Not all severe malaria cases are severe: Is it time to redefine severity criteria for malaria in non-endemic regions?

BACKGROUND: The current definition of severe malaria in non-endemic areas follows WHO criteria, which mainly target children in malaria-endemic areas, potentially misclassifying cases in non-endemic regions. We assessed the performance of a modified severe malaria classification criteria within our patient cohort. METHODS: A cohort study of patients managed for malaria in a non-endemic setting (2005-2023) was analyzed. We classified patients into severe malaria (SM) using WHO 2013 criteria except for hyperparasitemia, where 2 % threshold was applied. Patients with SM were distinguished as very severe malaria (VSM) when presenting at least one of the following conditions: parasitemia >10 %, pulmonary edema, impaired consciousness, seizures, renal failure, metabolic acidosis or hyperlactatemia, shock or hypoglycemia. In patients with SM and no criteria for VSM, less severe malaria (LSM) was defined by: 2-10 % parasitemia, hyperbilirubinemia, prostration, anemia or minor bleeding. The primary composite outcome was death or the need for a life-saving intervention, as analyzed in the three comparative groups. Secondary outcome was the prevalence of co-infections. RESULTS: Among 506 patients with malaria, 176 (34.8 %) presented with SM. A total of 37 (7.3 %) patients developed a life-threatening condition, namely death (n = 4) and/or the need for life-saving interventions (n = 34). All fatalities and 33 out of the 34 life-saving interventions occurred in the VSM group. Patients in LSM group did not develop any life-threatening conditions. As to co-infections, 28 (5.5 %) patients had a community-acquired co-infection, with no differences between groups (p = 0.763). CONCLUSIONS: Severity criteria definitions would benefit from a review when assessing patients with malaria in non-endemic areas. Within the spectrum of SM, patients reclassified as LSM have a low risk of developing a life-threatening condition and present low co-infection incidence and could benefit from management out of intensive care units and a restrictive use of empirical antibiotics.

Executive summary consensus statement of imported diseases group (GEPI) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SETMSI), on the diagnostic and treatment of imported schistosomiasis / Resumen ejecutivo del documento de consenso del Grupo de Patología Importada (GEPI) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC) y la Sociedad Española de Medicina Tropical y Salud Internacional (SEMTSI), sobre el diagnóstico y tratamiento de la esquistosomiasis importada

Schistosomiasis is a highly prevalent disease, especially in immigrant populations, and is associated with significant morbidity and diagnostic delays outside endemic areas. For these reasons, the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SEMTSI) have developed a joint consensus document to serve as a guide for the screening, diagnosis and treatment of this disease outside endemic areas. A panel of experts from both societies identified the main questions to be answered and developed recommendations based on the scientific evidence available at the time. The document was reviewed by the members from both societies for final approval (AU)

La esquistosomiasis es una enfermedad de elevada prevalencia, especialmente en población inmigrante, asociada a importante morbilidad y retraso diagnóstico fuera de zona endémica. Por estas razones, la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC) y la Sociedad Española de Medicina Tropical y Salud Internacional (SEMTSI) han elaborado un documento conjunto de consenso que sirva de guía para el cribado, diagnóstico y tratamiento de esta patología en zonas no endémicas. Un panel de expertos de ambas sociedades identificó las principales preguntas a responder y elaboró las recomendaciones siguiendo la evidencia científica disponible en el momento. El documento fue revisado por los miembros de ambas sociedades para su aprobación final (AU)

Characterization of Latin American migrants at risk for Trypanosoma cruzi infection in a non-endemic setting. Insights into initial evaluation of cardiac and digestive involvement.

