A 47-year-old man from a region endemic for leprosy presented with a 1-month history of high grade fever and red, raised skin lesions on the upper limbs. He had multiple tender papules and nodules on his forearm and thigh along with sensory loss and thickening of nerves. The complete blood count revealed normocytic normochromic red blood cells, a leukocyte count of 15.6×10⁹/L with 81% neutrophils, and a platelet count of 361×10⁹/L. A bone marrow aspiration was performed to investigate the fever. The myeloid to erythroid ratio was 1.5:1. Erythroid and myeloid series were within normal limits. No granuloma or abnormal cells were found in any of the examined smears. Modified Ziehl-Neelsen staining showed numerous acid fast bacilli in the macrophages as well as outside the cells, mainly in the cell fragments (A). Additionally, small clusters of foamy histiocytes in the paratrabecular region with Wade-Fite stain positive lepra bacilli were observed (B). An acid fast bacilli culture using Lowenstein-Jensen medium was negative. A skin biopsy showed numerous foamy histiocytic granulomas admixed with lymphocytes and focally infiltrated by neutrophils in the dermis and subcutis. Therefore, a diagnosis of lepromatous leprosy with a type 2 reaction was made.