A 46-year-old man, a resident of Punjab (low endemic state of India for leprosy), presented to us with tender nodules in the skin of forearms and legs for the preceding month. He also had a history of intermittent fever and joint pains of 1-year duration. Examination revealed multiple tender erythematous nodular skin lesions over arms (Fig. A) and legs (not shown). He had been diagnosed with systemic lupus erythematosus based on the presence of the skin manifestations, arthritis, fever, antinuclear antibody, and anti–double-stranded DNA positivity. Blood tests revealed a low-titer antinuclear antibody on indirect immunofluorescence (1+ speckled) and raised acute phase reactants (erythrocyte sedimentation rate, 45 mm/h; C-reactive protein, 26 mg/L). Fine-needle aspiration from nodular lesions showed sheets of polymorphs with few histiocytes and numerous acid-fast lepra bacilli (Fig. C and D). A diagnosis of leprosy was made and multidrug therapy for lepromatous leprosy was initiated. On follow up at 6 weeks, his symptoms had improved, and skin lesions had improved (Fig. B).