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Lupus erythematosus-lichen planus overlap
syndrome in an HIV-infected individual

Article in International Journal of STD & AIDS · November 2015
DOI: 10.1177/0956462415618109

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Priyanka Patil Chitra Nayak
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Tambe Swagata Dipti Das
Topiwala National Medical College & B. Y. L. … Mumbai, India
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She OPD Building. a raised erythrocyte sedimen- sensitivity.1177/0956462415618109 Case report International Journal of STD & AIDS 0(0) 1–6 ! The Author(s) 2015 Lupus erythematosus-lichen Reprints and permissions: sagepub. Keywords Lichen planus. breathlessness. There was a history of LP five years syndrome is an uncommon disorder. The patient gave a history suggestive of photo. There was no history of joint pain. Four months Department of Dermatology.sagepub. Chitra Nayak. 2015 as doi:10.com by guest on November 18. Department of Dermatology. Mumbai 400008. Her baseline CD4 count before initiation of anti- rare. Nair Hospital. lupus erythematosus-lichen planus overlap syndrome with HIV infection has never been reported in literature.1% cream. histological and immunological features. T4 with normal exposed to the sun. (haemoglobin – 10 g/dl).Y. To the best of our knowledge. Mumbai Central. OPD No.sagepub. Topiwala National Medical College and beforehand. histological and/or immunofluorescence fea. B. count over time and the development of cutaneous and mucosal lesions. chest pain. ago and has been on antiretroviral therapy for nine Coexistence of HIV with autoimmune conditions is years. (b) Corresponding author: Priyanka Patil.1177/0956462415618109 std. On cutaneous examination. painful lesions on both extremities and back. lamivudine and efavirenz both upper and lower extremities and back (CD4 count – 682 cells/l) presented with multiple (Figure 2(a) and (b)). was treated with oral prednisolone in tapering doses India. with a biopsy suggesting LP (Figure 1(d)). palpitation. she had experienced multiple violaceous B. with lesions healing with hyperpigmentation.com in an HIV-infected individual Priyanka Patil. histological and/or immu- nopathological features of both diseases. We report a case of lupus erythematosus-lichen planus overlap syndrome in a patient with HIV infection. with oral mucosal involvement (Figure 1(a). Table 1 depicts her CD4 with this syndrome. revealed buccal erosions with scalloped borders and with raw. human immunodeficiency virus Date received: 3 July 2015. flat. We report a female patient with HIV infection retroviral therapy was 279. painful lesions in the oral cavity associated also diffuse cheilitis (Figure 2(c)). Diagnosis depends on correlation patient was diagnosed with retroviral disease 10 years of clinical.Y. over three months and oral dapsone and topical Email: drpriyankapatil219@gmail. The tures of both diseases. 14. 2015 .L. published on November 17.uk/journalsPermissions. without much Lupus erythematosus-lichen planus (LE-LP) overlap improvement.nav planus overlap syndrome DOI: 10. lupus erythematosus. Swagata Tambe and Dipti Das Abstract Lupus erythematosus-lichen planus overlap syndrome is an uncommon disorder with clinical. Int J STD AIDS OnlineFirst. accepted: 28 October 2015 Introduction mometasone furoate 0.co. and (c)). treated with oral corticosteroids and dapsone. abdominal dis- tention. there were multiple Case report erythematous to depigmented atrophic scaly plaques A 40-year-old widow with retroviral disease on with peripheral hyperpigmentation on extensors of treatment with tenofovir. Second Floor. raised T3. India scaly papules and plaques on the upper trunk and extre- mities. pedal oedema or seizure disorder. Nair Hospital. Examination of the oral cavity red. Mumbai.com Downloaded from std.L. There is an overlap prior. with a burning sensation that had lasted for two The patient had microcytic hypochromic anaemia months. of clinical. with a burning sensation on her face when tation rate (40 mm in 1 h).

