Unusual manifestations of visceral leishmaniasis in children: a case series and its spatial dispersion in the western region of São Paulo state, Brazil

Abstract

BackgroundVisceral leishmaniasis (VL) is becoming endemic in São Paulo state, in the southeastern region of Brazil. Unusual manifestations with non-specific signs and symptoms may make diagnosis difficult and delay treatment, increasing the risk of severity and death, particularly in new endemic areas. There are few studies on patients with these characteristics in Brazil. We describe a case series of unusual manifestations of VL in children and its spatial dispersion in the western region of São Paulo state.Cases presentationFrom 2009 to 2014, five clinical cases involving children treated in the Regional Hospital of Presidente Prudente (RH) were selected. Two patients had multiple relapses requiring liposomal amphotericin B; one patient had VL-cytomegalovirus-dengue co-infection and liver injury; one patient was diagnosed with X-linked agammaglobulinemia, a primary immunodeficiency; and one patient was diagnosed with VL-human immunodeficiency virus/acquired immunodeficiency syndrome (VL-HIV/AIDS) co-infection. Primary or secondary immunodeficiencies were found in four children, and associated viral infections were found in three children. Three patients were referred from other hospitals to RH. With regard to the geographic spread of VL, more cases were found in the northern area, in the epicenter of the infection where the first cases were registered, flowing south; a spatial-temporal occurrence was found.ConclusionsPrimary and secondary immunodeficiencies and viral co-infectious should be considered among unusual manifestations of VL, especially in those with multiple relapses. Spatial-temporal occurrence was found. Thus, integrated actions and effective monitoring of the disease are needed to complement curative practices to stem the tide of the epidemic.

Clinical, Epidemiological, and Geospatial Characteristics of Patients Infected with Hepatitis C Virus Treated with Second-Generation Direct-Action Antivirals in a Reference Center in a Mesoregion of São Paulo State, Brazil

“…However, it seems that these measures do not reach the public health system of the small and poorer cities of our region. In this context, the region also harbors other endemic vector-borne diseases linked to poverty and undeveloped settings, including dengue fever and visceral leishmaniasis [ 36 ].…”

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

“…The main role of B‐1 in leishmaniasis is still controversial . B‐1 cells deficiency has been described in the literature as having the potential of causing a series of immunological problems, such as low antibody production and recurrent infections, several gastrointestinal alterations and symptoms, besides the worsening of visceral leishmaniasis …”

“…15,[17][18][19] B-1 cells deficiency has been described in the literature as having the potential of causing a series of immunological problems, such as low antibody production 34 and recurrent infections, 35 several gastrointestinal alterations and symptoms, 36 besides the worsening of visceral leishmaniasis. 25 Leishmania dissemination occurs via lymphatic or haematogenous circulation; the immune cells, such as dendritic cells, monocytes and macrophages, can participate in this transport. 37 Several reports in literature show the involvement of the gastrointestinal tract during visceral leishmaniasis, 10,11,38 with development of severe intestinal lesions, 11,38 inflammatory infiltrates and epithelial degeneration.…”

“…XID mice can mimic X‐linked human agammaglobulinemia (XLA) . Cases of VL in XLA patients have already been reported in the literature . Understanding the role of the B‐1 cells in VL is a strategy for new therapeutic approaches; moreover, knowledge on their systemic effects could be applicable.…”

Multiple Nodular Lesions in Spleen and Liver in Visceral Leishmaniasis

“…In newly endemic areas or in regions where sporadic cases have been reported, VL can be misdiagnosed leading to a significant delay in treatment (5). Over time mortality of VL increases if it is not treated (6).…”