This article describes an atypical case of post-kala azar dermal leishmaniasis associated with complications due to delayed diagnosis and poor case management.
"A Study of Clinical Profile of Leprosy in Post Leprosy Elimination Era"iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
A Short Report on Status of Leprosy in India by Rahul Shukla in Advances in Complementary & Alternative Medicine
Hansen’s disease, known as leprosy in colloquial language has been able to maintain its prevalence in the Indian subcontinent due to the haggard socio-economic status, lack of awareness and multiple other predisposing factors. Leprosy has been found to suppress the immune system thereby accentuating the chance of secondary infections. Contrary to the long held prevalent notion that the disease is not very contagious but shows long term effects that may lead to permanent limb and nerve disfigurement. The chronic effects of the ailment also include loss of visual acuity along with deformed limbs. Despite the prevalence and emergence of substantial number of new cases of leprosy each year in most of the developed and developing nations, the disease has still not been identified as a major health problem. The major hurdle in tackling the disease is also stemmed from the under reporting of the ailment caused by the excommunication of the afflicted individuals. India accounts for a large chunk of the global burden of leprosy, contributing almost 3/5th of the newly documented cases per annum. Reemergence of leprosy has been evidenced due to development of resistance in the causative bacterial strain. Yet much has not been accomplished in developing therapeutic regimen to curb the rampage of this insidious enemy. The aim of this short communication aims at portraying the true scenario of leprosy and there by attract the attention of policy makers and implementers to take radical actions to eradicate the menace to public health.
The document provides information on the COVID-19 pandemic as of April 2020. It discusses the epidemiology and spread of the virus globally. Key points include:
- COVID-19 originated in Wuhan, China in late 2019 and has since spread to over 210 countries. As of April 2020, there were over 29 lakh confirmed cases and 200,568 deaths worldwide, with the US becoming the new epicenter.
- The virus spreads mainly person-to-person via respiratory droplets. Common symptoms include fever, cough and shortness of breath, though many cases are asymptomatic. Chest CT scans show bilateral lung involvement like ground-glass opacities or consolidation.
- While most cases are mild, the elderly and those
The document provides information on the novel coronavirus (COVID-19) pandemic, including:
1) It describes the epidemiology and spread of COVID-19 globally, with over 29 lakh reported cases across 210 countries as of April 2020, and identifies the United States as the new epicenter.
2) It summarizes the natural history and clinical presentation of COVID-19, which commonly includes fever, cough, and shortness of breath, and can progress to severe pneumonia and multi-organ failure in vulnerable groups.
3) It discusses diagnosis of COVID-19 using RT-PCR testing of respiratory samples and treatment being primarily supportive care and ventilation for severe cases, as there is no proven antiviral treatment yet.
Tuberculosis: A Rare Cause of Linear Labial Ulcerationkomalicarol
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case of labial tuberculosis in a 16-year-old patient with underlying
lymph node localization.
Fungal keratitis is a fungal infection of the cornea that is common in developing nations. It is most often caused by filamentous fungi like Aspergillus, Fusarium, and Curvularia in tropical areas, and Candida species in temperate regions. Risk factors include corneal injury, topical steroid use, diabetes, and contact lens use. Symptoms include pain, blurred vision, photophobia, and corneal ulceration. Diagnosis involves corneal scraping and culture, though PCR is more rapid. Treatment consists of topical antifungals like natamycin, amphotericin B, or voriconazole, with systemic antifungals as adjunctive therapy for severe cases
"A Study of Clinical Profile of Leprosy in Post Leprosy Elimination Era"iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
A Short Report on Status of Leprosy in India by Rahul Shukla in Advances in Complementary & Alternative Medicine
Hansen’s disease, known as leprosy in colloquial language has been able to maintain its prevalence in the Indian subcontinent due to the haggard socio-economic status, lack of awareness and multiple other predisposing factors. Leprosy has been found to suppress the immune system thereby accentuating the chance of secondary infections. Contrary to the long held prevalent notion that the disease is not very contagious but shows long term effects that may lead to permanent limb and nerve disfigurement. The chronic effects of the ailment also include loss of visual acuity along with deformed limbs. Despite the prevalence and emergence of substantial number of new cases of leprosy each year in most of the developed and developing nations, the disease has still not been identified as a major health problem. The major hurdle in tackling the disease is also stemmed from the under reporting of the ailment caused by the excommunication of the afflicted individuals. India accounts for a large chunk of the global burden of leprosy, contributing almost 3/5th of the newly documented cases per annum. Reemergence of leprosy has been evidenced due to development of resistance in the causative bacterial strain. Yet much has not been accomplished in developing therapeutic regimen to curb the rampage of this insidious enemy. The aim of this short communication aims at portraying the true scenario of leprosy and there by attract the attention of policy makers and implementers to take radical actions to eradicate the menace to public health.
