Cutaneous leishmaniasis associated with visceral leishmaniasis in a case of acquired immunodeficiency syndrome (AIDS)

Introduction  Leishmania /human immunodeficiency virus (HIV) coinfection is emerging as an increasingly frequent and extremely serious new disease. Although many reports have described the association of visceral leishmaniasis and AIDS, cutaneous leishmaniasis associated with AIDS is very uncommon.
Case summary   We describe a case of visceral leishmaniasis/HIV coinfection associated with cutaneous Leishman body-positive lesions in a patient from Jahrom, a city in Fars province in Iran.
Conclusion   Our case demonstrated that it is better to evaluate the diagnosis of visceral leishmaniasis in patients who present with cutaneous leishmaniasis and HIV infection.     

Clinical features of cutaneous and disseminated cutaneous leishmaniasis caused by Leishmania (Viannia) braziliensis in Paraty, Rio de Janeiro

Background  American tegumentary leishmaniasis (ATL) caused by Leishmania (Viannia) braziliensis is endemic in Rio de Janeiro State (RJ), where the disease shows epidemiologic and clinical characteristics distinct from those of ATL in other Brazilian regions. Paraty is the second most important endemic area in RJ; however, reports on leishmaniasis in this region refer to the occurrence of the disease without describing its characteristics.
Methods  The clinical features of 71 cases of ATL reported between 1991 and 1997 in Paraty are presented. Thirty patients were re-evaluated 10 years later.
Results  Males and females were affected in similar proportions, and the disease was more prevalent in patients aged between 10 and 49 years (63.4%). Cutaneous leishmaniasis was the most prevalent clinical form observed. Unique lesions were present in 69% of cases, 91.6% of which displayed an ulcerated aspect. Although mucosal leishmaniasis was not observed, severe clinical manifestations, such as disseminated cutaneous lesions caused by L. braziliensis , were diagnosed in two patients. These patients presented skin lesions with different clinical aspects spread throughout the body, as well as low cellular immune responses. Montenegro skin test (92% positivity) and serology (8% IgM and 56% IgG anti- Leishmania positive results) were the most utilized tests for supporting the diagnosis of leishmaniasis. Parasites, detected in 27 of the 33 cases analyzed, were characterized as L. braziliensis .
Conclusion  ATL in Paraty shares the clinical and laboratory characteristics reported for ATL in other regions of RJ, probably because of the similar epidemiologic context related to the Atlantic rainforest region.     

Unusual clinical variants of cutaneous leishmaniasis in Sicily

Background  The term "leishmaniasis" defines a group of vector-borne diseases caused by species of the genus Leishmania and characterized by a spectrum of clinical manifestations. Parasite properties (infectivity, pathogenicity, virulence), host factors, and host responses regulate heterogeneous disease expression. Sicily is one of the major islands of the Mediterranean Basin and is considered to be a hypo-endemic area for cutaneous leishmaniasis. Leishmania infantum is the most common species on the island.
Methods  Fifty patients (both sexes and different ages) with lesions clinically suggestive of cutaneous leishmaniasis were recorded over a 1-year period. The diagnosis was based on positive slit-skin smear and histopathologic studies when needed. Polymerase chain reaction (PCR) was performed as test confirmation.
Results  Twenty-five patients had typical solitary lesions of cutaneous leishmaniasis. Multiple lesions were present in five patients. In 20 patients, the lesions were very unusual, including erysipeloid, zosteriform, and lupoid leishmaniasis. The results of Leishmania isoenzyme characterization identified Leishmania infantum as the species responsible for the 20 atypical cases.
Conclusion  The global number of cases of cutaneous leishmaniasis in Sicily has increased in recent years, and such increases can be explained, in part, by the fact that, in this region, sandflies are present during a large part of the year. This is a result of the climatic variation in recent years (increasing temperature and humidity). There has also been an increase in the number of new and rare variants of cutaneous leishmaniasis. A knowledge of the unusual clinical variants of cutaneous leishmaniasis, as well as classical forms, allows early detection.     

Presence of Leishmania organisms in specific and non-specific skin lesions in HIV-infected individuals with visceral leishmaniasis

