Leprosy, Syphilis, and Human Immunodeficiency Virus Coinfection:

A Case Report

Mochammad Rifky Luthfiandi, Satiti Retno Pudjiati, Hardyanto Soebono

Departement of Dermatology and Venerology, Faculty of Medicine Universitas Gadjah Mada, Dr.Sardjito General

Hospital, Yogyakarta, Indonesia

Keywords: leprosy, syphilis, HIV, sexually transmitted disease

Abstract: Coinfection between leprosy, syphilis and HIV is very rare, and this association remains unclear. We report

55 years old man from Bantul, Indonesia, who present almost all over the body covered with erytematous

patches and plaques in various sizes, multiple, discrete with ulnaris nerve enlargement. This patient was

diagnosed as BL leprosy, secondary syphilis and HIV infection. Laboratory investigation showed Bacterial

Index 3+ and Morphological Index 43.75%, positive TPHA, VDRL 1/32, and HIV reactive with CD4 count

4. Histologic finding demonstrated as acute viral exanthem. We treated this patient with WHO-multidrug

therapy regimen for MB leprosy, benzathin penicillin 2.4 million unit IM single dose, and triple FDC

(tenofovir, hiviral, and efavirenz) once a day. A month after therapy, VDRL was surprisingly increasing to

1/256 in titer. Hence, we re-treated him with benzatin penicillin 2,4 million unit once a week for 3

consecutive weeks. We conclude that coinfection between these three diseases make the clinical

manifestation and histological become atypical, and it amay influence each other. Treatment of these

diseases combination was the same as the disease separately.

1 INTRODUCTION

Leprosy is a chronic infection of the skin and

peripheral nerves by Mycobacterium leprae (M.

leprae). The clinical spectrum of leprosy depends on

specific host immunity. Patients with tuberculoid

leprosy have good cell-mediated immune responses

to M. leprae, whereas those with lepromatous

disease do not have cell-mediated immune responses

but rather produce high titres of M leprae-specific

antibodies (Britton,2004) (Ustianowski,2006).

Syphilis and human immunodeficiency virus

(HIV) are both transmitted sexually and so it is not

surprising that a substantial number of people are

infected with both agents. HIV has several effects on

the presentation, diagnosis, disease progression, and

therapy of syphilis (Lynn,2004)(Stevenson,2006).

The interaction between syphilis and HIV infection

is complex and remains incompletely understood,

despite there being more than 2 decades of clinical

experience with coinfected patients

(Stevenson,2006).

Prevalence rates of HIV infected persons are also

increasing in many countries where leprosy is

endemic. Although the number of coinfected

patients has not been estimated, the increasing

geographic overlap of these two diseases will result

in increasing number of individuals being dually

infected (Ustianowski,2006). Meanwhile, there are

few number of case reports of leprosy that

association with HIV (T.S. Chandra Gupta, 2007).

Furthermore, the long incubation period and low

incidence of leprosy make it hardly to do studies

about coinfection leprosy and HIV

(Ustianowski,2006).

Clinical manifestasion of leprosy present with

skin lesion from hypopigmented to nodular lesion

and nerve damage (Ustianowski,2006). Likewise

syphilis, the skin lesion can form ulceration,

maculopapullar, to nodular (lynn,2004). Patients

with HIV often have several simultaneous or

sequential cutaneous conditions. In general,

noninfectious cutaneous abnormalities are not

prognostic of rapid progression of

immunosuppression, but it might be specific markers

of the stage of HIV disease (Maurer,1998). All of

them can resembling other diseases and lead

misstaken and delayed diagnosed for the clinician.

Luthﬁandi, M., Pudjiati, S. and Soebono, H.

Leprosy, Syphilis, and Human Immunodeﬁciency Virus Coinfection: A Case Report.

DOI: 10.5220/0008159904690472

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 469-472

ISBN: 978-989-758-494-7

469

Coinfection between leprosy, syphilis and HIV

are very rare, and their correlation remain unclear.

This report is to present a man of 55 years of age

diagnosed of leprosy with laten syphilis and HIV.

Hopefully, this paper may remind clinicians the

possible co-incidence between these infectious

diseases.

2 CASE

A 55 years old man, lived in Bantul, visited

outpatient clinic of dermatology and venerology, Dr.

Sardjito General Hospital with reddish spot in

almost all over the body. The history of present

illnes had started from 2 months before admitted the

clinic with reddish spots on the face and scalp,

which gradually extended to the whole body. No itch

nor pain were reported. He had seen dermatologist,

and treated as allergy, but no improvement. He was

then refered to our hospital. He frequently applied

hair dyes, and various cosmetics. Beside his wife, he

had multisexual-partners of three other men. , with

last sexual activity was 6 month ago with wife.

According to patient confession, he was forced for

sexual intercourse with three man 5 years ago, then

after that he never had sex except with his wife. He

also reported that he travelled alot due to his

profession. No history of diabetes mellitus,

hypertension, nor were reported

Dermatological status demonstrated erytematous

patches and plaques in various sizes, multiple,

discret distributed all over the body (Fig. 1-3). There

was enlargement of both ulnar nerves but no

sensitibility impairment in lesions, and nor motoric

and sensoric nerve impairment. The differential

diagnosis were made Morbus Hansen-Multi

Bacillary (MH-MB) BL/ LL type, Secondary

Syphilis, HIV/AIDS, and Allergic Contact

Dermatitis (ACD).

