Leprosy and HIV Infection in Bahia, Brazil


Leprosy and HIV Infection in Bahia, Brazil

66, 2^ Correspoitdence—D. Samuel Thomson Sugumaran,M.I3.13.S.,,S'pecia/ist, Branch ofMedicineSundar Raj GOrla, M.B.B.S.Sunitha Abraham, M.B.B.S.Medica/ (Vicers,S'ehicf/M,/ Leprosy Research& Training CenterKari,i;iri 632 106Mini! NaduSouth hulloREFERENCES1. CoNN, II. 0. and BITF/L12. B. L. Nonassociation ofadreno-eorticosteroid therapy and peptic ulcer. N.Engl. J. 'Med. 294 (1976) 473-479.2. Gril.ANin, N. and Tin( ilium, A. Steroid ulcers; amyth revisited. BNB 304 (1992) 655-656.3. MEssiT, J., RISIKAN, D., SAcKs, II. S., SN11111, J.,JR. and ClIALNILIZS, T. C. AtisOCiatioil of adrenocorticosteroidtherapy and peptic-ulcer disease. N.Engl. J. Med. 309 (19S3) 21-24.4. SNP°, I I.M. Is the steroid ulcer a myth? N. Engl. J.Med. 309 (1983) 45-47.Leprosy and HIV Infection in Bahia, Brazil.l'o it EDI iotz:Human immunodeficiency virus (HIV)infection progression is characterized by agradual decrease of CD4+ T cells tissociatedwith the loss of host defenses againstseveral pathogens and development of op-portunistic infections. Since the protectionagainst leprosy correlates with the expressionof cell-mediated immunity, one couldexpect an increased number of leprosycases among 1-1 IV-infected individuals. InBrazil, the number of registered cases ofAIDS is continuously increasing. This isalso a problem in Bahia, where leprosy isan endemic disease (prevalence rate per10,000 was 3.91 in 1995). The aim of thisstudy is to determine the possible associationbetween new leprosy cases and HIVinfection.Newly diagnosed cases of leprosy whohad attended the outpatient leprosy serviceof the Hospital Universittirio Prof. EdgardSantos in Salvador, Bahia, Brazil, betweenMarch 1993 and May 1995 were enrolled inthe present study. Additionally, sera obtainedfrom leprosy patients and controlsliving at Irece, an endemic leprosy ruralarea in the center of Bahia, were also included.A case of leprosy was defined as anindividual with newly diagnosed and previouslyuntreated leprosy, aged between 15–60 years, and a resident of Bahia. Up to twocontrols living in the same area and/orhealthy contacts were chosen for each pa-.tient. A standardized questionnaire wasused to register gender, age, residence andhigh-risk behavior to HIV infection in thetwo groups, including sexual activity, intravenousdrug use and blood transfusion.Blood was obtained froin consenting patientsor controls and the serum was separatedand kept at –20°C until the realizationof the assays to determine anti-HIV antibodies.All sera were tested with an enzymeIi nked inummosorbent assay (ELISA) forantibodies to HIV (HIV-1/HIV-2 ELISAtest kit; Cambridge Biotech). The positivesamples were further analyzed with a secondEISA (Enzygnost anti-I 1IV 1/2 plus;Behring), or with a solid-phase enzyme immunoassay(Immunocomb Bi-spot HIV!and HI V2). The samples which gave negativeresults in the second NASA and/or Immunocombwere considered negative forHIV infection. The samples that remainedpositive were tested by Immunolluorescenceassay (IFA) or Western blot ( W13) (Genelabsdiagnostic 111.1'1 1.3, Cellular products) inorder to conlinll FI1V seropositivity.RESUI:FS AND DISCUSSIONSera from 234 patients and 468 controlswere evaluated. Distribution by gender andage are shown in Table 1. Most of the patients(79.5%) and controls (86%) lived inSalvador city and the remainder in ruralareas.Case distribution according to leprosyclassification and the results of HIV testsare shown in Table 2. Although 13 out of234 patients and 1 out of 468 controls hadat least one positive ELISA test, no positiv-

228^ International Journal of Leprosy^ 1998T,%131.E I. Distribution of patients and controls by gender and age.MaleFemale5590^45^3347.9%^24%^17.5%117^34^1064.9%^18.8%^5.5%Total188'100%180 ,100%ity was confirmed by Immunocomb or WB.The majority (9/14) of our HIV-positivecases in the first ELISA test were from thelepromatous leprosy group; only I wasfrom the control group (Table 2).HIV infection was not detected amongnewly diagnosed leprosy patients in Bahiain northeastern Brazil in this study. Otherstudies carried out in African countries andin some regions of India, where leprosy andAIDS are both endemic, did not show an associationbetween the two diseases (L-3.5-7).Another study conducted in Malawi foundhigher levels of HIV infection amongnewly diagnosed leprosy patients, but noclear association between HIV infectionand leprosy incidence was found (s).In some studies, HIV seropositivity wasmore frequent in multibacillary than in paucibacillarypatients (I•".7); in other studiesthis was not found (2.4.5). We found a higherratio of false-positive ELISA results for HIVantibodies in lepromatous leprosy patients.The reasons that may account for the unexpectedlack of correlation between HIVinfection and leprosy are not known. In ourstudy, a majority of the patients and controlsseemed to have very low behavioralrisk for HIV infection as indicated by thequestionnaire. In addition, most leprosy patientscame from areas in which HIV prevalenceis low. These factors may explain theHIV seronegativity found. Another way toexamine this association should include determinationof leprosy infection in newlydiagnosed HIV-positive patients, but this istechnically very difficult.Our results suggest that in our regionnew leprosy cases are not associated withHIV infection. Larger studies performed inother areas endemic for leprosy in Brazil,where an increase of HIV infection hasbeen detected, may help to better define thepotential interaction between the two diseasesin Brazil.Servico de ImunologiaHUPES—Paulo Machado, M.D.Yonara David, M.D.TA13LE 2. Prevalence of HIV seropositivity among leprosy cases and controls.Total l^ELISA 2"' ELISA Imcomb IFA WBLeprosy casesIndeterminate 48 1/48 0/1 ND' 0/1 NDTuberculoid 50 2/50 ND 0/2 ND 0/14%Borderline 73 1/73 0/1 ND 0/1 ND1.4%Lepromatous 63 9/63 1/4 0/3 1/4 0/314.3%All leprosy patients 234 13/234 1/6 0/5 1/5 0/45.3%Controls 468 1/468 1/1 ND 1/1 0/I0.21%ND = Not done.

