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.

Hemophagocytic lymphohistiocytosis secondary to visceral leishmaniasis in an endemic area in the north of Minas Gerais, Brazil

Abstract INTRODUCTION Visceral leishmaniasis (VL) is an ill-studied disease that is endemic to several regions of Brazil. It is often complicated by hemophagocytic lymphohistiocytosis (HLH), a potentially fatal disorder resulting from excessive non-malignant activation/proliferation of T lymphocytes and macrophages. Considering the overlapping clinical and laboratory characteristics of these diseases, diagnosing HLH is a challenge. Therefore, tracking the association between VL and HLH is necessary in endemic areas. Although HLH can be inapparent and resolve with antileishmanicides, this may not always occur. HLH causes high lethality; therefore, immunosuppressive therapy should be instituted immediately in order to avoid a fatal outcome. METHODS: We described the epidemiological, clinical, laboratory, and therapeutic profile of this association in a region of Brazil endemic for VL. RESULTS We presented 39 patients with this association in a retrospective cohort of 258 children who were admitted from January 2012 to June 2017. Of the 39 patients, 31 were from urban areas (79.5%), and 21 (53%) were males. The mean age and weight were 2.86 (2.08) years and 14.03 (5.96) kg, respectively. The main symptoms were fever (100%), hepatosplenomegaly (100%), pallor of the skin and mucosa (82.5%), edema (38.5%), bleeding (25%), and jaundice (7.5%). Hemophagocytosis was identified in 16/37 (43.24%) patients, and direct examination revealed that 26/37 (70.27%) patients were positive for VL. The patients were treated as recommended by the Ministry of Health. CONCLUSIONS It was observed that HLH is a common complication in endemic areas, and its diagnosis must consider the overlapping of clinical characteristics and pancytopenia.

Prevalence of HIV and associated factors among visceral leishmaniasis cases in an endemic area of Northeast Brazil

Abstract INTRODUCTION Cases of visceral leishmaniasis (VL) and HIV co-infection have increased worldwide. We investigated the prevalence of HIV and associated factors among VL patients in Sergipe state, Brazil. METHODS We conducted a population-based study of all cases of VL and HIV reported in Sergipe from 1999 to 2015. RESULTS We studied a total of 917 patients; 41 (4.5%) co-infection cases were detected. VL-HIV co-infected patients were more likely to have weight loss, cough, treatment failure or loss to follow-up and death. CONCLUSIONS The prevalence of VL-HIV co-infection was high and co-infected patients were more likely to have adverse outcomes.

Ceratoconjuntivite nodular em um caso de leishmaniose visceral canina: relato de caso / Nodular keratoconjunctivitis in a case of canine visceral leishmaniasis: case report

Relata-se um caso de leishmaniose visceral canina com ceratoconjuntivite nodular como queixa exclusiva do proprietário. O diagnóstico se deu pela observação de formas amastigotas de Leishmania sp. no exame parasitológico direto de citologia aspirativa conjuntival. Lesões oculares raramente são queixas principais únicas de cães com leishmaniose, como o caso em questão, o que demonstra a variabilidade de apresentação clínica da doença e a importância da realização de testes laboratoriais diagnósticos para leishmaniose como triagem para pacientes de áreas endêmicas.(AU)

We describe a case of canine visceral leishmaniasis with nodular keratoconjunctivits as the owner's only complaint. Diagnosis was made by the observation of Leishmania sp. amastigotes in parasitological examination from conjunctival aspirative cytology. Eye lesions are rarely the only complaint of dogs suspected of leishmaniasis, as the case reported, demonstrating the variability of clinical presentation of the disease and the importance of performing screening diagnostic laboratorial tests for leishmaniasis in endemic areas.(AU)

Epidemiological profile of patients co-infected with visceral leishmaniasis and HIV/AIDS in Northeast, Brazil

