CLINICAL AND INFECTIVE OUTCOME OF PARASITOLOGICALY CONFIRMED KALA-AZAR PATIENTS TREATED WITH SODIUM ANTIMONY GLUCONATE

A total of fifty consecutive cases of Kala-azar admitted in the medicine units of Rajshahi Medical College Hospital during the period from February 2006 to October 2006 were included in this study. The number of the patients clearly indicates that the burden of Kala-azar in this region is significant and expanding. Male to female ratio was 1.9:1. Fever (96%) and splenomegaly (100%) were the predominant features. Hepatomegaly was found in 82% of the cases. Other clinical manifestations were Hyperpigmentation (76%), weight loss (62%), pallor (60%), jaundice (10%), oedema (10%), cough (6%) and lymphadenopathy (4%). Fever of 75% cases subsided within one week of starting treatment. Weight of 89.6% cases increased after completion of treatment. After completion of treatment spleen size regressed in 95.8% cases and no LD (Leishmania donovani) body was seen in 46 (92%) patients splenic / bone marrow aspiration after completion of treatment. 2 (4%) patients remain LD body positive after completion of treatment and 2 (4%) patients died during treatment. Still sodium antimony gluconate (SAG) is very effective in the clinical and parasitologicaly confirmed Kala-azar patients. A combination of sand fly control, early detection and treatment of the patients is the best approach for controlling Kala-azar. Keyword: Kala-azar, Sodium Stibogluconate, LD (Leishmania donovani) body, splenic or bone marrow aspiration. 1. Professor, Dept of Medicine, Dhaka Medical College 2. MD course student, Dept of Neurology, BSMMU 3. Assistant Professor, Dept. of Medicine, Rajshahi Medical College 4. Postgraduate resident, Dept. of Medicine, Dhaka Medical College Hospital 5. Assistant Professor, Dept. of Medicine, Dhaka Medical College Hospital Correspondence: Prof. Quazi Tarikul Islam, Dept. of Medicine, Dhaka Medical College, E-mail: prof.tarik@gmail.com J MEDICINE 2010; 11 : 12-16

intramuscularly for 28-30 days. 5Common Side effects are arthralgia, myalgia, pancreatitis, and ECG changes. 5,6Occasionally severe cardiotoxicity like prolongation of QT c in ECG, ventricular ectopics, runs of ventricular tachycardia, torsades de pointes, ventricular fibrillation and sudden death can occur in excess dose or improperly manufactured or stored stibogluconate. 5,6Until a safe and effective vaccine is developed, a combination of sand fly control, early detection and treatment of the patients is the best approach for controlling Kala-azar. 2

Materials and methods
This was a cross sectional study carried out in the medicine unit of Rajshahi Medical College Hospital, during the period of February 2006 to October 2006.A total number of 50 subjects between 13-50 years were included in this study.Relevant history, clinical findings, laboratory records and follow-up of every case was recorded in a pre-designed data sheet.Subsequently, data were analyzed by statistical software SPSS version 11.Suspected cases of Kalaazar that were admitted under all three medicine units of Rajshahi Medical College Hospital were studied.After taking detail clinical history, splenic aspiration or bone marrow study for Leishmania donovani body (LD body) were done in highly suspected cases.All the parasitologicaly positive Kala-azar cases were included in the study.All parasitic positive cases were treated with Sodium Antimony Gluconate (SAG) for 28 days.At the end of the treatment follow up splenic aspiration were done in all the patients to see infective outcome.Table II shows that fever (96%), weight loss (62%) and loss of appetite (40%) were the predominant symptoms in most of the cases.Table III shows most of the patient presented with splenomegaly (100%), hepatomegaly (82%), hyperpigmentation (76%), and anaemia (60%).

Discussion
A large number of studies were carried out on Kalaazar including its clinical profile worldwide especially in Bangladesh, India and Sudan.The total numbers of Kala-azar cases were fifty, which constituted 1.9% of total admission in the department of Medicine, Rajshahi Medical College Hospital for a period of 8 months.In this series, majority (58%) of the patients were in the age of 13-20 years.As the patients less than 13 years of age were admitted in the Pediatrics department, they were not included in this study.So, incidence of the age group in this study is not consistent with other series, where majority of the cases were of 11-20 years of age. 7,8,9le to female ratio was 1.9:1 in our series.Male preponderance was also reported by other studies. 7,9,10,11In a study of 89 cases, Sharma et al found that sex incidence of Kala-azar at pre-puberty age group was equal but in the reproductive age group, there were significant less cases in females than males. 10Fever was the predominant symptom in this study (96%).Thakur found fever in 98.1% of the cases and Kager et al in 73.77% for the cases. 12,13n this study, intermittent fever was noted in 60% of the cases.Weight loss was the second most common presenting symptom (62%).Similar result was also reported by different studies. 7,8,9Splenomegaly was the most prominent sign (100%).This is consistent with the observations of others. 8,11,12Hepatomegaly was found in 82% of the cases which is in agreement with others, where hepatomegaly was present in 96.36% and 91% of the cases respectively. 7,8undice related to Kala-azar was noted in 10% of the patients.Study of Chowdhury et al reported jaundice only in 6.6% of the patients. 8Hyper pigmentation of the skin found 76% of the cases.Study of Choudhury et al and Starker et al reported hyper pigmentation in 46.2% and 21.81% of the cases respectively. 7,8In this series, lymphadenopathy was found only in 2 (4%) cases.Similar finding was reported by other series in Bangladesh. 7,8Though lymphadenopathy rare in Indian Kala-azar. 14,15It is one of the prominent clinical presentations in African Kala-azar patients. 1464% of the cases in this series had haemoglobin level of less than 10gm/dl, majority (50%) being in the range of 6-8 gm/dl.High ESR was noted in almost all the cases, 94% having >50mm in first hour.Progressive leucopenia with relative lymphocytosis is a characteristic finding of Kala-azar.74% of the patients had lower total leukocyte count (<5000/cu mm) of which 64% were leukopenic (<4000/ cu mm).All the above investigation results work in agreement with other reported data . 7,8,11,12,16ver of 75% cases subsided within one week of starting treatment.Weight of 89.6% cases increased after completion of treatment.After completion of treatment spleen size regressed in 95.8% cases.Epistaxis occurred during treatment in 4% cases.Gum bleeding occurred in 6% cases.2(4%) patients remain LD body positive completion of treatment.But they were clinically cured.They were advised for follow up after one and six months.In our study 2(4%) patients died during treatment.Study of Bora D shows mortality is 3.4% even in specialized hospital. 2This is consistent with our study.Recently in India, they have found many cases of SAG resistant Kala-azar, though it is the first line treatment of Kala-azar. 17In our study we have found that SAG is still effective in our parasitologicaly confirmed Kalaazar patients.

Conclusion
In endemic areas, high grade of clinical suspicion with the help of commonest clinical features, such as fever, anaemia, generalized weakness, weight loss with splenomegaly and with minimum laboratory aids, like decrease hemoglobin, high ESR, progressive leucopenia with relative lymphocytosis and positive ICT test, it is easy to come to clinical diagnosis.Sodium antimony gluconate, after 60 years of its use, still remains very effective in the treatment outcome of Kala-azar clinically and parasitologicaly.

Table V
Total leukocyte count (n=50)