Renal Leishmaniasis as Unusual Cause of Nephrotic Syndrome in an HIV Patient

Abstract

Renal involvement is a rare complication in HIV-1-infected patients leading to various pathologies and clinical symptoms. In addition to the classic HIV-1-associated nephropathy with collapsing-type focal segmental glomerulosclerosis and characteristic tubulocystic changes, which is more common in Afro-American than in Caucasian HIV-1 patients, immune complex GNs such as membranous GN and membranoproliferative GN are particularly common renal manifestations. Besides HIV-1 itself, a number of opportunistic infections may cause renal disease in HIV-1-infected patients. In this study, we report an unusual case of HIV-1 infection with a severe renal manifestation of systemic leishmaniasis that developed years after repeated visits to Mediterranean countries. The case presents several remarkable clinical, pathologic, and therapeutic aspects that may be important for daily clinical practice. 23: 586-590, 201223: 586-590, . doi: 10.1681 In April 2008, a 45-year-old Caucasian male patient was admitted to our hospital due to dyspnea and recurrent diarrhea during the past weeks. He had been known to be HIV-1 infected for 23 years, and he had been treated with various antiretroviral drug regimens since 1997. Despite therapy, he had experienced progressive immunodeficiency due to poor compliance and drug resistance. At a prior visit to our hospital in 2001, he had presented with a high viremia (500,000 copies/ml) and depleted CD4 cells (3/ml). At the current admission, he was on an antiretroviral combination regimen consisting of darunavir, low-dose ritonavir, tenofovir, and emtricitabine. J Am Soc NephrolPhysical examination revealed an elevated blood pressure of 170/110 mmHg, dyspnea, bilateral pleura effusions, gross edema of legs, scrotum, and penis, and reddish, macular and papular skin lesions on the dorsal hands, chest, abdomen, and thighs. Laboratory analyses showed abnormal renal parameters (serum creatinine 1.49 mg/dl [normal range ,1.1 mg/dl], creatinine clearance 35 ml/min [normal value 75-125 ml/min], urea 69 mg/dl [normal range 14-43 mg/dl], uric acid 7.5 mg/dl [normal range 3.5-7 mg/dl], and proteinuria of 9.6 g/24 h). Liver en-were elevated. Serum ferritin was strongly increased to 1770 ng/ml (normal range 34-310 ng/ml), and iron was slightly decreased to 28 mg/dl (normal range 40-160 mg/dl). Peripheral blood counts showed anemia (hemoglobin 8.3 mg/dl [normal range 12-16 mg/dl]), slight leukopenia (3900/ml [normal range 4000-10,000/ml]), and thrombopenia (99,000/ml [normal range 150,000-400,000/ml]). The number of CD4 + T cells was decreased to 174 cells/ml. Quantitative PCR analyses demonstrated low HIV-1 viremia (790 copies/ml), a low cytomegalovirus viremia (6 copies/10 5 cells), and shedding of BK virus in the urine (4400 copies/ml). PCR analyses yielded negative results for hepatitis C virus in serum and for adenovirus and John Cunningham virus in the urine. All other laboratory parameters including the complement factors C3 and C4, antinuclear antibodies, cryoglobulins, anti-dsDNA antibodies, ...

Visceral leishmaniasis due to Leishmania infantumwith renal involvement in HIV-infected patients

“…Histological findings reported in our series are in line with sporadic cases described in humans and in studies on dogs, where type III MPGN was the most commonpattern [15]-[22],[25],[26]. Interestingly, free Leishmania were observed inside the capillary lumen of two patients.…”

Renal AA-amyloidosis in intravenous drug users – a role for HIV-infection?

“…Several cases of amyloidosis in HIV infected IVDU have been described in the literature [5,6,13,14,16,17]. Besides IVDU, renal amyloidosis in HIV infected patients has been described in association with visceral leishmaniosis or multicentric Castleman`s disease [18-21], which were both not found in our cohort. During the same time period of this retrospective study, 25 HIV-infected patients without a history of IVDU underwent renal biopsy at our institutions and none of them had evidence of renal AA-amyloidosis [data not shown].…”

Detection of Leishmania siamensis DNA in Saliva by Polymerase Chain Reaction

“…Urine is another source for detection of L. siamensis DNA. Although there are several reports of renal involvement in patients with leishmaniasis, 12,[25][26][27] the six patients had no evidence of renal disease. DNA extraction from urine requires 30 mL of urine, and we found that 50% of the patients in our series were negative for Leishmania DNA yet positive for DNA in saliva.…”