We report two cases of visceral leishmaniasis from Kerala. A 4½-year-old boy was admitted with fever since 3 weeks. He was emaciated (11 Kg), and had remittent fever, anasarca, and splenohepatomagaly. He was anemic (Hb 6.8 g/dL). Total leucocyte count was 3800/mm3, with normal differential count. ESR was 106 mm in first hour. Peri-pheral smear and bone marrow examination showed dimorphic anemia. Tuberculin test was negative. Serum albumin was 3.2 g/dL. As he did not respond to empirical courses of anti-tubercular and antimalarial drugs, a bone marrow biopsy was done, which showed plenty of Leishmania parasites. He received liposomal amphotericin B 2 mg/kg IV OD × 5 days. He recovered completely, and gained 4 kg in the next 6 months.

The second case was a 12 year-old-girl with pallor, hepatosplenomegaly, and conges-tive cardiac failure. Investigations revealed severe anemia with Hb 4.8 g/dL; peripheral smear showed microcytic hypochromic anemia. Echocardiogram revealed minimal pericardial effusion. In response to oral iron the pericardial effusion disappeared and hemoglobin rose to 6.8 g/dL; hepato-splenomegaly also decreased. As there was no further improvement even after parenteral iron therapy, we did a bone marrow and later trephine biopsy which showed Leishmania parasites. She was treated successfully with liposomal amphotericin B 2 mg/kg IV on days 1, 5 and 10. Both children are now asymptomatic on follow up since over 1 year.

Kala-Azar is rare in South India, and there are no previous reports of visceral leishmaniasis from Kerala. There are occasional reports of cutaneous leishmaniasis from Thrissur District(1). Our patients are residing in Desamangalam and Palappilly near the forest, more than 75 km apart; they have never been out of Kerala. In one case, entomologists could catch the sandfly from the area.

Both these patients were treated with liposomal amphotericin B, as sodium stibogluconate and pentamidine are not available in Kerala. We conclude that Kala-Azar is no longer confined to its classical geographic boundaries.

Ananda Kesavan,
V.K. Parvathy,
Shiela Thomas,*
S.P. Sudha,*
Departments of Pediatrics and Pathology*,
Medical College,
Thrissur 680 596,
Kerala, India.

1. Criton S, Sreedevi PK, Ashokan PU. Lip Leishmaniasis. Indian J Dermatol Venerol Lepr 1995; 61: 303-304.