22 Case Presentation
Pasko and Jo 19/09/18
45 yr male, australian
Travelled through central america over 5 months
5 week worsening lesion over face, nostril and infraorbital
Demarcated swelling and erythrma over tip of nose.
You’re thinking cutaneous leishmaniasis
Get the other ddx from the slide
22.1 Biopsy
You’re looking for amastogotes!
22.2 Now what?
You want to do PCR to see if it’s viannia or not.
It was viannia so it needs IV treatment, you want to prevent mucocutaneous formation. Three weeks of sodium stibogluconate.
If you started to see QT prolongation, think of giving ambisome instead.
22.3 As a clinician
Tom Doherty - Key Facts
What’s the one thing you want to ask the parasitologist
If they have VL it’s obvious. They are super sick, they have splenomegaly, pancytopenia. You treat with IVs
If its cutaneous leish all you need to know is where they’ve been. If it’s the old world, intralesional. If it’s the new world, you need to know if it’s viannia.
| Types of Leish | Types of Treatment |
|---|---|
| VL | Parenteral |
| CL - Old World | Intralesional |
| CL - New World - Viannia Negative | Intralesional |
| CL - New World - Viannia Positive | Parenteral |
You also really need to emphasise that it may get worse before it get’s better
22.4 Case Presentation
39 year old ethopian in UK since 2005
2008 - 2 weeks of cough, rigors, weight loss
Cachectic with hepatosplenomegaly
HIV-positive, with a CD4 of 55
He had a lymph-node and liver biopsy
22.4.1 DDX
- TB!
- TB!!
- TB!!!
- Lymphoma
- Visceral Leishmaniasis (would be donovani as visceral and old world)
- Castlemans
- Disseminated Fungal Infections
Opportunistic infections are usually intracellular ones, things that are fought by cell mediated immunity
- Not really PCP (as it’s not going to give hepatosplenomegaly)
- Not really HAT (as East Africa, and not an opportunistic infection)
22.4.2 Treatment
Parenteral treatment, l-amB plus miltefosine
Was started ARVs
Was given empiric TB treatment
22.4.2.1 Problems with this treatment
What about IRIS? Immune Reconstitution Syndrome.
You get a rapid reconstitution of immunity, and if you haven’t cleared your leish or TB you can get an overwhelming inflammatory response.
In v low CD4 count and TB, there’s evidence that you should start ARVS early (within 2 weeks), as risk/benefit says you’re more likely to die of TB than of IRIS
In visceral leish, risk benefit is in favour of starting early
In cryptococcus start later (week 4,5,6)
Why start steroids? Probably shouldn’t in that situation. Data doesn’t really support this.
Why start TB meds? Reasonable (but arguable either way) as high rates of TB coinfection for this patient.
22.4.3 Then what happened?
Jan 2009 - Recurrence of symptoms and positive splenic aspirate. Needed retreated. This is common to get recurrence in HIV +ve patients
Sep 2009 - Starts getting SEs so put on monthly pentamidine
July 2011 - ARVs switched to a protease inhibitor
Oct 2011 - Now gets another recurrence of hepatosplenomegaly. this could be a bit of an IRIS as new HIV meds
Jan 2012 - Dry Cough, Fever, Malaise. CD4-90. PCP is top top diagnosis. Could be TB though. So now he needs steroids and cotrimoxazole. In these hypoxic patients it’s the steroids that saves you.
Then he gets leishmaniasis in his lungs. It was probably never PCP. The initial improvement was likely to be just cos of steroids
Feb 2013 - Repeat presentation, more leishmaniasis in his lungs
April 2013 - Maculopapular Rash, more amastagotes in his skin
2015 - Died