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Pathologic Quiz Case: A Patient With Acquired Immunodeficiency Syndrome and Endobronchial Lesions

2001; American Medical Association; Volume: 125; Issue: 11 Linguagem: Inglês

10.5858/2001-125-1511-pqcapw

1543-2165

Fernando López‐Ríos, Carmen González-Lois, Teresa Sotelo,

Eosinophilic Esophagitis

The patient was a 59-year-old homosexual man, who was first noted to be positive for human immunodeficiency virus (HIV) 3 years earlier. Subsequently, he was diagnosed as having hepatitis B, oral candidiasis, central nervous system toxoplasmosis, and perirectal herpes simplex virus. He owned a cat and a dog. The remainder of his past medical history was noncontributory.The patient was referred to the University Hospital in Madrid, Spain, because of a month-long history of shortness of breath and fatigue. On admission, a chest radiograph showed bilateral interstitial lung infiltrates. His CD4+ T-cell count was less than 200 cells/μL. Diagnostic bronchoscopy was performed, which showed endobronchial lesions consistent with pulmonary Kaposi sarcoma. Microscopic examination revealed numerous macrophages in the submucosa below the bronchial epithelium (Figure 1). This feature was better appreciated by Giemsa stain (Figure 2). Subsequent bone marrow biopsy showed identical images. The diagnosis was confirmed by culture, but speciation was not possible. The patient died shortly thereafter of multiorgan failure. An autopsy was not performed.What is your diagnosis?Visceral leishmaniasis is endemic in certain parts of Southern Europe, so it should be considered in HIV-positive patients living in or traveling to these areas.1–3 For example, 31.5 million people visited Spain in the first half of the year 2000.4 It is interesting to note that a significant travel history may be obtained from patients in cases developing in nonendemic areas.3,5 This issue is further complicated by the occurrence of atypical clinical forms (solitary pulmonary nodule, pleural effusion, endobronchial lesions, etc), which enhance the need for histologic study in this setting.1–3,6,7 The amastigotes are mainly found in skin, liver, gastrointestinal tract, lymph node, and bone marrow specimens.1–3 In this regard, cytologic examination often permits a specific diagnosis, thereby avoiding unnecessary procedures.8 Although Leishmania species have been identified in bronchoalveolar lavage specimens,1,5 diagnosis of visceral leishmaniasis on bronchial biopsies appears to be distinctly uncommon.1–3,9 Intracellular and extracellular Leishmania amastigotes are found below the bronchial epithelium. A recently reported case in an immunocompetent man showed only noncaseating granulomatous inflammation with multinucleated giant cells. The diagnosis was based on a positive polymerase chain reaction. Molecular evidence of Leishmania species was pursued using kinetoplast minicircle DNA-specific primers.9 Although such an approach may be useful in cases with scant evidence of parasites, most leishmaniasis in HIV-positive patients can be diagnosed by histology alone.Differential diagnosis includes other intracellular microorganisms.8 Leishmania species amastigotes are round and exhibit paranuclear bodies (kinetoplasts). Giemsa is the stain of choice. Histoplasma appears as a silver-stained structure with halo effect. Toxoplasma usually affects somatic cells and shows a characteristic crescentic shape. Finally, pathologists should remember that Leishmania species may coexist in the same surgical specimen with other acquired immunodeficiency virus–related diseases (mycobacteriosis, cytomegalovirus infection, Kaposi sarcoma, etc).1,10In summary, we have shown an apparently unique case in which initial diagnosis of visceral leishmaniasis was unexpectedly made on bronchial biopsies. This case illustrates the importance of considering visceral leishmaniasis in HIV-positive patients. Unusual clinical presentations could be promptly diagnosed if histologic diagnosis is performed.We thank the Department of Internal Medicine, "12 de Octubre" University Hospital, Madrid, Spain, for clinical information. We are also grateful to Melchor Baixas, BA, in Economics, for excellent bibliographic help.