Clinical Challenges in the Management of Leishmania/HIV Coinfection in a Nonendemic Area: A Case Report

We report on a 37-year-old male HIV-positive patient with generalized cutaneous leishmaniasis undiagnosed for several years. Upon presentation, visceral leishmaniasis was diagnosed in addition to cutaneous manifestation of the disease. Over a period of three years, several different treatment regimens including liposomal amphotericin B, liposomal amphotericin B with miltefosine, liposomal amphotericin B with interferon, and pentamidine combined fluconazole and allopurinol were applied until Leishmania PCR from blood turned negative. This case supports the necessity of multidrug combinational and sequential therapy over a very prolonged period of time in severely immunosuppressed patients infected with Leishmania and highlights the tremendous individual but also economic burden of this disease. 1. Introduction In areas where both HIV and leishmaniasis are endemic, leishmaniasis—although not included in CDC AIDS definition—has gained clinical importance as opportunistic infection in HIV-infected individuals. In the immunocompromised host, this infection poses diagnostic as well as therapeutic challenges since serology is not reliable, the clinical presentation may be unspecific, and therapeutic failure and relapse are common [1]. In the recent years, an increase in leishmaniasis incidence and prevalence has been noticed also in nonendemic countries not only due to increased international travelling, but also by the spread of the sandfly vector, further highlighting the relevance of this disease [2, 3]. 2. Report In June 2009, a 37-year-old man presented at our out-patient clinics with generalized multiple erythematous, pustular plaques, papules, and nodules preexisting since several years (Figure 1). In addition, in physical and laboratory examination, severe cachexia, pancytopenia, and hepatosplenomegaly were evident. The patient was known to be HIV positive for about 20 years, and in spite of long-term virological suppression, CD4 cells never exceeded 100？cells/ L. A skin biopsy revealed a dense infiltrate of histiocytic cells with Donovan bodies compatible with cutaneous leishmaniasis (Figure 2(a)). Leishmania serology was negative, but PCR from blood and skin samples was positive for L. donovani/infantum complex. In addition to cutaneous leishmaniasis, bone marrow aspiration showed infiltration with Leishmania confirming visceral leishmaniasis (Figure 2(b)). The patient reported yearly holiday trips to Ischia (Gulf of Naples) during prior decades. Figure 1: Generalized multiple erythematous, pustular plaques, papules, and nodules preexisting since