Digital gangrene caused by vasculitis in a young African female complicated with autoimmune disease and HIV/ hepatitis B co-infection: Case report

Abstract

Human Immunodeficiency Virus (HIV) is an epidemic in southern Africa. The World Health Organization reports that there are about 25.6 million people in Southern Africa who are infected with HIV. HIV is a disease of immune dysregulation and occasionally, autoimmune disease and vasculitis are seen together in some individuals. Vasculitis among HIV patients is multifactorial. HIV, hepatitis B and hepatitis C are some well recognised  infectious causes of secondary vasculitis. In our report, we described a 31-year-old female with digital gangrene in a patient with HIVhepatitis B co-infection and connective tissue disease. She was HIV positive with a CD4 count of 250 cells/ml and a viral load of <400 copies/ml. She was treated with first-line antiretroviral combination therapy of nevirapine and truvada (tenofovir disoproxil fumarate + emtricitabine) for 4 years before the presentation. She was also a hepatitis B virus-positive with hepatitis B virus DNA<20IU/ml copies. The patient developed digital gangrene initially in upper limbs followed by gangrene in the lower limb digit. Physical examination showed reduced pulsation on radial and dorsalis pedis artery. The  laboratory results showed positive serological markers such as ANA, anti-RNP without any cutaneous features of lupus. Angiography confirmed  arterial involvement in the limb. Secondary vasculitis mainly secondary polyarteritis nodosa was suspected from the arterial angiographic report. The patient was treated with mycophenolate mofetil with satisfactory clinical improvement. In this case report, we tried to explore the association of  the digital gangrene in relation to her multiple coexisting conditions.

Key words: Digital gangrene, Vasculitis, HIV