Splenectomy in Patients with Visceral Leishmaniasis Resistant to Conventional Therapy and Secondary Prophylaxis: A Retrospective Cohort

Abstract

Some patients with visceral leishmaniasis (VL), or kala-azar, suffer relapses and low quality of life despite adequate drug therapy, especially those co-infected with HIV. Occasionally, physicians indicate splenectomy, but the benefit of the procedure needs to be analyzed systematically. Therefore, a retrospective open cohort study was conducted in Teresina, Brazil. Inpatients from a reference hospital with relapsing VL who had a rescue splenectomy between 2012 and 2019 after the nationally recommended drug therapy failed were studied. The procedure’s risks and benefits were assessed in a limited-resource setting. The primary outcomes were surgical complications, complete blood count, CD4+ cell count, hospitalizations, survival time, and medical complications preceding death. Thirteen adult patients received medical and surgical indications of splenectomy (12 men and one woman). Eleven had HIV infection. Two had early and two had late complications. Four died, all of whom were infected with HIV. An additional HIV-coinfected patient, apart from the cohort, died just before surgery. The death rate after surgery was 13.3 overall and 22.1 per 100 person-years among HIV-infected patients (31% overall and 36%, respectively). The impressive rise of complete blood counts and reduction of blood transfusions and hospitalizations were observed among all patients. Also, a meaningful increase in CD4+ cells in HIV-infected patients was noted. Splenectomy may benefit patients with relapsing VL. However, before performing splenectomy, available combined drug therapy should be tried for relapsing VL.

The spleen is the graveyard of CD4+ cells in patients with the immunological failure of visceral leishmaniasis and AIDS

“…The spleen is highly parasitized during VL without HIV infection, [38] [39][40] including during relapses, [39,41] and splenectomy is curative in patients without immunosuppression and improves those with HIV coinfection. [42,43] The importance of spleen for the observed CD4 + fall is highlighted by the prolonged effect of splenectomy since CD4 + count remained correlated with past spleen size after splenectomy.…”

Case Report: FDG-PET/CT findings in co-infection of visceral leishmaniasis and chronic hepatitis B

“…Removal of a large number of parasites is one of the potential benefits of splenectomy, as the level of drugs used to treat VL in the enlarged spleen may not be sufficient to eradicate the parasite and cure the disease in the presence of severe splenomegaly. Splenectomy may be considered for curative purposes in patients with clinical impact on hypersplenism and coagulopathy ( Troya et al., 2007 ; Reinaldo et al., 2022 ). Therefore, while PET/CT may be useful for early intervention in suspected VL cases, its value in guiding splenectomy needs further study.…”

From Infection to Death: An Overview of the Pathogenesis of Visceral Leishmaniasis

“…The spleen increases in size to >10 times of its normal volume and appears to play a central role in the pathogenesis of VL. Splenectomy dramatically improves patients’ clinical conditions, although it does not cure the diseased HIV-co-infected patients [ 124 ]. Some degree of hypertrophy is also seen in the liver due to the proliferation of Kupffer cells in patients infected with either L. donovani or L. infantum [ 119 , 125 ].…”

“…In VL patients, all cytopenia are more severe due to systemic and splenic inflammation, exacerbating the mechanical destruction of blood cells and platelets [ 120 , 121 ]. The essential role of inflammation is highlighted by the facts that when the inflamed spleen of relapsing VL is taken out by splenectomy [ 120 ], leukopenia and thrombocytopenia subside rapidly and completely [ 124 ], while in noninflammatory hypersplenism, the recovery is only partial [ 114 ]. As discussed above, the anemia seen in VL is also a consequence of inflammation via the APR hepcidin, leading to iron-deficiency anemia.…”