Letters

Journal of Postgraduate Medicine April 2015 Vol 61 Issue 2 145

Offender: Virus or parasite or bothSir,A very interesting report has been described by the authors, in which a toddler developed hemophagocytic lymphohistiocytosis (HLH) after coinfection with Epstein-Barr virus (EBV) and Leishmania.[1] We also had experience with EBV infection where the clinical profile was suggestive of acute leukemia in two patients, but ultimately one was diagnosed as having infectious mononucleosis while the other was found to have HLH.[2] The case described by the authors is unique in many aspects. Primary HLH is more commonly seen in infants as compared to adults although the latter are not immune from HLH secondary to infections. The toddler here had a coinfection with EBV as well as leishmania. A workup for secondary immunodeficiency should also have been done, including serology against human immunodeficiency virus (HIV). Antibody to rK39 antigen carries a sensitivity and specificity above 90% for diagnosis of visceral leishmaniasis and can help to avoid costly tests like polymerase chain reaction (PCR).[3] It is not mentioned whether Antibody against rK39 antigen was done or not. Whether HLH was due to EBV or Leishmania or was a combined effect of both is difficult to say as both are common etiological agents of HLH, though EBV is more common. Moreover, fever can respond to amphotericin in febrile neutropenia due to acquired infections, apart from leishmania.

Chhabra PDepartment of Gastroenterology, Postgraduate Institute of

Medical Education and Research (PGIMER), Chandigarh, Haryana and Punjab, India

Address for correspondence: Dr. Puneet Chhabra,

E-mail: puneet.pgi@gmail.com

References

1. DomInguez-Pinilla N, Baro-Fernández M, González-Granado LI. Hemophagocytic lymphohistiocytosis secondary to Epstein Barr virus and Leishmania co-infection in a toddler. J Postgrad Med 2015; 61:44-5.

2. Chhabra P, Law AD, Sharma U, Suri V, Sachdeva MS, Kumari S, et al. Epstein-barr virus infection masquerading as acute leukemia: A report of two cases and review of literature. Indian J Hematol Blood Transfus 2014;30:26-8.

3. Sundar S, Singh RK, Bimal SK, Gidwani K, Mishra A, Maurya R, et al. Comparative evaluation of parasitology and serological tests in the diagnosis of visceral leishmaniasis in India: A phase III diagnostic accuracy study. Trop Med Int Health 2007;12:284-9.

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DOI:

10.4103/0022-3859.153114

PubMed ID:

***

Authors’ replySir,We thank Chhabra P for their comments.[1] The HIV test in our patient returned negative (HIV tests during pregnancy were also negative). It has also been reported HLH in AIDS is secondary not to the virus itself, but to overwhelming infections (particularly Pneumocystis jiroveci and nontuberculous mycobacteria). Complex immune mechanisms in HIV-Leishmania have been reported elsewhere.[2] In our country comparison between different microbiological techniques has been reported. However, serology is neither sensitive nor specific in the general Spanish population[3] and in HIV patients.[4] Our data on file in a pediatric cohort of HLH-Leishmania patients shows that only 32% of patients had a positive urine test. Thus, in our country the most reliable test remains PCR in bone marrow samples, followed by PCR in peripheral blood.

Dominguez-Pinilla N, Baro-Fernández M, Gonzalez-Granado LI

Department of Pediatrics, Hematology and Oncology Unit, Hospital 12 Octubre, Madrid, Spain

Address for correspondence: Mr. Luis Ignacio González-Granado,

E-mail: nachgonzalez@gmail.com

References

1. Chhabra P. Offender: Virus or parasite or both. J Postgrad Med 2015;61:145.

2. Okwor I1, Uzonna JE. The immunology of Leishmania/HIV co-infection. Immunol Res. 2013 May; 56:163-71.

3. Cruz I1, Chicharro C, Nieto J, Bailo B, Cañavate C, Figueras MC. Comparison of new diagnostic tools for management of pediatric Mediterranean visceral leishmaniasis. J Clin Microbiol. 2006;44:2343-7.

4. García-García JA, Martín-Sánchez J, Gállego M, Rivero-Román A, Camacho A, Riera C et al. Use of noninvasive markers to detect Leishmania infection in asymptomatic human immunodeficiency virus-infected patients. J Clin Microbiol. 200;44:4455-8.

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Longitudinal extensive transverse myelitis due to tuberculosis: A report of four casesSirWe read with interest the article by Sahu, Giri, and Gupta entitled “Longitudinal extensive transverse myelitis due to