amphotericin-b and Cryoglobulinemia

BACKGROUND Visceral leishmaniasis (VL) is an endemic systemic disease in the Mediterranean countries, including Spain. This vector-borne infection can present with several clinical presentations, from asymptomatic to severe forms. Renal impairment is frequently described in VL but is usually mild and related to interstitial nephritis, being that glomerular involvement is rarely found. CASE REPORT We describe a case of a 69-year-old Spanish male presenting with subacute renal failure due to membranoproliferative glomerulonephritis and mixed cryoglobulinemia accompanied by other autoimmune features (hypocomplementemia, antinuclear and antiDNA antibodies). No hepatosplenomegaly was found with abdominal ultrasound. Hepatotropic viruses and human immunodeficiency virus serological markers were negatives. We initially suspect the presence of an autoimmune disease and the patient was treated with steroids without improvement. After an extensive study including renal and bone marrow biopsy, a correct diagnosis of visceral leishmaniasis was made, and treatment with liposomal amphotericin B was initiated, achieving renal function recovery and normalization of immunological manifestations. CONCLUSIONS Renal involvement can be an important feature of VL and it might be associated with increased morbidity and mortality. The association between mixed cryoglobulinemia and renal involvement in VL have rarely been described. VL is frequently associated with diverse autoimmune manifestations and it can be initially misdiagnosed, which could lead to fatal consequences. The role of the immune system in the formation of cryoglobulins are discussed. In our case, an autoimmune disease was initially suspected, and starting treatment with steroids pulses was initiated. However, the presence of mixed cryoglobulinemia in this patient who was hepatitis C serological marker negative and who had poor renal function recovery after immunosuppressive treatment made us suspect other pathologies. The presence of cryoglobulinemia with renal disease in endemic areas of Leishmania should make us exclude this infection before starting immunosuppressive treatment.

Topics: Aged; Amphotericin B; Antiprotozoal Agents; Biopsy; Cryoglobulinemia; Glomerulonephritis, Membranoproliferative; Humans; Leishmania; Leishmaniasis, Visceral; Male; Renal Insufficiency; Urine

Topics: Amphotericin B; Antiprotozoal Agents; Arthritis, Rheumatoid; Bone Marrow; Bone Marrow Examination; Cryoglobulinemia; Cryoglobulins; Female; Humans; Immunocompromised Host; Incidental Findings; Leishmaniasis, Visceral; Middle Aged

Topics: Absidia; Aged, 80 and over; Amphotericin B; Anemia, Hemolytic, Autoimmune; Antibodies, Monoclonal, Murine-Derived; Antifungal Agents; Combined Modality Therapy; Cryoglobulinemia; Cyclophosphamide; Debridement; Dexamethasone; Fatal Outcome; Female; Humans; Immunocompromised Host; Immunosuppressive Agents; Leukemia, Lymphocytic, Chronic, B-Cell; Liposomes; Mucormycosis; Purpura, Thrombocytopenic, Idiopathic; Rituximab

Visceral leishmaniasis may present with cytopenias along with the formation of many autoantibodies and, rarely, with the presence of mixed cryoglobulinemia, type II, resembling an autoimmune disease. The syndrome of mixed cryoglobulinemia is characterized by the triad of purpura, arthralgias, and asthenia, in conjunction with cryoglobulins in the serum. In this article mixed cryoglobulinemia, type II, was diagnosed in a negative for hepatitis B or C patient suffering from visceral leishmaniasis. Antimicrobial therapy against leishmania eliminated the cryoglobulin titer, as well as the clinical manifestations of cryoglobulinemia. The role of the immune system and the type of immune response for the formation of cryoglobulins are discussed.

Topics: Aged, 80 and over; Amphotericin B; Antiprotozoal Agents; Bone Marrow; Cryoglobulinemia; Humans; Leishmaniasis, Visceral; Liposomes; Male; Purpura, Hyperglobulinemic; Treatment Outcome