1. A patient presented with weight loss, fatigue, and pallor and was found to have enlarged spleen and liver with pancytopenia. Biopsies revealed Leishmania donovani infection. 2. Leishmaniasis is transmitted by the bite of infected sandflies and presents as cutaneous, mucocutaneous, or visceral disease. Visceral leishmaniasis, known as kala-azar, is the most serious form.

5. WECOMEWECOME
ALLALL

6. 3 mo:3 mo: double rise F., wt.double rise F., wt.
loss, fatigue, severe pallorloss, fatigue, severe pallor
gross non-tender HSMgross non-tender HSM
pancytopeniapancytopenia

9. A.A. paronychia:paronychia:
ulcerated warty,ulcerated warty,
at base of thumb.at base of thumb.
B.B. AsymptomaticAsymptomatic
crusty, ulcers oncrusty, ulcers on
ankleankle
Smear: LD bodiesSmear: LD bodies

10. SevereSevere
disfigurementdisfigurement

11. Severedisfigurement
Severedisfigurement

13. Phlebotomus
The VectorThe Vector

14. BM findingsBM findings

15. LEISHMANIASISLEISHMANIASIS

16. 1. William Leishman, a Glasgwegian Dr served British Army in India. In1. William Leishman, a Glasgwegian Dr served British Army in India. In
Dum Dum, he discovered LD bodies in spleen of a British soldier. HeDum Dum, he discovered LD bodies in spleen of a British soldier. He
called it “Dum Dum Fever” & published it in 1903. 2. Charles Donovancalled it “Dum Dum Fever” & published it in 1903. 2. Charles Donovan
also recognized SS in other KA pts. & published it a few weeks lateralso recognized SS in other KA pts. & published it a few weeks later

17. Leishmaniasis: Key factsLeishmaniasis: Key facts
 3 main forms:3 main forms: visceral L.visceral L. (kala-azaar: the most serious),(kala-azaar: the most serious),
cutaneous L. (the commonest), & mucocutaneous L.cutaneous L. (the commonest), & mucocutaneous L.
 C/byC/by LeishmaniasLeishmanias transmitted by bite oftransmitted by bite of inf. femaleinf. female
phlebotomine sandfliesphlebotomine sandflies
 Affects the poorest, a/with malnutrition, displacement,Affects the poorest, a/with malnutrition, displacement,
poor housing, a weak immune system. Itpoor housing, a weak immune system. It is linked tois linked to
environmental changes: deforestation, building dams,environmental changes: deforestation, building dams,
irrigation, & urbanizationirrigation, & urbanization
 700,000 new cases700,000 new cases && 20,000 deaths/y20,000 deaths/y
 Only a small fraction of inf. will eventually develop d.Only a small fraction of inf. will eventually develop d.

18. At the end of this session you will learnAt the end of this session you will learn
– L.L. affects the poorest withaffects the poorest with little knowledge about it &little knowledge about it &
unlikely to seek early Rx./cannot afford Rxunlikely to seek early Rx./cannot afford Rx
 AA spectrum disease:spectrum disease:
• TheThe commonestcommonest is ~is ~ self-healingself-healing skin lesionskin lesion ((75%)75%)
• The worst/The worst/severest isseverest is visceral d.visceral d. Kala Azaar (Kala Azaar (25%)25%)
 60% in our60% in our Sub-continentSub-continent
a neglected ID,a neglected ID, should have been controlledshould have been controlled

1 of the important c/of1 of the important c/of PUOPUO
 L. & HIV/TB augments each otherL. & HIV/TB augments each other
 It isIt is curablecurable
Our country is leading to control itOur country is leading to control it

19.  Prevalence:Prevalence: 12 mln12 mln
 350 million at risk350 million at risk
– Cutaneous L (CL)Cutaneous L (CL):: 90% in Afghanistan, Iran, Syria, KSA, S90% in Afghanistan, Iran, Syria, KSA, S
Lanka, Peru, BrazilLanka, Peru, Brazil
– MCLMCL:: 90% in S America90% in S America
– Visceral L (VL)Visceral L (VL) (Kala Azar)(Kala Azar)
 60% in BD, India, Nepal. 30% in Brazil, Sudan60% in BD, India, Nepal. 30% in Brazil, Sudan
 EndemicEndemic in 88 countries (16 western)in 88 countries (16 western)
Depth of the ProblemDepth of the Problem

