Abstract
Introduction
In Southeast Asia, Bangladesh, India, and Nepal (the Terai region) are endemic for Visceral leishmaniasis (VL).1–3 Three clinical subtypes, viz. Cutaneous leishmaniasis (commonest), Mucocutaneous leishmaniasis (uncommon), and VL (serious) exist. VL (also known as Kala-Azar) is caused by an obligate intracellular protozoan Leishmania donovani (a vector- borne parasitic disease) and is transmitted to humans by being bitten by infected sandflies of the genus Phlebotomus. It can present with signs of pallor, organomegaly, and pancytopenia. The rise in VL cases in Nepal′s hilly and mountainous regions previously known to be non-endemic poses a significant challenge to the country′s elimination policy to be met by 2026. 2 Co-infection with malaria although poorly studied may occur due to similarity in clinical presentation and can cause significant morbidity and mortality even under treatment. 4
Case report
A 6-year old girl resident of Nepal (from a nonendemic region) was brought with progressive pallor and abdominal distension associated with low-grade, undocumented fever for two months.
On examination, she was emaciated and lethargic, with severe pallor, tachycardia, and splenohepatomegaly but no icterus, cyanosis, oedema, lymphadenopathy, nor bony tenderness. The liver was palpable 5 cm below the costal margin and massive splenomegaly was noted (12 cm below the costal margin).
The child was immunized to date with no history of recent travel. Birth and developmental history were insignificant. A full blood count revealed a severe anaemia (Hb 45 gm/L). The leucocyte count was 1.6 × 109/L with neutropenia (<0.5 × 109/L), platelets 50 × 109/L with anisopoikilocytosis but no abnormal cells on peripheral blood film (Fig. 1).
Abdominal ultrasound scan confirmed hepatosplenomegaly. Tests for malaria, dengue, salmonella, and tuberculosis were negative. Bone marrow smears demonstrated intra- as well as extra-cellular Leishmania donovani bodies (Fig. 2).
Amphotericin B was started at a dose of 1.0 mg/kg/ every alternate day for 20 doses. 5 Liposomal form of amphotericin B was not utilized because of financial constraints. Three units of packed red cells were also transfused.
On regular follow-up, the liver regressed completely, and the spleen minimally enlarged 2 cm below the costal margin at the last visit. The full blood count had likewise recovered with no atypical cells.
Discussion
VL is a tropical disease with significant morbidity and mortality. Early diagnosis of the disease is important for the management of cases. Pancytopenia and organomegaly must be evaluated for VL. 6 The disease can mimic acute leukemias, viral infections, autoimmune disease(systemic lupus erythematosus), 7 or immune cytopenia as seen in Evans syndrome. All autoimmune laboratory findings usually normalize after 3 months’ therapy. 8
Amphotericin B is an effective treatment. Miltefosine has a long half-life and its oral administration make it a good option for maintenance prophylaxis.9,10 VL, if left untreated, may prove fatal.
Blood smear showing pallor, pancytopenia. Bone marrow smear showing amastigote forms of Leishmania donovani bodies.
Footnotes
Acknowledgements
We are thankful to laboratory staff for their contributions.
Consent for publication
Informed consent obtained in written from the patient's parents.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
