Leishmanial lymphadenopathy in a native patient from the nonendemic region of Himachal Pradesh, India

Rashmi Kaul Raina; Shubham Sharma; Neha Verma; Meghavath Haritha Bai; Ritika Kashyap; Sujeet Raina

doi:10.4103/cjhr.cjhr_87_21

CASE REPORT

Year : 2022 | Volume : 9 | Issue : 2 | Page : 140-142

Leishmanial lymphadenopathy in a native patient from the nonendemic region of Himachal Pradesh, India

Rashmi Kaul Raina, Shubham Sharma, Neha Verma, Meghavath Haritha Bai, Ritika Kashyap, Sujeet Raina
Department of Pathology and Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Submission	29-Jul-2021
Date of Decision	10-Nov-2021
Date of Acceptance	16-Nov-2021
Date of Web Publication	20-Dec-2022

Correspondence Address:
Sujeet Raina
C-15, Type-V Quarters, Dr. Rajendra Prasad Government Medical College Campus, Tanda, Kangra - 176 001, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cjhr.cjhr_87_21

Abstract

A case of leishmanial lymphadenopathy in an immunocompetent native from a nonendemic area of the Ravi River valley area (altitude 996 m above the mean sea level) of Chamba, Himachal Pradesh, India, is reported. Diagnosis of visceral leishmaniasis by demonstration of Leishman–Donovan bodies in lymph nodes by fine-needle aspiration cytology has been rarely reported.

Keywords: Kala-azar, lymph node, nonendemic region

How to cite this article:
Raina RK, Sharma S, Verma N, Bai MH, Kashyap R, Raina S. Leishmanial lymphadenopathy in a native patient from the nonendemic region of Himachal Pradesh, India. CHRISMED J Health Res 2022;9:140-2

How to cite this URL:
Raina RK, Sharma S, Verma N, Bai MH, Kashyap R, Raina S. Leishmanial lymphadenopathy in a native patient from the nonendemic region of Himachal Pradesh, India. CHRISMED J Health Res [serial online] 2022 [cited 2023 Jan 30];9:140-2. Available from: https://www.cjhr.org/text.asp?2022/9/2/140/364538

Introduction

Visceral leishmaniasis (VL) has been reported from nonendemic sub-alpine valley along the Satluj river of Kinnaur, Shimla, and Kullu in the southeast and northwestern hilly region of Chamba, in Himachal Pradesh.^[1],[2] The clinical spectrum of VL from this nonendemic region is generally similar to that of the patients from the endemic region of India. The classical clinical features include fever, pallor, hepatosplenomegaly, and pancytopenia.^[1],[2] Uncommon manifestations such as leishmanial lymphadenopathy, hemophagocytosis, and gastrointestinal involvement have been reported in this region.^[1],[2] We describe a case of VL diagnosed by detection of amastigote form of Leishmania donovoni on fine-needle aspiration cytology of cervical lymph node. The case report is described for the following reasons:

The primary diagnosis of VL was made by the presence of Leishman–Donovan (LD) bodies in the cervical lymph node. The primary diagnosis of VL is commonly made by the demonstration of LD bodies in bone marrow or splenic aspirate
2. The patient was apparently immunocompetent
3. The patient belonged to a nonendemic region.