Abstract INTRODUCTION: Visceral leishmaniasis (VL) and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) co-infection has been a research topic of interest worldwide. In Brazil, it has been observed that there is a relative underreporting and failure in the understanding and management of this important association. The aim of this study was to analyze epidemiological and clinical aspects of patients with VL with and without HIV/AIDS. METHODS: We conducted an observational and analytical study of patients with VL followed in a Reference Service in the State of Maranhão, Brazil from 2007-2013. RESULTS: In total 126 patients were enrolled, of which 61 (48.4%) were co-infected with HIV/AIDS. There were more males among those with HIV/AIDS (85.2%, P>0.05) or with VL only (81.5%, P>0.05). These findings significantly differed based on age group (P<0.003); the majority of patients were aged 31-40 years (41.0%) and 21-30 years (32.3%) among those with and without HIV/AIDS co-infection, respectively. The incidence of diarrhea and splenomegaly significantly differed between the two groups (P=0.0014 and P=0.019, respectively). The myelogram parasitic examination was used most frequently among those with HIV/AIDS (91.8%), followed by those with VL only (69.2%). VL recurrences and mortality were significantly higher in the HIV/AIDS co-infected patients (P<0.0001 and P=0.012, respectively). CONCLUSIONS: Patients with VL with or without HIV/AIDS co-infection were mostly adult men. Diarrhea was more frequent in HIV/AIDS co-infected patients, whereas splenomegaly was more common in patients with VL only. In the group of HIV/AIDS co-infected patients, there was a higher rate of VL recurrence and mortality.

Análise das regiões polimórficas do gene HASPB (K26) de Leishmania infantum em amostras clínicas positivas para leishmaniose visceral e coinfecção LV/HIV / Analyzing of the polymorphic regions of HASPB (K26) gene from Leishmania infantum in positive clinical samples for visceral leishmaniasis and VL/HIV co-infection

A leishmaniose visceral(LV) é uma doença grave que afeta a população de vários países, onde o Brasil apresenta a maior prevalência da infecção nas Américas. Com o estudo do gene codificante da proteína B de superfície (HASPB ou K26) de Leishmania infantum é possível identificar as variações polimórficas intraespecíficas e, assim, será possível consolidar a descrição de um perfil polimórfico presente no Estado de Pernambuco. O objetivo do trabalho foi analisar as regiões polimórficas do gene HASPB (K26) de Leishmania infantum em amostras clínicas positivas para leishmaniose visceral e coinfecção LV/HIV. O sistema K26 PCR foi otimizado utilizando concentrações variadas de DNA genômico de L. infantum. Foi realizado o screening de amostras clínicas de DNA através de dois sistemas de PCR simples, kDNA e ITS1/RFLP, para ensaios posteriores com a K26 PCR nas amostras positivas. A curva de dissociação de alta definição (qPCR-HRM) foi empregada na localização de temperaturas de melting específicas para L. infantum. Os amplicons do gene K26 foram sequenciados e alinhados as sequencias selecionadas em base de dados. A K26 PCR apresentou limiar de detecção de 1 pg para amplicon de 700 pb. A especificidade dos primers foi avaliada experimentalmente e in silico, apresentando anelamento inespecífico com DNA humano. Em paralelo, foram selecionadas 78 amostras de DNA através dos dois sistemas screening, sendo 17 caracterizadas como L. infantum. Os ensaios com DNA das amostras clínicas para o sistema K26 PCR revelaram bandas espúrias. A análise através qPCR-HRM em DNA genômico do parasita resultou em amplificação com Tm de 88,2 °C, já o ensaio com amostra clínica revelou duas amplificações com distintas temperaturas de melting, 84,6 e 88,2°C. Três amplicons do gene K26 foram sequenciados e alinhados a cinco sequencias da base de dados, indicando 38,2 por cento de similaridade. Pode-se concluir que o sistema K26 PCR é recomendável para análise dos polimorfismos genéticos, contanto que o DNA seja extraído diretamente de espécies isoladas em meio de cultura.

Intraretinal hemorrhage associated with visceral leishmaniasis / Hemorragia intrarretiniana associada à leishmaniose visceral

ABSTRACT Visceral Leishmaniasis, also know as Kala-azar, is a parasitic tropical disease caused by protozoa of the genus Leishmania donovani. It is an endemic disease in many countries. It affects approximately 1,5 million people every year, and when associated with mal-nutrition and co-infection it may be fatal. Fever, hepatosplenomegaly, and pancytopenia is its typical clinical picture. Ocular manifestations of Kalaazar are relatively rare and can affect either anterior or posterior segment of the eye. We report a patient with kala-azar presenting intraretinal hemorrhages that regress completely after the successful treatment for visceral leishmaniasis.

