This case was an interesting one! As haematologists we have a privileged position of being able to get to know our patients extremely well and also have the skills to review their marrow under the microscope in order to reach a diagnosis. Usually we will have an idea of what we expect to find and sometimes we will not. It is important we keep an open mind when reviewing a patient’s material. In this case we were expecting to find a malignancy of some sort… In fact we found leishmaniasis! (very odd to see in the peripheral blood!)
This is a parasitic disorder caused by a protozoan of the genus Leishmania. There are three main clinical forms of the disease:
- cutaneous – skin involvement
- mucocutaneous – skin plus mucus membranes
- visceral – disseminated
It is spread by a sandfly and the most common affected areas are the Mediterranean, India, Bangladesh, Brazil and parts of Africa. In immune compromised patients it is common to have a lack of an ‘exotic’ travel history.
In visceral leishmaniasis symptoms can be similar to that of newly diagnosed lymphoma:
- Night sweats
- Weight loss, anorexia
- Dark pigmentation of the skin
Full work up of any patient with the above symptoms would include: FBC, renal and liver function, bone profile, CRP/ESR, immunoglobulins, B12/folate, HIV, hepatitis viruses, blood cultures and examination of the peripheral blood to include appropriate malaria staining. The cornerstone to diagnosing leishmaniasis is to obtain tissue – whether this be through skin biopsy, bone marrow biopsy, lymphoma node or splenic biopsy. Bone marrow is frequently used as it is probably safer than splenic biopsy. Leishmania amastigotes can be viewed microscopically as in our case. Cultures can be taken as well as serological and PCR studies. It is unusual to see the amastigotes in the peripheral blood!
This depends on a number of factors but can include amphotericin, miltefosine or pentamidine.
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