Diagnostic considerations on visceral leishmaniasis. Two case reports

Le Infezioni in Medicina, n. 3, 176-178, 2002
Casi
clinici
Case
reports
Diagnostic considerations
on visceral leishmaniasis.
Two case reports
Considerazioni diagnostiche sulla Leishmaniosi viscerale:
descrizione di due casi clinici
1
1
2
Maria Bruna Pasticci , Rita Papili , Francesco Menichetti ,
Stelvio Ballanti3, Letizia Ottaviani3, Antonio Tabilio3, Giuliano Stagni1
1
Dipartimento Medicina Sperimentale e Scienze Biochimiche,
Sezione Clinica di Malattie Infettive, Università degli Studi di Perugia, Perugia
2
Unità Operativa Malattie Infettive, Presidio Ospedaliero Cisanello,
Azienda Ospedaliera Pisana, Pisa
3
Dipartimento di Medicina Clinica e Sperimentale,
Sezione di Ematologia, Università degli Studi di Perugia, Perugia
■ INTRODUCTION
450 UI/l), AST 61 UI/l (<46 UI/l). Other parameters resulted within normal limits. The percentage of CD4 and CD8 lymphocytes was normal; HIV serology tested negative. A repeated
bone biopsy was consistent with midollary
iperplasia secondary to ipersplenism. Mean
time anti-Leishmania antibodies (Indirect Fluorescent Assay) resulted positive with a title of
1:2560 and the patient was started on liposomial amphotericin B (AmBisome) 3
mg/kg/die. Before treatment a new bone marrow aspirate was sent for Leishmania at the
Parasitology Laboratory, Istituto Superiore
Sanità in Rome. Both microscopy and culture
were positive. Within 48 hrs from treatment the
patient became afebrile, amphotericin was continued for a total of 10 days [1]. On discharge
the patient was well, abnormal laboratory tests
had improved and the spleen size was reduced of 3.5 cm. The patient was seen one
month later in good condition, hematologic parameters showed RBCs 4.100.000/mmc, Hb
10.4 g/dl, WBCs 3.400/mmc, platelets
237.000/mmc, normal ESR.
The clinical picture of Visceral leishmaniasis
(VL) is variable and often indistinguishable
from that of other diseases including hemathologic disorders. In endemic areas the presence
of fever, weight loss, massive splenomegaly,
hepatomegaly, anemia, leukopenia and hypergammaglobulinemia is highly suggestive of VL
and should prompt specific investigations. The
Authors describe two cases of VL in immunocompetent patients.
Case no. 1. A 23-year-old female from Sicily
was admitted at the Hemathology Department
of Perugia University because of 2 months history of fever, anemia, leukopenia, low platelet
count and splenomegaly. Since childhood the
patient reported repeated episodes of oral candidiasis, and chronic onycomycosis. During the
past month she had been investigated extensively including a bone biopsy without a definitive diagnosis. When her primary health care
physician suggested a diagnostic splenectomy
she signed out and was seen for the first time at
Perugia University. On hospitalization the patient was febrile, the temperature was 39°C,
had onycomycosis of the second finger of the
left hand, oral candidiasis, diffuse microlimphoadenopaty and splenomegaly.
The
laboratory
tests
showed
RBCs
2.800.000/mmc, Hb 6.9 g/dl, WBCs 1.100 mmc,
platelets 76.000/mmc, ERS 52, γ-globulin 1770
mg/dl (751-1560 mg/dl), LDH 1439 UI/l (230-
Case no. 2. A 64-year-old female from Calabria
was admitted at the Infectious Disease Institute
of Perugia because of suspected tuberculosis.
Three months before hospitalization the patient
reported one week of fever, with low grade temperature, followed by a discreet petecchial eruption on the left leg. At that time laboratory tests
revealed Hb 10.2 g/dl, platelets 72.000/mmc, γglobulin 4990 mg/dl. The abdominal ultra-
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2002
stration of amastigotes within macrofages or
close to disrupted cells in bone marrow, spleen,
liver, lymphonode and other tissue or upon culture (promastigotes). Microscopy is difficult
considering the size of the parasite itself. Culture requires specific techniques and media, it is
1 log more sensitive than smears.
In general, serology is not reported to be a very
useful test in both visceral and cutaneous leishmaniasis as it may give false positive as well as
false negative results [1].
In these two patients anti-Leishmania antibodies were obtained late during hospital admission, and were not considered significant until
the diagnosis of VL was confirmed by microscopic observation. In both patients Indirect
Fluorescent Assay tested positive with a title
well above the cut-off (1:80).
Data from the Reference Laboratory for Leishmania at the Istituto Superiore di Sanità in
Rome indicate sensitivity rates of serology
close to 100% and specificity of 98% in immunocompetent patients [5]. In the literature
similar values are reported for ELISA. In general, sensitivity drops to about 60% with both
tests when immunocompromised patients and
recepient of organ transplants are examined
[5]. It must be reminded that the same patient
population is more susceptible to symptomatic
visceral leishmaniasis [6-9].
