Diagnostic Dilemma

Kalaazar in child who has not visited endemic area

An 11 month old girl resident of Mumbai born of non consanguineous marriage presented with cough and fever since 15-20 days. She had diarrhea with septic shock, meningitis and anemia 2 months back for which she was hospitalized and treated with intravenous antibiotics and blood transfusion. She was alright for 1 month and again had pneumonia with anemia and was again treated with intravenous antibiotics and blood transfusion. However, now fever has restarted since 20 days. Birth history, immunization, development is uneventful. On examination, she had pallor, hepatosplenomegaly with generalized lymphadenopathy.

Investigations over a period of 2 months are as follows:

• CSF = 16 cells, cumm {all lymphocytes}, 59 sugar with proteins of 105 mg, dl
• Renal functions and liver functions = Normal
• HIV, Leptospira, Dengue ELISA = Negative
• Hemoglobin electrophoresis = Normal
• S. cholesterol = 110 mg, dl
• Blood culture = Staphylococcus aureus
• Bone Marrow aspiration {Day 48} prior to 2nd blood transfusion = LD bodies
• Prothrombin time and Partial thromboplastin time = Prolonged
• Fibrinogen = 250 mg percent {increased}
• Ferritin = 1293 IU, L {Normal = 7-140 IU, L}
• Chest X-Ray = Right lower zone pneumonia

This child had never been to an area endemic for Kalaazar though mother had been there 6 months prior to getting pregnant. Child was treated with Inj Amphotericin B to which the fever, pancytopenia responded and hepatosplenomegaly regressed.

How did the child get Kalaazar_?
Expert Opinion :
Wonderful replies. There have been very few cases of congenital leishmaniasis reported in the world. There have also been instances where mother has been asymptomatic but had antibody for leishmania positive {Pediatrics. 1999 Nov`104{5}:e65.} with history of travel to endemic area previously.
In your patient also we suspected congenital transmission of the leishmania but mother`s kalaazar elisa was negative for antibody.

Transfusion transmitted leishmaniasis {TTL} has also been reported in literature. L. donovani are expected to remain present in the blood for an undefined period between the bite of sand fly and their final localization to the target organs.The duration of asymptomatic parasitaemia varies with the infecting species. For Leishmania donovani this period varies from 1-14 months. For other species this period varies from two to eight weeks, although some cases have been reported following a one-year incubation period.

Thus, it looks like transfusion asscoiated leishmaniasis in this child.

Could it still be congenital leishmaniasis where the mother`s antibody titres may have become undetectable_?
Answer Discussion :
mavel gutierrez
mother infected
11 years ago
HanumanthaRao K.R
Either through blood transfusion or Transplacental transmission
11 years ago

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