WEC

OM

E W

ECO

ME

ALL

ALL

3 mo: 3 mo: double rise F., wt. double rise F., wt. loss, fatigue, severe pallorloss, fatigue, severe pallor

gross non-tender HSMgross non-tender HSM

pancytopeniapancytopenia

http://aapredbook.aappublications.org/content/images/large/2003/1/071_03.jpeg

A.A. 63y M: 63y M: paronychia: paronychia: ulcerated ulcerated warty, at warty, at base of R. base of R. thumb. thumb. B.B. AsymptomaAsymptomatic 7 crusty, tic 7 crusty, ulcers on ulcers on limbs (1 on L limbs (1 on L ankleankle

Smear: LD Smear: LD bodies. Rx bodies. Rx with with antimoniateantimoniate

Severe Severe disfigurementdisfigurement

Seve

re d

isfigu

rem

ent

Seve

re d

isfigu

rem

ent

Phlebotomus

The VectorThe Vector

BM findingsBM findings

LEISHMANIASISLEISHMANIASIS

At the end of this session you will learnAt the end of this session you will learn Leishmaniasis affects the poorest with Mn, displacement, Leishmaniasis affects the poorest with Mn, displacement,

poor housing, resources, weak immunitypoor housing, resources, weak immunity A A spectrum disease:spectrum disease:• TheThe commonest commonest is ~ is ~ self-healing self-healing skin lesion skin lesion ((75%)75%)

• The worst/The worst/severest is severest is visceral d.visceral d. Kala Azar (Kala Azar (25%)25%) 60% in our60% in our Sub-continent Sub-continenta neglected ID, a neglected ID, should have been controlledshould have been controlled 1 of the important c/of 1 of the important c/of PUOPUO

L. & HIV/TB augments each otherL. & HIV/TB augments each other It is It is curablecurable

Our country is leading to control itOur country is leading to control it

Neglected Tropical Diseases (NTD)Neglected Tropical Diseases (NTD)

Disabling/DisfiguringDisabling/Disfiguring– DALYs vs. mortalityDALYs vs. mortality

StigmaStigma Diseases of PovertyDiseases of Poverty Biblical DiseasesBiblical Diseases Economic tollEconomic toll

– Poverty-promotingPoverty-promoting

• AscariasisAscariasis• TrichuriasisTrichuriasis• HookwormHookworm• SchistosomiasisSchistosomiasis• L. filariasisL. filariasis• OnchocerciasisOnchocerciasis• TrachomaTrachoma• LeprosyLeprosy• Buruli ulcerBuruli ulcer

• Chagas diseaseChagas disease• HATHAT• LeishmaniasisLeishmaniasis• Dengue FeverDengue Fever

WormsWorms

BacteriaBacteria

TissueTissueprotozoaprotozoa

VirusVirus

Prevalence: Prevalence: 12 mln12 mln. . 1.31.3 mln/y mln/y; 30k death; 30k death 350 million at risk350 million at risk

– Cutaneous L (CL)Cutaneous L (CL): : 90% in Afghanistan, Iran, Syria, KSA, 90% in Afghanistan, Iran, Syria, KSA, S S Lanka, Peru, BrazilLanka, Peru, Brazil

– MCLMCL: : 90% in S America90% in S America– Visceral L (VL) Visceral L (VL) (Kala Azar)(Kala Azar)

60% in BD, India, Nepal. 30% in Brazil, Sudan60% in BD, India, Nepal. 30% in Brazil, Sudan

EndemicEndemic in 88 countries (16 western) in 88 countries (16 western) Affects the Affects the rural poorest:rural poorest:

– have little knowledge about it have little knowledge about it – unlikely to seek early Rx., cannot afford Rxunlikely to seek early Rx., cannot afford Rx

Depth of the ProblemDepth of the Problem

1.5 million globally

WORLD DISTRIBUTION OF VLWORLD DISTRIBUTION OF VL

109 districtsof BD, India& Nepal

Bangladesh ScenarioBangladesh Scenario A A re-emerging IDre-emerging ID since 1990; disappeared during since 1990; disappeared during

‘Malaria Eradication Pgm’ ‘Malaria Eradication Pgm’ (1961-70)(1961-70)– poor control of vectorpoor control of vector– lack of access to Rxlack of access to Rx

139 Upazillas: 139 Upazillas: 45 districts45 districts PrevalencePrevalence 45k. 45k. IncidenceIncidence 10k/y10k/y

– 55% in 55% in MymensinghMymensingh– 25% in 25% in Pabna, Tangail, JamalpurPabna, Tangail, JamalpurBD has committed to eliminate kA/2015 (<1/10k popn. at BD has committed to eliminate kA/2015 (<1/10k popn. at

Upazila level). Upazila level). Now it is almost controlled!Now it is almost controlled!

