A 38-year-old male patient, diagnosed with retroviral infection and disseminated tuberculosis presented with weakness and numbness of the right hand of 2 weeks duration. He also noticed an edematous reddish raised lesion on the inner aspect of right hand, which he attributed to the topical agent he used for relieving the numbness. Pain was present on the right elbow and forearm. The patient had been on antitubercular therapy (ATT) followed by antiretroviral therapy (ART), 5 months prior to presentation at our department. The CD4 count was 67 cells/muL during initiation of HAART.
Dermatological examination showed a single well-defined erythematous plaque, 20 x 5 cm with raised borders on the ulnar aspect of right hand and distal forearm, extending to the palm [Figures 1 and 2]. A satellite lesion was present on the upper part of forearm, which also showed erythema and edema. All modalities of sensations were lost in these lesions. Both ulnar nerves were thickened with tenderness on the right side. Slit skin smears from the earlobe, lesional, and normal skin were negative. Histopathological examination showed dermal edema, diffuse granulomas composed of Langhans type giant cells, surrounded by epithelioid cells, lymphocytes, multinucleated giant cells, and fibroblasts with perivascular lymphocytic infiltrate, consistent with Hansen's disease borderline tuberculoid type, with features suggesting type 1 lepra reaction [Figures 3-6]. AFB stain was negative. CD4 count after 5 months showed a rise to 160 cells/muL. The viral RNA load was not measured due to lack of facilities.
Thus correlating the clinical, bacteriological, and histopathological features, a diagnosis of Hansen's disease borderline tuberculoid with type 1 lepra reaction presenting as IRIS was made. MB-MDT was started, avoiding rifampicin from the regimen, as patient was also on ATT. HAART was continued and systemic steroids were also given in tapering doses. On follow up there was marked alleviation of his symptoms. However, the patient succumbed within 3 months to a brain tuberculoma.