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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2016  |  Volume : 27  |  Issue : 5  |  Page : 1059-1062
Mucocutaneous and visceral leishmaniasis in renal transplant patient from nonendemic region


Department of Nephrology, M. S. Ramaiah Hospital, Bengaluru, Karnataka, India

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Date of Web Publication22-Sep-2016
 

How to cite this article:
Mahesh E, Madhyastha P R, Varma V, Gurudev K C. Mucocutaneous and visceral leishmaniasis in renal transplant patient from nonendemic region. Saudi J Kidney Dis Transpl 2016;27:1059-62

How to cite this URL:
Mahesh E, Madhyastha P R, Varma V, Gurudev K C. Mucocutaneous and visceral leishmaniasis in renal transplant patient from nonendemic region. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Dec 8];27:1059-62. Available from: http://www.sjkdt.org/text.asp?2016/27/5/1059/190903
To the Editor,

Infection is a frequent cause of morbidity and mortality in solid organ transplant recipients, and the incidence depends on the immunosuppressive treatment and its duration. [1] Visceral leishmaniasis is a type of parasitosis that is endemic in many developing countries as well as in the Mediterranean region. [2] We are reporting a case report of visceral and mucocutaneous leishmaniasis which is an unusual parasitic infection in Karnataka (South India).

This patient is a 44-year-old male who had undergone renal transplantation 62 months ago and was receiving triple-drug immunosuppressive regimen [tacrolimus, mycophenolate mofetil (MMF), and steroids]. He was admitted with the history of nonhealing nodular lesions over the chin, a few crop lesions in the oral mucosa for three months [Figure 1] and [Figure 2] and fever for one month. Clinical examination and investigations revealed febrile illness with severe pancytopenia. The patient was initiated on treatment IV teicoplanin making a preemptive diagnosis of Staphylococcal infection awaiting for the reports, and MMF was reduced in view of pancytopenia. Further investigations revealed right upper lobe homogeneous opacity in the lung, and ultrasound abdomen confirmed hepatosplenomegaly. In spite of teicoplanin and discontinuation of drugs with potential hematologic toxicity, there was no improvement in his fever and blood picture. Hence, he was subjected for bone marrow aspiration and biopsy which was inconclusive and biopsy of the specimen from the nodular lesion showed focally edematous fibrovascular tissue with dense infiltrates of histiocytes and a few admixed lymphocytes and neutrophils, many of the histiocytes were stuffed with organisms resembling a safety pin indicative of Leishmania amastigotes [Figure 3]. Serological test for leishmaniasis was positive.
Figure 1: The purplish nodular lesion on the chin and a few oral satellite lesions before treatment.

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Figure 2: Purplish nodular lesions on the chin.

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Figure 3: Edematous fibrovascular tissue with dense infiltrates of histiocytes, stuffed with organisms resembling a safety pin indicative of Leishmania amastigotes.

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Considering his posttransplant status with elevated renal parameters, he was started on IV liposomal amphotericin B 3 mg/kg for 15 days, with a sustained clinical and laboratory improvement after the 2 nd day of therapy; the patient showed improvement in terms of recovery of leukopenia and thrombocytopenia in 10 days. However, improvement of the lesions over the face took about three weeks [Figure 4]. Serum creatinine improved from 4.3 to 1.6 mg/dL at the time of discharge. All other investigations including cytomegalovirus, HIV, and Hepatitis B and C were negative.
Figure 4: The lesion after 2 weeks of treatment.

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To the best of our knowledge, this is the first case of visceral and mucocutaneous leishmaniasis in a renal transplant recipient from Karnataka which is a nonendemic area for leishmaniasis. In India, leishmaniasis is endemic in states such as Bihar, Madhya Pradesh, Odisha, and Tamil Nadu. [3],[4],[5] The mean interval between transplantation and disease onset is known to be 32 months. [6] Since conventional immunosuppression does not alter the humoral response, the detection of antibodies to Leishmania in these cases is a useful diagnostic tool.

Lesions may begin as small red papules (5-10 mm initially). Depending on the species of Leismania, they can progress into erythematous nodules, indurated plaques, scaly plaques, or ulcers with raised, rolled dusky borders. [7],[8],[9] Lesions may be dry and crusted or accompanied by exudates, over a period of one to three months. [10] Acute lesions of cutaneous leishmaniasis often are mistaken for furuncles and methicillin-resistant Staphylococcusaureus infections. The differential diagnosis for patients with chronic lesions such as these and a travel history to endemic areas include deep fungal infections (paracoccidioidomycosis and histoplasmosis), mycobacterial infections such as (Mycobacterium marinum, cutaneous tuberculosis, and other atypical mycobacteria), syphilis, tertiary yaws, leprosy, sarcoidosis, and cutaneous neoplasms. Culture and identification of Leishmania species can provide useful information for treatment and prognosis. Most laboratories are not prepared to assist with speciation of Leishmania, especially in a nonendemic state like Karnataka. In an immunocompetent host, most lesions, particularly those under 10 mm, will resolve spontaneously.

