Concurrent Multibacillary Lepromatous Leprosy with Autonomic Dysfunction and Cavitary Pulmonary Tuberculosis Complicated by Spontaneous Pneumothorax and Subcutaneous Emphysema

The concurrent presentation of two distinct mycobacterial diseases – Mycobacterium tuberculosis and Mycobacterium leprae – in a single patient is exceptionally rare. Lepromatous leprosy (LL), the multibacillary form of Hansen’s disease, is characterized by profound defects in cell-mediated immunity, which may predispose individuals to other intracellular infections, including tuberculosis. We present a unique case of a patient with undiagnosed lepromatous leprosy presenting with ichthyosiform scaling and autonomic dysfunction who developed a life-threatening pulmonary complication from reactivation pulmonary tuberculosis (PTB). A 54-year-old male farmer presented to the emergency department with acute respiratory distress due to a large right-sided spontaneous pneumothorax complicated by bilateral massive subcutaneous emphysema. He reported a chronic cough, weight loss, and night sweats over several months, with a history of treated PTB 15 years back. Systemic examination revealed diffuse, symmetrical ichthyosiform scaling of the skin, bilateral peripheral neuropathy in a stocking-glove distribution, palpably thickened ulnar nerves, and orthostatic hypotension suggestive of autonomic dysfunction. Skin slit smear demonstrated numerous acid-fast bacilli (Bacteriological Index 5+), and skin biopsy confirmed lepromatous leprosy with a diffuse histiocytic infiltrate. Sputum examination was positive for Mycobacterium tuberculosis . The patient was managed with intercostal chest drain insertion for the pneumothorax and concurrently initiated on anti-tubercular therapy (ATT) and World Health Organization multi-drug therapy (MDT) for multibacillary leprosy. The pneumothorax resolved completely by day 7, and sputum smear converted to negative by day 12. At a 2-month follow-up, the patient remained clinically stable with no leprosy reactions and improving respiratory symptoms. This case highlights the importance of considering underlying immunosuppressive conditions, such as lepromatous leprosy, in patients presenting with complicated tuberculosis. The ichthyosiform presentation of leprosy is often misdiagnosed, and autonomic dysfunction indicates advanced disease. This report highlights the delicate and often difficult battle between mycobacterial diseases and the human body’s defences – a battle that has profound consequences for how we diagnose illness, care for patients, and protect the health of entire communities where these diseases are most common.