Oztoprak Nefise, Aydemir Hande, Pişkin Nihal, Seremet Keskin Ayşegül, Araslı Mehmet, Gökmen Ayla, Celebi Güven, Külekçi Uğur Aslıhan, Taylan Özkan Ayşegül
Zonguldak Karaelmas Üniversitesi Tıp Fakültesi, Enfeksiyon Hastalıkları Anabilim Dalı, Zonguldak, Türkiye.
Mikrobiyol Bul. 2010 Oct;44(4):671-7.
Visceral leishmaniasis (VL) which is a chronic disease caused by the protozoon, Leishmania, occurs widely worldwide and it is widespread in most of the countries in the Mediterranean basin. The infection which is transmitted by a sandfly (Phlebotomus) vector, has a prolonged incubation period and insidious onset. VL generally affects children and may be fatal if not treated. In this report, a 31 years old male patient, who was the first adult VL case from Zonguldak (a province located at western Black-Sea region of Turkey) was presented. He was admitted to the hospital with two-months history of fever, chills, sweating and weight loss. There was no history of travel outside the city nor insect bites, however, he indicated that there would be unnoticed sandfly bites since sandflies were very common in the coal mines he worked. His physical examination revealed body temperatue of 39.2°C and hepatosplenomegaly, while laboratory findings yielded anemia, leucopenia, hypoalbuminemia and hypergamaglobulinemia. Erythrocyte sedimentation rate was 62 mm/h, C-reactive protein was 113 mg/L and liver transaminases were 2 to 5 folds higher than the reference values. The only pathological finding was hepatosplenomegaly in the abdominal ultrasound and computerized tomography. He was further examined to rule out infections with similar signs and symptoms, connective tissue diseases and malignancies and all were found negative. Hypercellular bone marrow were detected in the aspiration material. Bone marrow smears, bone marrow samples inoculated in NNN medium and serum samples of the patient were sent to the reference parasitology laboratory of Refik Saydam National Public Health Agency for evaluation in terms of VL. The diagnosis was confirmed by the detection of Leishmania IgG titer as 1/512 with in-house indirect immunofluorescence antibody test, by positivite rK39 Dipstick (InBios, USA) test and by the observation of Leishmania amastigote forms in the bone marrow smears. Bone marrow culture in NNN medium also revealed positive result by the determination of Leishmania promastigote forms on the 7th day. The treatment was initiated by pentavalent antimony [glucantime 1 x 10 mg/kg/day intramuscular (IM)] however, due to severe adverse effects it has switched to liposomal amphotericin B (3 mg/kg/day). The patient completely recovered without complication. In conclusion VL should be considered in the differential diagnosis of patients, even adults, with persistent fever, hepatosplenomegaly and pancytopenia, in endemic countries such as Turkey.
内脏利什曼病（VL）是由原生动物利什曼原虫引起的一种慢性疾病，在全球广泛流行，在地中海盆地的大多数国家都有分布。该感染通过白蛉（Phlebotomus）传播，潜伏期长，起病隐匿。VL一般影响儿童，若不治疗可能致命。在本报告中，介绍了一名31岁男性患者，他是宗古尔达克（土耳其黑海地区西部的一个省份）的首例成人VL病例。他因发热、寒战、出汗和体重减轻两个月的病史入院。他没有出城旅行史或昆虫叮咬史，但他表示，由于他工作的煤矿中白蛉非常常见，可能有未注意到的白蛉叮咬。体格检查发现体温39.2°C，肝脾肿大，实验室检查结果显示贫血、白细胞减少、低白蛋白血症和高球蛋白血症。红细胞沉降率为62mm/h，C反应蛋白为113mg/L，肝转氨酶比参考值高2至5倍。腹部超声和计算机断层扫描的唯一病理发现是肝脾肿大。对他进行了进一步检查，以排除具有类似症状和体征的感染、结缔组织疾病和恶性肿瘤，结果均为阴性。骨髓穿刺材料中检测到细胞增多。将骨髓涂片、接种于NNN培养基的骨髓样本以及患者的血清样本送至Refik Saydam国家公共卫生机构的参考寄生虫学实验室进行VL评估。通过内部间接免疫荧光抗体试验检测到利什曼原虫IgG滴度为1/512、rK39试纸条（美国InBios公司）检测呈阳性以及在骨髓涂片中观察到利什曼无鞭毛体形态，确诊了该疾病。NNN培养基中的骨髓培养在第7天通过检测到利什曼前鞭毛体形态也显示出阳性结果。治疗开始时使用五价锑[葡甲胺1×10mg/kg/天，肌肉注射（IM）]，但由于严重不良反应，改为脂质体两性霉素B（3mg/kg/天）。患者完全康复，无并发症。总之，在土耳其等流行国家，对于持续发热、肝脾肿大和全血细胞减少的患者，即使是成人，在鉴别诊断中也应考虑VL。
