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CASE REPORT
Year : 2007  |  Volume : 28  |  Issue : 2  |  Page : 100-102
 

Leprosy in an HIV-infected person


Department of STD, Rangaraya Medical College, Government General Hospital, Kakinada, Andhra Pradesh, India

Correspondence Address:
T S Chandra Gupta
Department of STD, Government General Hospital, Kakinada - 533 001, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7184.39015

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   Abstract 

As per literature, very few case reports of leprosy ( M. leprae infection) in association with HIV are available till date. The cause for this rare coexistence when compared to Mycobacterium tuberculosis may be due to the fact that (a) M. leprae infection occurs due to affection of specific cell mediated immunity, (b) missing of signs and/or symptoms of leprosy both by physicians and patients as they are masked by overwhelming opportunistic infections and (c) long-time taken by M. leprae to manifest the disease. A case of lepromatous leprosy in an HIV-infected person is herewith reported for its rarity, wherein leprosy was nearly missed. Hence it is suggested to look for any evidence of leprosy in all HIV-positive cases. Then only the real incidence of leprosy in HIV-positive patients will come in the light.


Keywords: Cell-mediated immunity, HIV, lepromatous leprosy


How to cite this article:
Chandra Gupta T S, Sinha PK, Murthy V S, Swarna Kumari G. Leprosy in an HIV-infected person. Indian J Sex Transm Dis 2007;28:100-2

How to cite this URL:
Chandra Gupta T S, Sinha PK, Murthy V S, Swarna Kumari G. Leprosy in an HIV-infected person. Indian J Sex Transm Dis [serial online] 2007 [cited 2019 Sep 15];28:100-2. Available from: http://www.ijstd.org/text.asp?2007/28/2/100/39015



   Introduction Top


There are very few case reports of leprosy in association with HIV [1],[2] available in the literature. Out of five such studies, three are from India. This case report is first of its kind from Andhra Pradesh, India. Leprosy is a chronic disease caused by M. leprae . HIV also has a protracted course with complications. Many diseases are known to be either related or associated with HIV. Patients with HIV are more susceptible to infection with mycobacteriae such as Mycobacterium tuberculosis . But the same is not true with other mycobacteria, i.e., M. leprae . [3] A few studies have tried to evaluate the reasons for this rare co-existence. Tissue cell-mediated immune response against Mycobacterium leprae is known to be preserved even through the peripheral blood lymphocyte count (CD4) was reduced in concurrent leprosy and HIV-infected patients irrespective of the stage of HIV infection. [4] The deficiency in cell-mediated immunity (CMI) is specific to the M. leprae antigens [5] and has nothing to do with the decreased peripheral CD4 count of HIV. Thus probably, there are less reports of leprosy in association with HIV. [1],[2] The present case of lepromatous leprosy (LL) in an HIV-infected person is herewith reported for its rarity.


   Case Report Top


A 32-year-old married, male labourer from a nearby village of Kakinada (AP), presented to the STD Department with complaints of multiple, burning, erythmatous patches and plaques of various sizes distributed on the trunk and bleeding per rectum for 4 months. He gave history of multiple unprotected sexual exposures in the last 10 years.

On examination, papules and plaques of varying sizes 0.5-8 cm were present, distributed asymmetrically over the trunk [Figure - 1]. There was neither oral candidiasis nor generalised lymphedenopathy. The vitals signs were normal. The genital and systemic examination was normal except for piles at the anus. A differential diagnosis of polymorphic light eruption and secondary syphilis, with least probable chances of leprosy was considered. Routine blood examination was normal except for mild anaemia. VDRL and TPHA tests were non-reactive and test for HIV I antibodies were positive. To our surprise slit skin smear showed acid-fast bacilli (AFB). Bacteriological index was 4+. This made us to review the case, when the patient came for follow-up 6 weeks later [Figure - 2]. On detailed review, the patient revealed history of tingling and numbness of all four limbs and having had treatment for leprosy for four months about 1.5 years back.

On review examination, the sensations were found unequivocal with bilateral thickening of both ulnar and lateral popliteal nerves. Histopathology of skin biopsy showed flattened epidermis with loss of rete ridges and a subepidermal grenz zone. The dermis showed dense collection of foamy histiocytes with ill-defined granulomas. Fite-faraco stain showed plenty of bacilli both intracellularly and extracellularly [Figure - 3]. The features were consistent with LL. Hence a final diagnosis of HIV positive with LL and haemorrhoids was made.


