Visceral Leishmaniasis (VL), also known as Kala-azar, is caused by the protozoan Leishmania donovani and L. infantum. It is transmitted by the bite of the female Phlebotomine sandfly. Clinical manifestations include fever, splenomegaly, weight loss, and anemia. Diagnosis involves microscopic examination of bone marrow or spleen aspirates to identify the amastigotes, culture, PCR, and serology using rK39. Treatment is with liposomal amphotericin B in a single dose of 10mg/kg. Supportive care includes treatment of anemia, malnutrition, and secondary infections.

1. Visceral Leishmaniasis
(Kala-azar)
Dr Kamala Sanjel
Internal medicine,NAMS

2. Introduction
• Leishmaniasis consists of a complex of vector-borne
diseases caused by more than 20 species of the
protozoan genus Leishmania and is transmitted by
sand fly vectors.
• Clinical manifestations range from cutaneous ulcers
to systemic multiorgan disease.
Three forms of disease present
1. Visceral Leishmaniasis(VL)- a/k/a Kalaazar-
L. donovani, L .infantum
2. Cutaneous Leishmaniasis -Leishmania tropica
3. Mucocutaneous Leishmaniasis - L.brazileinsis

3. Epidemiology
• The epidemiology and ecology of VL in a particular
region are determined by characteristics of the
parasite species, sand fly species, and mammalian
reservoir host.
• In all major endemic areas, asymptomatic infections
(measured by seroconversion and/or leishmanin skin
testing) outnumber clinically manifest disease .

4. Epidemiology
• Close to 13,000 incident cases of VL were reported to
the World Health Organization in 2020.
• Among tropical diseases, leishmaniasis ranks second
in mortality and seventh in loss of disability-adjusted
life years (DALYs).
• Leishmaniasis is considered one of the "most
neglected diseases" given its strong association with
poverty and the limited resources invested in new
tools for diagnosis, treatment, and control.

5. Epidemiology
• 75 countries are endemic for VL
• 700000 to 10,00000 new cases of Leishmaniasis occurs
every year.
• Kalaazar is a major health problem in Nepal
,Bangaladesh and India in south east Asian region.
• Kalaazar is endemic in 18 districts , especially terai
areas, sporadic cases in hilly regions
• Sporadic cases seen from 55 out of 77 districts.
• 271 cases reported in 2017.

6. Factors favorable for elimination
• Human are only reservior
• Sandfly is only vector
• Vector is sensitive to insecticides
• Rapid diagnostic test and new efficacious
drugs
• Short treatment regimen
• Strong political commitment

7. Agent
• Visceral leishmaniasis (VL) is caused primarily by the
two related species Leishmania
donovani and Leishmania infantum
(synonym Leishmania chagasi).
• Leishmanis donovani- South Asia (India,
Bangladesh, and Nepal) and East Africa (Sudan,
Ethiopia, Kenya, and Somalia).
• Transmission is anthroponotic.
• In East Africa, transmission of L. donovani consists of
both anthroponotic and zoonotic components.

8. Agent
• L. infantum — VL due to L. infantum (synonym L.
chagasi) occurs in the Mediterranean (including
Spain, France, and Greece), the Middle East,
Afghanistan, Iran, Pakistan, and Brazil.
• Children <10 years and immunosuppressed adults
have a higher risk of clinical disease due to L.
infantum than immunocompetent adults
• Transmission of L. infantum infection is considered
zoonotic; the major reservoir is the domestic dog.

9. Host Factors
• Younger age
• Population movement
• Socio economic status
• Occupation
• Immunocompromised states ( HIV, Malnutrition)

10. Environmental Factors
• Rural areas less than 600m
• A heavy annual rainfall
• Humidity more than 70%
• Temperature- max 38 degree C, min 15 with variation
less than 7 degree
• Abundant vegetation
• Houses made of muds with Livestocks nearby
• Rainy season (June to October)

11. Transmission
Mode of transmission
• Anthroponotic-Kala Azar is transmitted from person to
person by the bite of the female Phlebotomine argentipes
Sandfly without involvement of other animals.
• Transmission may also take place by contamination of
the bite wound or by contact when the insect is crushed
during the contact act of feeding
• Blood transfussion
• Contaminated syringes and needles
• Organ transplantation, congenital infection, and
laboratory accidents