Laboratory examinations showed bacterial index

(BI) 3+ and morphological index (MI) 43.75%,

treponema palidum haemaglutination (TPHA)

positif, venereal disease research laboratory (VDRL)

1/32, HIV rapid test positive, and enzym linked

fluouroscent assay (ELFA) test for HIV was 23.31

(normal range <0.25) with CD4 only 4. Biopsy from

right upper arm lesion demonstrated histologially as

acute viral exanthem (Fig.4).

Working diagnosis in this case were MH MB

type BL/LL, latent syphilis, and HIV. We treated

him with MDT-MB regimen, intramuscular

injection of benzatin penicillin 2.4 million units in

single dose, and triple Fixed Drugs Combination

(FDC) (tenofovir 300mg, hiviral 300mg, and

efavirenz 600mg) once a day.

After a month, the skin manifestations were

improved leaving only hyperpigmentation in almost

all over the body. However, VDRL titer was even

higher which was 1/256. And the AFB smear were

+3 for BI and 20% MI. So, unresponsive diagnosis

of syphilis was made. Benzatin penicillin 2.4 million

units injection once a week in consecutive 3 weeks

was performed.. A month followed up showed that

VDRL titer was decreasing to 1/32.

3 DISCUSSION

Diagnosis for leprosy is made when one or more

cardinal sign are present, i.e hypopigmented or

reddish skin lesions with definite loss of sensation,

involvement (thickened) of the peripheral nerve, and

skin smear positif for acid fast bacilli (Britton,2004)

(ILA Technical Forum,2002). According to the

immunity, Ridley and Jopling clasifies the leprosy as

follows; indeterminate (I), tuberculoid tuberculoid

(TT), borderline tuberculoid (BT), borderline

borderline (BB), borderline lepromatous (BL), and

lepromatous leprosy (LL).

Which is tuberculoid

pole can be associated with rapid and severe nerve

damage, whereas lepromatous pole is associated

with chronicity and long-term complications.

Borderline disease is unstable and can be

complicated by reactions (Britton, 2004).

Figure 1. patches-plaques on the face

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

470

Figure 2. patches on the palm

Figure 3. patches-plaques on the trunk

Figure 4. A. HE staining 40x. B. HE staining 100x. C. HE

staining 400x. D. FF staining.

In this case, two cardinal sign was appear, i.e

thickened of the ulnaris nerve, and skin smear for

acid fast bacilli was positf 3 for BI and 43.75% for

MI. And there was no sensoric or motoric nerve

impairment. Even though histopathology

examination result was not suitable for leprosy. This

might be because the biopsy sample in the upper

right arm is a lesion from other diseases in this

patient. From this finding, we diagnosed the patient

as leprosy.

Syphilis is diagnosed using serological test, with

treponemal and non treponemal test. In majority, this

serological test can be accurately to diagnose

syphilis. However, direct testing methods, such as

dark-field microscopic examination, direct

fluorescent antibody-treponema pallidum (DFA-TP),

and polymerase chain reaction (PCR), should be

considered when the diagnosis of syphilis cannot be

confirmed (Stevenson,2006). In this case,

serological test with TPHA was positive, and VDRL

was positif with 1/32 in titer. With the manifestasion

rash almost all over the body and also found in

palms and soles, at the beginning we diagnosed with

secondary syphilis. But as the histopathology result

did not demonstrate skin lesion of syphilis, hence,

latent syphilis was considered. This was also

supported by the fact he might get the syphilis was

around 5 years ago, and that a month after treatment

with benzathin penicilin, the titer of VDRL was

increasing to 1/256 in titer.

Human immunodefiency virus were diagnosed

using rapid test with immunochromatographic (ICT)

and ELFA, which is the result was positif. With the

sensitivity 100% and specificity 98% for ELFA, we

can confirm the diagnosis for HIV (Ortiz,1996). In

this case, rapid test using ICT was done,with the

result was positive. Then we confirmed the result

with ELFA, and the result was positif. So, we

diagnosed this patient as HIV infection.

The therapy for leprosy with syphilis and HIV

coinfection is still the same with leprosy without

coinfection. HIV infection might affect the efficacy

of multidrug therapy for leprosy, with HIV-positive

patients potentially taking longer to clear

mycobacteria from lesions or experiencing a higher

relapse rate, but some published data suggest that

leprosy-HIV coinfected patients respond equally

well to multidrug therapy without the need for

prolonged treatment.

relapses are rare after

multidrug therapy, being about 1 per 1000 person-

years for tuberculoid patients and 0–20.4 per 1000

person-years for multibacillary patients

(Britton,2004)(Ustianowski,2006).

Penicillin remains the main therapy for all stages

and sites of syphilis and in all patient groups

(Lynn,2004)(US Centers for Disease Control and

Prevention,2002). the difference from syphilis

patients with and without HIV are in early phase of

the disease (< 2 years), where are patients without

HIV are treated with intramuscular benzatin

penicillin 2,4 million units in single dose. In

coinfetion with HIV, early disease can be treated

Leprosy, Syphilis, and Human Immunodeﬁciency Virus Coinfection: A Case Report

471

same as with non-HIV patient, but some clinician

recommend 3 dose at weekly interval (US Centers

for Disease Control and Prevention,2002).

4 CONCLUSION

We reported a case of 55 years old man with BL/ LL

leprosy, with latent syphilis, and HIV infection. The

skin manifestation and histopathological were

atypical, but these were supported by the laboratory

examinations which were acid fast bacilli,

serological test for syphilis and HIV serology. From

this case, we demonstrate that coinfection between

these three diseases is apparently possible, make the

clinical and histological features may be atypical, as

interactions each other between them. . In general,

the therapy is the same as the disease was separately.

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