Case Presentation: A 29 year-old Hispanic male with past medical history of AIDS and multiple-associated co-infections including CNS toxoplasmosis, CMV retinitis, genital HSV, PCP, noncompliance and multiple substance abuse, presented to the ED with 10 days of watery non-bloody diarrhea, abdominal pain, fever, chills, anorexia and dry cough. Patient was admitted for similar symptoms nine months prior. Home medications included Atripla, Azithromycin, Bactrim and Leucovorin. On physical exam, he was awake and alert. Cardiopulmonary examination was normal. The abdomen was tender with hepatosplenomegaly, but non-distended. Cervical lymphadenopathy was palpable. Labs revealed pancytopenia: WBC: 2.3×103/uL; Hgb: 7.8 g/dL; Hct: 22.8%; Platelets: 124; LDH: 719. HIV viral load was 12,000 and CD4 count was 1 cell/uL. Chest radiography showed bibasilar patchy opacities suggesting PCP pneumonia and Bactrim was started. Persistent pancytopenia prompted a bone marrow biopsy which demonstrated Donovan bodies consistent with Leishmaniasis. Esophagogastroduodenoscopy and colonoscopy were performed due to persistent diarrhea and biopsy was also consistent with Leishmaniasis. The patient was started on Amphotericin B (21mg/kg inpatient for 2 weeks and infusions 1q/week for a total of 6 weeks outpatient) with resolution of the digestive symptoms. Patient followed up in the clinic with improvement of the pancytopenia.
Discussion: Visceral Leishmaniasis (VL) is caused by a parasitic infection characterized by fever, pancytopenia and hepatosplenomegaly with progressive host deterioration. To date, there have been less than six reported cases of HIV with Leishmaniasis co-infection in the United States, thus far all imported. Incidence of VL is increasing in the developed world secondary to climate change, which has extended the natural habitat of the Leishmania vector into the southern United States. This case demonstrates the importance of having VL on the differential in HIV-positive patients with pancytopenia. There is debate regarding adding VL to the list of AIDs-defining opportunistic infections; therefore, a diagnosis of VL should prompt HIV screening. This is especially relevant as the mortality rate in patients with AIDS/Leishmaniasis co-infection is 53.7% as opposed to 7.5% in HIV-negative patients.
Conclusions: AIDS patients often present with significant hematologic abnormalities such as anemia, lymphocytopenia, thrombocytopenia and various coagulopathies. These irregularities stem from a variety of HIV-associated sources including opportunistic infections, malignancies or as consequences of treatment therapies such as antiretroviral therapy. Physicians should be aware of VL when evaluating an HIV-positive patient with pancytopenia and should consider performing bone marrow biopsy.
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