RESUMO Leishmaniose visceral, também conhecida como calazar é uma doença tropical parasitária, causada pelo protozoário do gênero Leishmania donovan uma doença endêmica em muitos países. Afeta aproximadamente 1,5 milhões de pessoas durante todo ano e quando associada à desnutrição e coinfecção pode ser fatal. Febre, hepatoesplenomegalia e pancitopenia e o quadro típico. Manifestações oculares são raras e podem afetar tanto o segmento anterior como o posterior do olho. Relatamos o caso de um paciente com calazar e hemorragia intrarretiniana que regrediu após tratamento para leishmaniose visceral.

Histopathological characteristics of post kala-azar dermal leishmaniasis: A series of 88 patients.

Background: Post kala azar dermal leishmaniasis (PKDL) is a sequel to visceral leishmaniasis or kala azar seen predominantly in the Indian subcontinent and Africa. Histopathological descriptions of the condition are limited. Methods: Biopsies of 88 skin and 16 mucosal lesions were evaluated for histopathological findings on formalin-fixed, paraffin-embedded tissues. Results: There were 71 (80.7%) males and 17 (19.3%) females with a mean age of 24.8 and 28.5 years, respectively. A past history of kala azar was present in 64 (72.7%) patients and post kala azar dermal leishmaniasis developed a mean of 6.2 years after visceral leishmaniasis. Of the biopsies studied, the clinical lesions were macular in 14 (15.9%), papulo-nodular in 32 (36.3%) and showed both macules and papulo-nodules in 42 (47.8%). Follicular plugging was a common epidermal finding. A clear Grenz zone was frequently noted. The dermal infiltrates were arranged mainly in three patterns: superficial perivascular infiltrates in 16 (18.1%), perivascular and perifollicular infiltrates in 24 (27.3%) and diffuse infiltrates in 41 (46.6%) biopsies. Leishman-Donovan (LD) bodies were noted in 13 (44.9%) of 69 cases on slit-skin smear and in 25 (28.4%) of 88 biopsies. In 16 patients, where both skin and mucosal biopsies were available, LD bodies were identified in 10 (62.5%) mucosal biopsies as compared to 3 (18.7%) skin biopsies. Limitations: The retrospective nature of the study and the lack of controls were limitations. Conclusion: The various histomorphological patterns of post kala azar dermal leishmaniasis are a useful clue to the diagnosis even when LD bodies have not been detected. This study also suggests that LD bodies are more frequently seen in mucosal biopsies in comparison to cutaneous biopsies.

Kidney involvement in leishmaniasis ? a review

Leishmaniasis is an infectious disease caused by protozoa of the genus Leishmania transmitted by insects of the genus Lutzomyia sp. or Phlebotomus sp. The main syndromes are cutaneous leishmaniasis, mucocutaneous leishmaniasis, visceral leishmaniasis (kala-azar) and post-kala-azar dermal leishmaniasis. This article reviews kidney involvement in cutaneous and visceral leishmaniasis, highlighting the aspects of their pathophysiology, clinical manifestations, histopathological findings, outcome and treatment.

Molecular and serological detection of tick-borne pathogens in dogs from an area endemic for Leishmania infantum in Mato Grosso do Sul, Brazil / Detecção sorológica e molecular de patógenos transmitidos por carrapatos em cães de uma área endêmica para Leishmania infantum do estado do Mato Grosso do Sul

Tick-borne pathogens affect a wide range of vertebrate hosts. To identify tick-borne pathogens among dogs from Campo Grande, MS, Brazil testing seropositive for Leishmania infantum (syn. L. chagasi), a serological and molecular study was conducted to detect Ehrlichia canis, Anaplasma platys and Babesia vogeli in 60 serum and spleen samples. A confirmatory diagnosis of L. infantum based on serological and molecular assays was also performed, as was sequence alignment and phylogenetic analysis to assess the identity of the parasite species infecting these animals. IgG antibodies to Ehrlichia spp., B. vogeli and L. infantum were found, respectively, in 39 (65%), 49 (81.6%) and 60 (100%) of the sampled dogs. Twenty-seven (45%), fifty-four (90%), fifty-three (88.3%), two (3.3%) and one (1.6%) dog were positive, respectively, for E. canis, Leishmania spp., Leishmania donovani complex, Babesia sp. and Anaplasma sp. in PCR assays. After sequencing, the amplicons showed 99% of identity with E. canis, B. vogeli, A. platys and Leishmania chagasi isolates. The findings of this study indicate that L. infantum-seropositive dogs from Campo Grande are exposed to multiple tick-borne pathogens, which should therefore be included in the differential diagnosis of dogs with clinical suspicion of leishmaniasis.

