PMC10243522_01
A) Schematic representation of Latin America, with Brazil and the states of Sao Paulo, Minas Gerais and Rio de Janeiro in colors, corresponding to endemic regions for visceral Leishmaniasis in Brazil; B) Areas visited by the patient in the period from September 2018 to September 2019.
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Upon admission, we retrieved a detailed clinical history, showing that she toured to many places, from the north and coastal areas of Sao Paulo State to the south region of Minas Gerais State, all considered endemic areas for leishmaniasis in Southeastern Brazil (Figure 1), from September 2018 to September 2019.
Ultrasound-guided minimally invasive autopsy findings of a fatal case of kala-azar, from the metropolitan area of Sao Paulo, Brazil: A) Post-mortem lung ultrasound shows thickened pleura (arrow), lines B (asterisk), irregular pleural line (white arrowhead), and hyperechogenic subpleural area (blue arrowhead and inset), corresponding to pulmonary condensation (pneumonia); B) Bone marrow fine needle aspirate shows, in the center, numerous amastigote forms within the macrophage cytoplasm. The inset shows a figure of hemophagocytosis; C and D) Necrotic red pulp of the spleen with debris and mononuclear cells phagocytosing amastigote forms (C, H&E), labeled by immunohistochemistry reaction, using an in-house primary antibody (D, peroxidase); E and F) Foci of suppurative pneumonia (E, H&E), by gram-positive bacilli, present in the alveolar space, with inflammatory cells surrounding the bacillary colonies (F, Brown-Brenn). The inset shows various bacilli within a small vessel and a neutrophil attached to the endothelial line.
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The US showed hepatomegaly, splenomegaly and lungs with irregular and thickened pleura, B lines, and subpleural hyperechogenicity, indicative of pneumonia (Figure 2A). Microscopic analysis showed: hypocellular bone marrow aspirate with hemophagocytosis and several macrophages containing amastigote forms of Leishmania spp. (Figure 2B); spleen with necrotic red pulp and hyperplastic sinusoidal cells containing amastigotes (Figure 2C); liver with hyperplastic Kupffer cells containing amastigotes, hepatic steatosis, and gram-negative bacilli in vessels. The immunohistochemistry labeled amastigotes forms, using as the primary antibody a polyclonal anti-Leishmania in the bone marrow, liver and spleen samples (Figure 2D). The lungs exhibited pulmonary edema and foci of suppurative pneumonia (Figure 2E), with numerous gram-negative bacilli in the alveoli and vessels (Figure 2F).