REVIEWS OF INFECTIOUS DISEASES • VOL. 12, NUMBER 3 • MAY-JUNE 1990 © 1990 by The University of Chicago. All rights reserved. 0162-0886/90/1203-0018$02.00
Bacterial Infection as a Presenting Manifestation of Visceral Leishmaniasis Jose M. Garces, Santiago Tomas, Juan Rubies-Prat, Juan L. Gimeno, and Ludvik Drobnic
From the Departments of Medicine and Infectious Diseases, Hospital del Mar, Universidad Autonoma de Barcelona, ~, Barcelona, Spain
Visceral leishmaniasis is a chronic disease caused by Leishmania donovani and is characterized by general malaise with fever, splenomegaly, polyclonal hypergammaglobulinemia, and hematologic disturbances [1]. The acute onset of symptoms is more common in children than adults. The disease may also be asymptomatic, as suggested by the presence of antibodies to Leishmania in otherwise healthy subjects [2, 3]. It is well known that patients with visceral leishmaniasis are prone to severe bacterial infections during the evolution of the disease [1, 4]. We describe two patients admitted because of a perianal abscess and pneumonia due to Escherichia coli and Streptococcus pneumoniae, respectively. The case of an additional patient with acute necrotizing infection of the pharynx in whom cultures failed to yield pathogens is also discussed. All three patients were later diagnosed as having visceral leishmaniasis.
scess was diagnosed. Laboratory studies disclosed the following values: hemoglobin, 9.7 g/dL; leukocyte count, 3,500/J,lL, with 570/0 neutrophils, 5% band forms, 36% lymphocytes, and 2% monocytes; and platelet count, 48,OOO/J,lL. The total serum protein level was 50 giL, with an albumin level of 24 giL and a y-globulin level of 16 giL. Cultures of blood and exudate of the perianal abscess yielded E. coli. Treatment consisted of incision and drainage of the perianal abscess and ampicillin therapy. A bone marrow aspirate revealed the presence of Leishmania in macrophages, and meglumine antimoniate therapy was begun. The patient improved and was discharged from the hospital in general good health 2 months after admission. Case 2. A 28-year-old previously healthy man was admitted to the hospital in May 1980 with diarrhea, cough, hemoptysis, chest pain, and 1 week of fever. On admission the patient's temperature was 38°C. Physical examination revealed lymphadenopathy, hepatomegaly, and splenomegaly. Crackles were heard at the base of the right lung. Chest roentgenogram revealed consolidation in the right middle lobe. Laboratory studies disclosed the following values: hemoglobin, 11 g/dL; white blood cell count, 2,100/J,lL, with 470/0 neutrophils, 30/0 band forms, 47% lymphocytes, and 3% monocytes; and platelet count, 46,OOO/J,lL. The total serum protein level was 84 giL with an albumin level of 33.7 giL and a y-globulin level of 36.6 giL. Two blood cultures yielded S. pneumoniae. Bone marrow aspirate revealed the presence of Leishmania in macrophages, and meglumine antimoniate therapy was begun. The
Case Reports
Case 1. A 43-year-old previously healthy man was admitted to the hospital in March 1974 with a 3-week history of chills, fever, and pain in the perianal region. On admission the patient's temperature was 38°C. Physical examination revealed a liver edge 3 em below the right costal margin. A perianal abReceived for publication 7 July 1989 and in revised form 16 October 1989.
Please address requests for reprints to Prof. J. Rubies-Prat, Department of Medicine, Hospital del Mar, Paseo Maritimo 25-29, 08003 Barcelona, Spain.
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Downloaded from http://cid.oxfordjournals.org/ at Florida Atlantic University on January 31, 2015
Twopatients admitted to the hospital because of severe bacterial infection werediagnosed as having visceral leishmaniasis. The types of bacterial infection were perianal abscess and pneumonia; Escherichia coli and Streptococcus pneumoniae were isolated from exudates and blood cultures, respectively. A third patient admitted because of acute necrotizing infection of the pharynx and visceral leishmaniasis is also discussed. Cultures from this patient failed to yield pathogens. Anemia, leukopenia, or thrombocytopenia was present in all patients, and bone marrow aspirate revealed the presence of Leishmania in macrophages. We conclude that in areas where leishmaniasis is endemic, early bone marrow aspirate should, in most instances, be performed in patients with bacterial infection associated with anemia, leukopenia, or thrombocytopenia if hepatomegaly and/or splenomegaly is present.
Bacterial Injection in Visceral Leishmaniasis
patient was discharged from the hospital in general good health 23 days after admission. Discussion
hematologic disorders, particularly pancytopenia, and especially if hepatomegaly and/or splenomegaly is present, the diagnosis of visceral leishmaniasis should be ruled out in areas where leishmaniasis is endemic. Thus, we consider early bone marrow aspirate to be obligatory in the management of these patients.
References 1. Pearson RD, De Queiroz Sousa A. Leishmania species: (kala-
2.
3.
4.
5.
6.
