Indian visceral leishmaniasis with extensive lymphadenopathy – An unusual presentation: A case report with literature review

Abstract

Visceral leishmaniasis (VL), also known as kala-azar, is a life-threatening systemic disease caused by the obligate intracellular protozoan, Leishmania, and transmitted to humans by the female phlebotomine sand fly (Phlebotomus argentipes). The disease is fatal, if left untreated. We report a case of a patient clinically suspected of disseminated tuberculosis, but fine needle aspiration cytology of cervical and axillary lymph nodes yielded a diagnosis of leishmaniasis. Diagnosis of VL was challenging as the disease closely mimicked tuberculosis in the setting of extensive lymphadenopathy including conglomerate of mesenteric lymph nodes, on and off fever, and granulomatous lymphadenitis on aspiration. Bone marrow examination was further performed. A detailed workup revealed patient to be severely immunocompromised and newly diagnosed human immunodeficiency virus (HIV) positive. Worldwide, India has the largest number of VL cases, accounting for 40%–50% of world's disease burden and the second largest HIV-infected population, accounting for approximately 10% of the global disease burden. HIV increases the risk of developing VL by 100–2320 times in endemic areas and concurrently VL promotes the clinical progression of HIV disease. Co-infection with HIV alters the body's immune response to leishmaniasis thus leading to unusual presentations. This case highlights the diagnostic problem in the aforesaid setting. Moreover, co-infection with HIV in VL can be a potential source of drug resistance. An early diagnosis and intensified treatment is the key to patient management.

Mediastinal Lymphadenopathy in Visceral Leishmaniasis

“…6,7 VL is commonly diagnosed by demonstrating parasites in the bone marrow and splenic aspirate and lymph node FNA has been rarely used for its diagnosis. [1][2][3] Most of the cases of lymph nodal leishmaniasis have been diagnosed by aspiration of cervical lymph nodes or ultrasound-guided FNA of mesenteric lymph nodes. [1][2][3] The diagnosis of VL by EUS-guided FNA of mediastinal lymph nodes is rarely reported in the literature.…”

“…[1][2][3] Most of the cases of lymph nodal leishmaniasis have been diagnosed by aspiration of cervical lymph nodes or ultrasound-guided FNA of mesenteric lymph nodes. [1][2][3] The diagnosis of VL by EUS-guided FNA of mediastinal lymph nodes is rarely reported in the literature. 6,7 In conclusion, leishmaniasis should be included in differential diagnosis of unexplained lymphadenopathy, especially in endemic areas.…”

“…2 Lymphadenopathy is usually reported in cases of VL from East African countries and is rarely reported from India. 3 VL is usually diagnosed by demonstrating parasites in the bone marrow or splenic aspirate, and fine-needle aspiration (FNA) from enlarged lymph nodes has been occasionally reported for its correct diagnosis. 1, 3 We report an interesting case of VL presenting with malaise, fever and weight loss along with isolated mediastinal lymphadenopathy and mimicked tuberculosis.…”

“…3 VL is usually diagnosed by demonstrating parasites in the bone marrow or splenic aspirate, and fine-needle aspiration (FNA) from enlarged lymph nodes has been occasionally reported for its correct diagnosis. 1, 3 We report an interesting case of VL presenting with malaise, fever and weight loss along with isolated mediastinal lymphadenopathy and mimicked tuberculosis. Absence of spleen because of previous splenectomy for symptomatic portal hypertension led to difficulty in establishing the correct diagnosis that was eventually established by endoscopic ultrasound (EUS)-guided FNA.…”

Case Report: Combination Therapy with Liposomal Amphotericin B, N-Methyl Meglumine Antimoniate, and Pentamidine Isethionate for Disseminated Visceral Leishmaniasis in a Splenectomized Adult Patient

“…The clinical VL symptoms seen in our patient are mainly associated with immunocompromised patients. 7,8 Splenectomy has been known to have deleterious effects on humoral and cellular immunity. 9 We, therefore, consider that asplenia should be included as a predisposing immunosuppressive condition for VL because this classification relates to both prognosis and treatment.…”