Atypical Presentation of PKDL due toLeishmania infantumin an HIV-Infected Patient with Relapsing Visceral Leishmaniasis

Abstract

We describe the case of an Italian patient with HIV infection who developed an atypical rash resembling post-kala-azar dermal leishmaniasis (PKDL) when receiving liposomal Amphotericin B (L-AMB) for secondary prophylaxis of visceral leishmaniasis (VL). At the time of PKDL appearance, the patient was virologically suppressed but had failed to restore an adequate CD4+ T-cell count. Histology of skin lesions revealed the presence of a granulomatous infiltrate, with lymphocytes, plasma cells, and macrophages, most of which contained Leishmania amastigotes. Restriction fragment length polymorphism-polymerase chain reaction was positive for Leishmania infantum. Paradoxically, cutaneous lesions markedly improved when a new relapse of VL occurred. The patient received meglumine antimoniate, with a rapid clinical response and complete disappearance of cutaneous rash. Unfortunately, the patient had several relapses of VL over the following years, though the interval between them has become wider after restarting maintenance therapy with L-AMB 4 mg/kg/day once a month. Even if rare, PKDL due to Leishmania infantum may occur in Western countries and represents a diagnostic and therapeutic challenge for physicians. The therapeutic management of both PKDL and VL in HIV infection is challenging, because relapses are frequent and evidence is often limited to small case series and case reports.

An unusual case of post-kala-azar dermal leishmaniasis in a patient with HIV and visceral leishmaniasis co-infection

“…5 Skin lesions have been described in patients with HIV-VL co-infection, and Leishmania amastigotes have been detected in healthy looking skin. 7 There are few reports of PKDL with L. infantum in PLWH, [8][9][10] and in some patients, PKDL can occur while the patient is still on treatment for VL; this is sometimes termed 'para-kala-azar dermal leishmaniasis'. 11 The optimum management of VL with HIV co-infection is not known.…”

Unusual Signs and Symptoms in HIV-Positive Patients Coinfected with Leishmania spp: The Importance of Neglected Tropical Disease in Differential Diagnosis

“…Moreover, it has been observed an enhanced secretion of Th2 cytokines, and in particular IL-10, in Visceral Leishmaniasis associated to HIV-infection, which can promote the dissemination of both the virus and the parasite [ 28 ] [ 32 ] [ 40 ] [ 41 ] [ 42 ] [ 43 ].…”

Comparative proteomic analysis of Leishmania parasites isolated from visceral and cutaneous leishmaniasis patients

“…Atypical case is quite a broad term and refers to abnormalities including the unusual appearance of lesions (Guimarães et al, 2016;Espinoza-Morales et al, 2017;Meireles et al, 2017) and unfamiliar clinical indications due to the coinfections and concurrent occurrence of other diseases (Calvopina et al, 2005;Da-Cruz et al, 1999;Kouyialis et al, 2005;Celesia et al, 2014;Hashemi et al, 2018;Martínez et al, 2018). Apart from that, clinical manifestations caused by unexpected Leishmania spp.…”