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visceral leishmaniasis (kala-azar)
Etiology:
1) Leishmania donovani
2) Leishmania infantum
3) Leishmania chagasi
Epidemiology:
1) Leishmania donovani predominates in Africa, India, Asia
- not common in West Africa [7]
2) Leishmania infantum predominates in the Mediterranean & Middle East
3) Leishmania chagasi occurs throughout Central & South America
4) humans, dogs & cats may serve as host reservoirs
5) opportunistic infection in AIDS patients
Clinical manifestations:
1) infection is generally benign & self-limited
2) recurrent fever
3) weakness
4) sweating
5) cough
6) nausea/vomiting
7) skin manifestations
a) pale macules
b) erythematous nodules
c) verrucae
8) hepatosplenomegaly
9) lymphadenopathy
10) disease may be fatal if not treated
Laboratory:
1) complete blood count (CBC) may show pancytopenia
- neutropenia is profound, eosinophils generally low
2) hypergammaglobulinemia
3) buffy coat
4) lymph node aspirate or biopsy
5) bone marrow aspirate*
6) liver biopsy
7) spleen biopsy
8) serology available, but utility not known [5]
* histopathology image [8]
Radiology:
- CT of abdomen*
* image [8]
Management:
1) classic kala-azar is generally fatal if not treated]
2) sodium stibogluconate
a) available from CDC (404 639-3670)
b) 20 mg Sb[V]/kg IM/IV for 28 days
c) patients become afebrile & feel better within 1 week
d) aminosidine 12-15 mg/kg/day IM or IV as adjunctive therapy (not FDA approved)
2) amphotericin B
a) amphotericin B deoxycholate: 0.5-1.0 mg/kg QD or QOD for a total dose of 7-20 mg/kg (15 doses)
b) liposomal amphotericin B: a single dose of 10 mg/kg as effect as 15 alternate day infusions of amphotericin B deoxycholate [6]
3) pentamidine 2-4 mg/kg QD or QOD IV or IM for a total of 15 doses
4) interferon-gamma & macrophage CSF have been proposed as adjunctive agents
5) miltefosine (Impavido)
Also see Leishmaniasis
Related
Leishmania chagasi
Leishmania donovani
Leishmania infantum
General
leishmaniasis
References
- Clinical Diagnosis & Management by Laboratory Methods,
19th edition, J.B. Henry (ed), W.B. Saunders Co., Philadelphia,
PA. 1996, pg 1266-68
- Harrison's Principles of Internal Medicine, 14th ed.
Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1190-91
- Medical Knowledge Self Assessment Program (MKSAP) 11, 18.
American College of Physicians, Philadelphia 1998, 2018.
- UpToDate 13.2
- Veterans Administration
- Sundar S et al
Single-dose liposomal amphotericin B for visceral leishmaniasis
in India.
N Engl J Med 2010 Feb 11; 362:504
PMID: 20147716
http://content.nejm.org/cgi/content/full/362/6/504
- Levine AC, Shetty PP, Henwood PC, Sabeti P, Katz JT, Vaidya A.
Interactive medical case. A Liberian health care worker with fever.
N Engl J Med. 2015 Jan 29;372(5):e7.
PMID: 25629759
http://www.nejm.org/doi/full/10.1056/NEJMimc1414101
- Loscocco GG, Piccini M
Visceral Leishmaniasis.
N Engl J Med 2019; 380:379
PMID: 30673546
https://www.nejm.org/doi/full/10.1056/NEJMicm1803648