A 40-year-old man of Albanian descent, living in Athens the last 20 years, was admitted on February 2008. His symptoms began one year prior to admission with dry cough and gradual weight loss of a total of 30 kg. Night sweats and scant hemoptysis appeared the last month. A limited workup 6 months ago had revealed the presence of chronic active hepatitis B. 
The patient was working in a restaurant, was a nonsmoker, and had no other remarkable medical history. Clinical examination revealed cachexia, hepatosplenomegaly, and small, discrete, and nontender axillary and cervical lymph nodes. There were no clinical signs of liver failure or portal hypertension such as jaundice, palmar erythema, spider nevi, encephalopathy, or ascites. 
Laboratory tests showed pancytopenia, elevated hepatic aminotransferases (3-4 times the upper limit) and polyclonal hypergammaglobulinemia. Erythrocyte Sedimentation Rate was 100 mm/h. Serum albumin, bilirubin and prothrombin time, were within normal limits. HIV was tested negative by ELISA twice by three months apart. Antibodies against Hepatitis C virus were negative as well. An abdominal ultrasound revealed increased dimensions of the liver and spleen and the presence of enlarged lymph nodes at the hepatic hilum. Diameter and flow through the portal vein were normal, and no ascites was detected. A Computerized Tomography scan of the chest revealed limited adenopathy; a 2 x 1 cm mass at the right hilum, and a 1.2 cm right lower paratracheal lymph node with hypodense centre. 
On bronchoscopy, epistaxis and pharyngeal inflammation consistent with candidiasis were noticed. There was mild diffuse redness throughout the tracheobronchial tree. Inflammation was more prominent on the medial aspect of the bronchus intermedius extending into the middle lobe bronchus. Interestingly, a discreet mucosal polypoid lesion was observed on the middle lobe carina (Figure 1). Bronchial biopsies taken from this lesion revealed epithelial hyperplasia and several Leishmania amastigotes within histiocytes (Figures 2(a) and 2(b)). Transbronchial needle biopsies (TBNB) targeted at the right lower paratracheal lymph node also revealed histiocytes containing abundant Leishmania amastigotes (Figure 3).
A bone marrow biopsy was also positive for Leishmania amastigotes, as was a liver biopsy. In the latter, there was considerable hepatic inflammation, attributed to both Leishmania and HBV infection, along with minimal fibrosis but not cirrhosis. Fluorescent antibodies against Leishmania were positive in high titers of >=1/640.
The patient was treated with IV liposomal Amphotericin B with prompt clinical and laboratory improvement. Six months later, white blood cell count and differential, lymphocyte subpopulations, and immunoglobulin levels were within normal limits. Due to the persistence of increased hepatic aminotransferases (1.5 times the upper limit) the patient began treatment with telbivudine. On the first and second year follow up, the patient remained in excellent clinical condition and had normal laboratory values.