When Hepatitis Masks Visceral Leishmaniasis: A Case of Secondary HLH in a Low-Endemic Region.

Visceral leishmaniasis (VL)-associated hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening hyperinflammatory syndrome. Diagnosis is often challenging due to overlapping clinical features, especially in low-endemic regions, where VL is not initially suspected. Severe hepatic dysfunction can further obscure the diagnosis and complicate treatment. We report a 14-year-old male from West Gojjam, Ethiopia, presenting initially with jaundice and clinical features of acute hepatitis. Over 3 months, he developed progressive abdominal distension, fever, pancytopenia, and coagulopathy. Imaging showed hepatosplenomegaly and ascites; viral and autoimmune hepatitis were excluded. Bone marrow examination revealed Leishmania donovani amastigotes and hemophagocytosis, confirming VL-triggered secondary HLH. Due to severe hepatic impairment, etoposide was withheld. The patient was treated with intravenous dexamethasone and a six-day course of liposomal amphotericin B, along with supportive care. Clinical and laboratory parameters improved steadily, with full recovery by 4 weeks. VL-HLH should be considered in patients with hepatitis-like presentations, even in low-endemic areas. Early recognition and treatment targeting the underlying infection with amphotericin B plus corticosteroids can achieve favorable outcomes, even when etoposide is contraindicated.