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Kala-azar

Prof. Dr. Saiyeedur Rahman


Professor of Medicine Dept. of Medicine, MMC

Definition
An infectious disease.
Normally zoonotic Caused by the protozoa of the genus leishmania. Transmitted by the phlebotomine sandfly.

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Kala-azar (Visceral Leishmaniasis)


The term Kala-azar:
Originated from India. Kala, means black Azar, means sickness As this disease causes generalized pigmentation
(blackish discolouration of the skin)

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Kala-azar (In Bangladesh)


Current prevalence estimated at 40,000 cases 18% Population are at risk At least 27 Districts are affected Highest case fatality in Mymensingh district recorded 6.4%

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Causative agent
Leishmania
L. Major L. Tropica L. Aethiopica L. Mexicana L. Amazonia

Donovani

Kala-azar
Cutaneous Leishmaniasis/oriental sore Cutaneous & mucosal Leishmaniasis/Espundia

L. Braziliensis

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Kala-azar (Visceral Leishmaniasis)


Vector:
Female Phlebotomus argentipes sandflies.

Forms of causative agents : 2


Amastigote
Promastigote

Incubation period : 1-2 months

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Sandfly

Life cycle
Amastigote Promastigote Multiplication Inoculation MPS Amastigote Multiplication Rupture of MPS Release of Amastigote (in circulation)
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Host

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Life cycle of Leishmania.

Humans serve as the


reservoir for L donovani in India as depicted

here. In most settings


leishmaniasis is zoonosis with rodents

or canines as reservoirs.

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Pathogenesis
Parasitaemia
Strong immune response Eradication of parasite Asymptomatic infection Poor Immune response Unrestricted spread to R/E system Granuloma

Sub clinical infection


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Established infection
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Clinical features
Asymptomatic Symptomatic
Classical presentation
Fever-Usually insidious in 100% cases Weight loss Unexplained well-being Increased pigmentation

Swelling of upper abdomen

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...Clinical features
Features of complication
Bleeding manifestation Features of infection

Atypical presentation
Sub clinical-No fever

Gradual weight loss & wasting

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...Clinical features
Signs: G/E
Increased temp. Skin changes Anaemia Lymphadenopathy Gum bleeding & epistaxis

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...Clinical features
Signs:
Abdominal
Splenomegaly in 100% cases Hepatomegaly Ascites

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...Clinical features
Cardinal Signs& symptoms:
H/O fever more than 2 wks Splenomegaly Loss of wt

Anaemia

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Why there is anaemia in Kala-azar?


Hypersplenism

(Sequestration & splenic pooling,


Destruction of RBC in spleen)

Short life span of RBC Haemolysis Ineffective erythropiesis Bleeding manifestations

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Differential diagnosis
Chronic malaria
CML Lymphoma Miliary TB CHA

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Complications
PKDL Secondary Infection (due to profound immunosuppresion)
Pul. tuberculosis

Pneumonia
Septicaemia Pneumococcal otitis media

Cirrhosis of liver CCF (due to moderate to severe anaemia) Renal


Nephrotic Syndrome
Glomerulonephritis

Post Kala-azar Splenomegaly


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Lab. diagnosis
A. Indirect evidence: a. Blood
Progressive leukopenia Relative lymphocytosis

Very high ESR


Hb%

b. Serum total protein Serum albumin Altered A/G ratio


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...Lab. diagnosis
B. Serologic or Immunological test:
AT becomes positive after 3 months
CT DAT positive in titre 1:3200 ICT done with K- 39 antigen ELISA

CFT
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...Lab. diagnosis
a. Demonstration of LD body (Amastigote)
Spleen Bone marrow Liver Lymph node Buffy coat 98% sensitive 64-85% 75-85% 64% 67-99%

C. Direct evidence of parasite in tissue smear:

b. Culture in N.N.N. media (Promastigote)


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Treatment of Kala-azar
A. Symptomatic & supportive treatment

B. Specific treatment

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...Treatment of Kala-azar
A. Symptomatic & Supportive treatment Treatment of intercurrent infection Correction of Malnutrition

Haemorrhage- inj. Vit K, Fresh bloodtransfusion


Anti-pyretics Protein-rich diet

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Treatment of Kala-azar
B. Specific treatment Sodium stibogluconate-Drug of choice Pentamidine isothionate Liposomal amphotericin B Oral Miltefosine Others-Aminosidine (Paromomycin)

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Treatment of Kala-azar
Sodium stibogluconate -Drug of choice
Dose: 20mg/kg daily not exceeding 850mg Duration: 20 days

Contraindications:
Severe Kidney, Heart or Liver disorder

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Treatment of Kala-azar
Relapse case: Definition If infection occurs within 6 months after completion of Rx If Rx is interrupted before a 10 days course is

completed
If Rx interruption is more than 7 days Treatment:

Full 20 days Rx regimen with Na-stibogluconate

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Kala-azar Treatment Failure


Definition: It means when Kala-azar does not respond to usual therapy

with Na-stibogluconate
If infection occurs Causes: Non-compliance Inadequate dose Drug resistance Interrupted Rx after a complete anti- Kala-azar Rx course With Na-stibogluconate in the last year

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Treatment Of KATF
Drug of choice: Pentamidine 50mg/ml

Dose:
4mg/kg b wt ,3 times/wk for 5 wks On 6th wk after completion of Pentamidine

Rx with SAG daily for 30 days

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...Treatment of Kala-azar
Follow up of response
Clinical
General well being
Subsidence of fever

Lab
Hb% to be corrected S. Albumin S. Globulin Absence of LD body in bone marrow

Wt gain Spleen Size


Anaemia
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Prognosis
Mortality
Without treatment : 85-90%
Death usually occurs within a year

With treatment : 0-50%

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...Prognosis
Causes of death
GI bleeding
Infection Renal failure

Severe malnutrition
Splenic infarction & shock Sudden, unwanted death related to treatment

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Post Kala-azar Dermal Leishmaniasis


Cutaneous form of leishmaniasis

Sometimes follows an overt attack of Kala-azar


Occurs in endemic areas of Kala-azar 1 in 50-100 cases of Kala-azar PKDL is related in immune reaction of the host

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...Post Kala-azar Dermal Leishmaniasis


Clinical features:
50% have H/O previous Kala-azar
Incubation period-Usually 2 years Rash may last upto 20 years

Symptoms & Signs 3 stages


Depigmented macular stage
Erythematous plaque
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Nodular stage

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...Post Kala-azar Dermal Leishmaniasis


D/D:
Lepromatous Leprosy SLE, DLE

Fungal skin inf.


Acne Rosasea Sarcoidosis

Syphilis

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...Post Kala-azar Dermal Leishmaniasis


Investigations:
Slit skin smear-Amastigote Leishman test (+) or (-) Serological test CFT (+) AT (-) ve.

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...Post Kala-azar Dermal Leishmaniasis


Treatment
Drug Dose : Sodium Stibogluconate : 20mg/kg/day not exceeding 850 mg

Duration

: A cycle consist of Daily for 20 days

Repeat the cycle 6 times allowing 10 days interval between each Rx cycle

Prognosis
Mortality rate -15-25% in advanced case.

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Thank you all


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