Post-kala-azar dermal leishmaniasis in HIV-infected patients with AIDS: a report of two cases diagnosed in the USA

Abstract

Post-kala-azar dermal leishmaniasis (PKDL) is an uncommon complication of visceral leishmaniasis (VL) but is emerging as an increasingly frequent and serious complication of acquired immunodeficiency syndrome (AIDS). It manifests as a macular, morbilliform, or nodular eruption in a patient who has recovered from VL. We present two cases of PKDL in the setting of AIDS. These two cases are notable because they demonstrate the severe course of VL, the rare appearance of PKDL in the U.S.A., and the recurrence of disease after >2 years of remission in the second case. Options for treatment include amphotericin B and pentavalent antimonials along with first-line antiretroviral therapy. The prevention of VL relapses, and the development of PKDL in HIV patients with Leishmania co-infection remains challenging. The vast differential diagnosis of other HIV-related cutaneous conditions, along with a lack of experience with this disease, often delays diagnosis. Therapeutic dilemmas concerning drug selection, dosage, scheduling regimen, and the respective durations of initial and maintenance therapy for PKDL need to be addressed. Treatment should aim to target the latent infection and prevent posttreatment VL relapses that may present in an unpredictable fashion. Leishmaniasis remains a recognized but uncommon opportunistic disease in the setting of HIV, which can be associated with atypical features including the appearance of skin lesions years after the treatment of VL.