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Leishmaniasis as an opportunistic infection in HIV-infected patients: determinants of relapse and mortality in a collaborative study of 228 episodes in a Mediterreanean region

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Abstract

The clinical presentation of visceral leishmaniasis shares similarities with other geographically specific infectious diseases associated with AIDS in terms of relapsing course and atypical presentation. However, visceral leishmaniasis has not, until now, been included in the AIDS case definition. The aim of this study was to describe the clinical features and determinants for relapse and case-fatality of visceral leishmaniasis in HIV-infected patients from a Spanish Mediterranean area. A chart review was conducted in 16 hospitals in the autonomous communities of Valencia and Murcia (Spain). From 1988 to 2001, a total of 228 episodes of visceral leishmaniasis were diagnosed in 155 HIV-infected patients by the detection of amastigotes in bone marrow aspirates or in other tissue samples. Most patients had advanced HIV disease, with a median CD4+ lymphocyte cell count of 55 cells × 109 l, and 56% of them had a previous AIDS-indicator disease. The median duration of follow-up was 8.4 months. HIV-infected patients with visceral leishmaniasis presented with fever (76%), hepatomegaly (77%), splenomegaly (78%), and varying degrees of cytopenias. Leishmania was detected in atypical sites in 22 (14%) patients. A total of 37 (24%) patients had a relapse of visceral leishmaniasis. Female gender was a risk factor for relapse, whereas administration of secondary prophylaxis for visceral leishmaniasis and a completed therapy for visceral leishmaniasis were protective factors against relapse. A total of 86 (54%) patients died. Independent determinants for survival were CD4+ lymphocyte cell count, completed therapy for leishmania, and secondary prophylaxis for visceral leishmaniasis. The findings show that, in HIV-infected patients, visceral leishmaniasis occurs in late stages of HIV disease and often has a relapsing course. Secondary prophylaxis reduces the risk of relapse. Visceral leishmaniasis in the HIV-infected population should be included in the CDC clinical category C for the definition of AIDS in the same way that other geographically specific opportunistic infections are included.

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Acknowledgments

We thank Rogelio López-Velez, M.D., for his helpful comments during the preparation of the manuscript and Stephanie Parker for her help with the translation. Members of the Leishmania-HIV Mediterranean Co-operative Group: Hospital Marina Baixa, Villajoyosa, Alicante, Spain: F. Pasquau (coordinator), J. Ena (coordinator), C. Amador, C. Benito, A. García, M. Lopez, C. Martinez, M.L. Tahoces.V. Fenoll; Hospital General Universitario de Alicante, Spain: R. Sanchez, E. Merino, V. Boix, J. Portilla; Hospital Universitario de San Juan, Spain: J.M. Cuadrado, P. Roig, F. Jover, L. Andreu; Hospital Arnau de Vilanova, Valencia, Spain: J Flores, A. Torrego; Hospital Arrixaca de Murcia, Spain: C. Redondo, G. Poza; Hospital La Fe de Valencia, Spain: J. Lacruz, J.A. Mota, V. Sanchis-Bayarri, P. Ubeda, M. Blanes, J. Lopez-Aldeguer; Hospital General de Valencia, Spain: V. Abril, E. Ortega; Hospital Rosel de Cartagena, Spain: J Onofre; Hospital Morales Meseguer de Murcia, Spain: A. Menasalvas, R. Blázquez; Hospital Clinico Universitario de Valencia, Spain: M.J. Galindo, R Alcácer; Hospital Vega Baja de Orihuela, Alicante, Spain: J. Gregori; Hospital General de Castellon, Spain: C. Minguez, J. Usó; Hospital Universitario de Elche, Alicante, Spain: S. Padilla, F. Gutiérrez; Hospital Peset de Valencia, Spain: J. Carmena; Hospital Marina Alta de Denia, Alicante, Spain: P. Martinez; Hospital General de Elda, Spain: J. del Pino; Hospital Ramon y Cajal de Madrid, Spain: R. Lopez-Velez. F. Pasquau initiated the study and wrote the study protocol. F. Pasquau and J. Ena contributed to the design and were resposible for the coordination, data analysis, and preparation of the paper. C. Amador and C. Benito contributed to data collection and critically reviewed the paper. R. Sanchez, J.M. Cuadrado, J. Flores, C. Redondo, J. Lacruz, V. Abril, and J. Onofre coordinated the study activities and data collection at their centres.

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Authors and Affiliations

  1. Department of Internal Medicine-HIV Unit, Marina Baixa Hospital, Partida de Galandú 5, 03570, Villajoyosa, Alicante, Spain

    F. Pasquau, J. Ena, C. Amador & C. Benito

  2. Infectious Diseases Department, University General Hospital, Maestro Alonso 109, 03010, Alicante, Spain

    R. Sanchez

  3. Department of Internal Medicine-HIV Unit, San Juan University Hospital, Carretera de Valencia km 87, 03550, San Juan, Alicante, Spain

    J. M. Cuadrado

  4. HIV Unit, Arnau de Vilanova Hospital, San Clemente 12, 46015, Valencia, Spain

    J. Flores

  5. Infectious Diseases Department, Virgen de la Arrixaca University Hospital, Carretera de Cartagena km 7, 30120, Murcia, Spain

    C. Redondo

  6. Infectious Diseases Department, La Fe University Hospital, Avenida Campanar 21, 46009, Valencia, Spain

    J. Lacruz

  7. Infectious Diseases Department, Universitary General Hospital, Avenida de Tres Cruces s/n, 46017, Valencia, Spain

    V. Abril

  8. Department of Internal Medicine-HIV Unit, Virgen del Rosell Hospital, Paseo Alfonso XIII, 30203, Cartagena, Spain

    J. Onofre

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  1. F. Pasquau
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  11. J. Onofre
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Leishmania HIV Mediterreanean Co-operative Group

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Correspondence to F. Pasquau.

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Pasquau, F., Ena, J., Sanchez, R. et al. Leishmaniasis as an opportunistic infection in HIV-infected patients: determinants of relapse and mortality in a collaborative study of 228 episodes in a Mediterreanean region. Eur J Clin Microbiol Infect Dis 24, 411–418 (2005). https://doi.org/10.1007/s10096-005-1342-6

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