RISK FACTORS: Children > young adults in endemic areas, Malnutrition, AIDS, Incomplete therapy of initial disease
GENERAL MEASURES
β’ Bed rest, oral hygiene, and good nutrition are important.
β’ Transfusions for anemia and antibacterial chemotherapy for bacterial complications must supplement specific
therapy.
β’ Periodic ECG monitoring during prolonged therapy with pentavalent antimonials
SURGICAL MEASURES
β’ Adjunctive splenectomy
β’ Reconstructive surgery for tissue damage
ACTIVITY
Bed rest during acute stages. Level of activity dependent on severity of disease and organ systems involved.
DIET
Rich nutritious diet
DRUG(S) OF CHOICE
β’ Sodium antimony gluconate (Pentostam) 100 mg Sb5+/mL IV/IM: single daily dose of 20 mg/kg/day for
20-30 days
β’ Meglumine antimonate (Glucantime) 85 mg Sb5+/mL, same dose and duration of treatment as above, can
also be used
β’ Relapses and incomplete responses should be treated with the same regimen for 40-60 days. Addition of oral
allopurinol (Zyloprim) 20-30 mg/kg/day in three divided doses has been effective.
ALTERNATIVE DRUGS
. Relapses with drug resistant organisms are usually treated with:
. Amphotericin B (Fungizone) IV: 0.5-1 mg/kg on alternate days
. Liposomal amphotericin B is excellent for visceral leishmaniasis. It has been administered IV at a total dose of 21 mg/kg given at 3 mg/kg/day on days 1-5, 7 and 14. OR
. Pentamidine (Pentam): 3-4 mg/kg, 3 times a week for 5-25 weeks
. In patients with concomitant HIV, the disease is resistant to all current drugs
. The new orally effective drug miltefosine is approved in India for visceral leishmaniasis - 2.5 mg/kg (100 mg/
day) for 4 weeks (94% cure rate). It has been effective in the cutaneous form at 133 mg and 150 mg daily.
. Paromomycin ointment has been shown to be effective for the cutaneous form
PATIENT MONITORING
β’ Follow-up at 3 and 12 months to detect relapses
β’ PKDL should be treated in the same fashion as the initial illness
β’ Periodic monitoring of ECG, liver function and renal function during prolonged therapy
PREVENTION/AVOIDANCE
β’ Use of pesticides against sandfl ies, especially synthetic pyrethroids. Resistance to DDT is high in many areas.
β’ Insect repellants - for travelers
β’ Permethrin - coated fi ne netting for travelers
β’ Early treatment of human cases
β’ Elimination of diseased dogs
β’ Deltamethrin-treated collars fi tted to dogs have reduced incidence of the disease in children in the treated areas
POSSIBLE COMPLICATIONS
β’ Edema, cachexia, hyperpigmentation in late stages
β’ Superinfections and gastrointestinal bleeding may cause death in untreated patients with visceral disease
(Kala-azar)
β’ 3-10% of the treated cases develop PKDL characterized by depigmented macules and wart-like nodules
over the face and extensor surfaces of limbs
β’ Metastatic lesions in nasopharynx with tissue destruction in patients with mucocutaneous leishmaniasis
EXPECTED COURSE/PROGNOSIS
With early treatment, cure rate is over 90%, though in advanced cases, mortality remains at 15-25%. In
untreated cases, death occurs in 3-20 months in up to 95% of adults and 85% of children.