Visceral Leishmaniasis as a Possible Reason for Pancytopenia

Abstract

Leishmaniasis is caused by different species of the protozoa, Leishmania, and frequently found in South-Western Asia, Eastern Africa, Brazil, and Mediterranean countries. Leishmania are transmitted to humans by the bite of sandflies. After weeks to months, unspecific symptoms may occur, accompanied by more specific findings like pancytopenia and organomegaly. We report two children with pancytopenia and hepato-/splenomegaly: a 1-year-old boy was first diagnosed with an Adenovirus-infection, accompanied by fever, pancytopenia, and hepatosplenomegaly who had spent his summer vacation in Spain and a 3-year-old boy of Macedonian origin who was first diagnosed with a Parvovirus B19-infection again accompanied by splenomegaly and pancytopenia. In both children, leukemia was excluded by an initial bone marrow puncture. As fever was still persistent weeks after the children's first hospital stay, both children received antibiotics empirically without sustainable effect. While different autoantibodies were present in both children, an immunosuppressive therapy was initiated in the younger boy without therapeutic success. A second bone marrow puncture was performed and Leishmania were finally detected morphologically and proven serologically. After weight-adjusted treatment with liposomal Amphotericin B for 10 days, both children recovered completely without relapse. Aim of this report is to broaden the spectrum of differential diagnoses in children with pancytopenia, splenomegaly, and fever to visceral leishmaniasis particularly when travel history is positive for the Mediterranean area. The infection may mimic more common diseases, such as leukemia, viral infections, or autoimmune diseases, because polyclonal B cell activation and other mechanisms may lead to multiple positive serologic tests. Both cases illustrate typical pitfalls and shall encourage taking Leishmaniasis into diagnostic consideration.

Keywords: children; hepatosplenomegaly; pancytopenia; recurrent fever; visceral leishmaniasis.

Figure 1

Photomicroscopy of the first bone marrow puncture in patient A (Pappenheim’s staining, 100× magnification): Leishmania are difficult to detect and subtle (arrowhead indicates Leishmania).

Figure 2

Photomicroscopy of the first bone marrow puncture in patient A (Pappenheim’s staining, 100× magnification): Leishmania can also be seen intracellular in the first smear (arrowheads indicate Leishmania).

Figure 3

Photomicroscopy of the second bone marrow puncture in patient A (Pappenheim’s staining, magnification 100×): numerous Leishmania species are clearly visible intra- and extracellularly.

Figure 4

Photomicroscopy of the second bone marrow puncture in patient A (Pappenheim’s staining, magnification 100×): numerous Leishmania species are clearly visible intra- and extracellularly.