Increased incidence of leprosy following HAART initiation: a manifestation of the immune reconstitution disease

Leprosy as immune reconstitution inflammatory syndrome in patients living with HIV: Description of French Guiana’s cases over 20 years and systematic review of the literature

Background

HIV infection is highly prevalent in French Guiana, a territory where leprosy is also endemic. Since the introduction of Highly Active Antiretroviral Treatment (HAART) in the management of HIV, leprosy has been reported as part of the immune reconstitution inflammatory syndrome (IRIS).

Methodology/Principal findings

We aimed to present a general description of these forms of leprosy as IRIS, highlighting clinical and therapeutic specificities. A retrospective study was conducted in French Guiana, including patients living with HIV (PLHIV) with advanced infection (CD4 < 200/mm3) and developing leprosy or a leprosy reaction within six months of HAART initiation, from 2000 to 2020. Clinical, histological and biological data were collected for all these patients. Six patients were reported in French Guiana. A systematic review of the literature was conducted, and its results were added to an overall analysis. Overall, seventy-three PLHIV were included. They were mainly men (74%), aged 22–54 years (median 36 years), mainly from Brazil (46.5%) and India (32.8%). Most leprosy cases (56.2%) were borderline tuberculoid (BT). Leprosy reactions were frequent (74%), mainly type 1 reaction (T1R) (68.5%), sometimes intense with ulceration of skin lesions (22%). Neuritis was observed in 30.1% of patients. The outcome was always favorable under multidrug therapy (MDT), continuation of HAART and additional corticosteroid therapy in case of neuritis or ulceration. There was no relapse.

Conclusion

Leprosy as IRIS in PLHIV mainly presents as a BT leprosy in a T1R state, sometimes with ulcerated skin lesions. Response to MDT is usually good. Systemic corticosteroids are necessary and efficient in case of neuritis.

Leprosy is an infection caused by Mycobacterium leprae characterized by skin and nerve lesions. Leprosy reactions can be observed, depending on variations in host-specific cellular immunity. Leprosy is described after antiretroviral therapy (HAART) initiation in immunocompromised PLHIV from countries where leprosy and HIV infections are endemic. This is known as immune restoration inflammatory syndrome (IRIS), a brutal inflammatory response directed against a latent or quiescent pathogen. In this study we searched for cases of leprosy as IRIS in French Guiana and those published in the literature in order to describe their clinical characteristics. Overall, our results show that these cases are mostly observed as borderline tuberculoid leprosy, associated with or quickly followed by a type 1 leprosy reaction, sometimes with neuritis and/or ulceration of lesions. The outcome is favorable under standard leprosy treatment with HAART maintenance.

Hansen's disease and HIV coinfection with facial nerve palsy

There are very few published reports of HIV leprosy co infection in India in spite of having a large burden of both leprosy and HIV. Herein we are reporting a case of co-infection of Hansen's disease and HIV with facial nerve palsy.

Epidemiological and clinical patterns of 92 patients co-infected with HIV and Mycobacterium leprae from Rio de Janeiro State, Brazil

BACKGROUND

Many articles have shown that HIV infection can modify the clinical course of leprosy, but very scant epidemiological and clinical data about this co-infection are available in the peer-reviewed literature.

METHODS

We herein describe the geographical distribution and demographic characteristics of 92 HIV/Mycobacterium leprae co-infected patients assisted in a Brazilian Leprosy referral center. A multivariate analysis was performed in order to establish clinical factors associated with type 1 reaction.

RESULTS

Co-infected patient admissions have steadily increased over the last years at this referral center. Most patients were men, with a mean age of 32.3 years and presenting with the paucibacillary form of leprosy. The use of antiretroviral therapy (ART) was the only factor associated with type 1 reaction. Most patients were living in the metropolitan area and the north sub area of Rio de Janeiro City.

CONCLUSION

Co-infected patients receiving ART have a greater chance to develop type 1 reaction. Patients living with both HIV and leprosy are likely to live in regions characterized by a high density impoverished population.

The impact of human immunodeficiency virus-related diseases on pigmented skin types

Infection with human immunodeficiency virus (HIV) remains a significant problem globally. Early diagnosis and treatment with antiretroviral drugs has considerably improved health outcomes and decreased disease-related morbidity. HIV infection is associated with a wide range of skin disorders enabling dermatologists to diagnose HIV as well as associated opportunistic infections early in the course of disease. Despite concerted efforts by international health organizations to limit disease incidence, the prevalence of HIV infection remains high and is highest in sub-Saharan Africa. The diagnosis of HIV-related skin diseases is challenging as immunosuppression often results in atypical disease presentation. In addition, the clinical presentation will vary in pigmented skin types. The aim of this article is to describe disease variation in pigmented skin types.