20. Neglected Tropical Diseases (NTD)Neglected Tropical Diseases (NTD)
 Disabling/DisfiguringDisabling/Disfiguring
– DALYs vs. mortalityDALYs vs. mortality
 StigmaStigma
 Diseases of PovertyDiseases of Poverty
 Biblical DiseasesBiblical Diseases
 Economic tollEconomic toll
– Poverty-promotingPoverty-promoting
• AscariasisAscariasis
• TrichuriasisTrichuriasis
• HookwormHookworm
• SchistosomiasisSchistosomiasis
• L. filariasisL. filariasis
• OnchocerciasisOnchocerciasis
• TrachomaTrachoma
• LeprosyLeprosy
• Buruli ulcerBuruli ulcer
• Chagas diseaseChagas disease
• HATHAT
• LeishmaniasisLeishmaniasis
• Dengue FeverDengue Fever
WormsWorms
BacteriaBacteria
TissueTissue
protozoaprotozoa
VirusVirus

22. 1.5 million globally

23. WORLD DISTRIBUTION OF VLWORLD DISTRIBUTION OF VL

24. 109 districts
of BD, India
& Nepal

25. Bangladesh ScenarioBangladesh Scenario
 AA re-emerging IDre-emerging ID since 1990; disappeared duringsince 1990; disappeared during
‘Malaria Eradication Pgm’‘Malaria Eradication Pgm’ (1961-70)(1961-70)
– poor control of vectorpoor control of vector
– lack of access to Rxlack of access to Rx
 139 Upazillas in139 Upazillas in 45 districts45 districts
 PrevalencePrevalence 45k.45k. IncidenceIncidence 10k/y10k/y
– 55% in55% in MymensinghMymensingh
– 25% in25% in Pabna, Tangail, JamalpurPabna, Tangail, Jamalpur
 BD is committed to eliminate kA/2015 (<1/10k popn. atBD is committed to eliminate kA/2015 (<1/10k popn. at
Upazila level).Upazila level). Now it is almost controlled!Now it is almost controlled!

26. Districts Affected in BangladeshDistricts Affected in Bangladesh

28. SynonymsSynonyms
 Kala-azar, visceral L (VL), black fever, leishmaniasis,Kala-azar, visceral L (VL), black fever, leishmaniasis,
Dumdum fever, Assam FDumdum fever, Assam F
 Mucocutaneous L, cutaneous L, bay sore,Mucocutaneous L, cutaneous L, bay sore, espundiaespundia,,
mucosal L, post-kala-azar dermal L,mucosal L, post-kala-azar dermal L,
viscerotropic L, forest yaws, Aleppo evilviscerotropic L, forest yaws, Aleppo evil
 Baghdad sore, Biskra button, Chiclero ulcer, DelhiBaghdad sore, Biskra button, Chiclero ulcer, Delhi
boil, Oriental sore, Rose of Jericho, Utaboil, Oriental sore, Rose of Jericho, Uta

29. Only a small fraction infected develop the d.Only a small fraction infected develop the d.
 A zoonosis; mammalian reservoirsA zoonosis; mammalian reservoirs
 Leishmanias areLeishmanias are obligate intracellular parasiteobligate intracellular parasite
– One sp. can cause different syn.One sp. can cause different syn.
– One syn. can be c/by different spp.One syn. can be c/by different spp.
 Vector:Vector: femalefemale sand-fly. 2-3mmsand-fly. 2-3mm
 Phlebotomus & LutzomyiaPhlebotomus & Lutzomyia
 ReservoirReservoir:: Indian KA: humanIndian KA: human
 rodents in Africa, foxes in Brazil, C. Asiarodents in Africa, foxes in Brazil, C. Asia
 dogs in the Mediterranean, China
EPIDEMIOLOGYEPIDEMIOLOGY

30. Mediterranean & ChinaMediterranean & China

31. The vectorThe vector lives in cracks of mud-houses, heaps of cowlives in cracks of mud-houses, heaps of cow
dung, in rat burrows, bushesdung, in rat burrows, bushes
 Feed mainly on cattle.Feed mainly on cattle. We are 2nd choice! MoreWe are 2nd choice! More exposure:exposure:
– extracting timber, mining, building damsextracting timber, mining, building dams
– irrigation, road making in forestsirrigation, road making in forests
Transmission:Transmission: CommonCommon:: bitebite by inf. F.by inf. F.
vector. Uncommon:vector. Uncommon:
– congenital, BT, needle sharingcongenital, BT, needle sharing
– rarely: inoculation from culturerarely: inoculation from culture
IP:IP: Cut. L: ~several weeksCut. L: ~several weeks
Visceral L:Visceral L: 6 w-6 mo (10 d-10 y)6 w-6 mo (10 d-10 y)

