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40The Journal of Association of Chest Physicians| Jan-Jun 2014 |
Vol 2 | Issue 1
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 34yearold male, laborer by occupation was admitted with
complaints of mucopurulent 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
illdefined erythematous hyperpigmented plaques with exfoliations
present over bilateral upper [Figure 1a] and lower limbs [Figure
1b] 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
AbstractThe 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 34yearold 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 multidrug
therapy for leprosy may lead to acquired drug resistance for
rifampicin, which is a mainstem of antitubercular therapy.
Key words: Coinfection, leprosy, tuberculosis
Case Report
Pulmonary tuberculosis and lepromatous leprosy coinfection in a
single individual: A Case report
Department of Pulmonary Medicine, Jawaharlal Nehru Medical
College, Wardha, Maharashtra, India
Address for correspondence: Dr. Satyadeo Choubey, M512, Meghdoot
Apartment, Jawaharlal Nehru Medical College, Datta Meghe Institute
of Medical Sciences Campus, Sawangi (Meghe), Wardha 442 004,
Maharashtra, India. Email: [email protected]
Satyadeo Choubey, Mukesh Sharma,
Bharat Agrawal
Access this article onlineQuick Response Code:
Website: www.jacpjournal.org
DOI: 10.4103/23208775.126512
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Choubey, et al.: Concomitant pulmonary tuberculosis and
leprosy
41 The Journal of Association of Chest Physicians | Jan-Jun 2014
| Vol 2 | Issue 1
were positive for lepra bacilli. Skin biopsy showed features
suggestive of lepromatous leprosy [Figure 2a and b]. Chest Xray
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.
Based on clinical findings and investigations, a diagnosis of
sputum positive pulmonary tuberculosis with Hansens 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 followup 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.[1]
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 Tolllike receptor 2 (TLR2) may blunt the triggering of host
defense mechanism. Reduced inducible chemokine ligand2 (CCL2) and
tumor necrosis factor (TNF) alpha responses in lepromatous leprosy
contribute to unrestricted growth and dissemination of tubercular
bacilli.[2,3]
Revich et al.,[4] in 1954 reported the association to be maximum
in lepromatous leprosy followed by borderline and uncommon in
tuberculoid form. Gajwani et al.,[5] in 1968, Gupta et al.,[6] in
1971 and Agnihotri MS,[7] et al., in 1973 reported cases of
tuberculoid leprosy with tuberculosis. Kumar B et al.,[8] in 1982
concluded that tuberculosis can occur during full spectrum of
leprosy [Table 1].
Both leprosy and tuberculosis are commonly spread via
aerosol.[10] Incubation period varies from 6 months to 40 years for
leprosy and 4 weeks for tuberculosis. Coinfection may have a gap of
2 months to 1015 years.[2] Usually leprosy predates tuberculosis
but the reverse has also been reported as by Agnihotri MS et
al.,[7] in 1973. In our case, both the diseases were diagnosed
simultaneously.
Tuberculosis has also been reported with the use of
glucocorticosteroids 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 socioeconomic 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%[9] but cases have been reported for
extrapulmonary tuberculosis also.[11]
Figure 3: Chest radiograph showing right upper zone
consolidation with bilateral patchy infiltrates
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
ba
Figure 1: (a) Erythematous hyperpigmented plaques with areas of
hypopigmentation and exfoliation of skin on right forearm, (b) and
in lower limb
ba
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Choubey, et al.: Concomitant pulmonary tuberculosis and
leprosy
42The Journal of Association of Chest Physicians| Jan-Jun 2014 |
Vol 2 | Issue 1
Radiologically, most of the time it is bilateral infiltrates. In
our case, he was sputum positive pulmonary tuberculosis with
bilateral infiltrates on chest Xray.
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.
PrasadR,VermaSK,SingR,HosmaneG.Concomittantpulmonarytuberculosis
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2.
NigamP,DubeyAL,DayalSG,GoyalBM,SaxenaHN,SamuelKC.Theassociationofleprosyandpulmonarytuberculosis.LeprIndia1979;51:6573.
3. HasanZ, JamilB,Zaidi
I,ZafarS,KhanAA,HussainR.ElevatedserumCCL2concomitantwitha
reducedmycobacteriuminducedresponseleadstodiseasedisseminationinleprosy.ScandJImmunol
2006;63:2417.4.
RelvichAL.Thetreatmentoftuberculosisinleprosypatients.Lepr
Rev1954;25:17986.5. Gajwani BW, Verma BS, Marwaha RK, Pande RS.
Simultaneous
infectionwithM. tuberculosis and M.
leprae.JAssocPhysiciansIndia1968;16:5634.
6.
GuptaMC,PrasadM.Associatedinfectionofpulmonarytuberculosisandleprosy.IndianJMedSci1971;25:1835.
7. Agnihotri MS, Rastogi S, Agarwal RC. Tuberculosis and
leprosy.IndianJTub1973;20:1367.
8. Kumar B, Kaur S, Kataria S, Roy SN. Concomitant occurrence
ofleprosyandtuberculosisAclinical,bacteriologicalandradiologicalevaluation.LeprIndia1982;54:6716.
9. Srilakshmi MA, Amit H, Jayantilal, Raveendranath S, Pais
N.Concomitant infection with pulmonary tuberculosis
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10.
Leprosy(Hansen'sdisease):TechnicalInformation.Availablefrom:http://www.cdc.gov/nczved/divisions/dfbmd/diseases/hansens_disease/technical.html.[Lastaccessedon2014Jan03].
11. Flanagan PM, McIlwain JC. Tuberculosis of the larynx in
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How to cite this article: Choubey S, Sharma M, Agrawal B.
Pulmonary tuberculosis and lepromatous leprosy coinfection in a
single individual: A Case report. J Assoc Chest Physicians
2014;2:402.Source of Support: Nil, Conflict of Interest: Nil.
Table 1: Comparative analysis of previous case reports
Reference No. of cases reported
First infection
Type of leprosy
Type of tuberculosis (pulmonary/extrapulmonary)
Lag time between two infections
Gajwani et al. 1968[5] 3 TB2Leprosy1
BT2TT1
Pulmonary 6 months2 years
Gupta et al. 1971[6] 2 Leprosy TT Pulmonary 6 months1
yearAgnihotri et al. 1973[7] 3 TB2
Leprosy 1TT Pulmonary 1 month4 years
Nigam et al. 1979[2] 20 Leprosy LL15BL3TT2
Pulmonary18Pleural effusion2
1015 years
Kumar et al. 1982[8] 9 Leprosy LL4BL3TT2
Pulmonary NA
Srilakshami et al. 2003[9] 1 Leprosy LL Pulmonary 10 yearsPrasad
R et al. 2010[1] 1 Leprosy BL Pulmonary 9 months
TB: Tuberculosis, BT: Borderline tuberculoid leprosy, TT:
Tuberculoid leprosy, BL: Borderline lepromatous leprosy, LL:
Lepromatous leprosy
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