Leprosy and HIV infection
To the Editor:
Leprosy and HIV infection are diseases of an endemic nature in Brazil and are a source of great concern for public health agencies. Brazil is second in the world, after India, in absolute numbers of leprosy cases. According to the Brazilian Health Ministry, the overall prevalence is 4-4.5 cases per 1000 inhabitants and 2 per 1000 in the Ribeirão Preto region. With respect to AIDS, Brazil is among the five countries in the world with the largest absolute number of recorded cases. According to the World Health Organization, the incidence of AIDS recorded in 1990 was 22.9 per 100,000 inhabitants. According to the Health Department of the state of São Paulo, the incidence of AIDS in the city of Ribeirão Preto is 100.7 per 100,000 inhabitants, and among injectable drug users the HIV prevalence is still 46.5 per 100,000 inhabitants.
The association of HIV infection with infection by mycobacteria such as Mycobacterium avium and M. intracellulare has been reported (1). Over the last few years, there have been reports of HIV infection associated with M. leprae infection. In the present report, we describe the first case of such association treated at University Hospital, Faculty of Medicine Ribeirão Preto, University of São Paulo.
The patient was a 26-year-old, unmarried male mulatto, a carpenter by profession, living in Ribeirão Preto city without risk factors for leprosy such as family contacts or residence in a hyperendemic part of the region. Seven years ago he presented with skin lesions of the erythema nodosum type, as well as erythematous-edematous and nummular lesions with purple centers on the upper and lower limbs, together with fever, generalized neuritis, orchitis and bilateral inguinal adenomcgaly. The diagnosis was lepromatous leprosy with type 2 reaction confirmed by skin biopsy, positive carlobe and skin lesion bacilloscopy, and a negative intradermal Mitsuda reaction. C-Reactive protein was positive. He was treated with a combination of rifampin (600 mg/day for 2 months) and dapsone (100 mg/day). Thalidomide (200 mg/day) was prescribed for 2 weeks to control the reaction. Over the subsequent months, the patient presented a number of reactional episodes of erythema nodosum leprosum (ENL) which were controlled with thalidomide. After 2 years and 9 months of leprosy treatment, he was admitted to the hospital with signs and symptoms similar to his original ones, plus generalized lymph node enlargement and discrete hepatomegaly. The hypothesis of a reactional episode of ENL was first advanced and a C-reactive protein test was positive. Thalidomide (300 mg/day) was prescribed and his signs and symptoms regressed after 10 days, although the lymph node enlargement, hepatomegaly, and fever persisted. After an exhaustive investigation, no infectious disease was detected.
At that point, the patient revealed that he had been using injectable drugs up to 2 years before. An anti-HIV test by enzyme-linked immunosorbent assay (ELISA) was negative. Ten months later, he returned with ENL reactions as described above and, again, no infectious disease was detected. Quantitation of C-reactive protein and earlobe and skin lesion bacilloscopy were negative. Within 2 days, the patient presented behavioral disorders, meningism, unconsciousness, and convulsive seizures. A spinal tap was performed and cerebrospinal fluid analysis revealed hypercellularity with a predominance of lymphocytes and increased proteins, with no other changes. The anti-HIV antibody test (ELISA) was positive (> 2000). At the end of the second day after admission the patient died. An autopsy was not performed.
Three years after the leprosy diagnosis, his anti-HIV antibody serologic test (ELISA) was negative although generalized lymph node enlargement of undefined etiology persisted. During treatment for his leprosy the patient presented a few episodes of type 2 reaction (ENL) which responded to thalidomide. During the last admission, the C-reactive protein test performed at the time of his serum conversion (anti-HIV antibody >2000) was negative. Since high levels of C-reactive protein are commonly observed in the type 2 reaction in leprosy (2), the generalized lymph node enlargement probably was not related to a reactional episode but, rather, to HIV infection. The stage of the viral infection could not be classified because the patient died within a few days.
The association of leprosy with HIV infection may not be random and perhaps may be more common than thought since the period of incubation of leprosy is very long and the patient may die of HIV infection before presenting overt clinical manifestations of leprosy. Furthermore, lepromatous leprosy may make the patient more susceptible to HIV, since leprosy also presents immunodepressant factors (3). Thus, we believe that studies of the detection of HIV infection should be continued in areas where leprosy is endemic, because of both the risk of dissemination of these mycobacteria and for a better understanding of the course of these patients.
- Ana Marcia de Almeida, M.D.
Ana Maria Ferreira Roselino, M.D., Ph.D.
Norma Tiraboschi Foss, M.D., Ph.D.
Department of Internal Medicine (Dermatology)
Faculty of Medicine of Ribeirão Preto
University of São Paulo
Ribeirão Preto, S.P., Brazil
Acknowledgment. We are grateful to Prof. Emilia Simão Trad, M.D., Ph.D., and Prof. José Fernando Figueiredo, M.D., Ph.D. for contributing to the clinical care of the patient.
REFERENCES
1. COLLINS, M. F. Mycobacterium avium -complex infections and development of the acquired immunodeficiency syndrome: casual opportunist or causal cofactor? Int. J. Lepr. 54(1986)458-474.
2. Foss, N. T., OLIVEIRA, E. B. and SILVA, C. L. Correlation between TNF production, increase of plasma C-reactive protein level and suppression of T lymphocyte response to concanavalin A during erythema nodosum leprosum. Int. J. Lepr. 61(1993)218-226.
3. TURK, J. L. and REES, R. J. W. AIDS and leprosy. (Editorial) Lepr. Rev. 59(1988)193-194.
Reprint request to Prof. A. M. de Almeida, Departamento de Clinica Medica, Faculdade de Medicina de Ribeirão Preto, 14049-900 Ribeirão Preto, SP, Brasil.