Visceral leishmaniasis in a patient with long-lasting corticosteroid treatment
Journal Title: Αρχεία Ελληνικής Ιατρικής - Year 2009, Vol 26, Issue 1
Abstract
A 66-year-old man from a rural area was admitted for evaluation of fever accompanied by abdominal discomfort, nausea, loss of appetite and weakness. The fever started a month ago and was of low-moderate grade (<40 oC), intermittent −often with two daily peaks, with alternating periods of apyrexia− and responded to antipyretics. On physical examination, the patient was alert and orientated. His heart rate was 92 beats per minute, blood pressure 160/110 mmHg, respiratory rate 25 breaths per minute, and his temperature was 38.9 oC. Physical examination of the heart and the lungs did not reveal any abnormal findings. Palpation of the abbdomen bowed plenomegaly, with the spleen extending 8 cm below the left costal margin. There were no palpable nodes or hepatomegaly. Skin examination did not show any ulcers, rashes, pruritus, or jaundice. The patient had not noticed any change in urination or defecation. Also, he denied any recent travels abroad for himself and his close persons. His medical history was significant for hyperuricemia, for which he was not receiving any medication. Nineteen years ago he had received a 9-month course of rifampin and isoniazid for pulmonary tuberculosis. Moreover, he had been treated with intermitted small doses of cortisone because of a dermatological disease for almost 22 years. His family history was unremarkable. A complete blood count revealed hypochromic microcyticanemia (Ht 26.1%, Hb 8.9 g/dl, MCV 68.9 fl, MCH 23.5 pg, MCHC 34.2 pg/dL) with leukocytes 1,800/μL (neutrophils 900/μL, lymphocytes 800/μL and monocytes 100/μL), platelets 50,000/μl and reticulocytes 1.21%. Serum chemistries revealed hyperuricemia (uric acid 11.6 mg/dL), elevated urea 59 mg/dL (range: 17−50 mg/dL) and creatinine 1.9 mg/dL (range: 0.6−1.2 mg/dL), normal total bilirubin, normal total proteins with reduced albumin at 2.6 g/dL (range: 3.5−5.5 g/dL), low total cholesterol at 55 mg/dL (range: 140−200 mg/dL), an elevated AST at 48 U/L (range: 5−40 U/L) with normal ALT at 22 U/L and ALP at 172 U/L, mild elevation of the γ-GT at 53 U/L (range: 7−32 U/L), elevated lactate dehydrogenase at 807 U/L (range: 200−460 U/L) and normal creatine kinase at 27 U/L. Serum iron levels were low (20 μg/dL) while the serum ferritin was markedly elevated (6,685 ng/mL). Serum haptoglobin levels were within normal range. C-reactive protein and ESR were increased at 112 mg/L (range: 0−5 mg/L) and 61 mm/h, respectively. The international normalized ratio was elevated at 1.77 and the activated partial thromboplastin time was prolonged at 43.2 sec, while fibrinogen levels were within the normal range. A tuberculin skin reaction was negative. Serologies for HBV, HCV and HIV were negative. Coombs’ test was positive (+++). Wrights’ test was negative. Repeated blood, urine and stool cultures for common aerobes and anaerobes, M. tuberculosis and Brucella were negative. A chest X-ray was normal, while a CT scan of the thorax showed pericardial effusion and emphysematous lungs. An MRI of the abdomen confirmed the splenomegaly. Serum protein electrophoresis was performed revealing diffuse hypergammaglobulinemia (fig. 1). A bone marrow smear was performed and the diagnosis was established by the morphology of the bone marrow smear. Appropriate treatment resulted in an early fever improvement as well as progressive amelioration of anemia and rapid normalization of bone marrow findings.
Authors and Affiliations
J. MELETIS, E. PAPAKOSTAS, P. KOUZIS, T. CHATZILEONIDA, A. GIAKOUMIS, C. FLOUDAS, S. MASOURIDI, M. ASPRADAKI, N. VINIOU
Keywords
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