Visceral leishmaniosis in HIV-positive patients:: primary infection, reactivation and latent infection.: Impact of the CD4+ T-lymphocyte counts

Objective: To discriminate cases of visceral leishmaniosis (VL) following a primary infection from cases originating in a reactivation of a latent Leishmania infection and to assess the impact of CD4+ T-cell counts on the occurrence of VL in patients with HIV disease. Methods: We searched by Western blotting for the presence of Leishmania infantum-specific antibodies in the sera of 236 HIV-positive patients. We performed a follow-up of antileishmanial serology and analysed the evolution of the CD4+ T-cell counts for 14 HIV-positive VL patients and for 18 HIV-positive Leishmania seropositive patients without VL. Results: This study (1) showed that the VL disease/Leishmania infection ratio in HIV positive individuals is high (1 : 10); (2) discriminated between a primary Leishmania infection (five patients who converted from Leishmania-seronegative to Leishmania seropositive) and a reactivation or a latent infection (seven patients); (3) showed that HIV-positive individuals with dramatically low CD4+ T-cell counts maintained or generated a specific antileishmanial antibody production; (4) demonstrated that the primary-VL appeared at significantly higher (P = 0.028) CD4+ T-cell levels than the reactivation-VL; (5) documented the existence of HIV-positive Leishmania-seropositive individuals who despite a severe and prolonged immunosuppression did not develop VL (eight of 18). Conclusion: Our data stress the utility of the follow-up by Western blotting for an early diagnosis of VL, and therefore an early treatment, for HIV-positive patients living in endemic areas. They suggest that in a latent leishmania infection supplementary control mechanism(s) might operate in addition to the T-cell mediated response, and provide a further example of non-appearance of an opportunistic infection despite a severe reduction in CD4+ T cells. (C) 1998 Lippincott Williams & Wilkins