Districts Affected in BangladeshDistricts Affected in Bangladesh

SynonymsSynonyms

Kala-azar, visceral L (VL), black fever, leishmaniasis, Kala-azar, visceral L (VL), black fever, leishmaniasis, Dumdum fever, Assam FDumdum fever, Assam F

Mucocutaneous L, cutaneous L, bay sore, Mucocutaneous L, cutaneous L, bay sore, espundiaespundia, , mucosal L, post-kala-azar dermal L, viscerotropic L, mucosal L, post-kala-azar dermal L, viscerotropic L, forest yaws, Aleppo evilforest yaws, Aleppo evil

Baghdad sore, Biskra button, Chiclero ulcer, Delhi Baghdad sore, Biskra button, Chiclero ulcer, Delhi boil, Oriental sore, Rose of Jericho, Uta boil, Oriental sore, Rose of Jericho, Uta

Only a small fraction infected develop the d.Only a small fraction infected develop the d. A zoonosis; mammalian reservoirsA zoonosis; mammalian reservoirs ETIOLOGY: ETIOLOGY: Leishmania:Leishmania: obligate intracellular obligate intracellular

– One sp. can cause different syn.One sp. can cause different syn.– One syn. can be c/by different spp.One syn. can be c/by different spp.

Vector: Vector: femalefemale sand-fly. 2-3mm sand-fly. 2-3mm Phlebotomus & LutzomyiaPhlebotomus & Lutzomyia

ReservoirReservoir:: Indian KA: humanIndian KA: human rodents in Africa, foxes in Brazil, C. Asiarodents in Africa, foxes in Brazil, C. Asia dogs in the Mediterranean, Chinadogs in the Mediterranean, China

EPIDEMIOLOGYEPIDEMIOLOGY

Mediterranean & ChinaMediterranean & China

VectorVector lives in cracks of mud-houses, heaps of cow dung, in lives in cracks of mud-houses, heaps of cow dung, in rat burrows, bushesrat burrows, bushes

Feed mainly on cattle. Feed mainly on cattle. We are 2nd choice! More We are 2nd choice! More exposure:exposure:– extracting timber, mining, building damsextracting timber, mining, building dams– irrigation, road making in forestsirrigation, road making in forests

Transmission: Transmission: CommonCommon:: bitebite by by vector. Uncommon: vector. Uncommon:

– congenital, BT, needle sharingcongenital, BT, needle sharing– rarely: inoculation from culturerarely: inoculation from culture

IP: IP: Cut. L: ~several weeksCut. L: ~several weeks Visceral L: 6 w-6 mo (10 d-10 y)Visceral L: 6 w-6 mo (10 d-10 y)

3 syndromes of Leishmaniasis3 syndromes of Leishmaniasis Cutaneous LCutaneous L

– Old World: Old World: L tropica, L major,L tropica, L major, L aethiopica, L donovaniL aethiopica, L donovani , , L infantum,L infantum, L mexicanaL mexicana

– New World: New World: L amazonensis, L braziliensis, L panamensis, L guyanensis,L amazonensis, L braziliensis, L panamensis, L guyanensis, L chagasiL chagasi

Mucocutaneous LMucocutaneous L by by L braziliensis, L panamensis, L guyamenis, L L braziliensis, L panamensis, L guyamenis, L amazonensisamazonensis

VLVL by by L donovani,L donovani, L infantum, L chagasi,L infantum, L chagasi, L tropica,L tropica, L amazonensisL amazonensis

Post-kala-azar dermal L (PKDL)Post-kala-azar dermal L (PKDL)Old WorldOld World: : L donovani, L infantumL donovani, L infantum

New World: New World: L donovani chagasi:L donovani chagasi: Central &, S America Central &, S America

Life cycleLife cycle

2 forms 2 forms – amastigoteamastigote (no flagella) in host (no flagella) in host– promastigotepromastigote in vector & in vector & mediummedium

