SQU Med J, May 2011, Vol. 11, Iss. 2, pp. 269-272, Epub. 15th May 11
Submitted 29th Aug 10
Revision ReQ. 5th Oct 10, Revision recd. 17th Oct 10
Accepted 9th Mar 11

Leishmaniases are a group of Zoonotic diseases caused by a haemoflagellate protozoan of the genus Leishmania. The 
parasites are present in the macrophages of a wide 
variety of vertebrates. They are transmitted to 
man from the animal reservoir through the bite of 
female sand flies of the Phlebotomus species.1 There 
are several species of Leishmania that can infect 
human and result in a spectrum of diseases known 
as leishmaniasis.2 Depending on the mode of 
presentation there are three main types: cutaneous 
leishmaniasis, which is often self-limiting, mucosal 
leishmaniasis and visceral leishmaniasis.3 Visceral 
leishmaniasis affects mainly the mononuclear 
phagocytic system of the bone marrow, liver 

and spleen1 and is caused mainly by Leishmania 
donovani and Leishmania infantum species.2 It 
shows a wide geographical spread in more than 88 
countries all over the world.4

Clinically, typical cases of visceral leishmaniasis 
are found primarily in children.4 It's features include 
fever, anaemia, hepatosplenomegaly, adenomegaly, 
hypergammaglobulinaemia, and pancytopenia, but 
it can also manifest itself atypically, mostly in patients 
infected with HIV and geriatric immunocompetent 
patients.5 The definitive diagnosis of visceral 
leishmaniasis is achieved by identification of the 
organism in a bone marrow biopsy. The characteristic 
Leishmania amastigotes are round to ovoid in shape 
and can be identified after routine haematoxylin-

Department of Pathology, Nineveh Medical College, University of Mosul, Iraq.
*Corresponding Author email: nazar3nhn@yahoo.com

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
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aBstract: Visceral leishmaniasis is a disease caused by a haemoflagellate protozoan of the genus Leishmania. 
It has a wide geographical spread. Classic cases are found primarily in children and present with typical features 
that include fever, anaemia, hepatosplenomegaly, hypergammaglobulinaemia, and pancytopenia. The diagnosis is 
usually achieved by bone marrow smears, culture and serology; however, it can manifest itself atypically, mostly 
in patients infected with HIV and geriatric immunocompetent patients. We report an unusual case of visceral 
leishmaniasis diagnosed in a 27 year-old HIV-infected male who presented with abdominal discomfort and 
diarrhoea of four weeks duration associated with nausea and vomiting, but with no typical symptoms or signs 
of visceral leishmaniasis. The diagnosis was established through the identification of the Leishmania organism in 
duodenal and colonic biopsies and confirmed by subsequent bone marrow smears. 

Keywords: Visceral leishmaniasis; HIV; Duodenal biopsy; Case report; Iraq

Visceral Leishmaniasis with an Unusual 
Presentation in an HIV Positive Patient

Nazar M.T. Jawhar

CASE REPORT



Visceral Leishmaniasis with an Unusual Presentation in HIV Positive Patient

270 | SQU Medical Journal, May 2011, Volume 11, Issue 2

eosin or Giemsa staining.4,6 Other diagnostic 
tools include isolation of promastigotes by Novy-
McNeal-Nicolle (NNN) culture2,4 and serological 
tests to detect antileishmanial antibodies, but the 
latter have low sensitivity.3,4 Histopathological 
identification of leishmania organisms in tissue 
sections is quite easy and very sensitive;4 however, 
the diagnosis of leishmaniasis in paraffin sections 
may be difficult in some conditions, such as when 
the parasites are present in unusual sites which is 
frequently observed in visceral leishmaniasis that 
develops in immunocompromised patients.2,7 This 
is a presentation of an unusual case of visceral 
leishamniasis diagnosed in an HIV-infected 
patient, with atypical clinical features, who was 
unexpectedly diagnosed through the identification 
of the Leishmania organism in an unusual site.

Case report
The patient was a 27 year-old Yemeni male, 
diagnosed with HIV infection 8 years previously,  
who presented with abdominal discomfort and 
diarrhoea of four weeks duration associated with 
nausea and vomiting, but no fever or anorexia. 
The diarrhoea (5–6 times a day) was watery and 
accompanied by mucus, but with no blood. On 
physical examination, the patient was conscious, 
oriented, afebrile and not pale. His vital signs 
were stable. His chest was clear and abdominal 
examination showed mild subumbilical tenderness, 
but no abdominal mass or organ enlargement was 
detected. No lymphadenopathy was present. The 
patient was not receiving any antiretroviral therapy. 

Laboratory investigations showed leukocytes 
10.88x103/µl, 83% neutrophils, 8.4% lymphocytes 
and 8.4% monocytes. The haemoglobin level was 
136 g/l, erythrocytes sedimentation rate 16 mm/
hour. Urine examination showed mild proteinuria 
and his serum creatinine was mildly elevated 
at 2.1 mg/dl. Stool samples were negative for 
Cryptosporidium and Clostridium difficile toxin and 
repeated stool culture revealed no pathogens. His 
CD4 cell count was 210 cells/mm3. An abdominal 
ultrasound showed no abnormalities. An upper 
GIT endoscopy showed normal oesophageal and 
gastric mucosa; however, the mucosa of the second 
part of the duodenum showed congestion with a 
peculiar whitish nodular appearance [Figure 1]. 
A colonoscopy showed normal colonic mucosa. 
Multiple biopsies were taken from the oesophagus, 
stomach, duodenum and colon for histopathological 
examination to exclude microscopic lesions and 
opportunistic infections.

