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Prednisolone/rifampicin Pulmonary tuberculosis, extrapulmonary tuberculosis and development of rifampicin resistance in leprosy: 3 case reports

In a case series comprising 6 patients with Mycobacterium tuberculosis and Mycobacterium leprae co-infection, 3 patients (1 woman and 2 men) aged 51–58 years were described, of whom, the woman developed rifampicin resistance while being treated for tuberculoid leprosy, and the remaining two men developed extrapulmonary tuberculosis (TB) or fatal pulmonary TB following treatment with prednisolone for lepromatous leprosy [routes not stated]. An approximately 58-year-old woman presented to hospital with extensive seborrheic dermatitis accompanied by tender facial induration. Subsequent investigations led to the diagnosis of borderline tuberculoid leprosy with type-1 reaction at the age of 57 years. Therefore, she started receiving multibacillary treatment for leprosy, involving monthly rifampicin [dose not stated], clofazimine and dapsone. However, after 1 year, she developed fever, appetite loss and weight loss, as well as widespread skin abscesses all over her body. Sputum examination for acid-fast bacilli was found to be positive; GeneXpert confirmed resistance to rifampicin. At this time, she also revealed being diagnosed with HIV infection and tuberculous lymphadenitis (extrapulmonary tuberculosis) 5 years earlier, wherein she had received a 6-month course of anti-TB therapy but had defaulted on antiretroviral therapy. Therefore, she started receiving a multidrug regimen, comprising kanamycin, cycloserine, ethionamide, ethambutol, levofloxacin, isoniazid and pyridoxine for pulmonary tuberculosis. Repeat analyses were found negative, and she continued receiving multidrug treatment-multibacillary therapy comprising clofazimine and dapsone for leprosy, without rifampicin. She later resumed highly active antiretroviral therapy. During 6-month follow-up, she exhibited clinical, haematological and radiological improvement. A 54-year-old man presented with a leonine face, asymptomatic infiltrated plaques and papules over the earlobes, accompanied by hypopigmented hypoanaesthetic patches all over the body for about 5 months. He was subsequently diagnosed with borderline lepromatous leprosy. Thereafter, he started receiving multibacillary therapy for leprosy, comprising clofazimine, dapsone, rifampicin and prednisolone 40mg daily, with tapering. However, after 6 months, he presented with nocturnal pyrexia and productive cough. Subsequent analyses revealed an elevated ESR (130 mm/hour), chest X-ray showed evidence of active pulmonary TB, and a sputum smear was found to be positive for acid-fast bacilli. Therefore, he started receiving anti-TB therapy with isoniazid, rifampicin, pyrazinamide and ethambutol. However, he defaulted treatment several times (in regard to both, TB and leprosy), and he eventually died due to pulmonary TB. An autopsy was not performed. An approximately 51-year-old man presented with facial infiltration, accompanied by erythematous painful nodules over