Splenectomy in Patients with Visceral Leishmaniasis Resistant to Conventional Therapy and Secondary Prophylaxis: A Retrospective Cohort.

Some patients with visceral leishmaniasis (VL), or kala-azar, suffer relapses and low quality of life despite adequate drug therapy, especially those co-infected with HIV. Occasionally, physicians indicate splenectomy, but the benefit of the procedure needs to be analyzed systematically. Therefore, a retrospective open cohort study was conducted in Teresina, Brazil. Inpatients from a reference hospital with relapsing VL who had a rescue splenectomy between 2012 and 2019 after the nationally recommended drug therapy failed were studied. The procedure's risks and benefits were assessed in a limited-resource setting. The primary outcomes were surgical complications, complete blood count, CD4+ cell count, hospitalizations, survival time, and medical complications preceding death. Thirteen adult patients received medical and surgical indications of splenectomy (12 men and one woman). Eleven had HIV infection. Two had early and two had late complications. Four died, all of whom were infected with HIV. An additional HIV-coinfected patient, apart from the cohort, died just before surgery. The death rate after surgery was 13.3 overall and 22.1 per 100 person-years among HIV-infected patients (31% overall and 36%, respectively). The impressive rise of complete blood counts and reduction of blood transfusions and hospitalizations were observed among all patients. Also, a meaningful increase in CD4+ cells in HIV-infected patients was noted. Splenectomy may benefit patients with relapsing VL. However, before performing splenectomy, available combined drug therapy for VL should be tried.

Recurrent kala-azar: report of two cured cases after total splenectomy.

In Latin America, the causative agent of kala-azar is the intracellular protozoan Leishmania infantum. Most cases in South America are reported in Brazil. Worldwide, it mainly affects Bangladesh, Ethiopia, India, South Sudan and Sudan. Despite the high morbidity and lethality of kala-azar, most infections are asymptomatic. However, a small portion of patients evolves with recurrence of kala-azar becoming symptomatic even after all available drug treatments. Kala-azar is not a formal indication for splenectomy in adults. Splenectomy is recommended as a saving measure, when kala-azar is associated with symptomatic hypersplenism and for drug-resistant cases. In the study, we report two cases of kala-azar with splenomegaly that presented several hospitalizations due to the recurrence of the kala-azar, in addition to hospitalizations for normalizing the blood count. After splenectomy, kala-azar cases and the effects of hypersplenism are cured. Thus, splenectomy should be seen as a surgical treatment option with a curative purpose in patients with recurrent kala-azar, in whom the possibilities of drug therapy have been exhausted and even so they progressed with hypersplenism and clinical repercussions.

[Visceral leishmaniasis]. / Viszerale Leishmaniose.

Visceral leishmaniasis is a worldwide distributed infectious zoonotic disease caused by protozoan pathogens of the genus Leishmania which are transmitted by sandflies. The main hosts are dogs. The prevalence in Germany is low. Predominantly affected are migrants and travelers returning from Mediterranean countries. The main clinical symptoms are fever, hepatosplenomegaly and pancytopenia. The diagnosis is made by polymerase chain reaction of peripheral blood or direct detection of Leishmania in bone marrow aspirates. Lesions of the liver and spleen can easily be misinterpreted as numerous benign or malignant differential diagnoses. Treatment is always systemic with antiparasitic drugs. Immunosuppressed patients with HIV co-infection or after solid organ transplantation are prone to infection as well as atypical and severe courses.

The role of rk39 serologic test in the diagnosis of visceral leishmaniasis in a Tertiary Hospital, Northern Ethiopia.

