| Abstract|| |
Leishmaniasis is a vector borne parasitic disease caused by obligate intracellular protozoa Leishmania and is transmitted by the bite of sand fly. The disease typically presents in visceral, cutaneous and mucocutaneous forms and is endemic in some states of India. Cases with atypical presentation are seen when patient has co- infection with HIV.
We report a case of Leishmaniasis occurring in a HIV seropositive expectant mother diagnosed initially on fine needle aspiration cytology. The patient was resident of non endemic area and had presented with isolated cervical lymphadenopathy and fever without spleenomegaly. Characteristic morphological features of Leishmania seen in the fine needle aspiration smears from the neck nodes were identified and definitive diagnosis of Leishmaniasis could be given. Cytological features were not suggestive of any other disease. Timely diagnosis of the disease facilitated proper management in our patient.
Keywords: Cervical lymphadenopathy, fine needle aspiration cytological diagnosis of Leishmaniasis, HIV co-infection
|How to cite this article:|
Bode AN, Poflee SV, Pande NP, Umap PS. Leishmaniasis in a patient with HIV co-infection: Diagnosis on fine needle aspiration cytology. Indian J Pathol Microbiol 2015;58:563-5
|How to cite this URL:|
Bode AN, Poflee SV, Pande NP, Umap PS. Leishmaniasis in a patient with HIV co-infection: Diagnosis on fine needle aspiration cytology. Indian J Pathol Microbiol [serial online] 2015 [cited 2019 Jun 18];58:563-5. Available from: http://www.ijpmonline.org/text.asp?2015/58/4/563/169020
| Introduction|| |
Leishmaniasis is a parasitic infection caused by protozoa Leishmania. India has high burden of Leishmaniasis, which has emerged as third most common opportunistic infection in HIV positive individuals in endemic areas. Typical clinical presentation of Leishmaniasis is modified by HIV co-infection. Diagnosis in these cases is often delayed due to lack of awareness about atypical presentation of Leishmaniasis, especially in patients belonging to nonendemic areas.
Fine needle aspiration cytology (FNAC) can be used as first line diagnostic modality for lymph node enlargement by demonstration of typical Leishmania-Donovani (LD) bodies in cytology smears.
| Case Report|| |
A 26-year-old female patient came for antenatal check-up with amenorrhea of 7 months. She complained of low-grade fever and generalized weakness since 7 months. The patient gave history of gradually increasing swelling on left side of the neck since last 6 months. There was no history of swelling at other site, blood transfusion or another major disease.
On examination, patient was emaciated, mildly febrile and pale. She had multiple palpable lymph nodes in left cervical region of the neck that had formed a nodular mass of 5 cm × 4 cm [[Figure 1]A inset]. The neck mass was visible as intraoral bulge with intact overlying mucosa. Ultrasonography (USG) neck showed enlarged left cervical and submandibular lymph nodes.
|Figure 1: (A) Inset - Enlarged left cervical and submandibular lymph nodes of 5 cm ×4 cm (a) cytological smear from left cervical lymph node showing many free Leishmania-Donovan bodies with few lymphocytes (May-Grünwald-Giemsa, ×400). (b) Biopsy from left cervical lymph node showing sheets of histiocytes filled with Leishmania bodies (H and E, ×40)|
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On abdominal examination, patient had 28 weeks gravid uterus with no hepatosplenomegaly. On abdominal USG uterus of 28 weeks size with single live fetus having intrauterine growth retardation was seen. Investigations revealed pancytopenia with Hb-6.9 g%, total lymphocyte count-2900/cumm, platelet-80,000/cumm. Patient was reactive for HIV I and II by Tri dot card ELISA and negative for HBsAg. Her absolute CD4 count was 239 and T helper cell count was 27%. Other than low albumin and total proteins, her liver function and kidney function tests were normal.
The patient was referred for FNAC of the cervical lymph node that yielded hemorrhagic aspirate repeatedly. The smears showed scanty cellularity of lymphocytes, macrophages and very few epithelioid cells. Smears also revealed the presence of purple blue structures with round nucleus and a rod-shaped dense mass, inside many macrophages. These were identified as amastigote forms of Leishmania known as LD bodies [Figure 1]a. Extracellular parasites were seen in plenty. There was no evidence of caseation necrosis, Langhans or foreign body type of giant cells or any other parasitic bodies like histoplasma or toxoplasma. Diagnosis of Leishmaniasis was conveyed.