BACKGROUND: Trypanosoma cruzi causes Chagas disease (CD), a potentially fatal disease characterized by cardiac disorders and digestive, neurological or mixed alterations. T. cruzi is transmitted to humans by the bite of triatomine vectors; both the parasite and disease are endemic in Latin America and the United States. In the last decades, population migration has changed the classic epidemiology of T. cruzi, contributing to its global spread to traditionally non-endemic countries. Screening is recommended for Latin American populations residing in non-endemic countries. METHODS: The present study analyzes the epidemiological characteristics of 2,820 Latin American individuals who attended the International Health Service (IHS) of the Hospital Clinic de Barcelona between 2002 and 2019. The initial assessment of organ damage among positive cases of T. cruzi infection was analyzed, including the results of electrocardiogram (ECG), echocardiogram, barium enema and esophagogram. RESULTS: Among all the screened individuals attending the clinic, 2,441 (86.6%) were born in Bolivia and 1,993 (70.7%) were female. Of individuals, 1,517 (81.5%) reported previous exposure to the vector, which is a strong risk factor associated with T. cruzi infection; 1,382 individuals were positive for T. cruzi infection. The first evaluation of individuals with confirmed T. cruzi infection, showed 148 (17.1%) individuals with Chagasic cardiomyopathy, the main diagnostic method being an ECG and the right bundle branch block (RBBB) for the most frequent disorder; 16 (10.8%) individuals had a normal ECG and were diagnosed of Chagasic cardiomyopathy by echocardiogram. CONCLUSIONS: We still observe many Latin American individuals who were at risk of T. cruzi infection in highly endemic areas in their countries of origin, and who have not been previously tested for T. cruzi infection. In fact, even in Spain, a country with one of the highest proportion of diagnosis of Latin American populations, T. cruzi infection remains underdiagnosed. The screening of Latin American populations presenting with a similar profile as reported here should be promoted. ECG is considered necessary to assess Chagasic cardiomyopathy in positive individuals, but echocardiograms should also be considered as a diagnostic approach given that it can detect cardiac abnormalities when the ECG is normal.

Cribado de estrongiloidiosis en España en el contexto de la pandemia SARS-CoV-2: resultados de una encuesta sobre diagnóstico y tratamiento / Screening for strongyloidiasis in Spain in the context of the SARS-CoV-2 pandemic: Results of a survey on diagnosis and treatment

Introducción: La generalización del tratamiento con dexametasona u otros inmunosupresores en pacientes con infección por SARS-CoV-2 puede aumentar el riesgo de aparición de formas graves de estrongiloidiosis. Se realizó una encuesta a nivel nacional para conocer mejor de la situación diagnóstica y terapéutica de la estrongiloidiosis en España en pacientes coinfectados por SARS-CoV-2. Materiales y métodos: Se diseñó una encuesta que fue enviada a todos los miembros de SEIMC durante los meses de febrero y marzo de 2021. Las respuestas se exportaron para su procesamiento informático al programa Microsoft Excel 2017 y se procesaron estadísticamente con el software libre PSPP. Resultados: Se recibieron 189 respuestas, de las cuales se seleccionaron 121 (64%) para su procesamiento posterior. En 84 centros (69,5%) no existía ningún protocolo de cribado específico de estrongiloidiosis. Cuarenta y dos centros (34,7%) disponían de técnicas serológicas en sus laboratorios y en el resto se enviaban a un laboratorio de referencia. Solo 22 centros (18%) realizaron cribado de estrongiloidiosis en pacientes infectados por SARS-CoV-2. Se diagnosticaron 227 casos de estrongiloidiosis en pacientes con infección por el SARS-CoV-2. En cuatro casos los pacientes desarrollaron un síndrome de hiperinfestación masiva que condujo al fallecimiento de uno. Conclusión: La COVID-19 ha puesto de manifiesto la necesidad de unificar protocolos de cribado y tratamiento de patologías importadas como la estrongiloidiosis. Es necesario realizar un esfuerzo de difusión del conocimiento para que esta patología potencialmente mortal sea tratada adecuadamente en los pacientes con mayor riesgo de complicaciones, como son aquellos con COVID-19.(AU)

Introduction: The generalization of treatment with dexamethasone or other immunosuppressants in patients with SARS-CoV-2 infection may increase the risk of occurrence of severe forms of strongyloidiasis. A nationwide survey was conducted to better understand the diagnostic and therapeutic situation of strongyloidiasis in SARS-CoV-2 co-infected patients in Spain. Materials and methods: A survey was designed and sent to all SEIMC members during February and March 2021. Responses were exported for computer processing to Microsoft Excel 2017 and statistically processed with the free software PSPP. Results: 189 responses were received, of which 121 (64%) were selected for further processing. Eighty-four centers (69.5%) had no specific strongyloidiasis screening protocol. Forty-two centers (34.7%) had serological techniques available in their laboratories and the rest were sent to a reference laboratory. Only 22 centers (18%) screened for strongyloidiasis in SARS-CoV-2 infected patients. A total of 227 cases of strongyloidiasis were diagnosed in patients with SARS-CoV-2 infection. In four cases patients developed a massive hyperinfestation syndrome leading to the death of one patient. Conclusion: COVID-19 has highlighted the need to unify screening and treatment protocols for imported pathologies such as strongyloidiasis. Efforts to disseminate knowledge are needed to ensure that this potentially fatal disease is adequately treated in patients with the highest risk of complications, such as those with COVID-19.(AU)

Executive summary consensus statement of imported diseases group (GEPI) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SETMSI), on the diagnostic and treatment of imported schistosomiasis.