33. 3 syndromes of Leishmaniasis3 syndromes of Leishmaniasis
 Cutaneous LCutaneous L
– Old World:Old World: L tropica, L major,L tropica, L major, L aethiopica, L donovaniL aethiopica, L donovani ,, L infantum,L infantum, L mexicanaL mexicana
– New World:New World: L amazonensis, L braziliensis, L panamensis, L guyanensis,L amazonensis, L braziliensis, L panamensis, L guyanensis, L chagasiL chagasi
 Mucocutaneous LMucocutaneous L byby L braziliensis, L panamensis, L guyamenis, LL braziliensis, L panamensis, L guyamenis, L
amazonensisamazonensis
 VLVL byby L donovani,L donovani, L infantum, L chagasi,L infantum, L chagasi, L tropica,L tropica, L amazonensisL amazonensis
Post-kala-azar dermal L (PKDL)Post-kala-azar dermal L (PKDL)
Old WorldOld World:: L donovani, L infantumL donovani, L infantum
New World:New World: L donovani chagasi:L donovani chagasi: Central &, S AmericaCentral &, S America

34. Life cycleLife cycle
 2 forms2 forms
– amastigoteamastigote (no flagella) in host(no flagella) in host
– promastigotepromastigote in vector &in vector & mediummedium
 Amastigotes in blood meal become flagellate in vector &Amastigotes in blood meal become flagellate in vector &
multiply over 6-9dmultiply over 6-9d
 Following bite: flagellates enter R.E.S. & change toFollowing bite: flagellates enter R.E.S. & change to
amastigote;amastigote; multiply by binary fissionmultiply by binary fission

36. PathogenesisPathogenesis
 R.E.S. is invaded:R.E.S. is invaded: mainlymainly spleen, liver, BMspleen, liver, BM
 Monocytes spread parasitesMonocytes spread parasites
 Outcome:Outcome: virulence vs immunityvirulence vs immunity
 MarkedMarked suppression of C.M.I.suppression of C.M.I. Overproduction of IgOverproduction of Ig
Spleen:Spleen: Bag of parasites!Bag of parasites!
– enlarged, soft, fragile, dilated BVenlarged, soft, fragile, dilated BV
– Billroth cellsBillroth cells are over-parasitized;are over-parasitized; No fibrosisNo fibrosis
Liver:Liver: Kupffer cellsKupffer cells over-parasitizedover-parasitized
BM:BM: parasitized monocytes replace normal tissueparasitized monocytes replace normal tissue

37. Kupffer cells (stellateKupffer cells (stellate
macrophagesmacrophages &&
Kupffer-BrowiczKupffer-Browicz
cells)cells)

38. Cutaneous L.Cutaneous L.
 Bite siteBite site macule/nodulemacule/nodule ⇒⇒ shallow ulcer,shallow ulcer, raised borders:raised borders:
commonly face, limbscommonly face, limbs
May have satellite lesions & LAPMay have satellite lesions & LAP
Self-healingSelf-healing in weeks-years within weeks-years with atrophic (cigaretteatrophic (cigarette
paper) scar.paper) scar. But can cause serious disfigurementBut can cause serious disfigurement
 On recovery:On recovery: immunityimmunity to infecting sp.to infecting sp.
CL. MANIFESTATIONSCL. MANIFESTATIONS

39. Typical C. LTypical C. L

40. Classic Leishmania lesion case inClassic Leishmania lesion case in
Iraq shows a volcanic appearanceIraq shows a volcanic appearance
with rolled edgeswith rolled edges

41. Atypical CL with local spread beyondAtypical CL with local spread beyond
the borders of the primary lesion. Manythe borders of the primary lesion. Many
of the lesions in cases from Iraq showof the lesions in cases from Iraq show
an atypical appearancean atypical appearance

42. CL located on the trunk: 3x4cm nontender ulceration x 6mo. TheCL located on the trunk: 3x4cm nontender ulceration x 6mo. The
patient reported seeing several rats around his encampmentpatient reported seeing several rats around his encampment

