Unusual endoscopic findings in an immunosuppressed patient

Immunosuppressed patients are susceptible to infections by opportunistic agents such as Leishmania that could cause visceral leishmaniasis with gastrointestinal involvement in up to 10 % of cases.

We report a 41-year-old man with human immunodeficiency virus (HIV) infection stage C3 with CD4 lymphocytes 81/mm³, 4,070 leukocytes (47.2 % lymphocytes, 0.0 % eosinophils, rest of differential normal) treated with antiretroviral therapy (dolutegravir/abacavir/lamivudine) with good adherence. He also reported mesangiocapillary glomerulonephritis type-1, hepatocutaneous porphyria, and a 7-year history of recurrent visceral leishmaniasis treated with liposomal amphotericin B as secondary prophylaxis. Esophagogastroduodenoscopy and colonoscopy indicated for chronic diarrhea and anemia performed 5 years ago displayed antral erythema, mild nodular appearance in the duodenal mucosa, and normal colonic mucosa. Gastric, duodenal, and colonic biopsies revealed Leishmania spp despite treatment with liposomal amphotericin B.

A video capsule endoscopy (VCE) was now indicated for persistent diarrhea. Enteropathy with atrophic and patchy, marked edema of the villus, and whitish nodularity with a “river bedrock” appearance ([Fig. 1 – 3]) in the duodenum and jejunum were identified ([Video 1]). Further gastric and duodenal biopsies showed an accumulation of macrophages in the lamina propria of the mucosa with intracytoplasmatic Leishmania spp ([Fig. 4]). Treatment with meglumine antimoniate was initiated owing to previous failure with liposomal amphotericin B, without response.

Fig. 1 Marked edema of villi and whitish nodularity in the proximal duodenum.

Fig. 2 Isolated erythematous nodules in the jejunum (arrows).

Fig. 3 Atrophic and patchy duodenal pattern with whitish nodularity observed on esophagogastroduodenoscopy.

Video 1 Unusual endoscopic findings in an immunosuppressed patient.

Fig. 4 Accumulation of macrophages in the lamina propria of the mucosa with amastigotes of Leishmania protozoa in their cytoplasm; hematoxylin and eosin, × 40.

Some cases of visceral leishmaniasis showing non-specific findings (atrophy, edema, and whitish nodular mucosa) on esophagogastroduodenoscopy have been reported [1] [2], with the mucosa appearing normal in up of 45 % of cases [3] [4]. There is only one case reporting VCE findings of visceral leishmaniasis in an immunocompromised patient with a diffuse intestinal atrophic pattern [5]. We observed a similar enteropathy, although in a patchy distribution, on VCE and esophagogastroduodenoscopy. Atrophic enteropathy displayed as a “river bedrock” appearance would be a possible sign of an advanced stage of life-threatening visceral leishmaniasis. VCE may provide useful information on diagnoses, extension, and severity of gastrointestinal lesions in patients with severe immunosuppression and gastrointestinal symptoms.

Endoscopy_UCTN_Code_CCL_1AC_2AG

• References

• 1 Samiullah S, Dinneen HS, Klein KM. et al. Endoscopic appearance of duodenal mucosa in GI leishmaniasis. Gastrointest Endosc 2013; 78: 962-963
• 2 Egea Valenzuela J, Baños Madrid R, Rodrigo Agudo JL. et al. Duodenal leishmaniasis in a HIV patient. Rev Esp Enferm Dig 2009; 101: 60-62
• 3 Laguna F, García-Samaniego J, Soriano V. et al. Gastrointestinal leishmaniasis in human immunodeficiency virus-infected patients: report of five cases and review. Clin Infect Dis 1994; 19: 48-53
• 4 Gómez-Espín R, Fuentes E, López-Espín MI. et al. Visceral leishmaniasis diagnosed by double balloon enteroscopy. Rev Esp Enferm Dig 2012; 104: 333-334
• 5 Marinoni B, Tontini GE, Maggioni M. et al. Intestinal leishmaniasis: a rare case of enteropathy. Endoscopy 2020; 52: E335-E336