title: A severe case of visceral leishmaniasis and liposomal amphotericin B treatment failure in an immunosuppressed patient 15 years after exposure.
abstract: Visceral leishmaniasis (VL) is a protozoan disease, which is responsible for 200.000-400.000 yearly infections worldwide. If left untreated, the fatality rate can be as high as 100% within 2 years. 90% of cases occur in just six countries: India, Bangladesh, Sudan, South Sudan, Ethiopia and Brazil. It is thus a disease rarely seen by physicians in Europe or North America. We report on the fatal case of VL in an 80-year-old immunosuppressed patient who presented with a latency of over 15 years after having visited an endemic region. This is the first report showing such extreme latency of VL in a European traveller. This case is furthermore unusual because it suggests primary treatment failure to liposomal amphotericin B.
  
  
  
  An 80-year-old man who was on immunosuppressive treatment due to a non-specific inflammatory disease of the liver and kidney presented to our hospital with recurrent fever, fatigue and bloody diarrhoea. Histopathological analysis from a colon biopsy showed intracellular amastigotes. The diagnosis of VL was confirmed by polymerase-chain-reaction (PCR) of the colon biopsy. PCR was also performed in plasma, a bronchopulmonary lavage, a lymph node, liver and bone marrow biopsy and proved L. donovani as causative species. The disseminated infection was unresponsive to treatment with liposomal amphotericin B as recommended in immunosuppressed individuals despite stopping immunosuppressive treatment.
  
  
  
  Imported cases of VL to non-endemic regions are increasing due to extensive international travel and migration. Furthermore, the increase of elderly patients and immunosuppressed individuals, secondary to HIV, post-transplant and chemotherapeutic agents, has resulted in an increase of VL also in endemic regions of Europe. It is thus important for physicians to be able to recognize the infection. This case also demonstrates treatment failure to amphotericin B, which was only a known problem in patients with HIV until now. The knowledge of this as a possible complication is important for specialists treating the disease.
authors.affiliation: Department of Infectious Diseases, Bern University Hospital (Inselspital), University of Bern, PKT2B, CH-3010, Bern, Switzerland. Anna.eichenberger@insel.ch.
authors.forename: Anna
authors.identifier: 0000-0001-9775-9424
authors.initials: A
authors.lastname: Eichenberger
authors.affiliation: Department of Infectious Diseases, Bern University Hospital (Inselspital), University of Bern, PKT2B, CH-3010, Bern, Switzerland.
authors.forename: Annina E
authors.initials: AE
authors.lastname: Buechi
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors.forename: Andreas
authors.initials: A
authors.lastname: Neumayr
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland.|University of Basel, Basel, Switzerland.
authors.forename: Chistroph
authors.initials: C
authors.lastname: Hatz
authors.affiliation: Department of Infectious Diseases, Bern University Hospital (Inselspital), University of Bern, PKT2B, CH-3010, Bern, Switzerland.
authors.forename: Andri
authors.initials: A
authors.lastname: Rauch
authors.affiliation: Department of Nephrology, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland.
authors.forename: Marc
authors.initials: M
authors.lastname: Huguenot
authors.affiliation: Institute of Pathology, University of Bern, Bern, Switzerland.
authors.forename: Eva
authors.initials: E
authors.lastname: Diamantis-Karamitopoulou
authors.affiliation: Department of Infectious Diseases, Bern University Hospital (Inselspital), University of Bern, PKT2B, CH-3010, Bern, Switzerland.
authors.forename: Cornelia
authors.initials: C
authors.lastname: Staehelin
mesh_terms: D000369:Aged, 80 and over; D000666:Amphotericin B / Q000627:therapeutic use*; D000981:Antiprotozoal Agents / Q000627:therapeutic use*; D001379:Azathioprine / Q000009:adverse effects; D001706:Biopsy; D003106:Colon / Q000469:parasitology / Q000473:pathology; D005060:Europe; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000009:adverse effects; D007194:India; D007214:Indonesia; D007674:Kidney Diseases / Q000188:drug therapy; D007898:Leishmaniasis, Visceral / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000276:immunology; D008107:Liver Diseases / Q000188:drug therapy; D008297:Male; D016133:Polymerase Chain Reaction; D000072078:Positron Emission Tomography Computed Tomography; D012720:Severity of Illness Index; D013997:Time Factors; D014195:Travel; D017211:Treatment Failure
chemical_list: D000981:Antiprotozoal Agents; D007166:Immunosuppressive Agents; C068538:liposomal amphotericin B; D000666:Amphotericin B; D001379:Azathioprine
keywords: Fever in returning traveller; Immunosuppression; L. donovani; Latency; Visceral leishmaniasis