12. Lifecycle of Leishmania

13. Pathophysiology
• Promastigotes that reach the puncture wound are phagocytized by
macrophages and other types of mononuclear phagocytic cells.
• Promastigotes transform in these cells into the tissue stage of the
parasite (i.e., amastigotes) , which multiply by simple division and
proceed to infect other mononuclear phagocytic cells
• Parasite, host, and other factors affect whether the infection
becomes symptomatic and whether cutaneous or visceral
leishmaniasis results.
• Leishmania invade and replicate within host macrophages, evading
innate and cell-mediated immune responses and affects the
reticuloendothelial system and results in clinical manifestations.

14. Clinical manifestation
• Many leishmaniasis infections are asymptomatic,
reflecting the ability of the host immune system to
control the parasite.
• The ratio of asymptomatic infection to clinically
manifest disease varies widely, from >30:1 in Europe
to 6:1 in Brazilian children and 4:1 in Bangladesh.
• This may be due to parasite virulence, human genetic
predisposition, nutritional status, the sensitivity and
durability of positive results by the assay used to
detect infection, and other factors.

15. Clinical manifestation
• Incubation period is 2- 6 months( few weeks to years)
• Seen mostly in underprivileged rural communities.
• Children and young adults most commonly affected.
• Onset of symptoms is usually insidious or subacute, with
slow progression of malaise, fever, weight loss, and
splenomegaly (with or without hepatomegaly) over a
period of weeks to months.
• In rare cases, acute febrile illness can occur with rapidly
progressive symptoms.
• Abdominal discomfort and fullness

16. Clinical manifestation
• Fever ,splenomegaly and weight loss in a person
from endemic region- Kalazar should be suspected.
• This triad was present in 97% of 1250 VL cases
treated at BPKIHS over past few years
• Kala-azar ("black fever") refers to darkening of the
skin, which is a common symptom in South Asia but
not elsewhere.
• This appears to have been more common in classic
descriptions of the disease from the early 20th
century but has also been reported in more recent
case series.

17. Clinical manifestation

18. Physical findings
• Fever –high grade for prolong duration (>2weeks)
• Lymphadenopathy is rare (may be present in teenegers).
• Patients may complain of abdominal discomfort and
fullness that may be localized to the left upper quadrant.
• Since parasites replicate in the reticuloendothelial system,
very high parasite loads accumulate in the spleen, liver, and
bone marrow.
• Pallor-Severe anemia can occur due to bone marrow
suppression, hemolysis, and splenic sequestration.

19. Physical findings
• Tachycardia with/out features of heart failure
• Advanced kala-azar is associated with marked
cachexia, hypoalbuminemia, and edema.
• Wasting with low BMI
• Spleenomegaly –most specific sign, regress after
cure,may takes months
• The spleen is usually firm and minimally tender,
but in some patients palpation is quite painful,
presumably due to capsular pressure from rapid
enlargement.

20. Physical findings
• Hepatomegaly is usually less marked than
splenomegaly.
• Late in the course of disease, hepatic dysfunction,
jaundice, and ascites can occur.
• Thrombocytopenia and hepatic dysfunction contribute
to hemorrhagic complications.
• Patients may have spontaneous bleeding from the
gingiva, nasal mucosa, or other sites.
• Rarely, chronic diarrhea and malabsorption can occur
as a result of parasitic invasion of the intestine.

21. • Mild renal impairment appears to occur in a
significant proportion of adults and children
with VL .
• Most published data come from areas where
VL is due to L. infantum, but a study of
children with VL in India suggests that both
parasite species affect the kidney.

