Case report: Co-infection of syphilis and leprosy in HIV2 patient

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Case report: Co-infection of syphilis and leprosy in HIV2 patient

Case Reports: Calicut Medical Journal 2003;1(1):e6 A Rare Co-Existence of Three

Disastrous Diseases

Najeeba Riyaz*, Roshni Balakrishnan**

*Professor and Head,**Postgraduate Student, Department of Dermartology,Calicut

Medical College,Calicut

Address for Correspondence:

Dr.Najeeba Riyaz,

Professor & Head of Dermatology,Medical College, Calicut - 673 008

Abstract

An unusual association of syphilis, lepromatous leprosy and HIV2 infection in a

37 year old married promiscuous man is presented.

Key words :HIV 2 infection , syphilis, lepromatous leprosy, promiscuous

Introduction

HIV infection, syphilis and leprosy commonly occur as separate diseases. Of

these, the combination of two is rare and all three is extremely rare. There are

several complimentary factors, which may affect the course and outcome of the

diseases in case of syphilis and HIV infection, and no such factors have been

established in case of leprosy and HIV infection. An extremely rare combination

of late latent syphilis, lepromatous leprosy and HIV2 infection is being

reported here.

Case report

A 37 - year old married man was referred to our department for VDRL reactivity

1/4. He was a painter in Saudi Arabia. He gave history of multiple unprotected

homo and heterosexual extramarital exposures, the last being 3 years back. There

was no history of genital ulcers and he was not aware of any skin lesions. He

was a chronic smoker and parenteral drug abuser. His wife and 5-year-old child

were asymptomatic.

On examination, he had multiple ill-defined hypo pigmented shiny patches and

plaques on the back of the trunk without any sensory impairment. Ear lobes were

infiltrated and had ciliary and superciliary madarosis. No nerve thickening or

anaesthesia was observed. Genital and systemic examinations were within normal

limits. Oral cavity showed features of candidiasis and oral hairy leukoplakia.

His blood VDRL was reactive 1/4 and TPHA was positive 1/320 . CSF examination

showed an elevated protein content of 75mg% with a non-reactive VDRL and

negative TPHA. Screening revealed a positive ELISA for HIV2 infection and HIV1

negativity. His routine blood and urine examination, renal and liver function

tests were normal. Ear lobe smear (ELS) showed globi with a morphological index

(MI) of 30 and slit skin smear showed bacterial index (BI) 4 + and MI 30.

Skin biopsy from the hypo pigmented patch showed features of lepromatous

leprosy.

Based on the findings we made a diagnosis of late latent syphilis with

lepromatous leprosy and HIV2 infection. In view of the elevated CSF protein.

content and co-existent HIV2 infection, he was given intensive treatment with

crystalline penicillin 30 L 4 hourly for 10 days followed by benzathine

penicillin 2.4 mega units weekly for 3 weeks, as for neurosyphilis. He was also

put on multi drug therapy with dapsone 100 mg, monthly rifamipicin 600 mg and

clofazimine 50mg daily. For confirmation of diagnosis and management of HIV2

infection he was advised Western blot and CD4 cell count.

But the patient was lost for follow up.

Discussion

The association of syphilis and lepromatous leprosy with HIV2 infection has not

been reported so far. The literature search revealed a single case of HIV

infection with syphilis and borderline lepromatous leprosy in a young Paraguan

man1.

Though various effects on immune system can be expected in a case of co-existent

leprosy with HIV infection, epidemiological studies failed to establish any such

effects in the clinical course of leprosy. A WHO meeting in 1993 concluded that

there is no convincing evidence for an association between HIV and leprosy2. A

case control study held in South India among leprosy patients also confirmed

these findings3.

There is strong epidemiological evidence suggesting the association between HIV

and syphilis. Concomitant HIV infection can cause alterations in the clinical

course of syphilis like early onset neurosyphilis, lack of response to

penicillin therapy, reactivation of the disease despite adequate therapy, false

positive or false negative serology etc. Our patient had elevation of CSF

protein with negative serology possibly due to associated HIV infection causing

disregulation of humoral immune response.

HIV2 infection is rather rare in India. The patient would have contracted HIV2

infection from abroad. The major mode of transmission of HIV2 is homosexual

contact. The latent period of HIV2 infection is longer and vertical transmission

is rare. Disease progression and severity are less due to low viral load. This

could be the reason for the comparatively good health of this patient, inspite

of HIV infection with the other two disastrous diseases.

Why these three diseases occurred together is an enigma. Rather than a rare

co-existence, this may be due to a common HLA association.

References

1. Graf Von Ballestren W et al :Leprosy in HIV positive and syphilitic young

Paraguan man. Acta Leprol 1992; 8(2) : 103 - 104.2. WHO report of a meeting of

HIV infection in leprosy. Geneva 1 - 2 May 1993. WHO / CTD / Lepr/93.3.

3. Sekar S, Jayasheela M, Chathopadhyaya : Prevalence of HIV infection and high

risk characteristics among leprosy patients of South India : A case control

study. Int J. Lepr. 1994; 62 : 527 - 531.

This is a peer reviewed paper. Accepted for publication on October 13,2003

Cite as:

Riyaz N, Balakrishnan R.A Rare Co-Existence of Three Disastrous Diseases.

Calicut Medical Journal 2003; 1(1):e6 .

URL: http://www.calicutmedicaljournal.org/2003;1(1)e6.htm