Visceral leishmaniasis escaping the diagnosis and withstanding treatment in a case of recurrent pyrexia

Though visceral leishmaniasis (VL) is the leading parasitic infection causing deatharound the world after malaria, it is a less suspected cause of pyrexia of unknown origin (PUO). We present a case of a middle aged man who was diagnosed with VL only months later owing to the stealthily masquerading disease as also to a generally low index of suspicion for it. A 59-year-old from Uttarakhand presented to us with complaint of fever of a few weeks duration. He was found to have a bicytopenia with elevated liver enzymes. Routine imaging studies were non-contributory. Cultures revealed candidemia while tests for viral and other atypical infections were negative. A bone marrow examination (BME) revealed haemophagocytosis. Positron emission tomography–computed tomography (PET-CT) showed mildly FDG avid hepatosplenomegaly. He was treated as a case of candidiasis with secondary hemophagocytic lymphohistiocytosis (HLH) and was discharged. He was readmitted months later with recurring fever. Repeat investigations revealed pancytopenia with marked hepatosplenomegaly. A repeat BME, however, revealed Leishmania donovani (LD) bodies. Patient was treated with liposomal amphotericin B (LAmB) and discharged. Though the patient’s symptoms improved soon after, he was again admitted a couple of months later and found to have VL persisting in the BM aspirate. This report underscores the need to extensively evaluate cases of PUO rather than summarily dismissing them as routine. VL is one of the less suspected etiologies despite being the second largest parasitic killer.

Research on the Virulence Identification and Preservation Methods of Desert-type Leishmania donovani Strains / 实验动物与比较医学

ObjectiveTo determine the virulence of desert-type Leishmania donovani strains through animal infection experiments and to explore preservation methods for maintaining their pathogenicity.Methods The isolated strain was cultured in vitro for 7, 30, 36, 44, 60, 90, and 150 days, respectively， and inoculated into Lagurus lagurus (L.lagurus) with the dose of 2.6×105 per animal by intraperitoneal injection. The spleen coefficient, infection rate, and antibody positive rate of the inoculated animals were detected at day 60 after infection. The desert-type Leishmania donovani strain was further inoculated with Cricetulus migratorius (C.migratorius) and L. lagurus, respectively, for passaging and preservation. The survival time of two kinds of animals andpathogenicity change of the stain in their bodies were compared.ResultsAfter inoculation of desert-type Leishmania donovani strains cultured in vitro for 7-150 days, the spleen coefficient of inoculated L.lagurus gradually increased from 1% on day 7 to 2.2% on day 30, which was more than 10 times of the normal spleen coefficient. Additionally, on day 60, the spleen coefficient remained 3 times higher than the normal value. The infection rate and antibody positive rate decreased from 80% on day 7 to 0% on day 60. At 90 days, there were no significant differences between the infected groups and the control group, and all the observed indexes were within the normal range. The survival time of L.lagurus infected with the in vivo passage strain ranged from 1 to 13 months, and half of the infected individuals died within 4 months. In contrast, C.migratorius had a survival time ranging from 5 to 31 months, and half of the infected individuals died within an average of 13.7 months. There was a significant difference in the average time of death between the two groups (t=0.000 1, P<0.001), but no significant difference in spleen coefficient (t=0.990, P>0.05). This strain exhibited equal virulence in both animals and remained virulent for up to 4 years after continuous passage.ConclusionWith the prolonged culture time, the virulence of the strain decreases gradually. At 90 d, it has no pathogenicity to L. lagurus. Long-term in vitro culture fails to preserve it's pathogenicity to L.lagurus. Only in vivo inoculation can maintain the virulence of this strain.

