Slow clinical improvement after treatment initiation in Leishmania/HIV coinfected patients

Abstract

INTRODUCTION: In Brazil there is a large area of overlap of visceral leishmaniasis (VL) and HIV infection, which favored a increased incidence of coinfection Leishmania/HIV. METHODS: This study evaluated 65 consecutive patients with VL and their clinical response to treatment in two health care settings in Belo Horizonte, Brazil. RESULTS: At baseline, the clinical picture was similar between both groups, although diarrhea and peripheral lymphadenomegaly were more frequent in HIV-infected subjects. HIV-positive patients had lower median blood lymphocyte counts (686/mm³ versus 948/mm³p = 0.004) and lower values of alanine aminotransferase (ALT) (48IU/L versus 75.6IU/L p = 0.016) than HIV-negative patients. HIV-positive status (hazard ratio = 0.423, p = 0.023) and anemia (HR = 0.205, p = 0.002) were independent negative predictors of complete clinical response following antileishmanial treatment initiation. CONCLUSIONS: This study reinforces that all patients with VL should be tested for HIV infection, regardless of their clinical picture. This practice would allow early recognition of coinfection with initiation of antiretroviral therapy and, possibly, reduction in treatment failure.

Epidemiological profile of patients co-infected with visceral leishmaniasis and HIV/AIDS in Northeast, Brazil

“…In the current study, there were more males in both groups; our findings are supported by those previously reported by Souza et al 15 and Hurissa et al 28 . Additionally, we found that there were a greater number of patients working in the agricultural sector among those with VL only while there were a greater number of patients working in the service sector among those co-infected with HIV/AIDS.…”

“…Both diseases tend to modify the immune response from Th1 to Th2 via a complex network of cytokines, thus reducing the cell-mediated immunity. This results in ineffective responses to drugs, changes in the diagnostic standards, recurrences, opportunistic infections, and increased mortality rates 2,14,15 . The clinical manifestations of this co-infection are variable, and patients may present classic symptoms, atypical conditions, or may present with opportunistic diseases associated with HIV/ AIDS, making early diagnosis more difficult 10,11,15,16 .…”

“…Serological tests have also been used; however, one should take caution when analyzing their results, as the sensitivity might be reduced due to the immunosuppression as a result of both pathologies 15 . The sensitivity of the indirect immunofluorescence reaction (IIFR) for co-infection is 50-60%, which is lower than that for patients without co-infection (80-95%) 10 .…”

HIV/AIDS-related visceral leishmaniasis: a clinical and epidemiological description of visceral leishmaniasis in northern Brazil

“…In general, patients with coinfections show very similar clinical features to classical VL 9 , although the usual clinical features associated with VL (prolonged fever, spleen and liver enlargement, wasting and pancytopenia) are not always present, and atypical presentations occur more often in immunocompromised patients. Furthermore, a clinical diagnosis can also be more diffi cult to establish due to other concomitant opportunistic diseases 10 .…”

Five-Year Retrospective Italian Multicenter Study of Visceral Leishmaniasis Treatment

“…Failures were more frequent in HIV patients with lower nadir CD4 counts (55.5 Ϯ 40.3 versus 172 Ϯ 221, P ϭ 0.1), whereas HIV suppression by HAART was not protective, a finding in line with similar data in the literature (2, 7). In the search for factors associated with the failure of first-line treatment, the final logistic-regression model indicated that the only independent predictors were HIV infection and older age, the first reflecting, as discussed above, the profound immune imbalance determined by CD4 ϩ T-cell depletion (32). The pinpointed significance of age was in agreement with another report showing a 5-fold-greater risk of relapse in African patients older than 45 years and treated with antimonial derivatives (28).…”