Patógenos transmitidos por carrapatos atingem uma variedade de hospedeiros vertebrados. Para identificar os agentes patogênicos transmitidos por carrapatos entre cães soropositivos para Leishmania infantum no município Campo Grande-MS, foi realizado um estudo sorológico e molecular para a detecção de Ehrlichia canis, Anaplasma platys e Babesia vogeli em 60 amostras de soro e baço, respectivamente. Adicionalmente, foi realizado o diagnóstico confirmatório de L. infantum por meio de técnicas sorológicas e moleculares. Também foi realizado o alinhamento e análise filogenética das sequências para indicar a identidade das espécies de parasitas que infectam esses animais. Anticorpos IgG anti-Ehrlichia spp., anti-B. vogeli e anti-L. infantum foram detectados em 39 (65%), 49 (81,6%) e 60 (100%) dos cães amostrados, respectivamente. Vinte e sete (45%), cinquenta e quatro (90%), cinquenta e três (88,3%), dois (3,3%) e um (1,6%) cães mostraram-se positivos na PCR para E. canis, Leishmania spp., Leishmania donovani complex, Babesia sp. e Anaplasma sp., respectivamente. Após o seqüenciamento, os amplicons mostraram 99% de similaridade com isolados de E. canis, B. vogeli e A. platys e Leishmania chagasi. Os resultados deste estudo indicaram que os cães soropositivos para L. infantum de Campo Grande, MS, são expostos a vários agentes transmitidos por carrapatos, e, portanto, devem ser incluídos no diagnóstico diferencial em cães com suspeita clínica de leishmaniose.

Canine visceral leishmaniasis and Chagas disease among dogs in Araguaina, Tocantins / Leishmaniose visceral canina e doença de Chagas em cães de Araguaina, Tocantins

The present study analyzed serum samples from 111 male and female dogs of various ages from the municipality of Araguaína in the State of Tocantins, Brazil. Serological diagnosis of canine visceral leishmaniasis (CVL) was initially performed at the Central Laboratory (Laboratório Central ­ LACEN) of Araguaína, resulting in 61 positive samples by an indirect immunofluorescence assay (IIFA) (≥1:40) and 50 non-reactive samples. The same samples were analyzed at the São Paulo Institute of Tropical Medicine (Instituto de Medicina Tropical de São Paulo ­ IMTSP) by an enzyme-linked-immunosorbent assay (ELISA), resulting in 57 positive samples (51.35%) and 54 negative samples (48.64%). The Kappa coefficient of agreement between the tests was 0.74. The serum samples were also subjected to a diagnostic assay for Trypanosoma cruzi (Trypomastigote Excreted/Secreted Antigens -TESA-blot) that detected five suspect animals; three of those animals were positive for leishmaniasis by ELISA but negative by IIFA. These findings suggest that the canine population of Araguaína may be simultaneously infected with Leishmania chagasi and T. cruzi. The results obtained demonstrate the difficulty of using serology to detect CVL, thus emphasizing the necessity for a reference test to diagnose CVL, particularly in regions where the infection is endemic.