Epidemic characteristics of kala-azar in Shaanxi Province from 2011 to 2022 / 中华地方病学杂志

Objective:To study the epidemic characteristics of kala-azar in Shaanxi Province, and to provide scientific basis for formulating effective prevention and control measures.Methods:Information of kala-azar confirmed cases and clinically diagnosed cases whose current addresses were reported in Shaanxi Province in the Surveillance Report Management System of China Disease Control and Prevention Information System from 2011 to 2022 was collected. Trend analysis was made on the number of cases in each year, and descriptive epidemiological methods were used to analyze the onset time, regional and population distribution characteristics and the time interval from onset to diagnosis of kala-azar cases.Results:A total of 225 kala-azar cases were reported in Shaanxi Province from 2011 to 2022, and the number of cases showed an increasing trend (χ 2trend = 98.50, P < 0.001), with the highest number in 2020 (42 cases). The onset time was mainly from March to May (77 cases, 34.22%). The top three cities with the number of reported cases were Hancheng (65 cases, 28.89%), Shangluo (47 cases, 20.89%) and Weinan cities (44 cases, 19.56%). The male to female ratio was 1.74∶1.00 (143/82), the age of onset was mainly concentrated in the age group of 36 - 60 years old (111 cases, 49.33%), and the occupation was mainly farmers (150 cases, 66.67%). The median interval from onset to diagnosis was 11 days, and 78.22% (176/225) of the cases were diagnosed within 1 month. Conclusions:From 2011 to 2022, the overall incidence of kala-azar in Shaanxi Province has showed an upward trend, with the main population being middle-aged male farmers. The main affected areas are Hancheng, Shangluo and Weinan cities. It is urgent to strengthen the surveillance and prevention and control of kala-azar in key populations and key regions.

What else in times of COVID-19? The role of minimally invasive autopsy for the differential diagnosis of acute respiratory failure in a case of kala-azar

ABSTRACT Visceral leishmaniasis (VL) is a chronic vector-borne zoonotic disease caused by trypanosomatids, considered endemic in 98 countries, mainly associated with poverty. About 50,000-90,000 cases of VL occur annually worldwide, and Brazil has the second largest number of cases in the world. The clinical picture of VL is fever, hepatosplenomegaly, and pancytopenia, progressing to death in 90% of cases due to secondary infections and multi-organ failure, if left untreated. We describe the case of a 25-year-old female who lived in the metropolitan area of Sao Paulo, who had recently taken touristic trips to several rural areas in Southeastern Brazil and was diagnosed post-mortem. During the hospitalization in a hospital reference for the treatment of COVID-19, the patient developed acute respiratory failure, with chest radiographic changes, and died due to refractory shock. The ultrasound-guided minimally invasive autopsy diagnosed VL (macrophages containing amastigote forms of Leishmania in the spleen, liver and bone marrow), as well as pneumonia and bloodstream infection by gram-negative bacilli.

Blood parasite load by qPCR as therapeutic monitoring in visceral leishmaniasis patients in Brazil: a case series study

ABSTRACT Background: This study aimed to describe the kinetics of Leishmania parasite load determined using kinetoplast DNA (kDNA)-based quantitative polymerase chain reaction (qPCR) in visceral leishmaniasis (VL) patients. Methods: Parasite load in blood was assessed by qPCR at five time points, up to 12 months post-diagnosis. Sixteen patients were followed up. Results: A significant reduction in the parasite load was observed after treatment (P < 0.0001). One patient had an increased parasite load 3 months post-treatment and relapsed clinically at month six. Conclusions: We have described the use of kDNA-based qPCR in the post-treatment follow-up of VL cases.

A rare case of pancytopenia due to leishmaniasis - A case report

Visceral Leishmaniasis (VL) or Kala Azar is a chronic protozoal infectious disease caused by the Leishmania donovani complex which causes a variety of hematologic manifestations. It is manifested by fever, hepatosplenomegaly, weight loss, pancytopenia and hypergammaglobinemia. In India it is mainly seen in the states of Bihar and West Bengal. Patients with VL can present to the hematologist for variety of hematological presentation even before the diagnosis of VL is made. Anemia is the most common hematological manifestation of VL. VL may also be associated with leucopenia, thrombocytopenia, pancytopenia, hemophagocytosis and disseminated intravascular coagulation. Hematological improvement is noted with the treatment for VL. Relapses are rare. In this case report, we present a rare case of leishmaniasis with pancytopenia, which is rare in Hyderabad, Telangana, India

Liposomal amphotericin B is more effective in polymorphic lesions of post kala-azar dermal leishmaniasis

