Visceral leishmaniasis in renal transplant patients

Updated diagnosis and graft involvement for visceral leishmaniasis in kidney transplant recipients: a case report and literature review

Purpose

Visceral leishmaniasis (VL) has become a rising concern to transplantation teams, being associated with graft dysfunction and reduced survival of renal transplant recipients. Here, we describe a case of VL occurring in a kidney transplant (KT) recipient in Italy, a country in which Leishmania infantum is endemic and we reviewed the literature on the clinical course and diagnosis of VL in KT recipients residing or travelling to southern Europe.

Results

The VL case was diagnosed 18 months after transplant and 28 days after the onset of symptoms by quantitative PCR (qPCR) on peripheral blood. A graft biopsy showed renal involvement, and PCR performed on graft tissue displayed the presence of Leishmania DNA. The retrospective confirmation of Leishmania-positive serology in a serum sample collected before transplantation, as well as the absence of anti-Leishmania IgG in the graft donor strongly suggest that reactivation of a latent parasitic infection caused VL in the current case.

Conclusion

VL is often underdiagnosed in transplant recipients, despite the presence of latent Leishmania infection being reported in endemic countries. This case report, as well as the literature review on leishmaniasis in KT recipients, underline the importance of rapid VL diagnosis to promptly undergo treatment. Serology is scarcely sensitive in immunocompromised patients, thus molecular tests in peripheral blood should be implemented and standardized for both VL identification and follow-up.

Epidemiology, Clinical Characteristics, Diagnostic Work Up, and Treatment Options of Leishmania Infection in Kidney Transplant Recipients: A Systematic Review

Current knowledge on Leishmania infection after kidney transplantation (KT) is limited. In order to offer a comprehensive guide for the management of post-transplant Leishmaniasis, we performed a systematic review following the latest PRISMA Checklist and using PubMed, Scopus, and Embase as databases. No time restrictions were applied, including all English-edited articles on Leishmaniasis in KT recipients. Selected items were assessed for methodological quality using a modified Newcastle–Ottawa Scale. Given the nature and quality of the studies (case reports and retrospective uncontrolled case series), data could not be meta-analyzed. A descriptive summary was therefore provided. Eventually, we selected 70 studies, describing a total of 159 cases of Leishmaniasis. Most of the patients were adult, male, and Caucasian. Furthermore, they were frequently living or travelling to endemic regions. The onset of the disease was variable, but more often in the late transplant course. The clinical features were basically similar to those reported in the general population. However, a generalized delay in diagnosis and treatment could be detected. Bone marrow aspiration was the preferred diagnostic modality. The main treatment options included pentavalent antimonial and liposomal amphotericin B, both showing mixed results. Overall, the outcomes appeared as concerning, with several patients dying or losing their transplant.

Liposomal Amphotericin B for Visceral Leishmaniasis in a Kidney Allograft Patient

Objective

To report a case of visceral leishmaniasis treated with liposomal amphotericin B (LAB) after probable failure with amphotericin B lipid complex (ABLC).

Case Summary

A 62-year-old white renal transplant recipient was admitted for pyrexia, hepato-splenomegaly, and pancytopenia. Leishmania amastigotes were detected from bone marrow aspirate and in circulating blood monocytes and neutrophils. The patient, who weighed 56 kg, received ABLC at a starting dose of 200 mg/d (3.6 mg/kg of body weight per day) for 13 days, achieving a total dose of 2,600 mg (46 mg/kg) without clinical improvement. The patient was switched to 100 mg/d (1.8 mg/kg) of LAB for 10 days, after which a dose of 250 mg (4.5 mg/kg) was repeated on days 17,24,31, and 38. Twenty-four hours after the first dose of LAB, the patient showed an excellent clinical response. On the following days, there was a progressive increase in hemoglobin concentration and leukocyte and platelet counts. Three months later, the patient was asymptomatic.

Discussion

Although treatment with ABLC appears to be effective for the treatment of Indian patients with visceral leishmaniasis, experience with immunocompromised patients is limited. This is the first case of a renal transplant recipient in which ABLC was used to treat visceral leishmaniasis without remarkable efficacy, but with infusion-related adverse effects perhaps due to the use of higher doses.

Conclusions

A randomized comparative trial is needed to compare LAB with ABLC in the treatment of visceral leishmaniasis in patients who have received kidney allografts.