Amastigotes in blood meal become flagellate in vector & Amastigotes in blood meal become flagellate in vector & multiply over 6-9dmultiply over 6-9d

Following bite: flagellates enter RES & change to Following bite: flagellates enter RES & change to amastigote; amastigote; multiply by binary fissionmultiply by binary fission

PathogenesisPathogenesis

RES is invaded: RES is invaded: mainly spleen, liver, BMmainly spleen, liver, BM Monocytes spread parasitesMonocytes spread parasites Outcome: Outcome: virulence ~immunityvirulence ~immunity Marked Marked suppression of CMI. suppression of CMI. Overproduction of IgOverproduction of Ig

Spleen:Spleen: Bag of parasites! Bag of parasites! – enlarged, soft, fragile, dilated BVenlarged, soft, fragile, dilated BV– Billroth cells Billroth cells are over-parasitized; are over-parasitized; No fibrosisNo fibrosis

Liver:Liver: Kupffer cells Kupffer cells over-parasitizedover-parasitizedBM: BM: parasitized monocytes replace normal tissueparasitized monocytes replace normal tissue

Kupffer cells (stellate Kupffer cells (stellate macrophagesmacrophages & & KupKup

ffer-Browicz cells)ffer-Browicz cells)

Cutaneous L.Cutaneous L. Bite site Bite site macule/nodule macule/nodule shallow ulcer,shallow ulcer, raised borders: raised borders:

commonly face, limbscommonly face, limbs May have satellite lesions & LAPMay have satellite lesions & LAP Self-healingSelf-healing in weeks-years with in weeks-years with atrophic (cigarette atrophic (cigarette

paper) scar.paper) scar. But can cause serious disfigurement But can cause serious disfigurement

On recovery: On recovery: immunityimmunity to infecting sp. to infecting sp.

CL. MANIFESTATIONSCL. MANIFESTATIONS

Typical C. LTypical C. L

Satellite lesionsSatellite lesionsCrater lesion of CLCrater lesion of CL

Diffuse CLDiffuse CL

Disseminate in skinDisseminate in skin Resistant to RxResistant to Rx DD from leprosyDD from leprosy

MCL (espundia)MCL (espundia)

Rare in children Rare in children Invasive Invasive disfiguringdisfiguring d.: destroys mucosa d.: destroys mucosa 90% in S America90% in S America Commonly around nose. Heals with Commonly around nose. Heals with scarsscars Significant mortality/morbiditySignificant mortality/morbidity Mucosa may perforateMucosa may perforate

MCL: mucocut. LMCL: mucocut. L

MCL: PerforationMCL: Perforation

CLCL

MCLMCL

Visceral L. (kala-azar)Visceral L. (kala-azar)Severest & Progressive. Severest & Progressive. Death Death in 2yin 2y Malnourished people most susceptibleMalnourished people most susceptible India-Bangladesh-Nepal: 300k/y. India-Bangladesh-Nepal: 300k/y. 200 million at 200 million at

riskrisk– 52 districts 52 districts of India of India – 45 ,, 45 ,, of Bangladeshof Bangladesh– 12 ,, 12 ,, of Nepalof Nepal

Control program in BD in 2007: new cases dropped Control program in BD in 2007: new cases dropped from 10k/y to 1463 in 2012, MR now close from 10k/y to 1463 in 2012, MR now close

to zero. BD is on track to eliminate VL/2015to zero. BD is on track to eliminate VL/2015

Typical PresentationTypical Presentation

Chr. F: double rise, good appetite, HSM, progressive pallor, Chr. F: double rise, good appetite, HSM, progressive pallor, weakness, wt. loss, darkening skinweakness, wt. loss, darkening skin

Panacytopenia, LAPPanacytopenia, LAP albumin, albumin, -Ig-Ig

2y infx. common2y infx. commonReactivation is common in HIV,Reactivation is common in HIV,TB, or immunodeficienciesTB, or immunodeficiencies

Jaundice Jaundice (10%)(10%) is rare: is rare: Bad prognosisBad prognosis Immune complexes: mild GNImmune complexes: mild GN Rh. Factor may be positiveRh. Factor may be positive Fulminant form Fulminant form mainly in children: pancytopenia & ALF (ac. mainly in children: pancytopenia & ALF (ac.

liver failureliver failure))