66, 2^ Correspotidetice^ 229Universidade Federal da BahaiRua Joao (las Botas„sin40.110-040 SSA-Bahia, Brasil—Celia Pedroso, B.Sc.Carlos Brites, M.D.HUPESUniversidade Federal da BahaiSSA-Bahia, Brasil—Aldina Barra], M.D.Manoel Barral-Netto, M.D.Servico de ImmologinHUPESUniversidade Federal da BahaiSSA-Bahia, BrasilandCentro de Pesquisas Gwicalo MunizF1OCRUZSSA-Bahia, BrasilReprint requests to Dr. Machado at theabove address or FAX 55-71-245-7110.Acknowledgment. We thank Dr. Howard Engersfor his encouragement in performing this study. Mrs.Aldacy Andrade provided efficient support in the outpatientleprosy clinic. M. B.-N. and A. B. are SeniorInvestigators and Y. D. received a scientific initiationfellowship from CNN" (Brazilian National ResearchCouncil). This work was supported by a grant from theSpecial Programme for Research and Training in TropicalDiseases (TDR) of the UNDP/World Bank/WorldHealth Organization.REFERENCESI. BORGDOREE, M. \V., VAN DEN BROEK, J., CHUM, H.J., KLOKKE, A. H., GRAF, P., BARONGO, L. R. andNEwo.I., J. N. HIV-I infection as a risk factor forleprosy; a case-control study in Tanzania. Int. J.Lepr. 61 (1993) 556-561.JAvAsiitio.A, NI., Sii.ARmA, R. N., SEKAR, B. andTtivAGARAJAN, S. P. 111V infection amongst leprosypatients in south India. Indian J. Lepr. 66(1994) 428-432.3. KAWUMA, H. J., Bwuth, R. and ADATU-ENGWAU, F.Leprosy and infection with the human immunodeficiencyvirus in Uganda; a case-control study. Int. J.Lepr. 62 (1994) 521-526.4. LIENHARDT, C., KAmATE, B., JAMET, P., TOUNKARA,A., FAYE, 0. C., Sow, S. 0. and BOBIN, P. Effect ofHIV infection on leprosy: a three-year survey inBamako, Mali. Int. J. Lepr. 64 (1996) 383-391.5. MUNYAO, T. M., BWYAO, J. J., Owiff, D. W.,NDINYA ActioALA, J. 0., KwAsA, T. 0. and KRoss,J. K. Human immunodeficiency virus-1 in leprosypatients attending Kenyatta National HospitalNairobi. East Air. Med. 71 (1994) 490-492.6. OitfiGE, P. A., FINE, P. E. M., LUCAS, S. B., OBt:RA,NI., CH:o.o, C., OKUKU, P. and Woti:, M. A casecontrolstudy on human immunodeficiency virus-I(111V-1) infection as a risk factor for tuberculosisand leprosy in western Kenya. Tuberc. Lung Dis.74 (1993) 377-381.7. SEKAR, B., JAYASIIIIELA, M., CIEVITOPADIIYA, D.,ANANDAN, D., RATIIINAVEI., L., VASANTIII, B., SUB-RAMANIAN, M. and RAo, P. S. Prevalence of HIVinfection and high-risk characteristics among leprosypatients of South India, a case-control study.Int. J. Lepr. 62 (1994) 527-531.8. STERNE, J. A. C., TURNER, A. C., FINE, P. E. M.,PARRY, J. V., LU(7AS, S. B., P0NsiG0Aus, J. M.,NIKANDwutE, P. K., NN'Astim, S. and WARNoRff, D.K. Testing for antibody to human immunodeficiencyvirus type 1 in a population in which mycobacterialdiseases are endemic. J. Infect. Dis. 172(1995) 543-546.Arsenic Poisoning Mimicking Polyneuritic LeprosyTo TIIE EDITOR:Arsenic and mercury compounds areknown ingredients of Indian ethnic remedies(5). These medicines are prescribed bypractitioners of Ayurvedic, Unani and otherindigenous systems of Indian medicine forvarious cutaneous and systemic diseases.Acute arsenic exposure may produce sensory-motorneuropathy without any cutaneouschanges. This could be confused forpolyneuritic leprosy. We report one suchcase of arsenic poisoning mimicking polyneuriticleprosy.CASE REPORTA 65-year-old housewife presented atour neurology outpatient department withcomplaints of tingling, paresthesias, difficultlyin rising from a squatting positionand bilateral weakness of the upper limbs of1-week duration. These symptoms developedwithin 3-4 days after intake of "desimedication"from a "Hakim" for cough and

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