Objective: Visceral leishmaniasis is rare in Western Europe. Morbidity and mortality is low in immunocompetent but may be fatal in immunosuppressed patients. Control of infection and immunity is achieved by the generation of leishmania-specific CD4-T-cells of TH1-type, the secretion of IFN-a and IL-2 and consecutively activation of macrophages to kill intracellular amastigotes. The infection can be reactivated years later in case of cellular immunosuppression. Methods: We describe two patients with reactivation of latent infection: the first after induction chemotherapy for acute lymphatic leukemia (ALL) and the second after treatment with steroids. Results: The first patient, a 41-year-old man from Turkey, was treated for newly diagnosed B-cell ALL with Cytarabine and Idarubicin. He developed fever in neutropenia, mucositis with diarrhoea and abdominal cramps. The patient deteriorated while on empirical treatment with broad spectrum antibiotics and Amphotericin B. Because of an acute abdomen, a laparotomy with resection of the duodenum was performed. The histology revealed an intestinal leishmaniasis. Despite adequate therapy with liposomal Amphotericin B the patient developed fatal septic shock with multiorgan-failure. The second patient was a 66-year-old swiss woman with a diagnosis of allopurinol-induced hepatitis. A liver biopsy showed fibrin ring granulomas. Prednison (75 mg/day) was started and 3 weeks later the patient was readmitted with pancytopenia. A bone marrow aspiration revealed leishmaniasis, identified as Leishmania infantum by PCR. A repeated liver biopsy showed infiltration of leishmania without evidence of fibrinous granulomas as shown on the first biopsy. The history revealed a travel to Malta 2 years earlier. Liposomal amphotericin was started. The patient developed septic shock and died after 15 days on the intensive care unit. Conclusion: Visceral leishmaniasis may become more frequent in non endemic regions because of international travel and increasing numbers of immunosuppressed patients. Reactivation of leishmaniasis should be considered particularly in patients with fever in neutropenia or with pancytopenia and fever under steroids.
Full conference title:
16th European Congress of Clinical Microbiology and Infectious Diseases
- ECCMID 16th (2006)