Background: Post kala-azar dermal leishmaniasis (PKDL) is thought to be the reservoir of infection for visceral leishmaniasis in South Asia. The development of strategies for the diagnosis and treatment of PKDL are important for the implementation of the visceral leishmaniasis elimination program. Aims: Liposomal amphotericin B (L-AMB) has been an overwhelming success in the treatment of visceral leishmaniasis. However, the empirical three-week regimen of L-AMB proposed for PKDL was shown to be inadequate, especially in the macular variant. This study aimed to delineate response of the different variants of PKDL to L-AMB. Methods: Skin biopsies were collected from PKDL cases at disease presentation and upon completion of treatment with L-AMB. Parasite DNA was detected by Internal Transcribed Spacer-1 PCR (ITS-1 PCR) and quantified by amplification of parasite kDNA. CD68 + macrophages were estimated in tissue sections by immunohistochemistry. Results: Treatment with L-AMB decreased the parasite load by 97% in polymorphic cases but only by 45% in macular cases. The median parasite load (89965 vs 5445 parasites/μg of genomic DNA) as well as infiltration by CD68+ cells before treatment was much greater in the polymorphic cases. Limitations: Although monitoring of the parasite load for 12 months post-treatment would have been ideal, this was not possible owing to logistical issues as well as the invasive nature of biopsy collection procedure. Conclusion: A dramatic decrease in the parasite burden was noted in patients with polymorphic lesions. Although patients with macular disease also had a decrease in parasite burden, this was not as marked as in the polymorphic cases. There was also a significantly greater infiltration of CD68 + macrophages in polymorphic PKDL before therapy

Analysis on the diagnosis of 47 cases of Kala-azar in Gansu Province / 中华地方病学杂志

Objective:To learn about the diagnosis of Kala-azar in Gansu Province, and to provide a basis for formulating corresponding prevention and control measures.Methods:The data (age, gender, onset time, diagnosis time, diagnosis unit, etc.) of Kala-azar cases in Gansu Province from January to December 2018 were collected from the China Disease Prevention and Control Information System. At the same time, a case report questionnaire was designed to collect information such as the initial diagnosis unit and initial diagnosis results; a diagnosis and treatment questionnaire of medical institutions was designed to investigate the knowledge of diagnosis and treatment of Kala-azar (main epidemic areas, main symptoms, common detection methods, main therapeutic drugs and drug use methods) among doctors in county and township hospitals, and the pass rate and awareness rate were calculated.Results:A total of 47 Kala-azar cases were included, with an average age of 17 years. Among them, men accounted for 57.45% (27/47) and women accounted for 42.55% (20/47). Among the initial diagnosis hospitals, the proportions of provincial, municipal, county and township hospitals were 2.13% (1/47), 12.77% (6/47), 42.55% (20/47) and 42.55% (20/47), respectively; among the hospitals with confirmed cases, provincial, municipal, county and township hospitals accounted for 48.94% (23/47), 31.91% (15/47), 19.15% (9/47) and 0 (0/47), respectively. The shortest time from initial diagnosis to diagnosis of the 47 cases was 1 day; the longest was 124 days, with an average of 27 days. A total of 96 valid questionnaires were collected from doctors in county and township hospitals, of which 30 scored 60 points or above, and the pass rate was 31.25% (30/96). Among the five surveys on diagnosis and treatment knowledge of Kala-azar, doctors in county and township hospitals had the highest awareness rate of "main therapeutic drugs", which was 77.08% (74/96), and there was significant difference (χ 2 = 9.86, P = 0.002) between doctors in the two-level hospitals [90.00% (45/50), 63.04% (29/46)]. The awareness rate of "main symptoms" was the lowest, which was 25.00% (24/96), and there was significant difference (χ 2 = 4.51, P = 0.034) between doctors in the two-level hospitals [34.00% (17/50), 15.22% (7/46)]. Conclusions:The awareness rate of diagnosis and treatment knowledge of Kala-azar among doctors in county and township hospitals in Gansu Province is low, and their diagnostic ability is weak. It is recommended to strengthen the training of clinicians, improve the timeliness of diagnosis, and achieve early diagnosis, early report and early treatment of Kala-azar.

