A 62-year-old male patient, resident of West Bengal, was suffering from cough and chest pain for the last 6 months. He underwent initial management in a local hospital. He was a non-smoker and non-alcoholic. He had no history of fever, hematemesis, malena, diarrhea, headache, or body ache. He had not suffered from diseases like tuberculosis, asthma, chronic obstructive pulmonary disease (COPD), or gastroesophageal reflux disease (GERD). He was not taking any drugs at that time.
Initial clinical evaluation in the local hospital revealed that the patient had moderate pallor, cachexia but no lymphadenopathy. Auscultation of chest showed bilateral normal breath sounds, Chest radiograph showed a small left-sided pleural effusion. Routine hematological investigations detected pancytopenia with hemoglobin level of 7.7 g/dl. Erythrocyte Sedimentation Rate was 100 mm/h. Mantoux test for tuberculosis was negative. Sputum culture for acid-fast bacilli (AFB) was negative. Ziehl-Neelsen stain of the sputum smears was also negative for AFB.
The patient was prescribed antitussives and analgesics, but no significant improvement occurred. He was then referred to our hospital for further management.
After examining the patient, we obtained another chest radiograph that confirmed the presence of a small left-sided pleural effusion [Figure 1]. Known causes of pleural effusion like heart failure, pneumonia, tuberculosis, or carcinoma of lung were absent in this patient. He did not have any symptoms of arthritis, which is commonly found in autoimmune diseases. Therefore, the cause of pleural effusion remained unexplained.
On thorough examination, a mild splenomegaly was detected. To detect the cause of splenomegaly, serum bilirubin, liver enzymes, and prothrombin time were estimated which were within normal limits. HBsAg, anti-HCV and anti-HIV antibodies were negative by ELISA technique. Widal test for enteric fever and test for malaria antigens were negative.
Total serum protein estimation was done, which was found to be within normal limits. However, the albumin/globulin ratio was reversed, being 0.2. Napier's aldehyde test was then performed which is based on the principle of hypergammaglobulinemia, that occurs in VL. About 1 ml of patient's serum was mixed well with a drop of 40% formalin, shaken and kept at room temperature. Opacification and solidification of serum was seen after 10 min signifying a positive result. Subsequently, bone-marrow aspiration was undertaken, which showed both intracellular and extracellular amastigote forms of L. donovani. Slight excess of plasma cells was also noted [Figure 2].
The patient was treated with IV Sodium Stibogluconate with prompt clinical and laboratory improvement. Chest radiograph was done after 1 month, which showed resolution of preceding pleural effusion [Figure 3]. He was on follow-up for another 6 months, which was uneventful.