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Visceral leismaniasis is considered as opportunistic infection in immunosuppressed patients particularly HIV infected. However, in the endemic areas like India, South America, Northeast Africa, and the Mediterranean basin it is quite common in immunocompetent persons as well. The atypical presentation of leishmaniasis is usually in association with HIV coinfection. [1-3] We present a case of atypical presentation of leishmania infection in a non immunocompromised patient who came with clinical symptoms mimicking celiac disease.
Case report
A 32 year old female presented in gastroenterology OPD with complaints of chronic diarrhea and weight loss for one year and fever for one month. Blood tests revealed normocytic normochromic anemia and leucocytosis. Anti transglutaminase (TTG) serology was positive. In view of chronic diarrhea and positive TTG, upper gastrointestinal endoscopy was performed and found to be mostly normal except for mild scalloping of duodenal mucosa and non-specific duodenitis. Biopsy was taken from the duodenum (D2) to rule out celiac disease.
Histopathological examination revealed a well oriented adequate biopsy with crypt villous ratio of 1:1 to 1:2. There was mild focal increase in intraepithelial lymphocytes. Lamina propria showed granular clumps under low power. High power examination showed abundant macrophages with intracytoplasmic and extracellular bodies of leishmania in the lamina propria (Figure 1). Later, she was tested for human immunodeficiency virus which was negative. Following treatment with liposomal amphotericin B the patient recovered from most of symptoms.
Discussion:
The classical presentation of visceral leishmaniasis is fever, weight loss, hepatosplenomegaly, hypergammaglobulinaemia and pancytopenia.[4] However, few patients show atypical manifestation particularly HIV infected and elderly immunecompromised individuals. Atypicality may be in terms of location, more severe cytopenias, high rate of recurrence and the higher mortality rate.[1]
We report a case of atypical presentation of duodenal leishmaniasis in a non immunecompromised patient who came with clinical symptoms mimicking celiac disease. There was no hepato/splenomegaly or lymph adenopathy, and there was unusual duodenal infiltration. Duodenal presentation of leishmania in patients with AIDS is well documented. In one of the series with 91 patients of AIDS the diagnosis of leismaniasis was established on gastrointestinal biopsies in 12 cases.[1] These patients usually underwent endoscopy and biopsy due to symptoms related to gastrointestinal tract. To conclude, atypical presentation of leishmaniasis should be kept in mind in the patient coming from endemic areas.
References
- Rosenthal E. HIV and Leishmania coinfection: a review of 91 cases with focus on atypical locations of Leishmania. Clin Infect Dis 2000;31:1093–5.
- Mc Bride MO, Fisher M, Skinner CJ, et al. An unusual gastrointestinal presentation of leishmaniasis. Scand J Infect Dis 1995;27:297–8.
- M L Alvarez-Nebreda, E Alvarez-Fernandez, S Rada, F Branas, E Maranon, M T Vidan, J A Serra-Rexach. Unusual duodenal presentation of leishmaniasis. J Clin Pathol 2005;58:1321–2.
- Berman JD. Human leishmaniasis: clinical, diagnostic and chemotherapeutic developments in the last 10 years. Clin Infect Dis 1997;24:684–703.