HIV and visceral leishmaniasis — DTM&H MCQ

Correct answer: B — Relapsed visceral leishmaniasis

Relapsed visceral leishmaniasis (B) is correct because recurrent fever, wasting and splenomegaly after prior kala-azar treatment in a patient with advanced HIV (CD4 70 cells/mm3) is the classic pattern of VL relapse. HIV coinfection markedly impairs parasitological cure and drives repeated relapse, with low CD4 count (below 200 cells/mm3) being a recognised major risk factor. Relapse occurs because HIV-related CD4 depletion prevents the Th1-driven macrophage activation needed to clear intracellular Leishmania, so parasites persist or re-emerge from sequestered sites (spleen, bone marrow) despite apparent initial response to antileishmanial therapy. This is why HIV-VL coinfected patients with low CD4 counts and prior VL episodes are prioritised for secondary prophylaxis. Why the other options are wrong: A Brucellosis: causes fever and hepatosplenomegaly but does not explain a relapse specifically after treated kala-azar, and there is no exposure history (unpasteurised dairy, livestock contact) given in the stem. C Immune reconstitution inflammatory syndrome alone: IRIS occurs after starting ART as immune function recovers and paradoxically worsens inflammation, but this patient has a persistently low CD4 count with no mention of recent ART initiation, so immune reconstitution is not occurring. D Schistosomal portal hypertension: produces splenomegaly from portal fibrosis but causes signs of portal hypertension (varices, ascites) rather than fever and wasting, and does not link to prior kala-azar treatment. E Chronic malaria: can cause splenomegaly (hyperreactive malarial splenomegaly) but does not typically follow leishmaniasis treatment and would not present with this specific relapse pattern in the immunosuppressed VL context. Key point: In HIV patients with CD4 counts below 200 cells/mm3, recurrent kala-azar symptoms after treatment represent VL relapse, not a new pathogen, because low CD4 counts prevent durable parasitological cure.

Reference: WHO / PAHO Guideline on Treatment of Visceral Leishmaniasis in HIV Co-infected Patients: secondary prophylaxis and relapse risk with CD4 <200 cells/mm3, https://www.guidelinecentral.com/guideline/1952096/