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Post‐kala‐azar dermal leishmaniasis in HIV‐coinfected individuals: problems in diagnosis and treatment

Association of visceral leishmaniasis (VL) with AIDS is common; however, post-kala-azar dermal leishmaniasis (PKDL) that presents as an immune reconstitution inflammatory syndrome in HIV-positive patients on antiretroviral therapy (ART) is infrequent. The treatment of such patients is difficult and lacks a proper regimen. A 45-year-old paramilitary man from Bihar (highly endemic region for VL in India) reported with facial eruptions of 10 days duration (Fig. 1a). He had been diagnosed in 2008 with HIV infection (WHO HIV stage IV having CD4 78 cells/mm) along with disseminated smear-positive tuberculosis and put on antitubercular and subsequently ART, including lamivudine, stavudine, and nevirapine. He had been treated with antimonials for VL in 1995. In 2010, he reported skin eruptions seen as erythematous papules on the face, including a few on the earlobes, trunk, and back. Histopathological examination showed a diffuse upper dermal infiltrate of lymphocytes, histiocytes, and plasma cells. Slit-skin smear/aspirate was positive for Leishman–Donovan bodies. Polymerase chain reaction (PCR) – restriction fragment length polymorphism confirmed Leishmania donovani as the causative species (Fig. 2). The parasite load determined by the quantitative real-time PCR was moderately high (4000 parasites/ll slit aspirate). Routine blood and urine investigations, including liver and renal function tests, VDRL, and x-ray of the chest, were within normal limits. CD4 count was 261 cells/mm. The patient was put on oral miltefosine (supplied by the National Vector Borne Diseases Control Program of the Department of Health, Government of India), 50 mg three times daily for two months, in addition to ART. At the end of miltefosine treatment, the skin lesions had subsided. The patient reported a relapse six months later, with small papules on the chin accompanied by erythema of the nose. The papules were Leishman–Donovan bodies positive with