Publication:

The ear, the nerves and the joints: a diagnostic puzzle in newly diagnosed HIV infection: a case report of HIV-associated inflammatory arthropathy mimicking Hansen disease and other infectious rheumatological mimics

A 53-year-old man with newly diagnosed HIV-1 infection (CD4+ T-cell count 178 cells/µL) developed a 3-month febrile inflammatory polyarthritis, dactylitis, painful auricular inflammation, nodular and ulcerative skin lesions, hypopigmented macules, and enlargement of bilateral common peroneal and ulnar nerves. Rheumatoid factor, anti-cyclic citrullinated peptide antibody and antinuclear antibody were negative. Slit-skin smears from two sites were negative for acid-fast bacilli (bacteriological index 0); the patient declined skin and lymph-node biopsies. Computed tomography of the chest showed bilateral cavitary consolidation, although sputum acid-fast smears and cartridge-based nucleic acid amplification testing were negative, mycobacterial culture was not performed, and bronchoscopic lavage was non-diagnostic. HIV-associated inflammatory arthropathy remained the working diagnosis. Arthritis and auricular inflammation improved during antiretroviral treatment, empirical antituberculous therapy and a tapering course of prednisolone, but Hansen disease and a lepra reaction could not be confidently excluded.