Visceral Dissemination of Mucocutaneous Leishmaniasis in a Kidney Transplant Recipient

Abstract

Intracellular protozoan of the genus Leishmania, endemic in the Mediterranean basin, are the cause of cutaneous (CL), mucocutaneous (MCL), and visceral leishmaniasis (VL). A 75-year-old woman was admitted nine years after a second kidney transplant (KT), due to persistent pancytopenia and fever. She presented edema and erythema of the nose in the last two years and an exophytic nodular lesion located on the left arm, with areas of peripheral necrosis and central ulceration in the last 18 months. A bone marrow biopsy revealed features compatible with Leishmania amastigotes, and polymerase chain reaction test (PCR) for Leishmania infantum was positive. Moreover, biopsy and PCR for L. infantum of the cutaneous lesion on the patient's left arm and nose and PCR from peripheral blood were positive. Thus, a diagnosis of CL, MCL, and VL was made, and liposomal amphotericin B was initiated, but the patient had an unfavorable outcome and died. This is the first report of a KT recipient presenting with the entire spectrum of leishmaniasis. In Portugal, this infection is rare-so a high degree of clinical suspicion is required for its diagnosis, especially in endemic regions, as visceral leishmaniasis is a potentially life-threatening infection.

Keywords: immunosuppression; leishmaniasis; transplant.

Figure 1

Ulcerative lesion on the left arm present in the past 18 months before (A) and after (B) initiation of Leishmaniasis treatment.

Figure 2

Patient’s nose lesion before (A) and after (B) initiation of Leishmaniasis treatment.

Figure 3

HE 400×—bone marrow with macrophage aggregates with structures compatible with Leishmania.

Figure 4

(a): HE 200×—squamous cell carcinoma; (b): HE 400X—skin with inflammatory infiltrate and macrophage with structures compatible with Leishmania.

Figure 5

Multiple sequence alignment (Clustal Omega) of nucleotide sequences of ITS-1. Comparison of ITS-1 sequence obtained from a patient with ITS-1 sequences and the following reference strains of L. infantum (MHOM/MA/67/ITMAP-263), L. infantum (MH).