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CASE REPORT
Year : 2013  |  Volume : 27  |  Issue : 3  |  Page : 227-228

Visceral leishmaniasis in acquired immunodeficiency syndrome patient


Department of Medicine, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India

Date of Web Publication19-Feb-2014

Correspondence Address:
Th. Bhimo Singh
Department of Medicine, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.127401

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  Abstract 

A 40 years male on highly active antiretroviral therapy presented with fever and hepatosplenomegaly. On evaluation it came out to be visceral leishmaniasis. Visceral leishmaniasis is an unusual opportunistic infection in Acquired immunodeficiency syndrome. Here we report a case of visceral leishmaniasis in Acquired immunodeficiency syndrome.

Keywords: Acquired immunodeficiency syndrome, Kala-Azar, Leishmania donovani


How to cite this article:
Singh N B, Synrem E, Singh T, Singh T. Visceral leishmaniasis in acquired immunodeficiency syndrome patient. J Med Soc 2013;27:227-8

How to cite this URL:
Singh N B, Synrem E, Singh T, Singh T. Visceral leishmaniasis in acquired immunodeficiency syndrome patient. J Med Soc [serial online] 2013 [cited 2020 Oct 20];27:227-8. Available from: https://www.jmedsoc.org/text.asp?2013/27/3/227/127401


  Introduction Top


There are about 2.5 million human immunodeficiency virus (HIV) infected patients in India. [1],[2] Manipur is the sixth highest HIV prevalent state in India, having many migrant workers from different regions of Northern-India. And being in the border between Myanmar and India, different patterns of opportunistic infections are seen along with HIV.

India contributes heavily to the global burden of visceral leishmaniasis (VL) accounting for 40-50% of world disease burden. Bihar, itself contributes 80% of total Indian cases. Brazil, Sudan, India, Nepal, and Bangladesh contribute 90% of the total global burden of VL in the world. From 30% to 60% of Kala-Azar patients do not respond to sodium stibogluconate, the first-line drug in Bihar, [2],[3],[4],[5] and it was suggested that this might be due to underlying HIV co-infection.

Here, we report the first case of VL in acquired immunodeficiency syndrome (AIDS) in Manipur.


  Case Report Top


A 40-year-old male from Uttarakhand, a known case of AIDS on highly active antiretroviral therapy (HAART) with >95% adherence for the last 3 years presented with generalized weakness, non-productive cough, and fever for 1 month. He had past history of Abdominal Koch's 3 years back for which he had completed a course of Antitubercular therapy. On examination, he was hypertensive; pallor was present, there was hepatosplenomegaly, which was non-tender. There was no icterus, lymphadenopathy or any significant skin lesions. Other systems were normal. His complete blood count showed pancytopenia, red blood cells were normochromic, normocytic, and erythrocyte sedimentation rate (ESR) was raised. His CD4 count, which was 135 cells/cumm 4 months back had reduced to 102 cells/cumm at the time of presentation. Other routine investigations were normal. hepatitis B surface antigen (HbsAg) and anti-hepatitis C were negative. Chest X-ray was normal, blood for malarial parasite was negative, Widal test, Mantoux and Mycodot were negative, and cerebrospinal fluid analysis was normal.

Bone marrow examination revealed intracellular and extracellular parasites [Figure 1] and [Figure 2], round to oval in shape with nucleus and kinetoplasts, indicating amastigote form of Leishmania donovani. Aldehyde test was positive and anti-leishmanial antibody test was also positive. Fungal culture of bone marrow aspirate showed no growth.
Figure 1: Bone marrow picture showing extracellular amastigotes of Leishmania donovani by Leishman stain

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Figure 2: Bone marrow picture showing intracellular amastigotes of Leishmania donovani by Leishman stain

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  Discussion Top


VL (Kala-Azar) is a protozoal infection primarily transmitted by sand flies and has been reported to be endemic in 66 countries worldwide. There have been reports of HIV with Leishmania infection in 33 countries, most common being in Europe where 50-70% of adult HIV cases had VL infection. Since, the host defence mechanism against this intracellular infection is T-cell-dependent, Kala-Azar has joined the list of AIDS-related opportunistic infections in endemic areas. In HIV-infected individuals, Kala-Azar has been hypothesised to represent the reactivation of previously controlled asymptomatic infection; and in drug users, newly acquired infection may result from transmission through shared needles.

Co-infected patients are frequently parasitemia and may show atypical clinical presentations, unusual multi-organ involvement, and absent anti-leishmanial antibodies. Diagnosis is made by direct microscopic examination or culture of aspirate or biopsy of any involved tissue (primarily bone marrow) or by blood smear or culture.

In India, VL occurs only in four eastern states of the country, whereas, the high-prevalence states for HIV are the southern and north-eastern states. Thus, the geographical distribution of HIV and VL in India do not currently overlap. A study in Northern-India in 2006 showed that out of 104 Kala-Azar cases, 6 (5.7%) were found to be co-infected with HIV. [3] Another study in Bihar (2003) showed that 1.5% of HIV cases were co-infected with Kala-Azar. [6],[7]


  Conclusion Top


In north-eastern states, where intravenous drug users are the main risk group for HIV transmission, VL has not been reported yet. Any migrant worker who is infected with HIV on HAART and who is experiencing a fall in CD4 cell count with classical symptoms of fever, weight loss and generalized weakness should be screened for VL also.

 
  References Top

1.Phatak UA, Joshi R, Badakh DK, Gosavi VS, Phatak JU, Jagdale RV. AIDS-associated cancers: An emerging challenge. J Assoc Physicians India 2010;58:159-62.  Back to cited text no. 1
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2.Murray HW. Kala-Azar as an AIDS-related opportunistic infection; AIDS patients care and STDs. AIDS Patient Care STDS 1999;13:459-65.  Back to cited text no. 2
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3.Bora D. Epidemiology of visceral leishmaniasis in India. Natl Med J India 1999;12:62-8.  Back to cited text no. 3
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4.Sundar S, Goyal AK, More DK, Singh MK, Murray HW. Treatment of antimony-unresponsive Indian visceral leishmaniasis with ultra-short courses of amphotericin-B-lipid complex. Ann Trop Med Parasitol 1998;92:755-64.  Back to cited text no. 4
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5.Thakur CP, Sinha GP, Pandey AK. Comparison of regimens of amphotericin B deoxycholate in kala-azar. Indian J Med Res 1996;103:259-63.  Back to cited text no. 5
    
6.Thakur CP, Narayan S, Ranjan A. Kala-Azar (visceral leishmaniasis) and HIV coinfection in Bihar, India: Is this combination increasing? J Acquir Immune Defic Syndr 2003;32:572-3.  Back to cited text no. 6
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7.Sinha PK, Rabidas VN, Pandey K, Verma N, Gupta AK, Ranjan A, et al. Visceral Leishmaniasis and HIV Coinfection in Bihar, India. J Acquir Immune Defic Syndr 2003;32:115-6.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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