Schistosomiasis is a highly prevalent disease, especially in immigrant populations, and is associated with significant morbidity and diagnostic delays outside endemic areas. For these reasons, the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) and the Spanish Society of Tropical Medicine and International Health (SEMTSI) have developed a joint consensus document to serve as a guide for the screening, diagnosis and treatment of this disease outside endemic areas. A panel of experts from both societies identified the main questions to be answered and developed recommendations based on the scientific evidence available at the time. The document was reviewed by the members from both societies for final approval.

[Screening for strongyloidiasis in Spain in the context of the SARS-CoV-2 pandemic: Results of a survey on diagnosis and treatment]. / Cribado de estrongiloidiosis en España en el contexto de la pandemia SARS-CoV-2: resultados de una encuesta sobre diagnóstico y tratamiento.

Introduction: The generalization of treatment with dexamethasone or other immunosuppressants in patients with SARS-CoV-2 infection may increase the risk of occurrence of severe forms of strongyloidiasis. A nationwide survey was conducted to better understand the diagnostic and therapeutic situation of strongyloidiasis in SARS-CoV-2 co-infected patients in Spain. Materials and methods: A survey was designed and sent to all SEIMC members during February and March 2021. Responses were exported for computer processing to Microsoft Excel 2017 and statistically processed with the free software PSPP. Results: 189 responses were received, of which 121 (64%) were selected for further processing. Eighty-four centers (69.5%) had no specific strongyloidiasis screening protocol. Forty-two centers (34.7%) had serological techniques available in their laboratories and the rest were sent to a reference laboratory. Only 22 centers (18%) screened for strongyloidiasis in SARS-CoV-2 infected patients. A total of 227 cases of strongyloidiasis were diagnosed in patients with SARS-CoV-2 infection. In four cases patients developed a massive hyperinfestation syndrome leading to the death of one patient. Conclusion: COVID-19 has highlighted the need to unify screening and treatment protocols for imported pathologies such as strongyloidiasis. Efforts to disseminate knowledge are needed to ensure that this potentially fatal disease is adequately treated in patients with the highest risk of complications, such as those with COVID-19.

Screening for strongyloidiasis in Spain in the context of the SARS-CoV-2 pandemic: Results of a survey on diagnosis and treatment.

INTRODUCTION: The generalization of treatment with dexamethasone or other immunosuppressants in patients with SARS-CoV-2 infection may increase the risk of occurrence of severe forms of strongyloidiasis. A nationwide survey was conducted to better understand the diagnostic and therapeutic situation of strongyloidiasis in SARS-CoV-2 co-infected patients in Spain. MATERIALS AND METHODS: A survey was designed and sent to all SEIMC members during February and March 2021. Responses were exported for computer processing to Microsoft Excel 2017 and statistically processed with the free software PSPP. RESULTS: 189 responses were received, of which 121 (64%) were selected for further processing. Eighty-four centers (69.5%) had no specific strongyloidiasis screening protocol. Forty-two centers (34.7%) had serological techniques available in their laboratories and the rest were sent to a reference laboratory. Only 22 centers (18%) screened for strongyloidiasis in SARS-CoV-2 infected patients. A total of 227 cases of strongyloidiasis were diagnosed in patients with SARS-CoV-2 infection. In four cases patients developed a massive hyperinfestation syndrome leading to the death of one patient. CONCLUSION: COVID-19 has highlighted the need to unify screening and treatment protocols for imported pathologies such as strongyloidiosis. Efforts to disseminate knowledge are needed to ensure that this potentially fatal disease is adequately treated in patients with the highest risk of complications, such as those with COVID-19.

