Öz
Visseral leishmaniasis (VL), Hint alt kıtasına özgü, yaşamı tehdit eden bir enfeksiyondur ve insan immün yetmezlik virüsü (HIV) enfeksiyonu olan hastalarda atipik ve şiddetli belirtilerle ilişkili olabilir. Sekonder hemofagositik lenfohistiyositoz (HLH), VL’nin nadir ancak ciddi bir komplikasyonudur. Antiretroviral tedaviye (ART) uyumsuzluğu ve ileri evre HIV enfeksiyonu olan ve uzun süreli ateş, melena, hepatosplenomegali ve pansitopeni ile başvuran 51 yaşında bir erkek hastayı bildiriyoruz. Bir dizi laboratuvar incelemesi yaygın fırsatçı enfeksiyonları ekarte etti. Negatif rK39 antijen testine rağmen, kemik iliği incelemesinde Leishmania donovani ve hemofagositoz saptanması temelinde sekonder HLH ile birlikte VL tanısı kondu. Üst gastrointestinal endoskopi ve ardından yapılan biyopsi, yaygın tutulumu doğrulayan Leishmania infiltrasyonunu ortaya çıkardı. Hasta, konvansiyonel amfoterisin B deoksikolat, ART’nin devamı ve kısa süreli kortikosteroid tedavisi ile tedavi edildi ve klinik ve hematolojik iyileşme sağlandı. Bu vaka, ileri HIV enfeksiyonunda seronegatif VL’nin tanısal zorluklarını ve endemik bölgelerde ateş, sitopeni ve organomegali ile başvuran hastalarda erken doku tanısı ve hedefe yönelik tedavinin önemini vurgulamaktadır.
Anahtar Kelimeler:
Viseral leishmaniasis, hemofagositik lenfohistiyositoz, HIV/AIDS, rK39 antijen testi, amfoterisin B deoksikolat
Kaynaklar
1
World Health Organization. Leishmaniasis. Last accessed date: 2026 Feb 23. Available from: https://www.who.int/india/health-topics/leishmaniasis.
2
Alvar J, Vélez ID, Bern C, Herrero M, Desjeux P, Cano J, Jannin J, den Boer M, Team WLC. Leishmaniasis worldwide and global estimates of its incidence. PLoS One. 2012;7: e35671.
3
World Health Organization. WHO guideline for the treatment of visceral leishmaniasis in HIV co-infected patients in East Africa and South-East Asia. Geneva: World Health Organization; 2022.
4
van Griensven J, Carrillo E, López-Vélez R, Lynen L, Moreno J. Visceral leishmaniasis and HIV coinfection: current perspectives. HIV AIDS Auckl. 2017;9:67-81.
5
Burza S, Mahajan R, Sanz MG, Sunyoto T, Kumar R. Changing trends in the epidemiology, clinical presentation, and diagnosis of Leishmania-HIV co-infection in India. Int J Infect Dis. 2014;29:103-9.
6
Alvarez-Nebreda ML, Alvarez-Fernández E, Rada S, Brañas F, Marañón E, Vidán MT. Unusual duodenal presentation of leishmaniasis. J Clin Pathol. 2005;58:1321-2.
7
Henter JI, Horne A, Aricó M, Egeler RM, Filipovich AH, Imashuku S, Ladisch S, McClain K, Webb D, Winiarski J, Janka G. HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007;48:124-31.
8
La Rosée P, Horne A, Hines M, von Bahr Greenwood T, Machowicz R, Berliner N, Birndt S, Gil-Herrera J, Girschikofsky M, Jordan MB, Kumar A, van Laar JAM, Lachmann G, Nichols KE, Ramanan AV, Wang Y, Wang Z, Janka G, Henter JI. Recommendations for the management of hemophagocytic lymphohistiocytosis in adults. Blood. 2019;133:2465-2477.
9
Shi Q, Huang M, Li X, Zheng X, Wang F, Zou Y, Wang L, Jia J. Clinical and laboratory characteristics of hemophagocytic lymphohistiocytosis induced by Leishmania infantum infection. PLoS Negl Trop Dis. 2021;15:e0009944.
