Case Report: Autochthonous Disseminated Cutaneous, Mucocutaneous, and Visceral Leishmaniasis Caused by Leishmania martiniquensis in a Patient with HIV/AIDS from Northern Thailand and Literature Review.

Autochthonous leishmaniasis cases have been increasing continuously in Thailand over the years. We report multiple presentations of leishmaniasis in a 47-year-old patient with HIV/AIDS from Chiang Rai Province, northern Thailand. Physical examination showed multiple ulcerated papules, nodules, and plaques in a sporotrichoid distribution. Firm mucosal nodules on the hard palate and nasal opening, hepatosplenomegaly, and bilateral inguinal lymphadenopathy were found. Histopathological examination of the biopsies revealed an inflammatory infiltrate containing intramacrophage amastigotes compatible with Leishmania infection. In addition, Leishmania promastigotes were isolated successfully from the palatal biopsy and assigned the code MHOM/TH/2022/CULE6. Using internal transcribed spacer 1 polymerase chain reaction and sequence analysis, the causative parasite was identified as Leishmania martiniquensis. A definitive diagnosis of multiform leishmaniasis with disseminated cutaneous, mucocutaneous, and visceral involvement was established. The patient was administered intravenous amphotericin B 1 mg/kg/d for 2 weeks, followed by oral itraconazole 400 mg daily. At the 2-month follow-up, the cutaneous and mucosal lesions had improved significantly. To our knowledge, this is the first report of mucocutaneous involvement caused by L. martiniquensis in an immunocompromised patient with HIV/AIDS. In addition, we provide a literature review of leishmaniasis cases, reported formally in Thailand, resulting from this autochthonous parasite.

Primary spinal hydatid cyst in a patient with acquired immunodeficiency syndrome.

Spinal hydatid cyst is a serious and unusual infectious disease. There is little information on infections caused by cestodes in patients with human immunodeficiency virus (HIV) infection. Although infrequent, infections by cestodes constitute a cause of disease in HIV-infected patients, especially in endemic areas. This report presents, for the first time in the literature, primary spinal cyst hydatid in a patient with acquired immunodeficiency syndrome.

Prevalence and genetic characteristics of Blastocystis hominis and Cystoisospora belli in HIV/AIDS patients in Guangxi Zhuang Autonomous Region, China.

Blastocystis hominis and Cystoisospora belli are considered to be common opportunistic intestinal protozoa in HIV/AIDS patients. In order to investigate the prevalence and genetic characteristics of B. hominis and C. belli in HIV/AIDS patients, a total of 285 faecal samples were individually collected from HIV/AIDS patients in Guangxi, China. B. hominis and C. belli were investigated by amplifying the barcode region of the SSU rRNA gene and the internal transcribed spacer 1 (ITS-1) region of the rRNA gene, respectively. Chi-square test or Fisher's exact test were conducted to assess the risk factors related to B. hominis and C. belli infection. The prevalence of B. hominis and C. belli was 6.0% (17/285) and 1.1% (3/285) respectively. Four genotypes of B. hominis were detected, with ST3 (n = 8) and ST1 (n = 6) being predominant, followed by ST6 (n = 2) and ST7 (n = 1). Females had a statistically higher prevalence of B. hominis (11.6%) than males (4.2%). The statistical analysis also showed that the prevalence of B. hominis was significantly associated with age group and educational level. Our study provides convincing evidence for the genetic diversity of B. hominis, which indicates its potential zoonotic transmission and is the first report on the molecular characteristics of C. belli in HIV/AIDS patients in China.

Visceral leishmaniasis in a kidney transplant recipient: parasitic interstitial nephritis, a cause of renal dysfunction.

