Diffuse cutaneous leishmaniasis with visceral dissemination in an AIDS patient in Guadeloupe, West Indies.

This is a report on the 1st case of disseminated cutaneous leishmaniasis (DCL) with visceral dissemination in a patient suffering from acquired immunodeficiency syndrome (AIDS). A Haitian man 39 years of age permanently residing in Guadeloupe who had not returned to Haiti since 1981 was treated for pyelonephritis Candida oesophagitis and salmonellosis in 1990. His Western blot was positive for human immunodeficiency virus (HIV) 1 antibodies and his CD4 count was 20 million/1. Zidovudine (250 mg twice daily) and cotrimoxazole (160 mg/800 mg daily) were administered. In November 1991 asymptomatic nonulcerated and multiple cutaneous papulonodular lesions appeared which later were preferentially distributed over the extensor surfaces of limb joints. They were painless and lignous on palpation. The face and mucosae were unaffected. Organomegaly fever and weight loss were not present which indicated that the visceral infection discovered later was not the primary one. There was a moderate leuconeutropeny (900 million/1). In September 1992 skin smears and biopsy were performed; a diffuse histiocytic infiltrate containing amastigotes was found in the dermis upon staining of the sections with hematoxylin eosin and Giemsa. Many intramacrophage Leishmania amastigotes were found in the liver biopsy and the bone marrow aspirate which indicated a wide visceral dissemination. Bone marrow cultures were positive on Schneiders drosophila medium at first but not in subsequent subcultures. Specific serological tests and the leishmanin skin test were not performed. Pentamidine isethionate was injected intramuscularly (6 mg/kg) for 5 days followed by monthly injections of the same amount. Bone marrow aspirate culture and smears were negative 5 months later. Cutaneous lesions have almost all disappeared. Parasites are still found rarely on skin imprints of former lesions. If the original infection in this case was due to a cutaneous strain of Leishmania that later spread to the viscera because of the compromised immune system of the AIDS patient the HIV epidemic may become responsible for the development of some unknown viscerotropic character from dermotrophic strains of Leishmania.