Complexity in diagnosis & treatment case studies from Kolkata

Prof Bibhuti Saha: There may be some people who had some toxicity to certain drugs. Some people with VL, they have certain other things– maybe HIV VL, maybe VL with tuberculosis.

I like to share one very interesting case. One patient had a neurological problem. He was admitted to a neuromedicine department, of an adjacent medical college hospital. The patient also, besides the neurological problem, had severe anaemia and his spleen was palpable– 3 centimetres, which is three centimetres below costal margin. The doctors there thought– elderly person, 62 years of age male– they thought he may be having some hemato/blood disorder, haemotological disorder. He was referred to the haematology department. To evaluate him they did a bone marrow examination. The bone marrow showed presence of LD bodies, Leishman donovan bodies. He was there for two hours. Now he’s a man from North Kolkata where we don’t have VL.

In West Bengal we have 11 districts who have VL, but Kolkata is not among them. We don’t have the disease, the sandflies, in Kolkata. So then how did the man get the infection? This is the question we’re asking. When we talked to the man, we came to know that he worked in a tea estate in North Bengal, northern part of West Bengal, for 30 years. That district has Leishmaniasis transmission. Possibly he got the infection that time. Now the story was matching. We treated him with a single dose of Liposomal Amphotericin B. His haemoglobin started increasing. His spleen regressed. He went back to the neuromedicine department for his treatment of his neurological disorders. That’s how it came.

Until now it was not mandatory to test for HIV, but now it is being done, because unless you test for HIV– we don’t know that some person has HIV infection or not– the national recommendation is now that if you have VL, you should be counselled and tested for HIV to know how is the thing. We do have quite a good number of HIV VL co-infected patients. Previously when they were not put on secondary prophylaxis, they were having relapses. I remember seeing a patient, an elderly man about 65 years old, maybe two years– maybe four years back.

He came to us with a fever, anaemia, and splenomegaly. He was carrying a record of our hospital. He was diagnosed with VL 20 years back. He was treated with sodium stibogluconate. That was the regimen at that time. Now he has come with it, and he was having fever. We did a splenic aspiration. We found that it showed LD bodies. Then why did the relapse occur? He was a little elderly person– 65, 66 years of age. We did HIV testing and we had found that he was HIV positive. So possibly after the first infection, in between when we recorded the HIV infection, which led to immune suppression and that has led to a relapse of the VL.

So that’s how you have to look at it. Previously we are not using secondary prophylaxis. These patients were coming back with VL again. You are giving a course– again coming back. Now we’re giving this prophylaxis, secondary prophylaxis. We’ll need to see how that goes on. We are learning. Every day we’re learning from our patients.