7.
azar, cutaneous, and mucocutaneous leishmaniasis). In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. New York: John Wiley, 1985:1522-31 Pampigliones S, Manson-Bahr P, Giungi F, Giunti G, Parente A, Trotti Gc. Studies on Mediterranean leishmaniasis. 2. Asymptomatic cases of visceral leishmaniasis. Trans R Soc Trop Med Hyg 1974;68:447-53 Badaro R, Jones TC, Carvalho EM, Sampaio D, Reed SG, Barral A, Teixeira R, Johnson WD Jr. New perspectives on a subclinical form of visceral leishmaniasis. J Infect Dis 1986;154:1003-11 Guerreiro J, Samia R, Carvalho EM, Badaro R, Heonir R. Infeccao bacteriana em pacientes portadores de Leishmaniose visceral. Mem Inst Oswaldo Cruz 1985;80:447-52 Rezai HR, Ardehal SM, Amirhaakimi G, Kharazmi A. Immunological features of kala-azar. Am J Trop Med Hyg 1978;27:1079-83 Carvalho EM, Teixeira RS, Johnson WD Jr. Cell-mediated immunity in American visceral leishmaniasis: reversible immunosuppression during acute infection. Infect Immun 1981;33:498-502 Mariscal Sistiaga F, Dominguez Moreno B, Lenguas Portero F, Martinez Forde JM, Galvan Guijo B. Kala azar en el hospital de enfermedades infecciosas. Revision de 104 casos. Rev Clin Esp 1980;159:47-49
Downloaded from http://cid.oxfordjournals.org/ at Florida Atlantic University on January 31, 2015
When patients with visceral leishmaniasis are untreated, death usually occurs because of pneumonia, sepsis, tuberculosis, or dysentery as well as anemia or gastrointestinal hemorrhage [1]. Bacterial infection in these patients is closely related to agranulocytosis and disturbances of the immune system [5, 6]. In Spain, up to lOltlo of patients with visceral leishmaniasis suffer a bacterial infection during their illness [7]. Our patients' clinical history was not suggestive of kala-azar. Severe bacterial infection was the presenting manifestation of illness, and diagnosis of visceral leishmaniasis was made only after routine bone marrow aspirate for pancytopenia. In 1974 we saw a 19-year-old patient who was admitted to the hospital because of an acute illness characterized by sore throat and fever. Physical examination revealed necrotizing angina, pallor, purpura, generalized lymphadenopathy, splenomegaly, and pancytopenia. In this patient cultures of blood and throat exudates failed to yield pathogens. A diagnosis of acute leukemia was considered, but a bone marrow aspirate confirmed the presence of visceral leishmaniasis. In our patients, the pathogens and, in most cases, the sites of infection (perianal abscess, lung, and necrotizing angina) were those usually found in neutropenic patients. Our experience suggests that in patients with
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Bacterial Infection as a Presenting Manifestation of Visceral Leishmaniasis Jose M. Garces, Santiago Tomas, Juan Rubies-Prat, Juan L. Gimeno, and Ludvik Drobnic
From the Departments of Medicine and Infectious Diseases, Hospital del Mar, Universidad Autonoma de Barcelona, ~, Barcelona, Spain
Visceral leishmaniasis is a chronic disease caused by Leishmania donovani and is characterized by general malaise with fever, splenomegaly, polyclonal hypergammaglobulinemia, and hematologic disturbances [1]. The acute onset of symptoms is more common in children than adults. The disease may also be asymptomatic, as suggested by the presence of antibodies to Leishmania in otherwise healthy subjects [2, 3]. It is well known that patients with visceral leishmaniasis are prone to severe bacterial infections during the evolution of the disease [1, 4]. We describe two patients admitted because of a perianal abscess and pneumonia due to Escherichia coli and Streptococcus pneumoniae, respectively. The case of an additional patient with acute necrotizing infection of the pharynx in whom cultures failed to yield pathogens is also discussed. All three patients were later diagnosed as having visceral leishmaniasis.
scess was diagnosed. Laboratory studies disclosed the following values: hemoglobin, 9.7 g/dL; leukocyte count, 3,500/J,lL, with 570/0 neutrophils, 5% band forms, 36% lymphocytes, and 2% monocytes; and platelet count, 48,OOO/J,lL. The total serum protein level was 50 giL, with an albumin level of 24 giL and a y-globulin level of 16 giL. Cultures of blood and exudate of the perianal abscess yielded E. coli. Treatment consisted of incision and drainage of the perianal abscess and ampicillin therapy. A bone marrow aspirate revealed the presence of Leishmania in macrophages, and meglumine antimoniate therapy was begun. The patient improved and was discharged from the hospital in general good health 2 months after admission. Case 2. A 28-year-old previously healthy man was admitted to the hospital in May 1980 with diarrhea, cough, hemoptysis, chest pain, and 1 week of fever. On admission the patient's temperature was 38°C. Physical examination revealed lymphadenopathy, hepatomegaly, and splenomegaly. Crackles were heard at the base of the right lung. Chest roentgenogram revealed consolidation in the right middle lobe. Laboratory studies disclosed the following values: hemoglobin, 11 g/dL; white blood cell count, 2,100/J,lL, with 470/0 neutrophils, 30/0 band forms, 47% lymphocytes, and 3% monocytes; and platelet count, 46,OOO/J,lL. The total serum protein level was 84 giL with an albumin level of 33.7 giL and a y-globulin level of 36.6 giL. Two blood cultures yielded S. pneumoniae. Bone marrow aspirate revealed the presence of Leishmania in macrophages, and meglumine antimoniate therapy was begun. The
Case Reports
Case 1. A 43-year-old previously healthy man was admitted to the hospital in March 1974 with a 3-week history of chills, fever, and pain in the perianal region. On admission the patient's temperature was 38°C. Physical examination revealed a liver edge 3 em below the right costal margin. A perianal abReceived for publication 7 July 1989 and in revised form 16 October 1989.
