A 38-year-old male, diagnosed as HIV-positive, presented to our department with multiple painful, erythematous skin lesions over extremities, face and abdomen of 2 days duration along with the history of evening rise of temperature with chills, malaise, body pains, joint pains, and ankle edema. The patient had history of nasal stuffiness and epistaxis. He was not a known case of leprosy. He was on ART zidovudine, lamivudine, nevirapine (ZLN) for 4 weeks prior to the onset of skin lesions. Further, history of sexual exposure with multiple heterosexual partners was noted. No history of diabetes mellitus, hypertension, or tuberculosis.
On general examination, he was pale, thin built, ill nourished and febrile. On examination, there was no generalized lymphadenopathy. There was diffuse infiltration of ear lobe [Figure 1]. Multiple erythematous, tender papules, and nodules were present on the face [Figure 2] and also on trunk and extremities [Figure 3]. Sensations of pain and touch were reduced over both the feet. Ulnar, radial cutaneous, lateral popliteal, and posterior tibial nerves on both sides were thickened and tender. Hair, nails and mucous membranes were normal. Systemic Examination revealed no abnormalities.
Hematological Examination revealed microcytic hypochromic anemia (Hb: 10 g%), and neutrophilic leukocytosis (TLC: 12,800/mm3) differential count N75L20M3E2, and raised ESR (68 mm in-first hour). VDRL was non-reactive, and HBsAg was negative. The findings of complete urine examination were normal. Blood glucose levels, renal function and liver function tests were normal. Chest X-ray and ultrasonography of abdomen were normal. HIV-1 was reactive, the viral load was 1,07,400 copies/mL and CD4 count 94 cells/cu. mm before starting ART. At the time of diagnosis of IRIS, which is 1 month after starting of ART, CD4 count was 151 cells/cu. mm. Slit skin smear examination for M. leprae revealed bacteriological index of 4 along with a morphological index of 20%. Biopsy taken from the nodule on the left hand [Figure 3] demonstrated mild hyperkeratosis in epidermis, grenz zone. Dermis shows edema with collection of macrophages [Figure 4]. Vessels showed acute and chronic perivascular inflammatory infiltrate [Figure 5] consistent with ENL.
On the basis of the history, clinical examination, and investigative findings, a diagnosis of IRIS presenting as ENL in a patient of HIV with unmasking of lepromatous leprosy was made.
The patient was continued on ART and started on MBMDT (rifampicin:-600 mg, dapsone:- 100 mg, and clofazamine:-50 mg). He was given oral steroids which were gradually tapered over a period of 3 months. After 9 months of MBMDT and ART, no further episodes of ENL were reported and his CD4 count is 367. The patient is doing fine and attending to his duties.