No abstract

Summaryobjectives To identify characteristics that increased the risk of mortality in Ethiopian visceral leishmaniasis patients in a treatment programme managed by Médecins sans Frontières, in Tigray, Northern Ethiopia.methods Retrospective review of a cohort of 791 patients treated for visceral leishmaniasis.results The cohort displayed all the classical signs and symptoms of the disease. The case fatality rate was 18.5% (146) (95% CI: 15.8-21.3%). Logistic regression showed that individuals who experienced at least one episode of vomiting or haemorrhage were more likely to die than those who did not.A subcohort of individuals who tested human immunodeficiency virus (HIV)-positive were more than four times more likely to die than those who tested HIV-negative (OR 4.5, 95% CI: 1.8-11.4).conclusion This study identifies characteristics associated with death in this population and highlights the devastating effect of co-infection with visceral leishmaniasis and HIV in the African context.

SummaryWe compared an rK39 dipstick rapid test (Amrad ICT, Australia) with a direct agglutination test (DAT) and splenic aspirate for the diagnosis of kala-azar in 77 patients. The study was carried out under field conditions in an endemic area of north-east Sudan. The sensitivity of the rK39 test compared with splenic aspiration was 92% (46/50), the specificity 59% (16/27), and the positive predictive value 81% (46/57). Compared with the diagnostic protocol used by Médecins sans Frontières, the sensitivity of the rK39 test was 93% (50/54), the specificity 70% (16/23), and the positive predictive value 88% (50/57). Compared with splenic aspirates, the sensitivity of a DAT with a titre ‡1:400 was 100% (50/50), but its specificity only 55% (15/27) and the positive predictive value was 80% (50/62). Using a DAT titre ‡1:6400, the sensitivity was 84% (42/50), the specificity 85% (23/27) and the positive predictive value 91% (42/46). All four patients with DAT titre ‡1:6400 but negative splenic aspirate were also rK39 positive; we consider these are probably ÔtrueÕ cases of kala-azar, i.e. false negative aspirates, rather than false DAT and rK39 seropositives. There were no false negative DATs (DAT titre £1:400 and aspirate positive), but there were four false negative rK39 tests (rK39 negative and aspirate positive). The rK39 dipstick is a good screening test for kala-azar; but further development is required before it can replace the DAT as a diagnostic test in endemic areas of the Sudan.keywords rk39, kala-azar, leishmaniasis, diagnosis, Sudan correspondence Dr Hans

Summaryobjective To compare the outcome of treatment of Sudanese kala-azar patients treated under field conditions with either branded sodium stibogluconate (SSG) (Pentostam GlaxoWellcome) or generic SSG (Albert David Ltd, Calcutta, supplied by International Dispensary Association, Amsterdam). method Randomised comparison. 271 patients were treated with Pentostam and 245 with generic SSG. results No statistically significant differences in cure rate or mortality were detected between Pentostam and generic SSG. No differences in side-effects between the two drugs were noted. The initial cure rate at the time of discharge was 93.7 and 97.6%, respectively; the death rate during treatment 5.9 and 2.4%. Six months follow up was achieved in 88.5% of the discharged patients. Two patients had died in the Pentostam group and two had died in the generic SSG group, giving a final death rate of 7.5 and 3.7%. The number of relapses in the Pentostam and generic SSG groups were 3 and 1, respectively. The final cure rates, calculated at 6 months after discharge, were 91.3% and 95.9%.conclusion No difference was observed in the performance of generic SSG compared to Pentostam for the treatment of visceral leishmaniasis in Sudan. Generic SSG can be routinely and safely used for the treatment of kala-azar. Generic SSG costs only 1/14 of the price of Pentostam. The use of generic SSG may make treatment of kala-azar affordable for national governments in Africa.keywords Kala-azar, visceral leishmaniasis, treatment, randomised trial, pentavalent antimonials, sodium stibogluconate correspondence Dr Hans Veeken, Médecins sans Frontières-Holland,

The diagnosis of visceral leishmaniasis is difficult. Due to the limitations of direct methods to detect parasites, indirect immunological methods are widely employed. The simple affordable and sensitive/specific direct agglutination test (DAT) is perhaps the most important diagnostic tool under field conditions. A significant improvement of this test is the use of a freeze-dried antigen, which is heat-stable and has a long shelf-live even under harsh conditions. The performance of this antigen in DAT has been evaluated using samples collected in East Africa. The results of these studies are presented. The detection of Leishmania infection in HIV-co-infected patients is difficult. The combination of DAT-PCR may be useful for the detection of parasite infection in these patients. Finally, we present data to show that the DAT based on the freeze-dried antigen can also be used for the detection of anti-Leishmania antibodies in dogs.