Validity of the polymerase chain reaction in the diagnosis of clinically suspected cases of American visceral leishmaniasis

To test the validity of the polymerase chain reaction for diagnosing American visceral leishmaniasis, 88 suspected cases were studied. Diagnosis was confirmed in 47 (53.5%) and ruled out in 41 (46.5%) patients. Samples of bone marrow and peripheral blood were processed by polymerase chain reaction to evaluate the sensitivity and specificity of the test and its agreement beyond chance with microscopy examination. The polymerase chain reaction was positive in bone marrow of 100% of the patients with amastigotes seen with microscopy examination, and in 59.5% in those where no parasite were seen. Agreement beyond chance between visualization of the parasite in bone marrow aspirates and polymerase chain reaction was considered weak (Kappa = 0.41). Concordance between polymerase chain reaction of bone marrow aspirates and of peripheral blood was considered excellent (Kappa = 0.88). The test turned out positive in all bone marrow aspirates of those with the disease and whereas the positivity rate was 58.5% among those without the disease, with specificity rate of 41.5%.

Hemophagocytic syndrome associated with Plasmodium falciparum infection.

Hemophagocytic syndrome (HPS) has been associated with infections, hematological malignancies and autoimmune conditions. Malaria is rarely reported to cause HPS. We report a case of an 11-month-old infant with fever, hepatosplenomegaly, pancytopenia, high serum ferritin, hypertriglyceridemia, and bone marrow hemophagocytosis, consistent with hemophagocytic syndrome. Gametocytes of plasmodium falciparum were identified on bone marrow aspiration. Rapid recovery was observed after treatment with antimalarials.

Neurological involvement in visceral leishmaniasis: case report / Envolvimento neurológico na leishmaniose visceral: relato de caso

Visceral leishmaniasis is a severe and potentially fatal vector-borne disease. The most typical symptoms are fever, hepatosplenomegaly, weight loss, bleeding and bacterial infections. Neurological changes are rarely reported. This paper describes a child who presented with neurological signs as the first symptoms of leishmaniasis; tone was diminished and tremors in the extremities were observed. A diagnosis of visceral leishmaniasis was confirmed by parasite detection in the bone marrow. Symptoms were reversed by specific treatment. The nature of a possible mechanism of neurological involvement in visceral leishmaniasis remains unexplained.

A leishmaniose visceral é uma doença severa e potencialmente fatal transmitida pela picada de flebótomos infectados pelo parasita. Os sintomas mais comuns incluem febre, hepatoesplenomegalia, perda de peso, sangramentos e infecções bacterianas. Alterações neurológicas têm sido raramente descritas nesses pacientes. Descrevemos aqui o caso de uma criança que desenvolveu um quadro de infecção pela Leishmania, tendo como principal sintoma tremor de extremidades. O diagnóstico da doença foi confirmado pela demonstração do parasita no aspirado de medula. Os sintomas foram revertidos pelo tratamento específico. A natureza do possível mecanismo do envolvimento neurológico na leishmaniose visceral permanece duvidoso.

A serological and molecular investigation of American cutaneous leishmaniasis in dogs, three years after an outbreak in the Northwest of Paraná State, Brazil / Investigação sorológica e molecular da leishmaniose tegumentar americana em cães, três anos após um surto, no Noroeste do Estado do Paraná, Brasil

Classic and molecular (polymerase chain reaction - PCR) techniques were used to diagnose American cutaneous leishmaniasis in 149 dogs from an area in the northwest of Paraná State, Brazil, where an American cutaneous leishmaniasis outbreak occurred in 2002. The results were compared to a set of previously obtained results. Twenty-five dogs had positive indirect immunofluorescence (IIF) (titers > 40), including two animals with suggestive lesions. The percentage of dogs with positive IIF was similar to that found in a previous study. The cultures of the lesion, blood and bone marrow were negative for Leishmania. A direct search for the parasite in the lesions proved negative, although PCR tests were positive. The PCR did not detect the DNA of Leishmania (Viannia) in the blood, even for those that had positive PCR in a previous study. The follow up of the 27 dogs showed that the majority of them had maintained the same levels of antibodies that had been detected previously. There was a reduction in the number of dogs with lesions, probably due to the transmission control measures that were adopted after the outbreak.

