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Case of the Month - July 2020

L. Richards MBBCh, Mmed(wits), FCP(SA)
J Nel MBChB, FCP(SA), Cert ID(SA), DTM&H
Department of Internal Medicine, division of Infectious Diseases, Helen Joseph Hospital

Photosensitive disorders in HIV

Case presentation

A 48-year-old female presented to hospital in February 2020 with a 1-week history of ‘generalised body weakness’ and diarrhoea. No haematochezia was noted. In addition, she had been coughing for 3 weeks and this was associated with loss of weight and night sweats. On further enquiry she complained of a 1- year history of a rash on her face, neck and arms. It started as raised, dark areas and progressed to its current state. It had never been pruritic or painful. She had no history of joint pain or stiffness, no Raynaud’s phenomenon, no mucosal ulceration, no sicca symptoms or alopecia. She had no animal exposure or travel history. She had never used any skin-lightening products and had no known allergies.

The patient was HIV reactive and is currently on zidovudine 300mg daily, lamivudine 300mg daily and lopinavir/ritonavir 400mg/100mg 12-hourly which was started on January 3rd 2020. Her antiretroviral treatment (ART) history prior to this is unclear, although it was thought that she was on tenofovir DF/emtricitabine/efavirenz fixed dose combination tablet previously. The patient was admitted to another hospital in December 2019 with a right cerebrovascular accident (CVA). Her other chronic medication includes aspirin and simvastatin started after her CVA.

On admission her vital signs were: a heart rate of 128b/min, blood pressure 92/63mmhg, she was pyrexial with a temperature of 38.2°C, her respiratory rate was 20b/min and a random glucose was 8.2mmol/L. Generally, she was wasted and chronically ill looking. She had hypopigmented, vitiligo-like, erythematous depigmentation of her face, neck and arms. (Figures 1-4) There was some skin scaling around these areas. She had no significant lymphadenopathy. On auscultation of her chest she had decreased breath sounds in the left lower zone. She has a residual left hemiplegia on her neurological exam with a power of 3/5, increased tone and hyperreflexia. Her cardiovascular and abdominal examination were unremarkable.

Figure 1: The patient’s rash on her forehead

Figure 2: The patient’s rash on posterior neck and upper back

Figure 3: The patient’s rash on her chest

Figure 4: The patient’s rash on her right forearm

She had a CD4 count of 5 cells/µL, an HIV viral load of 287 000 copies/mL and a negative serum cryptococcal antigen. Her sputum GeneXpert MTB/Rif Ultra came back positive for M. tuberculosis, with rifampicin sensitivity