Visceral leishmaniasis is caused by the L. donovani parasite and transmitted through sandfly bites. It is endemic in parts of Asia, Africa, South America, and around the Mediterranean. The patient is a 45-year-old male from Pakistan presenting with fever, weight loss, and wasting for 4-5 weeks. Laboratory findings show anemia, thrombocytopenia, and leukopenia. Sodium stibogluconate is the first-line treatment, though amphotericin B or pentamidine may be used if initial treatment fails.

1. Visceral
Leishmaniasis
Frank Meissner,MD,FACP,FACC,FCCP

2. Hx
●45 y/o Pakistani Male
●Fever X 4-5 wks with wasting illness

3. PE
●No spleenomegaly
●No hepatomegaly

4. Laboratory
●Anemia
●Thrombocytopenia
●Leukopenia

5. Etiology and Epidemiology
●L. donovani species complex includes
several species
○e.g., L. infantum, L. donovani, and L.
chagasi
●Endemic in areas of India, China, Central
and South America, East and West
Africa, and the countries surrounding the
Mediterranean

6. Etiology and Epidemiology
●Sandflies of genus Phlebotomus are the
insect vectors
●In India, no extrahuman reservoirs
known
●Other regions, several mammals,
including dogs, foxes, & wild rodents
reservoir hosts

7. Patient Specific Epidemiology
●Visceral leishmaniasis rural disease is
endemic countrywide
●Kala-azar outbreak affected widespread
areas of the Seraganj District, central
Bangladesh
●Late June, 1989, at least 1,000 cases
were reported

8. Patient Specific Epidemiology
●Outbreak probably related to earlier one
adjacent Pabna District
●Other risk areas: Shrifalgati, Nandiganti,
Newargacha, Dugli and Makarkole
districts

9. Croatian Epidemiology
●Foci of visceral leishmaniasis (VL) are
distributed countrywide
●Elevated risk in southeastern Serbia in
the area of Dobric
●Along the Dalmatian Coast
●Historically, active foci:Macedonia,
Dalmatia, the island of Mljet (Croatia),
and Montenegro

10. Pathogenesis
●Flagellated promastigotes L. donovani
introduced insect bite
●Enters macrophages of RES, morph =>
amastigotes
●Multiply in phagocytic cells

11. Pathogenesis
●Amastigotes disseminate
hematogenously
●Invade reticuloendothelial cells spleen,
liver, lymph nodes, bone marrow, and
skin

12. Clinical Features
●Symptoms gradual onset several months
after infection
●Weakness, dizziness, weight loss,
diarrhea, & constipation
●Fever, almost always develops, may
spike twice daily & is sometimes
acompanied by rigors

13. Clinical Features
●Liver & spleen enlarge
●Spleen often expands into iliac fossa
●Anemia & leukopenia

14. Clinical Features
●Thrombocytopenic pxt => gingivae,
nose, or GI tract bleeding,
●Cutaneous ecchymoses and petechiae
●Death 2ndary bacterial infections, severe
anemia, or uncontrolled bleeding

15. Laboratory Findings
●Anemia, leukopenia, thrombocytopenia
●Hyperglobulinemia &hypoalbuminemia
●(+) fever, hepatosplenomegaly, and
exposure endemic areas
●Definitive diagnosis organism in host
tissues cultured Novy-MacNeal-Nicolle
(NNN) medium

16. Laboratory Findings
●Leishman-Donovan bodies (amastigotes)
stained tissue samples
●Dx established by bone marrow
aspirates
●Splenic aspirates have highest yields -
risky
●Liver biopsy or aspiration lymph nodes
also diagnostic

17. Therapy
●Sodium stibogluconate (pentavalent
antimony) Rx of choice
○Pentostam - CDC Drug Service/Atlanta
(404-639-3670, days; 404-639-2888, nights
and weekends)
●If initial Rx fails, amphotericin B or
pentamidine used

18. Therapy
●Amphotericin B uniformly effective in
Indian comparative series
●May respond sodium stibogluconate +
recombinant human interferon gamma
●Or liposomal amphotericin B or
ketoconazole