Diffuse cutaneous leishmaniasis associated with the immune reconstitution inflammatory syndrome

Abstract

Leishmaniasis is an emerging disease in HIV-infected persons; visceral leishmaniasis is an AIDS-defining opportunistic infection. The parasite that causes this infection is usually transmitted by the sandfly and occasionally by nonsterile needles among intravenous drug users. Diffuse cutaneous leishmaniasis (DCL) is a rare anergic variant of leishmanial infection with the characteristic presentation of numerous nonulcerating nodules with an abundant parasite load, lack of visceral involvement, negative reaction to the leishmanin skin test, and a chronic course with incomplete response to treatment and frequent relapses. We report a case of DCL that developed in the context of the immune reconstitution inflammatory syndrome (IRIS) in a man with AIDS following initiation of antiretroviral therapy. We also review DCL to emphasize the importance of recognizing and treating this evolving disease in the growing population of patients on immunorestorative therapy.

Immunopathogenesis of non-healing American cutaneous leishmaniasis and progressive visceral leishmaniasis

“…These patients tend to produce elevated levels of anti- Leishmania antibodies and excessive amounts of proinflammatory cytokines (e.g., IFN-γ, TNF-α, and IL-6) [15, 17]. Large-scale, gene polymorphism studies indicated that promoter polymorphisms for high production of IL-10 by monocytes and regulatory T (T reg ) cells increase the risk of CL lesions [18], whereas polymorphisms for high production of IL-6 and CCL2 increase the risk of ML, but not of localized CL [19, 20]. These studies may indicate a differential link between the host genetic predisposition for dysregulated inflammatory responses and the risk of severe infections.…”

“…In patients with Leishmania tropica , L. major , or L. donovani infections in India and Africa, DCL or disseminated CL is also considered a clinical indicator of HIV co-infection [40, 41]. There is also a case report of DCL that developed in the context of the immune reconstitution inflammatory syndrome in a man with AIDS following initiation of antiretroviral therapy [18]. Generally speaking, patients with DCL share some clinical characteristics.…”

Indoleamine 2,3-dioxygenase activity as a potential biomarker of immune suppression during visceral leishmaniasis

“…In the literature, few cases of leishmaniasis that developed in the context of IRS were described, and all occurred in patients co-infected with HIV. 5,[7][8][9] Here, we report, for the first time, that VL can also be an underlying disease predisposing to the development of IRS. We investigated the immunologic environment through dosages of serum biomarkers, including cytokines, soluble histocompatibility-leukocyte-antigen-G (sHLA-G) molecule and indoleamine 2,3-dioxygenase (IDO) activity.…”

Treatment of American tegumentary leishmaniasis in special populations: a summary of evidence

“…Patients with suppressed immune systems: ATL infection is emerging as a result of immunosuppression, and HIV is the most common cause 62,[75][76][77][78][79][80][81][82][83][84][85][86][87][88] . Bone marrow or solid organ transplantation [89][90][91][92][93][94][95] and therapy with immunosuppressive or biologic drugs [96][97][98] also have been associated with the appearance of ATL.…”

“…syndrome: the association between ATL and HIV-AIDS has increasingly been described in many regions of the world 99 together with immune reconstitution infl ammatory syndrome presentation 82,84,85,100 .…”