Indian J Sex Transm Dis Indian J Sex Transm Dis
Official Publication of the Indian Association for the Study of Sexually Transmitted Diseases
Indian J Sex Transm Dis
The Journal | Search | Ahead Of Print | Current Issue | Archives | Instructions | Subscribe | Login    Users online: 1028   Home Email this page Print this page Bookmark this page Decrease font size Default font size Increase font size


 
CASE REPORT
Year : 2008  |  Volume : 29  |  Issue : 2  |  Page : 96-97
 

Leprosy presenting as immune reconstitution Inflammatory Syndrome


Dept of Dermatology, Civil Hospital and BJ Medical College, Asarwa, Ahmedabad, India

Correspondence Address:
Sujata Mehta
'Sumeru', St. Xavier's College Corner, Navrangpura, Ahmedabad
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7184.48734

Rights and Permissions

 

   Abstract 

A 35-year-old HIV-reactive female presented to us with multiple erythematous plaques on her face, trunk, and limbs, since five days. Bilateral ulnar and lateral popliteal nerves were thickened and tender. ­Antiretroviral drugs (d4T, 3TC, NVP) had been started one month prior. Slit skin smear was negative. Skin biopsy from infiltrated lesions showed ill-defined, noncaseating epitheloid granulomas, confirming the diagnosis of ­borderline tuberculoid leprosy, with reversal reaction. In the setting of the recent Antiretroviral Therapy (ART) this is considered clinically as Immune Reconstitution Inflammatory Syndrome (IRIS).


Keywords: Leprosy, antiretroviral therapy, immune reconstitution inflammatory syndrome


How to cite this article:
Mehta S, Padhiar B, Shah B. Leprosy presenting as immune reconstitution Inflammatory Syndrome. Indian J Sex Transm Dis 2008;29:96-7

How to cite this URL:
Mehta S, Padhiar B, Shah B. Leprosy presenting as immune reconstitution Inflammatory Syndrome. Indian J Sex Transm Dis [serial online] 2008 [cited 2019 Nov 11];29:96-7. Available from: http://www.ijstd.org/text.asp?2008/29/2/96/48734



   Introduction Top


Immune Reconstitution Inflammatory Syndrome (IRIS) is defined as the occurrence or worsening of clinical and/or laboratory parameters despite a favorable outcome in HIV surrogate markers (CD4 counts and viral load). [1] Earlier it was believed that, unlike tuberculosis, the course of leprosy was not significantly affected by HIV. However, we now know that immune suppression caused by HIV can suppress the clinical manifestations of leprosy, which can then be unmasked with ART, often as a reversal reaction.


   Case report Top


A-35-year old HIV-positive female presented with multiple, erythematous plaques on her face, trunk, and limbs since five days [Figure 1]. She had tingling and numbness in her extremities associated with fever, malaise, joint pain, and edema of feet. Her CD4 count was 114/uL and viral load was not performed because of cost constraints. She was started on antiretroviral therapy (d4T, 3TC, NVP) one month back. At that time her CD4 count was not done. Nine months back her CD4 count was 67/uL. On examination there were multiple erythematous, infiltrated plaques on her nose, chin, ear, forearm, trunk, and legs with loss of hair. Bilateral ulnar and lateral popliteal nerves were thickened and tender. Touch and temperature sensations were impaired over plaques and in the distal aspects of limbs. She had edema of feet and ichthyosis on the lower limb. Eyebrow hair was lost. There was no lymphadenopathy or other significant systemic findings. Slit skin smear was negative. Skin biopsy showed ill-defined, noncaseating epitheloid granulomas in the dermis without demonstration of bacilli, suggestive of borderline tuberculoid (BT) leprosy. She was diagnosed as a case of BT leprosy, with reversal reaction. In the setting of the recent ART, it was clinically considered a case of IRIS.

She also had a past history of few hypopigmented lesions on her face, trunk, and limbs before two years, which had subsided spontaneously within a few weeks without any therapy. No biopsy of these lesions was carried out.