43. CL on the R arm. This 2x3cm. Note the satelliteCL on the R arm. This 2x3cm. Note the satellite
lesionslesions

44. CL with likely secondary infCL with likely secondary inf

45. Cutaneous leishmaniasis with
keloid formation in a black soldier.

46. Satellite lesionsSatellite lesions
Crater lesion of CLCrater lesion of CL

47. Diffuse CLDiffuse CL
 Disseminate in skinDisseminate in skin
 Resistant to RxResistant to Rx
 DD from leprosyDD from leprosy

50. MCL (espundia)MCL (espundia)
Rare in childrenRare in children
 InvasiveInvasive disfiguringdisfiguring d.: destroys mucosad.: destroys mucosa
 90% in S America90% in S America
 Commonly around nose. Heals withCommonly around nose. Heals with scarsscars
 Significant mortality/morbiditySignificant mortality/morbidity
 Mucosa may perforateMucosa may perforate
MCL: mucocut. LMCL: mucocut. L

52. MCL: PerforationMCL: Perforation

54. CLCL
MCLMCL

55. Visceral L. (kala-azar)Visceral L. (kala-azar)
Severest & Progressive.Severest & Progressive. DeathDeath in 2y if untretedin 2y if untreted
 Malnourished people are most susceptibleMalnourished people are most susceptible
 India-Bangladesh-Nepal: 300k/y.India-Bangladesh-Nepal: 300k/y. 200 million at risk200 million at risk
– 52 districts52 districts of Indiaof India
– 45 ,,45 ,, of Bangladeshof Bangladesh
– 12 ,,12 ,, of Nepalof Nepal
Control program in BD in 2007: new cases droppedControl program in BD in 2007: new cases dropped
from 10k/y to 1463 in 2012, MR now closefrom 10k/y to 1463 in 2012, MR now close
to zero. BD is on track to eliminate VL/2015to zero. BD is on track to eliminate VL/2015

56. Typical PresentationTypical Presentation
Chr. F: double rise, good appetite, HSM, progressive pallor,Chr. F: double rise, good appetite, HSM, progressive pallor,
weakness, wt. loss, darkening skinweakness, wt. loss, darkening skin
Panacytopenia, LAPPanacytopenia, LAP
⇓⇓ albumin,albumin, ⇑⇑-Ig-Ig
2y infx. common2y infx. common
Co-morbidity withCo-morbidity with HIV, TB, orHIV, TB, or
Immunodeficiencies:Immunodeficiencies: more severemore severe

57. JaundiceJaundice (10%)(10%) is rare:is rare: Bad prognosisBad prognosis
 Immune complexes: mild GNImmune complexes: mild GN
 Rh. Factor may be positiveRh. Factor may be positive
 Fulminant formFulminant form mainly in children: pancytopenia & ac. livermainly in children: pancytopenia & ac. liver
failurefailure
Skin in VLSkin in VL
 dark, dry, thin, scalydark, dry, thin, scaly
 diffuse wartydiffuse warty
 petechiae, bruisespetechiae, bruises
 hair losshair loss
 edemaedema

58. Atypical presentations of KAAtypical presentations of KA
 PUO/FUO: an important causePUO/FUO: an important cause
 Pancytopenia without splenomegalyPancytopenia without splenomegaly
 Immune hemolysisImmune hemolysis
 Generalized LAP with/-out HSMGeneralized LAP with/-out HSM
 Massive hepatic necrosisMassive hepatic necrosis
 Retinal bleedRetinal bleed
Severe Anemia in KASevere Anemia in KA
 BM replaced by parasitesBM replaced by parasites
 BM depression, splenic sequestration, hge, hemolysis, 2y inf.BM depression, splenic sequestration, hge, hemolysis, 2y inf.

