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Case R e po r t

Pulmonary tuberculosis and lepromatous leprosy


coinfection in a single individual: A Case report
Satyadeo Choubey,
MukeshSharma,
BharatAgrawal

Department of Pulmonary Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
Address for correspondence:
Dr. Satyadeo Choubey, M5-12, Meghdoot Apartment, Jawaharlal Nehru Medical College, Datta Meghe
Institute of Medical Sciences Campus, Sawangi (Meghe), Wardha - 442 004, Maharashtra, India.
E-mail: chestsd@gmail.com

Abstract
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 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

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
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DOI:
10.4103/2320-8775.126512

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[Figure1a] and
lower limbs[Figure1b] 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 rate90
mm in the first hour, Mean corpuscular volume83 cu
micron, Mean corpuscular hemoglobin26.9 picogram,
Mean corpuscular hemoglobin concentration32.4%.
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

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Choubey, et al.: Concomitant pulmonary tuberculosis and leprosy

were positive for lepra bacilli. Skin biopsy showed features


suggestive of lepromatous leprosy[Figure2a 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.

Figure1:(a) Erythematous hyperpigmented plaques with areas of


hypopigmentation and exfoliation of skin on right forearm,(b) and in
lower limb

Figure2:(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

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 etal.,[4] in 1954 reported the association to be
maximum in lepromatous leprosy followed by borderline
and uncommon in tuberculoid form. Gajwani etal.,[5] in
1968, Gupta etal.,[6] in 1971 and Agnihotri MS,[7] etal., in 1973
reported cases of tuberculoid leprosy with tuberculosis.
Kumar B etal.,[8] in 1982 concluded that tuberculosis can
occur during full spectrum of leprosy[Table1].
Both leprosy and tuberculosis are commonly spread
via aerosol.[10] Incubation period varies from 6 months
to 40years for leprosy and 4weeks for tuberculosis.
Coinfection may have a gap of 2 months to 10-15years.[2]
Usually leprosy predates tuberculosis but the reverse has
also been reported as by Agnihotri MS etal.,[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 type1(reversal) reactions and type2 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.

Figure3: Chest radiograph showing right upper zone consolidation


with bilateral patchy infiltrates

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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]

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Choubey, et al.: Concomitant pulmonary tuberculosis and leprosy

Table1: 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 etal. 1968[5]

6 months-2years

2
3

BT2
TT1
TT
TT

Pulmonary

Gupta etal. 1971[6]


Agnihotri etal. 1973[7]

Pulmonary
Pulmonary

6 months-1year
1 month-4years

Nigam etal. 1979[2]

20

TB2
Leprosy1
Leprosy
TB2
Leprosy1
Leprosy

Pulmonary18
Pleural effusion2

10-15years

Kumar etal. 1982[8]

Leprosy

Pulmonary

NA

Srilakshami etal. 2003[9]


Prasad R etal. 2010[1]

1
1

Leprosy
Leprosy

LL15
BL3
TT2
LL4
BL3
TT2
LL
BL

Pulmonary
Pulmonary

10years
9 months

TB: Tuberculosis, BT: Borderline tuberculoid leprosy, TT: Tuberculoid leprosy, BL: Borderline lepromatous leprosy, LL: Lepromatous leprosy

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.

2.

3.

PrasadR, VermaSK, SingR, HosmaneG. Concomittant pulmonary


tuberculosis and borderline leprosy with typeII lepra reaction in
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NigamP, DubeyAL, DayalSG, GoyalBM, SaxenaHN, SamuelKC.
The association of leprosy and pulmonary tuberculosis. Lepr India
1979;51:6573.
Hasan Z, Jamil B, Zaidi I, Zafar S, KhanAA, Hussain R. Elevated
serum CCL2 concomitant with a reduced mycobacteriuminduced
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2006;63:2417.
RelvichAL. The treatment of tuberculosis in leprosy patients. Lepr
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5. Gajwani BW, Verma BS, Marwaha RK, Pande RS. Simultaneous
infection with M. tuberculosis and M. leprae. JAssoc Physicians India
1968;16:5634.
6. GuptaMC, PrasadM. Associated infection of pulmonary tuberculosis
and leprosy. Indian J Med Sci 1971;25:1835.
7. Agnihotri MS, Rastogi S, Agarwal RC. Tuberculosis and leprosy.
Indian J Tub 1973;20:1367.
8. Kumar B, Kaur S, Kataria S, Roy SN. Concomitant occurrence of
leprosy and tuberculosisA clinical, bacteriological and radiological
evaluation. Lepr India 1982;54:6716.
9. Srilakshmi MA, Amit H, Jayantilal, Raveendranath S, Pais N.
Concomitant infection with pulmonary tuberculosis and
lepromatous leprosy. JAssoc Physicians India 2003;51:5289.
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. JLaryngol Otol 1993;107:8457.
4.

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.
Source of Support: Nil, Conflict of Interest: Nil.

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