368. Successful treatment of resistant visceral leishmania with repeated trial of Liposomal Amphotericin B- A Case Report

Abstract

Background. Although visceral leishmaniasis is endemic in various parts of India, management is still a challenge due to multiple drug resistance. Here we describe a case of a 50 years old female who was diagnosed with visceral leishmaniasis at a tertiary care hospital in northern parts of India and was managed with a repeated trial of liposomal Amphotericin B. Methods. Case Discussion: The patient presented in the outpatient department with recurrent fever, mild intermittent abdominal discomfort associated with generalized weakness for the past one month. On per abdomen examination the patient had splenomegaly with spleen palpable 8 cm below the left costal margin. Blood investigations were suggestive of pancytopenia (leukocyte of 1800/cumm, Hemoglobin 7 g/dl, Platelet count: 80,000/ cumm) along with severe neutropenia (Absolute neutrophil count: 400/cumm) . The CT abdomen showed massive splenomegaly (23 cm) with mild hepatomegaly . Leishmania Immunoglobulin G was positive. Bonemarrow biopsy revealed hyperproliferativemarrow with plasmacytosis (12-15%). Bone marrow Leishman-Donovan bodies were negative. Serum immunofixation was negative forMspike and serumlight chain assay was also negative. She was managed with liposomal Amphotericin B (3mg/kg) for 7 days and was subsequently discharged. After 3 months, the patient again presented with continuous fever, lethargy, running nose, palpitations. Her blood work-up revealed severe pancytopenia again. She was tested for Leishmania anti- rk39 antibody, which was positive. She was given a repeat trial of Liposomal Amphotericin B with a different regimen-3mg/kg dose on Day 1 to 5, followed by 6th dose on Day 14, followed by 7th dose on Day 21, as per the FDA approved regimen. Patient recovered well. The most recent total leukocyte counts eventually improved to 4800 with normal differential count. Platelets increased to 180,000, Hemoglobin was around 10.8g/dl and spleen was non palpable on physical examination. Results. Treatment of leishmania can become complicated due to resistance to various drugs especially when a single agent is being given. Conclusion. But in resource limited countries different regimens of liposomal amphotericin B can be tried which might be helpful due to speedy clinical recovery and cost effectiveness.