Liposomal amphotericin B was successfully used to treat a case of kala-azar with prominent renal damage / 中华地方病学杂志

Objective:To analyze the diagnosis and treatment process of a kala-azar case with prominent renal damage treated with liposomal amphotericin B (L-AmB), and to provide theoretical basis for clinical diagnosis and treatment.Methods:A retrospective analysis method was used to analyze the clinical data, diagnosis and treatment process and laboratory test results of a case of kala-azar with prominent renal damage who presented to the Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University on June 30, 2020.Results:A 56-year-old female patient presented with fever (the highest body temperature was 38.2 ℃) and chills. The results of clinical laboratory tests showed that hemoglobin(55 g/L), red blood cell (2.68 × 10 12/L), white blood cell (1.06 × 10 9/L) and platelet count (8.00 × 10 9/L) were decreased, renal function showed abnormal blood urea nitrogen and creatinine, spleen enlargement, etc., and the diagnosis of kala-azar combined with kidney insufficiency was confirmed by blood and bone marrow Leishmania spp. examination. With the assistance of continuous renal replacement therapy (CRRT), after a small dose of L-AmB was initially and slowly increased and maintained at a low dose, the patient's body temperature was normal, the blood routine showed that the three-lineage cells gradually increased, and the renal function showed blood urea nitrogen and creatinine decreased gradually the spleen was retracted; no recurrence was found at follow-up after 6 months, and renal function returned to normal. Conclusions:L-AmB is safe and effective in the treatment of kala-azar with renal damage as the prominent manifestation. The patient is not only cured by etiology, but is also recovered renal function.

Acute uveitis: A rare adverse effect of miltefosine in the treatment of post-kala-azar dermal leishmaniasis

Abstract Post-kala-azar dermal leishmaniasis is a skin disorder occurring in 5-10% of visceral leishmaniasis patients after treatment with miltefosine,the first-line drug for this skin disorder. We reported a case of acute anterior uveitis,a rare adverse effect, experienced by a patient treated with miltefosine for post-kala-azar dermal leishmaniasis. This adverse effect developed after 15 days of miltefosine consumption, and the patient himself discontinued the treatment. The ophthalmic complication was completely resolved with antibiotics and steroid eye drops. After recovery from the ophthalmic complication, the patient was successfully treated with liposomal amphotericin B for the skin lesions.

Nutritional status and vitamin A and zinc levels in patients with kala-azar in Piauí, Brazil

Abstract INTRODUCTION: Malnutrition and kala-azar (or visceral leishmaniasis) are significant public health problems in different parts of the world. Immunity and susceptibility to infectious and parasitic diseases are directly linked to the host's nutritional state, but little is known about the interaction between nutrition and kala-azar. This study aimed to evaluate nutritional status with kala-azar and correlate these findings with the clinical and laboratory manifestations of the disease, and zinc and retinol levels. METHODS: This was a cross-sectional study of 139 patients with kala-azar. Nutritional status classification was performed according to international recommendations. Parametric or nonparametric tests were applied whenever indicated in a two-sided test with a 5% significance level. RESULTS: Weight loss and malnutrition were more frequent in adults. Body mass index-for-age, fat area of the arm, and upper arm muscle area were significantly associated with probability of death. The presence of human immunodeficiency virus, hepatomegaly, and splenomegaly was correlated with nutritional assessment. Blood leukocyte and lymphocyte, serum creatine, and vitamin A levels were significantly higher in adult men. Vitamin A levels were highly associated with the level of hemoglobin and C-reactive protein (CRP) in multivariate analysis. All patients had reduced plasma zinc levels, but this finding had no association with the outcome variables. CONCLUSIONS: Malnutrition was correlated with severe disease and was more prevalent in older people with kala-azar. Vitamin A deficiency was associated with hemoglobin and CRP. Zinc levels were reduced in patients with kala-azar.

