Diagnostic Dilemmas and Challenges in Kala Azar

Dr Dhananjay Singh

Kala Azar prevalence areas

Kala-azar
Primary KA or Relapse KA Derived from the urdu word meaning Black Fever Caused by protozoa-Leishmania donovani Enters our blood by bite of infected female Phlebotomus species-Sandfly Slow onset, low grade irregular fever of long duration Enlargement of the spleen and liver Anaemia, progressive emaciation Development of a strange earthy-greasy, dusky pigmentation of skin giving the disease its name. The skin often becomes dark and hair dry and brittle. If not treated the disease is fatal.

Case Definition
Fever > 2 weeks, with splenomegaly or wasting Epistaxis Nose bleeding Observe fever pattern for 3 days 3 times a day If a patient does not fit the clinical case definition, then positive serology is not enough to diagnose KA. 5-10% of adults in the endemic area will have anti- Leishmania antibodies.

Investigations
Rapid Diagnostic Test - rK39 DAT if rK39 is negative RDT for malaria CBC Tissue aspirate
Spleen Bone Marrow Lymph node

Diagnosis
Haemoglobin 6-8 Gm% Pancytopenia
Total Count 1200-2000 L(5000-10000 L)

Lymphocyte 750-1200 L (1300-4000 L)

Neutrophil 1000-2000 (2500-7500 L)

Platelet 70000-100000 L (150000-400000 L)

Diagnostic Algorithm
MSF Kala-Azar Diagnostic Algorithm Ethiopia
Clinical Suspect: Fever > 2 weeks; with Splenomegaly or Wasting

First time KA

Previous KA treatment

Severely ill suspect

rK39 RDT

Aspirate

Pos

Neg

DAT test

Pos

Borderline

HIV testing

Aspirate

Pos

Neg

HIV testing

Pos

Neg

Pos

Aspirate confirmation & parasite grading No VL Search other diagnosis Retest if symptoms persist

Treatment

Treatment
Liposomal Amphotericin-B AmBisome most safe and effective but ??? SSG Miltefosine

Parmomycin

Dosing
SSG 30 dose (20mg/kg body wt.) AmBisome 6/7 Dose (4mg/kg/body wt.) Miltefosine 100mg/day Metclopramide 5mg/day along with Miltefosine

Toxicity of Drugs
SSG toxicity appears with in 3 days
Persistent vomiting Pain Abdomen Pancreatits Hepato-toxicity

Miltefosine
Nausea vomitting

AmBisome
Hepatoxicity

Investigation
Blood Chemistry - Humanalyser

Logistics requirement
Auto-analyzer
CBC analyzer Chemistry

Rapid Diagnostic Kit

rK39 DAT Kit RDT for malaria

Bone Marrow aspiration needle

Regular supply of drugs

HR training on diagnosis and T/t protocols Standard Operating Procedures