Vol.3, No.1, 1-5 (2011) Health
doi:10.4236/health.2011.31001
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Visceral leishmaniasis in an immunocompetent
Hungarian adult patient
Zoltán Péterfi1*, Zsuzsanna Nemes1, Szabolcs Vigvári1, Árpád Szomor1, László Kereskai2,
István Kucsera3, Balázs Tánczos4, Gábor Ternák1
11st Department of Internal Medicine, University of Pécs, Medical Centre, Pécs, Hungary
*Corresponding Author: [e-mail]; The first two authors have equally contributed to the work
2 Department of Pathology, University of Pécs, Medical Centre, Pécs, Hungary
3 Department of Parasitology, National Centre for Epidemiology, Budapest, Hungary
4 Department of Parasitology and Zoology, Faculty of Vete rinary Science, Szent István University, Budapest, Hungary
Received 23 November 2010; revised 1 December 2010; accepted 3 December 2010
ABSTRACT
Background: V isceral leishmaniasis caused by L.
infantum Nicolle 1908 (Kinetoplastida, Trypano-
somatidae) is very rare in immunocompetent
adults. Clinical manifestation of the infection oc-
curs in children and immune-compromised pa-
tients associated with AIDS, haemopoietic ma-
lignancies or after renal, liver, and heart trans-
plantations in Europe. Hungary is regarded free
of leishmaniasis. Except for a single infection in
a small girl without a travel history, only a few
imported cases have been recorded among
Hungarians returning from endemic areas. Case
presentation: Visceral leishmaniasis was diag-
nosed in a 32 years old immumocompetent
Hungarian man who had spent his holidays
during the previous 3 years in Dalma tian territo-
ries (Dubrovnik, Makarska and Trogir) of Croatia.
He had two months history of fever, chills, and
night sweating associated with weight loss.
Physical examination showed mild hepatome-
galy and extreme splenomegaly. The protozoon
infection was confirmed by parasitological, se-
rological and molecular biological methods.
Clinical recovery of the patient was observed
af ter treatm ent with amphotericin B. Conclusion:
We want to highlight the effects of climate
changes and to call attention of health care
professionals in Central and Eastern European
countries to consider the possibility of leishma-
niasis as an emerging disease of tourists re-
turned from endemic regions.
Keywords: V isceral Leishmaniasis; Immunocompetent;
Human; Imported; Hungary; Amphotericin B
1. INTRODUCTION
Leishmaniasis is a group of the protozoan diseases,
transmitted by the bite of sandfly infected with Leish-
mania parasites [1]. The infection of humans appears
with multiple clinical manifestations including cutane-
ous (CL), mucocutaneous, diffuse and visceral (VL)
leishmaniasis. The latter is responsible for approx-
imately 59,000 deaths per year, a parasitic disease sur-
passed only by malar ia [2]. There are two types o f VL,
anthroponotic and zoonotic. Zoonotic VL (ZVL) is
wide spread and occurs in Latin America, Northern
Africa, Southern Europe and in areas of the Middle
East and Asia [2,3].
Two forms of leishmaniasis (VL and CL) present in
Europe are caused by Leishmania infantum [4]. While
cases of cutaneous leishmaniosis were reported in France,
Italy and Spain, ZVL is endemic in all countries border-
ing the Me diterranean Sea [5].
The reservoirs of the pathogen can be several wild and
domestic canid and rodent species but domestic dogs are
considered the main reservoir of L. infantum playing a
key role a s t he sourc e of human infection. Indeed, there is
a clear association between a high rate of infection in
dogs and a n i ncreased risk of human disease [1,2].
Geographically, the distribution of leishmaniasis is li-
mited by the distribution of its vector sandfly species.