Cutaneous parasitism in patients with American visceral leishmaniasis in an endemic area

Abstract INTRODUCTION: Visceral leishmaniasis (VL) represents a public health concern in several areas of the world. In the American continent, VL transmission is typically zoonotic, but humans with active VL caused by Leishmania infantum are able to infect sandflies. Thus, individuals with cutaneous parasitic infections may act as reservoirs and allow interhuman transmission. Additionally, the skin may be responsible for reactivation of the disease after therapy. This study's objective was to evaluate cutaneous parasitism in humans with VL in an American endemic area. METHODS: A cross-sectional hospital-based study was conducted in northeast Brazil from October 2016 to April 2017. Biopsies of healthy skin for histopathology and immunohistochemistry were performed prior to treatment in all study patients. RESULTS: Twenty-two patients between the ages of five months to 78 years were included in the study. Seven patients (31.8%) tested positive for HIV. Only one patient had cutaneous parasitism, as confirmed by immunohistochemistry prior to treatment. Parasitism was not detected after treatment. CONCLUSIONS: Cutaneous parasitism in the healthy skin of humans with visceral leishmaniasis, although unusual, may be a source of infection for phlebotomine sandflies.

Cytological and molecular detection of Leishmania spp. in different biological tissues of dogs in areas endemic for visceral leishmaniasis / Detecção citológica e molecular de Leishmania spp. em diferentes amostras biológicas de cães em áreas endêmicas para leishmaniose visceral

Devido à ampla distribuição da leishmaniose visceral (LV) no Brasil e à importância dos cães no ciclo de transmissão dessa zoonose, o presente estudo teve como objetivo avaliar a ocorrência de Leishmania spp. e caracterizar a espécie circulante em diferentes tecidos biológicos de cães da Baixada Cuiabana, Mato Grosso, Brasil. Amostras de sangue, linfonodo e medula óssea foram coletadas de 205 cães para realização de análise parasitológica por citologia e análise molecular por meio da nested PCR (nPCR) e do sequenciamento . Dos 205 cães estudados, 34 (16,58%) animais foram positivos pela nPCR, dos quais 12 possuíam formas amastigotas de Leishmania spp. na citologia. Amostras positivas na nPCR foram sequenciadas e caracterizadas como Leishmania (Leishmania) infantum. A sensibilidade da nPCR nas amostras de medula óssea, linfonodo e sangue foi de 94,87%, 91,8% e 98%, respectivamente, enquanto a especificidade foi de 100% para todas as amostras. O presente estudo relata a ocorrência de LV canina em 16,58% dos cães analisados, caracterizando a L. infantum como agente causador. Entre as amostras avaliadas, a medula óssea foi a única a apresentar concordância substancial entre as técnicas de nPCR e citologia (k = 0,643), sendo considerada a amostra mais adequada para o diagnóstico da doença. Os resultados ampliam o conhecimento de espécies de Leishmania infectando cães no Brasil, destacando a importância da identificação etiológica em áreas com escassos dados moleculares.(AU)

The Incidence of Leishmania donovani using RK39 and Buffy Coat Concentration Technique in Blood Donors in Gadarif State

Visceral leishmaniasis is an endemic disease in Sudan which affects many populations certainly in Gadarif State. A hospital-based cross-sectional study was conducted at Gadarif Teaching Hospital, 100 healthy apparent blood donors were included in the study and their blood specimens were examined microscopically by buffy coat technique and serologically by rk39 and there was no positivity reported in the study. Further study must be conducted with large sample size and molecular diagnostic method (PCR) must be used.

Assessment of Treatment Outcome in Post-Kala-Azar Dermal Leishmaniasis (PKDL) Patients– A Record-Based Observational study in a Speciality Public Hospital, Kolkata

