A forty-five-year-old male resident of Saile Sikhar Municipality, Ward no. 5, Darchula District, was admitted to Sukraraj Tropical and Infectious Disease Hospital on 24 January 2019. Prior to visitation to our center, the patient had already been treated with LAMB (5 mg/kg daily for 3 days) against the first episode while LAMB 5 mg/kg stat and paromomycin 15 mg/kg IM for 10 days against the second episode. Finally, the patient was treated with miltefosine (50 mg) twice daily directly observed treatment for 28 days (Figure 1).
The patient presented to a local hospital in Nepalgunj on 25 January 2018 with a history of abdominal pain, anorexia, and fever with chills and sweating for 3 months. Clinically, the patient showed pallor with hepatosplenomegaly. The following information was available in his case file: his rK39 test was positive; glucose level 109.8; urea 17.64; creatinine 0.75; total bilirubin 62; direct B 0.28 mg%; alanine aminotransferase 20.3 U/L; aspartate aminotransferase 21.5 U/L; and alkaline phosphatase 118.6 U/L. He was admitted and treated with three doses of LAMB, 5 mg/kg daily for 3 days in the hospital.
The patient went to the Zonal Hospital of Western Development Region on 20 August 2018. Bone marrow aspiration cytology was performed showing cellularity which was normal for age; myeloid : erythroid ratio was 1 : 2. There was normal maturation and morphology of normoblasts. Myeloblasts were not identified in the smears studied. The megakaryocyte was normal in morphology and distribution. There was an increase in plasma cells and macrophages. Rare histiocytes showed intracellular amastigotes (LD bodies). Sparse clusters and singly dispersed extracellular amastigotes (LD bodies) were also identified. His total blood count was 1630; neutrophils 11.1%; lymphocytes 68.4%; monocytes 8.9%; eosinophils 0.9%; basophils 10.7%; hemoglobin level 6.8 g/dl; platelet count 104,000; creatinine 0.8 mg/dl; glucose 108.4 mg/dl; alanine aminotransferase 13.8 U/L; urea 30.4.
At the time of admission, the patient had had a history of fever and loss of appetite for 4 weeks, vomiting for 2 weeks, constipation for 4 days, productive cough for 4 days, and bilateral pitting pedal and chest pain for 4 days. Laboratory parameters revealed a hemoglobin level of 5.4 g/dl; total count 800; platelet count 54,000; prothrombin time 10 sec with international normalized ratio 0.91; rK39-positive; malaria- and leptospira-negative; urea and creatinine 20/0.4 mg/dl; total bilirubin 0.7 mg/dl; direct bilirubin 0.02 mg/dl; HIV serology negative; acid-fast bacilli-negative sputum; serum albumin 1.1 mg/dl; and total protein 6.9 mg/dl; urine routine microscopy showed 18-20 pus cells and 8-10 red blood cells. The patient was treated with ceftriaxone, blood transfusion (2 pints), and LAMB 5 mg/kg single dose in day one followed by paromomycin 15 mg/kg IM for 10 days. On the basis of X-ray findings, antitubercular treatment category 1 was also started. Hospital stay was uneventful with no fever, and vitals were stable.
After a week of treatment, his laboratory parameters improved with hemoglobin 8.4 g/dl; total count 2000; platelet count 131,000; and creatinine 0.2 mg/dl. The liver function test showed alanine aminotransferase 24 U/L; aspartate aminotransferase 21 Units/L; total bilirubin 0.6 mg/dl; and direct bilirubin 0.1 mg/dl. Blood transfusion was performed on August 28 and 29. He received 3 units of blood in the hospital and was referred to our center.
Upon arrival, the patient complained about an intermittent fever and vague abdominal pain for the past one week. He also had epistaxis for 4 days. Clinically, he looked emaciated, pale, lean, and thin. There was massive splenomegaly crossing the midline extending below the umbilicus up to the right iliac fossa. Vitals were within normal limits (blood pressure 90/60 mm of Hg, temperature 96.2 F, and pulse 84/min). Laboratory parameters revealed a hemoglobin level of 5.8 g/dl; total count 400 cells/cumm; neutrophils 69%; lymphocytes 27%; monocytes 4%; and platelet count 29,000 cells/cumm. Peripheral blood smear showed anisopoikilocytosis; hypochromic red blood cells; very low white blood cell count with normal morphology; no abnormal cells; and very low platelet count with normal morphology. rK39 was positive. Sputum for acid-fast bacilli was negative. Lipid profile showed a cholesterol level of 67 mg/dl; triglyceride 136 mg/dl; high-density lipoprotein 20 mg/dl; and low-density lipoprotein 20 mg/dl. Serum albumin was 1.0 mg/dl; total protein 7.9; prothrombin time 15 sec; and international normalized ratio 1.3. Sputum for GeneXpert MTB/RIF was negative. Ferritin level was increased to 766 ng/ml. Bone marrow cytology was performed which showed parasitic Leishman-Donovan (LD) bodies. Chest X-ray was normal. Ultrasonography revealed massive splenomegaly measuring 26 cm. There was hepatomegaly with coarse echotexture. Portal vein caliber distended with mild portal hypertension. There was no lymphadenopathy with minimal ascites. Malarial parasite and HIV serology were negative.
The patient was treated with miltefosine 50 mg twice daily directly observed treatment for 28 days in hospital. The patient's general condition improved with 3 kg weight gain within a month. The spleen regressed and could be felt left to the midline six fingers below the costal margin. His total count improved and increased up to 2000 cells/cumm while the platelet count increased to 190000 cells/cumm. Liver function tests and renal function tests were normal, and bone marrow reports showed markedly hypercellular marrow showing adequate iron stores and no abnormal cells. The LD bodies were not visible in the bone marrow 30 days after treatment with miltefosine.
First follow-up after miltefosine treatment was done six weeks after discharge. The patient had 7 kg weight gain. His blood parameters showed a hemoglobin count of 9.6 gm/dl, total count 3200 cells/cumm, platelet count 189,000 cells/cumm, creatinine level 0.9 mg/dL, alanine aminotransferase 70 U/L, aspartate aminotransferase 30 U/L, serum albumin 3.2 mg/dl, and total protein 11.4 mg/dl. Abdominal ultrasound showed minimal hepatomegaly with coarse echotexture and moderate splenomegaly measuring 17 cm in size. Six-month follow-up of the patient showed the patient was healthy and free of VL.