Recurrence of kala‐azar after PKDL: role of co‐factors

Abstract

SummaryRecurrence of kala-azar after post kala-azar dermal leishmaniasis (PKDL) has remained uncommon. We report here two patients with recurrence of kala-azar (KA) after development of PKDL. In one case the second attack of KA was preceded by repeated attacks of malaria and tuberculosis, and in the other the recurrence of KA followed an attack of measles. While measles has earlier been suggested as co-factor in inducing transformation from sub-clinical to clinical kala-azar, malaria was demonstrated to enhance the virulence and invasiveness of Leishmania in an experimental model as well as under natural condition. We propose that in our cases, measles and repeated attacks of malaria or tuberculosis led to immunosuppression and recurrence of visceral leishmaniasis (VL).keywords PKDL, recurrent kala-azar, re-visceralization, co-factors correspondence Professor A. Nandy,

Transmission Dynamics of Visceral Leishmaniasis in the Indian Subcontinent – A Systematic Literature Review

“…However, the proportion of PKDL relapse following a 3mo PKDL treatment with miltefosine was significantly higher (43%) compared to PKDL patients treated with 4mo of miltefosine [ 121 ]. There were two case reports of recurrence of VL following PKDL possibly triggered by immunosuppression due to concurrent infection [ 123 ]. A higher proportion of macrophages infected with the parasite was reported in relapse.…”

Para-kala-azar dermal Leishmaniasis cases in Indian subcontinent – A case series

“…Nandy et.al study has shown that active cases of VL develop after successful treatment of PKDL. 5 In Sudan PKDL heals spontaneously and does not need treatment except in chronic cases of more than 6 months to one year duration. In India patients need treatment, as PKDL serves as reservoir for VL.…”

Impact of a co-factor on the dynamics ofLeishmania donovaniinfection: does HIV infection encourage the recurrence of visceral leishmaniasis following post-kala-azar dermal leishmaniasis?

“…Those who made the earliest reports of VL after PKDL (Brahmachari, 1928;Napier and Das Gupta, 1930;Sen Gupta, 1968) made no attempts to identify the event(s) that may have triggered the second attack of VL (in an era when HIV was unknown). In the two cases described by Nandy et al (1998), however, measles or pulmonary TB preceded the visceral recurrence and may have led to immunosuppression.…”

“…VL during or after PKDL is, in fact, an extremely rare phenomenon in India. Except for Nandy et al (1998), those who reported Indian patients in which the visceral disease has recurred after PKDL (Brahmachari, 1928;Napier and Das Gupta, 1930;Sen Gupta, 1968) appear to have made little attempt to understand the possible mechanism(s) involved in the recurrence. Surprisingly little is known, however, about the nature and extent of the immune response that usually provides life-long protection against the recurrence of VL.…”