A masquerade: An uncommon presentation of a dual infection of leprosy and human immunodeficiency virus

Varsha Rajat Bhatt; Abhishek Arvind Zanwar; Aditi Mahesh Patel; Mounika Sai Adapa

doi:10.4103/ijmy.ijmy_188_22

CASE REPORT

Year : 2022 | Volume : 11 | Issue : 4 | Page : 457-459

A masquerade: An uncommon presentation of a dual infection of leprosy and human immunodeficiency virus

Varsha Rajat Bhatt, Abhishek Arvind Zanwar, Aditi Mahesh Patel, Mounika Sai Adapa
Department of Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission	15-Aug-2022
Date of Decision	01-Nov-2022
Date of Acceptance	20-Nov-2022
Date of Web Publication	10-Dec-2022

Correspondence Address:
Varsha Rajat Bhatt
Department of Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijmy.ijmy_188_22

Abstract

Leprosy and human immunodeficiency virus (HIV) often mimic clinical features of connective tissue disease (CTD). They can present such as lupus, rheumatoid arthritis, scleroderma, or overlap syndromes and it sometimes creates confusion about the diagnosis. Serology may not be enough to differentiate the two and effective tissue biopsies are often the answer. We report the case of a 38-year-old female, who presented clinically with features of multisystem involvement suspected to be CTD, but was found to have dual infection: HIV and borderline tuberculoid leprosy.

Keywords: Arthritis, connective tissue disease, facial rash, human immunodeficiency virus, leprosy

How to cite this article:
Bhatt VR, Zanwar AA, Patel AM, Adapa MS. A masquerade: An uncommon presentation of a dual infection of leprosy and human immunodeficiency virus. Int J Mycobacteriol 2022;11:457-9

How to cite this URL:
Bhatt VR, Zanwar AA, Patel AM, Adapa MS. A masquerade: An uncommon presentation of a dual infection of leprosy and human immunodeficiency virus. Int J Mycobacteriol [serial online] 2022 [cited 2023 Feb 4];11:457-9. Available from: https://www.ijmyco.org/text.asp?2022/11/4/457/363169

Introduction

Several infectious diseases can mimic rheumatological disorders. Bacterial, viral, and mycobacterial infective arthritis can have features resembling rheumatoid arthritis (RA) and connective tissue disease (CTD). Leprosy is often called the great mimic. Prevalence of rheumatic manifestations in leprosy is approximately 60%–80% from rheumatology clinics.^[1],[2] It can mimic RA, lupus, scleroderma, mixed CTD (MCTD), etc., Human immunodeficiency virus (HIV) also has several rheumatic manifestations and also can present like a rheumatic disease. In underdeveloped and developing countries where the prevalence of infections remains high, rheumatologists and general practitioners should keep a high index of suspicion to diagnose infections that mimic rheumatic diseases.^[3]

Autoimmune CTDs are systemic rheumatological disorders involving multiple systems, clinically presenting with features such as photosensitivity, rash, oral ulcers, Raynaud phenomenon, arthritis, etc., and are antinuclear antibody positive.^[4] Systemic lupus erythematosus and MCTD are diagnosed based on the certain criteria. Overlap syndrome occurs when patient presents with features of two distinct rheumatic diseases.^[5] A dual infection of HIV and leprosy presenting clinically as a CTD is rare with not many cases reported in the literature.

We report the case of a 38-year-old female, who presented clinically with features of CTD, but was found to have HIV and borderline tuberculoid leprosy.

Case Report

A 38-year-old housewife came with malar rash and photosensitivity, inflammatory joint pain in small hand joints, Raynaud's phenomenon, and swelling over the fingers for 5 years. Burning paresthesia and decreased sensation in both the palms and soles were present for 2 years. There was altered mood with loss of interest in surroundings for 8 months for which she had consulted a psychiatrist 6 months before presenting to this hospital. There was also a history of sudden-onset left-sided hemiparesis 2 years back which improved over a month. On physical examination, there was a malar rash sparing nasolabial folds, puffy fingers, tenderness over the metacarpophalangeal, and proximal interphalangeal joints [Figure 1] and [Figure 2].

Figure 1: Photosensitive malar rash

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Figure 2: Puffy fingers and joint swelling

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On exposure to cold water, there was blanching in the digits. Ankle reflex was absent bilaterally and plantar reflexes not elicitable. She had decreased sensation by 80% in modalities of pain, touch, temperature, and vibration and proprioception in both palms up to wrist and feet up to ankle. As the disease seemed to involve multiple systems, including characteristic rash, polyarthritis, and involvement of nervous system, a provisional diagnosis of CTD, possible lupus, overlap CTD, or MCTD was made and the patient was investigated.

