Pancytopenia: a rare cause for a common presentation.

Filariasis is a major public health hazard in tropical and subtropical countries and is endemic among the Indian population. Asymptomatic microfilariaemia, elephantiasis, acute adenolymphangitis, hydrocoele and chronic lymphatic disease are its common manifestations. We hereby report a case of microfilaria found in the bone marrow presenting as pancytopenia. There was no classical feature of elephantiasis or lymphoedema present.

A man in his 80s with arthritis and persistent fever. / En mann i 80-årene med leddgikt og vedvarende feber.

BACKGROUND: Febrile illness is a common clinical problem and frequently caused by bacterial and viral infections. When blood cultures are negative and symptoms persist despite empirical antibiotic treatment, clinicians must consider other differential diagnoses including malignancy, rheumatologic disease and parasitic infections. CASE PRESENTATION: A Norwegian male in his eighties experienced febrile illness during a stay in Southern Spain. Upon return to Norway, he was hospitalized with fever, weight-loss, enlarged spleen, pancytopenia and hypergammaglobulinemia. After failing to respond to broad-spectrum antibiotics and antifungals, he was diagnosed with visceral leishmaniasis and Leishmania infantum was confirmed by PCR and sequencing of spleen biopsy and blood. INTERPRETATION: With increasing migration and tourism, doctors in non-endemic countries should be familiar with visceral leishmaniasis.

Visceral Leishmaniasis in Renal Transplant Recipients: Report of 2 Cases.

Visceral leishmaniasis is a disease caused by the protozoan Leishmania and is transmitted by Lutzomyia longipalpis (sand fly). It is an endemic parasitic infection in numerous areas around the Mediterranean basin. Though immunocompetent patients may not develop the disease, in transplant recipients the use of corticoids and intensified immunosuppressants to prevent graft rejection may accelerate the disease, causing severe damage to the liver, spleen, and hematopoietic system. We report 2 cases of visceral leishmaniasis with an atypical presentation in transplant recipients. The first patient, who had a kidney transplant, was treated successfully with liposomal amphotericin B, and the second patient, a combined kidney-pancreas transplant recipient, suffered a relapse 3 years after treatment. Visceral leishmaniasis should be considered in the differential diagnosis of pancytopenia or unexplained fever occurring after organ transplantation in patients living in endemic areas or returning from endemic countries.

Filariasis Presenting As Bone Marrow Suppression.

Lymphatic filariasis is caused by most commonly Wuchereria bancrofti in India. The diagnosis is made by demonstration of microfilariae in the peripheral blood, body fluids, fine needle aspirates and in bronchial brushings. Presence of microfilariae in the bone marrow is unusual and not been reported frequently. We are reporting here a case of a young male who had pancytopenia and was found to have microfilariae in the bone marrow.

An unusual case of pancytopenia in a nonagenarian: visceral leishmaniasis.

Older patients referred for further investigation of pancytopenia is common in internal medicine and geriatric clinics and it is important to consider a wide range of underlying diagnoses. We present an unusual case of febrile pancytopenia in a nonagenarian who was diagnosed with visceral leishmaniasis. This is a rare and unusual diagnosis in nonagenarians, although the leishmaniasis is endemic on the Mediterranean coast of Spain. It is important to identify it because it is treatable and curable.

A 75-year-old missionary with fever, splenomegaly and pancytopenia.

We present a case of hyperreactive malarial splenomegaly, a disease which is exceptional in Caucasian people, but which is expected to become more important since the increasing number of travelling to tropical areas. It is the chronic stage of an abnormal long-term stimulation of the immune system secondary to plasmodial infection. Diagnostic criteria include long-term stay in an endemic zone, large splenomegaly and overproduction of both IgM and IgG antibodies. The disease can be treated by a short-term antimalarial therapy as long as the patient resides out of a malarial endemic country.

Babesia microti: an unusual travel-related disease.

BACKGROUND: Human babesiosis is a rare tick-borne infectious disease. The clinical presentation ranges from an asymptomatic form to a life threatening infection with severe hemolysis. Human babesiosis due to Babesia microti is the most common and is endemic in North America. CASE PRESENTATION: We report a European patient with severe pancytopenia and reactive hemophagocytosis related to a Babesia microti infection. Babesia infection was acquired during a travel in the USA. CONCLUSION: Babesiosis should be considered in patients who traveled in endemic areas, especially North America for the most common agent Babesia microti.

Visceral leishmaniasis: a common cause of post-infectious febrile pancytopenia in children in an endemic area: experience of a children's tertiary hospital.

