A 50-year-old male, heterosexual, with a history of alcohol and non-intravenous drugs consumption.
He had lived in Spain for 25 years up to two years before.
He did not refer other relevant personal or family pathologies.
She had a history of progressive general malaise, weight loss and sweating.
At the third month of evolution, intermittent fever and diarrheal stools were added for the first time in a private healthcare center.
Physical examination revealed hepatomegaly.
Among laboratory tests, HIV serology was positive, with a CD4 lymphocyte count of 24 cells/ mm3 and pancytopenia in the blood count.
An abdominal CAT scan confirmed the existence of hepatomegaly, as well as multiple mesenteric adenopathies and retroperitoneal adenopathies.
He started HAART with lamivudine, tenofovir and efavirenz, apparently with good tolerance and adherence.
He was referred to Dr. Lucio Cordova Hospital for further study and treatment.
He was admitted in regular general conditions, subfebrile, pale, and suffering from constipation.
The patient presented with a large stenosis of soft consistency, a liver 4-5 cm below the costal margin and an inguinal adenopathy of 1 cm in diameter.
He was admitted with the diagnosis of HIV infection on HAART and hepatomegaly under study.
The most important laboratory tests were hepatic anemia 23.2%, hemoglobin 7.3 g/dl, leucopenia 680/mm3, ANC 330/mm3, and lactate 121 mg/mm3, platelets 109.000/mm3, leukopenia 680/mm3.
Protein profile and protein electrophoresis showed intense diffuse hypergammaglobulinemia and moderate hypoalbuminemia.
β2 microglobulin was elevated (8.1 mg/L).
Serology for Toxoplasma was positive with titers of 1/1,024.
CD4 count at that time was 35 cells/ml; viral load was 12,000 copies/ml.
Current hemocultives and mycobacteria, as well as sputum smears and cultures of Koch were negative.
VDRL was non-reactive, HBsAg and HCV were also negative.
The patient was evaluated by an ophthalmologist who found a normal eye fundus.
The patient remained afflicted with good mood and appetite, without specific discomfort, but restless and distressed by his health situation.
Until that time, she had been kept on treatment with lamivudine, tenofovir, efavirenz and with prophylaxis of opportunistic infections.
A bone marrow and femoral ganglion biopsy was also performed.
Approximately one month after admission, the result of the bone marrow biopsy was received, which described: "a large number of histiocytes with cytoplasm occupied by multiple punctiform structures basophils corresponding to the anterior half of the gallbladder".
He concluded that the findings were compatible with medullary compromise due to Leishmaniasis.
Biopsy of the inguinal ganglion was reported as follicular hyperplasia.
With the diagnosis of visceral leishmaniasis treatment was initiated with amphotericin B deoxycholate 1 mg/kg/day for 14 days, with a relative good tolerance, presenting a slight increase in nitrogen parameters and phlebitis towards the end of treatment.
She also had no red blood cell transfusion and potassium intake.
The patient was admitted with few symptoms but an increasing viral load (35,000 copies/ml).
Agreeing with the failure of HAART and the possibility that treatment with amphotericin also failed due to the severe immunosuppression of the patient, it was decided to change therapy to didanosine, atazanavir, ritonavir
At the end of 14 days of treatment with amphotericin, the patient was discharged with the commitment of maintaining good adherence to ART, not consuming drugs or alcohol, attending the medical controls that indicated CD4 and with a second course
At that time, the patient was in good general condition and the relative anomaly decreased considerably.
The hemogram showed anemia persistence with hematocrit of 21.1% and hemoglobin of 7.2 g/dl, relative improvement of leukocytes, which had increased to 1730/mm3 with ANC of 1.228 mm/dl and platelets 126.000.
Chest CT was normal and CT scan of the abdomen and pelvis was similar to that of admission.
The lymph node biopsy that had been reported in the first instance only as follicular hypertrophy, was reviewed by the pathologist with the diagnosis of VL, and basophilic structures were also found within histiocytes that corresponded to Leishmania. amas.
The patient remained in outpatient follow-up referring that he felt well and maintained good adherence to ART.
One month after the change in antiretroviral therapy, the patient had an undetectable viral load and an increase in CD4 count to 82 cells/mm3.
However, two months after discharge the bone had increased again in size, the blood count had deteriorated significantly and a new bone marrow biopsy showed presence of a reactive LV.
He received a new treatment with amphotericin B deoxycholate that, on this occasion, received for 21 days and continued with secondary prophylaxis with a dose of 50 mg every 14 days.
At the end of the second treatment, the patient was asymptomatic, had decreased hemoglobin levels and increased leukocytes and platelets.
Subsequently, the patient has continued in outpatient follow-up, with good adherence to treatment, performing normal activities, without stenosis, with a complete blood count within normal limits and without recurrence of VL for 29 months.
