the cutaneous manifestations of leprosy in patients who are coinfected with leprosy and hiv are not different from those in conventional leprosy . after the introduction of highly active antiretroviral therapy ( haart ) , the leprosy hiv coinfection has manifested itself as an immune reconstitution inflammatory syndrome ( iris ) or immune restoration disease or immune reconstitution disease . some persons with hiv infection experience a clinical deterioration following initiation of antiretroviral therapy that is believed to be a consequence of the restored ability to mount an inflammatory response . this has been described among hiv infected individuals coinfected with mycobacterium tuberculosis , nontuberculous mycobacteria , cytomegalovirus , and hepatitis b and c viruses . the first report of leprosy presenting as iris was published by lawn et al . in 2003 . here we report a case of hansen 's disease borderline tuberculoid presenting with manifestations of type 1 lepra reaction , one among the myriad manifestations of iris . a 38-year - old male patient , diagnosed with retroviral infection and disseminated tuberculosis presented with weakness and numbness of the right hand of 2 weeks duration . he also noticed an edematous reddish raised lesion on the inner aspect of right hand , which he attributed to the topical agent he used for relieving the numbness . the patient had been on antitubercular therapy ( att ) followed by antiretroviral therapy ( art ) , 5 months prior to presentation at our department . dermatological examination showed a single well - defined erythematous plaque , 20  5 cm with raised borders on the ulnar aspect of right hand and distal forearm , extending to the palm [ figures 1 and 2 ] . a satellite lesion was present on the upper part of forearm , which also showed erythema and edema . both ulnar nerves were thickened with tenderness on the right side . slit skin smears from the earlobe , lesional , and normal skin were negative . histopathological examination showed dermal edema , diffuse granulomas composed of langhans type giant cells , surrounded by epithelioid cells , lymphocytes , multinucleated giant cells , and fibroblasts with perivascular lymphocytic infiltrate , consistent with hansen 's disease borderline tuberculoid type , with features suggesting type 1 lepra reaction [ figures 3 - 6 ] . erythematous plaque on the ulnar aspect of right hand erythematous plaque extending to the palm diffuse granulomas in the dermis ( h and e , 40 ) dermal edema with langhans giant cells , epithelioid cells and lymphocytes ( h and e , 40 ) section under high - power showing diffuse dermal edema and granulomas ( h and e , 40 ) granuloma surrounded by lymphocytes and epithelioid giant cells ( h and e , 100 ) thus correlating the clinical , bacteriological , and histopathological features , a diagnosis of hansen 's disease borderline tuberculoid with type 1 lepra reaction presenting as iris was made . mb - mdt was started , avoiding rifampicin from the regimen , as patient was also on att . iris is characterized by a paradoxical worsening of an existing infection or disease process , soon after initiation of haart . the immunopathogenesis of the syndrome is unclear and appears to be the result of unbalanced reconstitution of effector cells and regulatory t cells , leading to exuberant inflammatory response in patients receiving art . biomarkers including inf- , tnf , crp , and il-2 , 6 and 7 are the subject of intense investigation at present . the most common forms of iris are associated with mycobacterial infections , fungi , and herpes viruses . there must be temporal association between initiation of art and subsequent development of symptoms ( usually within 3 months ) , with evidence of immune restoration ( viral and immunological response demonstrated by a decrease in plasma hiv rna level by more than 1log10 copies / ml and an increase in cd4 t - cell count from baseline ) , and must exhibit clinical symptoms and signs consistent with an inflammatory process . the clinical course should neither be consistent with the usual course of a previously diagnosed opportunistic infection or a new infectious process , nor should the symptoms and signs be explained by drug toxicity . the first case of hansen 's disease presenting as iris was reported in 2003 by lawn et al . in a previously healthy 37-year - old man from uganda , who also had pulmonary tuberculosis . furthermore , there have been several reports of hiv and leprosy coinfections in which iris occurred after initiation of haart . in the study by pereira , et al . , a significant percentage of co - infected patients were classified as the borderline tuberculoid leprosy . a review of the indian scenario revealed only five cases of hansen 's disease presenting as iris . all were of the borderline tuberculoid type and were asspciated with type 1 lepra reaction . our patient had pre - existing immunosuppression ; features of lepra reaction occurred within 5 months of initiation of haart . the diagnosis of hansen disease borderline tuberculoid with type 1 lepra reaction in this patient indicates an improvement in the cell - mediated immunity , specifically the low cd4 count at initiation of haart .
immune reconstitution inflammatory syndrome is characterized by a paradoxical worsening of an existing infection or disease process , soon after initiation of highly active antiretroviral therapy . 
 the first case of leprosy presenting as immune reconstitution inflammatory syndrome was published in 2003 . here 
 we report a case of hansen 's disease borderline tuberculoid presenting with type 1 lepra reaction 5 months after initiation of highly active antiretroviral therapy .