BACKGROUND: The study is done in Ayder Referral Hospital in Northern Ethiopia. Ethiopia is one of the countries where visceral leishmaniasis (VL) is endemic. Diagnosis of VL in Ethiopia is primarily based on rK39 immunochromatographic (rk39-ICT) strip. This test has been shown to have variable sensitivity and specificity in different countries. Hence the objective of the study is to determine the sensitivity and specificity of rk39-ICT in the diagnosis of VL in our set up. The study participants were VL suspected patients admitted to the hospital. A cross sectional study design was used. The study was conducted from January 14, 2013 to June 26, 2015. The rK39-ICT strip used was the InBios brand. Ethical clearance was obtained from the IRB of the college and written consent was obtained from the individual patients. RESULTS: A total of 62 VL suspects were involved in the study. The mean age was 26.3 years (SD = 6.94 years) with a median age of 25.5 years. Sixty-one (98.4%) of the patients was males. The rK39-ICT was positive in 50 (80.6%) of the patients. Splenic aspiration was positive in 44 (71%) of the patients. In 37 (59.7%) of the patients both rK39 and splenic aspiration were positive. Thirteen (21%) of the patients had positive rK39 but negative splenic aspiration. Five (8.1%) of the patients had both negative rK39 and splenic aspiration however seven (11.3%) of the patients had rk39 negative but splenic aspiration positive. The sensitivity, specificity, positive predictive value and the negative predictive value of rK39-ICT, taking splenic aspiration as a gold standard test, is 84.1% (95% CI 69.9-93.4%), 27.8% (95% CI 9.7-53.5%), 74.0% (95% CI 60-85.4%) and 41.7% (95% CI 15.2-72.3%) respectively. CONCLUSION: Sensitivity of rK39-ICT is low and its specificity is poor in our set up. Significant number of patients with confirmed VL did not have travel history to endemic areas. We recommend that the rK39-ICT needs improvement for clinical use in our set up and case definition for visceral leishmaniasis in Ethiopia needs to be revisited.

Successful therapeutic splenectomy in an HIV patient with relapsing visceral leishmaniasis.

A 43-year-old HIV-positive Ethiopian immigrant presented with persistent diarrhoea, hepatosplenomegaly and pancytopaenia. Visceral leishmaniasis was diagnosed by multiple gastrointestinal tract biopsies. Blood polymerase chain reaction (PCR) was positive for Leishmania donovani. Despite highly active antiretroviral therapy (HAART) and multiple courses of antileishmanial treatments, including liposomal amphotericin and sodium stibogluconate, the patient had multiple relapses. CD4 counts remained at 40-60 cells/µL although viral loads were undetectable. Splenectomy resulted in resolution of the patient's pancytopaenia and in rising CD4 levels, which enabled a long-lasting remission.

Splenectomy in a patient with treatment-resistant visceral leishmaniasis: a case report.

Visceral leishmaniasis (VL), also known as Kala-azar, is a systemic infection caused by a protozoan (Leishmania) and, in its classic form, is a serious illness associated with malnutrition, anemia, hepatosplenomegaly, infectious processes and coagulopathies. The effect of splenectomy in patients with visceral leishmaniasis is not well defined; however, it is known that the spleen is the largest reservoir of infected cells belonging to the reticulo endothelial system. Therefore, the surgical procedure is an option for the debulking of parasites, providing a cure for refractory VL and minimizing the complications of hypersplenism.

Splenectomy in a patient with treatment-resistant visceral leishmaniasis: a case report / A esplenectomia na leishmaniose visceral refratária ao tratamento clínico: relato de caso

Visceral leishmaniasis (VL), also known as Kala-azar, is a systemic infection caused by a protozoan (Leishmania) and, in its classic form, is a serious illness associated with malnutrition, anemia, hepatosplenomegaly, infectious processes and coagulopathies. The effect of splenectomy in patients with visceral leishmaniasis is not well defined; however, it is known that the spleen is the largest reservoir of infected cells belonging to the reticulo endothelial system. Therefore, the surgical procedure is an option for the debulking of parasites, providing a cure for refractory VL and minimizing the complications of hypersplenism.

A leishmaniose visceral (LV) ou calazar é uma infecção sistêmica causada por um protozoário (Leishmania) e na sua forma clássica é uma doença grave. Cursa com desnutrição, anemia, hepatoesplenomegalia, processos infecciosos e coagulopatias. O papel da esplenectomia em pacientes com leishmaniose visceral não é bem definido; entretanto, sabe-se que o baço é o maior reservatório de células parasitadas do sistema reticulo endotelial e o procedimento cirúrgico é, dessa forma, uma opção para debulking de parasitas, propiciando a cura da LV refratária e minimizando as complicações do hiperesplenismo.

Diagnostic splenectomy for visceral leishmaniasis.

A 57-year-old-man with a history of malaise, fever, night sweats and shortness of breath presented a diagnostic challenge to his medical team. He was pancytopaenic and had splenomegaly on admission but other investigations, including bone marrow aspiration, proved inconclusive. After the patient deteriorated clinically, the general surgical team was requested to perform a diagnostic splenectomy. The histology of this showed infection with visceral leishmaniasis. He recovered completely with Amphotericin treatment. Although this is a rare condition, particularly for the general surgeon, this case highlights the difficult position surgeons are often put in when performing major surgery diagnostically.

