Rifampicin and ofloxacin dual therapy as an adjunct to standard MB-MDT in the management of nodulo-ulcerative lepromatous leprosy with histoid-like features: a case report

Leprosy, induced by <i>Mycobacterium leprae</i>, and in some cases, <i>Mycobacterium lepromatosis</i>, remains an important public health issue in endemic regions despite ongoing elimination efforts. Histoid Hansen's disease, a variant of lepromatous leprosy, is characterised by shiny, well-defined nodules and a heavy acid-fast bacillary load. We present a case of a 50-year-old male agricultural worker from rural central India presenting during a community health camp with multiple cutaneous nodules clinically suggestive of histoid leprosy. Slit-skin-smears (SSS) revealed abundant needle-shaped acid-fast bacilli, with numerous globi, whereas histopathological examination of a lesional biopsy supported the diagnosis of lepromatous leprosy (LL). This report presents a novel two-step treatment approach that is aimed at rapidly reducing infectivity using a 28-day course of rifampicin and ofloxacin (RO therapy), followed by initiation of multi-bacillary multidrug therapy (MB-MDT) to ensure sustained bacillary clearance. Repeat SSS demonstrated fragmented and granular acid-fast bacilli, indicating effective bactericidal activity. This case underscores the need for vigilant surveillance, early identification, and potential strategies to combat relapses and drug-resistant strains in the post-elimination era.