chronic myelogenous leukemia ( cml ) is a chronic myeloproliferative disorder which remains in chronic phase for a variable period followed by accelerated phase and later blast crisis . various drugs have been used in the management of cml and these are busulfan , alpha - interferon , hydroxyurea , and imatinib , the last mentioned , a tyrosine kinase inhibitor . in last three decades , the incidence of human immunodeficiency virus ( hiv ) infection has been on the rise . the immunodeficiency state makes the patient vulnerable to various infections . with the introduction of anti - retroviral therapy and modern antibiotics , the long - term survival of hiv patients has certainly improved and now hiv is considered as chronic infection . however , it is also observed that there has been an increase in the incidence of cancers in hiv afflicted patients . there are few case reports about development of cml in hiv-1 patients in adult and pediatric age groups . we report a case here , where cml was diagnosed earlier and while the treatment was ongoing , hiv infection was detected . it was observed that the patient not only responded favorably to hydroxyurea , as far as cml was concerned , but is maintaining good health in the presence of hiv infection . the first case where both these conditions were coexisting was reported in 1995 . in this patient , record a case of congenital hiv infection who had cml for more than 10 years . this patient was treated with antiretroviral agent , zidovudine for hiv and alpha - interferon for coexisting cml webb studied 10 patients in whom cml and hiv was coexistent . the response to imatinib and combination anti - retroviral therapy ( cart ) was excellent . combination of imatinib with highly active retroviral therapy was shown to have a good control of cml and hiv over a period of 69 months . in 1997 , complete cytogenetic response was documented with a combination of alpha - interferon and zidovudine in an asymptomatic patient of cml and hiv . before tyrosine - kinase inhibitors appeared on the scene , hydroxyurea was used extensively for two reasons . one , the cost of the drug was affordable and secondly it offered good control of cml . in early 1980s , patients with hiv infection were treated with hydroxyurea alone and later this was combined with didanosine or stavudine as first line therapy . however , results of monotherapy with hydroxyurea in hiv infection were inferior to that of haart . in addition peripheral neuropathy was observed in 5.8% when hydroxyurea was used as a single agent . these patients due to altered immunological status often contracted pulmonary tuberculosis and isoniazid used for treating mycobacterial infection further enhanced the chances of peripheral neuropathy . a 50-year - old male patient was a known case of diabetes mellitus and was being treated for that since 1989 . he was ; however , quite irregular with this treatment and his diabetes was often out of control . in november 2005 the fever was low grade and there was no history of hemoptysis , dysuria and hematuria . routine laboratory investigations showed high white blood cell count which was 59,000/mm , and there were premature leucocytes on peripheral smear . his diabetes was out of control with fbs level 264 mg / dl and ppbs value 372 mg / dl . a provisional diagnosis of cml with uncontrolled diabetes mellitus was made and he was further investigated . he was given hydroxyurea 500 mg 3 times a day and subsequently the doses were titrated with reference to wbc count . during the follow - up that spanned over next several months for this , he was treated with antibiotics and insulin which controlled the infection promptly . in october 2010 , he complained of occasional fever , cough with slight expectoration and loss of appetite , weakness and weight loss . he was diagnosed to have pulmonary tuberculosis on the basis of his clinical picture and positive tb elisa test ( igm ) for which he received anti tubercular treatment for next 10 months . in february 2011 the treadmill test was strongly positive for exercise induced coronary insufficiency . as his symptoms and stress test suggested coronary heart disease , he was referred to a cardiac center for further evaluation . 2d - echo was carried out which showed echo - concentric lvh , normal resting systolic function , presence of diastolic dysfunction , no regional wall motion abnormalities , and normal pa pressure . coronary angiography was done on 1 march 2011 which showed lvef 50% and triple vessel disease . revascularization was contemplated ; however , his routine investigation showed a positive hiv test ; hence no further interventional treatment was carried out . cd3 , cd4 and cd8 count results were 2940 cells / mm , 393 cells / mm and 2477 cells / mm respectively . viral load was tested on 5 november 2011and it showed 43356 hiv-1 rna copies / ml . he was advised to start anti - retroviral therapy along with imatinib , however , patient declined to take this treatment due to lack of resources . patient continues to take hydroxyurea regularly and in spite of advanced hiv he has not developed any major complications of hiv or cml during his follow - up period . its incidence in india is recorded from 6 population based cancer registries and varies from 0.8 to 2.2/100,000 for males and from 0.6 to 1.6/100,000 populations for females . studies based on hospital patients show a higher incidence which ranges from 40% to 82 % of leukemia cases in adults . majority of patients ( 90 - 95 % ) present in an initial chronic phase of variable duration ( average-5 - 5 years ) . when initial treatment is started in chronic phase of cml , approximately 95% of patients achieve complete hematological response . they are : acquired immunodeficiency syndrome ( aids ) defining cancers which include non - hodgkin lymphoma , invasive cervical cancer and kaposi sarcoma . this patient of cml with hiv-1 infection shows a different clinical course than either presenting singly . his cml was diagnosed 7 years ago and so far has not shown any evidence of accelerated phase or blast crisis . the presence of hiv infection was detected 5 years after the diagnosis of cml and though he has not received triple drug therapy , he remains clinically stable . if imatinib was used for cml , he would also need triple drug anti - retroviral therapy because the tyrosine kinase inhibitor does not have any effect on hiv-1 . therefore for cml coexistent with hiv-1 infection , hydroxyurea as a single agent seems to be useful at least in this case . in fact , before the advent of effective anti - retroviral agents , many hiv patients were treated with a combination of hydroxyurea and didanosine as hydroxyurea has a synergistic effect with reverse transcriptase inhibitors such as didanosine . hydroxyurea significantly enhances the antiretroviral effects of the adenosine analog reverse transcriptase inhibitor dideoxyinosine by reducing intracellular de - oxyadenosine triphosphate concentrations due to inhibition of ribonucleotide reductase enzyme . as newer antiviral agents such as protease inhibitors , integrase inhibitors , entry blockers and other agents from reverse transcriptase class , were introduced the use of hydroxyurea in the management of hiv-1 became less and less . though , it was easily available at a lower cost , severe hematological toxicity and associated neuropathy , hydroxyurea was later omitted from the guidelines for the antiretroviral therapy . he is taking only one agent , hydroxyurea since the diagnosis of cml and has good performance status in spite of having a very low cd4/cd8 ratio . he was treated for tubercular infection but did not acquire other opportunistic infections in last several months . he has significant longer survival without an  ideal  treatment for cml or hiv infection . it is observed that when a single antiretroviral agent is used in the treatment of hiv-1 infection , drug resistance develops in a short time . this could probably be the first report of a patient who had cml first and later developed hiv . this case does not fit in conventional classification of hiv associated cancers . as per this definition , patients have retroviral infection first and later due to infections such as hhv8 , eb virus or other unknown viruses and/or mechanisms develop different types of cancer at a later date . at the time of preparing this report ( december 2012 ) the patient was taking hydroxyurea and the cml is fairly well controlled . his performance status remains at zero ( ecog score ) and he regularly visits for follow - up .