Performance of a rapid molecular test to detect Chlamydia trachomatis and Neisseria gonorrhoeae in women with pelvic inflammatory disease / Realización de una prueba molecular rápida para detectar Chlamydia trachomatis y Neisseria gonorrhoeae en mujeres con enfermedad inflamatoria pélvica

Objective: The aim of this study was to investigate the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in women with pelvic inflammatory disease (PID) and the usefulness and cost-effectiveness of a rapid molecular test for the diagnosis and clinical management of PID. Methods: This observational study included 75 patients with mild-to-moderate PID (n=33), severe PID (n=29) and non-specific lower abdominal pain (NSAP) (n=13). CT/NG infections were analyzed using a standard and a rapid test. A cost analysis was carried out. Results: Samples of 19 patients (25.3%) were CT/NG positive. Concordance between rapid and standard tests was 100%. No significant differences were observed in the incidence of CT/NG in mild-to-moderate compared to severe PID. Costs differed according only to disease severity. Conclusions: Rapid molecular tests could help with the diagnosis of PID in sexually active women in clinical settings in which a standard technique is not available.(AU)

Objetivo: El objetivo de este estudio fue investigar la prevalencia de Chlamydia trachomatis (CT) y Neisseria gonorrhoeae (NG) en mujeres con enfermedad inflamatoria pélvica (EIP) y la utilidad y costo-efectividad de una prueba molecular rápida para el diagnóstico y manejo clínico de la EIP. Métodos: Este estudio observacional incluyó a 75 pacientes con EIP leve a moderada (n=33), EIP grave (n=29) y dolor abdominal bajo inespecífico (n=13). Las infecciones por CT/NG se detectaron mediante una prueba estándar y una prueba rápida. Se realizó un análisis de costes. Resultados: Las muestras de 19 pacientes (25,3%) fueron positivas para CT/NG. La concordancia entre las pruebas rápida y estándar fue del 100%. No se observaron diferencias significativas en la incidencia de CT/NG en la EIP leve a moderada en comparación con la grave. Los costes difirieron solo según la gravedad de la enfermedad. Conclusiones: Las pruebas moleculares rápidas podrían ayudar en el diagnóstico de la EIP en mujeres sexualmente activas en entornos clínicos en los que no se dispone de una técnica estándar.(AU)

Performance of a rapid molecular test to detect Chlamydia trachomatis and Neisseria gonorrhoeae in women with pelvic inflammatory disease.

OBJECTIVE: The aim of this study was to investigate the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in women with pelvic inflammatory disease (PID) and the usefulness and cost-effectiveness of a rapid molecular test for the diagnosis and clinical management of PID. METHODS: This observational study included 75 patients with mild-to-moderate PID (n=33), severe PID (n=29) and non-specific lower abdominal pain (NSAP) (n=13). CT/NG infections were analyzed using a standard and a rapid test. A cost analysis was carried out. RESULTS: Samples of 19 patients (25.3%) were CT/NG positive. Concordance between rapid and standard tests was 100%. No significant differences were observed in the incidence of CT/NG in mild-to-moderate compared to severe PID. Costs differed according only to disease severity. CONCLUSIONS: Rapid molecular tests could help with the diagnosis of PID in sexually active women in clinical settings in which a standard technique is not available.

Impact of coronavirus disease 2019 epidemics on prevention and care for HIV and other sexually transmitted infections.

