4CPS-158 Management of a second visceral leishmania recurrence in a HIV patient with miltefosine: a case report

<h3>Background and Importance</h3> Visceral leishmaniasis (VL) or Kala-Azar is an infectious disease with significant prevalence in our region, particularly among patients with human immunodeficiency virus (HIV) infection. If effective immunological reconstitution isn’t achieved, they experience recurrences. Miltefosine is an analogue of phosphatidylcholine found in cell membranes inducing apoptosis-like cell death by the interaction with phospholipids and steroids in parasitic cell membranes and inhibition of cytochrome c oxidase. <h3>Aim and Objectives</h3> To describe management of second recurrence VL infection treated with liposomal Amphotericin B and Miltefosine on a HIV patient. <h3>Material and Methods</h3> A 48- year-old male living in a rural area of Spain since 2004. Patient was diagnosed with AIDS in 2016 without medical follow-up known. When admitted to our hospital for cerebral toxoplasmosis and VL infection in August 2020 he started treatment for AIDS with Bictegravir/Emtricitabine/Tenofovir alafenamide and VL was first treated with liposomal amphotericin B at an induction dose of 4mg/kg followed by monthly doses of 3mg/kg, 3 of 5 doses were given. Despite a scale up of AIDS treatment adding Darunavir/Cobicistat, he presented a VL recurrence in June 2021 treated with liposomal amphotericin B 4mg/kg for 5 days followed by 3mg/kg weekly doses, given 4 of 5 doses. Patient was responding to the treatment until February 2024 when second recurrence of VL was confirmed treated with liposomal amphotericin B 5mg/kg single dose plus Miltefosine 100mg/24h for 7 days administrated, as MENSA guidelines recommended. <h3>Results</h3> Clinical improvement was achieved with exceptional tolerance to treatment except for creatinine’s increment from 0,9 mg/dl to 1,79 mg/dl. The Infectious Diseases and Pharmacy hospital units took the decision to finish Miltefosine on the seventh day, to change HIV treatment to Dolutegravir/Lamivudine, and to continue liposomal Amphotericin B as prophylactic treatment 3mg/kg every 4 weeks. The infectious condition was successfully resolved, renal function was recovered, and HIV infection was controlled with indetectable viral load and 151 CD4/mm3. <h3>Conclusion and Relevance</h3> Our experience contributes additional evidence indicating that Miltefosine should be used for seconds VL recurrences in patients with HIV infection. Renal function should be monitored closely and ensure treatment adherence. Nevertheless, further studies involving a larger patient population are necessary to establish more precise conclusions. <h3>References and/or Acknowledgements</h3> <h3>Conflict of Interest</h3> No conflict of interest