The document provides information on the COVID-19 pandemic as of April 2020. It discusses the epidemiology and spread of the virus globally. Key points include:
- COVID-19 originated in Wuhan, China in late 2019 and has since spread to over 210 countries. As of April 2020, there were over 29 lakh confirmed cases and 200,568 deaths worldwide, with the US becoming the new epicenter.
- The virus spreads mainly person-to-person via respiratory droplets. Common symptoms include fever, cough and shortness of breath, though many cases are asymptomatic. Chest CT scans show bilateral lung involvement like ground-glass opacities or consolidation.
- While most cases are mild, the elderly and those
The document provides information on the novel coronavirus (COVID-19) pandemic, including:
1) It describes the epidemiology and spread of COVID-19 globally, with over 29 lakh reported cases across 210 countries as of April 2020, and identifies the United States as the new epicenter.
2) It summarizes the natural history and clinical presentation of COVID-19, which commonly includes fever, cough, and shortness of breath, and can progress to severe pneumonia and multi-organ failure in vulnerable groups.
3) It discusses diagnosis of COVID-19 using RT-PCR testing of respiratory samples and treatment being primarily supportive care and ventilation for severe cases, as there is no proven antiviral treatment yet.
Tuberculosis: A Rare Cause of Linear Labial Ulcerationkomalicarol
Oral location of tuberculosis is rare. It admits a clinical polymorphism and poses above all a problem of diagnosis. We report a
case of labial tuberculosis in a 16-year-old patient with underlying
lymph node localization.
Fungal keratitis is a fungal infection of the cornea that is common in developing nations. It is most often caused by filamentous fungi like Aspergillus, Fusarium, and Curvularia in tropical areas, and Candida species in temperate regions. Risk factors include corneal injury, topical steroid use, diabetes, and contact lens use. Symptoms include pain, blurred vision, photophobia, and corneal ulceration. Diagnosis involves corneal scraping and culture, though PCR is more rapid. Treatment consists of topical antifungals like natamycin, amphotericin B, or voriconazole, with systemic antifungals as adjunctive therapy for severe cases
Relapsing Polychondritis Case: An Important Diagnosis Not to Be Delayedsemualkaira
Relapsing Polychondritis (RP) is a rare disease characterized by
inflammation of cartilage and connective tissues with destructive
episodes. Although the pathogenesis is not completely known,
there is an autoimmunity in which antibodies against mainly type
II collagen play a role. In addition to chondritis of the ear, nose,
and trachea; organs having proteoglycan structure such as eyes,
the inner ear, heart, blood vessels, and kidneys can be affected, too.
A 25-year-old pregnant woman presented with an extensive lesion involving her nose, cheeks, upper lip, and lower eyelids. Biopsy showed necrotizing granulomatous inflammation and vasculitis consistent with Wegener's granulomatosis. She was positive for c-ANCA but had no other systemic involvement. After delivery, she was given steroids and cyclophosphamide but continued deteriorating and ultimately died from the locally advanced facial Wegener's granulomatosis.
