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· Leishmania/HIV co-infections impose specific difficulties in terms of diagnosis and treatment. The usual clinical features (fever, weight loss, liver and spleen enlargement, inflammation of the lymph nodes) are not always present. The clinical diagnosis can also be made difficult by associated diseases such as cryptosporidium, disseminated cryptococcosis, cytomegalovirus infection or mycobacterial infection.· The serological diagnosis is falsely negative in 42.6% of co-infected patients. HIV-positive patients have difficulty in producing antibodies against new infectious agents, especially at a late stage or during relapses. Consequently, there is a need to use two or more serological tests and antigens freshly prepared in the laboratory to increase sensitivity.
· Although multiple localizations are frequent (blood, skin, digestive tract, lungs, central nervous system), parasitological diagnosis can be difficult and has to be repeated to orient the treatment. Bone marrow aspirate (BMA) remains the safest and most sensitive technique, but spleen aspirate and liver biopsy are also used. When BMA cannot be performed, the search for Leishmania can be conducted in peripheral blood samples.
· Treatment for co-infected patients is aimed at clinical and parasitological cures and prevention of relapses. Unfortunately, in such patients treatment failure, relapses due to drug resistance and drug toxicity are very common. In south-western Europe, follow-up studies using pentavalent antimonials, the same first-line drug used to treat classic leishmaniasis, show a positive response in 83% of cases. However, 52% of patients relapse within a period of one month to three years, with the number of relapses ranging from one to four.
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