|Ahead of print publication
Leprosy presenting with papulosquamous skin lesions in a case of human immunodeficiency virus infection
Preema Sinha, Anwita Sinha, Prateek Kinra, Ruby Venugopal
Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Submission||22-Nov-2019|
|Date of Decision||04-Dec-2019|
|Date of Acceptance||14-Apr-2020|
|Date of Web Publication||12-Sep-2020|
Department of Dermatology, Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Leprosy has a wide range of clinical manifestations, which sometimes imposes a clinical challenge and may lead to misdiagnosis. Interactions between leprosy and human immunodeficiency virus (HIV) have been little studied and poorly understood to date. However, coinfection still poses dilemmas in leprosy as to the occurrence of the immune reconstitution inflammatory syndrome manifesting as clinical leprosy and reversal reactions, higher chances of relapse after the successful completion of the multidrug therapy (MDT) and drug interactions between MDT and antiretroviral therapy. Furthermore, coinfection can lead to atypical clinical manifestations of leprosy. Herein, we describe a rare presentation of leprosy in a patient of HIV infection who reported with papulosquamous lesions over both upper and lower limbs histopathologically consistent with Hansen's disease.
Keywords: Atypical presentation, human immunodeficiency virus and leprosy co-infection, papulosquamous skin lesions
| Introduction|| |
Interactions between leprosy and human immunodeficiency virus (HIV) have been little studied and poorly understood to date. However, coinfection still poses dilemmas in leprosy as to the occurrence of the immune reconstitution inflammatory syndrome manifesting as clinical leprosy and reversal reactions, higher chances of relapse after the successful completion of the multidrug therapy (MDT) and drug interactions between MDT and antiretroviral therapy (ART).,,
In the era of the HIV pandemic, it was expected that the co-infection of leprosy and HIV would increase the risk of multibacillary disease, with a faster clinical evolution, and that leprosy would be more difficult to treat. However, the literature review indicates that coinfection with HIV neither altered the incidence or the clinical spectrum of leprosy and that disease progression was comparable with a single infection.
Besides typical cutaneous and neurological manifestations of leprosy, few HIV patients may present with atypical hyperkeratotic eczematous and ulcerated lesions. Furthermore, the introduction of highly active ART can lead to increased Type 1 reactions, which can present as ulcerated lesions., Herein, we report a case of HIV infection manifesting with papulosquamous skin lesions of leprosy, which is a rare presentation.
| Case Report|| |
A 25-year-old male, a freshly diagnosed case of HIV infection presented with complaints of multiple light-colored numb patches over the body of 10 months duration and multiple red raised scaly lesions over the forearms, arms, and legs of 1-month duration not associated with itching or oozing. General and systemic examination was essentially normal.
Dermatological examination revealed the involvement of the chest, abdomen, back, and gluteal region in the form of multiple discrete to confluent hypopigmented, normal aesthetic patches tending to symmetry [Figure 1]a. Furthermore, there was the involvement of both arms and forearms, both thighs and legs in the form of multiple erythematous papules, and confluent erythematous scaly plaques [Figure 1]b. Grattage and auspitz sign were negative. There was no deep dermal tenderness. Bilateral ulnar and right common peroneal nerves were Grade 1 thickened and nontender.
|Figure 1: (a) Polysized discrete to confluent hypopigmented, normal aesthetic patches tending to symmetry over the arms and back. (b) The presence of multiple erythematous papules and confluent erythematous scaly plaques over both forearms|
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The bacillary index on slit skin smear from the ear lobule was 2+. Scrapings from the scaly plaques were negative for fungus. The Venereal Disease Research Laboratory test was nonreactor. Two skin biopsies were done; one from the hypopigmented patch on the back with the clinical suspicion of Hansen's disease and another biopsy was taken from the erythematous scaly plaque over the right forearm with the differential of psoriasis, eczema, and secondary syphilis. Skin biopsy from the back showed atrophic epidermis with superficial dermis showing a grenz zone. A collection of foamy histiocytes and lymphocytes was present both in the superficial and deep dermis around neurovascular bundles and adnexal structures [Figure 2]. Ziehl-Neelsen (ZN) stain showed numerous lepra bacilli. Skin biopsy from the papulosquamous lesion showed normal epidermis with no grenz zone. Numerous discrete epithelioid cell granulomas and Langhans giant cells were seen in the superficial and deep dermis [Figure 3]. ZN stain was negative for lepra bacilli; however, histopathology was consistent with borderline tuberculoid leprosy.