Leprosy: an overview of pathophysiology

Leprosy, also known as Hansen's disease, is a chronic infectious disease caused by Mycobacterium leprae, a microorganism that has a predilection for the skin and nerves. The disease is clinically characterized by one or more of the three cardinal signs: hypopigmented or erythematous skin patches with definite loss of sensation, thickened peripheral nerves, and acid-fast bacilli detected on skin smears or biopsy material. M. leprae primarily infects Schwann cells in the peripheral nerves leading to nerve damage and the development of disabilities. Despite reduced prevalence of M. leprae infection in the endemic countries following implementation of multidrug therapy (MDT) program by WHO to treat leprosy, new case detection rates are still high-indicating active transmission. The susceptibility to the mycobacteria and the clinical course of the disease are attributed to the host immune response, which heralds the review of immunopathology of this complex disease.

Leprosy and HIV coinfection: a critical approach

An increase in leprosy among HIV patients, similar to that observed in patients with TB, was expected approximately 20 years ago. Studies conducted in the 1990s together with those reported recently seemed to indicate that a coinfection with HIV did not alter the incidence and the clinical spectrum of leprosy and that each disease progressed as a single infection. By contrast, in countries with a high seroprevalence of HIV, TB was noted to increase. Explanations may be provided by the differences in the incubation time, the biology and toxicity of Mycobacterium leprae and Mycobacterium tuberculosis. After the introduction of HAART the leprosy-HIV coinfection manifested itself as an immune reconstitution inflammatory syndrome (IRIS), typically as paucibacillary leprosy with type 1 leprosy reaction. The incidence of leprosy in HIV-infected patients has never been properly investigated. IRIS-leprosy is probably underestimated and recent data showed that the incidence of leprosy in HIV patients under HAART was higher than previously thought.

Mycobacterium leprae-host-cell interactions and genetic determinants in leprosy: an overview

Leprosy, also known as Hansen's disease, is a chronic infectious disease caused by Mycobacterium leprae in which susceptibility to the mycobacteria and its clinical manifestations are attributed to the host immune response. Even though leprosy prevalence has decreased dramatically, the high number of new cases indicates active transmission. Owing to its singular features, M. leprae infection is an attractive model for investigating the regulation of human immune responses to pathogen-induced disease. Leprosy is one of the most common causes of nontraumatic peripheral neuropathy worldwide. The proportion of patients with disabilities is affected by the type of leprosy and delay in diagnosis. This article briefly reviews the clinical features as well as the immunopathological mechanisms related to the establishment of the different polar forms of leprosy, the mechanisms related to M. leprae-host cell interactions and prophylaxis and diagnosis of this complex disease. Host genetic factors are summarized and the impact of the development of interventions that prevent, reverse or limit leprosy-related nerve impairments are discussed.

Recent advances in leprosy and Buruli ulcer (Mycobacterium ulcerans infection)

PURPOSE OF REVIEW

After tuberculosis, leprosy (Mycobacterium leprae) and Buruli ulcer (M. ulcerans infection) are the second and third most common mycobacterial infections in humankind, respectively. Recent advances in both diseases are summarized.

RECENT FINDINGS

Leprosy remains a public health problem in some countries, and new case detections indicate active transmission. Newly identified M. lepromatosis, closely related to M. leprae, may cause disseminated leprosy in some regions. In genome-wide screening in China, leprosy susceptibility associates with polymorphisms in seven genes, many involved with innate immunity. World Health Organization multiple drug therapy administered for 1 or 2 years effectively arrests disseminated leprosy but disability remains a public health concern. Relapse is infrequent, often associated with higher pretreatment M. leprae burdens. M. ulcerans, a re-emerging environmental organism, arose from M. marinum and acquired a virulence plasmid coding for mycolactone, a necrotizing, immunosuppressive toxin. Geographically, there are multiple strains of M. ulcerans, with variable pathogenicity and immunogenicity. Molecular epidemiology is describing M. ulcerans evolution and genotypic variants. First-line therapy for Buruli ulcer is rifampin + streptomycin, sometimes with surgery, but improved regimens are needed.

SUMMARY

Leprosy and Buruli ulcer are important infections with significant public health implications. Modern research is providing new insights into molecular epidemiology and pathogenesis, boding well for improved control strategies.

Unmasking leprosy: an unusual immune reconstitution inflammatory syndrome in a patient infected with human immunodeficiency virus

Immune reconstitution inflammatory syndrome (IRIS) has become a frequent and potentially severe complication after initiation of following antiretroviral therapy (ART) in patients infected with human immunodeficiency virus (HIV). IRIS can unmask a previously clinically silent infection, such as tuberculosis, as recently described for Mycobacterium infections. We describe a case in a patient from Côte d'Ivoire living in France in whom skin papular lesions developed after initiation of ART. These lesions were associated with microbiologically proven leprosy. Thus, latent leprosy can appear as IRIS, and leprosy-associated IRIS should be considered in HIV-infected patients from areas endemic for leprosy.