Hiv & leprosy FRIEND OR FOE
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This case report describes a 52-year-old male patient with both HIV and leprosy. After starting antiretroviral therapy (ART), the patient developed immune reconstitution inflammatory syndrome (IRIS), with worsening of leprosy symptoms. He was later diagnosed with Dapsone hypersensitivity syndrome after developing a rash and other symptoms while taking Dapsone to treat his leprosy. The report concludes that while HIV and leprosy co-infection can allow immune recovery through IRIS, the patient was at higher risk for adverse cutaneous drug reactions due to HIV, as seen with his reaction to Dapsone.
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Hiv & leprosy FRIEND OR FOE
- 1. Dr. R.V.RANADE M.D.-DERMATOLOGY(Bom), D.D.V(BOM-CPS) Prof. & H.O.D. Dept. of DERMATOLOGY, Dr. D.Y.Patil Medical College. Kolhapur
- 2. HIV & Leprosy Friend or Foe
- 3. Case Report VM a 52 years old male admitted in our hospital in first week of July 2015. C/O Fever with chills , high coloured urine- 2 months Swelling around eyes and face-8 days Itching and swelling of face, trunk and extremities-5 days
- 4. Late October2014,patient had fever with chills ,anorexia-18 days At District hospital found to have urinary tract infection H/O Exposure He was HIV +ve and VDRL 1:8 TPHA negative HBs Ag negative CD4 count 297 cells/mm3 Started ART and Co-trimoxazole
- 5. Early March 2015 developed oedematous hypaesthetic plaques on extensor surface of both arms just above elbows. Lt. Ulnar Nerve uniformally thickened, slightly tender Started on MB-MDT and Prednisolone-30 mg tapered to 5 mg OD and then stopped
- 6. End April 2015 he developed fever, icterus and scaling all over body Urine BS, BP PRESENT Total serum Bilirubin-1.31mgs/dl SGPT -119.2 IU/L S. ALKALINE PHOSPATASE- 186 IU/L
- 7. On admission in our hospital in July 2015 patient had pallor and mild Icterus Oedema of periorbital region ,face and lower limbs Left foot-eczematous crusted plaque Multiple scaly papules and plaques on face trunk and extremities
- 12. Investigations Hb- 13.5 gms/dl WBC -10,800 cells/mm3 Urine dark yellow, BS,BP present Total Bilirubin-1.5 mgs/dl SGPT -28.9 IU/L S.ALK.PHOSPHATASE-298.9 U/L
- 13. CD4- 1050 cells/mm3 CD8 -1028 cells/mm3 CD4/CD8 ratio -1.02 WESTERN BLOT ASSAY- HIV 1 POSITIVE HIV viral load<50 RNA copies/ml(undetectable)
- 16. Biopsy of plaque from left arm Nodular granulomatous inflammation centered around neurovascular bundles Granuloma- lymphocytes epitheloid cells Occasional plasma cells, foreign body and Langhans giant cells Infiltration of dermo-epidermal junction Small amount of lymphocytic nuclear dust suggests Type I reaction. IMPRESSION: BT Hansens with mild type I reaction
- 17. Rx Dapsone and Rifampicin stopped Continued ART Clofazamine, Ofloxacin Methyl prednisolone 16 mg OD tapered to 4 mg OD then stopped
- 18. Present Status During the patients hospital stay, he had an episode of Herpes progenitalis Treated with Acylovir for 5 days At present the patient has Anorexia,Asthenia and Diarrhoea treated with Cipro + Tinidazole , No fever,itching,oedema Scaling reduced,no icterus Rifampicin has been reinstituted in monthly pulse dosages with Clofazimine and daily Clofazimine and Ofloxacin
- 21. Immune Reconstitution Inflammatory Syndrome (IRIS) Increase in patients lost immune status within 2-4 months of commencing ART (most rapid phase of increased recovery) Incidence 10-20% Sharp increase in CD4 cell count Rx symptomatic- steroids,Thalidomide, Ct ART IRIS unmasks sub clinical infection
- 22. Criteria for diagnosis of IRIS HIV Positive Receiving ART Decrease in HIV-1 RNA level and increase in CD4 + memory cells Clinically inflammatory process Clinical course not consistent with expected results
- 23. IRIS (ctd) IRIS associated with leprosy first described by Lawn et al in 2003 Disease suseptibility gene TNFA- 302*2 for mycobactereal diseases Characterised by development of type I reaction (reversal) in unstable borderline leprosy Low baseline CD4 count -higher risk of IRIS Minimal decrease in viral load in absence of significant increase in CD4 cell count can precipitate IRIS Recognition of Leprosy as an IRIS associate important for timely intervention
- 24. Adverse Cutaneous Drug Reactions (ACDR) Incidence of ACDR high in HIV disease Eruptions more severe than in non-HIV infected Pathogenic mechanisms responsible not known Defects of both T and B cells may be operative in hypersensitivity reactions The patterns of cutaneous reactions may be morbilliform eruptions, FDE,SJS and TEN commonest drugs causing reactions are sulphonamides and penicillins
- 25. Dapsone syndrome Dapsone is a non-antibiotic Sulphonamide(Sulfone) This hypersensitivity is sometimes seen in patients under Rx for some months. Complete form fever, skin rashes- maculopapular type or exfoliative dermatitis with lymphadenopathy and hepatitis usually 4-6 weeks after starting Dapsone In 50% patients one or more manifestations may be missing Dapsone discontinued Short course of steroids and supportive therapy required
- 26. Conclusion Coinfection of HIV with Leprosy is a boon(friend) Patient upgrades immune status(IRIS) In HIV patients, incidence of ACDR high Thus our patient developed Dapsone hypersensitivity syndrome (foe) although prognosis after stopping Dapsone is good. An unusual case of co-existent HIV disease and Leprosy developing first IRIS and then ACDR to Dapsone.