Skin lesions in VLSkin lesions in VL dark, dry, thin, scalydark, dry, thin, scaly diffuse wartydiffuse warty petechiae, bruisespetechiae, bruises hair losshair loss edemaedema

Atypical presentations of KAAtypical presentations of KA PUO/FUO: an important causePUO/FUO: an important cause Pancytopenia without splenomegalyPancytopenia without splenomegaly Immune hemolysisImmune hemolysis Generalized LAP with/-out HSMGeneralized LAP with/-out HSM Massive hepatic necrosisMassive hepatic necrosis Retinal bleedRetinal bleed

Severe Anemia in KASevere Anemia in KA BM replaced by parasitesBM replaced by parasites BM depression, splenic sequestration, hge, hemolysis, 2y inf.BM depression, splenic sequestration, hge, hemolysis, 2y inf.

Clinical case definition for KAClinical case definition for KAResiding/travelling in endemic areasResiding/travelling in endemic areasF. for >2w & any 1:F. for >2w & any 1:Splenomegaly or wt. loss or anemiaSplenomegaly or wt. loss or anemia

And ‘rk39’ test positiveAnd ‘rk39’ test positive

Clinical case definition for PKDLClinical case definition for PKDLResiding/travelling in endemic areasResiding/travelling in endemic areasRx of KA any time in pastRx of KA any time in pastSkin lesion lesions (macular, papular, nodular, or mixed) Skin lesion lesions (macular, papular, nodular, or mixed)

without loss of sensationwithout loss of sensationExclusion of other cause of skin d.Exclusion of other cause of skin d.‘‘rk39’ positive/slit skin smear positive/PCR positiverk39’ positive/slit skin smear positive/PCR positive

DefinitionsDefinitions Primary KA (PKA)Primary KA (PKA)Dx KA with case definition & not RxDx KA with case definition & not Rx

KA treatment failure(KATF)KA treatment failure(KATF)Dx. KA again with case defn. after Rx within last 1y. All efforts should Dx. KA again with case defn. after Rx within last 1y. All efforts should

be made to Dx parasitologically by splenic/BM smear or PCRbe made to Dx parasitologically by splenic/BM smear or PCR

Relapse KARelapse KADx KA with case defn. & Rx in past but not within last 1y. All efforts Dx KA with case defn. & Rx in past but not within last 1y. All efforts

are made to Dx parasitologically by splenic/BM smear or PCRare made to Dx parasitologically by splenic/BM smear or PCR

DxDx

Showing MOShowing MO

CL/MCL:CL/MCL: biopsy, scrapings, FNAC, biopsy, scrapings, FNAC, LN:LN: aspiration/ aspiration/ biopsy, biopsy, tissue tissue punch biopsypunch biopsy

VL: VL: spleen, BM, liver, LN puncturespleen, BM, liver, LN puncture

Blood culture may help (~1 mo): Novy-McNeal-Blood culture may help (~1 mo): Novy-McNeal-Nicolle medium (3N medium). Blood smears from Nicolle medium (3N medium). Blood smears from buffy-buffy-coat in HIVcoat in HIV

Immunological tests:Immunological tests:

Immunological testsImmunological tests

Specific: RDTSpecific: RDT (recombinant Ag.(recombinant Ag. rk39 rk39), DAT (IgM) at ), DAT (IgM) at early stage; ICT: highly sensitiveearly stage; ICT: highly sensitive

NonspecificNonspecific– CIE, CFT, IF Ab test: cross-react with leprosy, Chaga, CIE, CFT, IF Ab test: cross-react with leprosy, Chaga,

malaria, schistosomiasismalaria, schistosomiasis– Detection of hyper-Ig: AT. CT (3 mo)Detection of hyper-Ig: AT. CT (3 mo)

A negative serology does not exclude LA negative serology does not exclude L..

rK39rK39 Rapid dipstick test Rapid dipstick test Based on the Based on the

recombinant k39 recombinant k39 proteinprotein

Test Test Sensitivity %Sensitivity % Specificity %Specificity %CFTCFT 70-8070-80 60-7360-73

DATDAT 91-10091-100 72-10072-100IFATIFAT 55-7055-70 70-8970-89ELISA (CSA)ELISA (CSA) 80-10080-100 50-7050-70ELISA ( rK39)ELISA ( rK39) 100100 9898rK39 rapid strip testrK39 rapid strip test 100100 88-9888-98

