the Departments of Pediatrics and *Micro-
biology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Reprint requests: Dr. Kuldeep Singh, Department of Pediatrics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Manuscript Received: February 18, 1998; Initial review completed: March 18, 1998;
Revision Accepted: May 12, 1998
Indian Kala-Azar caused by Leishmania donovani is
prevalent in the endemic areas of Bihar, West Bengal in India and also in the
eastern' part of Nepal adjoining the
Bihar state of India. The disease is characterized by fever, anemia, weight
loss, darkening of skin and hepatosplenomegaly(1). Lymphadenopathy, which is a
common feature of Mediterranean countries is believed to be rare and even unknown in the Indian Kala-Azar(2). In this communication we report a case of Indian Kala-Azar in a 13 year old child with an unusual manifestation of lymphadenopathy in this eastern part of Nepal, endemic for Kala-Azar.
A 13-year-old girl coming from Sunsari district, endemic for Kala-Azar; presented to the Pediatrics ward of B.P. Koirala Institute of Health Sciences, Dharan
with intermittent moderate grade fever without any periodicity and mass in the
abdomen for last two months. The fever had failed to respond to antibiotic therapy offered by a private practitioner.
The child was sick looking, had moderate pallor and weighed 27 kg. There was no jaundice or peripheral edema. Small, non-tender, discrete but firm lymph nodes could be palpated in the both anterior and posterior cervical chain and axillae. The spleen was enlarged nine
cm below the costal margin. It was firm and non-tender. The liver was also firm and non-tender and extended one
cm below the costal margin. Other systems were normal.
Hemoglobin concentration was 7 g/ dl. White cell count was 2,700/mm3 with 45% neutrophils and 55% lymphocytes. Platelet count was 73,OOO/cu mm. Peripheral smear was negative for malarial parasites. Blood culture for pyogenic organisms was sterile. Mantoux test was negative and X-ray chest was within normal limits. Sputum for acid fast bacilli was negative on three different , occasions. Aldehyde test, carried out as a part of laboratory protocol followed in all cases of fever with splenomegaly in view of endemicity of Kala-Azar in the region, was positive. Examination of bone marrow asprirate stained by Giemsa revealed amastigote forms of Lieshmania donovani.
The girl was treated with sodium stibogluconate in a dose of 20 mg/kg/ day intramuscularly for a period of 20 days. The child responded to antimony therapy. Fever subsided by 5th day of therapy; spleen showed regression in size and lymphadenopathy disappeared within two weeks of starting therapy.
It is a recognized fact that amastigotes of L. donovani can affect the lymph nodes draining the oropharyngeal or mucocutaneous leishmania 1 lesions. Lymphadenopathy seen in the child, we report here was primary, as there were no mucocutaneous or oropharyngeal lesions.
The reports of primary lymphadenopathy in Indian Kala-Azar are
scanty (3-6). The first case of primary lymphadenopathy in Indian Kala-Azar in a child proved by biopsy was reported by Sengupta and Chatterjee in 1961(3). Shortly after, Talukdar et aI. in 1987 reported an- other case of lymphadenopathy in a 11 year old boy suffering from Indian Kala-Azar from Bihar(S). In addition to this, few reports of Indian Kala-Azar with lymphadenopathy in adults have also been reported( 4,6,7).
The report of this case of a child having Indian Kala-Azar with lymphadenopathy from this part of Nepal shows that lymphadenopathy could be a possibility in the presentation of Indian Kala-Azar in Nepal.
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Parija Sc. Text Book of Medical Parasitol- ogy: Protozoology and Helminthiology. Madras, AIPD Publishers, 1996; pp 75- 118.
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Sengupta PC, Mukherjee AM. Lymphadenopathy in Indian Kala-Azar and dermal leishmaniasis. Indian JPathol Bacteriol1968; 11: 172-178.
Talukdar B, Kanwar A, Saini L, Singh T, Chauhan S. Lymphadenopathy in Indian Kala-Azar. Indian Pediatr.1987; 24: 1043- 1045.
Nandy A, Choudhary AB. Lymphadenopathy in Indian Kala-Azar. Ann Trop Med Parasitol1984; 28: 331-332.
Naik SR, Rao PN, Datta DV, Mehta SK, Mahajan RC, Mehta S, et al. Kala-Azar
in north-western India. A study of 24 patients. Trans R Soc Trop Med Hyg 1979; 73: 61-65.