Lepromatous leprosy with erythema nodosum leprosum as immune reconstitution inflammatory syndrome in an HIV-1 infected patient after initiation of antiretroviral therapy

Abstract

We present the case of an HIV infected male patient with erythema nodosum leprosum and function loss of the peroneus nerve as manifestations of lepromatous leprosy. Since symptoms occurred after initiation of antiretroviral therapy and recovery of the immune system, the clinical picture is suggestive of a rare form of an immune reconstitution inflammatory syndrome.

Figure 1

First clinical manifestation of erythema nodosum leprosum on the arm of the patient with multiple painful skin nodules in August 2006.

Figure 2

First clinical manifestation of erythema nodosum leprosum on the chest of the patient with multiple skin nodules in August 2006.

Figure 3

Histology of one nodule from the left leg in August 2006 revealed infiltrations with histiocytes in the nerve sheath without granulomatous reaction.

Figure 4

Histology of an erythema nodosum leprosum nodule on the left hand of the patient in February 2009. A polymorphonuclear leukocyte inflammatory infiltrate in the deeper layer of the dermis and subcutis could be demonstrated.

Figure 5

Time course of the HIV viral load (VL), CD4 cell count, manifestation of leprosy symptoms and treatment for both diseases. Leprosy symptoms occurred only after recovery of the CD4 cells.