Multiple relapses of Visceral Leishmaniasis in a patient treated with liposomal amphotericin

Abstract

Sir, Pentavalent antimonial drugs have been used for many decades as standard treatment for Visceral Leishmaniasis Sundar et al. 1 The emergence of Leishmania strains resistant to pentavalent antimonials and the occurrence of side effects have prompted the evaluation of alternative drugs, including liposomal amphotericin B (L-amB) with Mediterranean VL Cascio et al. 2 A 7-year-old boy, who admitted to Pamukkale University in Turkey, had such as prolonged fever, cough, pallor, weight loss, splenomegaly and hepatomegaly. Full blood count was done and cytopenia (leucopenia (3200/µL), neutropenia (320/ µL), moderate anemia (8.8 gr/dl), high total protein (8.8 d/dl), hypoalbuminemia (2.5 g/dl), hypergammaglobulinemia (6.3 g/dl), inversion of A/G ratio, high IgG (1987 mg/dl; N: 670-1500), high aspartate aminotransferase (153 IU/l) and alanine aminotransferase (133 IU/l) levels was observed.The rK39 ELISA test was slightly positive. Leishmania antibodies titre (IFAT) was 1:128. Leishmania amastigotes were not detected on bone marrow aspirate.Diagnosis of VL was established by presence of clinical signs and IFAT at a titre of 1: 128 without finding any parasitological evidence of infection.The patient was treated with L-AmB at a dose of 3 mg/kg of body weight/day for 6 days and over a 10-day period (on days 1, 2, 3, 4, 5 and 10), reaching a total dose of 18 mg/kg. Patient became afebrile after 2-days of treatment. Whereas hematological, such as hemoglobulin, leucocyte, liver function tests, and gammaglobulin restroration occurred on the 17th, 12th, 21th and 19th days, respectively.IFAT was at a titre of 1:256 one month after the time treatment initiated.On the 72nd day, fever, anemia, SGOT and SGPT elevation, splenomegaly and high IgG level (3690 mg/ dl) was observed. IFAT was not different (1: 256) and the patient was accepted as relapse. First relapse was retreated with 3 mg/kg L -AmB for 10 consecutive days (a total dose of 30 mg/kg). After the first relapse therapy, on the 65th day, high fever, increase of SGOT and SGPT levels, splenomegaly and hypergammaglobulinemia (IgG: 4950 mg/dl) was observed again. IFAT was at a titre of 1: 1024 and the patient was accepted as second relapse. Leishmania amastigotes on bone marrow aspirate were not seen on the first and second relapses.On the second relapse, meglumine antimonate was administered i.m. for 28 days at a dosage of 20 mg/kg per day. For this time, clinical and laboratory responses were good. After one month of treatment, IFAT was at a titre of 1: 512. for 7 months, no more relapse was seen.The pentavalent antimony compound meglumine antimonite remains the worldwide standard antileishmanial treatment except in India, where resistance has curbed its use. Resistance to antimonial agents is rare in the MVL Tanir et al 3 carried out a treatment of VL with antimonials in pediatric patients in Turkey, which is a relatively inexpensive, safe and effective with low relapse rates. L-amB may be useful in cases of treatment failure with antimonials or significant adverse effe...

Evaluation of recombinant K39 antigen and various promastigote antigens in sero-diagnosis of visceral leishmaniasis in Bangladesh

“…We are recommending a combination of two tests using different antigens such as rK39 and promastigotes of L. donovani complex for IFAT to diagnose VL with declining case numbers. In addition, antibody titres measured by the IFAT can be used to monitor the patient's long-term recovery ( Akin et al, 2009 , Proverbio et al, 2014 ). Although not covered in our study, the collection of filter paper specimens that are mailed back to a reference laboratory for testing will overcome major logistical problems for further specimen testing ( Panteleeff et al, 1999 , Smit et al, 2014 ).…”

Utility of smear examination, culture, and serological tests in the diagnosis of visceral leishmaniasis/post-kala-azar dermal leishmaniasis at National Centre for Disease Control, Delhi

“…Antibody titer measured by the IFAT is for the whole antigen and can be used to monitor the patient's long-term recovery. [ 10 11 ] Antibodies are undetectable by IFAT 6 to 9 months after cure. If the antibodies persist in low titers, it is good indication of a probable relapse.…”