A 47-year-old married male with acquired immune deficiency syndrome (AIDS) who was a shopkeeper by profession presented with skin lesions on both lower limbs for past 9 months. It was associated with mild itching and pain. There were no complaints of joint pain or redness of eyes. The patient was diagnosed with HIV in 2007 and first-line antiretroviral therapy (ART) (tenofovir, lamivudine, efavirenz) was started in 2009. He developed severe fatigue, weight loss, cough, and dyspnea, and CD4 count dropped to 50 cells/mm3 with plasma viral load of 157 copies/ml, 11 months ago in March 2015. Due to treatment failure, he was then put on second-line ART (abacavir, lamivudine, atazanavir, and ritonavir) and his CD4 count increased to 204 cells/mm3 with plasma viral load of 38 copies/ml in September 2015. The present skin lesions started 2 months after initiation of second-line ART. Patient also had history of pulmonary tuberculosis (TB) in 2007 when his CD4 count was 213 cells/mm3, and Herpes Zoster in 2012 when CD4 count was 78 for which treatment was taken.
On general examination, patient was moderately built and nourished, and his vitals were within normal limits. Cutaneous examination revealed multiple well-defined nontender hyperpigmented papules and nodules on both ankles, dorsum of bilateral feet and soles [Figure 1a-c]. Inguinal lymph nodes were not palpable. There were no lesions elsewhere in the body. Hair, nail, and oral mucosa were normal. No ocular or systemic abnormality was noted.
Differential diagnoses considered were Kaposi's sarcoma and immune reconstitution inflammatory syndrome (IRIS) related infection including cutaneous TB. His routine blood investigations showed hemoglobin 11.5 g%, total leukocyte count 4300/mm3; and differential count neutrophil 70%, lymphocytes 28%, eosinophils 1% and monocytes 1%, and platelets 287,000/mm3. Liver function tests and renal function tests were normal. Mantoux test, serological tests for syphilis (VDRL, TPHA), hepatitis B and C, and anti-nuclear antibodies were negative. Chest radiography and abdominal ultrasonography were normal. Biopsy taken from the nodular lesion on dorsum of left foot showed a diffused dense infiltrate in reticular dermis with mild fibroplasia. The infiltrate consisted of neutrophils and histiocytes with scattering of lymphocytes and plasma cells. The infiltrate surrounded small thickened vessels and extended extensively into the interstitium. Small amount of neutrophilic nuclear dust was also present within the infiltrate [Figure 2]. Overlying epidermis and dermoepidermal junction were largely spared. These features were suggestive of EED. Patient was started on oral dapsone 100 mg/day and then increased to 200 mg/day to which he is responding gradually.