The histopathological examination demonstra-
ted widening of the duodenal villi with infiltration 
of duodenal and rectal mucosa by a large number 
of macrophages filled with intracytoplasmic 
Leishmania amastigote parasites (Donovan bodies) 
[Figure 2]. Gastric and oesophageal biopsies showed 
no significant pathologic changes. The case was 
diagnosed as visceral leishmaniasis. Subsequent 
bone marrow aspirate (showing Leishman–
Donovan bodies) confirmed the diagnosis [Figure 3]. 
The patient was treated with sodium stibogluconate 
(20 mg/kg/day), but he was lost to follow-up after 1 
week of therapy.

Figure 1: Upper GIT endoscopy revealing whitish 
nodular appearance of the duodenal mucosa.

Figure 2: Duodenal biopsy showing many macrophages 
with abundant intracytoplasmic leishmaniae.



Nazar M.T. Jawhar

Case Report | 271

Discussion
Although it affects mainly immunocompetent 
individuals, Leishmania is considered an 
opportunistic pathogen in immunosuppressed 
patients particularly those with AIDS.8,9 On the 
other hand, HIV infection increases the risk of 
developing visceral leishmaniasis by 100–1,000 
times in endemic areas.10 In fact, some studies 
showed that visceral leishmaniasis is the fourth 
most common opportunistic parasitic disease in 
HIV-positive individuals after pneumocystosis, 
toxoplasmosis, and cryptosporidiosis.4,10,11 Indeed, 
both HIV and leishmaniasis result in a cumulative 
deficiency of the cellular immune response since 
both agents damage similar immune resources thus 
promoting chronicity and, when untreated, result 
in death.6,10 The first case of leishmania/HIV co-
infections was diagnosed in 198512 and almost all 
cases of Leishmania co-infection with HIV have 
been described in patients with HIV-1.13 According 
to data from the World Health Organization, HIV-
Leishmania co-infection is widely distributed.14 
The most common areas are southern European 
countries (like Spain), and Brazil, India, Bangladesh 
and Nepal.1,10 The real impact of HIV-Leishmania 
co-infection is probably underestimated owing 
to constraints in the surveillance and reporting of 
cases. 

The majority of leishmaniasis cases in HIV-
positive patients appear in the advanced stages of 
the disease. In about 80% of patients, the number 
of CD4 lymphocytes is less than 200/mm3 while 
in c. 20 % of patient.1,4,15 In the current case, the 

number was low (210 cells/mm3). Leishmaniasis 
has different characteristics in patients with AIDS 
compared with immunocompetent patients.8 
Classic visceral leishmaniasis in immunocompetent 
individuals is found primarily in children, but in 
recent years an increasing number of adult cases 
have been observed mostly in HIV patients.4,5,15–17 
In the latter, the location is more likely to be atypical  
such as gastrointestinal tract, larynx, lungs,  
kidneys, pancreas and testes.5,6 Organomegaly, 
which is one of the typical clinical features of classical 
visceral leishmaniasis in immunocompotent 
individuals, is usually absent in HIV positive adults3 

as in our case. Also cytopenia is more frequent 
in immunosuppressed individuals along with  
 negative serology and higher relapse rate after 
therapy. 5,6,8,10 The gastrointestinal involvement and 
overt malabasorption in visceral leishmaniasis is 
reported more freqently in those with concomitant 
HIV infection.3,5,8,18–20 Lesions have been seen 
from the oesophagus to the rectum;6 however, the 
duodenum is the most common site.5 The exact 
pathogenesis of the diarrhoea and malabsorption 
is not clear, but it has been suggested that these 
symptoms in enteropathic visceral lesihsmaniasis 
may be a combination of the mechanical occlusion 
of the mucosa by parasites, bacterial overgrowth, 
partial villous atrophy, competition between the 
host and the parasite for nutrients, altered motility, 
bile salt deconjugation and lymphatic blockade.3 

Endoscopic examination of these patients 
is usually performed because of diarrhoea  
and epigastralgia. The findings are variable and 
may be unremarkable,6,18,21 showing non-specific 
inflammation,5,22 or an atrophic mucosal pattern.8 

In the current case, the mucosa of the second 
part of the duodenum showed congestion with a 
peculiar whitish nodular appearance, a rare and 
unusual finding also reported by others.1 The 
colonoscopy showed a normal colonic mucosal 
pattern. Histopathological examination of 
intestinal (duodenal and colonic) biopsies shows 
intact architecture and abundant macrophages 
with intracytoplasmic Leishmania amastigotes 
(Donovan bodies).5,6,19,22 Some cases may show 
duodenal villous atrophy.3,22

Conclusion
In conclusion, clinicians should be alert about the 

Figure 3: Bone marrow aspirate smear revealing 
intracytoplasmic leishmaniae.



Visceral Leishmaniasis with an Unusual Presentation in HIV Positive Patient

272 | SQU Medical Journal, May 2011, Volume 11, Issue 2

possibility of leishmaniasis in HIV positive patients 
presenting with diarrhoea, particularly in patients 
from endemic areas. Also pathologists should pay 
attention to the possible finding of Leishmania 
amastigotes in biopsies from intestinal mucosa in 
HIV infected patients.

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