Visceral leishmaniasis in a patient with ulcerative colitis – A case report

Goran Janković; Lena Martinović; Zorica Dakić; Dragana Mijač; Miloš Štulić; Miodrag Krstić

doi:10.2298/VSP180302076J

Goran Janković Clinic for Gastroenterology and Hepatology, Clinical Centre of Serbia, School of Medicine, University of Belgrade, Serbia
Lena Martinović Clinical Center of Serbia, Clinic for Gastroenterology and Hepatology, Belgrade, Serbia; University of Belgrade, Faculty of Medicine
Zorica Dakić University of Belgrade, Faculty of Medicine, Department of Microbiology
Dragana Mijač Clinical Center of Serbia, Clinic for Gastroenterology and Hepatology, Belgrade, Serbia; University of Belgrade, Faculty of Medicine
Miloš Štulić Clinical Center of Serbia, Clinic for Gastroenterology and Hepatology, Belgrade, Serbia; University of Belgrade, Faculty of Medicine
Miodrag Krstić Clinical Center of Serbia, Clinic for Gastroenterology and Hepatology, Belgrade, Serbia; University of Belgrade, Faculty of Medicine

DOI: https://doi.org/10.2298/VSP180302076J

Keywords: colitis, ulcerative;, diagnosis;, immunosuppressive agents;, leishmaniasis;, risk assessment;, serology

Abstract

Introduction. There is a rise of visceral leishmaniasis in immunocompromised patients due to increased availability of immunomodulatory drugs. In order to point at the occurrence of visceral leishmaniasis in patients with inflammatory bowel disease (IBD), we reported a case of female patient with a travel history to European Mediterranean countries, who was on immunosuppressive treatment due to ulcerative colitis. Case report. A 29-year-old female patient was admitted to hospital due to severe relapse of ulcerative colitis. Corticosteroid therapy was administered in addition to previous longterm azathioprine, with clinical response to the treatment. During the course of the disease she had recurrent high-grade fever with marked hepatosplenomegaly and pancytopenia. The diagnosis of leishmaniasis was established by positive serology tests and microscopic finding of amastigotes in bone marrow smears. The disseminated infection was responsive to treatment with liposomal amphotericin B, but therapy had to be discontinued due to urticarial rush. Subsequent therapy with antimony was administered, but it had to be stopped too due to liver toxicity. No further treatment for leishmaniasis was initiated as the clinical and laboratory data suggested that the patient had responded to the treatment. She was discharged from hospital in IBD remission and without signs of the infection. Conclusion. Visceral leishmaniasis should be considered in IBD patients with fever of unknown origin and relevant travel history in order to achieve favorable disease outcome.

Author Biography

Goran Janković, Clinic for Gastroenterology and Hepatology, Clinical Centre of Serbia, School of Medicine, University of Belgrade, Serbia

Profesor interne medicine Medicinskog fakulteta u Beogradu. Načelnik intenzivne nege Klinike za gastroenterologiju i hepatologiju KCS.

References

Centers for Disease Control and Prevention. CDC Health Information for International Travel. Yellow Book 2018. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/leishmaniasis-visceral.

Weisser M, Khanlari B, Terracciano L, Arber C, Gratwohl A, Bassetti S, et al. Visceral leishmaniasis: a threat to immuno-com¬pro¬mised patients in non-endemic areas? Clin Microbiol Infect 2007; 13(8): 751–3.

Eichenberger A, Buechi AE, Neumayr A, Hatz C, Rauch A, Huguenot M, et al. A severe case of visceral leishmaniasis and liposomal amphotericin B treatment failure in an immuno-suppressed patient 15 years after exposure. BMC Infect Dis 2017; 17: 81.

Burisch J, Munkholm P. The epidemiology of inflammatory bowel disease. Scand J Gastroenterol 2015; 50(8): 942–51.

Badaró R, Carvalho EM, Rocha H, Queiroz AC, Jones TC. Leishmania donovani: an opportunistic microbe associated with progressive disease in three immunocompromised patients. Lancet 1986; 1(8482): 647–9.

Hagenah GC, Wündisch T, Eckstein E, Zimmermann S, Holst F, Grimm W, et al. Sepsis-like disease in an immunocompromised patient with a travel history to Mallorca. Internist (Berl) 2007; 48(7): 727–30. (German)

Basset D, Faraut F, Marty P, Dereure J, Rosenthal E, Mary C, et al. Visceral leishmaniasis in organ transplant recipients: 11 new cases and review of the literature. Microbes Infect 2005; 7(13): 1370–5.

van Griensven J, Carrillo E, López-Vélez R, Lynen L, Moreno J. Leishmaniasis in immunosuppressed individuals. Clin Microbiol Infect 2014; 20(4): 286–99.

Kumar R, Chauhan SB, Ng SS, Sundar S, Engwerda CR. Immune Checkpoint Targets for Host-Directed Therapy to Prevent and Treat Leishmaniasis. Front Immunol 2017; 8: a1492.

Fletcher K, Issa R, Lockwood DN. Visceral leishmaniasis and immunocompromise as a risk factor for the development of visceral leishmaniasis: a changing pattern at the hospital for tropical diseases, london. PLoS One 2015; 10(4): e0121418.

