Liposomal Amphotericin B-induced Cardiac Arrhythmias in Infantile Visceral Leishmaniasis: A Case Report

Visceral Leishmaniasis is a systemic vector-borne infection with a poor prognosis if not treated. Classical antiparasitic therapy with liposomal amphotericin B (LAmB) is effective, but occasionally not well-tolerated.

An 11-month-old male infant was admitted to our hospital due to prolonged fever, following an RSV infection. The patient had pale skin and splenomegaly, but was hemodynamically stable. An infectious cause was investigated through serology for Leishmania species , Brucella melitensis , Toxoplasma gondii , EBV, CMV, PB19 and Salmonella species . After admission, the infant developed Hemophagocytic lymphohistiocytosis (HLH, with pancytopenia, triglycerides: 346 U/L, ferritin: 1071 ng/mL; γ-globulin was administered without clinical response). On the second hospitalization day, the Leishmania rapid test was positive, while blood polymerase chain reaction identified Leishmania Infantum as the cause of infection, and LAmB was initiated. After the 4th dose, the patient developed hypokalemia, bradycardia and premature supraventricular complexes. The arrhythmia persisted despite electrolyte replacement; amphotericin-induced cardiotoxicity was suspected, and LAmB was discontinued. Oral miltefosine was started after approval by the National Public Health Organization, since the medicine was given in Greece for the first time to a pediatric patient. Miltefosine therapy lasted 1 month, with remission. Hepatotoxicity occurred at the end of the treatment and gradually resolved over the following 4 months with complete normalization of hepatic markers. The child remained asymptomatic at the 1-year follow-up.

Leishmaniasis should always be investigated in pediatric patients with secondary HLH, especially in endemic countries. Cardiotoxicity of LAmB is extremely rare; in this case, however, miltefosine is an effective and safe alternative.