The patient had completed six months of antituberculosis therapy for pulmonary Koch's three months prior.

The patient was given anti-leprosy drugs Tab. Rifampicin (450 mg.) and Tab. Clofazimine (300 mg.) monthly, with oral clofazimine (50 mg.) and oral Ofloxacin (400 mg.) daily, along with continuation of ART (d4T, 3TC, NVP).

Non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids (prednisolone 40 mg daily) were given to tide over the inflammatory phase.


   Discussion Top


IRIS is a new and unexpected clinical interaction between HIV and leprosy in a patient who has started Highly Active Anti-Retroviral Therapy (HAART). In most cases, IRIS is the first manifestation of leprosy symptoms. [2]

The first published case of leprosy associated immune reconstitution disease occurred in 2003 in a Ugandan living in London. [3]

The unmasking of the leprosy by HAART and the severity of the reversal reaction suggest that immune reconstitution played an important role in the patient's clinical presentation.

IRIS most commonly presents with BT leprosy in patients who have HIV. [4]

At least in a proportion of patients, the clinical presentation of leprosy is suppressed by HIV-associated immunodeficiency. Borderline form of leprosy requires M. leprae specific cellular response, for the lesions to manifest. Antiretroviral Therapy may provide the immunological trigger leading to presentation of the disease, similar to the reversal reaction. [5]

In any HIV-infected patient on HAART, who develops tender erythematous plaques or sudden paralysis, leprosy should be ruled out on a priority basis, especially in endemic areas. [5] Many more reports are now trickling in from different parts of India. [6],[7]

Treatment of IRIS includes the use of anti-inflammatory drugs, steroids, and specific antimicrobial agents, with the continuation of HAART.[8]

The prevalence of leprosy is falling in our country and many states have reached elimination levels. We should not miss out on these patients as their prompt recognition and treatment is important, for the community in general and the patient in particular.

 
   References Top

1.French UA, Price P, Stone SF. Immune restoration disease after antiretroviral therapy. ADS 2004;18:1615-27.   Back to cited text no. 1    
2.Larson SD, Lockwood DN. Leprosy after starting antiretroviral treatment: An increasingly reported clinical problem but not a serious public health risk. BMJ 2007;334:217-8.   Back to cited text no. 2    
3.Lawn SD, Wood C, Lockwood DN. Borderline tuberculoid leprosy: An immune reconstitution phenomenon in a human immunodeficiency virus-infected person. Clin Infect Dis 2003;36:e5-6.   Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Bwire R, Kawuma HJ, Type 1 reaction leprosy, neuritis and steroid therapy: The impact at the immunodeficiency virus. Trans RSOC Trop Med Hyg 1994;88:315-6.   Back to cited text no. 4    
5.Ustianowsky AP, Lawn SD, Lockwood DN. Interactions between HIV infection and leprosy. Lancet Infect Dis 2006;6:350-60.   Back to cited text no. 5    
6.Kharkar V, Bhor UH, Mahajan S, Khopkar U. Type I lepra reaction presenting as immune reconstitution inflammatory syndrome. Indian J Dermatol Venereol Leprol 2007;73:253-6.  Back to cited text no. 6  [PUBMED]  Medknow Journal
7.Mukhopadhyay P, Pal S, Mallik S, Biswas S, Saha B. Borderline tuberculoid leprosy: A manifestation of immune reconstitution inflammatory syndrome in a human immunodeficiency virus infected person. Indian J Dermatol 2006;51:278-80.  Back to cited text no. 7    Medknow Journal
8.Stoll M, Schmidt RE. Adverse events of desirable gain in immunocompetence: The Immune Restoration Inflammatory Syndromes. Autoimmun Rev 2004;3:243-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]


    Figures

  [Figure 1]



 

Top
Print this article  Email this article
Previous article Next article

    

 
  Search
 
   Next article
   Previous article 
   Table of Contents
  
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (49 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1928    
    Printed183    
    Emailed0    
    PDF Downloaded174    
    Comments [Add]    

Recommend this journal