59. Case definition for KACase definition for KA
Residing/travelling in endemic areasResiding/travelling in endemic areas
F. for >2w & any 1:F. for >2w & any 1:
Splenomegaly or wt. loss or anemiaSplenomegaly or wt. loss or anemia
And ‘rk39’ test positiveAnd ‘rk39’ test positive
Case definition for PKDLCase definition for PKDL
Residing/travelling in endemic areasResiding/travelling in endemic areas
Rx of KA any time in pastRx of KA any time in past
Skin lesion lesions (macular, papular, nodular, or mixed)Skin lesion lesions (macular, papular, nodular, or mixed)
without loss of sensationwithout loss of sensation
Exclusion of other c/of skin d.Exclusion of other c/of skin d.
‘‘rk39’rk39’ positive/slit skin smear positive/PCR positivepositive/slit skin smear positive/PCR positive

60. DefinitionsDefinitions
 Primary KA (PKA)Primary KA (PKA)
KA as case definition & not treatedKA as case definition & not treated
 KA treatment failure (KATF)KA treatment failure (KATF)
Case defined. Rx within last 1y. All efforts should be made to DxCase defined. Rx within last 1y. All efforts should be made to Dx
parasitologically by splenic/BM smear or PCRparasitologically by splenic/BM smear or PCR
 Relapse KARelapse KA
Dx KA with case defn. & Rx in past but not within last 1y. All effortsDx KA with case defn. & Rx in past but not within last 1y. All efforts
are made to Dx parasitologically by splenic/BM smear or PCRare made to Dx parasitologically by splenic/BM smear or PCR

61. DxDx
Showing MOShowing MO
CL/MCL:CL/MCL: biopsy, scrapings, FNAC,biopsy, scrapings, FNAC, LN:LN:
aspiration/aspiration/ biopsy,biopsy, tissuetissue punch biopsypunch biopsy
VL:VL: spleen, BM, liver, LN puncturespleen, BM, liver, LN puncture
Blood culture may help (~1 mo): Novy-McNeal-Blood culture may help (~1 mo): Novy-McNeal-
Nicolle medium (3N medium). Blood smears fromNicolle medium (3N medium). Blood smears from
buffy-coat in HIVbuffy-coat in HIV
Immunological tests:Immunological tests:

62. Immunological testsImmunological tests
Specific: RDTSpecific: RDT (recombinant Ag.(recombinant Ag. rk39rk39), DAT (IgM) at), DAT (IgM) at
early stage; ICT: highly sensitiveearly stage; ICT: highly sensitive
NonspecificNonspecific
– CIE, CFT, IF Ab test: cross-react with leprosy, Chaga,CIE, CFT, IF Ab test: cross-react with leprosy, Chaga,
malaria, schistosomiasismalaria, schistosomiasis
– Detection of hyper-Ig: AT. CT (3 mo)Detection of hyper-Ig: AT. CT (3 mo)
A negative serology does not exclude LA negative serology does not exclude L..

63. rK39rK39
 Rapid dipstick testRapid dipstick test
 Based on theBased on the
recombinant k39recombinant k39
proteinprotein

64. TestTest Sensitivity %Sensitivity % Specificity %Specificity %
CFTCFT 70-8070-80 60-7360-73
DATDAT 91-10091-100 72-10072-100
IFATIFAT 55-7055-70 70-8970-89
ELISA (CSA)ELISA (CSA) 80-10080-100 50-7050-70
ELISA ( rK39)ELISA ( rK39) 100100 9898
rK39 rapid strip testrK39 rapid strip test 100100 88-9888-98
Latex agglut. testLatex agglut. test 68-10068-100 100100

65. Spleen
puncture
Slide preparation

66. A.A. intact macrophage full of LDBintact macrophage full of LDB
B.B. a rupturing macrophagea rupturing macrophage

67. LeishmaniaLeishmania organisms in PBF in HIVorganisms in PBF in HIV

68. Peripheral Blood PicturePeripheral Blood Picture
 Severe normocytic-chromic anemiaSevere normocytic-chromic anemia
 Leukopenic relative lymphocytosisLeukopenic relative lymphocytosis
 ThrombocytopeniaThrombocytopenia
 Raised ESRRaised ESR
 High Ig with reversal of AG ratioHigh Ig with reversal of AG ratio
BM aspirationBM aspiration
 Commonest method. Sensibility 86%. Safer than splenic p.Commonest method. Sensibility 86%. Safer than splenic p.
Splenic puncture:Splenic puncture: 98%.98%. Risk: bleedRisk: bleed
 If BM is inconclusiveIf BM is inconclusive

