a comparative evaluation of three methods for diagnosis of
TRANSCRIPT
A Comparative Evaluation of Three Methods for Diagnosis of VisceralA Comparative Evaluation of Three Methods for Diagnosis of VisceralLeishmaniasisLeishmaniasis in Serbiain Serbia
ZoricaZorica DakićDakić11, M. Pelemiš, M. Pelemiš2,32,3, G. Stevanović, G. Stevanović2,32,3, L. Lavadinović, L. Lavadinović2,32,3,, J. PolugaJ. Poluga2,32,3, B. Milošević, B. Milošević2,32,3,, N. IndjićN. Indjić44,,O. DulovićO. Dulović2,32,3, I. Ofori, I. Ofori--BelićBelić11,, M. PavlovićM. Pavlović2, 32, 3
11Parasitological LaboratoryParasitological Laboratory, Service of Microbiology, Service of Microbiology, Clinical Center of Serbia, Belgrade, Serbia, Clinical Center of Serbia, Belgrade, Serbia22Faculty of Medicine,Faculty of Medicine, University of Belgrade,University of Belgrade, Serbia;Serbia; 33Clinic of Infectious and Tropical Diseases,Clinic of Infectious and Tropical Diseases,CCS, Belgrade, SerbiaCCS, Belgrade, Serbia44Center of Preventive Medical Care, Belgrade, SerbiaCenter of Preventive Medical Care, Belgrade, Serbia
A Comparative Evaluation of Three Methods for Diagnosis of VisceralA Comparative Evaluation of Three Methods for Diagnosis of VisceralLeishmaniasisLeishmaniasis in Serbiain Serbia
ZoricaZorica DakićDakić11, M. Pelemiš, M. Pelemiš2,32,3, G. Stevanović, G. Stevanović2,32,3, L. Lavadinović, L. Lavadinović2,32,3,, J. PolugaJ. Poluga2,32,3, B. Milošević, B. Milošević2,32,3,, N. IndjićN. Indjić44,,O. DulovićO. Dulović2,32,3, I. Ofori, I. Ofori--BelićBelić11,, M. PavlovićM. Pavlović2, 32, 3
11Parasitological LaboratoryParasitological Laboratory, Service of Microbiology, Service of Microbiology, Clinical Center of Serbia, Belgrade, Serbia, Clinical Center of Serbia, Belgrade, Serbia22Faculty of Medicine,Faculty of Medicine, University of Belgrade,University of Belgrade, Serbia;Serbia; 33Clinic of Infectious and Tropical Diseases,Clinic of Infectious and Tropical Diseases,CCS, Belgrade, SerbiaCCS, Belgrade, Serbia44Center of Preventive Medical Care, Belgrade, SerbiaCenter of Preventive Medical Care, Belgrade, Serbia
A Comparative Evaluation of Three Methods for Diagnosis of VisceralA Comparative Evaluation of Three Methods for Diagnosis of VisceralLeishmaniasisLeishmaniasis in Serbiain Serbia
ZoricaZorica DakićDakić11, M. Pelemiš, M. Pelemiš2,32,3, G. Stevanović, G. Stevanović2,32,3, L. Lavadinović, L. Lavadinović2,32,3,, J. PolugaJ. Poluga2,32,3, B. Milošević, B. Milošević2,32,3,, N. IndjićN. Indjić44,,O. DulovićO. Dulović2,32,3, I. Ofori, I. Ofori--BelićBelić11,, M. PavlovićM. Pavlović2, 32, 3
11Parasitological LaboratoryParasitological Laboratory, Service of Microbiology, Service of Microbiology, Clinical Center of Serbia, Belgrade, Serbia, Clinical Center of Serbia, Belgrade, Serbia22Faculty of Medicine,Faculty of Medicine, University of Belgrade,University of Belgrade, Serbia;Serbia; 33Clinic of Infectious and Tropical Diseases,Clinic of Infectious and Tropical Diseases,CCS, Belgrade, SerbiaCCS, Belgrade, Serbia44Center of Preventive Medical Care, Belgrade, SerbiaCenter of Preventive Medical Care, Belgrade, Serbia
Clinical Center of SerbiaClinical Center of Serbia
A Comparative Evaluation of Three Methods for Diagnosis of VisceralA Comparative Evaluation of Three Methods for Diagnosis of VisceralLeishmaniasisLeishmaniasis in Serbiain Serbia
ZoricaZorica DakićDakić11, M. Pelemiš, M. Pelemiš2,32,3, G. Stevanović, G. Stevanović2,32,3, L. Lavadinović, L. Lavadinović2,32,3,, J. PolugaJ. Poluga2,32,3, B. Milošević, B. Milošević2,32,3,, N. IndjićN. Indjić44,,O. DulovićO. Dulović2,32,3, I. Ofori, I. Ofori--BelićBelić11,, M. PavlovićM. Pavlović2, 32, 3
