveendranath S, Pais N. Concomitant infection with pulmonary tuberculosis and lepromatous leprosy. J Assoc Physicians India 2003;51:528-9. |
|10.||Leprosy (Hansen′s disease): Technical Information. Available from: http://www.cdc.gov/nczved/divisions/dfbmd/diseases/hansens_disease/technical.html. [Last accessed on 2014 Jan 03]. |
|11.|| Flanagan PM, McIlwain JC. Tuberculosis of the larynx in a lepromatous patient. J Laryngol Otol 1993;107:845-7. |
[Figure 1], [Figure 2], [Figure 3]