An 18 year old male patient presented with a 2 weeks history of recurrent high-grade fever with chills and rigors associated with extreme fatigue, loss of appetite and significant weight loss. He also complained of painful lower abdominal cramps and frequent loose stool. He showed no improvement with empiric anti-malarial and ceftriaxone treatment.
He had history of travel to leishmaniasis endemic area 6 months prior. He had no history of cough, hemoptysis nor tuberculosis. He never smoked cigarettes. His past medical history was unremarkable.
He tested positive for SARS CoV-2 rt-PCR from nasopharyngeal swab sample at the referring hospital where he first sought medical care. He was then transferred to Eka Kotebe covid-19 treatment center in Addis Ababa.
On admission physical examination, he was apathetic. His vital signs were: blood pressure 102/53 mmHg, pulse rate 110 beats per minute, respiratory rate 34, body temperature 38.4°C, and 90% oxygen saturation on room air. Conjunctivae were pale. He had shotty axillary lymphadenopathy and tipped splenomegaly.
Admission laboratory tests showed pancytopenia and hyperbilirubinemia. Serology for HIV, HBsAg and HCV Ab were negative. No hemoparasite was demonstrated on blood film. Peripheral blood smear showed normocytic normochromic anemia with no blasts (table 1 summarizes the lab tests).
While on care for severe COVID-19 (intranasal oxygen 3-4 liter per minute, dexamethasone 6 milligrams intravenously per day, prophylactic heparin and as needed paracetamol) and work up for the possible causes of cytopenia, he developed septic shock (fever with body temperature of 38.8 degree Celsius, change in mentation, tachycardia, hypotension and hyperlactemia). He was resuscitated, started cefepime and vancomycin, transfused with blood components, dexamethasone shifted to hydrocortisone 100 mg every 8 hourly, and vasopressor initiated together with other supportive care. Over 2 days, shock state was corrected. Pressor was de-escalated. He later required blood products transfusion and prophylactic antimicrobials due to the severe neutropenia. Plumpy’nut was also given for subjective global assessment C (severe) malnutrition. Over the subsequent days, he deteriorated with progressive liver dysfunction and bleeding.
As some of the clinical presentations was likened to VL, a request for leishmanial serologic test was made. The rK39 rapid diagnostic test (IT LEISH Rapid Test,4 Bio-Rad Laboratories) gave positive result. After obtaining verbal consent, bone marrow aspiration was performed. Examination of the Giemsa stained smear demonstrated amastigotes. Parasite density was very low (grade 1: 1-10 amastigotes/1000 fields of oil immersion). Culture of the bone marrow specimen in Novy-McNeal-Nicolle (NNN) medium grew promastigotes after 2 weeks of inoculation.
At the time, the diagnosis of VL presented a dilemma on treatment approach as the patient was already deteriorating. A difficult decision was made to use sodium stibogluconate (SSG) - the only anti-leishmanial available at the time. On point-of-care ultrasound examination, he was edematous with serosal effusions. He later became hypotensive. He was resuscitated, transfused with blood components, and antibiotics revised to meropenem for empiric coverage of hospital acquired infection. SSG was withheld after 2 doses. He unfortunately passed away from hemorrhagic bleeding and septic complications after 10 days of hospitalization.