A 45-year-old Bangladeshi woman was complaining (May 2020) of severe generalized itching and skin lesions over different parts of the body (extremities, neck, upper back, chest, oral cavity, and genitalia) for the last four years (Figure 1(a)). During the course of illness, she has taken multiple consultations and was prescribed different topical and systemic antifungals along with steroids. She also received a course of dapsone as a suspected case of dermatitis herpetiform, but showed no significant improvement of the condition. Her baseline investigations were inconclusive. She came to us while experiencing a gradual loss of vision of her both eyes for one month. She also had a history of recurrent fever and weight loss for the same duration. On query, she mentioned that her husband is also suffering from a similar skin lesion for a long time and residing in South Africa for the last 08 years. The rest of her family members are in good health; there was no history of similar lesions in her family. She denied any history of tuberculosis or contact with smear-positive tuberculosis patients. She did not receive blood transfusion in the past.
She was found emaciated, moderately anaemic, normal vitals, and without any lymphadenopathy. On skin survey, she was found to have multiple excoriated lichenified papules over different parts of the body, e.g., extremities (Figure 1(a)), neck, and upper back. There were also exudation and crusting in some lesions. There were some whitish patches over her tongue and oral cavity and a nonhealing ulcer present over her labia. Fundoscopy reveals disc swelling, haemorrhage, and exudate present over superior and inferior quadrants of the right eye and a pale disc with exudates in the superior and inferior retinal quadrants of the left eye.
Routine investigations, including ultrasound abdomen, were normal. Haematological and biochemical profiles are given in Table 1. The fundal photograph was taken and showed disc swelling and splinter haemorrhage, exudate present over superior and inferior quadrants in the right eye, and pale disc with vascular sheathing, superiorly and inferiorly retinal exudate present in the left eye (Figure 1(b)). Recurrent, severely pruritic and exudative papular eruptions, which were refractory to treatment, along with ophthalmic findings, led to getting her investigated for HIV. The enzyme-linked immunosorbent assay (ELISA) for HIV came out to be positive. Other investigations including the serum venereal disease research laboratory (VDRL) test, TPHA, serum hepatitis B surface antigen (HBsAg), antibody against HCV, and antibodies (IgM + IgG) against HSV 1 and 2 were negative. X-ray of chest and ultrasonogram (USG) of the abdomen were normal.
The ELISA for HIV came out to be positive. Anticytomegalovirus (CMV) IgG was positive. The patient's CD4 count was 237 cells/mm. She was labelled as a case of HIV/AIDS, WHO stage 3, and she was started tenofovir, lamivudine, and efavirenz (TDF + 3 TC + EFV) regimen immediately. Due to COVID-19 pandemic, advanced ophthalmological services were limited and took a long time for consultation. Injection ganciclovir was advised to the patient, but she could not afford it. The patient clinically improved during discharge with impending concerns regarding her visual impairment.