A Zoonosis without Fever

Transmission of infectious agents from animals to man occurs by direct contact with the animal, by ingestion, inhalation or inoculation of infectious agent. Zoonosis are infectious diseases transmissible from vertebrate animals to humans under natural conditions. The infectious agents involved include bacteria, viruses, parasites, fungi and rickettsia, among others [1,2]. 

Leishmaniasis is a parasitic disease, most frequently in tropics, subtropics and southern Europe, caused by infection with Leishmania parasites, which are spread by the bite of female phlebotomine sand flies. Human and animal reservoirs are key elements in the transmission chain [1]. Most common forms of Leishmaniasis: cutaneous, mucocutaneous and visceral (also known as kala-azar) affects several internal organs (usually spleen, liver and bone marrow) and may be fatal if left untreated. The estimated number of new cases of Visceral Leishmaniasis (VL) per year is <100,000, symptoms evolve insidiously, with splenomegaly, irregular fever, anemia or pancytopenia, weight loss, and weakness occurring progressively over a period of weeks or even months [1,2]. Prompt diagnosis is important to prevent high mortality associated with missed diagnosis [3,4].

A 13 year-old female teenager, with cognitive impairment, third child of healthy consanguineous parents, rural area resident, with dog contact was referred to the paediatric department for frequent epistaxis with 1 week and thrombocytopenia and anemia, detected a month earlier in routine analysis, without fever, night sweats, tiredness, adynamia, anorexia, notion of recent weight lossor other symptoms. 

On examination, had a weight and height in the 3rd percentile, pale mucosae, without visible skin bruising andwith palpable hepatosplenomegaly. 

Initial laboratory tests showed normocytic/normochromic anemia (Hb 9g/dL; VGM 70fL; HGM 22pg), thrombocytopenia (80000/uL), mild hepatic dysfunction (AST 129U/L and ALT 77U/L), PCR 1,9 mg/dL, ESR 100mm/h and negative serologies for HIV 1/2 and IgM EBV/CMV.The chest x-ray was normal and abdominal ultrasound showed moderate hepatosplenomegaly regular contours and homogeneous echostructure, with no apparent focal lesions and no distortion of hepatic architecture. 

Due to the tests results already performed, the history of contact with a neighbor's sick dog and living in an endemic area, a diagnosis of Visceral Leishmaniasis (VL) has been proposed. 

The next laboratory tests showed normal myelogram,bone marrow aspiratewith positive leishmania PCR and peripheral blood positive leishmania IgM/IgG (ELISA), with negative leishmania PCR. 

She iniciatedtherapy with liposomal amphotericin B (5mg/kg for 5 days) in D8; then (5mg/kg) in D14 and in D21, with progressive clinical and analytical improvement.

We present this case due to the atypical presentation form and to underline the importance of detailed clinical history and physical exam in the early diagnosis and treatment of a potentially fatal disease. 

Diagnosis of VL is made by direct identification of the parasite by microscope in tissue specimens or bone marrow; blood tests to detect antibody to the parasite and molecular tests to look for the parasite (or it’s DNA). Treatment with liposomal amphotericin B or pentavalent antimony are the best choices available [3,4].

VL is a diagnostic challenge and high index of suspicion is required. Leishmaniasis is an endemic disease in some areas and prompt institution of treatment allows patients to survive [4].

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

The authors declare that they have no competing interests.

JSM, TM, GR, MC, IBL and GS contributed equally to the concept, clinical management of the patient, writing of the paper, manuscript review and editing. All authors approved the final version.

All relevant data are provided in the manuscript.

1. Michael T, Brady MD, Jackson MA (2018) Red Book 2018: Report of the Committee on Infectious Diseases, (31^st edn). American Academy of Pediatrics, USA.
2. Alves F, Bilbe G, Blesson S, Goyal V, Monnerat S, et al. (2018) Recent Development of Visceral Leishmaniasis Treatments: Successes, Pitfalls, and Perspectives. Clin Microbiol Rev 31: 18-48.
3. Lucero E, Collin SM, Gomes S, Akter F, Asad A, et al. (2015) Effectiveness and safety of short course liposomal amphotericin B (AmBisome) as first line treatment for visceral leishmaniasis in Bangladesh. PLoS Negl Trop Dis 9: 0003699.
4. Tamiru A, Tigabu B, Yifru S, Diro E, Hailu A (2016) Safety and efficacy of liposomal amphotericin B for treatment of complicated visceral leishmaniasis in patients without HIV, North-West Ethiopia. BMC Infect Dis 16: 548.