The sandfly vectors are mainly active during the night,
and therefore the highest risk for contracting the infective
stages of the parasite from sandfly bites is between dusk
and dawn [6]. Five haematophagous sandfly species of
the subgenus Larroussius belonging to Phlebotomus ge-
nus (Diptera, Psychodidae) are known in Europe as the
vectors of L. infantum. Phlebotomus ariasi and P. perni-
ciosus are present in the western Mediterraneum from the
Iberian to the Italian peninsula, while P. perfiliewi, P.
neglectus and P. tobbi are distributed from Italy across

Z. Péterfi et al. / Health 3 (2011) 1-5
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
2
Balkan to Turkey [4,7,8]. The presence of these vector
species is essential for the endemic transmission of the
parasite among dogs and humans [9]. Another sandfly
species, P. mascitti is mentioned as a suspected vector
species of the parasite which is widely distributed in Eu-
rope with a northern limit in Belgium [6].
Our knowledge of the geographical distribution of
phlebotomine sandflies in Hungary is incomplete due to
the lack of systematic monitoring. According to histori-
cal records a few dozen specimens of P. macedonicus
(recently known as P. perfiliewi) wer e caught a t the sou-
theastern part of the country in the early 1930s [10].
During the recent surveys in the EU FP6 EDEN project
small numbers of two sandfly vectors (P. neglectus and P.
perfiliewi) were trapped close to the Croatian and Ser-
bian borders of the country (Farkas, personal communi-
cation).
In Europe, human VL is considered to be a rare dis-
ease, although its incidence increased significantly in the
region during the 1990s [6], about 700 autochthonous
cases have been reported each year from southern coun-
tries of Europe [3, 11]. Asymptomatic Leishmania infec-
tion of humans is more frequent than clinically apparent
form. Once the clinical illness begins the disease rapidly
progress and patients die due to VL unless treated. The
factors that determine the progress of VL have not yet
been completely identified, but a Leishmania specific
cellular immune response seems to play a fundamental
role in the control of infection [12 ]. After an incubation
period of 2-8 months (range: from 10 days to longer than
2 years), the patient develops pyrexia, wasting, and hepa-
tosplenomegaly which may become excessive. Amasti-
gotes of L. infantum disseminate throughout the reticu-
loendothelial system causing hyperplasia of phagocytic
cells in spleen, liver, bone marrow and sometimes l y mp h
nodes. In endemic European areas most patients are
children [13].
A historical review on human leishmaniasis in Croatia
documents the presence of stable disease foci in coastal
and insular territories of central and southern Dalmatia
since the beginning of the 20th century with a substantial
increase in incidence from the 1990s [14]. In contrast to
the endemic occurrence of the disease in the neighbor
Balkanic countries Hungary is regarded to be free of
leishmaniasis, only imported cases have been reported.
Over 30 cases are known that were imported from the
hyperendemic countries of the Middle East [15] and only
a single human case of ZVL has been diagnosed by
identification of amastigotes from the iliac crest biopsy
in Hungary that originated from the neighboring Croatia
that is regarded hypoendemic for leishmaniasis [16].
2. CASE PRESENTATION
On the 4th November, 2009, a 32 years old man was
admitted to the Department of Internal Medicine, Uni-
versity of Pécs because of two months history of fever,
chills, and night sweating associated with weight loss.
The patient had no history of any kind of previous ill-
nesses. Laboratory results revealed severe pancytopenia:
white blood cell: 0.85 G /l with 24% monocytes, hemog-
lobin: 86 g/l and platelet: 50 G/l. These findings can be
signs of hematological disorders (such as myelodysplas-
tic diseases) or may indicate several infections (e.g.,
brucellosis, Q fever, leishmaniasis). The erythrocyte sedi-
mentation rate and C-reactive protein (135 mg/l) were
elevated but normal level of alanine aminotransferase
and creatinine were observed. The gamma globulin level
was beyond the measurable range (>40 g/l) with de-
creased albumin level and albumin-globulin ratio of 0.4.
