VLHIV Clinical features

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VL/HIV Clinical features

• At diagnosis, almost all cases of VL/HIV
  co-infection have been found to have fewer than
  200 CD4 cells/ml blood,
• About 50 meet the AIDS-defining criteria during
  their first episode of VL.

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VL/HIV Clinical features

• The clinical manifestations of VL in HIV-infected
  individuals may be similar to those seen in
  HIV-negative cases
• Fever, pancytopenia and hepato-splenomegaly, for
  example, are found in 75 of all the HIV-positive
  cases.
• Following the dissemination of the parasites,
  however, the HIV-positive cases may develop
  unusual, multi-organ pathology.

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VL/HIV Clinical features

• Gastro-intestinal involvement
• respiratory tract
• multi-organ dissemination

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VL/HIV Clinical features

• Almost all the cases of co-infection are very
  prone to VL relapses, even after carefully
  managed antileishmanial treatment.
• The opportunistic infections that are often seen
  in HIV-positives frequently develop during VL
  episodes,
• The signs and symptoms of the leishmaniasis then
  confusingly overlapping with those of the other
  infections.

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Treatment of VL/HIV

• Although, in southern Europe, there has been
  considerable experience in the treatment of
  visceral leishmaniasis (VL) in HIV-positive
  patients, the optimal therapy has yet to be
  established.
• Pentavalent antimony salts (20mg Sbv/kg.day)
• Free amphotericin B deoxycholate (ABD) (0.7
  mg/kg.day)
• lipidic formulations of amphotericin B
• Treatment with pentavalent antimonials requires
  daily injections for 28 days, is not well
  tolerated and leads to initial clinical cure in
  only 66 of the co-infected cases.
• Free ABD has to be given, intravenously, for just
  as long, has significant toxicity and leads to
  initial clinical cure in even fewer cases (62).
• In a prospective, comparative trial, treatment of
  co-infected cases with a pentavalent antimonial
  was found to have similar eficacy and toxicity to
  treatment with free ABD.

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LIPIDIC AMPHOTERICIN B

• Ampho B lipidic complex (Abelcet)
• Limited experience in co infected patients
• 3 mg/kg 5 days 33 response rate
• 3 mg/kg 10 days 43 response rate
• Total dose should be at least 30 mg/kg
• Liposomal ampho B (AmbiSome)
• Total dose at least 20 mg/kg
• Ampho B colesterol (ABCD)

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Repalses of Vl/HIV

• Frequent
• Liposomal amho B if initally treated with Sbv
  treatment,
• Although the data available on secondary
  prophylaxis are limited and often inconclusive,
  it appears that regular treatment with a
  pentavalent antimonial drug, liposomal
  amphothericin B or amphotericin B lipid complex
  can reduce the incidence of leishmanial relapses
  in HIV-positive patients with VL
• Immune restoration with HAART may prevent
  relapses
• Secondary prophylaxis may be discotinued when
  CD4 more than 200 per micro L