Hepatosplenomegaly in a patient returning from Spain

Abstract

A 73-year-old man presented with a 1-month history of anorexia, malaise, fevers, night sweats and weight loss. He had no past medical history of note. Since his retirement, he spent the winter months in Spain. He often travelled around Spain and recalled sleeping on the ground while camping in the Mazarron region 8 months before his illness. In the vicinity he recalled seeing dogs. On examination, he was jaundiced with hepatosplenomegaly. His liver was palpable 20 cm below the costal margin in the mid-clavicular line, and the spleen 16 cm. There was no lymphadenopathy. Blood tests showed a pancytopenia with a haemoglobin of 10.3 g/dl, white cell count of 2.86 × 109/litre and platelets of 84 × 109/litre. His inflammatory markers were elevated with a C-reactive protein (CRP) of 231 mg/litre. His liver function tests were deranged with a bilirubin of 73 mmol/litre, alkaline phosphatase of 402 U/litre (reference range 40–130), alanine transaminase of 101 U/litre (reference range 0–45) and albumin of 26 g/litre. During his admission, he spiked frequent fevers of up to 39.5°C. He was treated empirically with cefuroxime but with no improvement. Multiple sets of blood, urine and stool cultures were negative. Hepatitis B and C, Epstein–Barr virus and human immunodeficiency virus serology and blood films for malaria parasites were all negative. Serum electrophoresis showed a polyclonal increase in gammaglobulins. A computed tomography scan of his chest and abdomen showed hepatosplenomegaly with no focal lesions and minimal lymphadenopathy. A bone marrow aspirate and trephine biopsy showed a reactive picture with increased immature myeloid cells, but no evidence of haematological malignancy. A liver biopsy showed an interface hepatitis, consistent with infection. No parasites were seen in either sample. A sample of bone marrow sent for polymerase chain reaction analysis for Leishmania donovani was positive. He was referred to the local infectious diseases unit who started liposomal amphotericin 3 mg/kg for 5 days with a further dose at day 10. Three months later, he had regained 3 kg, his hepatomegaly measured 5 cm and his spleen was no longer palpable. His haemoglobin was 13.7 g/dl, white cell count 11.8 × 109/litre, platelets 616 × 109/litre, CRP < 5 mg/litre and albumin 38 g/litre.