Visceral leishmaniasis escaping the diagnosis and withstanding treatment in a case of recurrent pyrexia

Authors

  • Shipra Gulati Department of Medicine, Sir Ganga Ram Hospital, New Delhi, India
  • Rishikesh Dessai Department of Medicine, Sir Ganga Ram Hospital, New Delhi, India
  • Nikhil K. Patnaik Department of Medicine, Sir Ganga Ram Hospital, New Delhi, India
  • Kunal Chawla Department of Medicine, Sir Ganga Ram Hospital, New Delhi, India

DOI:

https://doi.org/10.18203/2320-6012.ijrms20232812

Keywords:

Visceral leishmaniasis, Kala-azar, PUO, Tropical disease, NTD

Abstract

Though visceral leishmaniasis (VL) is the leading parasitic infection causing deatharound the world after malaria, it is a less suspected cause of pyrexia of unknown origin (PUO). We present a case of a middle aged man who was diagnosed with VL only months later owing to the stealthily masquerading disease as also to a generally low index of suspicion for it. A 59-year-old from Uttarakhand presented to us with complaint of fever of a few weeks duration. He was found to have a bicytopenia with elevated liver enzymes. Routine imaging studies were non-contributory. Cultures revealed candidemia while tests for viral and other atypical infections were negative. A bone marrow examination (BME) revealed haemophagocytosis. Positron emission tomography–computed tomography (PET-CT) showed mildly FDG avid hepatosplenomegaly. He was treated as a case of candidiasis with secondary hemophagocytic lymphohistiocytosis (HLH) and was discharged. He was readmitted months later with recurring fever. Repeat investigations revealed pancytopenia with marked hepatosplenomegaly. A repeat BME, however, revealed Leishmania donovani (LD) bodies. Patient was treated with liposomal amphotericin B (LAmB) and discharged. Though the patient’s symptoms improved soon after, he was again admitted a couple of months later and found to have VL persisting in the BM aspirate. This report underscores the need to extensively evaluate cases of PUO rather than summarily dismissing them as routine. VL is one of the less suspected etiologies despite being the second largest parasitic killer.

References

Mathers CD, Ezzati M, Lopez AD. Measuring the burden of neglected tropical diseases: the global burden of disease framework. PLoS Negl Trop Dis. 2007;1(2):e114.

Endris M, Takele Y, Woldeyohannes D, Tiruneh M, Mohammed R, Moges F, et al. Bacterial sepsis in patients with visceral leishmaniasis in northwest Ethiopia. Bio Med Res Int. 2014;361058.

Zijlstra EE, Ali MS, el-Hassan AM, el-Toum IA, Satti M, Ghalib HW, et al. Kala-azar: a comparative study of parasitological methods and the direct agglutination test in diagnosis. Trans R Soc Trop Med Hyg. 1992;86:505-7.

Ho EA, Soong TH, Li Y. Comparative merits of sternum, spleen and liver punctures in the study of human visceral leishmaniasis. Trans R Soc Trop Med Hyg. 1948;41:629-36.

Sundar S, Sahu M, Mehta H, Gupta A, Kohli U, Rai M, et al. Non-invasive management of Indian visceral leishmaniasis: clinical application of diagnosis by K39 antigen strip testing at a kala-azar referral unit. Clin Infect Dis. 2002;35(5):581-6.

Kumar Bhat N, Ahuja V, Dhar M, Ahmad S, Pandita N, Gupta V et al. Changing Epidemiology: A New Focus of Kala-azar at High-Altitude Garhwal Region of North India. J Trop Pediatr. 2017;63(2):104-8.

Raina S, Raina RK, Sharma R, Rana BS, Bodh A, Sharma M. Expansion of visceral leishmaniasis to northwest sub-Himalayan region of India: A case series. J Vector Borne Dis. 2016;53(2):188-91.

Ahmad S, Chandra H, Bhat NK, Dhar M, Shirazi N, Verma SK. North Indian state of Uttarakhand: a new hothouse of visceral leishmaniasis. Trop Doct. 2016;46(2):111-3.

Raina S, Mahesh DM, Kaul R, Satindera KS, Gupta D, Sharma A et al. A new focus of visceral leishmaniasis in the Himalayas, India. J Vector Borne Dis. 2009;46(4):303-6.

Chandra H, Chandra S, Bhat NK, Sharma A. Clinicohaematological profile of infections in bone marrow - single centre experience in North Himalayan region of India. Hematology. 2011;16(4):255-7.

Atta AM, Carvalho EM, Jerônimo SMB, Sousa Atta MLB. Serum markers of rheumatoid arthritis in visceral leishmaniasis: Rheumatoid factor and anti-cyclic citrullinated peptide antibody. J Autoimmun. 2007;28(1):55-8.

Liberopoulos E, Kei A, Apostolou F, Elisaf M. Autoimmune manifestations in patients with visceral leishmaniasis. J Microbiol Immunol Infect. 2013;46(4):302-5.

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Published

2023-08-31

How to Cite

Gulati, S., Dessai, R., Patnaik, N. K., & Chawla, K. (2023). Visceral leishmaniasis escaping the diagnosis and withstanding treatment in a case of recurrent pyrexia. International Journal of Research in Medical Sciences, 11(9), 3467–3470. https://doi.org/10.18203/2320-6012.ijrms20232812

Issue

Section

Case Reports