Leishmaniasis in solid organ and hematopoietic stem cell transplant recipients

Leishmaniasis occurs in <1% of solid organ and hematopoietic stem cell transplant recipients in endemic countries in which transplants are performed. Visceral leishmaniasis (VL) makes up the bulk of reported cases. The onset generally occurs months after transplantation and the mode of acquisition is often impossible to determine, but de novo vector-borne infection and reactivation of inapparent infection are thought to be the principal means. The potential role of clinically inapparent donor infection is uncertain and screening is not currently recommended, nor is it recommended for recipients from endemic areas, some of whom may have detectable circulating protozoan nucleic acid. While transplant recipients with VL often present with the non-specific findings of fever and cytopenia, the additional presence of hepatosplenomegaly in patients from endemic areas should lead to a directed diagnostic evaluation with bone marrow examination and PCR testing of marrow and peripheral blood having a high yield. Management may often be complicated by the presence of concomitant infections. A lipid formulation of amphotericin B is the preferred treatment, especially for VL, but the relapse rate in transplant recipients is approximately 25%. PCR monitoring of blood for either secondary prophylaxis or preemptive therapy requires further study.

Visceral leishmaniasis after kidney transplantation: report of a new case and a review of the literature

Visceral leishmaniasis (VL) is a parasitic disease, caused by protozoa of the genus Leishmania, transmitted by the phlebotomies sand fly. In the last 20 years, the increasing frequency of organ transplantations and the improvement of associated immunosuppressive treatments have led to the recognition of several cases of VL complicating organ transplantation. Actually, less than 100 cases of VL after kidney transplantation are reported in the literature. In this context, VL is fatal without antileishmanial treatment which constitutes a difficult challenge. We report a case of VL in Tunisian renal transplant recipient treated successfully by liposomal amphotericin B (Ambisome®, Gilead Sciences Inc). Also, we review the epidemiological, clinical, biological and therapeutic aspects of VL associated with renal transplantation reported in the literature. Our report identifies that VL should be suspected in renal transplant recipients presenting unexplained fever, splenomegaly and pancytopeny. It also suggests a serological testing for leishmaniasis in the pre-operative check-up of transplant patients and donors living or traveling in endemic areas of leishmaniasis. Moreover, recipients should be tested regularly for leishmaniasis after transplantation. Liposomal amphotericin B may be considered the treatment of choice of VL, since it has a lower incidence of side effects.

Leishmaniasis among organ transplant recipients

Leishmaniasis is a rarely reported disease among transplant recipients; however, the number of published cases has quadrupled since the beginning of the 1990s. Most cases have been observed in patients living in countries of the Mediterranean basin. Leishmaniasis is most commonly associated with kidney transplantation (77%), and cases are also recorded among patients undergoing liver, heart, lung, pancreas, and bone marrow transplantation. Visceral leishmaniasis (VL) is the most frequently observed clinical presentation, followed by mucosal leishmaniasis and more rarely cutaneous leishmaniasis. Transplant recipients with VL develop the classic clinical form of the disease, which is a febrile hepatosplenic and pancytopenic syndrome. Immunodepression seems to predispose to development of mucosal leishmaniasis caused by viscerotropic strains. Early diagnosis of VL is crucial for patient therapy and outcome; however, this is frequently overlooked or delayed in transplant patients. Pentavalent antimonials are the most commom form of treatment for VL, but have a high incidence of toxicity (34%). Although used in fewer patients, liposomal amphotericin B seems to be better tolerated and should be considered as first-line therapy in transplant recipients.

Transmission of tropical and geographically restricted infections during solid-organ transplantation

In recent years, the increasing number of donors from different regions of the world is providing a new challenge for the management and selection of suitable donors. This is a worldwide problem in most countries with transplantation programs, especially due to the increase in immigration and international travel. This paper elaborates recommendations regarding the selection criteria for donors from foreign countries who could potentially transmit tropical or geographically restricted infections to solid-organ transplant recipients. For this purpose, an extensive review of the medical literature focusing on viral, fungal, and parasitic infections that could be transmitted during transplantation from donors who have lived or traveled in countries where these infections are endemic has been performed, with special emphasis on tropical and imported infections. The review also includes cases described in the literature as well as risks of transmission during transplantation, microbiological tests available, and recommendations for each infection. A table listing different infectious agents with their geographic distributions and specific recommendations is included.