11Parasitological LaboratoryParasitological Laboratory, Service of Microbiology, Service of Microbiology, Clinical Center of Serbia, Belgrade, Serbia, Clinical Center of Serbia, Belgrade, Serbia22Faculty of Medicine,Faculty of Medicine, University of Belgrade,University of Belgrade, Serbia;Serbia; 33Clinic of Infectious and Tropical Diseases,Clinic of Infectious and Tropical Diseases,CCS, Belgrade, SerbiaCCS, Belgrade, Serbia44Center of Preventive Medical Care, Belgrade, SerbiaCenter of Preventive Medical Care, Belgrade, Serbia
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
IntroductionIntroduction In former Yugoslavia, visceral leishmaniasis was endemic in Macedonia, southern Serbia, Montenegro coast, south Herzegovina and Dalmatia. From 1945-1955, three epidemic waves of VL were recorded in Serbia. In subsequent three years, 17 cases were reported, the result of eradication of malaria vectors. Rareautochthonous cases were noticed in 1968 and 1969 in Nis. According to epidemiological data, 39 VL cases were reported in Serbia and Montenegro from 1991 to 2000, withonly one being imported. Today, the predominant VL risk in Serbian citizens is the stay at the Montenegrian sea-coast, where as many as 10 cases have been diagnosedeach year in Bar. A retrospective diagnostic study of VL was carried out from December 2004 to August 2011 and included all patients with suspected VL referred to theParasitological Laboratory, Cinical Center of Serbia, Belgrade. This study compared efficiency of three methods for the diagnosis of VL.
PatientsPatients andand methodsmethods All patients with suspected VL (n=44) were examined by Giemsa-stained bone marrow smears, by the rapid dipstick rK39 test (DiaSys Europe,England) and indirect hemagglutination assay (Siemens, former Behring Diagnostics, Germany). Positive IHA result was defined as titer >1:64. Patients with suspected VL,were defined as patients with a history of fever of ≥14 days with either clinical splenomegaly or wasting syndrome. Clinical suspicion was supported if the patient was from thean endemic area or had travelled to one this area in the recent past. Diagnosis of VL was confirmed on the demonstration of Leishmania amastigotes in Giemsa-stained BMsmears. If the initial BM smear was negative but the clinical index of suspicion high, parasitological investigation was repeated, or the diagnosis based on the clinicalpresentation and positive serology. The control group included 62 patients with other diagnoses (imported malaria and other infectious and non-infectious diseases), who weretested by IHA and strip-test, without BM aspiration.
ResultsResults VL was diagnosed in 14 patients (8 male and 6 female; age, 11 to 69 years, mean 40). Eleven of them (79%) were treated at the Clinic of Infectious and TropicalDiseases, Belgrade. The infection was contracted in Montenegro (n=8), Herzegovina (n=4), southern Serbia and Portugal (n=1, each). The initial examination of BM smearswas successful in 85.7% patients. At the first examination, two patients had negative BM smears. In only one, parasitological investigation was repeated and VL wasconfirmed. In another patient, diagnosis was based on clinical picture, positive serology and therapeutic effect. Both the strip-test and IHA performed with a sensitivity of92.9%, specificity 96.7% and a positive predictive value of 92.9%. The density of Leishmania amastigotes and antibody titer by IHA were not always in correlation with eachother or with the clinical condition. One patient had positive both the strip-test and IHA (1:256), while parasitological investigation was negative; further examination confirmedliver and spleen multi-focal micro-abscesses. All patients in control group tested negative with both the strip-test and IHA.