|Figure 2: Biopsy from back showed atrophic epidermis with superficial dermis showing a grenz zone. The collection of foamy histiocytes and lymphocytes was present both in the superficial and deep dermis around neurovascular bundles and adnexal structures. (H and E, ×100)|
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|Figure 3: Biopsy from papulosquamous lesions showed numerous discrete epithelioid cell granulomas and langhans giant cells in the superficial and deep dermis. (H and E, ×100)|
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Based on the above features, the patient was diagnosed as a case of leprosy HIV coinfection and was started on three drug MDT in the form of rifampicin, clofazimine, and dapsone. The CD4 count was 190 cells/mm3, and the viral load was 69 HIV RNA copies per ml of blood. The patient was started on ART in the form of tenofovir, lamivudine, and efavirenz 1 month after starting MDT. No drugs for opportunistic infections were started at this time, as complete workup did not reveal any abnormalities. The patient is presently tolerating MDT and ART well with no reactional episodes with complete regression of papulosquamous lesions and is under regular follow-up [Figure 4]. He has completed 12 months of MDT to date without developing any new reactional episodes or side effects of drugs.
|Figure 4: Complete regression of skin lesions over forearms after 6 months of the multidrug therapy|
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| Discussion|| |
More than three decades after the onset of HIV/AIDS pandemic, the questions on its impact on the epidemiology, clinical presentation, pathogenesis, and treatment of leprosy remains still unanswered. However, the data so far have shown that unlike for tuberculosis (TB) and other mycobacterial infections, HIV has not contributed to the persisting burden of leprosy or delay in its elimination strategies. Furthermore, data indicating that the skin lesions or nerve involvement are substantially worse in HIV-infected leprosy patients are lacking., However, atypical skin lesions have been described in the case of leprosy patients in the form of scaly erythematous plaques, verrucous, ulcerated, and necrotic lesions predominantly in the setting of low CD4 count or consequent to starting ART as a manifestation of immune reconstitution syndrome. The exact cause of atypical lesions is unknown. The consequences of leprosy-HIV coinfection over specific immune mechanisms operating in leprosy can explain this atypical presentation.,,
Our patient had a CD4 of 190 cells/mm3 at presentation with a bacillary index of 2+ and the therapeutic dilemma faced was what to initiate first; MDT or ART. Simultaneous introduction of MDT and ART would lead to increased production of CD4 T cells with rapid restoration of the pathogen-specific immune response to the dying leprosy antigen leading to increased chances of reactions. Hence, in analogy with TB where antitubercular therapy is started 2–4 weeks before ART to prevent or subdue the manifestations of immune reconstitution syndrome, MDT was initiated first to lower the antigen load. The patient tolerated MDT well, and ART was administered 4 weeks later. The patient is responding well to ART and MDT with an increase in CD4 count to 450 cells/mm3 and not in reaction presently.
Psoriasiform skin lesions as a presentation of leprosy also find a mention in the case reports by Vora et al. and Rabinowitz et al., Other atypical morphological presentations in non-HIV patients mentioned in the literature include leprosy presenting as lichenoid skin lesions, palmoplantar keratoderma, and hyperpigmented macules.,,
Our case highlights the atypical manifestation which can be encountered in leprosy-HIV co-infection and sequential introduction of MDT and ART to avoid potential Type 1 reaction with devastating sequelae in the form of nerve damage which are more severe in HIV-infected patients. Further studies are needed to elucidate the exact mechanisms of the complex interactions of these two immunologically-mediated diseases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]