Pulmonary involvement in visceral leishmaniasis in the post-elimination era: a diagnostic masquerade

Visceral leishmaniasis (VL) is a systemic parasitic disease that predominantly involves the reticuloendothelial system, with pulmonary involvement being distinctly uncommon, particularly in individuals who are immunocompetent. We report a case of a middle-aged female who was immunocompetent presenting with acute hypoxaemic respiratory failure, characterised by progressive dyspnoea, bilateral lung consolidation and pleural effusion, initially mimicking severe pulmonary infection or haematological malignancy. The presence of pancytopenia, hypergammaglobulinaemia and massive hepatosplenomegaly raised suspicion of an underlying systemic disorder. Definitive diagnosis was established by demonstration of Leishmania donovani amastigotes in splenic aspirate, with further confirmation of direct pulmonary involvement through identification of intracellular amastigotes within alveolar macrophages on a transbronchial lung biopsy. The patient showed significant clinical and radiological improvement following treatment with liposomal amphotericin B and miltefosine. This case highlights that VL can rarely present with primary pulmonary manifestations even in immunocompetent hosts. It underscores the importance of considering VL in the differential diagnosis of unexplained pulmonary infiltrates with systemic features in endemic regions and demonstrates that histopathological confirmation from lung tissue can be crucial in establishing pulmonary involvement in atypical presentations.