Esophageal leishmaniasis presenting as multiple lower esophageal masses and the first manifestation of advanced HIV infection: A case report.

Visceral leishmaniasis is a vector-borne disease caused by protozoan parasites of the genus Leishmania and is endemic in parts of East Africa, including Ethiopia. Coinfection with HIV is associated with atypical clinical manifestations, reduced serologic sensitivity, and frequent relapse. We describe a 48-year-old Ethiopian man with a five-month history of dysphagia, odynophagia, and progressive weight loss. Examination revealed hepatosplenomegaly, and laboratory testing showed anemia and thrombocytopenia. Upper gastrointestinal endoscopy demonstrated multiple ulcerated, mass-like growths of the lower esophagus causing luminal narrowing; biopsy revealed numerous Leishmania amastigotes exhibiting the "marquee sign." Splenic and bone marrow aspirates were negative for parasites. Subsequent HIV testing was positive, with a CD4 + count of 133 cells/µL, representing the first indication of previously undiagnosed HIV infection. The patient was treated with intravenous liposomal amphotericin B and antiretroviral therapy, with marked clinical improvement; repeat endoscopy and biopsy after treatment showed resolution of the esophageal lesions and clearance of the parasite. This case illustrates that esophageal involvement, although rare, may be the initial presentation of visceral leishmaniasis and can unmask previously undiagnosed advanced HIV infection. Clinicians practicing in leishmania-endemic regions should consider this diagnosis in patients with unexplained esophageal masses, particularly when biopsies for malignancy are inconclusive.