OBJECTIVE: To assess the impact of coronavirus disease 2019 (COVID-19) epidemics on the prevention and care for HIV and other sexually transmitted infections at a major reference centre providing preventive and clinical services in Catalonia, Spain. DESIGN: We retrospectively compared anonymized clinical and laboratory data from March to December 2020 vs. 2019. METHODS: Monthly clinical data on HIV preexposure and postexposure prophylaxis users and on adults with HIV infection were retrieved from the administrative hospital database. Monthly tests for HIV, hepatitis B and C, Treponema pallidum, Neisseria gonorrhoeae,and Chlamydia trachomatis, and plasma lipids and glucose were recovered from the laboratory database. RESULTS: There were less (↓28%, P  = 0.003) but more advanced (mean CD4+ cells/µl 305 vs. 370, P  < 0.001) HIV infections and more gonorrhoea (↑39%, P  < 0.001) and chlamydia (↑37%, P  < 0.001) infections in 2020 vs. 2019. In people with HIV, rates of HIV RNA less than 50 copies/ml remained stable (11 vs. 11%, P  = 0.147) despite less scheduled visits (↓25%, P  < 0.001). However, they had less antiretroviral prescription changes (↓10%, P  = 0.018), worse plasma lipids [mean total cholesterol 190 vs. 185 mg/dl, P  < 0.001;mean low-density lipoprotein (LDL) cholesterol 114 vs. 110 mg/dl, P  < 0.001; mean triglycerides 136 vs. 125 mg/dl, P  < 0.001; mean high-density lipoprotein (HDL) cholesterol 47 vs. 48 mg/dl, P  = 006], and an excess of mortality (↑264%, P  = 0.006) due in great part not only to COVID-19 but also to other causes. CONCLUSION: In our setting, COVID-19 epidemics was associated with an increase in some prevalent sexually transmitted infections, with less but more advanced HIV infections, and with worse nonvirologic healthcare outcomes and higher mortality in people living with HIV.

Improved diagnosis of gastrointestinal infections using a semi-automated multiplex real-time PCR for detection of enteropathogens.

Introduction. The identification of enteropathogens is critical for the clinical management of patients with suspected gastrointestinal infection. The FLOW multiplex PCR system (FMPS) is a semi-automated platform (FLOW System, Roche) for multiplex real-time PCR analysis.Hypothesis/Gap Statement. FMPS has greater sensitivity for the detection of enteric pathogens than standard methods such as culture, biochemical identification, immunochromatography or microscopic examination.Aim.The diagnostic performance of the FMPS was evaluated and compared to that of traditional microbiological procedures.Methodology. A total of 10 659 samples were collected and analysed over a period of 7 years. From 2013 to 2018 (every July to September), samples were processed using standard microbiological culture methods. In 2019, the FMPS was implemented using real-time PCR to detect the following enteropathogens: Shigella spp., Salmonella spp., Campylobacter spp., Giardia intestinalis, Entamoeba histolytica, Blastocystis hominis, Cryptosporidum spp., Dientamoeba fragilis, adenovirus, norovirus and rotavirus. Standard microbiological culture methods (2013-2018) included stool culture, microscopy and immunochromatography.Results. A total of 1078 stool samples were analysed prospectively using the FMPS from July to September (2019): bacterial, parasitic and viral pathogens were identified in 15.3, 9.71 and 5.29 % of cases, respectively. During the same period of 6 years (2013-2018), the proportion of positive identifications using standard microbiological methods from 2013 to 2018 was significantly lower. A major significant recovery improvement was observed for all bacteria species tested: Shigella spp./enteroinvasive Escherichia coli (EIEC) (P <0.05), Salmonella spp. (P <0.05) and Campylobacter spp. (P <0.05). Marked differences were also observed for the parasites G. intestinalis, Cryptosporidium spp. and D. fragilis.Conclusion. These results support the value of multiplex real-time PCR analysis for the detection of enteric pathogens in laboratory diagnosis with outstanding performance in identifying labile micro-organisms. The identification of unsuspected micro-organisms for less specific clinical presentations may also impact on clinical practice and help optimize patient management.

Performance of a rapid molecular test to detect Chlamydia trachomatis and Neisseria gonorrhoeae in women with pelvic inflammatory disease.

OBJECTIVE: The aim of this study was to investigate the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in women with pelvic inflammatory disease (PID) and the usefulness and cost-effectiveness of a rapid molecular test for the diagnosis and clinical management of PID. METHODS: This observational study included 75 patients with mild-to-moderate PID (n=33), severe PID (n=29) and non-specific lower abdominal pain (NSAP) (n=13). CT/NG infections were analyzed using a standard and a rapid test. A cost analysis was carried out. RESULTS: Samples of 19 patients (25.3%) were CT/NG positive. Concordance between rapid and standard tests was 100%. No significant differences were observed in the incidence of CT/NG in mild-to-moderate compared to severe PID. Costs differed according only to disease severity. CONCLUSIONS: Rapid molecular tests could help with the diagnosis of PID in sexually active women in clinical settings in which a standard technique is not available.

Chagas disease in the United Kingdom: A review of cases at the Hospital for Tropical Diseases London 1995-2018. The current state of detection of Chagas disease in the UK.