Serology is less invasive than bone marrow aspirate or biopsy, and it may perform in a more
reproducible fashion in laboratories with less
expertness of parasitic diseases. Positive serology can be used also to monitor the response to
therapy and to detect relapse after treatment.
Liposomial amphotericin B has been shown to
be an effective treatment for visceral leishmaniasis, it has been recently approved by the
Food and Drug Administration with this indication. In immunocompetent patients the total
dose recommended is 21 mg/Kg given on 7
days over 21 day period [9, 10]. We used in one
case 18 mg/Kg, while in the other were infused
30 mg/kg, in both cases a prompt clearance of
symptoms was recorded along with no side effects.
sound documented hepatomegaly with
splenomegaly (18 cm of diameter). The bone
marrow histology was consistent with mild increase of plasmacellular component with normal cells of politopic origin. During the first admission a diagnostic splenectomy, along with
liver and abdominal lymphonode biopsy, was
performed.
The pathologist reported infiltration of lymphomonocytes with normal characteristic in all the
specimens. Within the spleen was also described a wide area of necrosis with caseosis. At
that point the patient was referred to the Infectious Disease Institute of Perugia for suspected
tuberculosis.
On admission the patient was afebrile, had mild
hepatomegaly. Laboratory test showed: ESR 95,
RBCs 4.080.000/mmc, WBCs 9.300/mmc, Hb
10.7 g/dl, platelets 371.000/mmc, total proteins
10.5 g/dl, albumin 3.3 g/dl, γ-globulin 5160
mg/dl, AST 97 UI/l (<46 UI/l), ALT 67 UI/l
(<46 UI/l), γGGT 78 UI/l (<51 UI/l), CD4 18%,
CD8 12.0%; anti-HIV antibodies were negative.
Anti-Leishmania antibodies (IFA) tested positive with a title of 1:20480. A new evaluation of
the previous spleen and liver preparates for the
presence of amastigotes of Leishmania was
again reported negative. A new bone marrow
aspirate was sent at the Parasitology Laboratory, Istituto Superiore Sanità, Rome and resulted positive for Leishmania (culture and microscopy). The patient was treated with liposomial amphotericin B 3 mg/Kg/die for 5 days,
th
plus a further dose on day 10 [1, 2]. The patient
was well on discharge and on follow-up, one
month later.
■ DISCUSSION
The Authors described two patients with visceral leishmaniasis whose clinical features are
quite typical but still allows evaluable considerations. Both patients lived in endemic regions for leishmaniasis in Italy [3, 4]. The diagnosis of leishmaniasis had to be considered by
the primary health care physicians also because bone marrow hystology was not diagnostic for malignancy. Further more one patient underwent splenectomy, liver and lymphonode biopsy. Spleen biopsy is reported diagnostic of VL in over 95% of cases, liver
biopsy and bone marrow sensitivity is reported
to be about 70% [1].
Diagnosis of Leishmaniasis relays upon demon-
Acknowledgments
We thank Dr. Luigi Gradoni, Laboratorio di Parassitologia, Istituto Superiore di Sanità, Rome, Italy
for his support.
Key words: visceral leishmaniasis, diagnosis, immunocompetent patients.
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2002
SUMMARY
Two cases of visceral leishmaniasis (VL) in
immunocompetent patients are described.
Both patients lived in endemic areas for leishmaniasis in the south of Italy, and tested positive for anti-Leishmania antibodies. A definitive diagnosis of VL was delayed by false
negative microscopic examinations. Both patients were treated successfully with liposomal amphotericin B. Our results show that
the search for anti-Leishmania antibodies using the Immuno Fluorescent Assay (IFA) is a
valid diagnostic approach. In the two cases
examined, it ensured correct diagnosis and
therapy. Although microscopy is reported to
be highly sensitive and specific in the diagnosis of VL, it may yield false negative results when used in laboratories without
high level of expertise.
RIASSUNTO
Sono descritti due casi di Leishmaniosi viscerale
in soggetti immunocompetenti. Entrambi i pazienti residenti in aree endemiche per Leishmaniosi in regioni meridionali d’Italia avevano presentato positività per la ricerca degli anticorpi
anti-leishmania. La diagnosi definitiva è stata ritardata dal risultato falso-negativo dell’osservazione microscopica. Entrambi i pazienti sono stati
trattati con successo con amfotericina B liposomiale.
Conclusioni: la ricerca degli anticorpi anti-leishmania nel siero con il metodo dell’Immuno Fluorescenza (IFA) rappresenta un test diagnostico
valido ed utile. Nei due casi descritti ha permesso
una corretta diagnosi e terapia. L’esame microscopico pur essendo il metodo diagnostico più sensibile e specifico per la diagnosi di Leishmaniosi viscerale, può condurre a risultati falsi negativi soprattutto quando l’osservazione è effettuata presso
laboratori che non hanno adeguata esperienza.
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