Case Report

A 48-year-old male, farmer by profession and a native of the Ravi River valley area (altitude 996 m above the mean sea level) in the Chamba district of Himachal Pradesh was admitted in July 2019 with a history of fever for 2 months. Fever was intermittent and associated with chills and rigors. He gave a history of loss of appetite and undocumented weight loss for the same duration. There was no significant past history. He denied ever visiting any endemic area of VL. Treatment records revealed that the patient had attended another hospital and was found to have massive splenomegaly with pancytopenia. The patient was not taking any immunosuppressant drugs. On examination, the patient was febrile and pallor was present. Right cervical lymphadenopathy was observed. The lymph nodes were mobile, nontender and the largest was 4 cm × 3 cm in size. On per abdomen examination, massive splenomegaly (8 cm below left costal margin) and hepatomegaly (total span 16 cms) were present. The rest of the examination was normal. On investigations, pancytopenia was observed. Hemoglobin was 8.5 g% and microcytic hypochromic picture was observed on peripheral smear examination. Total leukocyte count was 2750/cmm (neutrophil-41%, lymphocytes-52%, monocytes-5%, eosinophils-1%) and platelet count was 67,000/cmm. Total serum bilirubin was 5.5 mg% and conjugated was 3.1 mg%. The transaminases were raised (aspartate aminotransferase-127 IU, alanine aminotransferase-94 IU). The alkaline phosphatase was 82-KAU. Renal function tests and urine examination were normal. Ultrasound abdomen showed hepatosplenomegaly. Fine-needle aspiration of cervical lymph node revealed cellular smears showing the polymorphous population of reactive lymphoid cells consisting of mature lymphocytes, centroblasts, centrocytes, immunoblasts, and tingible body macrophages. The macrophages were packed with amastigote forms of Leishmania donovani. Many extracellular amastigotes were also seen [Figure 1]. He was negative for human immunodeficiency virus infection. The patient was treated with amphotericin B-deoxycholate 1 mg/kg on alternate days and given 15 doses. The patient became afebrile after the first dose of amphotericin B. At discharge, lymph nodes had regressed in size, spleen tip was just palpable, the liver span was normal, total leukocyte count and platelet count were normal. The patient remained asymptomatic at the end of 12 months during follow-up as reported telephonically. The informed consent of the patient has been taken before the submission of the manuscript.

Figure 1: Photomicrograph shows extracellular Leishman–Donovan bodies (arrows) in the fine-needle aspirate from the cervical lymph node. (Giemsa ×1000)

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Discussion

Lymphadenopathy is common in patients with VL in most of the endemic regions of the world. It is an uncommon feature in the endemic region of the Indian subcontinent and has been seldom reported in patients with Indian Kala-azar.^[3] A review of reports published between 1999 and June 2021 has recorded nine cases of VL diagnosed on lymph node aspiration in India.^[3],[4],[5] The geographic distribution among patients described, revealed that five were natives of the known endemic region of eastern UP and West Bengal. Three patients were from the nonendemic region of Maharashtra and Rajasthan. One patient was a native of Afghanistan. All the patients had HIV co-infection except one female who belonged to eastern UP and one teenager male from Rajasthan.

Himachal Pradesh is not an endemic region for VL though sporadic cases have being reported previously. In case series reports from the region, lymphadenopathy has been observed in eight cases. Significant axillary lymphadenopathy was noted in seven patients, cervical lymphadenopathy in three, and retroperitoneal among two patients. LD bodies were isolated on fine-needle aspiration cytology from lymph nodes in two patients.^[1] Sandfly survey in the region has established the presence of vector P. longiductus and P. major in the region and not Phlebotomus argentipes, the only known VL vector in Indian Kala-azar.^[6] Subsequently, P. argentipes have been found in the northern mountain ranges of the Himalayas (Himachal Pradesh is situated in these ranges).^[7] There is an uncertainty about the main sandfly vector species in this region. Humans are the only reservoir in the endemic region of the Indian subcontinent. It is suggested that zoonotic transmission may be occurring in this region as rk 39 antigen tests were positive in dogs.^[8] Their role as a vector for transmission of VL, in this particular region needs to be delineated. Lymphadenopathy is a common feature in this focus and raises the possibility of a genetically different strain of the genus Leishmania donovani complex as the etiological agent. It has been observed that both L. donovani and Leishmania tropica are responsible for cutaneous leishmaniasis in the region.^[9] HIV co-infection likely influences the presentation of visceral leishmaniasis and Leishmanial lymphadenopathy usually is a feature of immunocompromised state related to HIV infection.

Declaration of patient consent

The authors certify that we have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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