Disseminated mucocutaneous leishmaniasis in a patient with advanced HIV

We report a 43-year-old male farm worker from El Salvador residing in California's Central Valley who presented with 4 months of progressive upper lip swelling, ulcerative lesions on the nose and left forearm, weight loss, night sweats, headaches, and hoarseness of voice. He had severe HIV-related immunosuppression (CD4 count of 81 cells/mm). Biopsy of a forearm lesion and endobronchial tissue obtained at bronchoscopy revealed intracellular amastigotes consistent with leishmaniasis. Leishmania PCR on endobronchial tissue detected Leishmania donovani/infantum/chagasi complex, and plasma microbial cell-free DNA testing (Karius) confirmed L. infantum. The patient received intravenous liposomal amphotericin B and restarted on antiretroviral therapy; he was discharged to receive induction and maintenance amphotericin B infusions with outpatient HIV clinic follow-up. This case illustrates the diagnostic challenges of disseminated leishmaniasis in severely immunocompromised patients in nonendemic settings and underscores the importance of early recognition and a tiered diagnostic approach in high-risk populations.