An ultrasound scan of the abdomen and staining positive for IgM. (b) Reticular pattern in buccal mucosa. Four months prior.8). Fundus exam. TSH (T3 – 203. oral lesions. IgA. a diagnosis of LE-LP overlap syndrome. uterine fibroid. with colloid bodies in the papillary dermis negative. (d) Histopathology. 2015 . and topical tacrolimus 0. Features of LE viz. so oral methorexate periappendageal infiltrate with mucin were also present 10 mg weekly was added. Anti-dsDNA and anti-histone antibody were and C3. Biopsy from hypertrophic violaceous plaque on left lower leg showed compact hyperkeratosis. TSH – 1. deep perivascular and ment in oral and cutaneous lesions.4 cm. healed with hypopigmentation and oral erosions Direct immunofluorescence from the atrophic lesion completely resolved after one month of therapy on the back and uninvolved skin from the buttock had (Figure 3(a) and (b)). A biopsy from the atrophic mometasone furoate 0.8  3.2 International Journal of STD & AIDS 0(0) Figure 1. all suggest. There was a granular base- antibody was positive in a speckled pattern at 1:1000 ment membrane zone band staining positive for IgM titres.com by guest on November 18.7. wedge shaped hypergranulosis with evidence of interface dermatitis – suggestive of lichen planus.03% ointment at night for ation with interface lymphocytic infiltrate.1% cream in morning and top- plaque on the back revealed compact hyperkeratosis. Anti-nuclear features of both LP and LE. C3 and epidermal pelvis revealed an anterior wall heterogeneous fibroid ANA staining with IgG (Figure 2(f)). wedge-shaped hypergranulosis and basal cell degener. The lesions gradually (Figure 2(e)). (c) Multiple erythematous to violaceous scaly papules and plaques on leg. After one month. logical and immunofluorescence findings. topical junction (Figure 2(d)). histiocytic infiltrate hugging the dermoepidermal prescribed oral chloroquine 250 mg twice daily. The patient underwent a hysterectomy for the dermal cleft (Max Joseph space) with a dense lympho. 400. T4 – 13. measuring 3. ical tacrolimus 0.1% ointment at night for skin lesions. (a) Multiple erythematous to violaceous scaly papules on dorsum of hand. we reached ination was normal. there was no improve- ive of LP. H & E. Downloaded from std. anti-HCV Considering the clinical features and histopatho- antibody and VDRL were non-reactive.sagepub. Tests for HBsAg.6. A biopsy from the buccal mucosa revealed a subepi. She was advised on photoprotection.

atrophic hands and feet and back nevirapine Downloaded from std. dorsae of lamivudine. Oral cavity: multiple irregular. lower extremities.com by guest on November 18. planus Oral mucosa: reticular pattern in bilat. Correlation of clinical features with CD4 count.sagepub. Lichen plaques lower extremities lamivudine. 3 . Table 1. Features of atrophic scaly plaques with periph. 2015 plaques with white streaks in lacy pattern with violaceous hue on buccal mucosa 10 years prior 279 (baseline) Before initiation of ART ART: antiretroviral therapy. nevirapine eral buccal mucosa 5 years prior Multiple violaceous scaly papules and Extensors of both upper and Lichen planus 655 Stavudine. LE-LP: Lupus erythematosus-lichen planus. dorsae of lamivudine. CD4 count Cutaneous examination Sites Clinical diagnosis (cells/l) ART regimen Skin biopsy Present episode Multiple erythematous to depigmented Extensors of both upper and LE-LP overlap 682 Tenofovir. Not done plaques lower extremities. LP and LE eral hyperpigmentation hands and feet and back efavirenz Oral cavity: erosions with scalloped borders on bilateral buccal mucosa with diffuse cheilitis 4 months prior Multiple violaceous scaly papules and Upper trunk and both upper and Lichen planus 511 Tenofovir. Patil et al.

(a) Multiple erythematous to depigmented atrophic scaly plaques with peripheral hyperpigmentation on dorsae of hands. IgA. basal cell degeneration with interface lymphocytic infiltrate – suggestive of lichen planus with deep perivascular and periappendageal infiltrate with evidence of mucin. (f) Direct immunofluorescence (100) of uninvolved skin from buttock shows granular BMZ band with IgM and C3. suggestive of discoid lupus erythematosus. (c) Erosions with scalloped borders on buccal mucosa with diffuse cheilitis. 2015 . H & E.com by guest on November 18. wedge shaped hypergranulosis. C3 and epidermal ANA staining with IgG suggestive of lupus erythematosus and lichen planus. (b) Multiple erythematous to depigmented atrophic scaly plaques with peripheral hyperpigmentation on lower extremities. (d) Histopathology.sagepub. H & E. colloid bodies in the papillary dermis staining with IgM.4 International Journal of STD & AIDS 0(0) Figure 2. (b) Complete resolution of lesions in oral cavity after one month of therapy. 100. Present episode. (a) Lesions on dorsae of hands healed with hypopigmentation. 100. Figure 3. (e) Histopathology. Biopsy from the buccal mucosa revealed Max Josephs space with dense lymphohistiocytic infiltrate hugging the dermoepidermal junction. Downloaded from std. Biopsy from atrophic plaque on back revealed compact hyperkeratosis.