69. DrugsDrugs
 Liposomal Amphotericin B:Liposomal Amphotericin B: IV; Miltefosine: POIV; Miltefosine: PO
LABLAB is now DoC; single dose works (97%)is now DoC; single dose works (97%)
 Amphotericin B.Amphotericin B. Na stibogluconate (SSG): IMNa stibogluconate (SSG): IM
 MiltefosineMiltefosine is newis new
 PentamidinePentamidine
 Paromomycin in VL. It is low-costParomomycin in VL. It is low-cost
 Ketoconazole, ItraconazoleKetoconazole, Itraconazole
The commonest drug for VL wasThe commonest drug for VL was SSGSSG x 4w; now variablyx 4w; now variably
resistant in many countriesresistant in many countries

70. Amphotericin BAmphotericin B
an antifungal, used for serious mycosis & leishmaniasisan antifungal, used for serious mycosis & leishmaniasis
Treatable mycoses: aspergillosis, blastomycosis,Treatable mycoses: aspergillosis, blastomycosis,
candidiasis, coccidioidomycosis, cryptococcosiscandidiasis, coccidioidomycosis, cryptococcosis
Typically injection into a veinTypically injection into a vein
Common SE: F, chills, HA, kidney problems, anaphylaxis,Common SE: F, chills, HA, kidney problems, anaphylaxis,
hypotension, myocarditid. Safe in preg. LAB has lowerhypotension, myocarditid. Safe in preg. LAB has lower
SE. It works in part by interfering with the cellSE. It works in part by interfering with the cell
membranemembrane
It was isolated fromIt was isolated from Streptomyces nodosusStreptomyces nodosus
It costs in the developing world for a course between 162It costs in the developing world for a course between 162
and 229 USDand 229 USD

71. TREATMENTTREATMENT
CL CL may heal spontaneously.may heal spontaneously. TreatTreat ifif
– disabling/disfiguring ulcers, late healing, MCLdisabling/disfiguring ulcers, late healing, MCL
S. American CL: S. American CL: ketoconazole, itra-, paromomycin, plusketoconazole, itra-, paromomycin, plus
local heatlocal heat
VLVL
 Bangladesh: most are still sensitive to SSGBangladesh: most are still sensitive to SSG
DoC: LABDoC: LAB
 MiltefosineMiltefosine is taken p.o.is taken p.o.
 ParomomycinParomomycin has excellent safetyhas excellent safety
Always treat if MCL or VLAlways treat if MCL or VL

72. VL: Supportive RxVL: Supportive Rx
– RestRest
– High-calorie dietHigh-calorie diet
– BTBT
– Rx secondary inf.Rx secondary inf.
 Symptoms rapidly improveSymptoms rapidly improve
 Spleen regresses over monthsSpleen regresses over months
Patients must be counseled about the importance ofPatients must be counseled about the importance of
FU for relapseFU for relapse

73. Post KA Dermal L (PKDL)(10%)Post KA Dermal L (PKDL)(10%)
 FollowsFollows completecomplete Rx after 1-2y;Rx after 1-2y; may last up to 20ymay last up to 20y
No disability! No disability!
 Seek Rx for social stigma!Seek Rx for social stigma!
 SSG x 4 mo is potentially toxic & cumbersomeSSG x 4 mo is potentially toxic & cumbersome
 MiltefosineMiltefosine x12w is effective (93%)x12w is effective (93%)
 LAB 2 doses:LAB 2 doses: 5 mg/kg/w x 3w is successful5 mg/kg/w x 3w is successful
 Consider combinations of LAB & miltefosine, miltefosine &Consider combinations of LAB & miltefosine, miltefosine &
paromomycin, or miltefosine & SSGparomomycin, or miltefosine & SSG

76. DD of VLDD of VL
 Malaria, tropical splenomegaly syn.Malaria, tropical splenomegaly syn.
 EF, Portal HTNEF, Portal HTN
 Leukemias & lymphomasLeukemias & lymphomas
 Chr. hemolytic anemiaChr. hemolytic anemia
PKDLPKDL
 Yaws; Syphilis; LeprosyYaws; Syphilis; Leprosy
CL: CL: traumatic ulcerstraumatic ulcers
MCL: MCL: Leprosy; Sarcoidosis; Midline granuloma,Leprosy; Sarcoidosis; Midline granuloma,
Histoplasmosis; Syphilis, tertiary yawsHistoplasmosis; Syphilis, tertiary yaws

