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versión impresa ISSN 1130-0108
Rev. esp. enferm. dig. vol.104 no.6 jun. 2012
LETTERS TO THE EDITOR
Visceral leishmaniasis diagnosed by double balloon enteroscopy
Leishmaniasis visceral diagnosticada por enteroscopia de doble balón
Key words: Leishmaniasis. Double ballon enteroscopy.
Palabras clave: Leishmaniasis. Enteroscopia de doble balón.
Leishmaniasis is a parasitic disease caused by different species of the protozoan genus Leishmania that infect animals as well as humans. It is transmitted by the bite of infected female phlebotomine sandflies. There are three forms of leishmaniasis: cutaneus, mucocutaneus and visceral. Leishmania Donovani is the responsible for the visceral form and it causes fever, general discomfort and spleen and liver enlargement. Diagnosis of visceral leishmaniasis (VL) may require taking a blood sample and/or a biopsy from the affected tissue to show the parasite.
We report the case of a 37-years-old male with HIV infection and levels of CD4 < 100/mm3, who was admitted in our area because of watery diarrhea and fever. During his stay at the hospital, he went on with the diarrhea and secondarily malnutrition, severe pancytopenia, and colostatic liver injury with suprarenal failure. In the study of diarrheic stools culture were normal, gastroscopy and colonoscopy without findings, analysis and oral double balloon enteroscopy (DBE) taken up to medium ileum did not found mucosal lesions. Biopsies were taken at different levels. Biopsies taken in half jejunum and middle and proximal ileum by DBE made it possible to establish a definitive diagnosis making objective chronic inflammation by Leishmania (Fig. 1).
Visceral involvement by Leishmania appears in immunocompromised patients, mainly affected by HIV with CD4 < 200 and can affect liver, spleen, bone marrow or digestive tract. Gastrointestinal affectation is rare, being the most common location the small bowel, specifically the duodeno (1). The clinical picture is characterized by watery diarrhea, malabsorption, hypoalbuminemia, and malnutrition. The diagnosis of enteric VL is histological, identifying the parasite inside macrophages of the intestinal lamina propria. A characteristic endoscopic image of this invasion has not been described so far. Images similar to a gastroduodenitis or of a peptic ulcer disease have been described, but in 50% cases endoscopic vision is normal and the diagnosis is established by taking biopsies (2). Several cases of duodenal involvement by Leishmania have been reported in the recent years (3-5). It has been described gastric involvement in the form of epigastralgia and upper gastrointestinal bleeding, and also esophageal involvement, which manifests itself by dysphagia and odinophagia (6,7), but we have not found any case published in which a double balloon enteroscopy has allowed to determine the definitive diagnosis by biopsy of jejunum-ileum.
If the clinical picture makes you think of VL with small bowel involvement and all conventional studies have no findings, a DBE should be performed in search of visceral involvement in jejunum-ileum, areas not accessible to conventional endoscopy, because an early and appropriate treatment after the diagnostic confirmation of LV is necessary in these patients.
Rosa Gómez-Espín, Eliana Fuentes, María Isabel López-Espín, Paloma Bebia, Pilar Esteban,
Silvia Chacón, José Luis Rodrigo, Antonio López-Higueras and Enrique Pérez-Cuadrado
Department of Digestive Diseases. Hospital Morales Meseguer. Murcia, Spain
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2. Laguna F, García-Samaniego J, Soriano V, Valencia E, Redondo C, Alonso MJ, et al. Gastrointestinal leishmaniasis in human inmunodeficiency virus-infected patients: report of five cases and review. Clin Infect Dis 1994;19:48-53. [ Links ]
3. Del Olmo Martínez L, Aller de la Fuente R, Velayos Jiménez B, Fernández Salazar L, González Hernández JM. Visceral leishmaniasis diagnosed by duodenal biopsy. Rev Esp Enferm Dig 2009;101(6):439-40. [ Links ]
4. Egea Valenzuela J, Baños Madrid R, Rodrigo Agudo JL, Galera Peñaranda C, Torroba A, Molina Martínez J, et al. Duodenal leishmaniasis in a HIV patient. Rev Esp Enferm Dig 2009;101(1):60-2. [ Links ]
5. Ellul P, Piscopo T, Vassallo M. Visceral leishmaniasis diagnosed on duodenal biopsy. Clin Gastroenterol Hepatol 2007;5(7):A26. [ Links ]
6. Wilson ME, Streit JA. Visceral leishmaniasis. Gastroenterol. Clin North Am 1996;25:535-51. [ Links ]
7. Villanueva JL, Torre-Cisneros J, Jurado R, et al. Leishmania esophagitis in an AIDS patient: an unusual form of visceral leishmaniasis. Am J Gastroenterol 1994;89:273-5. [ Links ]