22. Clinical maifestations among 1250 kala-azar patients at
BPKIHS

24. Case definition

25. Differential diagnosis

26. Differential diagnosis

27. Diagnostic algorithm

28. Diagnosis
Diagnostic methods
• Visualization of the characteristic amastigote
in smears or tissue (histopathology)
• Parasite isolation by in vitro culture
• Molecular detection of parasite DNA
• Serologic testing .
Multiple diagnostic approaches to maximize the
likelihood of a positive result

29. 1)Histopathology
• Bone marrow aspiration (for histopathology, culture,
and molecular testing) is the preferred diagnostic
specimen.
• Other potential tissue specimens (for histopathology,
culture, and molecular testing) include spleen,
enlarged lymph nodes, and whole blood (buffy coat).
• Bone marrow or spleen aspiration-(sensitivity 70 and
96 percent in one comparative analysis).
• Aspirated material should be inoculated into culture
and used to prepare a Giemsa-stained smear and tissue
section.

30. • Amastigotes possess a large nucleus and a prominent
deeply stained rod-like organelle called the
kinetoplast, made up of tightly concatenated
extranuclear DNA.
• LD bodies inside and outside of macrophages
characterized by a kinetoplast and characteristic
double dot appearance

32. 2)Parasite isolation by in vitro culture
• Culture can be performed in Novy-McNeal-
Nicolle or other parasitic growth media .
• Two to three drops of buffy coat, bone
marrow, or splenic aspirate are inoculated into
the medium.
• The culture is checked weekly by microscopy
for the presence of promastigotes for up to
four weeks after inoculation.

33. 3)Molecular detection of parasite DNA
• PCR
• Sensitivity is highest in tissues (eg, spleen or
bone marrow)
• it is more variable in peripheral blood, likely
because the circulating parasite load varies
with the severity of disease.

34. 4)Serology
• In areas with access to advanced laboratory techniques,
serologic testing is used primarily for patients with
suspected VL who have negative or inconclusive results for
histopathology, culture, and molecular testing .
• In endemic regions with limited laboratory access,
serological tests are used as the primary test to confirm the
diagnosis in patients with high clinical suspicion of VL .
• Indirect fluorescent antibody tests (IFA) and enzyme-linked
immunosorbent assays (ELISAs) are useful diagnostic tools
since VL infection stimulates intense polyclonal B cell
activation, leading to production of a broad array of
antibodies.

35. Recombinant kinesin antigen (rK39)
• 39-amino acid residue (k-39) encoded by a kinesin-
related gene in the amastigotes of Leishmania chagasi, it
has been used in the format of enzyme-linked
immunosorbent assay (ELISA) and
immunochromatographic test (ICT).
• The recombinant kinesin antigen (rK39) is a useful
antigen in ELISA assays with high sensitivity and
specificity in immuno-competent patients in the Indian
subcontinent (92.8 to 100 percent and 96 to 100 percent,
respectively)
• Remain positive for years even after cure.

36. Recombinant kinesin antigen (rK39)
• In regions where VL is endemic, positive antibody test
results may be observed among asymptomatic
individuals with subclinical infection .
• Patients with clinical recovery after successful
treatment of VL continue to have positive serology for
months to years, so these assays cannot be used to
assess response to treatment and relapse.
• Positive serological test is not definitive proof of active
VL, such results must be interpreted in the context of
clinical and epidemiologic information.

37. RK39 Test

38. RK39 Test

39. Formol-gel (aldehyde) test
• Formol-gel (aldehyde) test- placing a drop of
formaldehyde in the serum from a patient with VL
would cause the specimen to form a gel.
• However, this finding is observed only when the
disease is quite advanced.
• In Nepal and Uganda, the sensitivity was noted to be
40 to 66 percent; specificity was also low.

40. Special Circumstances
• Post-kala-azar dermal leishmaniasis (PKDL) -is a chronic
skin rash observed following clinical response to
treatment for VL due to L. donovani .
• PKDL usually presents with erythematous or
hypopigmented macules that sometimes progress to
plaques or nodules.
• The lesions resemble (and must be differentiated from)
those of leprosy but are not associated with
sensorineural changes .
• Risk factors for progression to PKDL are uncertain but
may include immune response to infection, parasite
strain, and efficacy of therapy.

