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|Year : 1995 | Volume
| Issue : 1 | Page : 3-4
Outbreak of kala-azar in Bombay.
S Bhatia, N Patel, S Gulhane, V Dongre, FF Jijina, AV Pathare
Department of Hematology, KEM Hospital, Parel, Mumbai.
Department of Hematology, KEM Hospital, Parel, Mumbai.
Source of Support: None, Conflict of Interest: None
A chance diagnosis of kala-azar in a patient referred from Acworth Leprosy Home in Bombay was followed up, resulting in an investigation of a total of 25 patients (inpatients and residents) for the presence of the disease. 30.3% of the patients investigated were found to be suffering from the disease. This confirms the earlier suspicion that Bombay and especially the Acworth Leprosy Home is an endemic area for kala-azar.
Keywords: Adolescent, Adult, Animal, Disease Outbreaks, Female, Human, India, epidemiology,Leishmania donovani, isolation &purification,Leishmaniasis, Visceral, diagnosis,epidemiology,Male, Middle Age,
|How to cite this article:|
Bhatia S, Patel N, Gulhane S, Dongre V, Jijina F F, Pathare A V. Outbreak of kala-azar in Bombay. J Postgrad Med 1995;41:3-4
Kala-azar or leishmaniasis is a zoo-noses caused by the-organism Leishmania donovani. In India, the geographical distribution of kala-azar though extensive is believed to be confined to the eastern part of the peninsula. Recent surveys have reconfirmed this fact. Outside these few endemic areas a few sporadic areas have been reported from Punjab and Madras. An isolated case of cutaneous leishmaniasis has been reported from Bikaner.
For the last four decades, clinicians have discounted kala-azar as a disease of local origin in Bombay. We have found that kala-azar is indeed endemic to Bombay. More noteworthy, all reported cases are from one place namely, the Ac-worth Leprosy Home at Wadala. This is more of a rediscovery of the findings of Bhende et al, who reported 16 cases from the same place in 1949.
KB, a 55 yr old treated case of lepromatous leprosy confined to Ac-worth Leprosy Home for last 42 years under the Bombay Leprosy Act was referred to us with a history of fever for the last 8-9 months, with occasional chills. On examination, he was pale with a 12 cm spleen. He had previously been treated with antimalarials. A bone marrow examination revealed amastigotes of Leishmania Donovani. There was no history of travel outside Maharashtra and in the last 42 years he had not been outside Bombay,
Following this chance discovery the patients and residents of the leprosy home, who had prolonged fever or/and splenomegaly were screened. 24 additional subjects were found to have prolonged fever (duration more than 3 months) with or without splenomegaly.
After a detailed history (with particular emphasis on the place of origin, history of travel outside Bombay and the Ac-worth Leprosy Home) and a detailed physical examination, patients were investigated appropriately. The investigations included a complete hemogram, blood chemistries, a bone marrow and a splenic aspiration.
A diagnosis of kala-azar was made by demonstrating amastigote forms of Leishmania donovani in the bone marrow or in the splenic aspirate on Giemsa staining.
Of the 25 subjects investigated, 19 were fully treated cases of lepromatous leprosy still residing in Ac-worth Leprosy Home for various reasons, the rest were residents or their relatives living and working on the campus. All had prolonged fever and/or splenomegaly, 19(14 inmates, 5 residents) showed cytopenias in the hemogram and were subjected to a bone marrow and splenic aspirate. Of these, 7 patients (6 inmates, 1 resident) showed LD bodies in their BM or splenic aspirate. All of them were from Maharashtra and none had ever been out of the state, moreover these inmates had all been confined to the Leprosy home for a period of 12 to 42 years [Table - 1].
Leishmania donovani is not known to be endemic to the state of Maharashtra. The nearest suspected but unproven endemic area is Goa.
Most cases diagnosed here have been residents of or have a history of travel to a known endemic area in the North Eastern part of the country. However, isolated cases from the city of Bombay have been reported.
In our series, all 7 patients (6 inmates, 1 resident) had no history of travel outside Maharashtra. In fact, all had been in the Ac-worth Leprosy Home (ALH) for many years (12-42). This is longer than the known incubation period of kala-azar, which is between 10 days to 2 years. Thus none of the patients could have contacted the disease anywhere except in Bombay and that too in the ALK. The peculiar feature of this report is that a similar series has been reported by Bhende et al in 1949. From April 1948 to April 1949 autopsies were carried out on 22 patients from the Ac-worth Leprosy Home and 11 proved to have kala-azar on liver / splenic sections. Subsequently, in April 1949, the inmates were screened for the presence of splenomegaly, and a Napier's Aldehyde test for detecting raised globulins. Out of the 25 patients with a positive aldehyde test, 2 were proved to have kala-azar. Out of the 6 with splenomegaly, 3 had the disease. Thus, 16 cases in all, were documented from the ALH, 13 of whom had never been to an endemic area.
In view of this "rediscovery", an effort was made by the Bombay Municipal Corporation to isolate the only known vector (Phlebotomes spp) in the extensive 10 acre campus of ALK Unfortunately, amongst the various species of insects isolated, the sand fly could not be isolated. However, Bhende et al in 1949 were able to trap at least 32 sand-flies from the ALK L. Donovani were demonstrated in 4 female phlebotomus. Interestingly P. Argentipes were also caught in a house in Marine Lines and the municipal cowsheds in Parel, Dadar and Byculla in 1924-271. Our failure to isolate them is probably due to their actual scarcity in the dry months (April, May, June).
Whether there is a correlation between leprosy and kala-azar is unknown. But the decreased resistance due to leprosy could not have led to kala-azar alone as demonstrated in an experiment in which infected sand-flies were fed on lepers in good health but none of them developed kala-azar,,,,,. Also in our series, one of the patient was a healthy employee of the hospital. Perhaps any condition that compromises immunity, could predispose to kala-azar.
In summary, kala-azar should not be considered as a disease that is necessarily imported into Bombay. It should be considered in the differential diagnosis of all prolonged fevers, especially those associated with splenomegaly and/or leucopenia, even if there is no history of travel to the known endemic regions of the country.
We wish to thank the Dean, Seth GS Medical College & King Edward Memorial Hospital and Dr. GH Tilve, Prof. & Head of the Department of Hematology for permitting to publish this manuscript.
| :: References|| |
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|2.||WHO (1984) Tech. Report Serial No. 701. |
|3.||Bhende YM, Purandare NK, Banker DD. Kala-azar an endemic focus in Bombay. Indian Physician, October 1949, pp 298-303. |
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[Table - 1]
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