| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Letters to the Editor |
Department of Radiology, Trakya University School of Medicine, 11.kisim, Yasemin apt, D blok, Daire 35 Atakoy, Istanbul, Bak
rköy 34158, Turkeye-mail: demirkemal{at}superonline.com
The case report published by Dr Pérez-Solís and colleagues (1) in the January 2006 issue of Radiology prompted me to write a critical comment that I would like to share with the editorial board and the readers.
In patients infected with human immunodeficiency virus (HIV), it is important to consider visceral leishmaniasis (VL) as a differential diagnosis when the patient has hepatosplenomegaly and an erythrocyte sedimentation rate of over 100 mm per hour. The symptoms, physical examination findings, and laboratory data in the presented patient were all consistent with VL.
The presence of multiple nodular lesions in the spleen on imaging studies associated with micronodular chest findings in a patient infected with HIV is highly suggestive of tuberculosis rather than other causes discussed by Dr Pérez-Solís and colleagues. Also, the presence of a positive tuberculin skin test result 9 months earlier and the fact that the patient had been undergoing treatment with isoniazid for 6 months strengthened the possibility of tuberculosis as an expected opportunistic infection. Thus, in this case the most likely diagnosis, disseminated tuberculosis, is not challenging and must be ruled out at first.
VL, or kala azar, is a severe disease characterized by fever, hepatosplenomegaly, anemia, leucopenia or thrombocytopenia, and hypergammaglobulinemia. It is endemic in the Mediterranean region, including in Spain. In clinically expressed VL, fever, weakness, night sweats, anorexia, and weight loss are common and progress over the course of weeks to months in a manner very similar to tuberculosis. In fact, HIV infection, VL, and tuberculosis can also be seen in the same patient. Darkening of the skin (the term kala azar means black fever in Hindi) is infrequent (2).
Imaging findings of VL may vary. Leishmaniasis that involves the lung often manifests as interstitial pneumonitis but also can be seen as multiple nodules, although this is uncommon (3). There is also a case report (4) about CT and ultrasonographic (US) findings of multiple nodular lesions involving the spleen, which emphasizes that VL should be kept in mind in the differential diagnosis when multiple nodular lesions of the spleen and/or liver are seen on CT and US images.
In conclusion, the expanded differential diagnosis for disseminated tuberculosis must include VL, although the risk of visceralization for a person with HIV who is infected with Leishmania species is typically associated with cutaneous disease, and, in my opinion, the history and imaging findings in the presented case do not clearly exclude VL.
 |
References |
|---|
 TOP References References |
|---|
and
Luis H. Luyando, MD
* Department of Pediatrics Hospital Universitario Central de Asturias, Oviedo, Spain
Department of Radiology, Hospital Universitario Central de Asturias, Oviedo, Spain
Department of Pediatrics, Hospital San Agustín, Camino de Heros, 4, Avilés, Asturias 33006, Spain
e-mail: david.perez{at}sespa.princast.es
We thank Dr Ahualli and Dr Demir for their interest in our disseminated tuberculosis report in Diagnosis Please. Their comments contribute to complete the differential diagnosis of some of our findings.
CMLNS has been reported as multiple cystic mesenteric masses in the absence of mediastinal, retroperitoneal, or inguinal lymphadenopathy (1). Our patient's adenopathy was retroperitoneal, so CMLNS was not included in the differential diagnosis. However, we agree with Dr Ahualli that CMLNS must be considered when CT findings reveal a mesenteric low-attenuation center and contrast-enhanced rim lymph nodes.
On the other hand, as Dr Demir comments, VL has recently been reported as multiple hypoattenuating lesions in liver and spleen (2), so it must be included in the differential diagnosis of splenic abscesses. Nevertheless, to our knowledge, there is no evidence that abdominal lymphadenopathies in VL have a low-attenuation center and contrast-enhanced rim (3). Thus, we do not think the imaging findings support VL as a possible diagnosis in this particular case.
|
References |
|---|
|
TOPReferencesReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
