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Pancytopenia, needles, and parasites

The patient presented with a two month history of fever, dyspnoea, and fatigue. On examination she was pallid and had moderate splenomegaly. Laboratory studies showed pancytopenia. The patient had a history of injecting drug use and was HIV positive with a low CD4 count, suggesting increased risk of opportunistic infection. Leishmaniasis is endemic in some parts of southern Europe (primarily caused by L infantum), with subtypes of visceral, cutaneous, and mucosal leishmaniasis. Visceral leishmaniasis affects the spleen, liver, and bone marrow and should be considered in patients presenting with pancytopenia, fever, and splenomegaly. Direct transmission of leishmania parasites through sharing needles has been documented in Spain, predominantly in injecting drug users with HIV.1 This coinfection poses a challenge for diagnosis and treatment of leishmaniasis, because of the more severe clinical manifestations, higher risk of fulminant reactivation, and treatment failure when immunity is compromised.2