Image 48  Nine months after immigrating from Albania this 17 year old presented with a week of fever to 40° C, a sore throat for 2 days, malaise, and, on examination, a liver and spleen each 10 cm below the costal margins (see CT), a 2/6 ejection murmur and several <1cm cervical nodes. His hemoglobin was 73 g/L, WBC 1.2 x109, neutrophils 0.6 x109, platelets 98 x109 and there were no blasts. His SGOT was 500 U/L, bilirubin normal, total protein 70g/L and albumen 14 g/L. What was the diagnosis?

case provided by: Dr Valerie Lamarre Hôpital Sainte Justine Université de Montréal

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Image 48. A bone marrow aspirate was positive for leishmania amastigotes (see below) and a leishmania culture was positive. A PCR at the Canadian National reference Centre, McGill U (NCP) and an isoenzyme analysis at Walter Reid Army Institute of Research, Maryland (WRAIR) were positive for Leishmania of the donovani complex (which includes L. donovani and L. infantum).   The diagnosis was therefore Leishmania infantum based on the positivity for the donovani complex and the epidemiology (There is no L. donovani in the Mediterranean). He was HIV negative and responded rapidly to intravenous antimony (Pentostam).