Nephrotic syndrome in a patient with visceral leishmaniasis: a case report

Abstract

A 48-year-old woman from Kalutara, Sri Lanka returned after a 2-year stay in Dubai, United Arab Emirates as a domestic helper because of fever of one month. She was investigated at a local hospital for 2 months and later admitted to the National Hospital of Sri Lanka. On admission, she had fever, bilateral ankle swelling, anaemia and splenomegaly. She had nephrotic syndrome, pancytopenia, high ESR with ANA titre of 1:40. She developed rapid painful enlargement of spleen beyond the umbilicus 3 weeks after the initial admission. Light microscopy of splenic biopsy demonstrated Leishmania amastigotes, which was confirmed with splenic biopsy culture and bone marrow culture. She was treated with liposomal amphotericin B 3 mg/kg per day for 8 days, which was later withheld following a severe drug reaction. She made a partial recovery as indicated by remission of fever spikes, reduced size of the spleen, and haematological improvement. Parenteral nutrition and intravenous albumin were administered to prevent further hypoalbuminaemia. Routine splenectomy was planned but she refused surgery. At 11 weeks of hospital stay, she developed severe pain in the splenic area and ultrasound scan detected intrasplenic bleeding indicating urgent splenectomy. Her post-operative period was complicated by extravazation of fluid into the peritoneum due to hypoproteinaemia and she died on post-operative day 4 in the surgical intensive care unit.