Neste estudo, utilizaram-se técnicas clássicas e moleculares (reação em cadeia da polimerase - PCR) para o diagnóstico da leishmaniose tegumentar americana em 149 cães de uma área no noroeste do Estado do Paraná, Brasil, onde ocorreu um surto de leishmaniose tegumentar americana em 2002; os resultados foram comparados aos obtidos anteriormente. Vinte e cinco cães tiveram a imunofluorescência indireta (IFI) positiva (títulos > 40), incluindo dois animais com lesão sugestiva. O percentual de cães com IFI positiva foi semelhante aos encontrados nos inquéritos anteriores. As culturas dos materiais de lesão, sangue e medula óssea foram negativas para Leishmania. A pesquisa direta do parasito em lesão foi negativa, no entanto a PCR foi positiva. A PCR não detectou DNA de Leishmania (Viannia) no sangue dos cães estudados, mesmo naqueles que tiveram PCR positiva no estudo anterior. O acompanhamento de 27 animais mostrou que a maioria deles permaneceu com os mesmos níveis de anticorpos detectados anteriormente. Houve redução do número de cães com lesões, provavelmente em virtude das medidas de controle da transmissão adotadas após o surto de 2002.

Fatal haemophagocytic syndrome and hepatitis associated with visceral leishmaniasis.

Haemophagocytic syndrome (HPS) secondary to infections occurs due to excessive, non-malignant proliferation of histiocytes, with resultant haemophagocytosis. The syndrome is essentially treatable, provided timely etiological diagnosis is achieved. In this report, we present a rare case of a child who hailed from Uttaranchal and presented with severe hepatitis. Bone marrow examination revealed an unexpected diagnosis of HPS secondary to visceral leishmaniasis. Despite initiating appropriate antileishmanial treatment, the child had a fatal outcome.

Profile of fatal visceral leishmaniasis at an Indian tertiary care center.

Visceral leishmaniasis is a highly morbid and incapacitating infection, which usually presents with prolonged fever, weight loss and hepato-splenomegaly. Despite the availability of effective treatment, the disease can have a high mortality even at referral centers. A case series of fatal visceral leishmaniasis, encountered during a prospective, two year period is presented. All the patients died due to multisystem organ failure. However, delayed diagnosis due to atypical manifestations was an important factor contributing to the fatal outcome of the patients. Instead of relying solely on the classical clinical features of visceral leishmaniasis, simple laboratory findings like pancytopenia, altered albumin/globulin ratio and appositive aldehyde and rK 39 dipstick tests can help in making an early diagnosis even in atypical cases, thereby reducing the mortality of visceral leishmaniasis.

Microfilariae in bone marrow aspiration smears, correlation with marrow hypoplasia: a report of six cases.

Microfilariae have been reported in various cytological preparations, however there are very few case reports describing microfilariae in bone marrow aspirates. We report six such cases with the interesting finding of marrow hypoplasia in five of these cases.

New developments in diagnosis of leishmaniasis.

In this review recent advances made in the field of human leishmaniasis have been discussed with special emphasis on the parasite, and various serological and molecular methods of diagnosing the infection. The article also reviews various modes of parasite transmission including vector borne, blood transfusion, needle sharing, sexual and person-to-person. Microbiological methods including the bone marrow, spleen, liver, lymph node aspirations and various staining methods used to demonstrate the amastigotes of the parasites and various in vitro promastigote culture methods are discussed in detail with their comparative sensitivity rates.

Pre- & post-treatment evaluation of immunological features in Indian visceral leishmaniasis (VL) patients with HIV co-infection.

