A 55-year-old man, living in Yichang City, Hubei Province, with the diagnosis of hepatitis B virus-DNA (HBV-DNA)-positive chronic severe hepatitis, was admitted to the department of hematology in the local hospital because of intermittent fever of 1-month duration; his maximum body temperature was up to 40 C. The patient had worked on a farm in Xinjiang Province a month earlier, but this clue did not raise concerns for the clinicians. The physical examination revealed hepatosplenomegaly below the costal margin. The positive findings in the laboratory results included hepatic abnormality with alanine transaminase (ALT) 490 U/L (0-40 U/L), aspartate transaminase (AST) 558 U/L (0-40 U/L), total-value bilirubin (TBIL) 23.23 mumol/L (5.1-28.0), direct bilirubin (DBIL) 14.37 (0-10), total protein (TP) 51.54 g/L (65-85), albumin (ALB) 26.83 g/L (40-55), and HBV-DNA 3.19 * 104 IU/ml (<1.0 * 102 IU/ml). The results of routine blood examination were slightly disordered, with white blood cell (WBC) 3.12 * 109/L and platelets (PLT) 100 * 109/L. An enhanced CT scan was performed, which showed an enlarged spleen with sustained strengthening multinodular ( Figures 1B-D ), and angioma was suspected. No other abnormalities in bone marrow lesions were identified by CT images. The patient received a positron emission tomography-computed tomography (PET/CT), which showed a significant diffuse increase in the uptake of FDG in the splenomegaly and slightly diffuse FDG uptake in the bone marrow ( Figures 1A, E-G ). After 2 weeks of antibiotic and cortical therapy, the patient still had intermittent fever with progressive deterioration in routine laboratory examinations including WBC 0.95 * 109/L, PLT 56 * 109, ALT 524 U/L (0-40 U/L), and AST 640 U/L (0-40 U/L).
In addition, bone marrow aspiration and biopsy were performed twice to confirm the previous diagnosis with an interval of 2 months, and the results showed phagocytosis of reticulum cells. Regarding these clinical and imaging findings, splenic lymphoma was highly suspected. After the chemotherapy for hemophagocytic lymphohistiocytosis (HLH), the patient was discharged from the hospital in remission. Nevertheless, he was readmitted to the hospital again for persistent fever and pancytopenia 2 months later. The patient underwent splenectomy to confirm the initial diagnosis and remove a significant burden of disease. He also received antiviral treatment with entecavir due to the history of severe hepatitis B. Subsequently, the postoperative histopathological analysis indicated diffuse proliferation of extracellular and intra-macrophage amastigotes in the spleen. At this stage, the third bone marrow biopsy was performed again, and Leishmania amastigotes were found. Eventually, the patient received lipid amphotericin B therapy and related symptomatic treatment, which showed excellent clinical improvement within 1 week of treatment, and his serum ALT and AST levels all dropped to the normal range. There was no recurrence of leishmaniasis over 1 year.