Visceral leishmaniasis (VL) due to Leishmania infantum is an endemic parasitic infection in the Mediterranean area. It most commonly affects immunosuppressed individuals, especially HIV patients and less frequently organ transplant recipients. Renal involvement seems to be frequent and is mostly associated with tubulointerstitial nephritis, as described in autopsy reports. In the 61 cases of renal transplant recipients with VL reported in the literature, renal dysfunction was noted at clinical presentation and was more frequently observed as a complication of antiparasitic therapy. However, no pathological analysis of the allograft lesions was reported. We present the case of a Swiss renal transplant recipient who developed VL after vacations in Spain and Tunisia, complicated by acute parasitic nephritis in the renal allograft 3 months after a well-conducted treatment of liposomal amphotericin B.

A multiattribute utility evaluation of different methods for the detection of enteric protozoa causing diarrhea in AIDS patients.

BACKGROUND: Enteric protozoa and sporozoa have emerged as important opportunistic parasites and can cause fatal infections in AIDS patients. The line of treatment being different for them necessitates an accurate and prompt identification of these to avoid empirical treatment. In this study which is the first of its kind from India we did a comprehensive evaluation of different techniques, comparing them on the basis of the attributes like yield, cost, time taken, expertise and infrastructure. For the first time combination of Calcoflour White and DAPI, a nuclear stain, were used to identify Microsporidia spp. Thus, a diagnostic protocol was devised for rapid, sensitive and cost effective identification of the opportunistic enteric protozoa. RESULTS: The organisms isolated from the stool samples of the cases (450 HIV patients) were predominantly Cryptosporidium spp., Microsporidia spp. and Cyclospora spp. Interestingly, the control group (200 relatives of the patients who were HIV negative) showed a high incidence (21%) of Cryptosporidium spp. We found a significant increase in the sensitivity of microscopy in detecting Cryptosporidium spp. and Cyclospora spp. after formol ether concentration. Kinyoun's staining was better compared to Modified safranin staining for Cryptosporidium spp. identification. Although ELISA had a sensitivity of 93.25% and specificity of 97% for Cryptosporidium spp. detection, we ranked Kinyoun's staining better than ELISA because it is not affordable to most of our patients. For detecting Cyclospora cayetanensis, autoflourescence was the easiest and most cost effective method followed by Safranin technique. Combination of Calcoflour White stain and DAPI gave good results for the identification of Microsporidia spp. We assessed the above techniques and graded the attributes in the following descending order: cost effectiveness, sensitivity, ease of use and interpretation, time taken for the procedure and batch testing. CONCLUSION: Thus, we conclude that a combination of minimum three procedures should be carried out for the screening of stool specimens of HIV positive patients. Kinyoun's staining should be made mandatory for every diarrheal stool sample from HIV patients. Also every laboratory should assign its own value to the attributes and apply Multiattribute utility theory or the Analytical hierarchy process to decide the most appropriate methodology.

Diffuse small bowel thickening in AIDS patient--a case report.

BACKGROUND: Diarrhea is common in HIV/AIDS patients, caused by both classic enteric pathogens and different opportunistic agents. Infection with these different pathogens may lead to similar radiological findings, thus causing diagnostic confusion. CASE PRESENTATION: A 30-yr-old female with AIDS presented with chronic diarrhea of 4 months duration. She had diffuse small bowel thickening present on CT scan of her abdomen, with stool examination showing no parasites. She was erroneously diagnosed as abdominal tuberculosis and given antituberculosis drugs with which she showed no improvement. Repeat stool examination later at a specialized laboratory revealed Cryptosporidium parvum infection.The patient was given an extended course of nitazoxanide treatment, as her stool examination was positive for Cryptosporidium parvum even after 2 weeks of drug consumption. Parasite clearance was documented after 10 weeks of treatment. Interestingly, the bowel thickening reversed with parasitological clearance. CONCLUSIONS: Cryptosporidium parvum may lead to small bowel thickening in AIDS patients. This small bowel thickening may reverse following parasitological clearance.

High-intensity signals in the basal ganglia from gadolinium-enhanced T1-weighted MRI as an early change in toxoplasma encephalitis in an AIDS patient.