Neste estudo foram analisadas amostras de soros de 111 cães machos e fêmeas, de idades variadas, provenientes do município de Araguaína, estado do Tocantins, Brasil. O diagnóstico sorológico para leishmaniose visceral canina foi realizado, inicialmente, no Laboratório Central (LACEN) de Araguaína, resultando em 61 amostras positivas na Reação de Imunofluorescência Indireta - RIFI (≥1:40) e 50 amostras não reativas. As mesmas amostras foram analisadas no Instituto de Medicina Tropical de São Paulo (IMTSP) pelo Enzyme-Linked-Immunosorbent Assay (ELISA), sendo 57 amostras positivas (51,35%) e 54 amostras negativas (48,64%), com coeficiente de concordância entre os testes (Kappa = 0,74). Os soros foram submetidos também a um teste de diagnóstico para Trypanosoma cruzi (Trypomastigote Excreted/Secreted Antigens-TESA-blot), o qual detectou cinco animais suspeitos, dos quais três foram positivos para leishmaniose no ELISA, mas negativos na RIFI. Estas observações mostram que a população canina de Araguaína pode também estar infectada simultaneamente com Leishmania chagasi e T. cruzi. Estes resultados mostram a dificuldade da sorologia na detecção da Leishmaniose Visceral Canina (LVC), reforçando a necessidade de um teste de referência para o diagnóstico da leishmaniose visceral canina, principalmente em regiões endêmicas para tais infecções.

Perfil epidemiológico dos indivíduos HIV positivo e coinfecção HIV-Leishmania em um serviço de referência em São Luís, MA, Brasil / The epidemiological profile of HIV-positive individuals and HIV-Leishmaniasis co-infection in a referral center in São Luis, Maranhão, Brazil

A Aids é um problema de saúde pública e a Leishmaniose visceral (LV) a forma mais frequente de coinfecção. O objetivo é descrever aspectos epidemiológicos dos indivíduos HIV positivo e investigar a ocorrência de coinfecção HIV-Leishmania. Trata-se de estudo descritivo realizado com 287 indivíduos HIV positivo atendidos no Centro de Referência para DST/Aids em São Luís (MA). Foi realizado teste de Intradermorreação de Montenegro, aspirado de medula óssea para detecção da infecção por Leishmania sp e aplicado um questionário na coleta dos dados epidemiológicos. O teste qui-quadrado foi usado para diferenças entre gênero, com p < 0,05 de significância. Houve significância estatística entre os homens relacionados ao uso de fossa séptica e renda até dois salários. Quanto à exposição, foi predominante a categoria heterossexual para ambos os sexos, sendo observado um aumento entre as mulheres. Entre os indivíduos HIV positivo 4,2% apresentavam sintomatologia sugestiva de LV sendo identificadas formas amastigotas para Leishmania sp no aspirado de medula óssea. O perfil dos indivíduos HIV positivo não diferiu de outras regiões do Brasil com predomínio de jovens em idade produtiva, sendo constatada uma sobreposição das áreas de transmissão para a coinfecção HIV-LV.

AIDS is a public health problem and visceral leishmaniasis (VL) is the most frequent co-infection. This study seeks to describe the epidemiological aspects of HIV-positive individuals and to investigate the occurrence of HIV-Leishmania co-infection. It is a descriptive study with 287 HIV=positive individuals assisted at the reference center for HIV/AIDS in São Luís, MA. Montenegro's intradermal reaction and bone marrow aspiration were performed for detecting the Leishmania sp. infection. Epidemiological data were collected by means of a questionnaire. The chi-square test was used for gender differences, with p < 0.05 of statistical significance level. There was statistical significance among men regarding the use of septic tanks, and income of up to two salaries. Regarding exposure, heterosexual orientation was the most frequent category for both genders, and we observed an increase in this category among women. Among HIV-positive individuals, 4.2% had suggestive symptoms of VL with identification of Leishmania amastigotes in bone marrow aspirate (myelogram). The profile of HIV-positive individuals did not differ from what is commonly found in Brazil, with predominance of young people of productive age. Furthermore, a superposition of the transmission areas for HIV-LV co-infection was found.

Renal histopathllogical findings in dogs with visceral leishmaniasis / Achados histopatológicos renais em cães com leishmaniose visceral

Visceral leishmaniasis affects various organs including the kidneys; which can lead to renal failure and death. In order to verify this renal involvement, material was evaluated from 100 dogs naturally infected and with serological diagnosis of canine visceral leishmaniasis (CVL). Inflammatory changes were present in 25.3% of the tubules, in 67.0% of interstitium and in 52.0% of glomeruli. There was no significant difference (p > 0.05) between the presence of glomerulonephritis in symptomatic and oligosymptomatic dogs. The membranous and membranoproliferative glomerulonephritis were the most frequent, both with 18.0% frequency, followed by focal segmental glomerulosclerosis with 14.0%. Changes such as cylindruria, tubular and fibrosis hypertrophy, periglomerular inflammatory infiltrate, and multifocal and diffuse peritubular inflammatory infiltrate were observed. The findings are consistent with those of other authors indicating that renal involvement is common in CVL and the standards of membranous and membranoploriferative glomerulonephritis, as well as the tubulointerstitial involvement, are frequent.

