Leishmaniasis is endemic in India, Bangladesh, Nepal, parts of Africa, southwest Asia, Spain, as well as other Mediterranean coast. In Indian subcontinent, transmission is anthroponotic and humans are the reservoir. Cell-mediated immunity determines the outcome of infection, and hence only minority of infected individuals develop clinically apparent disease. The immunological response, particularly interleukin-12 driven Th1 response has been widely accepted as promoting protective immunity against all species of leishmania. Immunosuppressive drugs used in transplant patients hamper T-cell activation and proliferation, thereby altering defense mechanisms against intracellular microorganisms. With increasing frequency of renal transplantation as the preferred renal replacement treatment modality, several cases of visceral leishmaniasis are being detected in renal transplant recipients. Among the organ transplant leishmaniasis disease, renal transplant patients are more commonly affected than others.[1
] The immunosuppressive regimen used that is most commonly seen with disease is: Cyclosporine plus azathioprine and steroids.[1
] The total number of cases reported in renal transplant is less than 100.[2
Hernandez-Perez et al
. reported five cases of leishmaniasis in solid organ transplant recipient out of which three were renal transplant recipients.[3
] Oliveira et al
. reported eight cases (1%) of leishmaniasis in renal transplant recipients.[4
] Veroux et al
. reported five renal transplant recipients presenting in early post-transplant period and eventually leading to graft loss in two.[2
] The median time between transplantation and the onset of disease is 18 months.[1
] It presents with fever (94%), hepatomegaly (42%), splenomegaly (75%), and pancytopenia (85%).[1
] Lymphadenopathy in not commonly seen in transplant patients.[1
] Our patient had classical presentation of fever, splenomegaly, pancytopenia suggesting bone marrow suppression and in addition, lymphadenopathy. He had the deranged liver function test in form of mild hyperbilirubinemia, hypoalbuminemia, and elevated AST and ALT.
Definitive diagnosis of visceral leishmaniasis requires demonstration of parasite. Histopathological diagnosis rests on visualization of amastigotes, which are spherical, or ovoid bodies measuring 1 to 5 μm. Culture requires inoculation in Novy-McNeal-Nicolle or other parasitic growth media.[5
] Other diagnostic methods include serum antibody tests using IFA, ELISA, or DAT. The diagnosis of VL and ML in our case was done on the basis of biopsy of the lymph node, bone marrow, and vocal cord lesion, which provided unequivocal evidence of Leishman–Donovan bodies.
Laryngeal involvement in leishmaniasis is a rare presentation even in general population.[6
] It can either present with other systemic manifestations or isolated laryngeal involvement.[7
] Mucosal involvement of the nose, oral cavity, pharynx, or larynx occurs in 2–5% of persons infected with Leishmania braziliensis.[11
] Nandy et al
. described three cases of post kala-azar dermal leishmaniasis presenting with hoarseness of voice and biopsy of nodular lesions on vocal cord confirmed leishmaniasis in nontransplant patients.[10
] In separate reports, authors have described isolated laryngeal involvement in immunocompetent patients.[6
] Some of the patients have presented like mass lesions simulating neoplasia. Despite extensive pubmed literature search, we could not find a report of vocal cord leishmaniasis in a renal allograft recipient.
Agents used for treatment of visceral leishmaniasis include amphotericin B, pentavalent antimonial drugs, paromomycin, and miltefosine. Liposomal amphotericin B has highest therapeutic efficacy and it is safest among all these,[12
] although conventional amphotericin B has considerable renal toxicity. In India and Nepal, high level of resistance to antimonial drugs has been observed and hence amphotericin B is being used as first line agents.[14
Although leishmaniasis is a rare disease in a post-transplant setting even in endemic areas, it has got high morbidity and mortality in untreated cases. Clinical presentation may be atypical and high index of suspicion is a prerequisite for timely evaluation and appropriate treatment which can be life saving.