10
Rajagopala S, Dutta U, Chandra KS, Bhatia P. Hemophagocytic syndrome associated with visceral leishmaniasis. Int J Infect Dis. 2004;8:380-3.
11
World Health Organization. Visceral leishmaniasis control and elimination. Last accessed date: 2026 Feb 23. Available from: https://www.who.int/news-room/fact-sheets/detail/leishmaniasis.
12
Mahajan R, Owen SI, Kumar S, Pandey K, Kazmi S, Kumar V, Adams ER, Harshana A, Burza S. Prevalence and determinants of asymptomatic Leishmania infection in HIV-infected individuals living within visceral leishmaniasis endemic areas of Bihar, India. PLoS Negl Trop Dis. 2022;16:e0010718.
13
Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV: Leishmaniasis. Last accessed date: 2026 Feb 23. Available from: https://clinicalinfo.hiv.gov/en/guidelines.
14
Desjeux P, Alvar J. Leishmania/HIV co-infections: epidemiology in Europe. Ann Trop Med Parasitol. 2003;97(Suppl 1):3-15.
15
Singh SP, Ranjan A, Das VN, Siddiqui NA, Kumar N, Pandey K. Prevalence of HIV infection among visceral leishmaniasis patients in India: a systematic review and meta-analysis. Clin Epidemiol Glob Health. 2024;18:101241.
16
Molina R, Ghosh D, Carrillo E, Monnerat S, Bern C. Visceral leishmaniasis-HIV coinfection as a predictor of increased Leishmania transmission at the village level in Bihar, India. Front Public Health. 2021;9:631042.
17
Directorate of National Vector Borne Disease Control Programme. Annual visceral leishmaniasis reports. Last accessed date: 2026 Feb 23. Available from: https://nvbdcp.gov.in.
18
Lindoso JAL, Cunha MA, Queiroz IT, Moreira CHV. Insights into the HIV-associated visceral leishmaniasis clinical outcome: lessons learned about immune-mediated disorders. Front Immunol. 2018;9:126.
19
Lindoso JA, Cota GF, da Cruz AM, Goto H, Maia-Elkhoury AN, Romero GA, de Sousa-Gomes ML, Santos-Oliveira JR, Rabello A. Visceral leishmaniasis and HIV coinfection in Latin America. PLoS Negl Trop Dis. 2014;8:e3136.
20
Cota GF, de Sousa MR, Rabello A. Is visceral leishmaniasis the same in HIV-coinfected adults? Braz J Infect Dis. 2011;15:470-6.
21
Mathur P, Samantaray JC, Vajpayee M. Visceral leishmaniasis co-infection in people living with HIV/AIDS. Med J Armed Forces India. 2011;67:362-4.
22
Jawhar NM. Visceral Leishmaniasis with an Unusual Presentation in an HIV Positive Patient. Sultan Qaboos Univ Med J. 2011;11:269-72.
23
Alvar J, Cañavate C, Gutiérrez-Solar B, Jiménez M, Laguna F, López-Vélez R, Molina R, Moreno J. Leishmania and human immunodeficiency virus coinfection: the first 10 years. Clin Microbiol Rev. 1997;10:298-319.
24
Boelaert M, Verdonck K, Menten J, Sunyoto T, van Griensven J, Chappuis F, Rijal S. Rapid tests for the diagnosis of visceral leishmaniasis in patients with suspected disease. Cochrane Database Syst Rev. 2014;2014(Suppl)6:CD009135.
25
Cota GF, de Sousa MR, Demarqui FN, Rabello A. Reduced sensitivity of rK39 rapid diagnostic tests in HIV-infected VL patients. PLoS Negl Trop Dis. 2014;8:e2875.
26
Parikh SA, Kapoor P, Letendre L, Kumar S, Wolanskyj AP. A review of hemophagocytic lymphohistiocytosis in patients with HIV. Open Forum Infect Dis. 2020;7:ofaa006.
27
Ramon I, Libert M, Guillaume MP, Corazza F, Karmali R. Recurrent haemophagocytic syndrome in an HIV-infected patient. Acta Clin Belg. 2010;65:276-8.
28
Konkol S, Killeen RB, Rai M. Hemophagocytic lymphohistiocytosis. In: StatPearls. Last accessed date: 2026 Feb 23. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557776/
