Visceral leishmaniasis treatment — DTM&H MCQ

Correct answer: A — Visceral leishmaniasis

The correct answer is A, visceral leishmaniasis. This man from northern India (an endemic focus, along with Bihar and West Bengal) has the classical kala-azar triad of a prolonged, weeks-long fever, massive splenomegaly and pancytopenia with polyclonal hypergammaglobulinaemia. Persistent irregular fever and splenomegaly characterise visceral leishmaniasis, and pancytopenia, hepatomegaly, hypergammaglobulinaemia, and weight loss are common, particularly in patients presenting late. Splenic macrophages infected with Leishmania donovani drive hypersplenism (causing pancytopenia) and polyclonal B cell stimulation (causing hypergammaglobulinaemia), and this combination in a returning traveller or resident of an endemic area should trigger specific testing (serology, rK39 rapid test, or tissue/bone marrow amastigote identification) rather than empirical antibacterial or antimalarial treatment. Why the other options are wrong: E. Enteric fever relapse: Typhoid relapse causes fever and modest splenomegaly but does not produce massive splenomegaly, pancytopenia or hypergammaglobulinaemia, and the illness course is typically shorter and lacks marrow/splenic infiltration. D. Chronic brucellosis: Brucellosis causes undulant fever, arthralgia and hepatosplenomegaly but rarely massive splenomegaly, and pancytopenia with marked hypergammaglobulinaemia is not a defining feature. B. Disseminated strongyloidiasis: This occurs in immunosuppressed hosts (for example on corticosteroids or with HTLV-1) and presents with gastrointestinal, pulmonary and septic features from larval migration, not primarily massive splenomegaly and pancytopenia. C. Hyperreactive malarial splenomegaly: This follows years of repeated malaria exposure, produces massive splenomegaly with marked IgM elevation, but is not typically accompanied by fever or such a short symptomatic history of six weeks. Key point: In a patient from a leishmaniasis-endemic region with weeks of fever, massive splenomegaly, pancytopenia and hypergammaglobulinaemia, visceral leishmaniasis (kala-azar) is the diagnosis to actively exclude with rK39/serology or tissue parasitology.

Reference: The Lancet, Leishmaniasis (Burza, Croft, Boelaert), 2018: persistent irregular fever, splenomegaly, pancytopenia and hypergammaglobulinaemia characterise visceral leishmaniasis, particularly in late-presenting patients. https://www.sciencedirect.com/science/article/abs/pii/S0140673618312042