A man with hypoesthetic skin lesions: a case report of immune reconstitution inflammatory syndrome

The use of highly active antiretroviral therapy (HAART) has prevented opportunistic infections that often lead to death in HIV-positive patients. However, in resource-poor countries, HAART is only initiated at an advanced stage. This could lead to the antiretroviral-induced immune reconstitution syndrome or the immune reconstitution inflammatory syndrome (IRIS). The most frequently implicated pathogens associated with these syndromes are mycobacteria, varicella-zoster, herpes viruses, and cytomegalovirus. There are few numbers of case reports of leprosy that have an association with HIV. Meanwhile, lepra reactions are immunological phenomena that can occur before, during, or at the end of multi-drug treatment (MDT). Here, we report the case of a 39-year-old man who presented with four hypoesthetic skin lesions with left ulnar nerve thickening after two months on antiretroviral treatment. He was diagnosed with borderline tuberculoid leprosy as his slit-skin smear showed negative results with four skin lesions and his skin biopsy revealed tuberculoid leprosy with perineural involvement. The patient was started on the paucibacillary MDT regime consisting of dapsone and rifampicin. However, he developed two new hypoesthetic skin lesions over the left gluteal region and left arm, thus being switched to multibacillary MDT. He further developed a type 1 lepra reaction after one month of the regime, though this was successfully treated with prednisolone.