Prognosis
The syndromes caused by Leishmania are diverse in appearance and outcome. Cutaneous leishmaniasis (CL), apart from species associated with mucosal leishmaniasis, tends to impact quality of life and is generally not life-threatening. However, the importance of the stigma and morbidity related to chronic persistent lesions and permanent scarring should not be underestimated. Some patients with Viannia species parasites develop mucosal leishmaniasis. The ensuing disease can produce significant mutilation and patients can die from aspiration pneumonia or airway obstruction. The majority of visceral leishmaniasis (VL) infections remain latent, but infection that becomes symptomatic is typically fatal without treatment. The primary goal of therapy is to decrease or prevent mortality, though the treatments themselves are not without risk. Death during treatment of both CL and VL can be due to a complication of the disease (e.g., bacterial superinfection) or can be drug-related (e.g., cardiac arrest with antimonial compounds). Mortality is low among VL patients treated with liposomal amphotericin-B and miltefosine.[194] Mortality with pentavalent antimonial compounds is increased in patients older than 45 years, those who are severely malnourished, and those with signs of long-lasting illness or co-infection with HIV.[195][196] Mortality with amphotericin-B deoxycholate appears similar to pentavalent antimonial compounds in both immunocompetent and HIV-co-infected patients.[174][197] In general, death is more likely among immunosuppressed patients, even with appropriate treatment.
Clinical cure
Initial cure at the end of treatment is assessed clinically (flattening of cutaneous lesions or healing of ulcers in CL; disappearance of fever, improvement of general condition, and decrease in splenic size in VL) and by laboratory tests in VL (improvement of anaemia, normalisation of inflammation markers). Definite clinical cure in immunocompetent patients is declared 6 months after initial cure if clinical examination and laboratory tests have normalised. Parasitological methods to assess cure are generally not helpful, because parasitological cure does not occur in many cases; however, these methods can be used to assess for relapse. Immunosuppressed patients are at higher risk of non-response than immunocompetent patients, independent of the anti-leishmanial drug given.
Relapse
Relapses are uncommon with appropriate treatment in immunocompetent hosts. In contrast, relapse within 3 to 6 months after initial therapy occurs in most HIV-co-infected patients, who generally experience multiple subsequent relapses. Risk factors for relapse in HIV-VL co-infection are: absence of an increase in CD4+ cells at follow-up; lack of secondary prophylaxis; previous history of VL relapse; and CD4+ counts <100 cells/mL at the time of primary VL diagnosis.[198] Relapse is also common among other immunosuppressed patients, such as recipients of solid organ transplants.
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