Immune Reconstitution Inflammatory Syndrome in a Patient With Cutaneous Leishmaniasis and HIV: A Diagnostic Challenge for Clinicians Caring for a Migrant Population in the United States

Migration routes determine exposure to endemic infections. We present a case of complex cutaneous leishmaniasis in a man with HIV infection who migrated to the United States from Haiti, where <i>Leishmania</i> is uncommon, acquiring leishmaniasis while on his journey via South America and Central America. His presentation included hyperpigmented, nonulcerated plaques and nodules on his extremities, chest, back, face, palms, and soles; initially he had no mucosal lesions. Infection with <i>Leishmania panamensis</i> was confirmed via polymerase chain reaction. He was prescribed bictegravir/tenofovir alafenamide/emtricitabine with rapid suppression of HIV and liposomal amphotericin B for diffuse cutaneous leishmaniasis with a limited initial response. He subsequently developed mucosal lesions in the setting of immune reconstitution and was retreated with amphotericin dosed for mucocutaneous disease. A thorough migration history was critical to diagnosis. This case highlights the different presentations of leishmaniasis in people with HIV and the elevated risk for treatment failure.