BACKGROUND: Visceral leishmaniasis (VL, kala-azar) is caused by Leishmania spp, a parasite that is commonly encountered in Mediterranean countries. Leishmaniasis usually presents with fever, hepatosplenomegaly, lymphadenopathy, and pancytopenia. OBJECTIVES: The aim of the study was to prospectively examine the characteristics of cytopenia associated with VL and compare it with other post-infectious cytopenias observed in children with febrile illnesses. METHODS: We studied 112 children, aged (mean) 4.0 (SD, 3.8) years (range, 0-14 years), who were admitted to the pediatric ward because of febrile cytopenia associated with infections, during a 2-year period (March 2005 to June 2007). Study participants were investigated with measurement of acute-phase reactants, bacterial cultures, and serologic tests. RESULTS: Pancytopenia was detected in 9 (8%) of 112 patients (5 boys), with a mean age of 4.5 (SD, 3.0) years.The mean value of white blood cell was 3827 (SD, 1455)/mL; absolute neutrophil count, 1229 (SD, 655)/mL; hemoglobin, 8.3 (SD, 1.1) g/dL; and platelet count, 88,200 (SD, 20,186)/mL. All patients with pancytopenia had fever (mean duration, 8.9 [SD, 8.7] days) (maximum temperature, 39.5°C [SD, 0.6°C]) and hepatosplenomegaly (9/9), whereas 2 of 9 had lymphadenopathy. In these patients, a bone marrow aspiration was performed, and VL was detected in all 9 samples. They were treated with liposomal amphotericin B and had an excellent response rate. Pancytopenia resolved within a mean period of 17.6 (SD, 17.3) days (range, 8-60 days), and there was no relapse during a 2 years' follow-up. CONCLUSIONS: In endemic countries, leishmaniasis is the main cause of febrile pancytopenia among children in whom hematologic malignancy has been ruled out.

Refractory pancytopenia and megaloblastic anemia due to falciparum malaria.

Anemia is a common complication in malarial infection. Direct destruction and ineffective erythropoesis does not adequately explain the cause of anemia in malaria. We present a case with refractory megaloblastic anemia with asymptomatic falciparum malaria. We hypothesize that promoter variants in the inducible nitric oxide synthase gene might be the cause of severe refractory megaloblastic anemia and pancytopenia in our patient. Malaria should always be kept in mind as a cause of anemia especially in endemic areas even if the child is asymptomatic or there is no demonstrable parasite on routine smear examination.

[An adult case of visceral leishmaniasis in a province of Black-Sea region, Turkey]. / Zonguldak'ta eriskin viseral leysmaniyaz olgusu.

Visceral leishmaniasis (VL) which is a chronic disease caused by the protozoon, Leishmania, occurs widely worldwide and it is widespread in most of the countries in the Mediterranean basin. The infection which is transmitted by a sandfly (Phlebotomus) vector, has a prolonged incubation period and insidious onset. VL generally affects children and may be fatal if not treated. In this report, a 31 years old male patient, who was the first adult VL case from Zonguldak (a province located at western Black-Sea region of Turkey) was presented. He was admitted to the hospital with two-months history of fever, chills, sweating and weight loss. There was no history of travel outside the city nor insect bites, however, he indicated that there would be unnoticed sandfly bites since sandflies were very common in the coal mines he worked. His physical examination revealed body temperatue of 39.2°C and hepatosplenomegaly, while laboratory findings yielded anemia, leucopenia, hypoalbuminemia and hypergamaglobulinemia. Erythrocyte sedimentation rate was 62 mm/h, C-reactive protein was 113 mg/L and liver transaminases were 2 to 5 folds higher than the reference values. The only pathological finding was hepatosplenomegaly in the abdominal ultrasound and computerized tomography. He was further examined to rule out infections with similar signs and symptoms, connective tissue diseases and malignancies and all were found negative. Hypercellular bone marrow were detected in the aspiration material. Bone marrow smears, bone marrow samples inoculated in NNN medium and serum samples of the patient were sent to the reference parasitology laboratory of Refik Saydam National Public Health Agency for evaluation in terms of VL. The diagnosis was confirmed by the detection of Leishmania IgG titer as 1/512 with in-house indirect immunofluorescence antibody test, by positivite rK39 Dipstick (InBios, USA) test and by the observation of Leishmania amastigote forms in the bone marrow smears. Bone marrow culture in NNN medium also revealed positive result by the determination of Leishmania promastigote forms on the 7th day. The treatment was initiated by pentavalent antimony [glucantime 1 x 10 mg/kg/day intramuscular (IM)] however, due to severe adverse effects it has switched to liposomal amphotericin B (3 mg/kg/day). The patient completely recovered without complication. In conclusion VL should be considered in the differential diagnosis of patients, even adults, with persistent fever, hepatosplenomegaly and pancytopenia, in endemic countries such as Turkey.