41. Post-kala-azar dermal leishmaniasis (PKDL)
• In South Asia, the incidence of PKDL after VL is about 5 to 15
percent, with an average interval of about two years.
• PKDL is diagnosed by microscopy (skin biopsies or slit skin
specimens), culture, and/or molecular methods.
• In macular lesions, parasites are sparse and may be difficult to
detect in smears or histology (microscopy sensitivity 50 percent or
lower).
• RT-PCR in 3-mm skin biopsies has been shown to have sensitivity of
91 percent in one study including 91 patients with macular PKDL .
• Serological tests are often positive in patients with PKDL although it
is uncertain whether positive serology is an indicator of PKDL or a
persistent antibody response to the antecedent infection, since
serum antibodies can persist for years after treatment.

42. • HIV-VL coinfection — HIV coinfection of VL has been
identified as an emerging challenge for VL control . HIV
infection increases the risk of VL and, conversely, VL
accelerates HIV disease progression.
• Among patients with profound immunosuppression
(eg, CD4 <50), parasitic infection of atypical sites may
occur, including the gastrointestinal tract, peritoneal
space, lung, pleural space, and skin.
• VL-TB coinfection – VL cases should be screened for
tuberculosis as well.

43. Management
• In the absence of treatment, the case fatality rate
of fully manifest clinical VL (kala-azar) without
treatment is greater than 90 percent.
• Mortality is often due to hemorrhagic or
infectious complications.
• Treatment consists of anti-leishmanial therapy
and supportive therapy
• The main constraints on the choice of
antileishmanial drug are cost, availability and
drug resistance especially for VL originating in
South Asia.

44. Management
• Supportive therapy to address nutritional status,
concomitant anemia, hemorrhagic complications,
and secondary infections is also essential to
optimize treatment outcomes.
• Patients with VL should be evaluated for HIV
coinfection , if found, HIV should be treated
aggressively.
• In the absence of effective immune
reconstitution, treatment response is poor in
patients with HIV-VL coinfection.

45. Management

46. Management
• National guideline does not advocate
treatment of subclinical infection but patients
should be under observation for development
of sign and symptoms of VL.
• VL,MCL and PKDL cases should be treated
aggressively.
• CL can be observed,can resolve on its own,
needs treatment if severe.

47. Management
• South Asia − In India and Nepal, high-level resistance
to antimonial drugs is common
• Miltefosine and conventional or lipid-
associated amphotericin B deoxycholate have replaced
antimonial drugs as first-line treatments over the past
15 years .
• In South Asia, L. donovani responds to lower doses
of liposomal amphotericin B and paromomycin than L.
infantum or East African L. donovani .
• National guideline reccomends single dose liposomal
Amphotericin B at dose of 10mg/kg over 2 hrs.
• This ensures 100% treatment compliance.

48. Management
• Liposomal Amphotericin B is safe in pregnancy ,
children less than 2 yrs old and older patients as well in
HIV patients.
Things to remember for L-AmB treatment
• Do-not use underweight dose
• Give test dose before
• Do-not freeze
• Always prepare in dextrose solution
• L-AmB is not compatible with saline and other
solutions
• Prevent foam formation during reconstitution

49. • The liposomal drug formulation has improved
stability in blood, macrophages, and tissues,
permitting more effective tissue penetration
with sustained tissue drug levels, especially in
the liver and spleen.

50. Side effects(frequency of occurance)
• Infusion related fever and rigors
• Chills, nausea, vomiting, headache
• Hypokalemia
• Bronchospasm
• Hypotension
• Nephrotoxicity
• Hepatobiliary disorders

51. Successful therapy
• Improvement in general condition
• Fever resolves by end of a week
• Spleenomegaly regresses slowly and may take
months for complete regression
• Counts normalise in few weeks
• Indicator of successful therapy- absence of
clinical relapse in 6 months

52. Second line therapy( 95.6 – 99.78% cure rates)
• When L-AmB is not indicated or not available.
Includes
1) L-AmB (5mg/kg- single infusion) plus
miltefosine 50 mg BD( 2.5mg/kg) for 7 days
2) L-AmB (5mg/kg- single infusion) plus
paramomycin (11mg/kg) for 10 days
3) Miltefosine plus paramomycin for 10 days

53. • Third line therapy
In absence of first and second line therapy
Amphotericin B deoxycholate 0.75- 1mg/kg/day
via infusion daily or alternate days for 15 -20
doses.

