"Lepromatous leprosy as a presenting feature of HIV:" Diagnostic and management dilemmas.

The authors have diagnosed this case as LL with erythema nodosum leprosum (ENL) without considering carefully the clinical presentation and symptomatology. We feel that the clinical morphology of the lesions looks more like histoid leprosy (HL). The patient has papulonodular lesions with central depression, over the face with normal looking intervening skin, and the absence of madarosis also supports the diagnosis of HL.[2] Most of the lesions on legs are infiltrated papulonodules with few showing crusting suggestive again of HL. The presence of more than the usual number of lesions in this patient most likely indicates its possible transformation to LL, which is known to occur though not often. [3] Further, the absence of systemic features such as fever, arthralgias, and neuritis is unusual for ENL, which has acute presentation with associated systemic features. The authors also mention that Mycobacterium leprae and HIV act synergistically which could worsen the nerve damage, but surprisingly this patient had all the sensations intact. Enlarged nerves with no nerve function impairment (NFI) or tenderness are also more consistent with the diagnosis of HL rather than LL with ENL. HL may present with thickened nerves and the NFI may appear much later. Although the association of HL with HIV is quite rare, two cases (one presenting as immune reconstitution inflammatory syndrome) have been reported by Bumb et al.[4] and Sivasankari et al. [5] in HIV‐infected patients taking highly active retroviral therapy for 9 and 11 months, respectively.