Visceral leishmaniasis with hemophagocytic lymphohistiocytosis (HLH).

A 48-year-old woman presented with fever and significant weight loss for 6 months. She appeared ill and had palpable small sized cervical and axillary lymphadenopathy. Both her liver and spleen were massively enlarged. Lab tests showed White Blood Count: 0.9 × 103/uL, Absolute neutrophil count: 0.36 × 103/uL, Hemoglobin 10.9 g/dL, Hematocrit : 19.8%, Mean Cell Volume : 69 fL, Platelets : 37 × 103/uL. Peripheral Blood Smear was benign. HCV, HBV, HIV, Brucella, malaria, and Tuberculosis (TB) were unrevealing. Her serum ferritin was 5324 ng /mL. Bone marrow aspirate (Giemsa, Figs. 1 A&B and 2 ) and biopsy (Fig. 3, A&B) showed numerous macrophages that contained numerous intracellular organisms which had small paranuclear basophilic body (kineteplasts) with the characteristic double dot appearance of Leishman Donovan (LD) bodies (amastigotes) and some hemophagocytosis. The patient was diagnosed with visceral leishmaniasis-associated Hemophagocytic Lymphohistiocytosis (HLH). She received liposomal Amphotericin B (200 mg intravenously in day 1–4, day 7 and day 14). After two weeks the pancytopenia persisted and a tapering oral prednisone was started(starting dose 50 mg daily). The patient showed clinical recovery and at 6 months her complete blood count (CBC) was normal.

Fig. 1

Bone marrow aspirates (A & B), leishmaniasis, showing numerous organisms within a macrophages. Giemsa x 600.

Fig. 2

Bone marrow aspirate showing a macrophage that has ingested erythrocytes, lymphocyte and LD bodies. Giemsa x 600.

Fig. 3

Bone marrow biopsy section showing Leishmania donovani within macrophages. (A) H&E x 600. (B) Giemsa x 600.

Bone marrow (BM) aspirate and biopsy were needed to evaluate for pancytopenia and suspected HLH. Although BM aspirate is reported less sensitive than splenic aspirate for diagnosis of visceral leishmaniasis, BM is easy and less invasive. When HLH is associated with leishmaniasis, HLH directed therapy like corticosteroid, in addition to a specific leishmaniasis treatment, might sometimes be needed [1], [2].

Funding

No funding was required.

Consent

This educational material bears no private or potential identifying information. Hence consent is not needed. Hence consent was not sought.

Author contribution

H.A., R.B. and O.B. contributed equally to the data collection related to this case, and writing the masuscript. All authors read and approve the final masuscript.

Declaration of competing interest

The authors declare that they have no competeting interests.