Garcia-Vidal C, Rodríguez-Fernández S, Teijón S, Esteve M, Rodríguez-Carballeira M, Lacasa JM, et al. Risk factors for opportunistic infections in infliximab-treated patients: the importance of screening in prevention. Eur J Clin Microbiol Infect Dis 2009; 28(4): 331–7.

Marie I, Guglielmino E. Non tuberculous anti-TNF associated opportunistic infections. Rev Med Interne 2010; 31(5): 353–60. (French)

Marcoval J, Penín RM, Sabé N, Valentí-Medina F, Bonfill-Ortí M, Martínez-Molina L. Cutaneous leishmaniasis associated with anti-tumour necrosis factor-α drugs: an emerging disease. Clin Exp Dermatol 2017; 42(3): 331–4.

Guedes-Barbosa LS, Pereira da Costa I, Fernandes V, Henrique da Mota LM, de Menezes I, Aaron Scheinberg M. Leishmaniasis during anti-tumor necrosis factor therapy: report of 4 cases and review of the literature (additional 28 cases). Semin Arthritis Rheum 2013; 43(2): 152–7.

da Silva MR, Stewart JM, Costa CH. Sensitivity of bone marrow aspirates in the diagnosis of visceral leishmaniasis. Am J Trop Med Hyg 2005; 72(6): 811–4.

Besada E, Njalla RJ, Nossent JC. Imported case of visceral leishmaniasis presenting as pancytopenia in a Norwegian patient treated with methotrexate and etanercept for psoriasis arthritis. Rheumatol Int 2013; 33(10): 2687–9.

Iqbal J, Hira PR, Saroj G, Philip R, Al-Ali F, Madda PJ, at al. Imported visceral leishmaniasis: diagnostic dilemmas and comparative analysis of three assays. J Clin Microbiol 2002; 40(2): 475–9.

Malla N, Sengupta C, Dubey ML, Sud A, Ansari NA, Salotra P. Antigenaemia and antibody response to Leishmania donovani stage-specific antigens and rk39 antigen in human immunodeficiency virus-infected patients. Br J Biomed Sci 2003; 60(4): 210–6.

Ponte-Sucre A, Gamarro F, Dujardin JC, Barrett MP, López-Vélez R, García-Hernández R, et al. Drug resistance and treatment failure in leishmaniasis: A 21st century challenge. PLoS Negl Trop Dis 2017; 11(12): e0006052.

Laguna F, Videla S, Jiménez-Mejías ME, Sirera G, Torre-Cisneros J, Ribera E, et al. Spanish HIV-Leishmania Study Group. Amphotericin B lipid complex versus meglumine antimoniate in the treatment of visceral leishmaniasis in patients infected with HIV: a randomized pilot study. J Antimicrob Chemother 2003; 52(3): 464–8.

Antinori S, Cascio A, Parravicini C, Bianchi R, Corbellino M. Leishmaniasis among organ transplant recipients. Lancet Infect Dis 2008; 8(3): 191–9.

Cota GF, de Sousa MR, Fereguetti TO, Rabello A. Efficacy of anti-leishmania therapy in visceral leishmaniasis among HIV infected patients: a systematic review with indirect comparison. PLoS Negl Trop Dis 2013; 7(5): e2195.

Juzlova K, Votrubova J, Kacerovska D, Lukas M, Bortlik M, Rohacova H, et al. Visceral leishmaniasis with cutaneous symptoms in a patient treated with infliximab followed by fatal consequences. Dermatol Ther 2014; 27(3): 131–4.

Borges MM, Pranchevicius MC, Noronha EF, Romero GA, Carranza-Tamayo CO. Efficacy and safety of amphotericin B deoxycholate versus N-methylglucamine antimoniate in pediatric visceral leishmaniasis: an open-label, randomized, and controlled pilot trial in Brazil. Rev Soc Bras Med Trop 2017; 50(1): 67–74.

Rodrigo C, Weeratunga P, Fernando SD, Rajapakse S. Ampho-tericin B for treatment of visceral leishmaniasis: systematic review and meta-analysis of prospective comparative clinical studies including dose-ranging studies. Clin Microbiol Infect 2018; 24(6): 591–8.

Aronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, et al. Diagnosis and Treatment of Leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). Am J Trop Med Hyg 2017; 96(1): 24–45.

Aronson NE. Addressing a clinical challenge: guidelines for the diagnosis and treatment of leishmaniasis. BMC Med 2017; 15(1): 76.

Pavli A, Maltezou HC. Leishmaniasis, an emerging infection in travelers. Int J Infect Dis 2010; 14(12): e1032–9.

Zanger P, Kötter I, Kremsner PG, Gabrysch S. Tumor necrosis factor alpha antagonist drugs and leishmaniasis in Europe. Clin Microbiol Infect 2012; 18(7): 670–6.

Feuerstein J, Cheifetz A. Ulcerative Colitis: Epidemiology, Diagnosis, and Management. Mayo Clin Proc 2014; 89(11): 1553–63.