Introduction: malignant syphilis is an uncommon form of secondary syphilis.This presentation usually occurs in immunocompromised patients, especially in those ones infected by human immunodeficiency virus (HIV). However, it is known that it might exceptionally affect individuals with normal immune response.
This case report describes an immunocompetent 30-year-old male patient who presented with widespread painful skin lesions and uveitis of the right eye. Laboratory tests initially were negative for syphilis but later tested positive, confirming the diagnosis of early malignant syphilis. Malignant syphilis is an uncommon form of secondary syphilis typically seen in immunocompromised individuals. However, this report describes the second known case of an immunocompetent patient presenting with both skin and ocular involvement. The patient was treated with intravenous ceftriaxone for 14 days and experienced an excellent clinical response.
Covid november 8 2020 ce presentation covid and eyes Dr. Sandra Lora Cremers CarolinaClavijo8
The document summarizes research on COVID-19 and its relationship to the eye and ocular surface. It discusses how COVID-19 may potentially enter the eye, eye symptoms observed in COVID-19 patients, and whether conditions like dry eye disease increase the risk of viral entry. It also addresses whether masks can increase dry eye and reviews treatment options for dry eye. The economic burden of dry eye is substantial, costing billions annually in the US.
1) The document discusses India's National Leprosy Eradication Programme, including its history, strategies, infrastructure, and treatment protocols.
2) Key statistics provided include that India accounts for 60.9% of global leprosy cases, with a prevalence rate of 5.0 per 10,000 people.
3) The program's objectives are to eliminate leprosy through early case detection, short-term multidrug therapy, health education, and rehabilitation. Treatment involves multidrug regimens administered monthly or daily depending on the type of leprosy.
This document discusses the history and regulation of the drug thalidomide. It notes that thalidomide was discovered in the 1960s to cause birth defects but has continued to be studied to treat other conditions. In 1998, the FDA approved thalidomide under the brand name Thalomid to treat erythemanodosumleprosum, a complication of leprosy. Due to the risks of birth defects, the FDA took steps to strictly control the drug's use, distribution, and monitoring of patients, especially women of childbearing age, to prevent another public health issue. Research into thalidomide's use for other diseases continues.
Management of Lichen Planus through Ayurvedaijtsrd
Lichen Planus is a papulosquamous disorder that may affect the skin, scalp, nails, and mucous membranes. The primary cutaneous lesions are pruritic, polygonal, flat topped, violaceous papules. In Ayurveda, all skin diseases are lined beneath the term Kustha Roga. Vitiated Dosha cause abnormal colour of skin and produce degenerative changes called Kustha. CASE REPORT A 50 year old female came to OPD of National Institute of Ayurveda, Jaipur having complains of black papules on her whole body for last10 years. Oral mucosa was also involved. Mahamanjishtha Kwatha, Trivrit Leha, Tikta Ghrita, Khadiradi Vati and a combination of Rasamanikaya, Shuddha Gandhaka, Manjishthadi Churna, was given orally, Eladi Taila was given for local application and Irimedadi Taila was given for Gandusha . RESULTS Patient got significant relief in itching and discolouration of skin. Ayurvedic principle of Kustha is effective in the management of Lichen Planus. Dr. Deepti | Dr. Sunil Kumar | Dr. Anurag Singh Chandel "Management of Lichen Planus through Ayurveda" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-5 , August 2019, URL: https://www.ijtsrd.com/papers/ijtsrd27908.pdfPaper URL: https://www.ijtsrd.com/medicine/dermatology/27908/management-of-lichen-planus-through-ayurveda/dr-deepti
Postpartum Meningitis by Enterococcus Faecalis Secondary to Neuraxial AnesthesiaAnnalsofClinicalandM
Meningitis is an infrequent and serious cause of postpartum fever that requires early diagnosis and treatment to prevent serious complications and to reduce the high mortality rate.
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Meningitis is an infrequent and serious cause of postpartum fever that requires early diagnosis and treatment to prevent serious complications and to reduce the high mortality rate.
