Seronegative Disseminated Visceral Leishmaniasis with Secondary Hemophagocytic Lymphohistiocytosis in Advanced HIV Infection: A Case Report

Visceral leishmaniasis (VL) is a life-threatening infection endemic to the Indian subcontinent and may be associated with atypical and severe manifestations in patients with human immunodeficiency virus (HIV) infection. Secondary hemophagocytic lymphohistiocytosis (HLH) is a rare but serious complication of VL. We report a 51-year-old man with advanced HIV infection due to poor adherence to antiretroviral therapy (ART) who presented with prolonged fever, melena, hepatosplenomegaly, and pancytopenia. A series of laboratory investigations ruled out common opportunistic infections. VL with secondary HLH was diagnosed based on the identification of Leishmania donovani and hemophagocytosis on bone marrow examination, despite a negative rK39 antigen test. Upper gastrointestinal endoscopy with subsequent biopsy revealed Leishmania infiltration, confirming disseminated involvement. The patient was treated with conventional amphotericin B deoxycholate, continuation of ART, and a short course of corticosteroids, resulting in clinical and hematological recovery. This case highlights the diagnostic challenges of seronegative VL in advanced HIV infection and underscores the importance of early tissue diagnosis and targeted therapy in patients presenting with fever, cytopenias, and organomegaly in endemic regions.