A 52-year-old male abattoir worker originally from India presented with a 9-month history of a tender, paresthetic, cord-like, left-side neck lump diagnosed elsewhere as thrombophlebitis but had failed to improve after several months of conservative treatment (Figure 1). The patient was otherwise asymptomatic, but physical examination revealed six scaly, hypopigmented non-pruritic and non-hypoesthetic plaques on the forehead, left pinna, left upper arm, and right thigh in an asymmetrical distribution. Two months later, these lesions became spontaneously painful, erythematous, and edematous (Figure 2). Computed tomography of the neck to pelvis showed only mild lymphadenopathy in the right supraclavicular and deep cervical chains. The neck lump was identified as an inflamed left greater auricular nerve. Interferon-g release assay for tuberculosis was positive, but active tuberculosis was excluded by clinical and radiological assessment. Histopathological examination of lesion punch biopsies showed granulomatous dermatitis, with perivascular and peri-adnexal granulomas around nerve fibers (Figure 3). Wade-Fite stain for acid-fast bacilli was negative, but polymerase chain reaction for Mycobacterium leprae was positive, confirming the diagnosis of leprosy. The diagnosis was further defined as multibacillary midborderline leprosy based on clinical appearance, number and distribution of skin lesions, and histopathological findings, 1, 2 with concurrent latent tuberculosis. The acute inflammatory skin lesion changes were classic for type 1 lepra reaction (Table 1). Clofazimine, 50 mg/d and 300 mg/month; rifampicin, 600 mg/month; and dapsone 100 mg/d for 12