Fatal seronegative visceral leishmaniasis in Portuguese patient

Andrew Benzie and colleagues from St Marys reported the case of a 38 year old, ARV-naive Portuguese man, who presented in April 2005, with a 6-month history of intermittent episodes of high fever, dry cough and shortness of breath on exertion, which increased in severity with each episode.

CD4 count and viral load were 210 cells/mm³ and 34,000 copies/mL respectively, but CD4% was very low at only 6%.

The abstract details that on admission, he pyrexic with enlarged liver and spleen. He was thrombocytopenic (58 · 109/mL) and had a mild neutrophilia. CRP was 127 mg/L and albumin was low at 25 g/L. Chest X-ray and bronchoscopy were normal. Stains and cultures for Pneumocystis, Cryptococcus and Mycobacterium tuberculosis were negative. Initially, he was treated presumptively for community-acquired pneumonia and PCP. Fever resolved and he was commenced on HAART. His condition again deteriorated with worsening thrombocytopenia, hypoalbuminaemia and oedema and respiratory distress. Plasma tested positive for both EBV and HHV8 DNA by PCR. Castlemans disease was suspected.

Despite negative investigations including serology, bone marrow aspiration with culture for leishmania, the patient died and post-mortem revealed extensive pulmonary leishmaniasis.

The researchers concluded that diagnosis of visceral leishmaniasis in HIV infection is difficult as only 40-50% of cases have positive leishmania serology. Clinicians should have a high index of clinical suspicion for visceral leishmaniasis in patients who present with fever and hepatosplenomegaly, despite negative serology and bone marrow aspiration/culture.

Comment

Although leishmania and HIV co-infection is rare in the UK, it is increasingly frequent elsewhere. It could arguably be considered an AIDS defining illness, as immune suppression can activate previously latent infection, and HAART reduces risk of relapse after leishmaniasis treatment.

The most accurate diagnosis in HIV-positive patients is obtained by using PCR.

The highest incidence of leishmaniasis, including cases of coinfection, are probably in Central and South America (especially Brazil); North and East Africa; Asia (India, Bangladesh, Nepal) and in Southern Europe (2000 cases of coinfection were reported by 2003 from Spain, Portugal, France, Italy). In Spain 60% cases of leishmaniasis are in HIV-positive individuals, and leishmaniasis is a notifiable disease.

This report is important for doctors treating patients who come from regions where leishmaniasis is endemic.

Benzie AA, Goldin RD, Walsh J. A case report of seronegative pulmonary leishmaniasis in an HIV-hepatitis C co-infected patient. Abstract P100.