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Intravenous & Endocavitary Contrast Enhanced Ultrasound (CEUS) in Multiseptat...AnnalsofClinicalandM
Pyogenic liver abscess is a potentially life-threatening pathology, while image-guided drainage is highly indicative as first-line treatment approach. We report the case of an 84-year-old woman, diagnosed with large multiseptated pyogenic liver abscess,
Systemic Sclerosis Associated with Occupational Exposure to SolventsAnnalsofClinicalandM
Systemic Sclerosis (SS) is a rare multisystemic disorder with changes in the immune system, vascular and connective tissue. Furthermore, there is an increase in the synthesis and accumulation of collagen and extracellular matrix components in the skin and internal organs, with repercussions on the lungs, gastrointestinal...
Abnormal Renal Mass in Adult Polycystic Kidney Disease: A Diagnostic DilemmAnnalsofClinicalandM
The incidence of renal cell carcinoma (RCC) in patients with polycystic kidney disease (PCKD) has shown to be higher compared to the general population
Over the past few years, Robotic surgery has been an emerging field in colorectal surgery. Over years there has been continuous shift towards minimally invasive procedures with enormous potential advantages but progress is impeded because of limited evidence
Keratin 5 Mutation in a Bulgarian Family with Dowling – Degos Disease – A Cas...AnnalsofClinicalandM
Dowling-Degos Disease (DDD) is a rare reticular pigmentary disorder with an autosomal dominant inheritance. Morbus Galli-Galli is considered to be an acantholytic variant of the disease. Mutations in keratin 5 gene (KRT5) have been found in the majority of DDD patients...
Modern Military Neurotrauma and its Complications in War Conditions in megalo...AnnalsofClinicalandM
This document discusses modern military neurotrauma and its complications during wartime conditions in urban areas. It summarizes the types of head injuries seen in over 4000 patients during military operations from 2014 to present in Ukraine, including soft tissue wounds, open skull fractures, and penetrating brain injuries from bullets and shrapnel. It describes the medical treatment provided, including surgical removal of bone and metal fragments. It finds that over 50% of injuries were to the head, and time from injury to specialized neurosurgery was kept under 2 hours to reduce complications. Prognosis was better for injuries from shrapnel than bullets due to lower kinetic force.
A 28-year-old female presented with atypical chest pain, palpitations, and breathlessness. Imaging revealed an unusually large and aneurysmal left main coronary artery fistula terminating into the junction of the superior vena cava and right atrium. The patient underwent successful surgery to ligate the fistula on bypass without arresting the heart or using cardioplegia. This allowed ligation of the large fistula without risks of cardioplegic arrest. Following surgery, the patient's symptoms resolved and she has remained asymptomatic over the past two years.
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Relapsing Polychondritis (RP) is a rare disease characterized by
inflammation of cartilage and connective tissues with destructive
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there is an autoimmunity in which antibodies against mainly type
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Management of Lichen Planus through Ayurvedaijtsrd
Lichen Planus is a papulosquamous disorder that may affect the skin, scalp, nails, and mucous membranes. The primary cutaneous lesions are pruritic, polygonal, flat topped, violaceous papules. In Ayurveda, all skin diseases are lined beneath the term Kustha Roga. Vitiated Dosha cause abnormal colour of skin and produce degenerative changes called Kustha. CASE REPORT A 50 year old female came to OPD of National Institute of Ayurveda, Jaipur having complains of black papules on her whole body for last10 years. Oral mucosa was also involved. Mahamanjishtha Kwatha, Trivrit Leha, Tikta Ghrita, Khadiradi Vati and a combination of Rasamanikaya, Shuddha Gandhaka, Manjishthadi Churna, was given orally, Eladi Taila was given for local application and Irimedadi Taila was given for Gandusha . RESULTS Patient got significant relief in itching and discolouration of skin. Ayurvedic principle of Kustha is effective in the management of Lichen Planus. Dr. Deepti | Dr. Sunil Kumar | Dr. Anurag Singh Chandel "Management of Lichen Planus through Ayurveda" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-5 , August 2019, URL: https://www.ijtsrd.com/papers/ijtsrd27908.pdfPaper URL: https://www.ijtsrd.com/medicine/dermatology/27908/management-of-lichen-planus-through-ayurveda/dr-deepti
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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Atypical Presentation of Post-Kala Azar Dermal Leishmaniasis in Bhutan
1. Annals of Clinical and Medical
Case Reports
ISSN 2639-8109
Case Report
AtypicalPresentationofPost-KalaAzarDermalLeishmaniasisin
Bhutan
Pradhan A1#
, Tobgay T2#
, Dorjee S2
, Wangdi T3
, Zhou G4
and Karunaweera ND5*
1
Jigmi Dorji Wangchuck National Referral Hospital, Bhutan
2
Khesar Gyalpo University of Medical Sciences of Bhutan
3
Vector-borne Disease Control Programme, Ministry of Health
4
Program in Public Health, University of California, Irvine, USA.