PatientPatientNoNo
AgeAge SexSex Origin ofOrigin ofinfectionsinfections
IncubationIncubationperiodperiod
Clinical presentationClinical presentation PreexistentPreexistentdisesesdiseses
IHAIHAtitertiter
StripStrip--testtestresultresult
Dg by BMDg by BMsmearssmears
PatientPatientNoNo
AgeAge SexSex Origin ofOrigin ofinfectionsinfections
IncubationIncubationperiodperiod
Clinical presentationClinical presentation PreexistentPreexistentdisesesdiseses
IHAIHAtitertiter
StripStrip--testtestresultresult
Dg by BMDg by BMsmearssmears
11 2424 mm south Serbiasouth Serbia 18 mo18 mo Fever with sweating, weight loss, pancytopenia,Fever with sweating, weight loss, pancytopenia,hepatosplenomegalyhepatosplenomegaly
nono 1:10241:1024 ++ positive 1xpositive 1xnumerous amastigotesnumerous amastigotes
11 2424 mm south Serbiasouth Serbia 18 mo18 mo Fever with sweating, weight loss, pancytopenia,Fever with sweating, weight loss, pancytopenia,hepatosplenomegalyhepatosplenomegaly
nono 1:10241:1024 ++ positive 1xpositive 1xnumerous amastigotesnumerous amastigotes
22 6868 ff MontenegroMontenegroseasea--costcost
3 mo3 mo Fever, pancytopenia, hepatosplenomegalyFever, pancytopenia, hepatosplenomegaly SarcoidosisSarcoidosis 1:1:256256 ++ positive 1xpositive 1xmoderate amastigotesmoderate amastigotes
MontenegroMontenegroseasea--costcost
positive 1xpositive 1xmoderate amastigotesmoderate amastigotes
33 2727 mm HerzegovinaHerzegovina unknown,unknown,residentresident
Fever, heavy sweating, bicytopenia, hepatosplenomegalyFever, heavy sweating, bicytopenia, hepatosplenomegaly nono 1:10241:1024 ++ positive 1xpositive 1xnumerous amastigotesnumerous amastigotes
44 2828 ff MontenegroMontenegroseasea--costcost
7 mo7 mo Fever, weight loss, splenomegalyFever, weight loss, splenomegaly Ulcerative colitisUlcerative colitis 1:11:12828 ++ positive 2xpositive 2xrare amastigotesrare amastigotes
44 2828 ff MontenegroMontenegroseasea--costcost
7 mo7 mo Fever, weight loss, splenomegalyFever, weight loss, splenomegaly Ulcerative colitisUlcerative colitis 1:11:12828 ++ positive 2xpositive 2xrare amastigotesrare amastigotes
55 6868 ff HerzegovinaHerzegovina unknown,unknown,residentresident
Fever, pancytopenia, hepatosplenomegalyFever, pancytopenia, hepatosplenomegaly Diabetes mellitus,Diabetes mellitus,AnemiaAnemia
1:1:20482048 ++ negative 1xnegative 1xex iuvantibusex iuvantibusnegative 1xnegative 1xex iuvantibusex iuvantibus
66 6363 ff MontenegroMontenegroseasea--costcost
12 mo12 mo Fever, fatigue, cough, weight loss, muscularFever, fatigue, cough, weight loss, muscularpain,hepatosplenomegalypain,hepatosplenomegaly
nono 1:11:163846384 ++ positive 1xpositive 1xnumerous amastigotesnumerous amastigotes
77 4444 mm MontenegroMontenegroseasea--costcost
unknown,unknown,residentresident
Trombocytopenia, skin rashes, hepatosplenomegalyTrombocytopenia, skin rashes, hepatosplenomegaly nono 1:11:163846384 ++ positive 1xpositive 1xnumerous amastigotesnumerous amastigotes
77 4444 mm MontenegroMontenegroseasea--costcost
unknown,unknown,residentresident
