A 70-year-old man from Lucknow, India, presented with epistaxis, pallor, and splenomegaly for 3 months. He had no history of fever, anorexia, jaundice, and weight loss. His complete blood count revealed pancytopenia, with a hemoglobin level of 80 g/L; white blood cell count of 2.5×10⁹/L, with predominance of lymphocytes (65%); and platelet count of 80×10⁹/L. Peripheral smear examination revealed Rouleaux formation (A; Leishman stain, ×200). His serum protein level was 9.5 g/dL, with a reversed albumin/globulin ratio (1:2.8). His renal function, blood-sugar level, and liver function were unremarkable, except an elevated alkaline phosphatase level (780 IU/L). Stool examination for occult blood and viral markers (HIV, hepatitis B and C) was negative. Bone marrow examination revealed hypercellular differentiation with adequate megakaryocytes and increased lymphocytes (25%) and plasma cells (15%). The smears also showed intra- and extracellular amastigote forms (with nucleus and kinetoplast) of Leishmania donovani (B, C; Leishman stain, ×630).

Visceral leishmaniasis (VL) is an endemic infection in certain parts of India. The transmission is anthroponotic, with sand fly Phlebotomus argentipes as the vector. VL classically presents as fever, splenomegaly, and pancytopenia. Atypical presentation without fever in a non-endemic urban city, such as in this case, is rare.