[The leishmaniasis - a parasitel infection as differential diagnosis of malignant tumours of oral mucosa. A case report and review of literature]. / Die Leishmaniasis - eine parasitäre Erkrankung als Differenzialdiagnose maligner Mundschleimhauterkrankungen. Fallbericht und Literaturübersicht.

Although parasitel infections in northern Europe are rare, it must be considered as differential diagnosis of malignant tumours of mucous membrane. With increasing tourisms in endemic areas, infections with parasite pathogen are spreading in non-endemic areas as well. In this case a mucous membrane malignancy with clinical feature of ulcer on unusual location was imitated. In this reported case the patient suffers with hepatitis c, causing cirrhosis of the liver and making a liver transplantation necessary. In this patient a history of a leishmaniosis which had been treated successful by the tropical institute is reported, but because of a new actually leishmaniosis-infection a liver transplantation is contraindicated. Under oral therapy with Miltefosin (IMPADIVO) a remission was successful. The leishmaniosis is a classical tropical disease. WHO reported a morbidity of nearly 12 million people in 88 countries around the world especially in tropical areas. Repeatedly infections in northern Europe caused by the phlebotonus-sandflies are described. Therefore leishmaniosis must be considered as differential diagnosis in suspect lesions of mucous membrane.

[Visceral leishmaniasis--surgical aspects]. / Leishmanioza viscerala--aspecte chirurgicale.

Visceral Leishmaniasis is a multi-organic parasitic disease caused by an intracellular protozoon named Leishmania Donovani; the mean signs are: weight loss, cough, fever, hepatosplenomegaly, adenopathy and cutaneous lesions; death without treatment is the rule. The main treatment is a conservative one. Surgical treatment is necessary for complications, especially for those intra-abdominally. We wish to present a young female patient who underwent two subsequent interventions due to an unclear diagnosis. We emphasize the difficulties in achieving a certain diagnostic, because of the rarity of disease in Romania; there are also revealed surgical aspects, which are important because of very few available data in the literature.

Detection of Leishmania infantum kinetoplast DNA in laryngeal tissue from an immunocompetent patient.

Mucosal leishmaniasis of the upper respiratory tract is usually associated with the visceral form or is found in immunosuppressed individuals. This report presents a case of isolated mucosal leishmaniasis in an immunocompetent patient, whose diagnosis mainly rested on histology and positive polymerase chain reaction result for Leishmania donovani in the laryngeal tissue. A 59-year-old man, who never lived outside Italy, showed a subglottic mucosal polypoid-like lesion. The typical morphological picture and positive polymerase chain reaction result for L donovani by DNA extracted from laryngeal biopsy specimens allowed the diagnosis of mucosal leishmaniasis. Specific amphotericin B therapy was started, resulting in clinical and endoscopic improvement. Increased knowledge about the histological and molecular tissue analysis of Leishmania enhances the diagnostic testing for mucosal leishmaniasis, as primary mucosal leishmaniasis may occur in both immunosuppresed and immunocompetent patients who travel to or reside in areas endemic for Leishmania.

Isolated visceral leishmaniasis presenting as an adrenal cystic mass.

A 69-year-old woman presented with a large left retroperitoneal suprarenal mass. Radical resection of the left kidney and the mass revealed a cystic adrenal tumor with a weight of 1500 g. Histologic examination showed that the cyst was composed mostly of partially organized clotted blood. The periphery of the mass consisted of a thin rim of cortical and medullary adrenal tissue with superimposed granulomatous chronic inflammation. The infectious nature of the process was manifested by the scattered intracellular and extracellular Leishmania amastigotes that were found throughout the lesion. The differential diagnosis of cystic adrenal masses and the unusual presentation of visceral leishmaniasis are discussed in this context.

Splenectomy in kala-azar.

At the beginning of the century, splenectomy was used in the treatment of kala-azar, but now is rarely needed, the major indication being for drug resistant kala-azar. Inadvertent splenectomy prior to the diagnosis of kala-azar continues to occur, probably because of a reluctance to perform splenic aspiration in the investigation of splenomegaly. Five Kenyan children underwent splenectomy for drug resistant kala-azar. All were immediately improved, but one died of overwhelming post splenectomy infection (OPSI) two months later and another of a malignant lymphoma seven months after surgery. The other three patients appear to be cured. Splenectomy was considered in a sixth child with kala-azar because of a Salmonella abscess in the spleen, but the abscess ruptured catastrophically before surgery could be arranged.