BACKGROUND: Leishmania coinfection is frequently seen in human immunodeficiency virus (HIV)-infected patients in endemic areas, and from time to time the protozoan is detected in cutaneous biopsies. OBJECTIVE: To establish the characteristics and possible ethiologic role of the presence of Leishmania in these lesions. METHODS: We studied 12 cutaneous biopsies with Leishmania organisms from nine HIV-infected patients (seven men and two women) with visceral leishmaniasis, diagnosed by bone marrow examination, seen over a period of 9 years. RESULTS: Based on clinical characteristics, evolution and response to anti-leishmanial treatment, cutaneous alterations were found to be related to the presence of the protozoan in six cases, whereas in the other six cases it was not considered responsible for the dermatological lesions (dermatofibroma, and lesions of psoriasis, Reiter's syndrome, bacillary angiomatosis, cryptococcosis and oral aphthae). Of note was the high prevalence of specific mucocutaneous manifestations, usually accompanied by intense pruritus, great variability, and a tendency to relapse after treatment stopped. On two occasions, detection of the protozoa in skin biopsies led to the diagnosis of a previously unsuspected visceral leishmaniasis. CONCLUSIONS: Cutaneous detection of Leishmania is frequent in HIV-infected individuals with visceral leishmaniasis. Sometimes Leishmania is associated with changes attributable to other dermatological processes, and its presence does not imply a causative role. A clear relationship between the systemic process and the therapeutic response is necessary to demonstrate an ethiologic role.     

Comparative study of cutaneous leishmaniasis in human immunodeficiency virus (HIV)-infected patients and non-HIV-infected patients in French Guiana

BACKGROUND: Few data are available on cutaneous leishmaniasis caused by dermotropic species in human immunodeficiency virus (HIV)-infected patients. OBJECTIVES: To describe nine cases of cutaneous leishmaniasis in HIV+ patients and to compare their clinical features and their response to treatment with those of HIV- patients with the forms of leishmaniasis commonly found in French Guiana. METHODS: A case-control study was carried out between July 1994 and December 2000 in French Guiana. We compared the following variables in nine HIV-infected patients with leishmaniasis and 27 matched controls: clinical type of leishmaniasis, number of lesions, presence of lymphangitis and adenopathy, the rate of recovery after treatment, and recurrence or reinfection. RESULTS: Eight of the HIV-infected patients had localized cutaneous leishmaniasis and one had mucocutaneous leishmaniasis. All of the controls had localized cutaneous leishmaniasis. Leishmania guyanensis was the only species isolated from HIV-infected subjects. HIV-Leishmania coinfected patients had a higher rate of recurrence or reinfection (P < 0.02) and a lower rate of recovery after one treatment cycle with pentamidine (P < 0.02) than did HIV- subjects. The CD4+ lymphocyte counts exceeded 200 mm(-3) in all HIV+ patients at the time of the diagnosis with leishmaniasis. CONCLUSIONS: In French Guiana, cutaneous leishmaniasis in moderately immunosuppressed HIV-infected subjects (> 200 CD4+ T cells mm(-3)) is characterized by a higher rate of recurrence or reinfection and is more difficult to treat than that in HIV- subjects.     

Imiquimod 5% cream for external genital or perianal warts in human immunodeficiency virus-positive patients treated with highly active antiretroviral therapy: an open-label, noncomparative study

Background  Human immunodeficiency virus (HIV)+ patients have an increased risk of anogenital warts. High-risk (HR) human papillomaviruses (HPVs), especially types 16 and 18, are major risk factors for precancerous and cancerous lesions of the anogenital tract, while low-risk (LR) HPVs are associated with benign lesions. Cure of genital warts with ablative techniques, surgical excision, podophyllotoxin or trichloroacetic acid is frequently difficult. Treatment with imiquimod cream showed a total clearance of external genital or perianal warts in about 50% of immunocompetent subjects. However, total clearance was reduced in HIV+ subjects not treated with highly active antiretroviral therapy (HAART).
Objectives  To assess clinically and by monitoring HPV content the efficacy of 5% topical imiquimod to treat anogenital warts in HIV+ subjects with at least partially restored immune functions.
Methods  Fifty HIV+ patients successfully treated with HAART (total CD4+ cells ≥ 200 cells mm⁻³ and plasma HIV RNA load < 10⁴ copies mL⁻¹) with anogenital warts were included. Imiquimod 5% cream was applied on external genital or perianal warts three times weekly for up to 16 weeks. Warts were tested at entry and after treatment for human LR- and HR-HPV DNA.
Results  Total wart clearance was observed in 16 of 50 (32%) patients at week 16. At enrolment, HPV DNA was present in more than 90% of lesions with a majority of lesions co-infected by HR- and LR-HPV. At study end, the HPV load decreased or became undetectable in 40% of cases studied.
Conclusions  Imiquimod 5% cream did not show safety concerns and is suitable for use in HIV+ subjects with anogenital warts and successful HAART treatment.     