The patient and her family members were residents of Maharashtra which is nonendemic state for Leishmania and they have never visited known endemic areas. The patient did not have evidence of disseminated disease.
Lymph node biopsy [Figure 1]b and bone marrow aspiration were performed. Leishmaniasis was confirmed, and there were no features of any other disease. Biopsy material was sent to Research Institute, ICMR Patna for species identification of Leishmania and was confirmed as LD – the most common species in Indian subcontinent.
The patient was treated with Sodium Stibogluconate along with antiretroviral drug therapy. Patient delivered by vaginal delivery in 8th month of pregnancy, but the low birth weight baby did not survive long. On subsequent monthly follow-up visits, the patient had become afebrile, and there was marked reduction in size of her cervical lymph nodes.
| Discussion|| |
Leishmaniasis with HIV co-infection is emerging as a new disease with increasing frequency in endemic areas. In India, the first Leishmania-HIV co-infection case was reported in 1999 from the sub-Himalayan region. Underreporting of cases of co-infection is attributed to lack of awareness about atypical clinical presentation as well as of characteristic morphology of the parasite seen under microscope.
Leishmaniasis typically presents in cutaneous, mucocutaneous and visceral forms and also as post-kala-azar dermal Leishmaniasis. Clinical presentation of Leishmaniasis changes with HIV co-infection and patients present with muco-cutaneous nodular lesions or isolated lymph node enlargement with absent splenomegaly and frequent gastrointestinal involvement. With HIV co-infection, Leishmaniasis shows high incidence of disseminated disease and increased rate of resistance to antimonial drugs. Visceral Leishmaniasis (VL) occurring during pregnancy can be life-threatening for both mother and infant.
Confirmatory diagnosis of Leishmaniasis is based on microscopic demonstration of the parasites in tissue aspirates or biopsies from spleen, lymph nodes or bone marrow. Other methods of laboratory diagnosis are serological, immunological or molecular.
In HIV positive patient, diagnosis of Leishmaniasis is difficult because of atypical clinical presentation. Secondly in VL/HIV co-infection as CMI reduces, only40–50%of VL/HIV co-infected patients have positive serology. Thus, diagnosis in these cases rests mainly on microscopic demonstration of the parasite. FNAC of enlarged, localized lymph node as well as draining lymph node of cutaneous lesion show characteristic LD bodies and should be considered as a method of choice. Cytology results in easy and rapid identification of Leishmania amstigotes, allowing specific and prompt treatment even in unusual clinical context.
Under light microscope Leishmania organisms appear as purple, ovoid structures of 3–5 µ meter with central round nucleus and adjacent rod-shaped kinetoplast that is a dense mass of mitochondrial DNA. The amastigote stage of the parasite seen in clinical samples from the human host is known as LD bodies. LD bodies are present inside macrophages and outside.
When the HIV positive pregnant patient was referred for FNAC of cervical lymph nodes, differential diagnoses considered initially were tuberculosis, other granulomatous infections like histoplasmosis, toxoplasmosis and lymphoreticular malignancy. Her initial diagnosis was based on presence of typical LD bodies in smears.
With HIV co-infection isolated cervical lymphadenopathy in our patient seems to be atypical presentation of Leishmniasis by visceralizing species. However, the mode of disease transmission could not be ascertained. Timely diagnosis and specific treatment resulted in positive outcome for the patient.
| Conclusion|| |
Our case highlights the importance of including Leishmaniasis in the differential diagnosis of lymphadenopathy even in patients belonging to nonendemic areas.
With awareness of atypical presentation of Leishmaniasis in HIV co-infection and characteristic morphological features of the parasite seen in FNAC smears rapid and reliable diagnosis of Leishmaniasis is possible at the centers with no other facilities for diagnosis.
Dr. Anuradha Shrikhande Head of Department for her constant support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Anjali N Bode
401 Shivali App Renge Layout, Trimurti Nagar, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None