leprosy also known as hansen 's disease is a chronic disease caused by mycobacterium leprae . the propensity of the bacilli to affect peripheral nerves , produce characteristic deformities or debilitating type 1 or type 2 lepra reactions are the major causes of morbidity . type 2 lepra reaction is an immunologically mediated gell and coomb 's type iii hypersensitivity reaction . it presents in patients with lepromatous and borderline lepromatous leprosy usually before , during and rarely after multidrug therapy ( mdt ) for leprosy . human immunodeficiency virus ( hiv)-infected patients also having leprosy usually present with type 1 lepra reaction and there are many reports and review about this phenomenon . this presentation is considered to be a form of immune reconstitution inflammatory syndrome . on the contrary , the occurrence of type 2 lepra reaction is very rare in these patients even in the lepromatous spectrum . there is no well - explained cause for this phenomenon till date . in the last decade in spite of numerous reports of type 1 lepra reaction in hiv - coinfected leprosy patients , reports of type 2 lepra reaction in such patients has been scarce . we present a case of acquired immunodeficiency virus ( aids ) with lepromatous leprosy with tubercular lymphadenitis with recurrent type 2 lepra reaction manifesting as erythema nodosum leprosum ( enl ) probably precipitated by filariasis . due to relative rarity of the occurrence of this phenomenon , we are reporting this case . a 35-year - old male presented with recurrent episodes of high grade fever without diurnal variation with red , raised lesions for past 1 year . the lesions were mainly present on face , ears , upper trunk , and upper limbs and the present episode was for 1 week . he also complained of pain in bilateral knee joints for 1 week without any swelling or restricted movements . patient was on antiretroviral therapy ( art ) for past 1 year with zidovudine , lamivudine , and efavirenz . he had inguinal lymphadenitis 7 months ago for which fine needle aspiration cytology was done which showed tubercular lymphadenitis , and antitubercular treatment ( att ) was instituted . he is now taking isoniazid 300 mg , rifampicin 450 mg , and ethambutol 825 mg . he had taken mdt twice in the past year for multibacillary leprosy and was a defaulter . on examination , patient was febrile on presentation and emaciated with body mass inde 18.5 kg / m . severe pallor with bilateral pitting pedal edema was noted . there was glove and stocking anesthesia on bilateral hands and feet with thickening of right superficial radial , bilateral ulnar , and common peroneal nerve . patient had tender erythematous nodules on his face , upper limbs , upper trunk , and ears [ figures 1 and 2 ] . there was no associated nerve tenderness , testicular swelling , lymphadenopathy , ocular pain , or photophobia . his investigations showed severe anemia with hemoglobin ( hb ) 4.4 g% and mean corpuscular volume ( mcv ) 77 fl , and total count was 3,700 cells / mm , but his differential count was normal . absolute cd4 lymphocyte count was 90 cells/l and dipstick enzyme - linked immunosorbent assay ( elisa ) for filarial antigen was positive . his liver and renal function tests , chest x - ray , x - ray of bilateral knee joints , and urine routine were within normal limits . blood and stool culture and streptococcal throat swab showed no growth of organisms and his widal test for typhoid and microscopy for malarial parasite was negative . skin - slit smear was 6 + for acid - fast bacilli ( afb ) [ figure 3 ] . biopsy from a nodule showed superficial and deep periadnexal granulomatous inflammation with neutrophils and nuclear debris around vessels [ figure 4 ] . based on the above , a diagnosis of aids , lepromatous leprosy with type 2 lepra reaction manifesting as enl , tubercular lymphadenitis , and filariasis was made . the patient was started on clofazimine 50 mg daily and monthly 300 mg supervised dose , rifampicin 150 mg monthly , ofloxacin 200 mg twice daily , thalidomide 100 mg daily , and diethylcarbamazine 100 mg thrice daily with iron supplements . dapsone was stopped due to fear of further hemolysis and zidovudine was stopped for suspicion of bone marrow suppression . clinical photograph showing erythematous papulonodular lesions on extensor aspect of forearms and arms erythematous plaques with ill - defined irregular borders on back of arms and shoulders skin - slit smear examination showing 6 + acid - fast bacilli histopathology showing superficial and deep periadnexal granulomatous inflammation with neutrophils around vessels . leprosy is a chronic disease by infection of various tissues of the body by mycobacterium leprae . unfortunately , india is a leprosy endemic country . india is also endemic for aids and hence there is a relatively higher probability of the two occurring together . in a study by vinay et al . , the incidence of leprosy in patients on art was 5.22 per 1,000 person - years ( 95% confidence interval , 2.25 - 10.28 ) . patients affected with both aids and leprosy commonly present with type 1 lepra reaction , usually on initiation of art as a type of immune reconstitution disease ( ird ) . rarely such patients when affected with lepromatous or borderline lepromatous leprosy can present with type 2 lepra reaction . type 2 lepra reaction is an inflammatory systemic reaction in which immune complexes can deposit in any organ or tissue and can have varied presentations . neuritis , orchitis , uveitis , periostitis , lymphadenitis , and glomerulonephritis can occur rarely . vinay et al . , reported a case series of eight patients in which three had type 2 lepra reaction . similarly pai et al . , reported a case series of 11 patients coinfected with hiv and leprosy in which two patients had type 2 lepra reaction . in our review of literature on the concerned topic it has been postulated that type 2 lepra reaction can be precipitated by intercurrent infections , stress , pregnancy , lactation , and various drugs . there have been case reports of filarial infection precipitating type 2 lepra reaction from our country . our case was having aids with tubercular lymphadenitis with type 2 lepra reaction manifesting as enl with filariasis . his filarial infection was diagnosed by dipstick elisa for filariasis with 98% sensitivity for detection of both brugian and bancroftian filariasis . the cause of precipitation of the present episode could have been both default of treatment and filarial infection . india being a country endemic to hiv , leprosy , and infections like filariasis and tuberculosis ; concurrent occurrence of any of these can modify the course and presentation of each other and pose diagnostic and therapeutic challenges .
though patients affected with both acquired immuno deficiency syndrome ( aids ) and leprosy commonly present with type 1 lepra reaction , there are few isolated reports of type 2 lepra reaction in retropositive patients affected with leprosy . 
 we are presenting a case report of 35-year - old male affected with aids , tubercular lymphadenitis , and lepromatous leprosy with recurrent episodes of type 2 lepra reaction manifesting as erythema nodosum leprosum ( enl ) . 
 dipstick enzyme - linked immunosorbent assay ( elisa ) for filarial antigen was also positive . 
 the patient was treated with 100 mg thalidomide daily , 300 mg diethylcarbamazine , and modified multidrug therapy ( mdt ) for leprosy . 
 he responded well and has not had any further reaction in the last 6 months .