Leprosy Reversal Reaction as Immune Reconstitution Inflammatory Syndrome in Patients with AIDS

Abstract

We report 2 instances in which reactional borderline leprosy manifested itself as an immune reconstitution phenomenon in patients with acquired immunodeficiency syndrome. We discuss the clinical, laboratory-based, histopathologic, and immunohistochemical characteristics of both patients. Furthermore, we review similar reports from the literature.

Immune Reconstitution Inflammatory Syndrome: A Reappraisal

“…Examination of the histopathologic characteristics and/or inflammatory cell infiltrate of affected tissues or organs has demonstrated that CD8 + T cells predominate in IRD that is provoked by viruses, such as JC virus [18], HIV [8,18], and cytomegalovirus [19]. In contrast, granulomatous inflammation usually predominates in IRD that is provoked by fungi, such as Histoplasma species and cryptococci [14,20]; by protozoans, such as Leishmania species [21]; and by mycobacteria, such as M. tuberculosis, Mycobacterium leprae [22,23], and nontuberculous mycobacteria [5]. In patients with M. tuberculosis or cryptococcal IRD, the inflammation is often associated with other characteristics of a Th1 immune response, including increased numbers of circulating T cells that produce IFN-g when they are stimulated with pathogen-specific antigens [24][25][26].…”

Leprosy and Kaposi sarcoma presenting as an immune reconstitution inflammatory syndrome in a patient with AIDS

“…This is not true for two patients (including the current one) with borderline lepromatous multibacillary disease; these patients were probably anergic against mycobacteria and as HAART increased cellular immune response, it triggered reactional type-1 leprosy, instead of type-2 reactions. 13 These cases may, therefore, provide indirect evidence that, at least in some patients, the clinical presentation of leprosy is suppressed by HIV-associated advanced immunodeficiency until HAART provides the immunologic ''trigger'' that leads to disease presentation, in all cases within 6 months after the introduction of HAART. 8,15 An association between KS and HIV infection is also well established.…”

“…[3][4][5][6][7][8][9][10][11][12][13][14][15] Since its first report in 2003, it has become clear that the introduction of HAART changed the natural history of leprosy in HIV-infected patients. 3,15 In 19 cases (including the patient we describe) the clinical manifestations of IRIS were leprosy type-1 reactions, some unusually severe and associated with vasculitis and ulcerous progression.…”

Reversal Reaction as a Manifestation of Immune Reconstitution Inflammatory Syndrome

“…The mean time that patients developed reaction after initiation of HAART was 18.95 (4-172) weeks (median:8, Mode:8, standard deviation:31,1) (Tables 1 and 2). Twenty three (56.09%) of the cases were from Brazil (Pereira et al, 2004;Visco-Comandini et al, 2004;Trindade et al, 2005;Talhari et al, 2007;Caruso et al, 2007;Batista et al, 2008;Deps et al, 2008& Menezes et al, 2009, 13 (31.7%) from India (Narang et al, 2005;Singal et al, 2006;Kharkar et al, 2007;Kar et al, 2009&Vinay et al, 2009, 3 (7.31%) from Haiti (Couppié et al, 2004& Pavie et al, 2009), 1 (2.43%) from Uganda (Lawn et al, 2003) and 1(2.43%) from French Guiana (Couppié et al, 2004). Thirty one (75.6%) patients were man and 10 (27.3%) women.…”