In the absence of effective vector control measures and vaccines against leishmaniasis, effective chemotherapy remains the mainstay of treatment. Identification of post-kala-azar dermal leishmaniasis (PKDL) is important due to the long and toxic treatment and the fact that PKDL patients may serve as a reservoir for visceral leishmaniasis (VL). This retrospective study was done to assess the outcome of pharmacotherapy in post-kala-azar dermal leishmaniasis (PKDL) patients in a specialty public hospital in Kolkata. Methods: The hospital records of all consecutive PKDL patients admitted at Calcutta School of Tropical Medicine (CSTM), Kolkata during the last five years - 2010-2014, were reviewed and the relevant information inputs as documented studied to realize the noted objectives. Clinical presentation on admission including presence of co-infections (particularly HIV), trends and patterns of treatment regimens and rationale thereof, if available; treatment (anti-leishmaniasis) outcomes in reference to efficacy, safety and tolerability, fatality like serious complications and mortality and adverse drug reactions (for anti-leishmaninal drugs primarily), if any was noted. Results: PKDL cases presented with insidious onset skin lesions of different types without much systemic illness. 2 out of 19 cases presented with fever and 2 other cases had mild anemia. PKDL cases presented with 4 types of skin lesions. Multiple macular or hyppigmented macular lesions were commonest, 8 out of 19 cases (42.10%). In PKDL cases treatment outcome was difficult to say unless parasitologically declared negative, though clinically regression of the lesions were visible in all cases. Tolerability was least with AmB followed by SSG and best with miltefosine. Conclusion: So, it can be concluded from this study that in this institute PKDL were treated with conventional and liposomal AmB as well as with SSG, miltefosine and combination therapy. Among the regimens short course L-AmB was found to be the most efficacious and tolerable in respect to ADRs and hospital stay.

A Hospital Based Retrospective Study of Post Kala-Azar Dermal Leishmaniasis (PKDL) Cases

Post Kala-azar dermal leishmaniasis (PKDL) is a cutaneous form of leishmaniasis and usually occurs one to several years after apparent cure of visceral leishmaniasis (VL). Methods: The present work was designed as a retrospective tertiary urban hospital based, observational, clinico-epidemiological study during the period from February 2018 to January 2019. Results: A total of 24 PKDL patients, 16 males (66.66%) and 8 females (33.34%) were included in the study. The age of the patients ranged from 8 years to 56 years (mean age 30.6 years). Lesions in most of our patients (n=21, 87.50%) were located on the face, including the lip and nose. Most of our patients (n=20, 83.33%) were nodular (non-ulcerative), while two (08.33%) had nodulo ulcerative lesions and one (04.16%) had macular lesions. In the present study, 91.66.47 % (n = 22) of PKDL patients reported history of VL. The median time of manifestation of PKDL after VL treatment were 32 months (range = 5–286 months). Majority (n=20) of cases with history of VL had been treated with amphotericin B while the remaining (n=4,) had been treated with sodium stibogluconate. Conclusion: The present study highlights occurrence of PKDL in endemic area.Further epidemiological studies are required for identification of vector and strain of Leishmania involved.

Where, when, and how the diagnosis of human visceral leishmaniasis is defined: answers from the Brazilian control program

BACKGROUND Timely diagnosis is recommended by the Brazilian Visceral Leishmaniasis (VL) Surveillance and Control Program to reduce case fatality. Attempts at assessing this topic in Brazil are scarce. OBJECTIVE This study aimed to describe where, when, and how the diagnosis of VL has been performed in a Brazilian endemic setting. METHODS Data of all autochthonous cases confirmed between 2011 and 2016 (N = 81) were recorded. The care-seeking itinerary until the confirmation of VL diagnosis was assessed among 57 patients. FINDINGS The majority of VL cases (79.1%) were reported by referral hospitals. The patients mainly sought primary health care centres at the onset of symptoms. However, they had to visit seven health services on average to achieve a confirmed diagnosis. The time from the onset of symptoms to the diagnosis of VL (TD) ranged from 1-212 (median, 25) days. The TD was longer among adult patients. There was a direct correlation between the patient's age and TD (r = 0.22; p = 0.047) and a higher occurrence of deaths due to the disease among older patients (p = 0.002). Almost all the patients (98.9%) underwent laboratory investigation, and the VL diagnosis was mainly confirmed based on clinical-laboratory criteria (92.6%). Positive results for the indirect fluorescence antibody test (22.7%) and parasitological examination plus rk39-based immunochromatographic tests (21.3%) were commonly employed. MAIN CONCLUSIONS VL diagnosis was predominantly conducted in hospitals with a long TD and wide application of serology. These findings may support measures focused on early diagnosis, including a greater involvement of the primary health care system.