A leishmaniose visceral acomete vários órgãos entre eles os rins; o que pode levar a insuficiência renal e a morte. Com o objetivo de verificar este acometimento renal foram avaliados materiais de 100 cães naturalmente infectados e com diagnósticos sorológicos de leishmaniose visceral canina - LVC. As alterações inflamatórias estavam presentes em 25,3% dos túbulos, em 67,0% do interstício e em 52,0% dos glomérulos. Não houve diferença significativa (p > 0,05) entre a presença de glomerulonefrite em cães sintomáticos e oligossintomáticos. As glomerulonefrites membranosa e membrano proliferativa foram as mais freqüentes, ambas com 18,0% de freqüência seguidas da glomeruloesclerose segmentar e focal com 14,0%. Foram observadas alterações como cilindrúria, hipertrofia tubular e fibrose e infiltrados inflamatórios periglomerulares e peritubulares multifocais e difusos. Os achados concordam com os de outros autores indicando que o acometimento renal é comum na LVC e que os padrões de glomerulonefrites membranoploriferativa e membranosa; assim como o acometimento tubulointersticial são freqüentes.

Factors of poor prognosis of visceral leishmaniasis among children under 12 years of age: A retrospective monocentric study in Belo Horizonte, State of Minas Gerais, Brazil, 2001-2005

INTRODUTION: A major concern with the visceral leishmaniasis (VL) is its high lethality rate, even with proper treatment. Low age, prior malnutrition, disease duration prior to diagnosis, severe anemia, fever for more than 60 days, diarrhea and jaundice are known poor prognostic factors. The goals of this study are to describe the clinical and laboratory characteristics of VL among children under 12 years of age and to identify the factors associated with VL poor outcome. METHODS: Two hundred and fifty children under 12 years of age with confirmed VL admitted to Hospital João Paulo II (FHEMIG), Belo Horizonte, Brazil, between January 2001 and December 2005 were evaluated retrospectively. The primary outcome was the poor clinical evolution: sepsis, and/or pneumonia, and/or urinary tract infection, and/or of bleeding (expect epistaxis), and/or severe neutropenia (neutrophil < 500 cells/mm³). Odds ratio (crude and adjusted) and its 95% confidence interval for each variable were calculated. Values less than 0.05 were considered significant. RESULTS: Average age was 3.3 years (3.6 months-11.6 years), 71.2% were younger than 5 years and 47.2% lived in Metropolitan Area of Belo Horizonte. The mean fatality rate was 3.6%. Sixty-six (26.4%) patients presented poor evolution. After a multivariate analysis, age <18 months, abnormal respiratory physical examination on hospital admission, and platelets <85,000/mm³ remained associated with increased chance of poor evolution. CONCLUSIONS: The results suggest that patients aged between 12 and 18 months, with platelet counts bellow 85,000/mm³, and respiratory abnormalities at admission should be considered potentially severe.

Clinicohaematological spectrum of pancytopenia in a tertiary care hospital

To determine the frequency, clinical presentation and underlying causes of pancytopenia inpatients presenting to a tertiary care hospital in Peshawar. This cross-sectional, observational study was conducted at Department of Pathology, Lady Reading Hospital Peshawar from January to December 2011. Patients of all ages having pancytopenia on blood film examination [TLC < 4000/ul, Hb < 10 gm/dl and Platelets < 150000/ul] were included in the study. Already diagnosed patients of Aplastic Anemia, Acute Leukemia receiving treatment and those not willing for bone marrow examination were excluded from the study. History, General Physical and systemic examination were recorded at presentation. The peripheral blood counts were performed with sysmex - automated hematology analyzer. Bone marrow aspiration and trephine biopsy were performed according to the standard protocol and examined microscopically to find the underlying cause of pancytopenia. Other relevant investigations were also done. During the study period, we received 600 patients for bone marrow examination from various units. Out of these, 160 [26.7%] patients had pancytopenia. Common clinical presentations were Pallor[95%, n=150], followed by generalized weakness [75%, n=120], fever [52%, n=83], bleeding manifestation[37.5%, n=60], gastrointestinal symptoms [32.5%, n=52] and splenomegaly [23.5%, n=38]. The common causes of pancytopenia were aplastic anemia [37.5%, n=60] followed by magaloblastic anemia [13.75%,n=22], Acute Leukemia [13.75%, n=22] and hypersplenism [10%, n=16]. Pancytopenia is a common occurrence. Aplastic Anemia and Magaloblastic Anemia are the commonest causes of Pancytopenia followed by Acute Leukemia. Common clinical presentations were Pallor, fever, weakness, bleeding manifestation and Splenomegaly

