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Histoid leprosy in an HIV positive patient taking cART.

It is well known that HIV infected patients are more susceptible to infection with M. tuberculosis, but this is not clear for M. leprae. Only a few studies have reported this coexistence. Co-infected cases have been reported in the past in the whole spectrum of leprosy i.e. tuberculoid, borderline, and lepromatous. The deficiency of cell mediated immunity in leprosy is specific toM. leprae antigen and probably, the reason why the clinical course of leprosy is not influenced by HIV infection. When HIV positive patients are treated with highly active anti-retroviral treatment (cART) there is treatment-induced recovery of the immune system of the host which may lead to immune reconstitution inflammatory syndrome (IRIS). Various authors have reported tuberculoid leprosy and Type I lepra reaction as a manifestation of IRIS in HIV positive patients. We are reporting an HIV positive patient who developed histoid leprosy in spite of taking cART for 9 months, without any signs and symptoms of IRIS. Case report: A 42 year old married, male truck driver, presented with genital ulcers to the Department of Dermatology, SP Medical College, Bikaner. He gave a history of multiple unprotected acts of sexual intercourse with many roadside prostitutes in different parts of the country for many years. On examination, there were superficial serpigenous painless ulcers over the glans and prepuce. Clinically he was diagnosed as a case of herpes genitalis and treated with oral and topical acyclovir. A history of high-risk behaviour prompted an HIV test, which was performed after pre-test counselling, and found to be reactive by Tridot as well as ELISA test. The VDRL test was non-reactive. IgG and IgM antibodies against HSV-2 were raised. He refused tests for CD4 þ cell count, viral load and cART due to financial constrains. Post test counselling was then done. After 2 months the patient returned with herpes genitalis along with oral candidiasis. He was treated with oral acyclovir and fluconazole. Routine haematological investigations were within normal limits except raised ESR. CD4 þ cell count was 150/mm and viral load of HIV was 1, 55 000 copies/mL. He was counselled and cART was started with a combination of zidovudine, lamivudine and nevirapine, which was well tolerated. After 9 months of cART therapy he returned with generalised skin coloration, shiny, non-itchy, painless and non-tender, discrete,