Dual Mycobacterial Infection with Tuberculosis and Leprosy: A Case Highlighting Diagnostic and Programmatic Challenges in Endemic Settings

Introduction: Tuberculosis (TB) and leprosy are chronic infectious diseases caused by Mycobacterium species and remain significant public health concerns in endemic countries like India. According to the World Health Organization Global TB Report 2025, India continues to carry one of the highest TB burdens globally. Although both diseases are well known individually, their simultaneous occurrence is rarely reported in modern literature. Co-infection poses diagnostic and therapeutic challenges, particularly due to the shared use of rifampicin in treatment regimens. Case Presentation: A 62-year-old female farmer presented with fever, multiple painless cervical swellings with yellowish discharge, swelling of the right thumb, and multiple ulcerative skin lesions over the extremities. Clinical examination revealed matted cervical lymphadenopathy, nodular swellings on the hand, hypo- and hyper-pigmented macular lesions on the back, and thickened ulnar nerve. Investigations showed anemia and raised inflammatory markers. Ziehl-Neelsen staining and histopathology confirmed lepromatous leprosy, while fine needle aspiration cytology and CBNAAT of cervical lymph nodes confirmed tuberculous lymphadenitis without rifampicin resistance. Imaging revealed osteomyelitis of the right thumb consistent with tubercular involvement. The patient was treated with multidrug therapy for leprosy along with standard anti-tubercular therapy and showed clinical improvement on follow-up. Conclusion: Concurrent TB and leprosy, though uncommon, require early recognition and evaluation for rifampicin resistance to ensure appropriate treatment and prevent drug resistance. Routine screening for TB in patients diagnosed with leprosy is recommended in endemic regions.