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Background: Visceral leishmaniasis (VL) is becoming endemic in São Paulo state, in the southeastern region of Brazil. Unusual manifestations with non-specific signs and symptoms may make diagnosis difficult and delay treatment, increasing the risk of severity and death, particularly in new endemic areas. There are few studies on patients with these characteristics in Brazil. We describe a case series of unusual manifestations of VL in children and its spatial dispersion in the western region of São Paulo state., Cases Presentation: From 2009 to 2014, five clinical cases involving children treated in the Regional Hospital of Presidente Prudente (RH) were selected. Two patients had multiple relapses requiring liposomal amphotericin B; one patient had VL-cytomegalovirus-dengue co-infection and liver injury; one patient was diagnosed with X-linked agammaglobulinemia, a primary immunodeficiency; and one patient was diagnosed with VL-human immunodeficiency virus/acquired immunodeficiency syndrome (VL-HIV/AIDS) co-infection. Primary or secondary immunodeficiencies were found in four children, and associated viral infections were found in three children. Three patients were referred from other hospitals to RH. With regard to the geographic spread of VL, more cases were found in the northern area, in the epicenter of the infection where the first cases were registered, flowing south; a spatial-temporal occurrence was found., Conclusions: Primary and secondary immunodeficiencies and viral co-infectious should be considered among unusual manifestations of VL, especially in those with multiple relapses. Spatial-temporal occurrence was found. Thus, integrated actions and effective monitoring of the disease are needed to complement curative practices to stem the tide of the epidemic.

Leishmaniasis is a "neglected tropical disease" and serious public health issue in Brazil. While dogs are recognized as particularly important reservoirs, recent reports of domestic cats infected with Leishmania sp. in urban areas suggest their participation in the epidemiological chain of the parasite in endemic areas. The aim of this study was to screen domestic cats for Leishmania sp. infection in an area where human and canine visceral leishmaniasis are endemic, followed by the identification of the species circulating in cats. We collected peripheral blood, lymph-node aspirates and bone marrow from 100 adult animals, both male and female, and analyzed the samples using cytological and molecular (PCR) detection techniques. We detected Leishmania in 6% of animals, which were then analyzed by RFLP-PCR to identify the species. Leishmania infantum (synonym: L. chagasi), a species responsible for visceral leishmaniasis in humans and other animals, was identified from all six samples. Amastigotes were observed in the peripheral blood, bone marrow and lymph-node aspirates in 4 of the 6 PCR-positive animals. The presence of infected cats in endemic areas should not be neglected, because it demonstrates the potential role of these animals in the biological cycle of the pathogen., (Copyright © 2016 Elsevier B.V. All rights reserved.)