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: chestsd@gmail.com

Satyadeo Choubey, Mukesh Sharma,

Bharat Agrawal

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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 and borderline leprosywith typeII lepra reaction insinglepatient.LungIndia2010;27:1923.

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 andlepromatousleprosy.JAssocPhysiciansIndia2003;51:5289.

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 alepromatouspatient.JLaryngolOtol1993;107:8457.

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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