   Discussion Top


This case report is presented because of its rarity where in leprosy was nearly missed. The clinical course of leprosy in HIV patients has long been an issue of debate. [3] As per the literature though there are only a few case reports of leprosy in HIV, the present case is proven to be a case of LL which is consistent with Tanzanian study by Burgdorff et al. , [6] who concluded that HIV-1 infection is significantly associated with multibacillary type of leprosy. There was no alteration in the histopathology of leprosy in this case. This is consistent with a study by Bhargava et al. at Jaipur [3] which showed that there was no alteration in the histopathology of leprosy in HIV. Though a study by Jacob et al. [7] reported that HIV does not influence the course of M. leprae infection, the same could not be examined in the present case as the patients were lost to follow-up. The possible reasons for less number of leprosy cases in HIV-positive individuals could be due to the fact that leprosy infection is due to affection of specific cell mediated immunity. The second reason may be due to missing of signs and symptoms of leprosy by both the physicians and the patients as the relevant symptoms are least troublesome when compared to the overwhelming symptoms and signs of opportunistic infections in HIV. Physicians are likely to miss peripheral neuritis due to 'leprosy without skin lesions', in HIV-positive patients. The common cause of peripheral neuropathy in HIV-positive patients may be due to acute mononeuritis multiplex, [8] ATT drugs, e.g., INH (isoniazid), ART drugs, e.g., d4T (stavudine), ddl (Didanosine), HIV itself [9] and syphilis. The other reason could be slow multiplication of M. leprae taking longer time to manifest the disease [10] with loss of sensations. Mean while the physicians may miss to identify or patient may die of HIV complications/AIDS, even before leprosy is manifested. Hence a routine history and examination to rule out leprosy in all HIV-positive patients is suggested.


   Conclusion Top


This case report is presented because of its rarity. Since patients are less likely to project symptoms of peripheral neuritis when compared to more distressing symptoms of opportunistic infections, physicians are likely to miss cases of peripheral neuritis in HIV, one of the causes of which could be leprosy. Hence it is suggested that all physicians managing HIV-positive patients, should look for any evidence of peripheral neuropathy, one of the causes being leprosy, irrespective of patients complaints. Then only exact incidence of leprosy in HIV can be assessed.

 
   References Top

1.Goodle DR, Viciana AL, Pardo RJ, Ruiz P. Borderline tubercuoid Hansen's disease in AIDS. J Am Acad Dermatol 1994;30:866-9.  Back to cited text no. 1    
2.Schettine AP, Ribas J, Rebello PF, Ribas CB, Schettini MC. Leprosy and AIDS in Amazon basin. Int J Lepr Other Mycobact Dis 1991;64:171-2.  Back to cited text no. 2    
3.Bhargava, Agrawal US, Kanodia et al . HIV and leprosy - A case report. Indian J Sex Transm Dis 2005;26:89-90.  Back to cited text no. 3    
4.Nabakumar Singh TH, Nandakishore TH, Lokendro Singh. Leprosy with HIV infection in Manipur. Indian J Dermatol Venereol Leprol 2000;66:40.  Back to cited text no. 4    
5.Anantnarayana R, Jayaram CK. Text book of micro biology. 5 th ed. Orient Longman: Arumbakkam, Chennai; 1996. p. 347.  Back to cited text no. 5    
6.Borgdorff MW, van den Broek J, Chum HJ, Klokke AH, Graf P, Barongo LR, et al . HIV infection as a risk factor for leprosy: A case control study in Tanzania. Int J Lepr Other Mycobact Dis 1993;61:556-62.  Back to cited text no. 6    
7.Jacob M, George S, Pulimood S, Nathan N. Short-term follow up of patients with multibacillary leprosy and HIV infection. Int J Lepr Other Mycobact Dis 1996;64:392-5.  Back to cited text no. 7    
8.Dan L, Anthony S, Fauci, et al . Harrisons principal of medicine. 16 th ed. McGraw Hill: New York; 2005. p. 1115.  Back to cited text no. 8    
9.Christina M. Management of neurologic disease in HIV-1 infection. In : Holmes KK, Frederick P, Per-Anders Mardh, editors. Sexually Transmitted Diseases. 3 rd ed. McGraw Hill: New York; 1999. p. 1053-9.  Back to cited text no. 9    
10.Jopling WH, MC Dougall AC. Hand book of leprosy. 5 th ed. CBS Publishers: Dariyaganj, New Delhi; 1996. p. 145.  Back to cited text no. 10    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    References
    Article Figures

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