How do effector memory CD4+ T cells migrate to the epidermis?

Clinical case study 1

Patient Presentation

A 55-year old HIV-infected male was referred to the Dermatology Outpatient Clinic with a four month history of a swollen face and multiple skin nodules.

Acknowledgement

Ranks Lehloenya, Dr. Khadija Shebe and Prof. Gail Todd from the Department of Dermatology.
Dr Sipho Dlamini from the Department of Infectious Diseases, Groote Schuur Hospital, Cape Town.
Dr Carol Hlela, Institute of Infectious Disease and Molecular Medicine, University of Cape Town

History

Three years prior to this presentation, the patient was treated at his local clinic for a persistent rash, diagnosed as eczema. There was minimal response to a standard therapy of topical steroids, he experienced only a minimal response.

Past Medical History

He was diagnosed with pulmonary tuberculosis (TB) and tested positive for HIV at the same time. He completed six months of standard TB treatment.

His CD4 count over three months showed a steady decline:

1st measurement: CD4 count was 987 cells/ul
3 months later his CD4 count was 603 cells/ul

HAART was initiated five months later when his CD4 count dropped below 350 cells/ul. He was started on antiretroviral therapy (ARV), consisting of lamivudine (3TC), stavudine (d4T) and efavirenz (EFV)

He defaulted treatment and was lost to follow-up for more than a year.

When he returned to the clinic he was re-initiated on ARV. Four months after restarting treatment he developed facial swelling and bulky, non-tender nodules on the trunk and limbs.

A skin biopsy showed dermal infiltration of atypical lymphoid cells.

Following his biopsy results, he was referred to a specialist skin lymphoma clinic.

Past Surgical History

Previous laparotomy for small bowel obstruction, cause unknown.

Family History

Nothing of significance

Allergies

None known

Medication

Topical steroids

ARV: 3TC, d4T and EFV

Travel History

None noted

Social History

Non-smoker

No alcohol use

No illegal substance use

Differential Diagnosis

HIV-associated atypical cutaneous lympho-proliferative disorder (ACLD)
Leprosy
Mycoses fungoides
Sezary syndrome
Other lymphomas

Examination

Appearance: ambulatory, underweight, erythrodermic male, awake, alert and co-operative.

Vitals

Temperature: afebrile
Blood pressure: 124/76
Heart rate: 75
Respiratory rate: 16

General

Erythrodermic, skin, generally indurated
Palpable axillary and groin lymph nodes
No jaundice, pallor or oedema

Chest

Chest clear

Cardiovascular

Normotensive
No murmurs, no added heart sounds

Abdomen

Mild tenderness over the liver and the spleen with accompanying hepatosplenomegaly.

Neurological

No abnormalities detected

Dermatological

Erythrodermic, skin generally indurated
Diffusely indurated face with leonine features
Boggy non-tender multiple nodules and tumors on the face, of varying sizes
Similar tumourous nodules on thighs
Fine non-palpable purpuric rash on upper the trunk
Non-tender tumourous nodules on forearm


	On Admission	6 weeks	14 weeks	Reference ranges
WCC +peripheral smear	50.51 with > 10% circulating atypical lymphocytes	8.6	11.1	4-12×109/L
Hb	13.3	10.6	7.4	12.1-15.2g/L
MCV	105			79-98.9fL
MCH	33.4			27-32.0pg
MCHC	31.8			32-36.0g/dL
Platelets	383	93	130	140-450×109/L
Diff Count:
Neutrophils	6.57			2.0-7.50 x109/L
Lymphocytes	34.35			1-4×109/L
Monocytes	3.54			0.18 – 0.80 x109L
Eosinophils	1.01			0.0 – 0.45 x10 9 /L
CD4 count	94
Viral Load	1890

Discussion points to consider:

Our presenting case was a middle-aged man with severely indurated face presenting as a leonine facies as well as skin nodules and tumours on his trunk and limbs. He was previously diagnosed as HIV-infected and was initiated on ARV. It is uncertain whether the skin lesions were a result of drug toxicity following initiation of ARV, or possibly due to immune reconstitution inflammatory syndrome (IRIS). It is also possible this could be an aggressive progression of a pre-existing condition due to his immune-compromised state