Akademik Veri Yönetim Sistemi
33RD ECCMID, Kobenhavn, Danimarka, 15 - 18 Nisan 2023, ss.1
itle
Visceral Leishmaniasis presenting as fever of unknown origin in non-endemic area: A case report
Introduction
Fever of unknown origin (FUO) etiology varies. In its etiopathology immunological disorders, infectious diseases, systemic rheumatological diseases and malignancies are present. After the elimination of other causes, differential diagnosis of infectious diseases should be done. In the diagnosis of FUO endemic causes are important. We present a Visceral Leishmaniosis case in a non-endemic area from Turkey.
Case
A 76-year-old woman is admitted to Acıbadem Atakent Hospital hematology department with the symptoms of anemia, fever, joint pain and weakness. According to clinical (paleness, fever, hepatosplenomegaly), laboratory and radiological evaluations myelodysplastic syndrome (MDS) and lymphoma are considered. (BURADAKİ LABLARINDA ANEMİ THROMBOSİTOPENİ VE RADYOLOJİDE SPLENO MEGALİ) FIGURE 1 OLACAK. When MDS and lymphoma are eliminated by bone marrow biopsy, she’s referred to the infectious diseases department. In her history, she said that she had COVID-19 two months ago. She was hospitalized with the thought that the symptoms might be due to post-COVID-19. During the follow up her fever got higher, especially at night. FIGURE2. When an extensive blood work is done, anemia was evaluated as chronic disease anemia. The blood smear showed no abnormality and the blood cultures were negative. In the following days, she had periods without fever however it wasn’t under control. She was discharged with symptomatic treatment. She was followed by the outpatient clinic. During the follow-up, her symptoms didn’t get better. Also, her splenomegaly progressed (10 cm progression). FIGURE3 OLABİLİRSE USG GÖRÜNTÜSÜ. Reported PET-CT was compatible with MDS. The patient is referred to the general surgery department due to the progression of splenomegaly. Splenectomy is planned and done (Figure 1 YENİ FIGURE 3 OLACAK). Pathologic evaluation reported that primarily tuberculosis then granulomatous diseases should be considered by the responsible physician. Patient is presented to the council. After the meeting, re-evaluation of the biopsy material is done. Histopathologist saw L. donovani amastigotes in histiocytes and the diagnosis was evaluated as VL. (FIGURE 4) Histopathologic diagnosis verified by the serology (Table 2). With Amphotericin B treatment total cure is achieved. When asked, patient didn’t define any bite history, the most recent bite history she remembers is nearly 10 years ago. ???? year after splenectomy, the patient was symptom free and in good health.
Discussion:
Visceral Leishmaniasis , kala azar, is primarily caused by L. donovani and transmitted by phlebotomine sandflies. Patients with leishmanial infection rarely show Visceral Leishmania (VL). It represents as cutaneous leishmania mainly. Also, leishmania is an endemic disease. Thus, in endemic regions clinicians can suspect according to the clinical presentation of the patients. Although it is mainly true for the cutaneous leishmaniasis. Because for VL mainly affects the reticuloendothelial system, lymph nodes, spleen, liver and bone marrow clearly causing a systemic infection and making it nearly impossible for clinician to make a diagnosis. After an incubation period lasting months to years, VL patients present with progressive systemic infection for weeks to months. RES and blood invasion causes hepatosplenomegaly and enlarged lymph nodes. Anemia and thrombocytopenia are also commonly seen as they are commonly seen in parasitic infections. Due to anemia there will be decreased oxygen supply to tissues, so we see pallor, fatigue and weakness. Chronic intermittent fever is typically associated with rigor and chills. Tuberculosis is
Conclusion
In non- endemic areas, suspicion and diagnosis of VL can be challenging for the clinician. This case demonstrates the significance of including VL in the differential diagnosis of a FUO patient even in a non-endemic region. Diagnosis process in this case proves the importance of multidisciplinary approach in our case council to fever of unknown origin and guidance of the pathologists with patient’s laboratory results.