A 30-year-old Brazilian man hospitalized with AIDS developed a high-grade fever. Neither culture studies nor radiological examinations revealed the cause; small yet highly intense signals in the basal ganglia were detected upon gadolinium (Gd)-enhanced T1-weighted magnetic resonance imaging (MRI) of the head. This finding was equivocal at that time but obviously abnormal for his age. A week later, he developed a movement disorder in his right arm, speech apraxia, and a worsening disturbance of consciousness. Repeated Gd-enhanced T1-weighted MRI demonstrated incredible changes in the brain; enhanced lesions in the basal ganglia deteriorated over time, multiple nodular and ring-enhanced lesions were observed in almost the entire brain. A diagnosis of toxoplasma encephalitis (TE) was confirmed by the detection of Toxoplasma gondii DNA in the cerebrospinal fluid. After initiation of intravenous trimethoprim-sulfamethoxazole (TMP-SMX; 10 mg/kg/day of TMP and 50 mg/kg/day of SMX) treatment, his symptoms and radiological findings improved dramatically. Our case suggests that high-intensity signals seen in the basal ganglia of a Gd-enhanced T1-weighted MRI, even at the preclinical stage, is indicative of TE. Because the use of MRI in general has become more widespread, it is predicted that preclinical lesions of TE will be found in various clinical settings more frequently.

Intestinal parasites infections in hospitalized AIDS patients in Kinshasa, Democratic Republic of Congo.

To determine the prevalence and the species spectrum of intestinal parasites (IP) involved in hospitalized AIDS patients, a prospective observational and cross-sectional study was carried out in the four main hospitals in Kinshasa, Democratic Republic of the Congo. From November 2006 through September 2007, a single stool sample was collected from 175 hospitalized AIDS patients older than 15 years. Parasites were detected by light microscopy, including Ziehl-Neelsen, Fungi-Fluor, modified trichrome stains, and by immunofluorescence antibody tests and PCR for species diagnosis of microsporidia. At baseline, 19 patients (10.8%) were under antiretroviral therapy and 156 (89.2%) were eligible for ART. The main diagnosis for justifying hospitalization was intestinal infection associated with diarrhea in 87 out of 175 (49.7%). 47 out of 175 (26.9%) were found to harbor an IP, and 27 out of 175 (15.4%) were infected with at least one opportunistic IP (OIP). Prevalence rate for OIP were 9.7%, 5.1%, 1.7% and 0.6% for Cryptosporidium sp., Enterocytozoon bieneusi, Isospora belli and Encephalitozoon intestinalis respectively. Considering patients with diarrhea only, prevalence rate were 12.6%, 4.6%, 3.4% and 1.1% respectively. The other IP observed were Entamoeba histolytica/Entamoeba dispar in nine cases (5.1%), Ascoris lumbricoides in seven cases (4.0%), Giardia intestinalis in three cases (1.7%), hookworm in two cases (1.1%) and Trichiuris trichiura, Enterobius vermicularis, Schistosoma mansoni in one patient each (0.6%). No significant relationship was established between any individual IP and diarrhea. These results underline the importance of OIP in symptomatic AIDS patients regardless of diarrhea at the time of the hospitalisation, and showed that routine microscopic examination using stains designed for Cryptosporidium spp. or the microsporidia should be considered due to the absence of clinical markers.

[Clinical analysis of 16 AIDS patients complicated with toxoplasmic encephalitis].

Sixteen AIDS patients complicated with toxoplasmic encephalitis (TE) were retrospectively analyzed between August 2008 to August 2009 with a mean age of (37.0 +/- 11.6) years. The most common clinical symptoms were headache (68.8%, 11/16) and fever (62.5%, 10/16), and 6 with Babinski sign (37.5%). 81.3%(13/16) were with CD4+ cells < 200/mm. Both sera and CSF showed 62.5% (10/16) TOXO-IgG positive by ELISA. CT and MRI scan demonstrated bilateral and multiple lesions with marked peripheral edema effect, and an enhanced scanning showed small finger ring as the major feature. 15 patients got improved by either oral sulphadiazine tablets or sulphadiazine tablets plus clindamycin capsule, 10 cases received combined HAART treatment, and 1 case died with septic shock.