The treatment options for mucocutaneous leishmaniasis are sodium stibogluconate 20 mg/kg/day IV, but this is known to cause pancreatitis and arthropathy in posttransplant recipients. Meglumine antimoniate 20 mg/kg/ day is known to cause pancreatitis, acute kidney injury, and leukopenia. As the patient had leukopenia and renal failure, liposomal amphotericin B 2-3 mg/kg/day was the safest option. [11],[12],[13],[14] Liposomal amphotericin B has demonstrated to have less renal toxicity compared to the other alternative drugs. [15],[16]

Depending on the species and treatment regimen, a clinician can anticipate a reduction in lesion size by two-thirds within the 6 th week of treatment. An alternate regimen has to be considered if reduction remains between onethird and two-third of the original size. A definite indication for an alternate regimen is if lesion reduction is less than one-third. [17]

Mucocutaneous leishmaniasis should be considered in patients who are in endemic regions. In India, it is a serious problem in Bihar, West Bengal, Eastern Uttar Pradesh, Madhya Pradesh, and Tamil Nadu, especially in women and children 0-9 years of age. Clinical trials in India have reported encouraging results with liposomal amphotericin B (recommended as a third-line drug by the National Malaria Eradication Programme). [18] However, we would like to highlight in our case that this patient was neither from an endemic state nor did he travel to one. Treatment with liposomal amphotericin B with 3 mg/kg lead to good results and sustained clinical and laboratory response. Serum creatinine regressed to baseline within three weeks of treatment. Liposomal amphotericin B is the safest available treatment in renal transplantation with graft dysfunction

Conflict of interest: None declared.

 
   References Top

1.
Rubin RH, Wolfson JS, Cosimi AB, TolkoffRubin NE. Infection in the renal transplant recipient. Am J Med 1981; 70:405-11.  Back to cited text no. 1
    
2.
Pearson RD, Sousa AQ. Clinical spec-trum of leishmaniasis. Clin Infect Dis 1996;22:1-13.  Back to cited text no. 2
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3.
Ma DD, Concannon AJ, Hayes J. Fatal leishmaniasis in renal-transport patient. Lancet 1979;2:311-2.  Back to cited text no. 3
    
4.
Broeckaert-van Orshoven A, Michielsen P, Vandepitte J. Fatal leishmaniasis in renaltransplant patient. Lancet 1979;2: 740-1.  Back to cited text no. 4
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5.
Lamas S, Orte L, Parras F, García Laraña J, Matesanz R, Ortuño J. Non-fatal leishmaniasis in a renal transplant recipient. Nephron 1987; 45:71.  Back to cited text no. 5
    
6.
Apaydin S, Ataman R, Serdengeçt K, et al. Visceral leishmaniasis without fever in a kidney transplant recipient. Nephron 1997;75: 241-2.  Back to cited text no. 6
    
7.
Dowlati Y. Cutaneous leishmaniasis: clinical aspect. Clin Dermatol 1996;14:425-31.  Back to cited text no. 7
[PUBMED]    
8.
Machado P, Araújo C, Da Silva AT, et al. Failure of early treatment of cutaneous leishmaniasis in preventing the development of an ulcer. Clin Infect Dis 2002;34: E69-73.  Back to cited text no. 8
    
9.
Magill AJ. Cutaneous leishmaniasis in the returning traveler. Infect Dis Clin North Am 2005;19:241-66.  Back to cited text no. 9
[PUBMED]    
10.
Sinha PK, Pandey K, Bhattacharya SK. Diagnosis & management of Leishmania/HIV coinfection. Indian J Med Res 2005;121:407-14.  Back to cited text no. 10
    
11.
Herwaldt BL, Berman JD. Recommendations for treating leishmaniasis with sodium stibogluconate (Pentostam) and review of pertinent clinical studies. Am J Trop Med Hyg 1992;46:296-306.  Back to cited text no. 11
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12.
Aronson NE, Wortmann GW, Johnson SC, et al. Safety and efficacy of intra-venous sodium stibogluconate in the treatment of leishmaniasis: recent U.S. military experience. Clin Infect Dis 1998; 27:1457-64.  Back to cited text no. 12
    
13.
Andersen EM, Cruz-Saldarriaga M, LlanosCuentas A, et al. Comparison of meglumine antimoniate and pentamidine for peruvian cutaneous leishmaniasis. Am J Trop Med Hyg 2005;72:133-7.  Back to cited text no. 13
    
14.
Sampaio RN, Marsden PD. Treatment of the mucosal form of leishmaniasis without response to glucantime, with liposomal amphotericin B. Rev Soc Bras Med Trop 1997;30: 125-8.  Back to cited text no. 14
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15.
Oliveira-Neto MP, Mattos M, Pirmez C, et al. Mucosal leishmaniasis ("espundia") responsive to low dose of N-methyl glucamine (Glucantime) in Rio de Janeiro, Brazil. Rev Inst Med Trop Sao Paulo 2000;42:321-5.  Back to cited text no. 15
    
16.
Amato VS, Tuon FF, Campos A, et al. Treatment of mucosal leishmaniasis with a lipid formulation of amphotericin B. Clin Infect Dis 2007;44:311-2.  Back to cited text no. 16
    
17.
Murray HW, Berman JD, Davies CR, Saravia NG. Advances in leishmaniasis. Lancet 2005; 366:1561-77.  Back to cited text no. 17
    
18.
Bora D. Epidemiology of visceral leishmaniasis in India. Natl Med J India 1999; 12:62-8.  Back to cited text no. 18
    

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Correspondence Address:
Dr. P Rakesh Madhyastha
Department of Nephrology, M. S. Ramaiah Hospital, Bengaluru, Karnataka
India
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DOI: 10.4103/1319-2442.190903

PMID: 27752024

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