ASSOCIATION OF HIV LEPROSY AND ACDR TO DAPSONE WITH IRIS

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.