Gastric leishmaniasis in the setting of HIV/AIDS infection at Community Hospital in Southeastern United States

Abstract

Introduction. Visceral leishmaniasis, caused by the Leishmania donovani complex, is responsible for over 20 000 deaths per year. This disease often affects the immunocompromised with an increased prevalence in those with human immunodeficiency virus (HIV). The immunocompromised are not only more susceptible to infection, but disseminated disease including gastric leishmaniasis. This is a case of gastric leishmaniasis occurring in a non-endemic region in a patient with comorbid HIV. Case Presentation. The patient is a 39 year old originally from Central America currently living in Southeast Georgia. His history is significant for HIV, alcohol abuse, tobacco dependency and bone marrow biopsy-proven leishmaniasis. He denied any recent travel. At initial presentation, he had abdominal pain, nausea/vomiting, chills and dysphagia along with leukopenia and thrombocytopenia. Treatment with amphotericin B was initiated for his leishmaniasis as well as highly active antiretroviral therapy (HAART). The patient was discharged home on a 3 month course of amphotericin B with continued HAART therapy. Following resolution of his acute symptoms, six months later, the patient developed acute abdominal pain with nausea prompting presentation to the emergency department. Leishmaniasis was found again following bone marrow biopsy and the patient restarted amphotericin B and HAART. Several years later the patient presented again with similar symptoms, this time with accompanying rectal bleeding. The patient received an esophagogastroduodenoscopy and on gastric mucosal biopsy was found to have gastric leishmaniasis. Conclusion. This manuscript highlights the key features of this case, including recognizing leishmaniasis clinically, proving diagnosis through definitive testing and understanding the connection between leishmaniasis and HIV.

Non-Endemic Leishmaniases Reported Globally in Humans between 2000 and 2021—A Comprehensive Review

“…Among travelers, most people were tourists, traveling for work or visiting friends and relatives; only three VL cases were described as military personnel: two deployed in Afghanistan [21] and one in Bangladesh [19]. Refugees were from Somalia (n = 17; [16]) and Ethiopia (n = 1; [17]), while migrants with VL were from Europe and Central Asia (n = 19; [25,36,44,60,208,214,216]), Sub-Saharan Africa (n = 4; [20,28,29]), Latin America (n = 2; [55,199]) and Middle East (n = 2; [10,20]). In one case, a transplacental transmission was described [45].…”

“…Patients were diagnosed in 22 countries, mostly in Europe (n = 434). Outside the European region, cases were diagnosed in Australia (n = 10, [28,36,45,57,64,211,251]), Kenya (n = 16, [16]), Kuwait (n = 36, [19]), Saudi Arabia (n = 35, [259]) and the USA (n = 8, [21,43,49,51,55,60,215]). The predominance of cases from the Mediterranean region likely reflects more intensive travel to southern Europe, especially in people from countries where most cases were diagnosed such as France (n = 107, [6,18,61,68]), the UK (n = 80, [22,38,50,52,58,201,204,207,210,214,219,252,253,261]) and Germany (n = 68, [8,20,25,27,33,35,37,40,44,46,47,53,…”

“…Clinical presentation of non-endemic cases showed many similarities with the classical description of VL from endemic areas [285][286][287]: fever, isolated or combined hepatomegaly/splenomegaly and constitutional symptoms were the signs/symptoms most commonly described (Table 2). Dermatologic manifestations were reported in nine cases, of which three were described as CL (with typical ulcerated lesions) [40,66,257], while six presented other symptoms such as hyperpigmentation, rash, erythroderma [19,31,35,55,204,252]. Rare and atypical manifestations, with the exception of two patients with isolated lymphadenopathy [37,198] and one with kidney involvement [29], were reported in immunocompromised patients, namely involvement of the eye (n = 1, [35]), lung (n = 2, [32,34]) gastrointestinal tract (n = 6 gastroduodenal, [28,197,261]; n = 4 colorectal, [48,204,252,261]; n = 1 with both, [35]).…”

“…Relapse or treatment failure occurred in 14% of the cases where treatment was known (n = 35) in 12% of patients initially treated with LAmB and 19% of patients initially treated with antimonials. Retreatments (n = 19, [21,32,35,44,47,51,55,58,66,252,260,261] often consisted of additional single or multiple courses of the same treatment strategy (53%, [44,47,51,55,58,66,260,261]) and rarely consisted in combined therapy [35]. Seventy-seven percent of the failures/relapses occurred in immunosuppressed patients [32,35,47,55,58,66,252,257,260,261].…”

“…Retreatments (n = 19, [21,32,35,44,47,51,55,58,66,252,260,261] often consisted of additional single or multiple courses of the same treatment strategy (53%, [44,47,51,55,58,66,260,261]) and rarely consisted in combined therapy [35]. Seventy-seven percent of the failures/relapses occurred in immunosuppressed patients [32,35,47,55,58,66,252,257,260,261]. Patients medically immunosuppressed by chemical or biological drugs or presenting immunodeficiencies (such as HIV infection/AIDS) are prone to VL relapses [295,296]; therefore, close monitoring until a sustained immune reconstitution has occurred is advisable [297].…”