Febrile hepatosplenomegaly in an infant

Fever and splenomegaly are a diagnostic challenge, mainly from Primary Care Centres. We describe here the case of a female infant with intermittent fever over several weeks, in which a giant splenomegaly of 7-8 cm and a smaller hepatomegaly were the main symptoms. Diagnostic protocol was followed, and normal accounts of leucocytes were found, but also anemia and mild thrombopenia, with increased cholesterol, triglicerydes and ferritine. The procedure included cultures (urine, blood, faeces) and serology from virus, atypical bacteria and leishmania, all of them negative. Increasing anemia was the cause of hospital admission for one week, although no diagnosis was reached. Afterwards, when the patient was being followed in our Primary Care Centre, a positive result for Leishmania sp PCR (Polimerase Chain Reaction) was informed. With a diagnose of visceral leishmaniasis, the patient then received standard doses of liposomal Amfotericin B disappearing afterwards fever and (slowly over a period of several months) splenomegaly. From the beginning of symptoms, our infant showed a scabbed lesion on her scalp, which was biopsied two months after treatment with amfotericin, being ?cutaneous leishmaniasis? the new diagnose. The patient did not receive any other treatment and her lesion improved, although it remains as an atrophic scar. Kala-azar or visceral leishmaniasis is endemic in the Mediterranean countries, being L. infantum the most prevalent species in our area. Pancytopenia and high fever are common, although afebrile periods of time can also be found in leishmaniasis case series. Splenomegaly is the most common symptom. Classic treatment included pentavalent antimonials but due to recent resistance of Indian species to this drug, visceral leishmaniasis can be treated with liposomal amfotericin B. Concomitant cutaneous and visceral leishmaniasis have been described, moreover among immunodepressed adults. We believe this is a very interesting case, where we describe a healthy infant with both types of leishmaniasis: visceral and cutaneous, which is the first one described in our country.