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178 14 Case Reports

confirmed the presence of pericardial effusion. On further questioning, he said that
he had worked in Rio De Janeiro, Brazil for 5 months and since his return, he had
been working in Singapore. The new information has led us to investigate for leish-
maniasis. Intravenous deoxycholate amphotericin B (1 mg/kg/day) was initiated
empirically. Fever subsided at the third dose of therapy. Amastigotes were not noted
in full blood picture, bone marrow aspirates and trephine biopsy. However, PCR for
Leishmania on peripheral blood was positive. This confirmed our diagnosis of vis-
ceral leishmaniasis. At this point, serial echocardiography showed worsening of
pericardial effusion. Drainage was performed after consultation with a cardiologist.
Interestingly, very scanty acid fast bacilli was noted from one of the many sputum
specimens. There were conflicting opinions about commencement of anti-tubercu-
lous treatment at this point as bronchoscopic examination was unremarkable.
Bronchio-alveolar lavage, pericardial fluid, peripheral blood, and bone marrow
aspirates for acid fast bacilli, mycobacterium culture, and PCR were all negative.
He was discharged after receiving a total of 18 doses of amphotericin B. On dis-
3
charge, his white blood cells was 3.61 × 10 /μL, haemoglobin was 9.4 g/dL, and
3
platelets was 97 × 10 /μL.
Two months later, he was readmitted for fever, chills and rigors with worsening
pancytopenia (white blood cells 2.26 × 10 /μL, haemoglobin 8.6 g/dL, platelets
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90 × 10 /μL). Echocardiography showed reaccumulation of pericardial effusion but
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was not causing cardiac tamponade. Intravenous amphotericin B was re-initiated.
However, he did not demonstrate response to amphotericin this time. A repeated
leishmania PCR on blood was negative, indicating the possibility of co-infection.
Anti-tuberculosis treatment was initiated. He improved dramatically with this ther-
apy. At 56th dose of intensive anti-tuberculosis therapy, he remained asymptomatic.
Echocardiography showed complete resolution of pericardial effusion. A clinic
review 2 years later showed his blood counts were within normal range (white blood
counts 13.2 × 10 /μL, haemoglobin 13.2 g/dL, platelets 229 × 10 /μL).
3
3
Learning Points
1. Clinicians should maintain a high index of suspicion for visceral leishmaniasis
in a patient who has returned from an endemic country and presents with fever,
hepatosplenomegaly, and pancytopenia.
2. PCR-based assays can be performed on peripheral blood and bone marrow aspi-
rates to detect leishmania DNA.
3. Visceral leishmaniasis may trigger an overt T-cell response, exhausting the body
immune system. This immunosuppressive stage may render patient more sus-
ceptible to other infections, e.g., Tuberculosis.

Acknowledgement
We are grateful to Dr. Low Lee Lee, Consultant Infectious Diseases Physician,
Hospital Sultanah bahiyah, Kedah, Malaysia, and Dr. Dharmaraj Karthikesan
(Cardiologist) for their contribution of this case report.