Sporotrichoid papulo-nodules with Retiform rash:Unusual presentation of Leishmaniasis

Background: Leishmaniasis is caused by intracellular protozoal parasites belonging to the genus Leishmania. HIV infection is an important factor for atypical presentation and widespread progression of visceral leishmaniasis Methods & Materials: A 54-yr-old Nepali male diagnosed with HIV infection in 1994 on HAART from 2012 with baseline CD4 count 90,complained of multiple dome shaped painful lesion over both hands since 12 months. He has received multiple blood transfusion for pancytopenia in last 3 years without any improvement in blood count. On examination he was emaciated,had pallor with generalised lymphadenopathy. He had distended abdomen with massive hepatosplenomegaly. Cutaneous examination showed multiple sporotrichoid dome shaped firm tender papules and nodules over bilateral hands with isolated nodules on nose, bilateral elbows, buttocks, ankles along with net-like violaceous to erythematous coalescing papules over bilateral legs and trunk. Results: Punch biopses from a nodule on hand and violaceous papule over the leg showed multiple intracytoplasmatic amastigotes within histiocytes on H & E and Giemsa stain. Bone marrow aspirate showed intra and extra-cellular LD bodies on Giemsa staining. Diagnosis of Visceral Leishmaniasis with cutaneous dissemination in a HIV-AIDS patient was kept.IV Amphoterecin 1 mg/kg/day was administered for 30 days along with blood tranfusion.1 month later patient followed up with partial resolution of skin lesions which showed persistent parasites and CD4 count remain below 100/mm3. In spite of HAART and anti-leishmanial therapy, no significant increase in CD4+ T-cells was ob-served. Patient died later Conclusion: In the setting of HIV,visceral leishmaniasis represents an opportunistic infection. Cutaneous localization is rarely described in AIDS and usually represents the primary site of infection,with a low number of lesions; however, a diffuse skin localization secondary to visceral dissemination of the protozoa is exceedingly uncommon