Leishmaniasis cutánea difusa en un paciente con sida
Palabras clave:
leishmaniasis, leishmaniasis cutánea difusa, síndrome de inmunodeficiencia adquirida, infecciones oportunistas relacionadas con sida, diagnóstico diferencial, inmunosupresión
Resumen
Objetivo. Estudiar un paciente con leishmaniasis cutánea difusa y sida y comentar el tema.Materiales y métodos. Soldado de 29 años, procedente de San José del Guaviare, con pérdida de 18 kilos de peso en los últimos 10 meses y erupción generalizada de dos meses de evolución. El Elisa y el Western blot fueron positivos para virus de inmunodeficiencia humana. Tenía 92 LT CD4/mm3. Presentaba máculas, pápulas y placas eritematoescamosas, psoriasiformes y generalizadas, cuyas biopsias demostraron abundantes microorganismos fagocitados por macrófagos, que se teñían de negro con la coloración de Gomory. Se diagnosticó histoplasmosis diseminada. Se inició tratamiento antirretroviral y antimicótico con itraconazol sin observar mejoría.
Resultados. La anfotericina B produjo mejoría, pero las lesiones recidivaron más numerosas y nodulares con compromiso oral. Once meses después del comienzo de su enfermedad, nuevas biopsias de piel y la revisión de las anteriores confirmaron que el paciente tenía leishmaniasis cutánea difusa. El cultivo no permitió aislar el parásito. La miltefosina produjo mejoría importante. Las pápulas y máculas recidivaron varios meses después; recibió 52 ampollas de glucantime® durante dos meses, consiguiéndose la curación clínica, situación que permanece dos años y medio después de iniciada la enfermedad.
Conclusiones. La leishmaniasis cutánea difusa debe plantear sospecha de sida. El tratamiento es difícil; debe ser antirretroviral y antileishmaniásico, con profilaxis antiparasitaria. Los amastigotes de Leishmania no son positivos con la coloración de Gomory en técnicas controladas; se diferencian del histoplasma por morfología, cultivo, inmunohistoquímica, anticuerpos específicos y reacción en cadena de la polimerasa. La asociación leishmaniasissida es beneficiosa para ambos gérmenes; es posible el aumento de casos en Colombia por el auge de ambas entidades.
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Referencias bibliográficas
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2. Albrecht H. Redefining AIDS: towards a modification of the current AIDS case definition. Clin Infect Dis 1997;24:64-74.
3. Paredes R, Muñoz J, Diaz I, Domingo P, Gurgui M, Clotet B. Leishmaniasis in HIV infection. J Postgrad Med 2003;49:39-49.
4. Catorze G. Leishmaniose e sida. Med Cut Iber Lat Amer 2005;6:327-50.
5. Alvar J. Leishmaniasis and AIDS co-infection: the Spanish example. Parasitol Today 1994;10:160-3.
6. Botella ER, Sanmartín JO, Febrer BML, Aliaga BA, Salavert LM, Roig RP, et al. Leishmaniasis cutáneovisceral: una nueva infección oportunista en pacientes con HIV. Med Cut Iber Lat Am 1990;18:119-23.
7. Altés J, Salas A, Riera M, Udina M, Galmés A, Balanzant J, et al. Visceral leishmaniasis: another opportunistic infection? Report of eight cases and review of the literature. AIDS 1991;5:201-7.
8. Herwaldt BL. Leishmaniasis. Lancet 1999;354:1191-9.
9. Harms G, Feldmeier H. Review: HIV infection and tropical parasitic diseases- deleterious interactions in both directions? Trop Med Int Health 2002;7:479-88.
10. Pasquau F, Ena J, Sanchez R, Cuadrado JM, Amador C, Flores J, et al. Leishmaniasis as an opportunistic infection in HIV-infected patients: determinants of relapse and mortality in a collaborative study of 228 episodes in a Mediterranean region. Eur J Clin Microbiol Infect Dis 2005;24:411-8.
