Visceral Leishmaniasis presenting with intestinal failure: a case report and literature review

Abstract

We describe an unusual case of visceral Leishmaniasis affecting the gastrointestinal tract in a young immunocompetent patient whose only recent foreign travel was a trip to Mexico 9 months previously. She presented insidiously with diarrhoea, weight loss and developed subacute intestinal failure. Interestingly, she lacked most of the typical features of acute infection, including visceromegaly, fevers and hypergammaglobulinaemia. Atypical visceral involvement involving the gastrointestinal tract is well recognized in HIV coinfection, but very rare in immunocompetent patients. Repeated microscopy and culture of endoscopic biopsies failed to identify Leishmania parasites. Serological tests - direct agglutination test and anti-K39 antibody tests - were negative. This case highlights a very rare presentation of the condition with the absence of other visceral involvement and diagnosis being eventually made solely on polymerase chain reaction of rectal tissue, with a subsequent excellent response to therapy with intravenous liposomal amphotericin.

Immune Activation and Bacterial Translocation: A Link between Impaired Immune Recovery and Frequent Visceral Leishmaniasis Relapses in HIV-Infected Patients

“…Considering that the sCD14 levels were positively correlated with the parasite load [data not shown], further studies will be necessary to elucidate whether L . infantum infection can also affect the gut-associated lymphoid tissue (GALT) [42,43]. It is currently believed that the role of L .…”

“…It is currently believed that the role of L . infantum is likely indirect because, similar to what has been described for HIV [24,44], this parasite can also be involved in some damage to the gut-associated lymphoid tissue (GALT) [42–43]. Thus, both pathogens can contribute to increased intestinal permeability and consequent microbial translocation, which in turn can maintain the activation status in co-infected patients.…”

Evidence That Lipopolisaccharide May Contribute to the Cytokine Storm and Cellular Activation in Patients with Visceral Leishmaniasis

“…Considering that systemic T-cell depletion can also affect gut-associated lymphoid tissues, as has been suggested for other immunosuppressive pathologies [18], one can suggest the hypothesis that microbial translocation into the blood circulation may also occur in VL. More importantly, gut damage has been extensively documented in VL patients [44]–[46], and cells are heavily parasitized by Leishmania amastigotes due to parazitation of mucosal cells, causing frequent diarrhea [45] that is likely to affect the function of this innate barrier. The elevated levels of IFABP, an important plasma marker of gut injury, indicate that intestinal permeability is increased in these patients.…”

Leishmaniasis in rheumatology, haematology and oncology: epidemiological, immunological and clinical aspects and caveats: Figure 1

“…For example, VL can present as glomerulonephritis and nephrotic syndrome,141–143 as intestinal failure with malabsorption and diarrhoea,144 as chronic liver disease,145 as bronchopulmonary and mediastinal lymphadenopathy146 or as polymorphic skin manifestation 147. Atypical presentations are very common in HIV-infected patients 11…”