Visceral leishmaniasis associated hemophagocytic lymphohistiocytosis – Case report and systematic review

SummaryBackgroundThe clinical features of leishmaniasis overlap with that of hemophagocytic lymphohistiocytosis (HLH) and the diagnosis of visceral leishmaniasis (VL) related HLH can be challenging.ObjectivesTo review information available on disease course, treatment, adjunctive therapy used and the outcomes of VL related HLH.MethodsWe describe an illustrative case and review all reported cases of VL associated HLH in the English literature till March 2007.ResultsVL associated HLH is rare, with 56 cases reported in the English literature. Clinical features lack discriminating value to recognize VL as the inciting etiology. Bone marrow aspiration (BMA) establishes the diagnosis in 78% of cases but is often negative at onset of the syndrome due to the pauci-microbial nature of the disease and patchy involvement. Repeated marrow aspiration, liver biopsy, blood cultures and serology may be required to establish the diagnosis. Liposomal amphotericin is the drug of choice. IVIG may be considered when there is an inadequate response to anti-leishmanial therapy in severe and refractory disease.ConclusionsVL related HLH is often under-recognized because of overlapping clinical features and negative marrow evaluation at onset, leading to high mortality rates.