The most common form of systemic amyloidosis is amyloid A induced by a chronic inflammation or chronic infections such as tuberculosis, chronic osteomyelitis, familial Mediterranean fever and rheumatoid arthritis. In HIV-infected patients, elevated serum amyloid A levels have been reported to be associated with chronic inflammation.^1,2 HIV infection may cause amyloidosis by either direct action of HIV or its immunosuppressive effect.^3,4 Clinical presentation depends on systemic organ involvement by amyloid fibrils, and the most common clinical manifestations proteinuria that leads to renal insufficiency.⁵ Here, a rare clinical presentation of amyloidosis in a patient infected with HIV was reported. Written informed consent was also taken from the patient, and the case report was approved by Erciyes University Local Ethics Committee (no: 352/2017).

A 43-year-old male patient with HIV and/or AIDS was admitted to the Infectious Diseases Department for the investigation of papular lesions around his eyes in November 2014. The patient was diagnosed with HIV and/or AIDS and hepatitis B virus (HBV) coinfection in 2004 and antiretroviral therapy was initiated with a combination of lamivudine, zidovudine and lopinavir and ritonavir. This regimen was given between 2007 and 2010. Later, the therapy regimen was switched to tenofovir and emtricitabine and efavirenz. A bladder carcinoma was diagnosed in 2011 and he received mitomycin C in cycles. He denied fever and pain but sometimes complained of bleeding from his perianal polyp, and he claimed the lesion colour changed from pale to violet. On physical examination, periocular, perioral and anogenital papules and papular lesions in the external auditory canal and intranasal polyps were present. The lesions were lilac-coloured, soft and painless (Figure 1a, 1b, 1c and 1d). His body mass index was 21 kg/m².

Serum amyloid A is an acute-phase protein produced by the liver and it is related to high-density lipoprotein particles.¹ One cause of systemic inflammation may be mitochondrial dysfunction, which is induced by nucleoside reverse transcriptase inhibitors.⁶ Amyloid may be induced by chronic inflammation and cancer.¹ The presented case had HIV infection and HBV coinfection since 2004 and bladder carcinoma since 2011. Either of these might lead to secondary amyloidosis. A limited number of cases have been reported of secondary amyloidosis in HIV patients who had nephrotic syndrome.^7,8 In this case, renal biopsy could not be performed because the patient refused the biopsy. The most common clinical presentation of amyloidosis is related to renal disease, which includes nephritic syndrome.^3,7,8 Although this patient had nephrotic renal disease with proteinuria of 3 g/day; however, the patient’s main presenting complaint was related to cutaneous involvement periocular, intranasal and perioral papules.

In conclusion, unusual presentations of amyloidosis with multiple cutaneous involvement may be seen in HIV patients especially complicated with cancer and HBV coinfection.