title: Visceral leishmaniasis in a patient with systemic lupus erythematosus.
abstract: Visceral leishmaniasis is an infection with an insidious and disabling course caused by parasites of the genus Leishmania. In Europe, it is mostly associated with HIV infection. Systemic lupus erythematosus and its treatment are associated with increased risk of infection, neoplastic and concomitant autoimmune disorders. The association of these diseases may go unnoticed. A 60 year-old Caucasian woman with lupus presented with a one-year history of fever, malaise, weakness and weight loss. The highlights on physical examination were pallor, palpable hepatosplenomegaly and low-grade fever. Blood tests showed pancytopenia, hyperproteinemia with hypoalbuminemia and hypergammaglobulinemia; electrophoresis showed a polyclonal gamma curve. Full-body CT scan revealed massive hepatosplenomegaly. Microbiology investigation was negative for the most common pathogens, including tuberculosis. There were no signs of hematologic malignancy in the bone marrow smear. PCR for Leishmania infantum was positive both in blood and bone marrow. The patient was treated with liposomal amphotericin B, and immunosuppression was adjusted. She showed rapid clinical improvement and 6 months later had no signs of disease. The differential diagnosis in a patient with lupus presenting with fever and multisystemic manifestations includes infectious or neoplastic disorders. The patient lived in an endemic area of Leishmania, and typical clinical and analytical changes were all present, making this case highly educational. The case highlights the importance of a patient's epidemiological background and how it can lead to the diagnosis and timely treatment of a rare disease.
authors.affiliation: Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal.
authors.forename: André Filipe
authors.initials: AF
authors.lastname: Santos Silva
authors.affiliation: Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal.
authors.forename: João Paulo Branco Calheiros
authors.initials: JP
authors.lastname: Figueiredo Dias
authors.affiliation: Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal.
authors.forename: João Miguel Neves Gonçalves Santos
authors.initials: JM
authors.lastname: Nuak
authors.affiliation: Rheumatology Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal.
authors.forename: Francisca
authors.initials: F
authors.lastname: Rocha Aguiar
authors.affiliation: Rheumatology Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal.
authors.forename: José António
authors.initials: JA
authors.lastname: Araújo Pinto
authors.affiliation: Infectious Diseases Department, São João Hospital Center, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal; Faculty of Medicine of the University of Oporto, Alameda Hernâni Monteiro, Estrada da Circunvalação, 4200-019 Oporto, Portugal.
authors.forename: António Carlos Eugénio Megre
authors.initials: AC
authors.lastname: Sarmento
keywords: ANA, anti-nuclear antibodies; AmB, amphotericin B; CMV, cytomegalovirus; CT, computerized tomography; EBV, Epstein–Barr virus; ENA, anti-extractable nuclear antigens; ESR, erythrocyte sedimentation rate; Fever; HIV, human immunodeficiency virus; ID, infectious diseases; LAB, liposomal amphotericin B; LDH, lactic dehydrogenase; PCP, primary care physician; PCR, polymerase chain reaction; RNA, ribonucleic acid; SLE, systemic lupus erythematosus; Systemic lupus erythematosus; VL, visceral leishmaniasis; Visceral leishmaniasis; WBC, white blood cell count; dsDNA, double-stranded deoxyribonucleic acid