Laboratory investigations revealed a normal hemogram, raised erythrocyte sedimentation rate (56 mm), raised C-reactive protein (10 mg/dl), normal liver and renal functions and urine. We sent her serologies for HIV, hepatitis B surface antigen, and hepatitis C virus. She was HIV positive by ELISA and her CD4 count was 346/cm. However, her antinuclear antibodies (ANA) by immunofluorescence were negative and ANA Blot was negative for all extractable nuclear antigens (ENAs).

To further investigate her peripheral nerve disease, nerve conduction study was done which revealed lower amplitudes, prolonged latency, and slow conduction velocity suggestive of sensory-motor polyneuropathy of mixed axonal-demyelinating type. T2-weighted images of magnetic resonance imaging brain of the patient showed an old infarct in the right corona radiate. As she had dermatological features of CTD but her ANA and ENA were negative, it was decided to take a biopsy from her malar area.

Skin biopsy suggested prominent focal perivascular collection of mononuclear inflammatory cells close to nerve twigs with focal areas of ill-formed granulomas and was negative for acid fast bacilli, suggestive of borderline tuberculoid leprosy, but no features suggestive of a CTD [Figure 3]. A nerve biopsy was also done which showed a nonspecific macrophage infiltration of nerves with axonal damage.

Figure 3: Skin biopsy (white solid arrow) showing focal perivascular collection of mononuclear inflammatory cells close to nerve twigs and ill formed granulomas

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Thus, she was diagnosed as borderline tuberculoid leprosy with peripheral neuropathy (mixed axonal and demyelinating) in a person living with HIV. There was no evidence of a coexisting CTD. Multidrug treatment for leprosy was advised for 2 years along with antirRetroviraltreatment. She had complete resolution of the rash, Raynaud phenomenon and joint pain over a period of 6–7 months, paresthesia and sensory loss remained, although better.

Discussion

Leprosy is called the great mimic/masquerader. Rheumatological manifestations can be the presenting features of various forms of leprosy. It can lead to confusions surrounding diagnosis. Conversely, the prevalence of rheumatic manifestations in leprosy may even be 60%–80% from various rheumatology clinics.^[6]

Leprosy may mimic diseases such as RA and seronegative spondyloarthropathy: reactive arthritis, psoriatic arthritis, scleroderma, myositis, remitting seronegative symmetrical synovitis with pitting edema, vasculitis, sarcoidosis, relapsing polychondritis, and gout.^[6]

Charcot's arthropathy or neuropathic joint is a known complication of leprosy. Acute symmetric polyarthritis can occur in lepra reaction. Other types of arthritis in leprosy are chronic polyarthritis and asymmetric lower limb oligoarthritis. Only tenosynovitis in the form of swollen hands and feet syndrome can occur in pure neuritic leprosy, generalized lepra reaction, lepromatous leprosy, sometimes borderline leprosy (20%–66% prevalence).^[7]

Biopsy-proven cases of leprosy can present with heliotrope rash, muscle weakness and elevated muscle enzymes mimicking myositis. Oral ulcers, malar rash, and photosensitivity may also occur, mimicking lupus. Raynaud's phenomena, pitting scars, skin thickening, sclerodactyly have also been reported.^[8] Lucio leprosy can mimic vasculitis. In this, the skin of the patient is diffusely infiltrated so the natural wrinkles are obliterated, imparting a shiny hue.^[9]

HIV infection can mimic the clinical features of autoimmune disease. Fevers, lymphadenopathy, rash, renal dysfunction, neurological and hematological disorders, Sicca syndrome, and polyarthralgias can occur with HIV.^[10] Photosensitivity is common dermatological manifestation of HIV and hence HIV and leprosy can both be bestowed with the title of the great mimickers.^[11]

Paucibacillary leprosy still poses a diagnostic challenge. As was seen in our case, nonspecific nerve biopsy and negative results of smears in this leprosy can confuse many a good clinician.^[12]

Presence of granulomas in the nerve biopsy often clinches the diagnosis as is seen in established literature.^[13] Treatment is by multidrug regimens under the national program although emerging drug resistance is of concern.^[14] A special point of interest could be Lucio leprosy which mimics vasculitis, and which in some parts of the world is caused by another species Mycobacterium lepromatosis. This would need special diagnostic tests.^[15] The Bacille Calmette-Guérin vaccine prevents dissemination of tubercular bacilli from the primary foci to other parts of the body but similar protection is not seen with Mycobacterium leprae.^[16]

Conclusion

It is rare to see both disorders together presenting as a CTD and physicians should always keep a high index of suspicion for an infective disease in the setting of a clinically apparent CTD as the treatment protocols are diametrically opposite.

Consent

Written, informed consent was taken from the patient for presenting this case and her images are presented with full confidentiality by blocking patient identity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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