A 62-year-old patient with history of refractory multiple myeloma was admitted to our hematology ward because of persistent  fever and pancytopenia. He had already undergone two lines of treament, consisting of  four cycles of bortzezomib-thalidomide-dexamethasone followed by double autologous stem cell transplant ad maintenance with lenalidomide and two cycles with isatuximab-carfilzomib-dexamethasone. Serum proteine electrophoresis showed hypogammaglobulinemia and no monoclonal component was detected. He was empirically treated with meropenem, linezolid and lyposomal amphotericin.  Fever resolved and  he was discharged.  After a few days his fever recurred. Pending results from the bone marrow aspiration became available showing amastigotes of Leishmania.  The patient was then restarted on lyposomial amphotericin 3 mg/kg of body weight/day for 4 days, with resolution of  fever and improvement of cytopenias. 

This case was notable because the diagnosis of visceral leishmaniosis is often suspected in patients presenting with fever, cytopenias and typical serum electrophoresis profile . This feature was lacking in the case displayed probably because of immunoparesis. If no bone marrow aspiration/trephine biopsy had been performed, the diagnosis would have hardly be done in a timely manner, and the patients would have been exposed to ineffective and maybe harmful treatments. Maybe we should take in our mind that zebras still exist …and not all of them are black with white stripes ..