Leprosy presenting as immune reconstitution inflammatory syndrome - report of three cases

Abstract

The introduction of highly active antiretroviral treatment (HAART) has led to the emergence of a new clinical syndrome, immune reconstitution inflammatory syndrome (IRIS). This syndrome affects human immunodeficiency virus (HIV)- positive patients at an advanced stage of the disease (CD4 lymphocyte counts 200/μL). In these patients, clinical signs of inflammation appear mostly in association with opportunistic infection, when HAART triggers a generalized immune activation during the transition phase of viral load suppression and CD4 lymphocyte counts increase. The infectious agent may have been treated previously or may have been present in a latent state, but is always present in the patient’s body before the introduction of antiretroviral treatment. In the first situation, the opportunistic infection, which is initially improved by specific treatment, then leads to generalized or localized inflammation. In the second situation, the opportunistic infection is first detected when the CD4 lymphocyte count increases. In the first reported cases of IRIS, in 1998, the infectious agents were mycobacteria (Mycobacterium avium complex and M tuberculosis). The syndrome has since been described in association with more than a dozen different infectious conditions, with herpes zoster (41 cases), M tuberculosis (37 cases), M avium complex (32 cases), and cytomegalovirus (22 cases) in 73% of the first 182 published cases. In some cases, IRIS appears in the absence of opportunistic pathogens and manifests itself as an autoimmune or granulomatous disease, of which sarcoidosis is the most frequent (10 cases). The first case of leprosy diagnosed after HAART initiation was reported in 2003.1 We herewith report three cases of leprosy presenting as IRIS as the first manifestation.