Annals of PIMS-Editorial Board

Background: Visceral leishmaniasis (VL) is prevalent in Azad Kashmir and some areas of Northern Pakistan. Many of these patients seek medical treatment in hospitals of Rawalpindi-Islamabad, and majority of them present in advanced stage of the disease.
Objective: To document the clinical and laboratory presentation of visceral leishmaniasis in patients presenting from the northern areas of Pakistan Study Design: Retrospective Chart Review
Place and Duration: Department of Pathology, Holy Family Hospital, Rawalpindi from Jan 2002 to December 2007
Materials and Methods: 42 biopsy diagnosed patients with VL out of 1165 bone marrow biopsies done were studied on clinical and laboratory parameters.
Results: It was found that most of the patients (2/3rd) belonged to Azad Kashmir, rest of patients belonged to Murree. Sign and symptoms included fever (95.2%), Nausea/vomiting/diarrhea (66.7%), Weight loss (33%), Pallor (95.2%), hepatomegaly (85.5%), splenomegaly (81%), and enlarged Lymph nodes (50%). Regarding hematological tests done, mean TLC was found to be (4.3%) with range from 1.4-7.8. Mean Neutrophil count was (24.5%), Lymphocytes (69.9%), monocytes (4.0%), eosinophils (0.52%), blast cells (0.86) and Platelets (55 x (103/ul). Average hemoglobin was found to be 6.57g.dl (range 3.4 – 9.9), RBC count (3.2 x 109/L), PCV (21.8), MCV (68.1 fl), MCH (26.7 pg), MCHC (27.4). Anisocytosis (95.2%) with most common distribution in + (38.1%) and ++ (52.4%) followed by poikilocytes (95.2%) with majority (61.9%) reported as “+”. Microcytosis in (91%), hypochromia (90.2%), and dimorphic Blood picture (33.3%). In bone marrow examination, aspirate was found Hyper cellular in (86.7%). Myeloid precursors were immature in (57.5%). No blast or fungi were seen (0%).There were increased hemophagocytic and histiocytic cells (72.2%).
Conclusion: Patient from northern areas with varied symptomatology of fever, NVD, anemia and hepatosplenomegaly should be suspected of VL for early detection of disease and to adopt treatment options.

Introduction

Visceral Leishmaniasis (VL), also known as kala-azar and black fever, is the most severe form of leishmaniasis. This disease is caused by Leishmania donovanii, a protozoa transmitted by the bite of the sandfly, Phlebotomus. The insect vector of Leishmania is found throughout the world's inter-tropical and temperate regions.¹ It is estimated that there are 500,000 new cases of symptomatic VL each year, resulting in up to 5000 deaths annually. More than 90 percent of the cases are reported from Bangladesh, India, Sudan and Brazil, where there have been epidemics over the past 10 years.

Visceral leishmaniasis is characterized by irregular bouts of fever, substantial weight loss, enlargement of the spleen and liver, and anemia (occasionally severe). If left untreated, the fatality rate in developing countries can be as high as 100% within 2 years.¹ The peak age for developing symptoms from VL varies in different geographic regions. Laboratory findings in visceral leishmaniasis (VL) include pancytopenia and hypergammaglobulinemia. Anemia, neutropenia, and thrombocytopenia are associated with a variable degree of splenomegaly.²

Visceral leishmaniasis is endemic in Azad Kashmir and in some areas of NWFP. It is found in population in asymptomatic state but often diagnosed in very advanced stage when it has already spread to liver, spleen or bone marrow, etc. This study was conducted in an urban area of Pakistan where patients are referred from different parts of the country including Azad Kashmir, hilly areas around Rawalpindi and even NWFP.