Update on 19/01 case of the month "Visceral leishmaniasis in HIV-infected patient”

Authors of the case:
MD Consultant Pathologist Ugnius Mickys; MD Dr. Infectologist Birutė Zablockienė; Resident doctor Gintarė Ražanskienė
In January 2019 we started this section of interesting cases in our center with visceral leishmaniasis (VL) in HIV-infected patient, which was confirmed after identifying multiple phagocytized Leishmania spp. parasites in bone marrow trephine biopsy. The correct diagnosis and appropriate treatment with liposomal amphotericin B gave excellent results. The patient was discharged from the hospital five days after the initiation of the treatment.
After the standard Leishmaniasis treatment course, the patient also commenced antiretroviral therapy and attended regular check-ups. He noticed improved appetite as well as overall physical status, although he admitted ongoing alcohol abuse while on medication. Furthermore, follow-up abdominal ultrasound-scans showed persistent hepatosplenomegaly.  
Patient relapsed 9 months after initial hospitalization and treatment, complaining of fatigue, headache, nausea, intermittent subfebrile temperature, loss of appetite and gradual weight loss (about 10 kg in a couple of months). His blood tests revealed elevated liver enzymes (ALT – 99 U/L, AST – 283 U/L, GGT – 3482 U/L, ALP – 1678 U/L) and pancytopenia. His CD4 cell count was low – 56 cells/mL with an undetectable HIV viral load. In order to confirm relapse of VL, bone marrow trephine aspiration was obtained, which showed numerous parasites with morphological features characteristic of Leishmania amastigotes.
The patient received second course of liposomal amphotericin B. Unfortunately, four months later a second relapse occurred, manifesting with febrile fever and generalized lymphadenopathy.  Lymph node core biopsy revealed massive infiltration of macrophages with numerous phagocytized leishmanias, obliterating normal lymph node architecture.
According to WHO and other international organizations, liposomal amphotericin B is the treatment of choice for VL– HIV coinfection. Regardless of appropriate treatment, VL– HIV coinfected patients are at increased risk of relapse and higher lethality. The reason for this tendency is compromised immune response, mainly due to low CD4+ cell count also evident in this current case.