Hemophagocytic lymphohistiocytosis associated with H1N1 virus infection and visceral leishmaniasis in a 4.5-month-old infant / Linfohistiocitose hemofagocítica associada pela infecção do vírus H1N1 e leishmaniose visceral em um bebê de 4,5 meses de vida

We present a case of a 4.5-month-old boy from Turkey with hemophagocytic lymphohistiocytosis (HLH) associated with H1N1 virus and Leishmania spp. coinfection. Because visceral leishmaniasis can mimic hematologic disorders like HLH, it is important to rule out this clinical condition before starting immunosuppressive therapy. In our case, treatment with liposomal amphotericin B resulted in a dramatic resolution of clinical and laboratory abnormalities.

É relatado um caso de um menino de 4,5 meses de idade, da Turquia, com linfohistiocitose hemofagocítica (HLH) associado à coinfecção com o vírus H1N1 e leishmaniose visceral. Como a leishmaniose visceral pode imitar doenças hematológicas como HLH, é importante afastar essa condição clínica antes de iniciar a terapia imunossupressora. No caso relatado, o tratamento com anfotericina B lipossomal resultou em uma resolução dramática das anomalias clínicas e laboratoriais.

Recent advances in the diagnosis and treatment of kala-azar.

In India, about 100 000 cases of visceral leishmaniasis (VL) or kala-azar are estimated to occur annually, 90% of which occur in the state of Bihar. Currently, antibody-based tests such as the rK39-based immunochromatographic strip test and the direct agglutination test (DAT) are widely used for the diagnosis of VL. However, their major drawback is continued positivity both long after cure and in a high proportion of individuals living in endemic areas. Thus, antibody-based tests must always be used in combination with a standardized clinical case definition for VL. There have been many breakthroughs in the past decade in the treatment of kala-azar in India, such as approval of oral miltefosine and paromomycin, single-dose treatment with liposomal amphotericin B and multidrug treatment. Encouraged by these advances, an ambitious VL elimination programme was launched with the aim to eliminate VL as a public health problem in India, Nepal and Bangladesh by 2015. Early diagnosis, complete treatment of cases, integrated vector management, effective disease surveillance, and clinical and operational research should be the five key components of the strategy to achieve this goal.

Clinical and laboratory alterations in dogs naturally infected by Leishmania chagasi / Alterações clínicas e laboratoriais em cães naturalmente infectados por Leishmania chagasi

INTRODUCTION: Canine visceral leishmaniasis (CVL) is a zoonotic disease with different clinical manifestations. Parasitism often occurs in bone marrow, but changes have been observed in peripheral blood and serum biochemical parameters. The aim of this study was to evaluate the hematological and biochemical parameters in dogs naturally infected by Leishmania chagasi. METHODS: Eighty-five adult dogs of both sexes and various weights and ages from the Zoonosis Control Center of Fortaleza (CCZ) were used, selected by immunofluorescence assay (IFA) and considered positive with IFA titers greater than 1:40 and by visualizing amastigotes of Leishmania chagasi in smears obtained by bone marrow aspiration. The dogs (n = 85) were grouped according to clinical signs: negative (CN = 7), subclinical (CS = 10), and clinical (CC = 68). Blood samples were collected for determination of hematological and biochemical serum values. The experimental protocol was approved by the CEUA/UECE. RESULTS: The most frequent clinical signs were cachexia (77.9 percent), keratitis (61.8 percent), and lymphadenopathy (55.9 percent), and 86.8 percent of the animals showed more than one clinical sign characteristic of CVL. In CC were observed reductions in red blood cells (63 percent), hematocrit (72 percent), and hemoglobin (62 percent), as well as leukocytosis (33 percent), neutropenia (28 percent), thrombocytopenia (50 percent), uremia (45 percent), hyperproteinemia (53 percent, p<0.05), hypergammaglobulinemia (62 percent, p<0.01), and hypoalbuminemia (58 percent). CONCLUSIONS: Animals with the clinical form of the disease demonstrate hematological and biochemical changes consistent with anemia, uremia, hyperproteinemia, and hyperglobulinemia, which present themselves as strong clinical markers of visceral leishmaniasis associated with the signs previously reported.