54. Fourth line of Therapy
• Miltefosine – only available oral drug, 10 mg
and 50 mg capsule.
• Paramomycin- 15mg(11mg base) per kg IM for
21 days

55. Reccomended dose for Miltefosine

56. Contraindications of Miltefosine

57. Paramomycin

59. Sodium stibogluconate
• The most serious adverse effects are
cardiotoxicity and clinical pancreatitis, either
of which can lead to death.
• Other side effects are frequent and include
myalgia and arthralgia, nausea, vomiting,
abdominal pain, headache, fatigue, rash,
electrocardiographic (EKG) abnormalities

60. Treatment Outcome
• Assessed at end of regimen/15 days after single ,short regimen
• Re-assesssed at 6 months of treatment
• Initial cure at 15 days- if no fever+ regression of spleenomegaly+
return of appetite/gain in weight
• Failure(non response)- Sign and symptoms persist, recur after
treatment at initial assessment
• Final cure -remain symptom free at 6 months after initial cure
• Relapse: sign and symptoms of VL with parasitological
confirmation at any time after initial cure
• Lost to follow up
• Death

61. Criteria for cure
• Absence of parasites from splenic and bone
marrow smears
• Available only in specialised institutes
Assessed by clinical parameters like
• Full course of therapy taken
• Fever absent
• Regression of splenomegaly
• Gain in appetite/weight
• Improvement in Hb

62. Treatment of PKDL
• 85- 90% PKDL occurs after cure for VL
• 10-15 % occur without preceding VL
• PKDL lesions act like reservior for continous
trasmission at community level
• Needs aggressive treatment

63. Treatment of PKDL

64. Treatment Outcome of PKDL
Initial cure
• Clinical improvement at the end of treatment(
at least 80% resolution of number and size of
macules)
Final cure
• Complete resolution of skin lesions 12months
after the end of treatment

65. Treatment of Kala-azar in special situations

66. Treatment of Relapse/Non responder
• Rescue therapy with L-AmB with cummulative
dose upto 30 mg/kg
Or,
• Conventional Amphotericin B deoxycholate
5mg/kg/day for 3 days
Or,
• Combination regime of two drugs

67. VL and HIV
• Visceral leishmaniasis is an AIDS defining illness.
• HIV infection increases the risk of VL and, conversely, VL
accelerates HIV disease progression.
• Patients with HIV-VL coinfection may have severe and/or
atypical clinical presentations and may respond poorly to
treatment in the absence of immune reconstitution.
• ART decrease the likelihood of relapse after antileishmanial
therapy
• Start ART irrespective of CD4 counts as soon as possible.
• Antiparasitic therapy — Started at diagnosis
• Treatment regimens for patients with HIV-VL coinfection
differ by geographic region.

68. VL and HIV
• HIV-VL coinfected patients tend to have relatively low
antibody titers.
• The sensitivity of various serological tests ranged from
25 to 50 percent in HIV.
• Therefore, histopathologic or molecular confirmation is
warranted for definitive diagnosis.
• Molecular techniques have high sensitivity in HIV-VL
coinfected as parasite load is high in peripheral blood
specimens and amastigotes may be visualized in buffy
coat smears.
• The parasite load tends to be inversely proportional to
the CD4 counts.

69. VL and HIV
• For patients infected with VL in South
Asia, liposomal amphotericin B (5 mg/kg
intravenously administered on days 1, 3, 5, 7, 9,
and 11) with miltefosine(100 mg orally daily for
14 days) is given.
• If miltefosine is not available, monotherapy with
liposomal amphotericin B (5 mg/kg intravenously
on days 1-4, 8, 10, 17, and 24) is an appropriate
alternative.

70. Vector control
• The methods of choice are indoor residual
spraying for endophilic sandflies.
• Use of WHO-recommended insecticide-
treated or long-lasting insecticidal nets.
• Environmental management including local
sanitation and improved housing.
• Pyrethroid-treated clothing, curtains.

71. References
1) Harrisson’s principle of internal
medicine,22nd edition
2) National guideline for diagnosis and
management of Kalazar
3) Uptodate

72. Thank you