Psychological distress, killer lymphocytes and disease severity in HIV/AIDS.

Immunocellular mechanisms that account for the association between psychosocial risk factors and increased susceptibility to faster progression of HIV/AIDS are largely unknown. This study used structural equation modeling to test the hypothesis that enumerative and functional alterations in killer lymphocytes mediate the relationship between higher levels of psychological distress (defined by perceived stress, anxiety and depressive symptoms) and greater HIV disease severity (defined by HIV-1 viral load and T-helper (CD4(+)) cell count), independent of standard demographic and various HIV-related covariates. Participants were 200 HIV-1 seropositive adults on combination antiretroviral therapy (ages 20-55 years; 67% men; 62% black; 84% AIDS). The data fit a psychoimmune model in which the significant relationship between higher distress levels and greater disease severity was mediated by diminished natural killer (NK) cell count and cytotoxic function, as well as increased cytotoxic (CD8(+)) T-cell activation. Overall the findings indicated that the psychoimmune model accounted for 67% of the variation in HIV disease severity. In contrast, the data did not support a reverse directionality mediation model, where greater HIV disease severity predicted greater distress as a function of killer lymphocyte status. In sum, the psychoimmune associations of the final model are physiologically consistent and suggest that distress-related alterations in killer lymphocyte immunity may play a role in the biobehavioral mechanisms linked with HIV-1 pathogenesis.

[First isolate of Encephalitozoon intestinalis from stools of a Colombian patient with AIDS]. / Primer aislamiento de Encephalitozoon intestinalis a partir de muestra de materia fecal de un paciente colombiano con sida.

INTRODUCTION: Microsporidia are obligate intracellular parasites that are recognized as important opportunistic pathogens of immunocompromised and transplanted patients. Enterocytozoon bieneusi and, less frequently, Encephalitozoon intestinalis are the most prevalent species in humans; both of them are associated with enteric infections. Cell cultures have been useful in the study of microsporidia biology. In Colombia, however, no isolates of microsporidia from patients with AIDS have been obtained. OBJECTIVE: A cell culture of intestinal microsporidia was established from stools of positive patients in order to isolate a native strain. MATERIALS AND METHODS: Stool from a single AIDS patient was concentrated with the water-ether technique, and the sediment was treated with a mixture of antibiotics and antifungal agents for 18 hours at 37 degrees C. Vero cells were cultivated in 24-well plates with Gibco RPMI medium supplemented with 10% bovine fetal serum and antibiotics. The culture was subsequently inoculated with previously concentrated spores. The medium was changed every second day and the presence of spores was evaluated with the Quick Hot Gram chromotrope stain. RESULTS: Two weeks post-infection, microsporidial spores were identified with characteristic morphology and staining properties. PCR results showed that Encephalitozoon intestinalis was the isolated species. CONCLUSIONS: A cell culture of microsporidia was established from a stool sample. This protocol is important to isolate and maintain additional native Colombian strains and it will contribute to biochemical, immunological and epidemiological studies of the currently established strain.

[Intestinal cryptosporidiosis in HIV infected children]. / Criptosporidiosis intestinal en niños con HIV/Sida.

