Introduction
We present the clinical case of a 71 years old man with chronic renal failure of unclear etiology. After 16 years of hemodialysis, he underwent successful deceased donor kidney transplantation 3 years ago. His immunosuppression included basiliximab, tacrolimus, mychophenolate and prednisone.3 years after transplant renal function was stable and in normal range, but there was evidence of anemia, thrombocytopenia and mild leukopenia; mycophenolate dose was reduced with no significant improvement. He developed low grade fever with urinary retention, requiring bladder catheterization; because of rapid deterioration of clinical picture, with dehydration and worsening of neurological status, he underwent hospitalization.
Methods
Blood chemistry tests showed pancytopenia with high inflammatory indices, hyperkalemia, hyponatremia; PCR SARS-Cov2 in nasopharyngeal swab was negative. Brain CT was negative for acute lesions, chest CT showed minimal pleural effusion without lymphadenopathy. Empiric antibiotic therapy with piperacillin /tazobactam and ciprofloxacin was started and mycophenolate was discontinued.He was transferred to our facility. Hematological tests confirmed severe pancytopenia, worsening renal function, coagulopathy with increased INR and APTT, increased inflammatory indices, normal haptoglobin, slightly increased LDH, hypoalbuminemia and hypergammaglobulinemia (See Table).Urine culture was positive for an extended spectrum beta-lactamase E. Coli infection, and antibiotic therapy was targeted based on antibiogram. Abdomen CT showed splenomegaly (17 cm in diameter).Patient underwent hematological consult, and a diagnosis of disseminated intravascular coagulation (DIC) secondary to infection was made, excluding a primary hematological cause. Tacrolimus was discontinued and prednisone 5 mg was replaced with dexamethasone 20 mg/day.The search for bacteria and fungi on blood was negative, as well as viremia by PCR for CMV, EBV, Parvovirus B19, HHV8, VZV, HSV, BKV, JCV. HIV serology was negative.
Results
We considered the diagnosis of visceral leishmaniasis and bone marrow aspirate and Leishmania PCR research on peripheral blood and bone marrow were performed. Therapy with intravenous liposomal amphotericin B 4 mg /kg/day was started. Laboratory tests showed:Leishmania serology: positive (1: 2560 at indirect immunofluorescence titration IFAT)Leishmania PCR on blood: positive (1300 leish/ml)Leishmania PCR on bone marrow: positive 1,500,000,000 leish/ml)Bone marrow aspirate smear showed Leishmania amastigotes inside macrophages (Image). Patient was treated with Liposomal amphotericin for 12 consecutive days, with a total dose of 48 mg/kg. Dexamethasone was decreased and then switched to prednisone.
Conclusions
Patient’s clinical condition significantly and rapidly improved, with resolution of fever, pancytopenia and coagulopathy, and dramatic decrease of Leishmania copies on blood. Two further doses of Liposomal Amphotericin were given weekly. Our case focuses on the importance of considering leishmaniasis in the differential diagnosis for fever with pancytopenia and coagulopathy, especially in countries where the disease is endemic.
Magnification (40x) of the bone marrow aspirate smear: the arrows indicate the presence of amastigotes.
No conflict of interest