The patient was female, 29 years old and single; born and living in the municipality of Rio de Janeiro; resident of Caju neighborhood, working as a cleaner in the cemetery of Caju, RJ. She denied any trips outside of the city limits of Rio de Janeiro throughout her life. Five months before the hospitalization, the patient experienced an intermittent night fever of 39  C that was not improved by antipyretics and was accompanied by poor appetite, postprandial fullness, nausea and vomiting episodes. There was no history of liver disease or alcohol abuse. Between the months from October to December 2012, she gradually noticed yellow sclera and skin, dark urine, and weight loss of approximately 10 kg, increased abdominal size and a soft and cold edema of the lower limbs up to the knees. The patient sought treatment in emergency units on several occasions but only received symptomatic prescriptions. In January 2013, she was admitted for diagnostic investigation to the 10th ward of the Gaffree and Guinle University Hospital, UNIRIO.
A physical examination revealed poor general health, malnutrition, numbness, pallor +3/+4, dehydrated +1/+4, jaundice +2/+4, cyanosis, fever, tachycardia and eupnea. An abdominal examination revealed moderate ascites, hepatomegaly that was 7 cm from the right costal margin and splenomegaly that was palpable 2 cm below the navel (Fig. 1). Additionally, the lower limbs showed bilateral soft edema up to the knees.
Laboratory examinations (Table 1) revealed a complete blood count showing severe pancytopenia, an extended prothrombin time, a significant elevation of the aminotransferase levels, hypoalbuminemia and hypergammaglobulinemia accompanied by severe jaundice with a cholestatic pattern. A total abdominal ultrasound evaluation revealed the presence of free fluid in the peritoneal cavity, hepatomegaly of approximately 20 cm, splenomegaly of 25 cm and gallstones.
The diagnostic hypotheses contemplated disseminated tuberculosis and visceral leishmaniasis. Other hypotheses covered dengue, yellow fever, prolonged septicemic salmonellosis, brucellosis, malaria, Chagas disease and lymphoproliferative malignancies. An evaluation by thick and thin blood smear, blood culture, stool tests, bone marrow biopsy and aspiration and serology for dengue, yellow fever, brucellosis and Chagas disease were requested. A diagnosis of AIDS was refuted by HIV testing. The bone marrow aspirate confirmed the presence of Leishmania amastigotes (Fig. 2). The case was reported by telephone immediately, followed by an investigation by the Municipal Civil Defense and Health Surveillance. Infected dogs were found in the cemetery in Caju and were sacrificed. The Municipal Civil Defense and Health Surveillance then implemented a plan to combat the vector, to improve environmental sanitation and to search for new cases, which initially yielded two new suspected cases.
For the patient, a therapeutic regimen was initiated with amphotericin B at 0.25 mg/kg/day diluted in 500 mL 5% dextrose and 1000 IU heparin and infused for 6 h. We routinely administered a dose of 100 mg hydrocortisone IV and one g dipyrone IV prior to infusion to reduce the probability of an allergic reaction to amphotericin B. The dose of amphotericin B was increased by approximately 2.5 mg every 3-5 days if there were no complications, such as severe hypokalemia, cardiac arrhythmia or a significant increase in creatinine. Adjustments and suspension of the amphotericin B treatment were necessary for a few days because of increased creatinine levels and hypokalemia. Electrolyte replacements were also needed, as well as therapy to treat iron deficiency-related anemia and the extension of the prothrombin time, which included 300 mg ferrous sulfate orally twice daily, 5 mg folic acid PO daily and 10 mg vitamin K SC in a single dose.
Over a period of seven weeks (January-February 2013), a cumulative dose of 700 mg amphotericin B was administered. Fever reduction, an improvement in the level of consciousness, a noticeable improvement in general health and nutrition and a significant reduction of hepatosplenomegaly were noted during the treatment. Laboratory tests showed pancytopenia and the progressive improvement of dyscrasia, the normalization of liver enzyme levels and cholestasis (Table 1). The patient was discharged in February 2013 and is undergoing a follow up at the outpatient clinic, demonstrating clinical improvement.