Contrasting outcomes of visceral leishmaniasis in two patients with membranous nephropathy receiving immunosuppressive therapy: a case report.

BACKGROUND: Visceral leishmaniasis (VL) often presents with an atypical and fulminant course in immunocompromised hosts, and treatment faces multiple challenges including drug toxicity, immunosuppressive status, and complications. CASE PRESENTATION: Here we report two cases of VL in patients with membranous nephropathy(MN) who developed the infection after long-term immunosuppressive therapy. Both patients presented with fever, pancytopenia, and markedly elevated inflammatory markers. Case 1 had relapsed VL complicated by pre-existing renal insufficiency, experienced disease relapse after anti-parasitic treatment, and ultimately died of multi-organ failure. Case 2 developed hemophagocytic lymphohistiocytosis (HLH) but achieved clinical reversal after the addition of glucocorticoids to anti-parasitic therapy. Both patients received standard treatment with amphotericin B cholesteryl sulfate complex (ABCD). However, Case 1 with pre-existing renal insufficiency eventually died, whereas Case 2 with a milder degree of immunosuppression was successfully cured. CONCLUSION: These cases suggest that when patients with MN develop VL after long-term immunosuppressive therapy, treatment faces multiple challenges including renal insufficiency, depth of immunosuppression, and secondary HLH, necessitating individualized and comprehensive management.