Immune reconstitution inflammatory syndrome: A therapeutic paradox

A 41-year-old HIV positive woman was started on highly active antiretroviral therapy when her CD(4) count was 54/cu mm. Three weeks later, she developed erythematous to skin-colored plaques over the face. Investigations revealed a moderate eosinophilia, raised ESR, elevated 24-hour urinary calcium and hyperglobulinemia. Skin biopsy of the facial plaque revealed prominent epithelioid cell granulomas in the dermis. Reticulin stain showed reticulin fibers within the granulomas. Five months later, all the facial lesions regressed with continuation of HAART, with no specific treatment for facial plaques. Repeat CD(4) count was 104/cu mm. A diagnosis of cutaneous sarcoidosis occurring as a part of immune reconstitution inflammatory syndrome was made. Although systemic sarcoidosis has been reported, the occurrence of cutaneous sarcoidosis as part of immune reconstitution inflammatory syndrome has not been elucidated conclusively.