PMC4150118_01
Cutaneous tuberculosis: fagedenic perianal ulcer.
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F1
On physical examination, a clean 10-cm diameter phagedenic perianal ulcer (Figure 1) and two longitudinal suppurative ulcers on the inguino-crural region were observed.
Lepromatous leprosy: erythematous papules and nodules on the upper limbs.
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F2
During investigation, and soon after reducing the corticosteroid dose, disseminated erythematous papules and nodules were observed in the upper limbs (Figure 2).Histopathology of the perianal ulcer revealed a dense histiocytic dermal infiltrate and a granulomatous inflammatory response with central caseous necrosis (Figure 3).
Histopathological exam of the perianal ulcer showing a dense histiocytic infiltrate and central caseous necrosis.
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F3
During investigation, and soon after reducing the corticosteroid dose, disseminated erythematous papules and nodules were observed in the upper limbs (Figure 2).Histopathology of the perianal ulcer revealed a dense histiocytic dermal infiltrate and a granulomatous inflammatory response with central caseous necrosis (Figure 3).
Skin nodule consisting of foamy macrophages with globi of bacilli. Fite-Faraco staining revealed the presence of lepromatous leprosy acid-fast bacilli.
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F4
The histopathology of upper limbs papular and nodular lesions showed foamy macrophages with globi of bacilli, suggesting lepromatous leprosy (Figure 4).
Cutaneous tuberculosis: phagedenic perianal ulcer showing worsening of the perianal ulcer after treatment for leprosy lesion, for two months.
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F5
Four weeks later, the patient had fever, weight loss, asthenia and worsening of the perianal ulcer (Figure 5), but without erythema nodosum leprosum.
M. tuberculosis, 
positive culture on Lowenstein-Jensen medium at 37 C.
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F6
The tuberculin skin test was positive (20 x 20 mm) and culture of M. tuberculosis - using a biopsy sample from the perianal ulcer - on Lowenstein-Jensen medium was positive (Figure 6).
M. leprae
, positive polymerase chain reaction DNA analysis.
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F7
Polymerase chain reaction (PCR) and DNA analysis from upper limb skin samples were positive for M. leprae (Figure 7).
Perianal ulcer completely healed with antituberculous treatment for two months.
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F8
HIV, HBV or HCV infection as well as lung, renal or colon compromising were negative. Hence, the patient was treated with isoniazid, ethambutol and rifampin for nine months with complete healing of the perianal and inguinal lesions after two months (Figure 8).