Visceral Leishmaniasis without Splenomegaly – Atypical presentation

Visceral leishmaniasis (kala-azar) is caused by a protozoan parasite of genus Leishmania. India and neighboring countries comprise the largest focus of VL. Moderate to higher degree of fever accompanied by rigor and hepatosplenomegaly is the most typical clinical picture. We present a case of 50 years old male from Bhadohi (Uttar Pradesh) with high grade fever for 2 months without hepatosplenomegaly. On evaluation, there was bicytopenia with hyper-gammaglobulinemia. Work-up for tropical fever, tuberculosis, chronic viral etiologies and multiple myeloma was negative. Further evaluation on lines of fever of uncertain cause showed amastigote forms of Leishmania donovani (LD bodies) in bone marrow aspiration smears. Serology test rk-39 was positive. Thus final diagnosis of visceral leishmaniasis (kala-azar) with the atypical presentation without splenomegaly was made. Fever totally resolved in a week of starting treatment and blood parameters improved at 1 month follow-up. As definite treatment options are available, duration of illness and case fatality rate can be reduced by timely detection of atypical cases.