BACKGROUND: Chagas disease (CD), is a parasitic disease endemic in Latin America. Presentation in non-endemic areas is either in the asymptomatic indeterminate phase or the chronic phase with cardiac and/or gastrointestinal complications. METHODS: The Hospital for Tropical Diseases (HTD) based in central London, provides tertiary care for the management of CD. We reviewed all cases managed at this centre between 1995 and 2018. RESULTS: Sixty patients with serologically proven CD were identified. Most were female (70%), with a median age at diagnosis of 41 years. Three quarters of the patients were originally from Bolivia. 62% of all patients were referred to the HTD by their GP. Nearly half of the patients were asymptomatic (47%). Twelve patients had signs of cardiac involvement secondary to CD. Evidence of gastrointestinal damage was established in three patients. Treatment was provided at HTD for 31 patients (47%). Most patients (29) received benznidazole, five of them did not tolerate the course and were switched to nifurtimox. Of the seven patients receiving this second line drug, five completed treatment, whilst two interrupted it due to side effects. CONCLUSIONS: Despite the UK health system having all the resources required to diagnose, treat and follow up cases, there is lack of awareness of CD, such that the vast majority of cases remain undiagnosed and therefore do not receive treatment. We propose key interventions to improve the detection and management of this condition in the UK, especially in pregnant women and neonates.

Ribotype 027 Clostridioides difficile infection presented as a traveller's diarrhoea / Infección por Clostridioides difficile Ribotipo 027 presentada como diarrea del viajero

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Imported Malaria in Countries where Malaria Is Not Endemic: a Comparison of Semi-immune and Nonimmune Travelers.

The continuous increase in long-distance travel and recent large migratory movements have changed the epidemiological characteristics of imported malaria in countries where malaria is not endemic (here termed non-malaria-endemic countries). While malaria was primarily imported to nonendemic countries by returning travelers, the proportion of immigrants from malaria-endemic regions and travelers visiting friends and relatives (VFRs) in malaria-endemic countries has continued to increase. VFRs and immigrants from malaria-endemic countries now make up the majority of malaria patients in many nonendemic countries. Importantly, this group is characterized by various degrees of semi-immunity to malaria, resulting from repeated exposure to infection and a gradual decline of protection as a result of prolonged residence in non-malaria-endemic regions. Most studies indicate an effect of naturally acquired immunity in VFRs, leading to differences in the parasitological features, clinical manifestation, and odds for severe malaria and clinical complications between immune VFRs and nonimmune returning travelers. There are no valid data indicating evidence for differing algorithms for chemoprophylaxis or antimalarial treatment in semi-immune versus nonimmune malaria patients. So far, no robust biomarkers exist that properly reflect anti-parasite or clinical immunity. Until they are found, researchers should rigorously stratify their study results using surrogate markers, such as duration of time spent outside a malaria-endemic country.

Acute liver failure due to visceral leishmaniasis in Barcelona: a case report.

BACKGROUND: Leishmaniasis is an emerging infectious disease. Due to human migration and tourism, visceral leishmaniasis may become more common in non-endemic areas. In the Mediterranean basin, visceral leishmaniasis typically occurs in rural regions. CASE PRESENTATION: We present an unusual urban case of acute liver failure due to visceral leishmaniasis, following a prolonged fever of unknown origin. After obtaining negative results from the bone marrow aspirate, we performed a liver biopsy that elucidated the diagnosis. The liver involvement in visceral leishmaniasis may appear as chronic granulomatous hepatitis. However diffuse hepatitis process, a necro-inflammatory pattern, without forming granulomas were observed in the liver biopsy specimens in this case. Intracytoplasmic Leishmania amastigotes were observed in the liver biopsy specimens and a polymerase chain reaction confirmed the diagnosis. Only five pathological confirmed cases of acute hepatitis due to visceral leishmaniasis have been described so far, just two in adults and both from Barcelona. A revision of the literature is performed. CONCLUSIONS: Acute hepatitis is an uncommon debut of visceral leishmaniasis in immunocompetent patients. Furthermore there are only few cases in the literature that describe the histopathological changes that we found in this patient. In conclusion, in case of acute hepatitis leading to liver failure, leishmaniasis should be considered a differential diagnosis (even in non-endemic countries and without clear epidemiological exposure) and liver biopsy can elucidate the diagnosis.