Brazil is endemic for leprosy and HIV/AIDS. This coinfection may affect immune response, favoring atypical manifestations of leprosy and leprosy reactions, including erythema nodosum leprosum (ENL) and reversal reactions, especially after initiation of antiretroviral therapy (ART). Thalidomide, associated with corticosteroids in cases of neural or systemic involvement, is the cornerstone of ENL treatment. This case highlights the complexity of clinical management and the importance of investigating opportunistic systemic fungal infections in patients with HIV/AIDS and leprosy who present therapeutic failure and severe immunodeficiency. A 48-year-old woman diagnosed with HIV/AIDS in 2004 and lepromatous leprosy in 2020, with a history of poor treatment adherence. On 12/05/2024, she sought care at a Leprosy Reference Center with a 30-day history of afternoon fever, night sweats, chest pain, headache, and mood changes. At that time, HIV viral load was 162,000 copies/mL and CD4 T-lymphocyte count was 73 cells/mm³. During hospitalization, she developed intracranial hypertension requiring external ventricular drainage, orotracheal intubation, and mechanical ventilation. Diagnostic workup confirmed disseminated histoplasmosis and excluded central nervous system involvement by leprosy (qPCR for M. leprae DNA negative in cerebrospinal fluid). The patient was irregularly using ART (tenofovir, lamivudine, darunavir/ritonavir) and had received two leprosy regimens (rifampicin, ofloxacin, minocycline; later rifampicin, moxifloxacin, clarithromycin, minocycline), in addition to prednisone, thalidomide, and pentoxifylline for leprosy reaction. Despite multiple interventions, including intensive management of intracranial hypertension, the patient died after 25 days of hospitalization due to opportunistic infection by Histoplasma capsulatum in the presence of the reported comorbidities. This case reinforces the importance of a multidisciplinary approach and rigorous monitoring in patients coinfected with HIV/AIDS and leprosy who develop persistent leprosy reactions. Active surveillance for opportunistic infections is essential to identify and treat subclinical infectious triggers and to prevent severe and highly lethal outcomes. The complex interaction between diseases and their impact on the patient’s immune system require individualized treatment and comprehensive investigation.
Lima et al. (Sun,) studied this question.