Cryptosporydium parvum is an intracellular parasite that infects gastrointestinal epithelium and produces diarrhea that is self-limited in immunocompetent persons but potentially life-threatening in immunocompromised, especially those with the acquired immunodeficiency syndrome (AIDS). C. parvum enteric infection's incidence in a pediatric HIV/AIDS cohort, during a 6 years period, was studied. Clinical and immunologic characteristics of the dual infection were also recorded. Highly active antiretroviral therapy (HAART) was started or continued by all the patients during follow-up. Azithromicyn was used as antiparasitic drug. Cryptosporidiosis incidence was 13.7%; 33 out 240 children showed chronic diarrhea lasting 14 days at least, or recurrent, without dehydration and electrolytic disturbance. Peripheral blood T CD4+ percentage levels of the patients were variable and without relationship with C. parvum presence. Viral load levels in 31 out 33 patients were over cut-off at the enteric episode time. Mild or moderate eosinophilia were recorded in 23% of the patients and other intestinal parasites were present in 11 children. When the number of enteric episodes were compared with the clinical and immunological patient's status, not significant differences were recorded. HAART is the best treatment to improve immune function in HIV patients avoiding potentially fatal complications that accompany acute diarrhea during concomitant infection with C. parvum.

[The neglected intestinal parasite co-infection with AIDS].

In order to increase the recognition of intestinal parasitic infections in AIDS, this article reviews the common intestinal parasites co-infected in HIV carriers and AIDS patients, namely, Cryptosporidium spp., microsporidia, Giardia lamblia, and Strongyloides stercoralis, referring to aetiology, epidemiology, clinical features, diagnosis and prevention.

[Diagnosis and treatment of major protozoal infections among acquired immune deficiency syndrome patients].

Protozoal infection is one of the most important opportunistic infections among patients with acquired immune deficiency syndrome (AIDS). In order to enhance the knowledge of protozoal infections in AIDS, the current status of diagnosis and treatment of toxoplasmic encephalitis, cryptosporidiosis, microsporidiosis and isosporiasis was reviewed in this paper.

Opportunistic and non-opportunistic intestinal parasites in HIV/ AIDS patients in relation to their clinical and epidemiological status in a specialized medical service in Goiás, Brazil.

Patients infected with the Human Immunodeficiency Virus (HIV) often have opportunistic infections, among which strongyloidiasis and coccidiosis are the most common parasitic infections that aggravate their health status. This study examined the prevalence of intestinal parasites, particularly of Strongyloides stercoralis and intestinal coccidia in patients with the Human Immunodeficiency Virus (HIV)/ Acquired Immunodeficiency Syndrome (AIDS) who were treated at the Specialized Assistance Service (SAE) of Jataí, State of Goiás, Brazil, and analyzed its correlation with clinical, laboratory, and socio-epidemiological parameters. A total of 270 stool samples were analyzed by the Lutz technique, Rugai's method, Agar Plate Culture, Ritchie's method and specific staining, Ziehl-Neelsen modified technique, Kinyoun's method and the rapid safranin method. The prevalence of intestinal parasites was 28.88% including 3.8% of S. stercoralis, Cryptosporidium sp. and Cystoisospora belli. There was a significant positive correlation between intestinal parasites and the clinical status and the use of antiretroviral therapy (ART), smoking, CD4+ lymphocyte counts and sexual orientation. In conclusion, the widespread use of antiretroviral therapy and health assistance contributed to the low prevalence of S. stercoralis and coccidiosis in patients with HIV/ AIDS who were followed up at the SAE.

Disseminated Balamuthia mandrillaris amoeba infection in an AIDS patient from Brazil.

This report describes a 32-year-old male AIDS patient. He presented with a clinical picture characterized by severe headache, blurred vision, and fever that had lasted for 10 days. At admission, no remarkable neurologic abnormalities were observed. Cranial tomography showed a ring-enhanced lesion with edema and a mass effect in the right occipital lobe. The initial diagnosis was toxoplasmosis, and treatment of this was administered. However, 5 days later, the patient's clinical status worsened and he died. The necropsy showed necrotizing and hemorrhagic encephalitis, with trophozoites similar to an amoeba species. Furthermore, the kidneys, adrenal glands, thyroid gland, and liver were also involved. The amoeba Balamuthia mandrillaris was identified by an immunofluorescence test.

Prevalence of intestinal parasitic infestation in HIV/AIDS patients with diarrhea in Madurai City, South India.