Physical examination showed mild hepatomegaly and
extreme splenomegaly (the spleen reached the upper rim
of the pelvis). The patient’s general condition was rela-
tively good. The reason for referral was a suspicion of
malignant hematological disease but the bone marrow
trephine biopsy excluded malignancy. The patient had
never received any transfusions or injections of blood or
blood products before the onset of his illness.
Detailed medical history revealed that the patient
spent his holidays during the previous 3 years in Dalma-
tian territories (Dubrovnik, Makarska and Trogir) of
Croatia. This raised the possibility of an imported “e xot-
ic” disease. Such imported disease which does not occur
in Hungary can be leishmaniasis although immunocom-
petent adults are affected very rarely. Examination of the
immune status of our recent patient excluded immuno-
suppression or HIV-1 co-infection. HIV- 1 test were
negative as well as the blood cultures, the Brucella ag-
glutination and Coxiella burnetti indirect immunofluo-
rescent assays.
The clinical diagnosis of visceral leishmaniasis was
confirmed by detection of amastigotes in bone-marrow
aspirate followed by serological and molecular assays.
Acute-phase serum sample was tested by Leishmania
Western-blot IgG qualitative Immunoblot Assay (Ldbio
Diagnostics, France), that showed well-defined bands
which are indicative for the presence of specific anti-
Leishmania IgG in the sample. The patient’s bone mar-
row aspirate and blood samp le were collected before and
after two week therapy, respectively. These samples
were studied with a L. donovani sl. kDNA minicircle
specific PCR assay [17]. DNA extracted with QIAamp
DNA Mini Kit (QIAgen, Hilden, Germany) was
processed in 25 µl final reaction-volume with RV1 (5’-
CTTTTCTGGTCCCGCGGGTAGG-3’) and RV2 (5’-
CCACCTGGCCTATTTTACACCA-3’) primers (25 pmole
both) and the PCR Core System I. (Promega, Madison,
WI, USA) to amplify an approximately 145 bp long re-
gion of the parasites DNA. Final concentrations

Z. Péterfi et al. / Health 3 (2011) 1-5
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Figure 1. Fragments amplified in the L. dono-
vani sl. kDNA minicircle specific PCR assay.
BM: DNA extracted from bone marrow; BL:
DNA extracted from blood sample; N: negative
control; P: positive control; M: molecular weight
marker.
of the reagents were 1x for GoTaq Green buffer, 2 mM
for MgCl2 and 0.2 mM for each nucleotide, while 1.25
U of GoTaq DNA polymerase and 5 µl of DNA extract
were administered. Amplification was performed on a
Tpersonal 48 thermal cycler (Biometra, Göttingen, Ger-
many). An initial denaturation step for 4 minutes at 94 ˚C,
was followed by 40 cycles of 30 s 94 ˚C denaturation, 30
s 59˚C anellation and 30 s 72˚C elongation. A final ex-
tension at 72˚C for 10 minutes was followed by the hold
step at 4˚C. Products of amplification were visualized in
ethidium bromide stained 1.5% agarose gel. The PCR
assay proved the presence of Leishmania kDNA in the
patient´s bone marrow, but blood sample was negative
probably due to the efficacy of the treatment (Figu re 1).
Amphotericin B of total dose of 20 mg/body weight
was used conform to international recommendations.
After second day of treatment the patient become free of
fever, the leukocyte and platelet count continuously in-
creased reaching 3.63 G/l and 130 G/l respectively.
During treatment only temporary mild creatinine eleva-
tion (156 μmol/l) were observed, which normalized after
hydration. The patient’s spleen size decreased gradually;
on the second week of treatment declining half of the
original size whilst normalize at the end of treatment. In
the follow-up period no relapses were observed.
