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Case report
- Oral ulcer as an unusual feature of visceral leishmaniasis in an AIDS patient

A 35-year-old homemaker, resident of Etah district in western Uttar Pradesh, presented with 6 year's history of fever, diarrhea with gross loss of weight; an ulcer on the undersurface of the tongue for 1 month and bleeding per rectum for 4 days. She was referred to the Dermatology Department after she tested positive for HIV 1 and 2.

The fever was low grade and intermittent in character. The patient had frequent painless watery stools. Bleeding per rectum was spontaneous, painless and fresh and mixed with stool. She had been treated for suspected abdominal tuberculosis a year ago. The oral ulcer under the tongue was painful and had been increasing in size. It bled on touch. The patient had received blood transfusion 10 years ago during cesarean delivery of her second child. The history was not suggestive of extramarital sexual relation or intravenous drug abuse either by the patient or her spouse.

The patient was pale and emaciated. There was a single well-defined ulcer 3 cm × 2 cm in size on the fraenulum of tongue with raised rolled and irregular margins. The floor of the ulcer was clean but bled on touch. The base was firm and could be clearly felt. In addition, the dorsal aspect of the tongue showed adherent white plaques with underlying erythema. Bilateral submandibular and submental lymph nodes were enlarged, discrete, firm, nontender with smooth surface and nonadherent to the overlying skin. Per speculum examination of the vagina did not reveal any significant finding. On per rectal examination, the finger was stained with fresh blood. Liver surface was smooth and nontender and was enlarged 2 cm below the costal margin. Spleen was smooth, firm in consistency and was enlarged 1.5 cm below the costal margin.

Ocular examination revealed retinal hemorrhage with white retinal necrosis in the left eye.

Serological test (ELlSA) for leishmaniasis was highly positive. Chopra's aldehyde test was negative. Potassium hydroxide 10% preparation of the scrapings from the tongue showed candida.

Her blood tests revealed that her hemoglobin was 8.8 gm percent; total leukocyte count, 8,800 per cu. mm; polymorphs, 84 percent; lymphocytes, 15%; eosinophils, 01%; platelet count, 1.2 lakhs per cu. mm. Bleeding time, clotting time, blood glucose, urea, electrolytes, immunoglobulin profile, liver and kidney function tests were within normal range. V. D. R. L. was nonreactive. ELlSA for HIV was positive for HIV 1 and 2 and was confirmed by western blot test. Her CD 4 and CD 8 counts were 12 per cu. mm and 18 per cu. mm respectively.

The skiagram of chest, electrocardiogram and colonoscopy did not reveal any abnormality. Ultrasonography of the abdomen confirmed mild hepatosplenomegaly.

Fine needle aspiration cytology from submandibular lymph nodes showed macrophages studded with amastigote form of leishmania and a few lymphocytes. Biopsy from the edge of the sublingual ulcer demonstrated macrophages full of amastigote form of leishmania on hematoxylin and eosin preparation. There was no evidence of malignancy in the tissue, and staining for acid fast bacilli was negative. Patient refused permission for liver, spleen and bone marrow biopsy. She died 3 days after admission.

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