Endoscopy 2021; 53(12): E440-E441
DOI: 10.1055/a-1328-2365
E-Videos

Unusual endoscopic findings in an immunosuppressed patient

1  Virgen Macarena University Hospital, Endoscopy Division, Sevilla, Spain
2  Hospital Vithas Nisa Sevilla, Endoscopy Unit, Sevilla, Spain
,
1  Virgen Macarena University Hospital, Endoscopy Division, Sevilla, Spain
2  Hospital Vithas Nisa Sevilla, Endoscopy Unit, Sevilla, Spain
,
Juan Rios-Martin
3  Virgen Macarena University Hospital, Pathology Division, Sevilla, Spain
,
Federico Argüelles-Arias
4  Virgen Macarena University Hospital, Gastroenterology Division, Sevilla, Spain
5  University of Seville, Department of Medicine, Seville, Spain
,
Adoracion Valiente-Mendez
6  Virgen Macarena University Hospital; Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva; Universidad de Sevilla and Instituto de Biomedicina de Sevilla, Seville, Spain
,
Pedro Hergueta-Delgado
1  Virgen Macarena University Hospital, Endoscopy Division, Sevilla, Spain
,
Angel Caunedo-Alvarez
1  Virgen Macarena University Hospital, Endoscopy Division, Sevilla, Spain
4  Virgen Macarena University Hospital, Gastroenterology Division, Sevilla, Spain
› Author Affiliations

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.

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Fig. 1 Marked edema of villi and whitish nodularity in the proximal duodenum.
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Fig. 2 Isolated erythematous nodules in the jejunum (arrows).
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Fig. 3 Atrophic and patchy duodenal pattern with whitish nodularity observed on esophagogastroduodenoscopy.

Video 1 Unusual endoscopic findings in an immunosuppressed patient.


Quality:
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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.

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Publication History

Publication Date:
27 January 2021 (online)

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