Immune reconstitution inflammatory syndrome associated with dermatophytoses in two HIV-1 positive patients in rural Tanzania: a case report

Abstract

BackgroundImmune reconstitution inflammatory syndrome associated with dermatophytoses (tinea-IRIS) may cause considerable morbidity. Yet, it has been scarcely reported and is rarely considered in the differential diagnosis of HIV associated cutaneous lesions in Africa. If identified, it responds well to antifungals combined with steroids. We present two cases of suspected tinea-immune reconstitution inflammatory syndrome from a large HIV clinic in rural Tanzania.Cases presentationA first case was a 33 years-old female newly diagnosed HIV patient with CD4 count of 4 cells/μL (0 %), normal complete blood count, liver and renal function tests was started on co-formulated tenofovir/emtricitabine/efavirenz and prophylactic cotrimoxazole. Two weeks later she presented with exaggerated inflammatory hyperpigmented skin plaques with central desquamation, active borders and scratch lesions on the face, trunk and lower limbs. Tinea-IRIS was suspected and fluconazole (150 mg daily) and prednisolone (1 mg/Kg/day tapered down after 1 week) were given. Her symptoms subsided completely after 8 weeks of treatment, and her next CD4 counts had increased to 134 cells/μL (11 %). The second case was a 35 years-old female newly diagnosed with HIV. She had 1 CD4 cell/μL (0 %), haemoglobin 9.8 g/dl, and normal renal and liver function tests. Esophageal candidiasis and normocytic-normochromic anaemia were diagnosed. She received fluconazole, prophylactic cotrimoxazole and tenofovir/emtricitabine/efavirenz. Seven weeks later she presented with inflammatory skin plaques with elevated margins and central hyperpigmentation on the trunk, face and limbs in the frame of a good general recovery and increased CD4 counts (188 cells/μL, 6 %). Tinea-IRIS was suspected and treated with griseofulvin 500 mg daily and prednisolone 1 mg/Kg tapered down after 1 week, with total resolution of symptoms in 2 weeks.ConclusionThe two cases had advanced immunosuppression and developed de-novo exaggerated manifestation of inflammatory lesions compatible with tinea corporis and tinea facies in temporal association with antiretroviral treatment initiation and good immunological response. This is compatible with unmasking tinea-IRIS, and reminds African clinicians about the importance of considering this entity in the differential diagnosis of patients with skin lesions developing after antiretroviral treatment initiation.

Case of Trichophyton tonsurans infection which emerged after using corticosteroid to treat herpetic encephalitis

“…This paradoxical phenomenon is very similar to that of exacerbation of dermatophytosis during treatment for AIDS using highly active antiretroviral therapy. 2 In our patient, there was no apparent inflammation on the scalp during the course. Avoidance of inflammation on the scalp was explained as follows: fungal elements resided in the hair shafts as endothrix; the amount of fungal elements did not increase during the short period of corticosteroid administration; prompt initiation of oral TBF; therefore, recovered immunity did not induce inflammation on the scalp.…”

Skin and mucosal manifestations of immune reconstitution inflammatory syndrome in people living with HIV: a review

“…In IRIS associated with dermatophytosis a few weeks after starting ART, lesions previously manifested as pruritic papular eruption involving the upper and lower limbs, then progressed to inflammatory plaques with central desquamation and active borders over the neck, trunk, and face. Total resolution of the symptoms was observed in all cases after the antifungal treatment combined with oral prednisolone 40 …”

“…Total resolution of the symptoms was observed in all cases after the antifungal treatment combined with oral prednisolone. 40…”

Immune reconstitution inflammatory syndrome, a controversial burden in the East African context: a systematic review and meta-analysis

“…The symptoms are therefore heterogeneous, and hence their severity is highly dependent on the underlying pathogen or illness involved. Different etiologies can occur at the same time in the form of co-infection, which thereby woefully complicates the diagnosis and management of IRIS, typically in the context of low-income countries ( 17 , 18 , 21 , 22 ).…”