Paediatric visceral leishmaniasis in Tunisia: a retrospective analysis of 45 children Héla SAKLY, Nada BELHADJ SALAH, Habib BESBES, Chouchane SLAHEDDINE Centre hospitalo-universitaire, Fattouma Bourguiba Monastir, TUNISIE Presenting author: Belhaj Salah Nada
INTRODUCTION ➢ Visceral leishmaniasis (VL) is endemic in areas bordering the Mediterranean Sea. ➢ Rare in pediatric age. ➢ Caused by Leishmania infantum++++ ➢ Little information is available about infantile visceral leishmaniasis in Tunisia as regards incidence, diagnosis and management of the disease.
MATERIALS AND METHODS ➢ A retrospective study was conducted between 1994 to 2017. ➢ The epidemiologic, clinical, and therapeutic features were collected. ➢ VL was diagnosed by serology tests and/or the presence of amastigote of Leishmania in bone marrow aspirate. ➢ IFA and ELISA serology tests were performed according to World Health Organization (WHO) manual protocol using cultured promastigote of local L. infantum as antigen.
RESULTS ➢ The median age was 25 months (4 months-120 months). ➢ 78 % of patients were from areas evenly distributed in 25 rural or suburban areas, where stray dogs and sandflies exist. ➢ A tendency toward the onset of symptoms during the spring or summer was observed ( 67% of cases). ➢ The median time from the onset of symptoms to admission was 30 days (3 days-80 days).
Table 1: Clinical manifestation in visceral leishmaniasis hospitalized children Clinical characteristics N % Fever 43 97,1 Splenomegaly 42 94,3 Loss of weight 35 77,7 Oedema 15 33,3 Diarrhoea 9 20 Vomiting 8 17,7 Abdomen enlargement 3 6,6
➢ The detection of serum Leishmania antibodies by an immunofluorescent antibody test was positive in 77.2 % 97.90% 82% (27 cases). 77.70% 77.10% ➢ A bone marrow aspiration was obtained from all patients, and Leishmania amastigotes were detected in 18 cases (51.4%). ➢ Polymerase-chain – reaction (PCR) was positive in 11 cases (31.4%). FIGURE 2: HEMATOLOGICAL FINDINGS
➢ All patients were cured with meglumine antimonate. ➢ 30 patients noted reduction of spleen size — up to half of the initial palpated size within a median of 13 days (range, 6 – 30 days) after treatment was begun.
2 2 1 1 1 RASH DRY CAUGH TACHYCARDIA DIARRHEA INDURATION AT THE INJECTION SITE Fig. Adverse effects of meglumine antimonite in visceral leishmaniasis hospitalized children
DISCUSSION ➢ In the present study, fever, splenomegaly and hepatomegaly were the most prevalent clinical signs and anemia, leukopenia, and thrombocytopenia were the prominent laboratory findings, which agrees with previous studies [1,2] . ➢ Diarrhoea was observed as a non-specific symptom in 20 % of these children. This sign was previously reported in 23% of children with VL hospitalized in Tehran Pediatric Medical Center [3] . 1- Sarkari B, Naraki T, Ghatee MA, et al. Visceral leishmaniasis in Southwestern Iran: a retrospective clinicohematological analysis of 380 consecutive hospitalized cases (1999 – 2014). PLoS One 2016; 11: e0150406. 2- Miao R, Wang Z, Guo Q, et al. Clinical and epidemiologic features of visceral leishmaniasis in children in southwestern China: a retrospective analysis from 2001 to 2015. Pediatr Infect Dis J 2017; 36: 9 – 12. 3-Bokaie S, Sharifi L, Mamishi S, et al. A case series study on clinical and epidemiologic aspects of Kala azar in patients referred to the Children’s Medic al Center since 1991 to 2003. Iran J Epidemiol 2006; 1: 21 – 26
DISCUSSION ➢ Despite the use of alternative drugs to treat leishmaniasis, Glucantime still plays an essential role in the treatment of the disease in Tunisia. ➢ In studies conducted in Ardebil [4] and southwest Iran [1] , Glucantime was used in 96% and 97.1% of patients, respectively. ➢ In this study, bone marrow samples or their culture were positive in 51,4% of cases. ➢ The sensitivity of bone marrow aspiration does not to appear consistent in diagnosing this disease in various studies and depends on sampling method, culture, and timing of sampling. 4- Mohammadi KK, Mohebali M, Mamishi S, et al. Epidemiological characteristics of Kala-azar in hospitalized patients in Ardebil province [in Persian]. J Sch Public Health Inst Public Health Res 2003; 6: 11 – 24
CONCLUSIONS: CONCLUSION ➢ Visceral leishmaniasis in pediatric age is relatively rare in Tunisia. ➢ Because of its distribution pattern, identifying infected focal points, clinical manifestation, early diagnosis and treatment have a significant role in controlling the disease and its mortality. ➢ Despite recent reports on decreased responses to antimonial drugs of patients with Mediterranean VL, meglumine antimoniate treatment is still highly effective in Tunisia.
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