Latex agglutination Latex agglutination testtest

68-10068-100 100100

Spleen puncture

Slide preparation

A. intact macrophage full of LDB. B. Amastigotes are freed A. intact macrophage full of LDB. B. Amastigotes are freed from a rupturing macrophagefrom a rupturing macrophage

LeishmaniaLeishmania organisms in PBF in HIV organisms in PBF in HIV

Peripheral Blood PicturePeripheral Blood Picture Severe normocytic-chromic anemiaSevere normocytic-chromic anemia Leukopenic relative lymphocytosisLeukopenic relative lymphocytosis ThrombocytopeniaThrombocytopenia Raised ESRRaised ESR High Ig with reversal of AG ratioHigh Ig with reversal of AG ratio

BM aspirationBM aspiration Commonest method. Sensibility 86%. Safer than splenic Commonest method. Sensibility 86%. Safer than splenic

puncturepuncture

Splenic puncture: Splenic puncture: 98%. 98%. Risk: bleedRisk: bleed If BM is inconclusiveIf BM is inconclusive

DrugsDrugs Liposomal Amphotericin B: IV; Miltefosine: POLiposomal Amphotericin B: IV; Miltefosine: PO

LABLAB is now DoC; single dose works (97%) is now DoC; single dose works (97%) Amphotericin B. Amphotericin B. Na stibogluconate (SSG): IMNa stibogluconate (SSG): IM MiltefosineMiltefosine is newis new PentamidinePentamidine Paromomycin in VL. It is low-costParomomycin in VL. It is low-cost Ketoconazole, ItraconazoleKetoconazole, Itraconazole

The commonest drug for VL was The commonest drug for VL was SSGSSG x 4w; now variably x 4w; now variably resistant in many countriesresistant in many countries

TREATMENTTREATMENTCL CL may heal spontaneously. may heal spontaneously. TreatTreat if if

– disabling/disfiguring ulcers, late healing, MCLdisabling/disfiguring ulcers, late healing, MCL

S. American CL: S. American CL: ketoconazole, itra-, paromomycin, plus ketoconazole, itra-, paromomycin, plus local local heatheat

VLVL Bangladesh: most are still sensitive to SSGBangladesh: most are still sensitive to SSG

DoC: LABDoC: LAB MiltefosineMiltefosine is taken p.o. is taken p.o. Paromomycin Paromomycin has excellent safetyhas excellent safety

Always treat if MCL or VLAlways treat if MCL or VL

VL: Supportive RxVL: Supportive Rx– RestRest– High-calorie dietHigh-calorie diet– BTBT– Rx secondary inf.Rx secondary inf.

Symptoms rapidly improveSymptoms rapidly improve Spleen regresses over monthsSpleen regresses over months

Patients must be counseled about the importance ofPatients must be counseled about the importance ofFU for relapseFU for relapse

Post KA Dermal L (PKDL)(10%)Post KA Dermal L (PKDL)(10%) Follows Follows completecomplete Rx after 1-2y; Rx after 1-2y; may last up to 20ymay last up to 20y

No disability! No disability! Seek Rx for social stigma!Seek Rx for social stigma! SSG x 4 mo is potentially toxic & cumbersomeSSG x 4 mo is potentially toxic & cumbersome MiltefosineMiltefosine x12w is effective (93%) x12w is effective (93%) LAB 2 doses: LAB 2 doses: 5 mg/kg/w x 3w is successful5 mg/kg/w x 3w is successful Consider combinations of LAB & miltefosine, miltefosine & Consider combinations of LAB & miltefosine, miltefosine &

paromomycin, or miltefosine & SSGparomomycin, or miltefosine & SSG

DD of VLDD of VL Malaria, tropical splenomegaly syn.Malaria, tropical splenomegaly syn. EF, Portal HTNEF, Portal HTN Leukemias & lymphomasLeukemias & lymphomas Chr. hemolytic anemiaChr. hemolytic anemia

PKDLPKDL Yaws; Syphilis; LeprosyYaws; Syphilis; Leprosy

CL: CL: traumatic ulcerstraumatic ulcers

MCL: MCL: Leprosy; Sarcoidosis; Midline granuloma, Leprosy; Sarcoidosis; Midline granuloma, Histoplasmosis; Syphilis, tertiary yawsHistoplasmosis; Syphilis, tertiary yaws