77. PROGNOSISPROGNOSIS
 CL: CL: may be self-limiting. Excellentmay be self-limiting. Excellent
 Diffuse CL & MCL: Diffuse CL & MCL: good on Rxgood on Rx
 VL: VL: fatal if untreated: mortality 10% in Rxfatal if untreated: mortality 10% in Rx
Causes of death in VLCauses of death in VL
 2y infx.: pneumonia; septicemia2y infx.: pneumonia; septicemia
 DysenteryDysentery
 TB, HIVTB, HIV
 Cancrum oris, uncontrolled hgeCancrum oris, uncontrolled hge

78. KA elimination in SEA is possibleKA elimination in SEA is possible
 Confined to 3 countriesConfined to 3 countries
 Humans are the only reservoirHumans are the only reservoir
 Only 1 vector: control by indoorOnly 1 vector: control by indoor residualresidual sprayspray
Permethrin treated nets, good housing, screen,Permethrin treated nets, good housing, screen, clothing,clothing,
repellent, minimum outdoor exposuresrepellent, minimum outdoor exposures dusk-dawndusk-dawn
 A RDT is availableA RDT is available
 LAB & Miltefosine are safeLAB & Miltefosine are safe
 Strong political willStrong political will

79. Target:Target:
To reduce incidence of KA &PKDL to <1/10k popn.:To reduce incidence of KA &PKDL to <1/10k popn.:
Early DxEarly Dx & complete Rx:& complete Rx: stops transmissionstops transmission
Surveillance; health educationSurveillance; health education
Reducing incidence in endemic communitiesReducing incidence in endemic communities
Reducing CFR (case fatality rates)Reducing CFR (case fatality rates)
Rx PKDL to reduce the parasite reservoirRx PKDL to reduce the parasite reservoir
Px & Rx of KA-HIV-TB co-inf.Px & Rx of KA-HIV-TB co-inf.
 Integrated vector managementIntegrated vector management

81. Integrated vector Mx (IVM)Integrated vector Mx (IVM)
Indoor Residual Spray (IRS):Indoor Residual Spray (IRS):
 Insecticide Deltamethrin; 6 rounds; 1 round inInsecticide Deltamethrin; 6 rounds; 1 round in
moderate & low endemic areasmoderate & low endemic areas
 Piloting was done at Fulbaria in 2011Piloting was done at Fulbaria in 2011
81
IRSAT DHANIKHOLAVILLAGE OFTRISHAL UPAZILLA
Dr.Shah
Golam Nabi,
DPM,KEP,
CDC,DGHS
with the IRS
Team ( Spray
man,Team
leader & 1st
Line
Supervisor) at
Dhanikhola
Village,Trishal
Upazilla.

82. Integrated Vector Mx (IVM)Integrated Vector Mx (IVM)
LLIN (Long Lasting Insecticidal Net)LLIN (Long Lasting Insecticidal Net)
DistributionDistribution

83. Larvicide Spray in Cow & chicken shadeLarvicide Spray in Cow & chicken shade

84. Effective disease surveillanceEffective disease surveillance
 WHO supported staffs forWHO supported staffs for
strengthening Surveillancestrengthening Surveillance
National ConsultantNational Consultant
Surveillance Medical OfficerSurveillance Medical Officer
Data ManagerData Manager
 Regular collection of Data fromRegular collection of Data from
all KA Endemic UHCall KA Endemic UHC
 Active case search for detection ofActive case search for detection of
KA in household levelKA in household level

85. Social mobilization &Social mobilization &
partnershipspartnerships
 Partnership with- WHO, MSF & icddr,b

87. MCQMCQ
 In L. spectrum d. the commonest is Kala AzarIn L. spectrum d. the commonest is Kala Azar
KA, is 2nd
biggest parasitic killer after malaria
 KA is spread by infected mosquitoKA is spread by infected mosquito
 Thrombocytopenia is a common featureThrombocytopenia is a common feature
 Reservoir in Indian KA is dogReservoir in Indian KA is dog
 LAB single dose is effectiveLAB single dose is effective

88. MCQMCQ
 DAT is a specific test for KADAT is a specific test for KA
 ICT is a non-specific test for KAICT is a non-specific test for KA
 Splenic puncture more sensitive than BMSplenic puncture more sensitive than BM
 Most VL in Bangladesh is sensitive to SSGMost VL in Bangladesh is sensitive to SSG
 Severe anemia is common in KASevere anemia is common in KA
 HIV, TB & VL augments each otherHIV, TB & VL augments each other

89. Evening at TeknafEvening at Teknaf

91. THANK YOUTHANK YOU