AMAZON REGION SPECIAL SECTION LETTERS

3. De Vries GA, Laarman JJ. A case of Lo- Variations in with 21 patients with leprosy and HIV bo’s disease in the dolphin Sotalia guian- co-infection. ensis. Aquatic Mammals. 1973;1:26–33. Leprosy 4. Caldwell DK, Caldwell MC, Woodard Patient 1 was a 29-year-old JC, Ajello L, Kaplan W, McClure HM. Manifestations woman whose HIV-1 infection was Lobomycosis as a disease of the Atlantic among HIV-Positive diagnosed in May 2002 at antenatal bottle-nosed dolphin (Tursiops truncatus examination. Her CD4 cell count in Montagu, 1821). Am J Trop Med Hyg. Patients, Manaus, 1975;24:105–14. 2002 was 513 cells/μL. In Novem- 5. Symmers WS. A possible case of Lôbo’s Brazil ber 2007, she sought treatment at disease acquired in Europe from a bot- the Institute of Tropical Medicine of tle-nosed dolphin (Tursiops truncatus). To the Editor: Contrary to early Amazonas with a 3-month history of a Bull Soc Pathol Exot Filiales. 1983;76: expectations, the co-occurrence of lep- single erythematous plaque on her left 777–84. rosy and HIV has not increased glob- 6. Simões-Lopes PC, Paula GS, Xavier FM, arm, which was clinically diagnosed Scaramelo AC. First case of lobomy- ally (1). However, most of the larger as borderline tuberculoid (BT) lep- cosis in bottlenose dolphin from south- studies on the subject were conducted rosy. The patient’s sensitivity to pain ern Brazil. Marine Mammal Science. in the early to mid-1990s in African was decreased. There was no nerve 1993;9:329–31. DOI: 10.1111/j.1748- countries, and the research designs 7692.1993.tb00462.x enlargement. Histopathologic exami- 7. Reif JS, Mazzoil MS, McCullogh SD, Va- had limited power to describe the true nation confi rmed the diagnosis, show- rela R, Goldstein JD, Fair P, et al. Lobo- effects of co-infection (1). Moreover, ing a granulomatous dermatitis with mycosis in Atlantic bottlenose dolphins the introduction of highly active an- no acid-fast bacilli on Wade stain. At from the Indian River Lagoon, Florida. tiretroviral therapy (HAART), which J Am Vet Med Assoc. 2006;228:104–8. this time, her CD4 cell count was 342 DOI: 10.2460/javma.228.1.104 has been used routinely in Brazil since cells/μL. HAART and multidrug ther- 8. Van Bressem M-F, Van Waerebeek K, 1996, altered the clinical evolution of apy (MDT) for paucibacillary leprosy Reyes JC, Felix F, Echegaray M, Siciliano HIV infection (2) and led to increas- were initiated. The leprosy resolved, S, et al. A preliminary overview of skin ing reports of immune restoration and skeletal diseases and traumata in and the lesion disappeared within 2 small cetaceans from South American wa- infl ammatory syndrome (IRIS) as- months of therapy. ters. Latin Journal of Aquatic Mammals. sociated with leprosy (3,4). Although Patient 2 was a 22-year-old man 2007;6:7–42. some researchers have argued that who had neurocryptococcosis and 9. da Silva VM, Martin AR, Mikesh E. Skin this association may not affect public disease and lesions in the boto Inia geof- HIV infection diagnosed in September frensis in the central Amazon. Abstracts health (2), its true importance remains 2007. At that time, he exhibited dis- of the 2008 Workshop on Cetacean Skin to be clarifi ed. Finally, leprosy has a seminated, infi ltrated lesions on the Diseases; 2008 May 30–31; Santiago de wide range of clinical manifestations, trunk and upper and lower limbs. Bor- Chile, Chile. Cambridge (UK): Interna- which sometimes imposes a clinical tional Whaling Commission; 2008. Ab- derline lepromatous (BL) leprosy was stract: SC/60/DW5. challenge and may lead to misdiag- clinically diagnosed. Skin biopsy con- 10. Taborda PR, Taborda VA, McGinnis MR. nosis (5). Together, these factors may fi rmed the diagnosis; the biopsy speci- Lacazia loboi gen. nov., comb. nov., the have helped mask the true scenario of men showed a granulomatous dermati- etiologic agent of lobomycosis. J Clin Mi- leprosy and HIV co-infection, particu- crobiol. 1999;37:2031–3. tis, foamy cells, and multiple acid-fast larly in areas where these conditions bacilli. His CD4 cell count was 6 cells/ Address for correspondence: Alberto Enrique are highly endemic. In this context, μL. HAART and MDT for multibacil- Paniz-Mondolfi , Department of Pathology and case reports from referral centers lary leprosy were prescribed. In Feb- Laboratory Medicine, St. Luke’s-Roosevelt- that refl ect the broad clinical aspects ruary 2008, the patient was readmitted Beth Israel Medical Center, University Hospital of leprosy and HIV co-occurrence to the Institute of Tropical Medicine of Columbia University College of Physicians are important to increase clinicians’ of Amazonas and died of nonspecifi ed and Surgeons, 1000 10th Ave, New York, NY awareness of both diseases. bacterial pneumonia and sepsis. 10019, USA; email: [email protected] We report 3 HIV-positive/AIDS Patient 3 was a 23-year-old wom- patients who showed different clinical an who had HIV-1 infection (CD4 cell manifestations of leprosy; their condi- count 435 cells/μL) diagnosed in No- tions were diagnosed before and after vember 2006 at antenatal examination. HAART initiation. All patients lived HAART was begun 3 months later. In in Manaus, the capital of the state of August 2008, she sought treatment Amazonas in Brazil, an area where with a 3-month history of a single both leprosy and HIV infection are patch on the left leg with erythematous endemic. The 3 patients represent a papules on its border (Figure). There sample from our 11-year experience was decreased pain sensitivity in the

Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 4, April 2009 673 THE AMAZON REGION LETTERS

Author affi liations: Institute of Tropical Medicine of Amazonas, Manaus, Brazil (C. Talhari, C. Matsuo, A. Chrusciak-Talhari, L.C. de Lima Ferreira, S. Talhari); State University of Amazonas Faculty of Medi- cine, Manaus (C. Talhari, C. Matsuo, A. Chrusciak-Talhari, L.C. de Lima Ferreira, S. Talhari); and Pontifi cal Catholic University of Parana, Curitiba, Brazil (M. Mira)

DOI: 10.3201/eid1504.081300

References

1. Ustianowski AP, Lawn SD, Lockwood DNJ. Interactions between HIV infection and leprosy: a paradox. Lancet Infect Dis. 2006;6:350–60. DOI: 10.1016/S1473- 3099(06)70493-5 Figure. Skin lesion of patient 3, a solitary patch on the left leg with erythematous papules 2. Lawn SD, Lockwood DN. Leprosy af- on the border. ter starting antiretroviral treatment. BMJ. 2007;334:217–8. DOI: 10.1136/ bmj.39107.480359.80 lesion and no nerve enlargement. At a full-blown AIDS background). For 3. Lawn SD, Wood C, Lockwood DN. Bor- derline tuberculoid leprosy: an immune that time, her CD4 cell count was 372 patient 3, a distinct outcome was ob- reconstitution phenomenon in a human cells/μL. Histopathologic examination served: the appearance of an atypical immunodefi ciency virus–infected per- showed tuberculoid granulomas con- BT lesion during HAART. Recently, son. Clin Infect Dis. 2003;36:e5–6. DOI: sisting of lymphocytes and epithelioid we reported 3 cases of IRIS associ- 10.1086/344446 4. Talhari C, Machado PRL, Ferreira LC, cells. Wade staining showed no acid- ated with leprosy in which BL leprosy Talhari S. Shifting of the clinical spec- fast bacilli. Histopathologic fi ndings shifted unexpectedly to BT leprosy trum of leprosy in an HIV-positive patient: led to a diagnosis of BT leprosy. MDT (4,6). Host genetic make-up and un- a manifestation of immune reconstitu- for paucibacillary leprosy was prompt- known consequences of HIV-infection tion infl ammatory syndrome? Lepr Rev. 2007;78:151–4. ly started, and HAART was continued. over specifi c leprosy immune mecha- 5. Britton WJ, Lockwood DN. Leprosy. Lan- When she was last seen, in December nism may be implicated in these un- cet. 2004;363:1209–19. DOI: 10.1016/ 2008, the skin lesion had disappeared usual outcomes. Further prospective S0140-6736(04)15952-7 and she was still receiving MDT. studies should be performed to eluci- 6. Talhari C, Ferreira LC, Araújo RB, Chr- usciak-Talhari A, Talhari S. immune re- The reliability of the cardinal date these fi ndings. constitution infl ammatory syndrome or signs of leprosy (hypopigmented or Although previous studies have upgrading type 1 reaction? Report of two reddish patches with defi nite loss shown that HIV infection is not a risk AIDS patients presenting a shifting from of sensation, thickened peripheral factor for leprosy (1), clinicians should borderline lepromatous leprosy to bor- derline tuberculoid leprosy. Lepr Rev. In nerves, and positive skin smears or be aware of this potential co-infection, press. biopsy material) has been widely ac- which may mimic different skin dis- 7. Martiniuk F, Rao SD, Rea TH, Glickman cepted (5). However, in some diffi cult eases. Moreover, reports of leprosy MS, Giovinazzo J, Rom WN, et al. Lepro- cases, the defi nitive diagnosis relies after HAART initiation have been de- sy as immune reconstitution infl ammatory syndrome in HIV-positive persons. Emerg solely on the histopathologic exami- scribed from countries where leprosy Infect Dis. 2007;13:1438–40. nation, which often depends on the ex- is not endemic (7). Precise diagnosis perience of the pathologists working and prompt treatment of leprosy in co- Address for correspondence: Sinésio Talhari, in referral centers. According to most infected persons are mandatory. Institute of Tropical Medicine of Amazonas, pre-HAART studies, the clinical spec- State University of Amazonas, Dermatology trum of leprosy seems to be preserved Carolina Talhari, and Pathology, Av Pedro Teixeira 25, in HIV-positive and AIDS patients (1). Christiane Matsuo, Manaus, Amazonas 69040-000, Brazil; email: This is in agreement with the course of Anette Chrusciak-Talhari, [email protected] disease in patient 1 (a typical BT lesion Luis Carlos de Lima Ferreira, before initiating HAART) and patient Marcelo Mira, 2 (a typical multibacillary leprosy in and Sinésio Talhari

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