Trombocytopenia, skin rashes, hepatosplenomegalyTrombocytopenia, skin rashes, hepatosplenomegaly nono 1:11:163846384 ++ positive 1xpositive 1xnumerous amastigotesnumerous amastigotes
88 3333 ff MontenegroMontenegroseasea--costcost
unknown,unknown,frequentlyfrequentlytravelingtraveling
Fever, pancytopenia, moderate hepatosplenomegalyFever, pancytopenia, moderate hepatosplenomegaly ChronicChronic mmeningoeningo--encephalitisencephalitis
1:1:20482048 ++ positive 1xpositive 1xNumerousNumerous amastigotesamastigotes
MontenegroMontenegroseasea--costcost
unknown,unknown,frequentlyfrequentlytravelingtraveling
ChronicChronic mmeningoeningo--encephalitisencephalitis
positive 1xpositive 1xNumerousNumerous amastigotesamastigotes
99 2222 mm HerzegovinaHerzegovina unknown,unknown,residentresident
Fever, nocturnal sweating, cough, fatigue, weight loss,Fever, nocturnal sweating, cough, fatigue, weight loss,pancytopenia, hepatosplenomegalypancytopenia, hepatosplenomegaly
nono 1:1:3232±±negativenegative
++ positive 2xpositive 2xrare amastigotesrare amastigotes
1010 6969 mm MontenegroMontenegroseasea--costcost
unknown,unknown,frequentlyfrequentlytravelingtraveling
Fever, headaches,Fever, headaches, bicytopenia,bicytopenia, cough, nocturnalcough, nocturnalsweating, fatigue,sweating, fatigue, muscular pain, artralgia,muscular pain, artralgia,hepatosplenomegalyhepatosplenomegaly
CChronic renalhronic renal failure,failure,DMDM
1:1:65366536 ++ positive 2xpositive 2xrare amastigotesrare amastigotes
unknown,unknown,frequentlyfrequentlytravelingtraveling
Fever, headaches,Fever, headaches, bicytopenia,bicytopenia, cough, nocturnalcough, nocturnalsweating, fatigue,sweating, fatigue, muscular pain, artralgia,muscular pain, artralgia,hepatosplenomegalyhepatosplenomegaly
1111 3434 mm MontenegroMontenegroseasea--costcost
unknown,unknown,residentresident
Fever, sweating, weight loss, pancytopenia,Fever, sweating, weight loss, pancytopenia,hepatosplenomegalyhepatosplenomegaly
nono 1:40961:4096 ++ positive 2xpositive 2xrare amastigotesrare amastigotes
1212 4444 mm MontenegroMontenegroseasea--costcost
unknown,unknown,frequentlyfrequentlytravelingtraveling
Trombocytopenia, skin rashes, hepatomegalyTrombocytopenia, skin rashes, hepatomegaly nono 1:1:256256 ++ positive 1xpositive 1xnumerous amastigotesnumerous amastigotes
unknown,unknown,frequentlyfrequentlytravelingtraveling
1313 1111 mm HerzegovinaHerzegovina unknown,unknown,residentresident
Fever, sweating, weight loss, pancytopenia,Fever, sweating, weight loss, pancytopenia,hepatosplenomegalyhepatosplenomegaly
nono 1:1:6464 ++ positive 1xpositive 1xmoderate amastigotesmoderate amastigotes
1414 1919 ff HerzegovinaHerzegovina 8 mo8 mo Fever,Fever, pancytopeniapancytopenia,, hepatosplenomegaly,hepatosplenomegaly,lymphadenopathylymphadenopathy
nono 1:1:10241024 ++ positive 2xpositive 2xrarerare amastigotesamastigotes
ConclusionConclusionss The diagnosis of VL would have been missed in these patients if diagnosis had been solely on one diagnostic method. Inadequate sensitivity of the initial BMsmears and rare false-negative reactions of the strip-test and IHA requires introduction of molecular diagnosis.