Visceral leishmaniasis in organ transplant recipients: 11 new cases and a review of the literature

Eleven new cases of visceral leishmaniasis (VL) are reported in organ transplant patients in France. The epidemiological, clinical, biological, diagnostic and therapeutic features are reviewed, based on these cases and 46 cases reported in the literature. VL was most commonly associated with renal transplantation (77% of the cases). Most patients were from Southern European countries. The main clinical symptom was fever. Leucopoenia and anaemia were the most frequent haematological disorders. Diagnosis was by direct finding of the parasite in smears of bone marrow (85.2%) or, by positive serology (90.9%). Without antileishmanial treatment, VL in transplant recipients was fatal. Treatment using either antimonials or amphotericine B gave similar cure rates of around 80% of the cases. But toxicity was higher for antimonials. Relapses occurred in 14.3%.

Therapy of visceral leishmaniasis in renal transplant recipients intolerant to pentavalent antimonials

Visceral leishmaniasis should be suspected in renal transplant recipients in whom a fever develops of unknown origin. A 53-year-old renal transplant recipient developed pyrexia, hepatosplenomegaly, and pancytopenia 4 years after transplantation. Antileishmaniasis serology was negative, and the diagnosis was confirmed through bone marrow examination. Treatment with glucantine (N-methylglucamine antimoniate) led to acute pancreatitis, and treatment with ketoconazole plus allopurinol for 21 days was effective to eradicate Leishmania donovani.

Visceral leishmaniasis (Kala-Azar) in transplant recipients: case report and review

BACKGROUND

In endemic areas, visceral leishmaniasis has been identified as an opportunistic infection in patients with derangements in their cellular immune system.

METHODS

We report a renal transplant patient with visceral leishmaniasis. We also reviewed the previously published cases of 17 organ transplant recipients with this parasitic disease.

RESULTS

Visceral leishmaniasis occurred a median time of 8 months after transplantation, and the clinical picture was characterized by fever, splenomegaly, and blood cytopenias. Leishmaniae were detected in bone marrow in 16 of 18 patients and diagnostic serology results were found in 8 of 10 tested patients. Pentavalent antimonials were used to treat 16 patients, five of which developed pancreatitis. Five of 18 patients died, including two untreated patients. Relapses of visceral leishmaniasis occurred in 4 of 13 survivors.

CONCLUSIONS

In endemic areas, visceral leishmaniasis may complicate the clinical course of organ transplantation and can have fatal consequences, particularly when untreated.

Leishmania and human immunodeficiency virus coinfection: the first 10 years

Over 850 Leishmania-human immunodeficiency virus (HIV) coinfection cases have been recorded, the majority in Europe, where 7 to 17% of HIV-positive individuals with fever have amastigotes, suggesting that Leishmania-infected individuals without symptoms will express symptoms of leishmaniasis if they become immunosuppressed. However, there are indirect reasons and statistical data demonstrating that intravenous drug addiction plays a specific role in Leishmania infantum transmission: an anthroponotic cycle complementary to the zoonotic one has been suggested. Due to anergy in patients with coinfection, L. infantum dermotropic zymodemes are isolated from patient viscera and a higher L. infantum phenotypic variability is seen. Moreover, insect trypanosomatids that are currently considered nonpathogenic have been isolated from coinfected patients. HIV infection and Leishmania infection each induce important analogous immunological changes whose effects are multiplied if they occur concomitantly, such as a Th1-to-Th2 response switch; however, the consequences of the viral infection predominate. In fact, a large proportion of coinfected patients have no detectable anti-Leishmania antibodies. The microorganisms share target cells, and it has been demonstrated in vitro how L. infantum induces the expression of latent HIV-1. Bone marrow culture is the most useful diagnostic technique, but it is invasive. Blood smears and culture are good alternatives. PCR, xenodiagnosis, and circulating-antigen detection are available only in specialized laboratories. The relationship with low levels of CD4+ cells conditions the clinical presentation and evolution of disease. Most patients have visceral leishmaniasis, but asymptomatic, cutaneous, mucocutaneous, diffuse cutaneous, and post-kala-azar dermal leishmaniasis can be produced by L. infantum. The digestive and respiratory tracts are frequently parasitized. The course of coinfection is marked by a high relapse rate. There is a lack of randomized prospective treatment trials; therefore, coinfected patients are treated by conventional regimens. Prophylactic therapy is suggested to be helpful in preventing relapses.