The prevalence and pattern of parasitic infestation among 80 HIV/AIDS patients with diarrhea in Madurai, south India, was studied by microscopy. Eighty HIV-negative patients were used as controls. Intestinal parasites were detected in 31 HIV/AIDS patients (38.7%) and in 14 (17.5%) HIV-negative patients, a difference that was statistically significant (P < 0.05). In HIV/AIDS patients with diarrhea, protozoa accounted for the majority of diarrhea cases (Entamoeba spp. 37.5%, Cryptosporidium parvum 28.7%). It is therefore suggested that enteric infections are more common in HIV-infected patients than in HIV-negative persons in south India, and this may be due to differences in immunological profile, susceptibility as well as factors related to sanitation and the environment.

Leishmaniasis in Thailand: A Review of Causative Agents and Situations.

Before 1999, leishmaniasis was considered an imported disease in Thailand. Since then, autochthonous leishmaniasis was reported in both immmunocompetent and immmunocompromised patients especially in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). A new species was identified and named as Leishmania siamensis consisting of two lineages, that is, lineages TR and PG. Analysis of isoenzymes has clarified the more commonly detected L. siamensis lineage PG as Leishmania martiniquensis (MON-229), a species originally reported from the Martinique Island, whereas the L. siamensis lineage TR has been identified as the true novel species, L. siamensis (MON-324). Both cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) have been found among Thai patients. Disseminated CL and VL could be presented in some reported patients who had HIV/AIDS coinfection. So far, only sporadic cases have been reported; thus, the true prevalence of leishmaniasis should be determined in Thailand among the high-risk populations such as people with HIV/AIDS. A recent survey among animals identified L. martiniquensis DNA in black rats (Rattus rattus) suggesting a potential animal reservoir. In addition, L. martiniquensis DNA was identified in Sergentomyia gemmea and Sergentomyia barraudi, the predominant sandfly species in the affected areas. However, further studies are needed to prove that these sandflies could serve as the vector of leishmaniasis in Thailand.

New developments in diagnosis of leishmaniasis.

In this review recent advances made in the field of human leishmaniasis have been discussed with special emphasis on the parasite, and various serological and molecular methods of diagnosing the infection. The article also reviews various modes of parasite transmission including vector borne, blood transfusion, needle sharing, sexual and person-to-person. Microbiological methods including the bone marrow, spleen, liver, lymph node aspirations and various staining methods used to demonstrate the amastigotes of the parasites and various in vitro promastigote culture methods are discussed in detail with their comparative sensitivity rates.

[Preliminary study on infection status and gene types of Cryptosporidium among HIV/AIDS patients in Guangxi].

OBJECTIVE: To understand the infection status and gene types of Cryptosporidium among HIV/AIDS patients in Guangxi Zhuang Autonomous Region. METHODS: The fecal samples were collected from 285 HIV/AIDS cases in Nanning, Guilin, Qinzhou, Baise, Hechi cities of Guangxi and 150 HIV negative persons in Nanning City. The modified acid-fast staining and nested-PCR based on 18S rRNA were employed to detect the infection status of Cryptosporidium. The nested PCR products were sequenced, and the homology searches and identification for the gene types of Cryptosporidium were done by DNAStar software. RESULTS: The infection rate of Cryptosporidium in HIV/AIDS patients was 0.70% (2/285), and the rate of those with chronic diarrhea was 6.67% (2/30), the latter was significantly higher than that of the HIV negative persons (0, 0/150) (P = 0.002). Both the two HIV/AIDS patients infected with Cryptosporidium were from Guilin City. By molecular identification, the Cryptosporidium strains which the above 2 patients were infected with were Cryptosporidium andersoni and Cryptosporidium hominis respectively. CONCLUSIONS: Cryptosporidium co-infection can be found in HIV/AIDS patients in Guangxi. The genotypes of the infection strains include Cryptosporidium andersoni and Cryptosporidium hominis.