5
Department of Parasitology, Faculty of Medicine, University of Colombo, Sri Lanka.
#Equal contribution as first authors
2. Key words
Leishmania donovani; Skin lesions;
Neglected tropical disease; Indian sub-
continent; Asia; Kala azar elimination;
Cutaneous leishmaniasis
3. Introduction
1. Abstract
This article describes an atypical case of post-kala azar dermal leishmaniasis associated with
complications due to delayed diagnosis and poor case management. The grave consequences
of the prolonged disease process, which included facial disfigurement, visual impairment and
distress both to the patient and the family with increased the risk of infection spread in the
community are elaborated.
Bhutan is a member of the leishmaniasis elimination network in Asia and the government con-
tinues to invest in maintenance of the national healthcare system. The case study highlights the
gaps in the healthcare system with hardships faced by a patient to access quality healthcare and
poor patient outcome used as proxy indicators. It also point towards the key challenges faced
by a resource poor nation like Bhutan in achieving universal health coverage and reaching the
set goals for disease elimination unless the national health care system is carefully reviewed and
deficiencies are adequately addressed.
leishmaniasis, unless diagnosed early and treated effectively may
Bhutan plans to achieve Universal Health Coverage (UHC) early
[1] and to eliminate leishmaniasis by 2020. However, leishmani-
asis surveys have not been conducted since 2006 [2]. Therefore,
the existing VL incidence data [3] are unreliable and are based on
clinical suspicion while the actual cases may go unrecorded due to
the dearth of healthcare professionals. The causative agent of VL in
Bhutan is Leishmania donovani, closely related to the Indian sub-
type with several Phlebotomus spp. identified as probable vector(s)
[4].
This article reports the first case of Post-Kala Azar Dermal Leish-
maniasis (PKDL) from Bhutan with an atypical presentation. Its
complex nature, prolonged history and resultant complications
underscore the need for careful review of the healthcare delivery
system in Bhutan, with a focus on successful control of Neglect-
ed Tropical Diseases (NTDs). This case adds to the evidence that
result in considerable debility and devastating socio-economic
consequences and therefore, poses as a formidable challenge to
achieve UHC in Bhutan.
4. Methodology
Patient consent was sought as per study protocol and ethics ap-
proval granted by Research Ethic Board of Health, Bhutan. Wecol-
lected information through review of medical records, laboratory
reports and prescriptions maintained since 1999 and patient and
family member interviews.
5. Case Description
We present the case of a 37-year-old female, a mother of three
children from the eastern part of Bhutan, seen by a dermatolo-
gist in 2014 at Jigmi Dorji Wangchuck National Referral Hospital
(JDWNRH). The patient presented with extensive erythematous
plaques on forehead, central face, peri-oral, cheeks that extended
*Corresponding Author (s): Nadira D. Karunaweera, Department of Parasitology, Faculty of
Medicine, University of Colombo, Sri Lanka, Tel: +94(11)2699284, E-mail: nadira@parasit. Citation: Nadira D, Pradhan A and Tobgay T, Atypical Presentation of Post-Kala Azar Dermal Leishmania-
cmb.ac.lk sis in Bhutan. Annals of Clinical and Medical Case Reports. 2020; 3(5): 1-4.
