Can Cutaneous Leishmaniasis Present After Amphotericin B Treatment for Visceral Leishmaniasis?
Yes, cutaneous leishmaniasis can present after amphotericin B treatment for visceral leishmaniasis, particularly in HIV-coinfected or immunosuppressed patients, where dissemination to cutaneous and mucosal sites can occur with any Leishmania species, and this may represent treatment failure, relapse, or an immune reconstitution inflammatory syndrome (IRIS) reaction. 1
Mechanisms of Post-Treatment Cutaneous Manifestations
The development of cutaneous lesions after VL treatment occurs through several distinct pathways:
Disseminated infection in immunosuppressed patients: In HIV-coinfected persons, cutaneous, mucosal, and visceral dissemination can be caused by essentially any Leishmania species that infect humans, not just species stereotypically associated with these forms 1
IRIS reactions: Occasional cases of presentation or worsening of cutaneous or mucosal/uveal involvement that might represent IRIS reactions have been reported in both New and Old World settings in persons without current or past evidence of VL 1
Treatment failure or relapse: Immunosuppressed persons with VL are less likely to complete an initial treatment course or have a durable, relapse-free response and may be more likely to have drug-associated toxicity 1
Clinical Context and Risk Factors
The risk of post-treatment cutaneous manifestations is substantially elevated in specific populations:
HIV-coinfected patients: These patients have broader clinical manifestations and higher rates of treatment failure, with secondary prophylaxis mandatory for those with CD4 counts <200 cells/mm³ 2
Other immunosuppressed patients: Those receiving immunomodulating agents or post-transplant patients require close monitoring for at least 1 year after VL treatment 1
Geographic considerations: The spectrum of clinical manifestations varies by region, with some coinfected persons in the Americas developing mucosal lesions as the first identified form, sometimes followed by cutaneous lesions 1
Management Approach
When cutaneous lesions develop after amphotericin B treatment for VL:
Treat as active Leishmania infection: Leishmania infection that becomes manifest or worsens after initiation of antiretroviral therapy should be treated with antileishmanial therapy (and, if indicated, corticosteroid therapy for IRIS) 1
Optimize immunosuppression management: Doses of immunosuppressive drugs should be decreased during antileishmanial therapy whenever possible 1
Consider combination therapy: For immunosuppressed patients with treatment failure, combination therapy (e.g., liposomal amphotericin B plus miltefosine) may be necessary 2
Extended monitoring: Immunosuppressed persons with VL who are not HIV-coinfected should be monitored for a minimum of 1 year, while HIV-coinfected patients require indefinite monitoring until effective immune reconstitution 1, 2
Critical Pitfall to Avoid
Do not assume cutaneous lesions after VL treatment represent a different disease process—they require parasitologic confirmation and antileishmanial treatment, as the clinical management issues are more complex in immunosuppressed persons with broader manifestations and weaker evidence base for treatment decisions 1