Infection DOI 10.1007/s15010-015-0813-7
CASE REPORT
Development of visceral leishmaniasis in an HIV+ patient upon immune reconstitution following the initiation of antiretroviral therapy Benjamin T. Schleenvoigt1 · Ralf Ignatius3 · Michael Baier2 · Thomas Schneider4 · Marko Weber5 · Stefan Hagel1,5 · Christina Forstner1,6 · Mathias W. Pletz1
Received: 24 March 2015 / Accepted: 18 June 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract Case presentation Here, we report on a case of VL in an HIV-infected patient from the Republic of Georgia who had moved to Germany 14 years before and who had travelled several times to southern Europe in between. After presenting with typical Pneumocystis jiroveci pneumonia, which was treated appropriately, the patient was started on antiretroviral therapy. Shortly thereafter, however, he developed fever of unknown origin. All laboratory assays for the diagnosis of various infectious agents including serological assays and polymerase chain reaction testing of bone marrow aspirate to diagnose VL did not yield positive results at first. Only upon repetition of these tests, diagnosis of VL could be made and the patient treated accordingly. Case discussion Visceral leishmaniasis (VL) is a common opportunistic infection in HIV-positive patients from endemic countries but occurs rarely following antiretroviral treatment.
* Benjamin T. Schleenvoigt
[email protected]‑jena.de 1
Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, 07740 Jena, Thuringia, Germany
2
Institute for Medical Microbiology, Jena University Hospital, Jena, Germany
3
Institute of Tropical Medicine and International Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
4
Department of Internal Medicine – Gastroenterology, Infectious Diseases, and Rheumatology, Charité – Universitätsmedizin Berlin, Berlin, Germany
5
Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
6
Department of Medicine I, Medical University of Vienna, Vienna, Austria
This case demonstrates that patients who develop VL upon immune reconstitution may not be diagnosed initially by standard laboratory assays for the diagnosis of VL and underlines the necessity to repeat serologic and molecular biologic testing for VL in cases of fever of unknown origin in patients from or with travel history to endemic countries. Keywords Immune reconstitution inflammatory syndrome · IRIS · HIV infection · Visceral leishmaniasis
Case presentation A 37-year-old man was admitted to the Jena University Hospital in July 2011. He presented with fever, dyspnea and dry cough for 6 weeks. Born in the Republic of Georgia, the patient had moved to Germany in 1997. Working as a truck driver, he had spent several weeks in Southern Europe (Italy, Greece) within the last 5 years. There was no history of previous disease or medication. Clinical examination revealed a reduced general condition, fever, palpable submandibular and supraclavicular lymph nodes, and decreased breath sounds with hyperresonance on percussion [heart rate 105/min; blood pressure 120/74 mm/Hg; temperature 38.5 °C, height 182 cm, weight 71 kg, body mass index (BMI) 21.43 kg/m2]. Chest X-ray showed evidence of bilateral infiltrates, which was confirmed by computed tomography (CT). Basic laboratory testing revealed leukopenia and hypochromic microcytic anemia (leukocytes 3.3 gigaparticle per liter (Gpt/l) (reference range 4.4–11.3), erythrocytes 3.6 tetraparticle per liter (Tpt/l) (reference range 4.5–5.9), hemoglobin 5.1 mmol/l (reference range 8.7–10.9), MCV 73 fl (reference range 80–96), MCH 1.41 fmol (reference range 1.74–2.05), platelets 261 Gpt/l (reference range 150– 360). Liver and renal function tests were normal. Lactate
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dehydrogenase (LDH) was slightly elevated (4.36 µmol/ l*s, reference range,
