Gopal Shankar Sahni

We are reporting an unusual case of visceral leishmaniasis (VL) in a 7-year-old male, presenting without splenomegaly.

A 7-year-old male child presented with fever often associated with rigor and chills and loss of weight and appetite for last one month. There were no other significant localizing symptoms. A general physical examination revealed significant pallor. Systemic examination, including absence of organomegaly on abdominal evaluation, was non-contributory. Hematological parameters revealed pancytopenia with hemoglobin 4 g/dL, total leukocyte count of 2100 (N-22%,L-74%,E-2%,M-2%,B-0%), ESR in first hr 86mm, platelet count of 38000 and peripheral smear showing a leucoerythroblastic picture. Hypregama-globulinemia with albumin globulin ratio of 0.3 was seen. Liver function test on admission was normal. Peripheral smear for microfilaria was negative. Human immunodeficiency virus (HIV), Hepatitis B (HBsAg), hepatitis C (HCV) and dengue serology were negative. Chest X-ray was normal and Mantoux test was negative. Urine culture showed no growth. Ultrasound of whole abdomen was a normal. RK-39 was positive. Bone marrow examination was done, which revealed Leishmania Donovani (LD) bodies.

A final diagnosis of kala- azar was made. Absence of splenomegaly was outstanding finding in our patient. Patient was started on amphotericin B and other supportive therapy including blood and platelet transfusions. The patient improved and was discharged after giving full course of amphotericin B.

VL comprises a broad range of manifestations of infection. Infection remains asymptomatic or subclinical in many cases or can follow an acute or chronic course. The clinical symptoms are characterized by prolonged and irregular fever often associated with rigor and chills, splenomegaly, lymphadenopathy, hepatomegaly, pancytopenia, progressive anemia, weight loss and hypergamma-globulinemia (mainly IgG from polyclonal B cell activation) with hypoalbuminemia [1]. A presumptive provisional clinical diagnosis is made on the basis of presenting clinical features and history of living in an area endemic for VL. Leishmanial infection does not lead to clinical disease in all cases; asymptomatic and subclinical forms are frequent which has been demonstrated in various epidemiological surveys [2,3].

The main intention of reporting this case is to raise the awareness of possibility of kala-azar in absence of splenomegaly. Instead of relying solely on the classical clinical features of visceral leishmaniasis (pyrexia with splenomegaly), simple laboratory findings like pancytopenia, altered albumin/globulin ratio and a positive aldehyde and RK- 39 dipstick tests can help make an early diagnosis even in atypical cases, thereby reducing the mortality of visceral leishmaniasis.

1. Berman JD. Human leishmaniasis: clinical, diagnostic, and chemotherapeutic developments in the last 10 years. Clin Infect Dis. 1997; 24:684-703.

2. Pampiglione S, Manson-Bahr PE, La Placa M, Borgatti MA, Musumeci S. Studies in Mediterranean leishmaniasis. 3. The leishmanin skin test in kala-azar. Trans R Soc Trop Med Hyg. 1975;69:60-8.

3. Carvalho EM, Barral A, Pedral-Sampaio D, Barral-Netto M, Badaró R, Rocha H, et al. Immunologic markers of clinical evolution in children recently infected with Leishmania donovani chagasi. J Infect Dis. 1992;165: 535-44.

4. Carvalho EM. Immunoregulation in visceral leishmaniasis. In: Ozcel MA, Alkan MZ, editors. Parasitology for the 21st Century. Oxon, UK: Cab International; 1996. p. 35-9.

5. Gama ME, Costa JM, Gomes CM, Corbet CM. Subclinical forms of American visceral leishmaniasis. Mem Inst Oswaldo Cruz. 2004;99:889-93.