Please address requests for reprints to Prof. J. Rubies-Prat, Department of Medicine, Hospital del Mar, Paseo Maritimo 25-29, 08003 Barcelona, Spain.
518
Downloaded from http://cid.oxfordjournals.org/ at Florida Atlantic University on January 31, 2015
Twopatients admitted to the hospital because of severe bacterial infection werediagnosed as having visceral leishmaniasis. The types of bacterial infection were perianal abscess and pneumonia; Escherichia coli and Streptococcus pneumoniae were isolated from exudates and blood cultures, respectively. A third patient admitted because of acute necrotizing infection of the pharynx and visceral leishmaniasis is also discussed. Cultures from this patient failed to yield pathogens. Anemia, leukopenia, or thrombocytopenia was present in all patients, and bone marrow aspirate revealed the presence of Leishmania in macrophages. We conclude that in areas where leishmaniasis is endemic, early bone marrow aspirate should, in most instances, be performed in patients with bacterial infection associated with anemia, leukopenia, or thrombocytopenia if hepatomegaly and/or splenomegaly is present.
Bacterial Injection in Visceral Leishmaniasis
patient was discharged from the hospital in general good health 23 days after admission. Discussion
hematologic disorders, particularly pancytopenia, and especially if hepatomegaly and/or splenomegaly is present, the diagnosis of visceral leishmaniasis should be ruled out in areas where leishmaniasis is endemic. Thus, we consider early bone marrow aspirate to be obligatory in the management of these patients.
References 1. Pearson RD, De Queiroz Sousa A. Leishmania species: (kala-
2.
3.
4.
5.
6.
7.
azar, cutaneous, and mucocutaneous leishmaniasis). In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. New York: John Wiley, 1985:1522-31 Pampigliones S, Manson-Bahr P, Giungi F, Giunti G, Parente A, Trotti Gc. Studies on Mediterranean leishmaniasis. 2. Asymptomatic cases of visceral leishmaniasis. Trans R Soc Trop Med Hyg 1974;68:447-53 Badaro R, Jones TC, Carvalho EM, Sampaio D, Reed SG, Barral A, Teixeira R, Johnson WD Jr. New perspectives on a subclinical form of visceral leishmaniasis. J Infect Dis 1986;154:1003-11 Guerreiro J, Samia R, Carvalho EM, Badaro R, Heonir R. Infeccao bacteriana em pacientes portadores de Leishmaniose visceral. Mem Inst Oswaldo Cruz 1985;80:447-52 Rezai HR, Ardehal SM, Amirhaakimi G, Kharazmi A. Immunological features of kala-azar. Am J Trop Med Hyg 1978;27:1079-83 Carvalho EM, Teixeira RS, Johnson WD Jr. Cell-mediated immunity in American visceral leishmaniasis: reversible immunosuppression during acute infection. Infect Immun 1981;33:498-502 Mariscal Sistiaga F, Dominguez Moreno B, Lenguas Portero F, Martinez Forde JM, Galvan Guijo B. Kala azar en el hospital de enfermedades infecciosas. Revision de 104 casos. Rev Clin Esp 1980;159:47-49
Downloaded from http://cid.oxfordjournals.org/ at Florida Atlantic University on January 31, 2015
When patients with visceral leishmaniasis are untreated, death usually occurs because of pneumonia, sepsis, tuberculosis, or dysentery as well as anemia or gastrointestinal hemorrhage [1]. Bacterial infection in these patients is closely related to agranulocytosis and disturbances of the immune system [5, 6]. In Spain, up to lOltlo of patients with visceral leishmaniasis suffer a bacterial infection during their illness [7]. Our patients' clinical history was not suggestive of kala-azar. Severe bacterial infection was the presenting manifestation of illness, and diagnosis of visceral leishmaniasis was made only after routine bone marrow aspirate for pancytopenia. In 1974 we saw a 19-year-old patient who was admitted to the hospital because of an acute illness characterized by sore throat and fever. Physical examination revealed necrotizing angina, pallor, purpura, generalized lymphadenopathy, splenomegaly, and pancytopenia. In this patient cultures of blood and throat exudates failed to yield pathogens. A diagnosis of acute leukemia was considered, but a bone marrow aspirate confirmed the presence of visceral leishmaniasis. In our patients, the pathogens and, in most cases, the sites of infection (perianal abscess, lung, and necrotizing angina) were those usually found in neutropenic patients. Our experience suggests that in patients with
519
