A severe case of visceral leishmaniasis and liposomal amphotericin B treatment failure in an immunosuppressed patient 15 years after exposure

Abstract

BackgroundVisceral leishmaniasis (VL) is a protozoan disease, which is responsible for 200.000–400.000 yearly infections worldwide. If left untreated, the fatality rate can be as high as 100% within 2 years. 90% of cases occur in just six countries: India, Bangladesh, Sudan, South Sudan, Ethiopia and Brazil. It is thus a disease rarely seen by physicians in Europe or North America. We report on the fatal case of VL in an 80-year-old immunosuppressed patient who presented with a latency of over 15 years after having visited an endemic region. This is the first report showing such extreme latency of VL in a European traveller. This case is furthermore unusual because it suggests primary treatment failure to liposomal amphotericin B.Case presentationAn 80-year-old man who was on immunosuppressive treatment due to a non-specific inflammatory disease of the liver and kidney presented to our hospital with recurrent fever, fatigue and bloody diarrhoea. Histopathological analysis from a colon biopsy showed intracellular amastigotes. The diagnosis of VL was confirmed by polymerase-chain-reaction (PCR) of the colon biopsy. PCR was also performed in plasma, a bronchopulmonary lavage, a lymph node, liver and bone marrow biopsy and proved L. donovani as causative species. The disseminated infection was unresponsive to treatment with liposomal amphotericin B as recommended in immunosuppressed individuals despite stopping immunosuppressive treatment.ConclusionImported cases of VL to non-endemic regions are increasing due to extensive international travel and migration. Furthermore, the increase of elderly patients and immunosuppressed individuals, secondary to HIV, post-transplant and chemotherapeutic agents, has resulted in an increase of VL also in endemic regions of Europe. It is thus important for physicians to be able to recognize the infection. This case also demonstrates treatment failure to amphotericin B, which was only a known problem in patients with HIV until now. The knowledge of this as a possible complication is important for specialists treating the disease.

Infection by Leishmania (Leishmania) infantum chagasi causes intestinal changes B‐1 cells dependent

“…As previously described, VL causes several intestinal changes, since the parasite leads to disruption of the intestinal homeostasis . It can happen due to the presence of the parasite in the organ or as a systemic reaction and could be related to the B‐1 cells.…”

“…These results show that there was greater presence of immature cells, whereas in XID + B1 I group there was an increase in both types of mucin. Thus, more fluid mucus is formed, causing diarrhoea, which is a clinical sign of VL patients . These events can generate epithelial damage in the intestinal villi, requiring the cellular renewal that leads to less differentiated cells and higher villi.…”

“…Thus, more fluid mucus is formed, 46 causing diarrhoea, which is a clinical sign of VL patients. 7,8,12 These events can generate epithelial damage in the intestinal villi, requiring the cellular renewal that leads to less differentiated cells and higher villi. In addition, the quantitative change with regard to the proportion of goblet cells and, consequently to mucus composition, modifies the environment of resident microbiota 45 and intestinal homeostasis.…”

“…The intestine is an important immune organ affected in the presence of VL . Intestinal changes have been evidenced, such as inflammatory infiltration, epithelial degeneration and alterations in the muscular layer in dogs, in addition to intracellular amastigotes that were found in humans along with diarrhoea and malabsorption …”

“…Although some morphological and functional changes have been shown in the human and dog intestines in the presence of VL, the participation of B‐1 cells in this organ during L (L) infantum chagasi infection is still poorly studied. Therefore, the histopathological changes in the ileum of mice in the presence or absence of B‐1 cells during infection by L (L) infantum chagasi were evaluated.…”