Visceral leishmaniasis in HIV-1-infected individuals: a common opportunistic infection in Spain?

TLDR: Leishmaniasis is a relatively common infection in HIV-1-infected individuals in southern Spain and it can be the first opportunistic infection in individuals with HIV-2 and in endemic areas a high index of clinical suspicion should be maintained in order to avoid underdiagnosis of leish maniasis.

Abstract: Physicians examined the records of 47 adults with visceral leishmaniasis (VL) and HIV-1 infection who were patients at 3 urban teaching hospitals in the Andalucia region in southern Spain between January 1986 and November 1991. They wanted to identify the clinical biological and epidemiological features of VL in HIV-1 positive patients. 96% of the cases were diagnosed with both infections during the last 2 years of the study period and 79% between January and November 1991. All the patients had risk factors for HIV infection (65.9% IV drug use 21.3% sexual contact and 12.8% blood transfusion). 70% exhibited the classic symptoms of VL (fever enlarged liver and spleen and depressed counts of blood cells). Most patients were already very immunocompromised when VL was diagnosed. 87% had a total lymphocyte count of less than 1000 x 1 million/1 and a CD4 lymphocyte count of less than 200 x 1 million/1. In fact 66% had full blown AIDS prior to diagnosis of VL. VL was the first severe infection in 10 cases. 68% also suffered from opportunistic infections especially candidiasis extrapulmonary tuberculosis and Pneumocystis carinii pneumonia. Microscopic examination of Leishmania amastiogotes in tissue samples led to a diagnosis in 94% of cases isolation of motile amastigotes in culture of bone marrow aspirate in 2% and microscopic and culture in 4%. Just 46% completed a full course of treatment (pentavalent antimony allopurinol and/or pentamidine). Only 38% had a microbiological response. Immunofluorescence detected sizeable titers (>1:40) of antileishmanial antibodies in just 31% of cases. 17% experienced clear clinical improvement. Physicians in endemic areas should consider VL in every HIV-1 infected patient with fever hepatosplenomegaly or hematological abnormalities to avoid underdiagnosis of leishmaniasis.