Indian J Pediatr 1988; 55 : 1003-1004

Letter to the Editor

Splenic puncture for diagnosis of visceral leishmaniasis

Visceral leishmaniasis is endemic in cer- tain parts of India, Kenya and in different parts of the world. 1 Leishmania donovani (LD) bodies are generally demonstrated for diagnosis of visceral leishmaniasis ei- ther in bone marrow aspiration or in liver biopsy. We have diagnosed two cases on splenic puncture aspirate which is simpler, quicker and much less painful than the conventional methods of demonstration of LD bodies. However, we failed to observe LD bodies in bone marrow aspiration in one of these cases.

Case I : AJ - A 3-year-old-boy was ad- mitted with pallor, low grade irregular fe- ver and progressively increasing lump in the left hypochondrium and anorexia of six months duration. He had severe anemia with bilateral multiple inguinal lymphnodes of 1-2 cm in size and weighed 12 kg. Hepatomegaly of 4 cm and firm sple- nomegaly of 20 cm was observed. His hemoglobin was 4.8 g/dl, total leucocyte count of 3,800/ul with polymorphs 35%, lymphocytes 61%, monocytes 3%, eosino- phils 1% and the red cells had normocytic and normochromic picture, platelet count was 106 ul. The mantoux test was negative while the skiagram of the chest was nor- mal. Amongst the liver function tests se- rum albumin (1.8 g/di) and serum globulin (4.7 g/dl) were abnormal. Aldehyde test was positive. Bone marrow examination done twice was negative for LD bodies. He

was treated with injection of sodium sti- bogluconate (300 mg) on every alternate days for 10 injections. Fever and hepato- splenomegaly regressed while appetite and anemia on the above treatment.

Case 2 : P - A 3-year-old boy was admit- ted with chronic diarrhoea and low to mod- erate grade fever of two and half years alongwith progressive abdominal disten- sion and weakness of two years duration. He had moderate pallor with puffiness of eyes, and weighed 12 kgs. Hepatomegaly of 6 cm and firm splenomegaly of 11 cm was also present. His hemoglobin was 6.4 g/dl, total leucocyte count of 7100/ul with poly- morphs 64%, lymphocytes 30%, monocytes 5% and eosinophils 1%. Peripheral smear showed mild anicytosis, poikilocytosis, normocytic and mild hypochromic picture. Platelet count was 1,70,000/ul. Amongst the liver function tests only serum albumin (2.1 g/dl) and serum globulin (4.4 g/dl) were abnormal. Aldehyde test was positive. Immunofluorescence antibodies test for leishmaniasis was positive in 1 in 80 dilu- tion. First bone marrow was diluted with blood and LD bodies were not seen. How- ever, the second bone marrow aspiration was positive for LD bodies. Splenic punc- ture was also positive for LD bodies. He improved on the same management as given in the previous case.

These two children had classical features of kala-azar like intermittent low grade re-

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1004 THE INDIAN JOURNAL OF PEDIATRICS Vol. 55, No. 6

ver, anorexia, weight loss, pallor and hepa- tosplenomegaly. Serum globulin were grossly elevated with reversal of albumin : globulin ratio. Aldehyde test was positive in both, while immunofluorescent antibodies were positive in case II. LD bodies in bone marrow could not be demonstrated in AJ. LD bodies could be easily demonstrated on splenic puncture aspiration smear in both cases. Splenic puncture is much simpler, quicker, less painful and less traumatic procedure than bone marrow or liver bi- opsy, whereas it is perfectly safe if done when the platelet count is more than 10 x 106/ul. We had punctured the spleen with 21 gauge needle below the costal margin and entered the spleen at an angle of 45- 60 ~ maintaining the suction throughout the procedure. Few drops of blood thus ob-

tained is sufficient for demonstration of LD bodies and it should be possible to cul- ture it in appropriate media. We feel that splenic puncture should be preferred over fiver biopsy or bone marrow as a diagnostic tool for diagnosis of visceral leishmaniasis.

V.P. Choudhry, G.N. Aram, Madhu Choudhry*, Rashid Ghani

Department of Pediatrics and Clinical Pathology*, Indira Gandhi Institute of

Child Health, Kabul, Afghanistan

Reference

1. Anatwani GM, Bryceson ADM. Visceral lei- shmaniasis in Kenyan children. Indian Pediatr 1982; 19 : 819

SIMPLE CLINICAL SIGNS FOR THE DIAGNOSIS OF ACUTE LOWER RESPIRATORY TRACT INFECTION

Acute lower respiratory tract infection (LRI) is one of the commonest causes of death among infants and under-5s in developing countries. It accounts for 20-24% of childhood deaths in India.

The reliability of clinical signs that might be used by village health workers in distin- guishing acute lower respiratory infection (LRI) from upper respiratory infections (URI) in children was evaluated. 142 infants and 108 preschool children with URI, attending hos- pital, were studied. Respiratory rates of over 50/min in infants and over 40/rain in children 12-35 months of age, as well as a history of rapid breathing and the presence of chest re- tractions in both age groups, were found to be sensitive and specific indicators of LRI. In- creased respiratory rates and history of rapid breathing were also sensitive in diagnosis of less severe LRI that did not necessitate admission to the wards, whereas chest retraction was not. All these clinical signs had a low sensitivity in diagnosing LRI in children aged 36 months and over.

Abstracted from : Cherian T et al. Lancet 1988; ii : 125-128