Volume 3 Issue 5- 2020
Received Date: 10 Apr 2020
Accepted Date: 25 Apr2020
Published Date: 27 Apr2020
3. Volume 3 Issue 5-2020 Case Report
Figure 2: Microscopic image (X1000) of punch biopsy tissue section
stained with hematoxylin and eosin (H and E). Arrow points to
Leishman-Donovan parasite bodies
6. Socio-Economic Aspects
The patient lives with her children and parents in a remote village
of Kalapang. Her husband is a cook and lives away from home in
another district. The family lives by subsistence farming. A narrow
walking path leads to the village. Residents walk for 4-5 hours to
reach the nearest town to hire a taxi to reach Mongar, where the
eastern regional referral hospital is located. It takes a further two
day-bus rides to reach Thimphu, the capital city to access services
of the dermatologist. Over a period of 20 years (1999 to 2019), she
has visited multiple health centers incurring a considerable cost
that the family could barely afford. Chronic and debilitating form
of disease has had devastating impact on her and her family in
terms of economic, social stigmatization andisolation.
7. Discussion
PKDL that manifests as painless macular and/or papulo-nodular
skin lesions may be a rich source of parasites, promoting transmis-
sion. Therefore, early patient management with appropriate drugs
is critical to contain the infection spread [5]. Its pathophysiology is
obscure and associated risk factors remain debatable [6, 7]. As per
records 10-20% in the Indian subcontinent [6, 8] and almost 50%
in Sudan are affected [9] months to years after apparent drug-cure
of VL or as a sequel of asymptomatic infections [6]. Mucosal in-
volvement rarely occurs [10-12]. Blephero-conjuctivitis and uveitis
as sequelae are known with organisms demonstrated in extra/in-
tra ocular and adnexal muscles [13]. Associated eye inflammation
may have grave consequences (aptly demonstrated through this
http://www.acmcasereport.com/
case study). Diagnosis of PKDL is based on clinical picture and
epidemiological pattern as confirmation through parasite isolation
has low sensitivity [14] nevertheless can be improved with the use
of molecular techniques [6]. Serological diagnosis (rk39 or ELISA)
though useful to detect exposure to infection, the interpretation of
its results may be difficult due to post-VL persistence of antibod-
ies. Availability of effective treatment options in endemic areas re-
mains important to minimize both the resultant morbidity due to
PKDL and the risk of further community spread. The latter is due
its potential to act as a reservoir for VL and trigger the emergence
of infection in non-endemic areas or its re-emergence in areas that
have successfully eliminated the disease. PKDL is, therefore, of
considerable public health significance in the region [15].
8. Conclusion
This case portrays the challenges faced by patients and clinicians in
PKDL management, particularly in resource-poor settings where
the disease is generally prevalent. It highlights areas that need at-
tention within the healthcare system, including the need for na-
tional-level guidelines for leishmaniasis treatment and more effec-
tive disease-awareness programs for public as well as healthcare
personnel. Active case detection studies to assess the true burden
of leishmaniasis (including PKDL) will also help to understand the
magnitude of the problem. The apparent hurdles to achieve UHC
in Bhutan highlight the need for remodeling of services based on
primary healthcare principles to ensure equality in access to qual-
ity healthcare.
9. Acknowledgements
The study was supported through funds awarded by the National
Institute of Allergy and Infectious Diseases of the National Insti-
tutes of Health, USA under Award Number U01AI136033. The
content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of
Health. Editing and review of manuscript by Richard Carter, For-
merly from the University of Edinburgh, United Kingdom is grate-
fully acknowledged.
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