11. Desjeux P, Alvar J. Leishmania/HIV co-infections: epidemiology in Europe. Ann Trop Med Parasitol 2003; 97(Suppl 1):3-15.
12. Instituto Nacional de Salud. Programa de Enfermedades de Transmisión Vectorial. Informe sobre leishmaniasis en Colombia. Sivigila 2005. Semana 52.
13. Instituto Nacional de Salud. Programa de Enfermedades de Transmisión Vectorial. Situación de leishmaniasis en Colombia. Sivigila 2006. Semanas epidemiológicas 1-12.
14. Vélez ID, Gilchrist K, Arbeláez MP, Rojas C, Puerta JA, Antúnez CF, et al. Failure of killed Leishmania amazonensis vaccine to protect against American cutaneous leishmaniasis in Colombia. Trans R Soc Trop Med Hyg 2005;99:593-8.
15. Corredor A, Kreutzer RD, Tesh RB, Boshell J, Palau MT, Cáceres E, et al. Distribution and etiology of leishmaniasis in Colombia. Am J Trop Med Hyg 1990;42:296-314.
16. Rodríguez G, Motta A, Ordóñez N. Estudio histopatológico de 19 biopsias cutáneas de pacientes con sida e histoplasmosis diseminada. Biomédica 2001;21:107-15.
17. Sinha PK, Pandey K, Bhattacharya SK. Diagnosis & management of leishmania/HIV co-infection. Indian J Med Res 2005;121:407-14.
18. Singh S, Sivakumar R. Recent advances in the diagnosis of leishmaniasis. J Posgrad Med 2003;49:55-60.
19. Schalling HD, Oskam L. Molecular biological applications in the diagnosis and control of Leishmaniasis and parasite identification. Trop Med Int Health 2002;7:641-51.
20. Deniau M, Canavate C, Faraut-Gambarelli F, Marty P. The biological diagnosis of leishmaniasis in HIVinfected patients. Ann Trop Med Parasitol 2003;97(Suppl. 1):115-33.
21. Rodríguez G, Ricaurte O, Naranjo JP. Granulomas infecciosos del hígado. Biomédica 1994;9:32-57.
22. Rosatelli JB, Souza CS, Soares SA, Foss Nt, Roselino AM. Generalized cutaneous leishmaniasis in acquired immunodeficiency syndrome. J Eur Acad Dermatol Venereol 1988;10:229-32.
23. Nogueira-Castañón MC, Pereira CA, Furtado T. Unusual association of American cutaneous leishmaniasis and acquired immunodeficiency syndrome. Int J Dermatol 1996;35:295-7.
24. Machado ES, Braga MP, Da Cruz AM, Coutinho SG, Vieira AR, Rutowitsch MS, et al. Disseminated American muco-cutaneous leishmaniasis caused by Leishmania braziliensis braziliensis in a patient with AIDS: a case report. Mem Inst Oswaldo Cruz 1992;87:487-92.
25. Fernández-Guerrero ML, Robles P, Rivas P, Mojer F, Muniz G, de Gárgolas M. Visceral leishmaniasis in immunocompromised patients with and without AIDS: a comparison of clinical features and prognosis. Acta Trop 2004;90:11-6.
26. Pintado V, Martín-Rabadán P, Rivera ML, Moreno S, Bouza E. Visceral leishmaniasis in human immunodeficiency virus (HIV)-infected and non-HIV infected patients. Medicine (Baltimore) 2001;80:54-73.
27. Corredor A, Gallego JF, Tesh R, Morales A, Ferro C, Young D, et al. Epidemiology of visceral leishmaniasis in Colombia. Am J Trop Med Hyg 1989;40:480-6.
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Cómo citar
1.
Pérez C, Solías Y, Rodríguez G. Leishmaniasis cutánea difusa en un paciente con sida. biomedica [Internet]. 1 de diciembre de 2006 [citado 18 de abril de 2024];26(4):485-97. Disponible en: https://revistabiomedica.org/index.php/biomedica/article/view/314
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2006-12-01
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