pain. papu. This LE-LP overlap syndrome has a 3. autoimmune. et al. Ng SK. 15: 171–174.12 did not reveal Most of the cases occur between the ages of 25 and occurrence of opportunistic infection with moderate 45 years. Hospital. The presence of deep perivascular The author(s) declared no potential conflicts of interest with and peri-appendageal infiltrate with evidence of mucin respect to the research. Funding ping cases due to similarities between the two disorders. legs. In LP. Direct immunofluorescence (DIF) is helpful in histolo. Clin Exp Dermatol 1998.8 ciclos. procainamide and acebutolol. authorship. 2015 .6 The authors thank Dr Alka Gupta. article. Characteristically. are genetic. LE-LP overlap syndrome has features of both LP and had not suffered from any opportunistic infection and LE. Hautarzt 2004. immunoglobulin and complement deposition in a 2. successfully and safely treated with methotrexate is 5.3 Hashimoto’s thyroiditis. porin. primary biliary cirrhosis. Acknowledgement ing systemic LE are 5–10%. therefore. Sjogren’ssyndrome) associated with the lupus erythematosus/lichen planus a moderately immunocompromised patient who was overlap syndrome.7 In our patient. association of LE-LP overlap in derma. et al. gically doubtful cases. oral lichen planus in a patient with systemic lupus erythe- The medications effective in this syndrome are potent matosus and thymoma. diseases with auto. to cause LE-LP overlap syndrome are isoniazid.1 had severe mucosal and cutaneous involvement not Various etiologies postulated for this overlap syndrome responding to topical therapy and oral chloroquine. 5 Discussion Our patient was doing well on antiretroviral therapy. Coexistence granular pattern along the dermo-epidermal junction. centrally atrophic plaques and severe refractory psoriasis after the failure of first-line patches with hypopigmentation and telangiectasia are treatment. Abramovits W. Inaloz HS. 23: topical and systemic steroids. non-Hodgkin lymphoma. usually displays pecia.com by guest on November 18. and discoid lupus erythematosus overlap syndrome Downloaded from std. immune syndrome.9 Hydroxychloroquine10 and topical tacrolimus 4. oral retinoids. Reynold’s HIV-positive patients with psoriasis was contraindi- syndrome.sagepub. hypocomplementemia. However. Pemphigus foliaceus and chronic course with a variable response to treatment. Methotrexate can be considered in patients commonly seen on extremities. Motley R. Jamison TH. and/or publication of this article. Muller FB. Currently. the histopathological findings are some- times insufficient as a distinguishing feature in overlap. Max Joseph cleft and dense. of lichen planus and systemic lupus erythematosus. Chng HH. Mumbai. Classic lesions of LP and discoid lupus erythematosus are uncommon. viral or drugs. Department of Histologically. face and trunk published consensus on treatment for psoriasis in with palmoplantar involvement. LE and LP. Lichen planus being reported for the first time. bluish red. J Am Our patient exhibited these mixed features of both Acad Dermatol 1982. of LE-LP overlap syndrome with HIV who do not lonodular lesions on the hands and arms.11 in 1987.1% ointment. with slight female preponderance. methotrexate is considered for ful. band-like lymphocytic infiltrate was Declaration of Conflicting Interests suggestive of LP. J Eur Acad Dermatol Venereol 2000. King Edward Memorial (KEM) present in the same biopsy. Burkitt lymphoma. Multiple auto- 0. patients with HIV. reports by Maurer et al.5 However. tosis. cases of HIV-related CD8þ cutaneous pseudolym- immune aetiology may occur simultaneously. Methotrexate in foliaceus. cryoglobulinemia and cated based on reports of Duvic et al. Patricia S. Groth W.2 Drugs known Financial constraints precluded the use of acetretin. Mahrle G. 181–184. Ahmed AR. Reynolds syndrome (acral sclero- To our knowledge. Nail dystrophy. Professor. Lupus erythe- matosus/lichen planus overlap syndrome with scarring alo- ition to IgM staining of cytoid bodies. It is seen that in a Methotrexate has been successfully used in reported genetically predisposed individual. 55: 465–470. as well as verrucous. according to a recently lesions mostly affect the distal arms. have also been reported. wedge-shaped hypergranulosis. DIF reveals groups of cytoid bodies that stain for IgM. et al.Patil et al. DIF of LE lesions. respond to topical therapy and chloroquine in mucous membrane involvement and scarring alopecia resource-limited setting. as phoma. Approximately 50 cases have been reported so far. scaly. in add. Chances of develop. Ng PP. IgG and C3 intraepi- References dermally and for fibrin in a fibrillar pattern along the dermo-epidermal junction. features of LP and LE are usually Obstetrics & Gynaecology. and/or publication of this suggested LE. Chowdhury M. et al. we prescribed oral methotrexate. 1. Cutaneous immunosuppression. 7: 478–483. hyperkera. authorship. Cooper NM and Epstein WV. seen by reported associations with vitiligo.2 pemphigus polyarthritis and placenta percreta. The author(s) received no financial support for the research.4 hypothyroidism.

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