Psoriasis as a manifestation of HIV-related immune reconstitution inflammatory syndrome
Authors: Shivani V. Tripathi, Kieron S. Leslie, Toby A. Maurer, Erin H. Amerson
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Immune reconstitution inflammatory syndrome (IRIS) is a paradoxical exacerbation of a pre-existing condition or emergence of a previously unknown disease occurring in an HIV-infected patient after initiating combined antiretroviral therapy (cART). IRIS begins days to months after starting cART, and is associated with decreasing viral load.1Shelburne S.A. Montes M. Hamill R.J. Immune reconstitution inflammatory syndrome: more answers, more questions.J Antimicrob Chemother. 2006; 57: 167-170Crossref PubMed Scopus (245) Google Scholar The skin accounts for 52% to 78% of presentations, including a range of infectious, inflammatory, and neoplastic conditions.2Osei-Sekyere B. Karstaedt A.S. Immune reconstitution inflammatory syndrome involving the skin.Clin Exp Dermatol. 2010; 35: 477-481Crossref PubMed Scopus (27) Google Scholar Inflammatory dermatoses such as eosinophilic folliculitis, seborrhea, and acne vulgaris have all been reported.3Lehloenya R. Meintjes G. Dermatologic manifestations of the immune reconstitution inflammatory syndrome.Dermatol Clin. 2006; 24 (vii): 549-570Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 4Kreuter A. Schlottmann R. Altmeyer P. Brockmeyer N.H. Acne vulgaris as an immune reconstitution syndrome in a patient with AIDS after initiation of antiretroviral therapy.J Eur Acad Dermatol Venereol. 2002; 16: 638Crossref PubMed Scopus (14) Google Scholar Here we present, to our knowledge, the first report of paradoxical worsening of psoriasis as a presentation of IRIS. A 63-year-old man with type 2 diabetes mellitus, hypertension, hepatitis C, HIV diagnosed in 1997, and a history of mild, untreated less than 1% total body surface area psoriasis presented to dermatology 1 month after starting a new cART, Stribild (elvitegravir, tenofovir, cobicistat, emtricitabine). The patient was switched 1 month prior from his previous cART regimen of Truvada (emtricitabine and tenofovir disoproxil fumarate), darunavir, and ritonavir, to Stribild, a once-a-day cART, because of concerns of medication noncompliance. His most recent CD4 count, 5 months before presentation, was 204 cells/μL and his viral load was 177,857 copies/mL. Skin examination demonstrated confluent erythema, edema, and focal areas of platelike desquamation over the palmar surfaces of both hands; thick sharply demarcated plaques with silvery scale over the elbows; and an erythematous patch over the sacrum, with sparing of the feet and nails, affecting approximately 10% total body surface area. Despite reports of mild joint stiffness in his hands, plain film x-rays did not show signs of psoriatic arthritis. A repeated CD4 count was 138 cell/μL and viral load was 257 copies/mL. He met the proposed diagnostic criteria for IRIS, with worsening of a pre-existing condition (psoriasis) and a concomitant greater than log 10 reduction in viral load.5Haddow L.J. Easterbrook P.J. Mosam A. Khanyile N.G. Parboosing R. Moodley P. et al.Defining immune reconstitution inflammatory syndrome: evaluation of expert opinion versus 2 case definitions in a South African cohort.Clin Infect Dis. 2009; 49: 1424-1432Crossref PubMed Scopus (85) Google Scholar He was started on topical psoralen plus ultraviolet A light 3 times per week and clobetasol ointment 0.05% twice daily, with improvement over the course of 2 months, eventually returning to less than 1% affected total body surface area. Of interest, 1 week before worsening psoriasis, he also developed herpes zoster involving the right leg and buttock, which was resolving at the time of his initial presentation to dermatology. At the 12th World AIDS Conference in Geneva in 1999, French et al6French M.A. Lenzo N. John M. Mallal S.A. McKinnon E.J. James I.R. et al.Immune restoration disease after the treatment of immunodeficient HIV-infected patients with highly active antiretroviral therapy.HIV Med. 2000; 1: 107-115Crossref PubMed Scopus (368) Google Scholar reported numerous conditions worsening after starting cART and introduced the term "immune restoration disease," which is now more commonly termed "immune reconstitution inflammatory syndrome." Over 15 years after the first reports, IRIS remains a well-described but poorly understood phenomenon. There is emerging evidence that one of the immunopathogenic mechanisms of IRIS involves the rapid and dysregulated shift from the T helper (Th)2-predominant state of advanced HIV infection to the Th1- and Th17-dominant state of immune recovery. It is intriguing that psoriasis, a Th1- and Th17-mediated inflammatory condition, has not, to our knowledge, until now been reported to undergo an IRIS reaction, despite being a relatively common HIV-associated dermatosis.