Severe Immunosuppression and Hemophagocytosis in Coinfection With Leishmania, Hiv and Tuberculosis: A Diagnostic and Therapeutic Challenge

Visceral leishmaniasis is a systemic and potentially fatal zoonosis with chronic evolution and high lethality when untreated. Transmission occurs via the phlebotomine vector. Although more common in endemic regions of Brazil, sporadic cases have been reported in Rio Grande do Sul, where the disease had been historically rare. A 36-year-old male, HIV positive since early 2024 with irregular treatment, had CD4 142 cells/mm³ and viral load 905 copies in December 2024. He had pulmonary tuberculosis diagnosed in December 2023 (AFB ++), initially abandoned treatment, and restarted RHZE in August 2024, later switched due to hepatotoxicity. He presented in November 2024 with clinical decline, abdominal pain, and hepatosplenomegaly. Workup revealed visceral leishmaniasis via liver biopsy. Liposomal amphotericin B was started on 12/31. He developed severe pancytopenia and progressive liver dysfunction. Hemophagocytic syndrome was suspected after bone marrow aspirate showed activated macrophages; dexamethasone and IV immunoglobulin were initiated. He was admitted to the ICU on 01/07 with sepsis, acute respiratory failure, and non-oliguric acute kidney injury. Cultures grew Klebsiella pneumoniae KPC and Enterococcus faecium. Treatment was guided by susceptibility profile, with hemodynamic and ventilatory support. CT on 01/16 showed splenic necrosis with likely superinfection, prompting splenectomy. He evolved with multiorgan dysfunction, severe metabolic acidosis, persistent hyperlactatemia and refractory instability. Death occurred on 01/24. Coinfection with HIV, tuberculosis and leishmaniasis carries extremely high mortality. Overlapping drug toxicities, profound immunosuppression and multidrug-resistant bacterial infections contributed to a refractory clinical course. Suspected hemophagocytic syndrome highlights the need for vigilance regarding dysregulated inflammatory manifestations in immunosuppressed patients. This case demonstrates the severity of coinfection and the high risk of sepsis, underscoring the importance of an early multidisciplinary approach with rapid access to diagnosis and targeted treatment to reduce mortality.