BACKGROUND & OBJECTIVE: The risk of human immunodeficiency virus (HIV) co-infection in patients with visceral leishmaniasis (VL) or kala-azar in endemic areas has posed a major challenge in control programmes. We undertook this study to identify the high risk groups vulnerable to Leishmania-HIV co-infection in VL endemic State of Bihar, India. Further, immunological responses were also evaluated in these patients before and after treatment for VL to see the immune impairment associated with CD4 T cell count. METHODS: A total of 1511 subjects attending Voluntary Counselling and Testing Centre (VCTC) at Patna, Bihar were included in this study. VL was confirmed by splenic or bone marrow aspirates testing for parasite. HIV states was confirmed by two kits. Immunological parameters (CD4, CD8, IFN-gamma, IL-4) were studied in co-infection patients. RESULTS: Of the 280 (18.53%) HIV-positive individuals, eight were diagnosed serologically and pathologically as VL patients co-infected with HIV. The humoral and cellular immune responses were evaluated in 18 Indian VL patients with (n = 8) or without HIV (n = 10) and 10 HIV seropositive subjects. Among the eight confirmed cases of VL, false negative direct agglutination test (DAT) result was observed in two who had HIV co-infection (sensitivity 80%), while none in 10 other VL cases who were HIV negative (sensitivity 100%). A very low CD4 cell count was observed in VL cases that had HIV co-infection compared to HIV negative VL or controls. All VL cases with or without HIV infection had lower Th1/Th2 ratio compared to controls. VL patients with or without HIV infection responded well to anti-leishmanial/anti-retroviral therapy with considerable degree of immunological reconstitution. INTERPRETATION & CONCLUSION: A different immune response was noticed in patients with co-infection of HIV and Leishmania. Anti-leishmanial drug treatment led to improvement in immunological response in co-infected patients. Further studies need to be done to see the effect of combined therapy for VL and HIV on immunological parameters in these patients.

Pharmacokinetic and parasitological evaluation of the bone marrow of dogs with visceral leishmaniasis submitted to multiple dose treatment with liposome-encapsulated meglumine antimoniate

The aim of the present study was to evaluate the impact of a multiple dose regimen of a liposomal formulation of meglumine antimoniate (LMA) on the pharmacokinetics of antimony in the bone marrow of dogs with visceral leishmaniasis and on the ability of LMA to eliminate parasites from this tissue. Dogs naturally infected with Leishmania chagasi received 4 intravenous doses of either LMA (6.5 mg antimony/kg body weight, N = 9), or empty liposomes (at the same lipid dose as LMA, N = 9) at 4-day intervals. A third group of animals was untreated (N = 8). Before each administration and at different times after treatment, bone marrow was obtained and analyzed for antimony level (LMA group) by electrothermal atomic absorption spectrometry, and for the presence of Leishmania parasites (all groups). There was a significant increase of antimony concentration from 0.76 æg/kg wet organ (4 days after the first dose) to 2.07 æg/kg (4 days after the fourth dose) and a half-life of 4 days for antimony elimination from the bone marrow. Treatment with LMA significantly reduced the number of dogs positive for parasites (with at least one amastigote per 1000 host cells) compared to controls (positive dogs 30 days after treatment: 0 of 9 in the LMA group, 3 of 9 in the group treated with empty liposomes and 3 of 8 in the untreated group). However, complete elimination of parasites was not achieved. In conclusion, the present study showed that multiple dose treatment with LMA was effective in improving antimony levels in the bone marrow of dogs with visceral leishmaniasis and in reducing the number of positive animals, even though it was not sufficient to achieve complete elimination of parasites.

Haematological profile of childhood visceral leishmaniasis.

Visceral leishmaniasis is the most severe form of the disease affecting children. Definite diagnosis relies on the demonstration of the parasite in various tissues. Bone marrow examination is a well accepted method, but has sensitivity between 60-85%. In the present study we analyzed other associated bone marrow features in 28 cases of pediatric leishmaniasis, which would help raise the suspicion level and thus bring about more positive results. Pancytopenia was observed in 54% cases and bicytopenias in another 20.5% cases. Peripheral absolute lymphocyte count did not increase in any case. Increase in plasma cells (mean 6.7%) and increase of phagocytic cells (28.5%) with haemophagocytosis (21.43%) was observed frequently in the bone marrow.

Sensitivity of splenic and bone marrow aspirate study for diagnosis of kala-azar.

Fifty adult patients of kala-azar were included in this prospective study from Medicine Unit-I of Mymensingh Medical College Hospital. Splenic and bone marrow aspiration were done simultaneously to compare the sensitivity and other related merits and demerits of each procedure. Splenic aspiration appeared to be more sensitive procedure than bone marrow aspiration. Leishman - Donovan (LD) bodies were found in 90 percent and 72 percent of the spleen and bone marrow aspirates respectively. Splenic aspiration was found more acceptable to patients (96%) as it was less painful. Both the procedures were hazardless. There was no major complication except mild pain after splenic aspiration; even a few patients had history of epistaxis. Splenic aspiration was also more acceptable by the physicians because of an easy and reliable diagnostic procedure.

