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Patient case: Leishmaniasis

Patient case: Leishmaniasis

Discussion

A 35-year-old man presents to a clinic with a three-month history of progressive weight loss, fever, and fatigue. He reports night sweats and a loss of appetite. He recently traveled to a rural region where he spent several weeks working outdoors. He recalls being bitten by insects multiple times but did not seek medical attention at the time.

On examination, he appears thin and pale. His temperature is 38.5°C (101.3°F), and he has marked splenomegaly and mild hepatomegaly. Laboratory tests reveal pancytopenia (low white blood cell, red blood cell, and platelet counts) and elevated inflammatory markers. A bone marrow biopsy and serologic testing confirm the presence of Leishmania donovani, diagnosing visceral leishmaniasis (kala-azar).

The patient is started on liposomal amphotericin B and advised to follow up for monitoring of treatment response. Over the following weeks, his symptoms improve, and his blood counts gradually normalize.

Questions
1. What is the most likely diagnosis in this patient?

a) Malaria

b) Visceral leishmaniasis (kala-azar)

c) Tuberculosis

d) Brucellosis

2. Which clinical finding is most characteristic of visceral leishmaniasis?

a) Enlarged lymph nodes without organ involvement

b) Hepatosplenomegaly with pancytopenia

c) Jaundice and dark urine

d) Chronic cough with hemoptysis

3. What is the most appropriate confirmatory test for this disease?

a) Blood culture

b) Bone marrow biopsy and serologic testing

c) Stool examination for ova and parasites

d) Chest X-ray

4. What is the first-line treatment for visceral leishmaniasis in this patient?

a) Chloroquine

b) Liposomal amphotericin B

c) Doxycycline

d) Ivermectin

Reveal answers

Answers

1. Answer: b) Visceral leishmaniasis (kala-azar)

The patient’s prolonged fever, weight loss, splenomegaly, and pancytopenia strongly suggest visceral leishmaniasis, a parasitic disease caused by Leishmania donovani.

2. Answer: b) Hepatosplenomegaly with pancytopenia

The hallmark of visceral leishmaniasis is an enlarged spleen and liver, along with pancytopenia due to bone marrow infiltration by Leishmania parasites.

3. Answer: b) Bone marrow biopsy and serologic testing

Visceral leishmaniasis is diagnosed by detecting Leishmania parasites in bone marrow aspirates or using serologic tests to identify antibodies against the parasite.

4. Answer: b) Liposomal amphotericin B

Liposomal amphotericin B is the preferred treatment for visceral leishmaniasis, especially in severe cases, due to its high efficacy and lower toxicity compared to other treatments like antimonial drugs.