A 56-year-old woman presented with fever. Her symptoms weren't improved after 1 week of anti-infective treatment in a local hospital. Similar to case 2, she also had picked Zanthoxylum seeds in Hancheng 1 years ago, and she had a history of mosquito bites. She was healthy in the past. Her body weight was 50 kg. Physical examination revealed splenomegaly, mild lower extremity edema, and multiple skin petechiae. Blood cultures as well as tests for bacteria, fungi, tuberculosis, parasites, and brucellosis agglutination were all negative. The patient's laboratory results revealed pancytopenia and elevated liver enzyme levels (aspartate aminotransferase, 121 U/L; alanine aminotransferase, 36 U/L). Her PCT, CRP, and creatinine levels were 5.67 ng/mL, 89.7 mg/L, and 641 mumol/L, respectively. Computed tomography of the abdomen revealed homogeneous splenomegaly. Her bone marrow smear was negative for Leishmania. Conversely, antibodies against Leishmania were detected in peripheral blood, and PCR was positive for Leishmania. The patient was diagnosed with VL combined with acute renal impairment.
Continuous renal replacement therapy (CRRT) was administered on days 2, 4, and 6 after admission, and this treatment resulted in significantly diminished creatinine levels. To avoid the aggravation of pre-existing renal injury, the low-dose therapy of L-AmB was initiated with a starting dose of 5mg (~ 0.10 mg/kg) on days 9-10 after admission. The L-AmB administration protocol is presented in Figure 3. During therapy, an increase of plasma creatinine levels was observed, peaking at 178 mumol/L on day 4 of treatment. Her creatinine level subsequently declined to 148 mumol/L on day 8 in the absence of CRRT. Thus, slow dose escalation appeared to prevent the further deterioration of renal function. The patient's creatinine further declined during maintenance therapy. Routine blood testing revealed gradual increase of red blood cell, white blood cell, and platelet counts. Her spleen size was gradually decreased, and her kidney function was gradually improved by therapy. The patient's liver function also gradually returned to normal during treatment. No relapse was observed during the 3- and 6-month follow-up visit. In addition, we observed complete recovery of her renal function at 6 months after discharge (urea, 5.66 mmol/L; creatinine, 75 umol/L).