Visceral leishmaniasis mimicking systemic lupus erythematosus

Abstract Visceral leishmaniasis (VL), or kala-azar, a serious disease resulting from a systemic infection caused by a protozoan of the genus Leishmania, is potentially fatal to humans. According to data from Sistema de Informação de Agravos de Notificação (Brazil's Information System for Notifiable Diseases) from 2015 to 2016, 6,489 new cases were recorded in Brazil in 22 of the 27 federative units. In addition to typical clinical findings, VL may be associated with autoimmune phenomena, including simulating systemic lupus erythematosus (SLE). We present the first case of autochthonous VL mimicking SLE in Santa Catarina in southern Brazil.

Revisiting the role of the slit-skin smear in the diagnosis of Indian post-kala-azar dermal leishmaniasis

Background: Post kala azar dermal leishmaniasis (PKDL) is a neglected dermatosis that develops as a sequel to kala azar after apparent complete treatment. Being a non life threatening condition, patients often delay treatment thereby maintaining a reservoir of infection. The diagnosis of PKDL rests on the demonstration of the parasite in tissue smears, immune diagnosis by detection of parasite antigen or antibody in blood, or detection and quantitation of parasite DNA in tissue specimens. Sophisticated molecular tests are not only expensive but also need skilled hands and expensive equipment. To be useful, diagnostic methods must be accurate, simple and affordable for the population for which they are intended. Aims: This study was designed to assess functionality and operational feasibility of slit-skin smear examination. Methods: Sensitivity and specificity was evaluated by performing slit-skin smear and histo-pathological examination in 46 PKDL patients and the results were compared with the parasite load in both the slit aspirate and tissue biopsy specimens by performing quantitative Real-time PCR (Q-PCR). Results: The slit-skin smear examination was more sensitive than tissue biopsy microscopy. The parasite loads significantly differed among various types of clinical lesions (P < 0.05). The threshold of parasite load for detection by SSS microscopy was 4 parasites/μl in slit aspirate and 60 parasites/μg tissue DNA in tissue biopsy while that for tissue microscopy was 63 parasites/μl and 502 parasites/μg tissue DNA respectively. As detection of Leishmania donovani bodies may be challenging in inexperienced hands, the microscopic structure of these has been detailed along with a comprehensive discussion of pre analytical, analytical and post analytical variables affecting its identification. To facilitate the diagnosis of PKDL, some scenarios have been suggested taking into consideration the clinical, epidemiological, immunological and microscopic aspects. Conclusion: Such evidence based medicine helps minimize intuition, systematize clinical experience and provides a diagnostic rationale as sufficient grounds for a clinical decision.

Epidemiology of human visceral leishmaniasis in the urban centers of the lower-middle São Francisco Valley, Brazilian semiarid region

Abstract INTRODUCTION: Visceral leishmaniasis (VL) is a zoonosis caused by parasites of the Leishmania genus. VL is present in countries with tropical climates, being endemic in Brazil,, including the region of the lower-middle São Francisco Valley which includes the urban centers of Petrolina (Pernambuco state) and Juazeiro (Bahia state). METHODS: This retrospective and descriptive epidemiological study analyzed secondary data obtained from the mandatory visceral leishmaniasis notification forms of the Ministry of Health, which were compiled in the Information System for Notifiable Diseases (SINAN) database. We analyzed 181 autochthonous cases reported in the two aforementioned cities between 2010 and 2016. Data collection occurred in June 2017. RESULTS: Of the 181 VL cases in the study area, 40.9% (n=74) occurred in Juazeiro and 59.1% (n=107) occurred in Petrolina. The average numbers of cases per year were 9.5 in Juazeiro and 14 in Petrolina; respectively, the incidence ranges were 2-8.6 cases and 2.8-6.1 cases per 100,000 inhabitants. Fever, weakness, weight loss, and pallor were the most commonly observed clinical manifestations. Coinfection with human immunodeficiency virus (HIV) was observed in 16.8% and 5.4% of cases in Petrolina and Juazeiro, respectively. The lethality rates were 2.8% and 5.4% in Petrolina and Juazeiro, respectively. CONCLUSIONS: Both cities had a high incidence of VL during the studied period. The findings of this study contribute to a better understanding of the behavior of VL during recent years and may help to direct regional disease control measures.