the female child is six - years - old and comes from fortaleza in the state of ceara in brazil .
initial symptoms began six months ago and included fever , asthenia , and weight loss .
tests findings include : cbc : normochromic and very microcytic anemia ( hb : 7.1 g ) , leucopenia ( 3,300 wbc ) , and thrombopenia ( 70,000 platelets / mm ) ; esr : 77 mm for first hour ; serology of leishmaniasis : positive ( 1/1600 using immunofluorescence and 5 archs in electrosyneresis ) ; bone marrow biopsy : the medulla is rich , but no leishmania are seen .
the patient is given a meglumine antimoniate treatment with increasing doses reaching 60 mg / kg / day after three days .
transient hepatic cytolysis emerges with alanine transaminasi ( alt ) and aspartate aminotransferase ( ast ) 1.5 times above upper normal limit .
according to the world health organization , leishmaniasis is a poverty - related disease whose public health impact has been , until recently , grossly underestimated .
the disease is caused by protozoan parasites belonging to the genus leishmania that are transmitted by the bite of a phlebotomine sandfly .
there are approximately two million new cases each year  1.5 million of cutaneous leishmaniasis and 500,000 of visceral leishmaniasis or kala - azar .
kala - azar is endemic to south america , east africa , the mediterranean basin , the middle east , india , and china .
the cardinal sign of kala - azar is an anarchic type of fever resisting all forms of treatment .
the disease always yields splenomegaly and is thought by many to produce the largest spleens in parasitology .
contrary to adult manifestations , cutaneous signs such as erythematous , hyper- or hypopigmented papules and nodules of various sizes are rare in children . although not performed in the case reported , protein immunoelectrophoresis reveals hypergammaglobulinemia with an igg peak in patients with kala - azar .
serological tests , which are useful for the diagnosis of kala - azar , include elisa ( enzyme linked immunosorbent assay ) , direct agglutination test ( dat ) , indirect fluorescent antibody test ( ifat ) , and the rk39 dipstick test .
elisa is widely performed , particularly in epidemiological studies , because it is very simple .
anemia secondary to kala - azar is aregenerative because of bone medullar parasitic invasion . even without direct evidence of leishmania ,
this child s poor health condition coupled with the epidemiological , clinical , and biological presentations called for immediate treatment . in brazil ,
side - effects of this case s treatment drug of choice , meglumine antimoniate , include the following : i ) intolerance that usually appears after the first injections and consists of fever , chills , cough , myalgia , and/or skin rash .
treatment discontinuation is mandatory if such intolerance occurs ; ii ) intoxication resulting in fever , cough , skin rash , polyneuritis , hepatitis , cardiac , and renal signs .
alternative treatments for kala - azar include sodium stibogluconate , amphotericin b , liposomal amphotericin b , pentamidine , and paromycin .
the cardinal sign of kala - azar is an anarchic type of fever resisting all forms of treatment .
the disease always yields splenomegaly and is thought by many to produce the largest spleens in parasitology .
contrary to adult manifestations , cutaneous signs such as erythematous , hyper- or hypopigmented papules and nodules of various sizes are rare in children .
although not performed in the case reported , protein immunoelectrophoresis reveals hypergammaglobulinemia with an igg peak in patients with kala - azar .
serological tests , which are useful for the diagnosis of kala - azar , include elisa ( enzyme linked immunosorbent assay ) , direct agglutination test ( dat ) , indirect fluorescent antibody test ( ifat ) , and the rk39 dipstick test .
elisa is widely performed , particularly in epidemiological studies , because it is very simple .
anemia secondary to kala - azar is aregenerative because of bone medullar parasitic invasion . even without direct evidence of leishmania ,
this child s poor health condition coupled with the epidemiological , clinical , and biological presentations called for immediate treatment . in brazil , the etiological agent of kala - azar is leishmania donovani . without treatment ,
side - effects of this case s treatment drug of choice , meglumine antimoniate , include the following : i ) intolerance that usually appears after the first injections and consists of fever , chills , cough , myalgia , and/or skin rash .
treatment discontinuation is mandatory if such intolerance occurs ; ii ) intoxication resulting in fever , cough , skin rash , polyneuritis , hepatitis , cardiac , and renal signs .
alternative treatments for kala - azar include sodium stibogluconate , amphotericin b , liposomal amphotericin b , pentamidine , and paromycin .
 we report the case of a six - year - old brazilian girl referred for splenomegaly who first presented with fever , asthenia , and weight loss . geographical location , clinical exam , and blood laboratories suggested kala - azar . 
 serology confirmed kala - azar diagnosis , but direct evidence of the parasites was not made . a treatment by meglumine antimoniate is given under hospital surveillance for two weeks . 
 thereupon , the patient is asymptomatic and all tests are normal . 
Case Report
Background
Signs and Symptoms
Diagnosis
Treatment