误诊为丙型病毒性肝炎肝硬化的内脏利什曼病1例

A case of visceral leishmaniasis misdiagnosed as liver cirrhosis induced by hepatitis C

患者,男,74岁,农民,山西省阳泉市平定县人。2023年1月因咳嗽、咳痰伴全身乏力就诊于当地医院,诊断为支原体、新型冠状病毒等合并肺部感染伴轻度贫血,予持续吸氧、抗感染等对症治疗后暂时好转。后患者仍因反复全身乏力,于多家医院治疗长达6月余,7月10日至山西医科大学第一医院感染病科就诊。入院查体:间断低热,贫血貌,全身皮肤可见搔抓后瘢痕伴色素沉着,腹软、膨隆,肝、脾大,双下肢轻度水肿。血常规示白细胞计数2.4×109/L,血红蛋白62.0 g/L,红细胞计数2.09×1012/L,血小板计数94×109/L;丙型肝炎病毒抗体阳性;腹部CT示,肝硬化、肝大、脾大;腹部彩超示,腹腔积液;肝脏瞬时弹性硬度值24.7。初步诊断为丙型病毒性肝炎肝硬化。行骨髓穿刺,涂片示粒细胞胞浆内可见中毒颗粒,未见利什曼原虫。7月17日复查,ELISA检测结果示丙型肝炎病毒抗原及抗体均为阴性,荧光定量PCR检测结果为丙型肝炎病毒核酸低于1.0×103 IU/ml,发现初诊有误。患者曾多次因贫血输血,有多次流浪犬接触史,白蛉叮咬史不详。血清经内脏利什曼病rK39免疫层析试纸检测为阳性,全血病原微生物高通量基因检测示利什曼原虫属DNA序列数检出4101条,其中婴儿利什曼原虫DNA序列数检出95条,最终确诊为内脏利什曼病。予葡萄糖酸锑钠注射液肌肉注射1疗程(6 ml/d,10 d),同时保肝、补充人血白蛋白、输注浓缩红细胞、补液、利尿等治疗共15 d后,患者体温恢复正常,B超检查示肝脏及脾脏体积明显缩小,皮肤瘙痒及皮损改善,病情稳定后出院。

The individual was a 74-year-old farmer from Pingding district of Yangquan City,Shanxi Province.In January 2023,he went to the local hospital due to cough,expectoration and general fatigue.He was diagnosed with mycoplasma,SARS-Cov-19 and other pulmonary infections with mild anemia.The condition temporarily improved after receiving ongoing oxygen therapy and antimicrobial treatment.The patient continued to experience repeated systemic fatigue and was treated in multiple hospitals for over 6 months.On July 10th,he went to the Department of Infectious Diseases at the First Hospital of Shanxi Medical University for treatment.Admission examination:The patient had intermittent low fever,anemic appearance,skin pigmentation from scratching,ascites,soft abdomen and distended,hepatomegaly,splenomegaly,mild lower limb edema.Blood tests showed a leucocyte count of 2.4×109/L,hemoglobin 62.0 g/L,red blood cell count of 2.09×1012/L,platelet count of 94×109/L,and hepatitis C virus antibody positive,abdominal CT noted cirrhosis,hepatomegaly,splenomegaly,while abdominal ultrasound revealed ascites,and liver transient elastography was 24.7,the initial diagnosis was hepatitis C virus cirrhosis.Bone marrow puncture and smear analysis revealed toxic granules in neutrophil cytoplasm and the absence of Leishmania.During a reexamination on July 17th,ELISA returned negative for hepatitis C virus antigen and antibody,and fluorescence quantitative PCR detected hepatitis C virus nucleic acid concentration below 1.0×103 IU/ml,implying misdiagnosis initially.The patient had a history of multiple blood transfusions for anemia and had multiple contact histories with street dogs.The history of sandfly bites was unclear.The rK39 immunochromatography strip result and subsequent high-throughput nucleotide sequencing of pathogenic microorganisms identified 4101 Leishmania DNA sequences,including 95 Leishmania infantum DNA sequences,confirming leishmaniasis.Following treatment with sodium stibogluconate injection(6 ml/d,10 d),the temperature remained normal,liver and spleen sizes significantly decreased,and skin lesions improved after 15 days of therapy,involving liver protection,protein and red blood cell transfusion,fluid replacement,and diuresis.