Parasitismo duodenal de Leishmania spp. em pacientes com coinfecção HIV/Leishmania

Abstract

Visceral leishmaniasis (VL) has a high incidente and morbidity in the world and in Brazil. The associated infection by the human immunodeficiency virus (HIV) and the protozoan Leishmania spp. characterizes the HIV/Leishmania (HIV/VL) coinfection, which is considered a serious ermerging disease in various regions of the world with a high mortality rate. Coinfected patients may have unusual manifestations, such as the presence of Leishmania in the gastrointestinal mucosa and in the duodenum in particular. This condition might be initially diagnosed by the means of a duodenal biopsy. The current study aims to characterize HIV/VL coinfected patients with positive duodenal biopsy for Leishmania, to quantify the duodenal parasite burden, and to describe the inflammatory changes in the mucosa. This is the first description of a series of patients with HIV/VL coinfection and positive parasitism of the duodenal mucosa. We studied a total of 25 such patients from an Infectious Diseases reference hospital (São José Hospital) in Fortaleza- Ceará, Brazil, diagnosed between 2011 and 2017. The average age was 43 years of age (SD 10.27). 80% were male, and 69.6% reported alcohol consumption. The average peripheral blood CD4+ T lymphocytes was 113.78/mm3, and the average viral load was 72,278 copies/mL. 72% had already been previously treated for VL. The macrophages seen in the duodenum were heavily parasitized, with the biopsies of 64% of the patients containing more than 120 affected macrophages/10hpf. There was a significant association between low peripheral blood CD4+ T cell count and high duodenal parasitic load (p = 0.009). The degree of the mucosal inflammatory infiltrate varied from mild to dense. 16% of the patients died during the hospital admission in which the duodenal biopsy was performed. In coinfected HIV/VL patients, the marked depletion of CD4+ T cells in the small bowel makes this location a suitable place for the persistence of Leishmania, explaining the high rates of recurrence found in this population. Thus, a coinfected patient with positive duodenal biopsy for Leishmania is at great risk of developing relapses, warranting a closer follow-up, and potentially should only discontinue treatment for Leishmania after elimination of the parasite from the GI tract. Our findings contribute to increasing our understanding of the HIV/VL coinfection and help establish further strategies for the treatment and control of these diseases.