PROGNOSISPROGNOSIS CL: CL: may be self-limiting. Excellentmay be self-limiting. Excellent Diffuse CL & MCL: Diffuse CL & MCL: good on Rxgood on Rx

VL: VL: fatal if untreated: mortality 10% in Rxfatal if untreated: mortality 10% in Rx

Causes of death in VLCauses of death in VL 2y infx.: pneumonia; septicemia2y infx.: pneumonia; septicemia DysenteryDysentery TB, HIVTB, HIV Cancrum oris, uncontrolled hgeCancrum oris, uncontrolled hge

KA elimination in SEA is possibleKA elimination in SEA is possible Confined to 3 countriesConfined to 3 countries Humans are the only reservoirHumans are the only reservoir Only 1 vector: control by indoor Only 1 vector: control by indoor residualresidual spray spray

Permethrin treated nets, good housing, screen, Permethrin treated nets, good housing, screen, clothing, repellent, minimum outdoor exposures clothing, repellent, minimum outdoor exposures dusk-dusk-dawndawn

A RDT is availableA RDT is available LAB & Miltefosine are safeLAB & Miltefosine are safe Strong political willStrong political will

Target:Target:To reduce incidence of KA &PKDL to <1/10k popn.:To reduce incidence of KA &PKDL to <1/10k popn.:Early Dx Early Dx & complete Rx: & complete Rx: stops transmissionstops transmissionSurveillance; health educationSurveillance; health educationReducing incidence in endemic communitiesReducing incidence in endemic communitiesReducing CFR (case fatality rates)Reducing CFR (case fatality rates)Rx PKDL to reduce the parasite reservoirRx PKDL to reduce the parasite reservoirPx & Rx of KA-HIV-TB co-inf.Px & Rx of KA-HIV-TB co-inf. Integrated vector managementIntegrated vector management

Integrated vector Mx (IVM)Integrated vector Mx (IVM)Indoor Residual Spray (IRS):Indoor Residual Spray (IRS):

Insecticide Deltamethrin; 6 rounds; 1 round in Insecticide Deltamethrin; 6 rounds; 1 round in

moderate & low endemic areasmoderate & low endemic areas

Piloting was done at Fulbaria in 2011Piloting was done at Fulbaria in 2011

72

IRS AT DHANIKHOLA VILLAGE OF TRISHAL UPAZILLA

Dr. Shah GolamNabi, DPM, KEP, CDC, DGHS with the IRS Team ( Spray man, Team leader & 1st

Line Supervisor) at Dhanikhola Village, Trishal Upazilla.

Integrated Vector Mx (IVM)Integrated Vector Mx (IVM)

LLIN (Long Lasting Insecticidal Net)LLIN (Long Lasting Insecticidal Net) Distribution Distribution

Larvicide Spray in Cow & chicken shadeLarvicide Spray in Cow & chicken shade

Effective disease surveillanceEffective disease surveillance

WHO supported staffs for WHO supported staffs for strengthening Surveillancestrengthening SurveillanceNational ConsultantNational ConsultantSurveillance Medical OfficerSurveillance Medical OfficerData ManagerData Manager Regular collection of Data from Regular collection of Data from

all KA Endemic UHCall KA Endemic UHC Active case search for detection of Active case search for detection of

KA in household levelKA in household level

Social mobilization & Social mobilization & partnerships partnerships

Partnership with- WHO, MSF & icddr,b

MCQMCQ In L. spectrum d. the commonest is Kala AzarIn L. spectrum d. the commonest is Kala AzarKA, is 2nd biggest parasitic killer after malaria KA is spread by infected mosquitoKA is spread by infected mosquito Thrombocytopenia is a common featureThrombocytopenia is a common feature Reservoir in Indian KA is dogReservoir in Indian KA is dog LAB single dose is effectiveLAB single dose is effective

MCQMCQ

DAT is a specific test for KADAT is a specific test for KA ICT is a non-specific test for KAICT is a non-specific test for KA Splenic puncture more sensitive than BMSplenic puncture more sensitive than BM Most VL in Bangladesh is sensitive to SSGMost VL in Bangladesh is sensitive to SSG Severe anemia is common in KASevere anemia is common in KA HIV, TB & VL augments each otherHIV, TB & VL augments each other

Evening at TeknafEvening at Teknaf

Next lecture: Next lecture: RABIESRABIES