Mediterranean leishmaniasis in HIV-infected patients: epidemiological, clinical, and diagnostic features of 22 cases

Abstract

Twenty-two Italian HIV-infected patients developed leishmaniasis, clinically manifested as visceral (13 cases), cutaneous (2 cases) and disseminated disease (7 cases). Twenty were males and two females (mean age: 32.8 years) with a mean CD4+ cell count of 46.8/microliter at diagnosis; risk factors were intravenous drug use (17 patients) and sexual behaviour (two bisexual, two homosexual, one heterosexual). All but one patient lived or travelled in hypoendemic Italian regions and other Mediterranean countries. Apart from the two patients with cutaneous leishmaniasis, the clinico-pathological and biological spectrum of the infection was often atypical, especially in patients with disseminated disease. The diagnosis was routinely made by direct recovery of parasites in biological specimens, mainly in bone marrow aspirate, whereas serology was negative or borderline in most of the patients. Among 17 in vitro isolates, Leishmania infantum was the only species involved with previously undescribed isoenzyme patterns in two cases. Treatment with antimonials and other drugs showed only temporary clinical improvement in some patients. Relapses were the rule. Leishmaniasis confirms itself as an opportunistic infection in HIV-positive persons. Secondary chemoprophylaxis should be considered in cases of relapsing disease.

PIP: The majority of the 850 HIV-associated Leishmania infections reported worldwide involve men and women from Mediterranean countries, particularly Spain, Italy, and France. This article describes a retrospectively identified series of 22 patients (20 men and 2 women) from northern Italy's Lombardy region with HIV/Leishmania coinfection in the period 1989-97. At leishmania diagnosis, the mean CD4+ lymphocyte count was 46.8/mcl and 21 patients had been previously diagnosed with an AIDS-defining illness. Intravenous drug use was the HIV risk factor in 17 patients; an additional 4 were bisexual or homosexual. The diagnosis of leishmaniasis was made by direct recovery of parasites in biologic specimens, mainly in bone marrow aspirate. Serology was generally negative or borderline due to the frequent occurrence of humoral immunity imbalances. Anemia, leukopenia, thrombocytopenia, and hypergammaglobulinemia were present in all but 1 patient. Leishmaniasis was clinically manifested as visceral in 13 cases, cutaneous in 2 cases, and disseminated disease in 7 cases. The clinicopathologic and biologic spectrum of infection tended to be atypical, especially in patients with disseminated disease. Leishmania infantum was the only species involved in 17 in vitro isolates; 2 cases exhibited previously undescribed isoenzyme patterns. Treatment with antimonials and other drugs produced, at best, only temporary clinical improvement. Relapses were the rule during follow-up in all but the 2 patients with cutaneous leishmaniasis. Inclusion of Leishmania spp. among the infectious agents of AIDS-defining diseases is recommended.