3. DISCUSSION
Classic ZVL in immunocompetent individuals in
Mediterranean countries is found mainly among children,
although since 1989 an increase in the number of cases
among adults has been observed in south-western Euro-
pean countries mostly (20-70%) due to Leishmania and
HIV-1 co-infectio ns. After a peak in 1990s, the incidence
of co-infections d ecreased notably due to introdu ction of
highly active antiretroviral therapy for AIDS. Even in
those areas as well where leishmaniasis is widespread
the incidences of ZVL among immunocompetent adults
were extremely rare [1,11 ,13,18,19].
Human VL has known to occur in Croatia since 1911,
although the first well-documented, microscopically
confirmed case was reported only in 1930 in the Du
brovnik area [14]. From 1931 through 1957 an average
of 15 cases were recorded yearly in several Dalmatian
territories. Starting from the 1960s, only sporadic cases
of both VL and CL were identified in central and south-
ern Dalmatia [14]. However, a substantial increase was
recorded in VL cases during the recent (1991-1995) w ar
in Croatia and in the post-war period in that region the
most of those cases (64.3%) were found in children be-
low 10 years [14].
Except for a single infection in a small girl without a
travel history [20], only imported human cases have
been recorded in Hungary. Várnai et al. [10] reported 31
cases of cutaneous or visceral leishmaniasis (CL, VL)
among Hungarians returning from endemic areas, and
Fried et al. [16] diagnosed VL in a Hungarian woman
who had spent her holidays in Dalmatia.
In the past two decades VL incidence rates without
HIV-1 co-infection have increased in Italy and France
(including a four-fold increase in Alpes-Maritimes), and
new endemic areas have been detected where no pre-
vious autochthonous cases had been reported (e.g. in
northern Italy, North Croatia, Switzerland and Germany)
[11,21]. The distribution of VL in Europe is significantly
more restricted than the distribution of the sandfly vec-
tors. The transmission of the disease agent within the
range of the vectors depends on vector abundance, vec-
tor survival, vector biting rate (i.e. gonotrophic cycle),
the extrinsic incubation period, and the length of the
transmission season. Each of these parameters is climate
dependent [6]. Climatic changes are likely to extend
northwards the range reached by the sandfly vectors. In
currently endemic areas, higher seasonal temperatures
would lead to prolonged activity periods and shorter
diapauses periods. This could result in an increased
number of sandfly generations per year. In addition,
higher temperatures may accelerate the maturation of the
protozoal parasite, thereby increasing the risk of infec-
tion [6,7,21]. Thus, climate-induced changes may in-
crease the risk of the emergence of new diseases includ-
ing leishmaniasis in Central and Western Europe [22,23].
Imported infected dogs can also contribute to the emer-
gence of leishmaniasis in new locations.
Whereas Hungary is regarded as free of leishmaniasis
the tourist traffic towards to the leishmania endemic re-
gions of Croatia is increasing year by year. So the
chance of appearance of new imported cases can be tak-
en into account. To prevent this greater emphasis should
be placed in education of travellers with a focus on the
available prevention methods.

Z. Péterfi et al. / Health 3 (2011) 1-5
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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4. CONCLUSIONS
Zoonotic VL is a re-emerging disease in the Mediter-
ranean area primarily due to climate induced changes.
Classic clinical pictures of the disease in immunocom-
petent individuals are found mainly among children.
Adults are affected very rare. Nevertheless as our case
suggests the occurrence of ZVL should be also consi-
dered in patients presenting with fever of unknown ori-
gin, hepatosplenomegaly, and pancytopenia who re-
turned from endemic areas.
5. ACKNOWLEDGMENT
The authors acknowledge the support provided by Prof. Róbert Far-
kas, Eszter Barna, Gábor Kovács and Zsofia Feiszt.
The molecular work was funded by EU grant GOCE-2003-010284
EDEN (Emerging Diseases in a changing European eNvironment)
and is catalogued by the EDEN Steering Committee as EDEN0236
(www.edenfp6project.net). The contents of this publication are the
sole responsibility of the authors and do not necessarily reflect the
views of the European Commission.
This work was supported by PTE ÁOK-KK grant No: 2010/10-23.
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