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.

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 patient’s 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.