Diffuse cutaneous leishmaniasis - A rare cutaneous presentation in an HIV-positive patient

Case Report: Coinfection by Leishmania amazonensis and HIV in a Brazilian Diffuse Cutaneous Leishmaniasis Patient

Diffuse cutaneous leishmaniasis (DCL) is a rare type of leishmaniasis characterized by diffuse skin lesions. In Brazil, Leishmania (L.) amazonensis is the main etiological agent of this clinical form. The state of Maranhão has the highest prevalence of this disease in the country, as well as a high rate of HIV infection. Here, we report the first case of DCL/HIV of Brazil. A 46-year-old man from the Amazonian area of Maranhão state presented atypical lesion in the left upper limb and dissemination of diffuse erythematous nodules over his entire body. Histopathological examination confirmed the presence of intracellular amastigotes of Leishmania, and a polymerase chain reaction and molecular identification by restriction fragment profile identified L. (L.) amazonensis as the causative agent of the disease. The patient was also diagnosed with HIV virus after the leishmaniasis diagnosis. The initial treatments for leishmaniasis were liposomal amphotericin B (AmB-L) (4 mg/kg) for 10 days and prophylactic use of Glucantime^® (10 mg/Sb⁺⁵/kg) for 2 months. After unsuccessful initial treatments, he was treated with a combination of AmB-L (4 mg/kg) alternated with pentamidine (4 mg/kg) for 10 days but failed in the first therapeutic cycle. Subsequently, he had a good response to treatment with pentamidine (4 mg/kg).

Unusual presentation of mucocutaneous leishmaniasis in HIV-infected patient

Leishmaniasis is caused by protozoan parasite of genus leishmania. Visceral leishmaniasis, diffuse cutaneous leishmaniasis, and atypical forms of cutaneous leishmaniasis are common in HIV-infected patients. Our patient presented with an obstructive mass in nasal cavity and was diagnosed as a case of mucocutaneous leishmaniasis. Spontaneous healing of lesions in HIV-infected patients is rare rather they are unresponsive to treatment and have frequent relapses, especially in patients with low CD4 count. However, in our patient, the lesion improved significantly after 2 months of highly active antiretroviral therapy and co-trimoxazole prophylaxis.

Chronic generalized fibrotic skin lesions from disseminated leishmaniasis caused by Leishmania martiniquensis in two patients from northern Thailand infected with HIV

BACKGROUND

Leishmaniasis is a newly emerging infection in Thailand. Most of the previous human cases have presented with the clinical features of visceral leishmaniasis and were mainly found in southern Thailand. Here we report the first two patients from northern Thailand presenting with disseminated cutaneous leishmaniasis.

OBJECTIVES

To determine the nature of the infection of leishmaniasis and to identify the species of parasite responsible.

METHODS

Clinical investigations included the taking of biopsy samples and histology. Parasitological diagnosis was performed by establishment of Leishmania promastigote cultures, and identification was performed by DNA sequencing of four independent gene loci (ribosomal RNA internal transcribed spacer 1; large subunit of RNA polymerase II; heat shock protein 70; RPL23a intergenic sequence).

RESULTS

Both patients were infected with HIV, and had multiple cutaneous lesions and accompanying visceral leishmaniasis. They had similar cutaneous manifestations characterized by chronic generalized fibrotic lesions, which were more prominent on traumatic areas. In both patients the parasite was identified as Leishmania martiniquensis. This is a recently described species that is distinct and only distantly related to the classical agents of cutaneous leishmaniasis in Asia (Leishmania major and Leishmania tropica) or of visceral leishmaniasis (Leishmania donovani and Leishmania infantum). Each patient responded well to therapy with intravenous amphotericin B followed by oral itraconazole.

CONCLUSIONS

Leishmania martiniquensis is a cause of cutaneous leishmaniasis in Thailand.

Changing trends in the epidemiology, clinical presentation, and diagnosis of Leishmania-HIV co-infection in India

Following the HIV epidemic, several countries have reported co-infections of Leishmania with HIV. Co-infection with these two pathogens results in rapid disease progression, more severe disease, and a poor response to treatment. A systematic review of the literature from India is presented herein. Since the first case of visceral leishmaniasis (VL) and HIV was published from India in 1999, a number of cases of HIV-Leishmania co-infection have been reported, but the proportion has been low (0.029-0.4%), as also reported in other countries where these two diseases are co-endemic. More than 89 cases of VL-HIV and 10 cases of cutaneous leishmaniasis (CL)-HIV have been published since 1999. Of these latter 10 cases, five had simple CL and five cases manifested with diffuse cutaneous leishmaniasis (DCL). In addition, one case of post-kala-azar mucocutaneous leishmaniasis in a patient with full-blown AIDS has also been reported. In two cases, it could not be ascertained whether they were cases of DCL or post-kala-azar dermal leishmaniasis from the description. Although the first case of VL-HIV co-infection was reported from the sub-Himalayan state of Uttarakhand, most cases have been reported from the VL endemic state of Bihar. HIV-Leishmania is not alarmingly high in India. Most cases were found to have occurred during 1997-2007. After that, the number of new cases decreased. This is most probably due to the low prevalence of HIV in VL and CL endemic regions and to the free supply of highly active antiretroviral therapy for HIV-infected patients.

PKDL and other dermal lesions in HIV co-infected patients with Leishmaniasis: review of clinical presentation in relation to immune responses

Background

Co-infection of leishmaniasis and HIV is increasingly reported. The clinical presentation of leishmaniasis is determined by the host immune response to the parasite; as a consequence, this presentation will be influenced by HIV-induced immunosuppression. As leishmaniasis commonly affects the skin, increasing immunosuppression changes the clinical presentation, such as in post-kala-azar dermal leishmaniasis (PKDL) and cutaneous leishmaniasis (CL); dermal lesions are also commonly reported in visceral leishmaniasis (VL) and HIV co-infection.

Methods

We reviewed the literature with regard to dermal manifestations in leishmaniasis and HIV co-infection, in three clinical syndromes, according to the primary presentation: PKDL, VL, or CL.

Results

A wide variety of descriptions of dermal leishmaniasis in HIV co-infection has been reported. Lesions are commonly described as florid, symmetrical, non-ulcerating, nodular lesions with atypical distribution and numerous parasites. Pre-existing, unrelated dermal lesions may become parasitized. Parasites lose their tropism and no longer exclusively cause VL or CL. PKDL in HIV co-infected patients is more common and more severe and is not restricted to Leishmania donovani. In VL, dermal lesions occur in up to 18% of patients and may present as (severe) localized cutaneous leishmaniasis, disseminated cutaneous leishmaniasis (DL) or diffuse cutaneous leishmaniasis (DCL); there may be an overlap with para-kala-azar dermal leishmaniasis. In CL, dissemination in the skin may occur resembling DL or DCL; subsequent spread to the viscera may follow. Mucosal lesions are commonly found in VL or CL and HIV co-infection. Classical mucocutaneous leishmaniasis is more severe. Immune reconstitution disease (IRD) is uncommon in HIV co-infected patients with leishmaniasis on antiretroviral treatment (ART).

Conclusion

With increasing immunosuppression, the clinical syndromes of CL, VL, and PKDL become more severe and may overlap. These syndromes may be best described as VL with disseminated cutaneous lesions (before, during, or after VL) and disseminated cutaneous leishmaniasis with or without visceralization.