Leishmania infantum/HIV co-infection: cutaneous lesions following treatment of visceral leishmaniasis

BACKGROUND: The Mediterranean basin is an endemic region of leishmaniasis caused by Leishmania infantum. With the advent of human immunodeficiency virus (HIV) infection, the number of cases of visceral leishmaniasis has dramatically increased in this area over the last years, mainly in adults. Moreover, the presence of cutaneous lesions infested with Leishmania has been frequently reported in these patients. CASE-REPORT: A 35-year-old Portuguese woman, a former intravenous drug user HIV1-positive since 1997, developed visceral leishmaniasis in 2000, with several relapses in 2001 and 2002, treated successively with pentavalent antimonial salts (Glucantime), liposomal amphotericin B and Glucantime associated with itraconazole. Several weeks after therapy for the second relapse of visceral leishmaniasis, physical examination revealed asymptomatic erythematous papules on the face that later spread to the trunk and upper limbs. Histopathologic studies of a skin biopsy revealed a granulomatous infiltrate in the dermis with the presence of Leishmania amastigotes. After culture, the parasite was identified as L. infantum MON-1. In spite of improvement of the patient's visceral leishmaniasis with the above-mentioned treatment, the cutaneous lesions became increasingly numerous and infiltrated. After 2 months of therapy with intravenous pentamidine (4 mg/kg/3 times a week) and oral dapsone (100 mg b.i.d), the cutaneous lesions disappeared completely. Prevention with dapsone was successfully maintained for 6 months. Several weeks after discontinuation of treatment, further lesions appeared. The patient improved again on reintroduction of dapsone. DISCUSSION: This case confirmed the existence of a clinical form similar to post-kala-azar dermal leishmaniasis in a patient co-infected with L. infantum MON-1/HIV. The cutaneous lesions were resistant to classical antileishmanial drugs but disappeared on treatment with dapsone.     

Kaposi's sarcoma-like lesions and other nodules as cutaneous involvement in AIDS-related visceral leishmaniasis

A 40-year-old human immunodeficiency virus (HIV)-positive man had three relapses of visceral leishmaniasis (VL). In the third he developed nodular skin lesions of three types, some reminiscent of Kaposi's sarcoma. Biopsy of each type disclosed abundant dermal macrophages with a huge number of intracellular and extracellular Leishman-Donovan bodies. Rapid improvement of lesions was achieved after antiparasitic treatment. AIDS leads to atypical forms of leishmaniasis. Leishmania has been detected both in normal and pathological skin of these patients due to dissemination during VL. It is suspected that a considerable proportion of the population may be infected in endemic areas, Leishmania being opportunistic in immunosuppressed individuals. It is important to recognize the range of lesions that may occur in patients with HIV and VL, many of which are non-specific and may cause diagnostic difficulty.     

Juvenile acute cutaneous leishmaniasis: the first case report from North Scandinavia

A case of juvenile acute cutaneous leishmaniasis is reported. Treatment with freezing with CO₂ snow was beneficial in healing of cutaneous lesions and no relapses have occurred.     

Leishmaniasis

Leishmaniasis is a protozoan disease whose clinical manifestations depend both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sandfly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis (CL), to the mucous membranes in mucosal leishmaniasis or spread internally in visceral leishmaniasis (VL). In the last 2 decades, leishmaniasis, especially VL, has been recognized as an opportunistic disease in immunocompromised patients, particularly those infected with HIV. Leishmaniasis is characterized by a spectrum of disease phenotypes that correspond to the strength of the host's cell-mediated immune response. Both susceptible and resistant phenotypes exist within human populations. Clinical cutaneous disease ranges from a few spontaneously-healing lesions, to diffuse external or internal disease, to severe mucous membrane involvement. Spontaneously-healing lesions are associated with positive antigen-specific T cell responsiveness, diffuse cutaneous and visceral disease with T cell non-responsiveness, and mucocutaneous disease with T cell hyperresponsiveness. Current research is focused on determining the extent to which this spectrum of host response is genetically determined. In endemic areas, diagnosis is often made on clinical grounds alone including: small number of lesions; on exposed areas; present for a number of months; resistant to all types of attempted treatments; and usually no pain or itching. Multiple diagnostic techniques are available. When evaluating treatment, the natural history of leishmaniasis must be considered. Lesions of CL heal spontaneously over 1 month to 3 years, while lesions of mucocutaneous and VL rarely, if ever, heal without treatment. Consequently, all the latter patients require treatment. Therapy is not always essential in localized CL, although the majority of such patients are treated. Patients with lesions on the face or other cosmetically important areas are treated to reduce the size of the resultant scar. In addition, the species of parasite should be identified so that infection with Leishmania braziliensis and Leishmania panamensis can be treated to reduce the risk of development of mucocutaneous disease. Treating patients with Leishmania and HIV co-infection requires close monitoring for effectiveness of treatment, especially because of the high relapse rates. Proven treatments include: antimonials, pentamidine, amphotericin B, interferon with antimony. Treatments where current clinical experience is too limited include: allopurinol, ketoconazole, itraconazole, immunotherapy, rifampin, dapsone, localized heat, paromomycin ointment and cryotherapy. Investigational treatments include: WR6026, liposomal amphotericin and miltefosine. In addition, vaccines for leishmaniasis are being investigated in clinical trials.