Emergence of co-infection of visceral leishmaniasis in HIV-positive patients in northeast Iran: A preliminary study

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Summary

Visceral leishmaniasis (VL) serosurvey was carried out on 49 HIV/AIDS patients among 500 asymptomatic HIV/infected patients who registered in the Khorasan Razavi Province during the last 14 years. HIV infections were detected by ELISA and confirmed using western blot assay at the AIDS centre of the Khorasan Razavi Province. All collected sera were screened using the direct agglutination test (DAT). The sera with anti-Leishmania infantum antibodies at a titre of 1:100 were considered positive for VL infection and serum titration was performed from 1:100 to 1:102,400. Nine (18.4%) patients were sero-positive according to DAT. The distribution of sera titrations were as follows: 1:100 (n = 6) 1:1600 (n = 1); 1:25,600 (n = 1) and 1:102,400 (n = 1). All sero-positive cases showed clinical signs and symptoms. The most predominant signs and symptoms of co-infection of visceral leishmaniasis in HIV-positive patients were pneumonia (n = 2), hepatosplenomegaly (n = 2), lymphadenopathy (n = 2), anaemia (n = 1), prolonged fever (n = 1) and cachexia (n = 1). Our finding shows that VL (or kala-azar) is an opportunistic disease in HIV-positive patients that may be occurred in VL endemic areas of Iran.

Introduction

Human VL is a neglected vector-borne parasitic disease and an important emerging opportunistic infection in HIV/AIDS cases in areas where both infections are endemic, especially in southern Europe and Africa [1], [2], [3]. HIV attacks the CD4+ T cells and enters the cells through antigenic determinants. Therefore, HIV infection can increase occurrence of the diseases related to the immune system suppression. Therefore, in HIV-positive patients, the prevalence of infectious disease likes VL increases [4].

HIV–VL co-infection may appear in different clinical forms and is difficult to diagnose [5]. Usually in HIV-positive patients treated with anti-retroviral therapy (HAART), the incidence of leishmaniasis can decrease significantly [6]. However, HAART does not seem to prevent relapses in patients who develop VL [7].

In Iran, HIV/AIDS is an emerging disease and both Leishmania and HIV infections occur sporadically. These co-infections are becoming an important public health problem, as only two studies have reported disseminated leishmaniasis caused by Leishmania tropica in HIV-positive patients in Iran [8], [9]. Zoonotic VL caused by Leishmania infantum species is one of the most important protozoan infections in different parts of Iran [10]. In 1949, the first case of human VL in Iran was reported [11]. Ardabil and Fars Provinces in the northwest and south of Iran are the 2 areas where kala-azar is endemic, also, there are some reports on sporadic occurrences of kala-azar in other provinces of Iran [12], [13], but to date a limited number of co-infections have been reported in Iran.

Direct agglutination test (DAT) is a simple, practical, reliable, and highly sensitive serological technique for the diagnosis and seroepidemiological surveys of VL in humans and animals, in Iran and other parts of the world [14], [15], [16], [17], [18]. DAT has been validated in several endemic areas of VL for the diagnosis of co-infected patients [18], [19], [20].

In the last decade Phlebotomus kandelakii was one of the vectors of VL in northeast Iran [21], and also there are some reports of VL in this region [22], [23]. So, the present study aimed to serosurvey on VL infection with DAT using sera of HIV/AIDS patients collected from northeastern Iran and to describe the clinical manifestations of infected cases.

Section snippets

Materials and methods

From a total of 500 HIV-positive individuals who were registered in the Khorasan Razavi Province during the last 14 years, we could only access to 49 of them from March to December 2012 because majority of remainder cases were inaccessible due to death, migration, no inclination with this study. Diagnosis of HIV infection in the patients was based on detection of anti-HIV antibodies by ELISA and the results were confirmed using western blot; the diagnosis of AIDS was based on the count of CD4+

Characteristics of the population studied

Of the 49 HIV/AIDS patients in this study, 32 (65/3%) were male and 17 (34/7%) were female. The mean of age was 43.7 years (range 10–60 years); the highest frequency of patients was observed in the 30–40-year-old range (44.9%), while patients less than 20 years of age had the lowest frequency. Most of the patients came from urban areas (87.8%).

The patients had been infected by HIV from 1 to 14 years ago. The most observed transmission route in HIV-positive patients was through intravenous drug

Discussion

In HIV/AIDS patients, visceral leishmaniasis is the third most frequent opportunistic infection in various parts of the world [26]. To date, VL–HIV co-infection has been reported from at least 33 countries where in 25%–70% of adult patients with VL, HIV co-infection is observed [26], [27].

Previous studies showed that VL could be a co-factor in HIV disease progression [28]. These patients are highly susceptible to HIV infection, and in HIV patients, leishmaniasis accelerates the beginning of

Conflict of interest

None.

Acknowledgements

This study received financial support from Tehran University of Medical Sciences (Project No: 90-02-27-14264).

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