Title: Visceral leishmaniasis in an immunocompetent patient
Domingos Sousa1, Miguel Seruca2, Ana
Isabel Rodrigues1, Mourão Carvalho1,
Sara Aleixo Duarte1, Sérgio Antunes
Silva1, Micael Mendes1, Alejandra
Pereira2, Amparo Mingo3, Elena
Rios1, Mário Lázaro1
1 Internal Medicine Department, Centro Hospitalar e
Universitário do Algarve, Unidade de Faro, Portugal
2 Clinical Pathology Department, Centro Hospitalar e
Universitário do Algarve, Unidade de Faro, Portugal.
3 Infeccious Diseases Department, Centro Hospitalar e
Universitário do Algarve, Unidade de Faro, Portugal.
Email address of Corresponding author: domingos.sousaa@gmail.com
orcid.org/ 0000-0001-6657-5921
telephone: +351 913334854
Key clinical words: fever, anemia, leishmaniasis,
immunocompetent
Key clinical message: Visceral leishmaniasis in immunocompetent
patients is rare and should be suspected in patients with fever,
bicytopenia and elevated inflammatory markers.
A previously healthy man with 26-year-old presented to the emergency
department with a 6-month history of fever, fatigue and an unintentional
12 kilogram weight loss. At physical examination, an enlarged spleen was
notable. Further studies revealed a leucocyte count of 2200 per cubic
millimeter, a hemoglobin level of 9.4 g per deciliter, a platelet count
of 200,000 per cubic millimeter and hyperglobulinemia. Blood cultures as
well as serologies for human immunodeficiency virus, hepatitis B virus,
hepatitis C virus, Epstein–Barr virus, and cytomegalovirus came back
negative. Computed tomography (CT) of the abdomen confirmed the presence
of a heterogeneous hepatosplenomegaly (Figure 1A). Examination of a bone
marrow aspirate revealed the presence of amastigotes within the
macrophages’ cytoplasm, a classic appearance of Leishmania spp
( Figure 1B). Leishmaniasis is a globally widespread zoonosis that is
transmitted by the bite of an infected female phlebotomine sandfly.
Domestic dogs are the parasite reservoirs. Clinically, leishmaniasis is
subdivided into cutaneous, mucocutaneous and visceral (kala-azar) forms.
The most severe form is Visceral leishmaniasis(VL) that is characterized
by a a disseminated intracellular protozoan infection that targets
tissue macrophages in the liver, spleen and bone marrow. BothLeishmania infantum and Leishmania donovani can cause
VL, being Leishmania infantum the most prevalent pathogen
in Portugal and remaining Mediterranean countries. The patient started
treatment with liposomal amphotericin B leading to complete symptom
resolution and splenomegaly on physical examination. Moreover, the
differential diagnosis in a patient with fever and splenomegaly must
include other infective causes such as typhoid, tuberculosis,
leptospirosis; autoimmune disorders such as rheumatoid arthritis,
sarcoidosis, amyloidosis and systemic erythematous lupus and
haematological disorders such as leukaemia, lymphoma, polycythaemia vera
and myelofibrosis. The present report intends to raise awareness of VL
in immunocompetent patients that should be included in the diagnostic
workup of patients with splenomegaly.