“Visceral leishmaniasis in HIV-infected patient”

Authors of the case:
MD Consultant Pathologist Ugnius Mickys; Resident doctor Gintarė Baranauskaitė


40-year-old male was admitted to the hospital, complaining of five-days-lasting high fever with epigastrium and upper left abdomen pain.  The patient had a 10-year history of untreated HIV and HCV infections. 15 months ago he came back to Lithuania from southern Spain, there he was working in agricultural sector. One month after the return, he started experiencing fatigue and recurring subfebrile three-to-four-day long fever with two-week intervals of remission.  These episodes lasted for about 3 months with several recurrences later on. 

Laboratory investigation showed leukopenia (leukocytes: 1,59 x109/l, neutrophils: 1,31 x109/l), normochromic-normocytic anemia (hemoglobin: 114 g/L) and thrombocytopenia (platelets: 43 x109/). The biochemical tests showed elevated C-reactive protein (171 mg/L), and liver enzymes (ALT: 119 U/L; AST: 411 U/L). CD4 cell count was 51/µl. Abdominal ultrasound revealed hepatosplenomegaly and mild ascites. Blood culture showed Salmonella enteritidis growth, therefore stage 3 HIV (AIDS) infection with Salmonella sepsis was diagnosed.  Despite the improvement of patient’s clinical status after the administration of adequate antibiotic and antiretroviral therapy, a persistent pancytopenia remained. To exclude lymphoproliferative disorder, bone marrow aspiration and biopsy was performed. Bone marrow study showed multiple CD1A negative leishmania amastigotes phagocytized by macrophages. HIV-related bone marrow findings included panhyperplasia with architectural distortion, diffuse mild reticular fibrosis, relative megakaryopoiesis hyperplasion/dysplasion, neo-capillarization, plasmacytosis and lymphoid hyperplasia. Antibodies against Leishmania donovani was negative.

After the successful diagnosis of visceral leishmaniasis, therapy with liposomal amphotericin was commenced. Patient’s clinical status significantly improved and he was discharged from the hospital five days after the initiation of the treatment.