Clinical Improvement of Disseminated Acanthamoeba Infection in a Patient with Advanced HIV Using a Non-Miltefosine-Based Treatment Regimen in a Low-Resource Setting

Abstract

Disseminated Acanthamoeba species infection is likely an underrecognized and underdiagnosed opportunistic infection in patients with advanced human immunodeficiency virus (HIV) disease in South Africa. It presents a unique clinical challenge in that the diagnosis can be difficult to establish and management options are limited in low-resource settings. To our knowledge, there is a paucity of literature to date on the successful use of combination treatment options for patients in low-resource settings without access to miltefosine. We present a case describing the clinical improvement of disseminated Acanthamoeba infection in a patient with advanced HIV using a non-miltefosine-based treatment regimen. The case serves to highlight that Acanthamoeba sp. infection should be considered as a differential diagnosis for nodular and ulcerative cutaneous lesions in patients with advanced HIV in South Africa, and that although there are alternative options for combination treatment in countries without access to miltefosine, efforts should be made to advocate for better access to miltefosine for the treatment of acanthamoebiasis in South Africa.

Keywords: HIV; acanthamoeba; amphotericin B deoxycholate; miltefosine; opportunistic infections.

Figure 1

Patient’s torso with lesions at different stages: skin-coloured papules, subcutaneous nodules and plaques with a necrotic centre.

Figure 2

Patient’s left upper arm and elbow, showing dermal nodules.

Figure 3

Patient’s right forearm, showing skin ulcers originating from dermal nodules.

Figure 4

Patient’s right hand on admission, showing joint and finger swelling.

Figure 5

Photomicrograph of skin punch biopsy showing numerous amoebic organisms (arrows) and a polymorphous background inflammatory infiltrate (haematoxylin and eosin, ×400).

Figure 6

Acanthamoeba organisms (arrows), as seen under oil immersion. Note the characteristic targetoid appearance of the nuclei (haematoxylin and eosin, ×1000).

Figure 7

Patient’s chest X-ray on admission, demonstrating a nodular infiltrate in the lower lobe and lingula of the left lung.

Figure 8

X-ray of patient’s right hand, demonstrating a periosteal reaction in the 3rd proximal phalanx and osteolysis of the 5th proximal interphalangeal joint.

Figure 9

2 mm diameter fistula in hard palate.