Complex case report that illustrates the paucity of data for long term management of Visceral Leishmania-HIV co-infection.
HIV-associated leishmaniasis, endemic in the Mediterranean basin is a growing problem in India, Brazil and East Africa. Despite surviving for than 20 years, the clinical course of our visceral-leishmania (VL)-HIV co-infected patient illustrates several management challenges including diagnosis, speciation and drug resistance; monitoring burden of disease; access to and use of VL-treatments; end-organ toxicity and the combined immunosuppressive effects of HIV-VL.
Methods: Descriptive case report. results: A 58-year-old man, diagnosed with HIV-1 in 1985 was subsequently diagnosed with VL in 1996 on gut biopsy; the latter was unmasked through HIV-associated immunodeficiency as leishmania was likely acquired during childhood years in Greece. Challenge 1: presumed L.infantum infection, as formal speciation was only possible in 2003 using an in-house PCR. Challenge 2: although the WHO “gold standard” for monitoring disease burden is splenic aspiration and culture, no unit would perform this due to understandable safety concerns – instead repeated bone marrow biopsies were used to “quantify” disease burden. Challenge 3: between 1996-2012 in accordance with various “guidelines” – based largely on HIV-negative experience, the patient received, in addition to combination antiretroviral therapy (cART ), successive “induction-maintenance” with pentavalent antimonials; miltefosine (imported from Germany); liposomal amphotericin and monthly pentamidine with azoles (posaconazole on compassionate access, later fluconazole). There was rapid clinical failure and ultimately clinical evidence of pan-resistance to all anti-parasitics. Progressive renal impairment, liver cirrhosis (Challenge 4) and increasing fraility meant that parenteral paromomycin was not a viable treatment option. Challenge 5 – immune failure ultimately leading to death from recurrent gram negative sepsis arising from ulcerated skin lesions infiltrated with leishmania.
Conclusion: Further data on induction-maintenance strategies using combination VL-therapeutics coupled with improved microbiological techniques for diagnosis and monitoring in the HIV setting are urgently needed. Moreover, these VL-therapeutics and cART need to be affordable and accessible in countries with endemic HIV-VL co-infection.
