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BRIEFCLINICALOBSERVATIONS

MAINTENANCE ITRACONAZOLEFORVISCERAL LEISHMANIASISIN HIV INFECTION Because visceral leishmaniasis (VL) is endemic in southern Europe, its association with human immunodeficiency virus (HIV) infection is frequently encountered [l]. In this situation, Leishmania donovani acts in an opportunistic manner, and conventional therapeutic approaches often produce only partial remissions [2]. Relapses can occur after discontinuation of therapy, even when results of bone marrow examination are normal. In our experience, itraconazole, a new antifungal agent with antileishmania1 activity, can be useful as secondary prophylaxis for VL in immunocompromised patients. A 22-year-old female drug addict with CDC (Centers for Disease Control) class IVC2 HIV infection (oropharyngeal candidiasis) was admitted in August 1990 because of pancytopenia and pyrexia of 2 months’ duration. Her CD4+ cell count was 34 X 106/L, and L. donovani was isolated from bone marrow, blood, and duodenal biopsy specimens. Therapy with antimonilial agents was initiated but stopped after 3 days because of cardiac intolerance. She received two courses of pentamidine infusions during 15 days (4 mg/kg every other day), at the end of which results of bone marrow examination and culture were negative. Maintenance therapy with orally administered itraconazole (400 mg/day) was given in September 1990 and terminated in February 1991 when she traveled to northern France. Six weeks after discontinuation, she complained of intermittent fever, and relapsing VL was diagnosed on bone marrow aspiration. Conventional therapy for VL with antimonilials or pentami-

dine cannot be used for secondary prophylaxis because of toxicity and parenteral administration. The efficacy of ketoconazole in VL is still discussed [3], but long-term therapy is limited by hepatic toxicity. Itraconazole has shown activity in several cases of cutaneous leishmaniasis, one associated with HIV infection [4-61. In the case we observed, although no drug employed was able to eradicate the parasite definitively, itraconazole seemed useful in prolonging the state of partial remission obtained. Randomized clinical trials are warranted to confirm the efficacy of this regimen.

done well with maintenance oral fluconazole therapy, similar to the experience reported by Bozzette et al [l]. One patient, however, was exceptional, with a second relapse of cryptococcal meningitis 10 days after discontinuation of maintenance oral fluconazole. We herein report on this case. Case Report. A 43-year-old man, found to be HIV-seropositive in February 1986 with a CD4 count of 20/mm3, presented with cryptococcal meningitis in February 1989. Cerebrospinal fluid (CSF) parameters are summarized in Table I. Therapy was initiated with amphotericin, but his A. LAFEUILLADE course was complicated by P. CHAFFANJ~N thrombocytopenia, interstitial E. DELBEKE pneumonitis, and line sepsis due R. QUILICHINI H6pital Chalucet to Staphylococcus epidermidis. Toulon, France After 650 mg of amphotericin, 1. Altes J, Salas A, Riera M. et al. Visceral leishmanitherapy was interrupted for 4 asis: another HIV-associated opportunistic infecweeks by oliguric renal failure betion? Report of eight cases and review of the literalieved to be secondary to concomture. AIDS 1991; 5: 201-7. itant amphotericin, pentamidine, 2. Lafeuillade A, Quilichini R, Dhiver C, Mary C, Gastaut JA. The need for new therapeutic approaches and vancomycin administration. in visceral leishmaniasis during HIV infection. PostNineteen weeks after diagnograd Med J 1990; 66: 789-90. sis, he had received 2 g of ampho3. Sundar S, Kumar K, Singh VP. Ketoconazole in tericin, but CSF culture still grew visceral leishmaniasis. Lancet 1990; 336: 1582-3. 4. Borelli D. A clinical trial of itraconazole in the C. neoformans. Therapy with treatment of deep mycoses and leishmaniasis. Rev oral fluconazole 200 mg/day reInfect Dis 1987; 9 Suppl 1: S57-63. sulted in a sterile CSF culture 8 5. Albanese G, Giorgetti P, Santagostino L, Crippa weeks later. For 7 months, he did D, Sala G. Cutaneous leishmaniasis treatment with itraconazole. Arch Dermatol 1989; 125: 1540-2. well. 6. Pialoux G, Hennequin C, DuPont B, Ravisse P. In

Rapid relapse of cryptococcal meningitis after termination of maintenance fluconazole in AIDS.

~_1 BRIEFCLINICALOBSERVATIONS MAINTENANCE ITRACONAZOLEFORVISCERAL LEISHMANIASISIN HIV INFECTION Because visceral leishmaniasis (VL) is endemic in so...
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