A 42-year-old male presented to the medical emergency department with complaints of weakness and significant weight loss over 1 year. He had episodes of low-grade fever in the past year, for which the patient was treated for pulmonary tuberculosis 2 years back. At present, he was again put on antitubercular therapy (ATT) for the past 1 month; however, no improvement was noted and hence the patient was referred to our hospital. There was no significant family history. On general physical examination, the patient was found to be thin built, pale, and afebrile with abdominal distension. Left submandibular and left axillary lymph nodes were enlarged and measured 1.5 cm in diameter. Mild hepatosplenomegaly was noted, however no fluid thrill could be discerned. Ultrasound abdomen revealed enlarged multiple conglomerate of mesenteric lymph nodes with the largest node measuring 22 mm x 18 mm. Clinical chemistry revealed A:G reversal with total protein of 9.5 g%, albumin of 2.0 g%, globulin of 7.5 g%, and A:G ratio of 1:3.75. Other parameters of liver function test and kidney function test were found to be within normal limits. Complete hemogram revealed pancytopenia with hemoglobin: 6 g%, total leukocyte count: 1800/muL, differential leukocyte count: polymorphs 47%, lymphocytes 51%, eosinophils 1%, monocytes 1%, platelets: 48,000/muL, and erythrocyte sedimentation rate (ESR) of 50 mm/h. Peripheral smear revealed the presence of rouleaux; however, no hemoparasite was noted.
Fine needle aspiration cytology was performed on the left submandibular and axillary lymph nodes, which yielded thick aspirate. Smears prepared showed few epithelioid cell granulomas interspersed with discrete and aggregates of histiocytes in a background of reactive lymphoid cells and many plasma cells. Numerous intracellular as well as extracellular amastigote forms of Leishmania species were seen [Figure 1]. In view of strong clinical suspicion, Ziehl-Neelsen staining for acid-fast bacilli (AFB) was also done which came out to be negative. Both polymerase chain reaction for Mycobacterium tuberculosis and AFB culture yielded negative result. Later on, rK39 antigen was also found to be positive. Bone marrow examination (both aspirate and biopsy) revealed a prominence of plasma cells and histiocytes along with infiltration by numerous intracellular as well as extracellular amastigote forms of Leishmania spp. Average parasite density (APD) of 5+, i.e., 10-100 Leishman-Donovan (LD) bodies/field, was noted in the bone marrow aspirate (BMA) [Figure 2]. In view of high APD, the patient's human immunodeficiency virus (HIV) status was evaluated which showed positive serology. Immune status evaluation revealed a low CD4 count; 28/muL (reference range: 400-1600/muL). The patient was started on intravenous amphotericin B along with highly active antiretroviral therapy. Improvement was noted after 14 days of treatment (CD4 count: 36/muL). Subsequent bone marrow evaluations revealed a significant fall in APD and clinical improvement in patient's health; weight gain, improved appetite, and rise in CD4 counts.