INTRODUÇÃO: A leishmaniose visceral canina (LVC) é uma zoonose com diferentes manifestações clínicas. O parasitismo ocorre frequentemente na medula óssea e têm sido relatadas alterações hematológicas e bioquímicas. Objetivou-se avaliar os parâmetros clínicos, hematológicos e bioquímicos de cães naturalmente infectados por Leishmania chagasi. MÉTODOS: Utilizaram-se 85 cães adultos, ambos os sexos, peso e idade variados, oriundos do Centro de Controle de Zoonoses de Fortaleza, selecionados pela reação de imunofluorescência indireta (RIFI), sendo considerados positivos os animais com títulos de RIFI > 1:40 e pelo exame parasitológico das formas amastigotas de Leishmania chagasi em esfregaços de medula óssea. Os cães foram agrupados conforme os sinais clínicos associados à doença: negativos (CN=7); subclínicos (CS=10) e clínicos (CC=68). Amostras de sangue foram coletadas para determinação dos parâmetros hematológicos e bioquímicos séricos. O protocolo experimental foi aprovado pelo CEUA/UECE, protocolo n° 08622833-1. RESULTADOS: Os sinais clínicos mais frequentes foram caquexia (77,9 por cento), ceratoconjuntivite (61,8 por cento) e linfadenopatia (55,9 por cento), sendo que 86, 8 por cento dos animais apresentaram mais de um sinal clínico característico de LVC. Em CC foram observadas reduções nas hemácias (63 por cento), hematócrito (72 por cento) e hemoglobina (62 por cento), leucocitose (33 por cento), neutropenia (28 por cento), trombocitopenia (50 por cento), uremia (45 por cento), hiperproteinemia (53 por cento, p<0,05), hiperglobulinemia (62 por cento, p<0,01) e hipoalbuminemia (58 por cento). CONCLUSÕES: Concluiu-se que os animais com a forma clínica da doença apresentam alterações condizentes com anemia, uremia, hiperproteinemia e hiperglobulinemia, as quais se apresentam como marcadores clínicos da leishmaniose visceral, associados aos sinais previamente relatados.

Splenectomy in a patient with treatment-resistant visceral leishmaniasis: a case report / A esplenectomia na leishmaniose visceral refratária ao tratamento clínico: relato de caso

Visceral leishmaniasis (VL), also known as Kala-azar, is a systemic infection caused by a protozoan (Leishmania) and, in its classic form, is a serious illness associated with malnutrition, anemia, hepatosplenomegaly, infectious processes and coagulopathies. The effect of splenectomy in patients with visceral leishmaniasis is not well defined; however, it is known that the spleen is the largest reservoir of infected cells belonging to the reticulo endothelial system. Therefore, the surgical procedure is an option for the debulking of parasites, providing a cure for refractory VL and minimizing the complications of hypersplenism.

A leishmaniose visceral (LV) ou calazar é uma infecção sistêmica causada por um protozoário (Leishmania) e na sua forma clássica é uma doença grave. Cursa com desnutrição, anemia, hepatoesplenomegalia, processos infecciosos e coagulopatias. O papel da esplenectomia em pacientes com leishmaniose visceral não é bem definido; entretanto, sabe-se que o baço é o maior reservatório de células parasitadas do sistema reticulo endotelial e o procedimento cirúrgico é, dessa forma, uma opção para debulking de parasitas, propiciando a cura da LV refratária e minimizando as complicações do hiperesplenismo.