The renal transplant patient with visceral leishmaniasis who could not tolerate meglumine antimoniate—cure with ketoconazole and allopurinol

Introduction A 66-year-old white Caucasian man was admitted to our hospital 21 weeks after renal transplantation for the evaluation of mild heart failure, low-grade fever Visceral leishmaniasis is an endemic parasitic infection in the Mediterranean area [1]. Shortly after the initial and weight loss. Before renal transplantation, he had been treated with haemodialysis for a period of 3 infection, the parasite spreads through the monocyte macrophage system and a granulomatous cellular years for end-stage renal disease of unknown aetiology. Immunosuppression for renal transplantation conimmune response develops, leaving the parasite in a latent form. Therefore, hosts may remain free of clinsisted of a monotherapy with cyclosporin A (Sandimmun NeoralB). The early post-transplantation ical symptoms for long periods of time. Although impairment of cellular immunity could trigger overt period was uneventful and he was discharged 9 days later with a serum creatinine of 150 mmol/l. During the disease, visceral leishmaniasis is uncommon in allograft recipients, even in endemic areas. However, immunofirst 3 months, he experienced three episodes of graft rejection, which were each treated with three pulses of compromised hosts have a worse outcome since the disease behaves more aggressively. These individuals 500 mg/day of 6-methylprednisolone. After the last graft rejection episode (8 weeks before admission), have an atypical clinical presentation and course of disease, which may delay the diagnosis, and they 1.5 g/12 h of mycophenolate mofetil were added to the immunosuppression regime. Serum creatinine at his respond more poorly to therapy [2,3]. Pentavalent antimonial drugs have been classically discharge was 398 mmol/l. On admission, physical examination revealed paleconsidered the therapy of choice, but the frequency of serious adverse events and the increasing incidence of ness, tachycardia, a few basilar rales and peripheral pitting oedema. A grade 2 soft systolic murmur was primary parasitic resistance or relapses have stressed the need for alternative treatments. However, informaheard along the lower left sternal border. No diastolic murmur or pericardial friction rub was detected. tion is insufficient and an optimal therapeutic regime lacking adverse effects has not yet been described Abdominal examination revealed a firm and nontender 8-cm splenomegaly and a normal renal allograft. should any problem occur [4]. We report the case of a renal allograft recipient with Funduscopic examination was normal. Thoracic radiographs showed a mild cardiac enlargement and visceral leishmaniasis who developed acute pancreatitis during the initial phase of treatment with meglumine some fluid in fissures. Laboratory tests revealed: serum creatinine 292 mmol/l (creatinine clearance: antimoniate. We then successfully treated the patient using a novel combination of ketoconazole and allopu18 ml/min/1.73 m2); urea nitrogen (BUN) 10.9 mmol/l; whole-blood cyclosporin levels 102 ng/ml (RIA specific monoclonal antibody, CYCLO-Trac-SP, Incstar, Stillwater, MN); serum alanine aminotransferCorrespondence and offprint requests to: Josep M. Grinyo MD, ase 0.17 mkat/l; serum albumin 34 g/l; serum total Department of Nephrology, Hospital de Bellvitge, C. Feixa Llarga s/n, 08907 L’Hospitalet, Barcelona, Spain. proteins 51 g/l; serum protein electrophoresis a1