Colonic Leishmaniasis Followed by Liver Transplantation

A 17-year-old, 37-kg Brazilian man was diagnosed with autoimmune hepatitis at the age of 7 years and underwent liver transplant (cadaveric) at the age of 14 . Immunosup pressants included tacrolimus and prednisone. He had lost 3 kg over the previous year and had diarrhea with blood streaks in the previous 3 months but no history of fever. Laboratory tests showed pancytopenia (hemoglobin = 8.1 g/dL; leukocytes = 1,300/mm 3 ; platelets = 79,000/mm 3 ; albumin = 2.7 g/dL). Physical examination showed enlarged liver and spleen. Unrevealing imaging included upper gastroenterointestinal endoscopy, abdominal ultrasound, and computerized tomography of the chest and abdomen ( Figure 1 ) but showed hepatosplenomegaly. Viral serologies were negative. Colonoscopy showed gross nodularity, hyperemia, and friability of the colonic mucosa ( Figure 2 ). Biopsy of terminal ileum region showed amastigote forms of Leishmania inside macrophages ( Figure 3A and B ). The nature of the agent was confirmed by immunohistochemistry ( Figure 3C ) and polymerase chain reaction (PCR), which showed L. chagasi infection. 1 Examination of a bone-marrow biopsy showed innumerable Leishmania amastigotes ( Figure 3D ). Serology for leishmaniasis was negative. Treatment with amphotericin B desoxycholate was initiated; renal function deteriorated, and treatment with liposomal amphotericin was substituted (3 mg/ kg for 7 days). 2 The patient clinically responded with resolution of diarrhea, weight gain, and normalization of spleen size. Two months later, hemoglobin was 11.3 g/dL, leukocytes were 3,670/ mm 3 , platelets were 164,000/mm 3 , and albumin was 3.8 g/dL. 1 , 2