Visceral leishmaniasis in HIV-infected patients in the south of France.

Brief communication Visceral leishmaniasis in HIV-infected patients in the south of France J. Dereure,1 J. Reynes,2 F. Pratlong,' 1. Lamaury,2 J.A. Rioux,1 F. Janbon,2 & J.-P. Dedet1 Between 1989 and 1993, investigations by classical parasitological procedures of 139 HIV-infected adults living in visceral leishmaniasis (VL) endemic areas showed that 10 of them (7.2%) were positive for Leishmania (by stained smears and culture). In the same period we identified 15 VL cases in patients not infected with HIV. Thus, 40% (10/25) of our VL cases were associated with HIV infection. Since 1985, about 400 cases of visceral leishmania- sis (VL) associated with AIDS-mainly from the Mediterranean region- have been reported (1, 5); prevalence data of the co-infection in this endemic area are rarely available. Methods and results Since 1989, we systematically searched for VL -based on the recent CDC classification (2)- in a cohort of HIV-infected adults who presented with prolonged fever of unexplained origin. Several Grunwald-Giemsa-stained smears and NNN-medium cultures with bone marrow aspirate were carried out on 139 HIV-infected patients, 10 of whom were found to be infected with Leishmania (positive smears in 9 and positive cultures in all 10). These patients were aged 24 to 56 years, and present- ed with fever, pancytopenia, a raised erythrocyte sedi- mentation rate, and a CD4 count of <200 per cu.mm. The spleen was enlarged in five of the 10 patients. Leishmanial serological tests (indirect immunofluo- rescence and counter-immuno-electrophoresis) were positive in only four patients (Table 1). The isoenzyme characterization of Leishmania isolates obtained from these 10 patients identified the following zymodemes of the L. infantum complex: MON-1, MON-29, MON-33 and MON-183. MON-1 I Laboratoire d'Ecologie m6dicale et de Pathologie parasitaire, 163 rue A. Broussonet, 34000 Montpellier, France. Requests for reprints should be sent to Dr J. Dereure at this address. 2 Service de maladies infectieuses et tropicales, Hopital Gui de Chauliac, Montpellier, France. Reprint No. 5593 is the common zymodeme found in VL of the Medi- terranean countries. MON-29 and MON-33 zymo- demes are responsible for localized cutaneous leish- maniasis in immunocompetent patients; they have nevertheless been found in co-infected VL-AIDS patients by others (3, 6). However, MON-183 zymo- deme has only been reported so far in two VL-AIDS co-infected cases (7). The MON-29, MON-33 and MON-183 zymodemes vary slightly from the MON-1 zymodeme, differing in only two or three enzymes out of the 15 tested (7, 8). Five of the 10 co-infected patients were living in the French department of Pyrenees-Orientales and occasionally travelled to Spain. Two were from Mar- seilles and three from the Cevennes region (south of France). One of the patients from Marseilles left the endemic area two years ago. During the same observation period (1989-93), 15 VL cases (13 adults and 2 children) were diag- nosed in our laboratory in patients not infected with HIV. The proportion of the VL-AIDS association in relation to the total number of VL cases found by our laboratory is 10/25 or 40%, which is comparable to that reported by others (4). The proportion of VL in the cohort of AIDS patients investigated is 10/139 or 7.2%. Conclusion These results are consistent with previous observa- tions on the occurrence of HIV/Leishmania co-infec- tion in southern Europe, and emphasize the increas- ing importance of VL as an opportunistic infection among AIDS patients in areas where both infections are endemic. Bulletin of the World Health Organization, 1995, 73 (2): 245-246 © World Health Organization 1995 245 J. Dereure et al. Table 1: Clinical and biological data of ten HIV-infected patients with visceral leishmaniasis Patient 1 2 3 4 5 6 7 8 9 10 Sex F M M M M M M F F M Age (years) 27 55 35 26 24 24 39 56 35 36 HIV group (CDC criteria) NA8 C3 C3 C3 B3 C3 C3 C3 B3 C3 Fever Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Spleen enlargement No No No Yes No No Yes No Yes Yes Diagnostic tests: Haemoglobin (g/l) 8.2 10.2 9.2 8.9 10.4 9.3 12.1 9.2 8.8 8 Leukocytes (x 109/l) 1.8 1.1 0.8 1 2.4 2.8 2.1 1.4 2.5 1.3 Lymphocytes CD4 (x 106/I) NAa 5 20 11 1 191 170 12 88 15 Platelets (x 109/l) 135 65 68 112 137 77 106 163 128 107 Bone marrow smears + + + 0 + + + + + + NNN-medium culture + + + + + + + + + + Identification (zymodeme MON-) 1 1 33 183 29 1 1 1 1 29 Immunofluorescence antibodies test (IFAT) 1/80 1/20 0 1/320 0 0 0 1/20 1/640 1/160 Counter-immuno-electrophoresis (CIE) + 0 0 0 0 0 0 0 + + a NA: not available. Our results confirm the usefulness of classical parasitological procedures for diagnostic purposes in patients with immune defects. Although they are time-consuming, these tests are indispensable for the further isoenzyme characterization of the strains and useful for identification of visceralizing strains dur- ing immunosuppressive conditions. More sensitive techniques (Westem-blot, polymerase chain reaction, and detection of circulating antigen) are nevertheless required to confirm a suspected diagnosis of VL in AIDS patients living or travelling in leishmaniasis endemic areas. Resume Leishmaniose visc6rale chez des patients infect6s par le VIH dans le sud de la France Entre 1989 et 1993, des investigations realisees par des techniques parasitologiques classiques chez 139 patients infectes par le VIH et vivant dans des zones d'endemie de la leishmaniose vis- cerale (LV) ont montre que 10 d'entre eux (7,2%) etaient positifs pour Leishmania (frottis colores et culture). Au cours de la meme periode, nous avons identifie 15 cas de LV chez des sujets non infectes par le VIH. Parmi les cas de LV que nous avons recenses, 40%/10/25) etaient donc asso- ci4s a l'infection par le VIH. References 1. Altos J et al. Visceral leishmaniasis: another HIV- associated opportunistic infection? Report of eight cases and review of the literature. AIDS, 1991, 5: 201-207. 2. Centers for Disease Control and Prevention. Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and mor- tality weekly report, 1993, 41 (No. RR-17): 1-19. 3. Jimenez M et al. Cutaneous Leishmania (L.) infant- um zymodemes isolated from bone marrow in AIDS patients. Research and reviews in parasitology, 1991, 51: 91-94. 4. Marty P, Le Fichoux Y. Leishmanioses a Leishma- nia infantum et immunodepression acquise. Revue frangaise des laboratoires, 1991, 223: 116-121. 5. Peters BS et al. Visceral leishmaniasis in HIV infec- tion and AIDS: clinical features and response to therapy. Quarterly journal of medicine (new series), 1990, 77 (No. 283): 1 101-1 1 1 1. 6. Portus M et al. Enzymatic heterogenecity among strains of Leishmania infantum from human visceral and cutaneous leishmaniasis in Catalonia (Spain). Revista iberica de parasitologia, 1989, 49: 287-289. 7. Pratlong F et al. AIDS-associated leishmaniasis: characterization of Leishmania isolates from two patients originating from Valencia (Spain). Transac- tions of the Royal Society of Tropical Medicine and Hygiene, 1993, 87: 705-706. 8. Rioux JA et al. Taxonomy of Leishmania: use of isoenzymes. Suggestions for a new classification. Annales de parasitologie humaine et compar6e, 1990, 65: 111-125. 246 WHO Bulletin OMS. Vol 73 1995