Aplastic anaemia following varicella infection with coexistent microfilaremia of Wuchereria bancrofti--a case report.

Filariasis is a common public health problem in various regions of Indian subcontinent. There are many reports describing detection of microfilaria in different organ systems. There are limited number of reports available describing the presence of microfilaria in bone marrow. Here we report a young patient who developed aplastic anaemia following varicella infection. Peripheral blood and bone marrow showed many microfilariae of Wuchereria bancrofti. There are no reports describing this unique combination in the available literature.

Envolvimento da função renal em pacientes com leishmaniose visceral (calazar) / Involvement of the renal function in patients with visceral leishmaniasis (kala-azar)

Envolvimento da funçäo renal em pacientes com leishmaniose visceral (calazar). Apresenta-se estudo prospectivo de 11 pacientes com LV, com o intuito de verificar as repercussöes clínico-laboratoriais da funçäo renal na doença. Realizou-se análises laboratoriais das amostras de sangue e urina, colhidas logo após confirmaçäo diagnóstica, através do encontro de leishmanias no aspirado de médula óssea. Dois (18 por cento) pacientes apresentaram complicaçöes associadas a LV. Cinco (45,4 por cento) apresentaram hematúria macroscópica e em um caso (No.9) manifestaçöes clínicas compatíveis com síndrome nefrítica aguda. Os resultados dos exames de urina mostraram: proteinúria em 10 (90,9 por cento) pacientes, hematúria 7 (63,6 por cento) e leucocitúria em 6 (54,5 por cento) casos. Nove (81,8 por cento) pacientes apresentaram níveis elevados de microalbuminúria caracterizando lesäo glomerular. A presença de tubulopatia proximal medida através da proteína ligadora de retinol, foi observada em 5 (45,4 por cento) casos. Concluiu-se que o envolvimento renal se fez presente na maioria dos pacientes, contribuindo para a gravidade da doença

Visceral leishmaniasis in two cases of leukemia.

Two cases of visceral leishmaniasis (VL), one in a 51-year-old man with accelerated-phase chronic myeloid leukemia and another in a 35-year-old woman with acute myeloblastic leukemia, are reported. Incidental finding of Leishman-Donovan (LD) bodies in patients with leukemia highlights VL as a potent opportunistic infection in immunosuppressed patients.

Un caso de Leishmaniasis viscel / A case of visceral leishmaniasis

Se presenta el caso de leishmaniasis en una niña de cinco años de edad, residente de Acatlán, estado de Puebla. El cuadro se caracterizó por la presencia de fiebre intermitente de hasta 39ºC, mialgias, artralgia generalizadas sin sinovitis o flogosis, hiporexia y pérdida de siete kilogramos de peso. Asimismo se observó palidez de tegumentos e incremento en el perímetro abdominal secundario a esplenomegalia. En el laboratorio destacó la presencia de pancitopenia; un estudio de médula ósea mostró amastigotes de Leishmania denovani. Se confirmó el diagnóstico mediante cultivo en medio NNN (Novy - Nicolle - MacNeal). La paciente recibió tratamiento de N-metilglucamina con remisión total de la sintomatología. Se presenta también una revisión de la literatura nacional con relación a leishmaniasis visceral

Clinicopathological study of clinically undiagnosed cases of kala-azar with special reference to grading of parasites.

Clinicopathological study of 34 clinically undiagnosed cases of kala-azar has been undertaken with a view to establish the diagnosis and correlate the quantitative grading of Leishmania donovani in bone marrow/splenic aspirates with clinical features and duration of disease. The ages of the patients were between 5 and 45 years. The duration of illnesses ranged from 2-24 months with 47% having 2 months' duration. Splenomegaly was less than 7 cm in 70.5% cases. Anaemia, leucopenia and mild thrombocytopenia were present in all the cases. Aldehyde test was positive in 47% cases. Bone marrow aspiration revealed the parasites in 82.3% cases. L donovani was also observed in 66.6% cases of splenic aspiration including 6 cases where bone marrow failed to reveal the parasite. Grading of the parasites in bone marrow and splenic aspirates revealed majority of the cases (73.5%) were in 3+ and 4+ grades. No correlation between splenic size and duration of illness or parasite grading was detected. Neither any positive correlation between parasite grading and duration of illness was observed.