Noor Ahmad Noor  ( Department of Clinical Medicine, Nishtar Medical College and Hospital, Multan. )
A.W. Qazi  ( Department of Clinical Medicine, Nishtar Medical College and Hospital, Multan. )
M. Saleem  ( Department of Clinical Medicine, Nishtar Medical College and Hospital, Multan. )
M. Masood  ( Department of Clinical Medicine, Nishtar Medical College and Hospital, Multan. )
Zulfiqar Ahmad  ( Department of Clinical Medicine, Nishtar Medical College and Hospital, Multan. )

A case of Visceral leishmaniasis from Multan is presented. The patient was a middle aged male and the history was suggestive of a long incubation period of 24 years. The disease under went spontaneous remission (JPMA 36: 212, 1986).

Kala-azar or visceral leishmaniasis is a disease produced by a protozoal organism leishmania donovani, which was described by Leishman and Donovan in 1903. Initial cases were recorded in Assam and Madras. Visceral Leishmaniasis is a communicable disease, transmitted to healthy human being by infected female sandfly which inturn is infected by feeding on patients or reservoir hosts like rodents, canines and gebrils. Leishmaniasis has world wide distribution and is seen in all continents except Australia. In the Indian Sub-Continkt, distribution of cutaneous leishmaniasis and visceral leishmaniasis have been defined and separated. In the present territories of Pakistan there was no record of visceral leishmaniasis until 1960 when Ahmad et al¹ and Burney et al² reported cases of leishmaniasis from Northern Areas of Pakistan (Baltistan).
No- case of visceral leishmaniasis has been registered so far in Multan and the present case may well be the first to be reported from this part of the country.

A. K., a 55 year old retired army personnel, resident of Multan Cantt, presented with fever of 10 days duration. It was high grade intermittent fever accompanied by regors and chifis and subsided with profuse sweating. The fever was associated with weakness, easy fatigability, pain and aches all over the body and burning sensation in hands and feet. During the World WarIl, he served in Iraq, Syria, Burma and Indonesia. After independence, he served for four years in Baltistan and Kashmir and for the last 24 years he was settled in Multan.
The Patient was clinically anaemic, with a pulse of 125/mm, temperature 102.8 F. Spleen was enlarged by 5 cm below left costal margin and liver by 3 cm below right costal margin.
His ESR was 22 mm in 1st hour; Hb l0.2G/dl, TLC 5000/mm, ³ Polys 52% and lymphocytes 48%. The urine examination showed albumin in traces, 2-3 Pus cells, 1-3 red cell/HPF. Fasting blood sugar was 70mg/dl. Ultrasound of the abdomen showed hepato-Splenomegaly. Bone marrow aspirate revealed normo cellular picture with slight increase in the erythroid cells. Climps of Leishman Donovan bodies were seen in the marrow smear. Formal gel test was positive indicating increase in serum globulins.
The patient remained in hospital for four weeks when spontaneous remission occurred.

Generally the incubation period of the disease is about 3smonths. The onset of the disease may be insidious or abrupt. Fever is the commonest symptom and is accompanied by tachycardia without signs of toxaemia. Diar rhoea and cough are frequent. Spleen is invariably enlarged while hepatomegally is not a constant feature. Pancytopenia is characteristic, hypoalbuminaemia and hypergammaglobulinaemia are often present. Characteristics of the disease are similar throughout the world but there are certain regional variations which justify the classification of kalaazar into three main types, i.e. African Kala-azar, Mediterranean Kala-azar and Indian Kala.azar. The differences are attributed to variation in the strains of leishmania donovani in a given area. Leishmaniasis can occur at any age, but mostly it is a disease of child-hood and adolesence. Once infection occurs life long immunity develops. In a study from Baltistan1, the disease was common in 4-6s years of age, while a few cases between 30-3 5 years were also seen. Fenech³ described a case of kala-azar from Malta in a 67 year old male. Incubation period varies from weeks to years. Longest incubation period of 10 years was reported by Wright⁴. The case under study is residing in Punjab (Multan) for the last 24 years and he contracted this disease probably from Northern Area (Baltistan) or from Burma 24 years ago. Thus this will be the longest incubation period ever described.
In adults unlike children, fever is the most variable symptom. Fenech³ described an adult case in Malta who had no fever. Like childhood kala-azar, in our case, fever was the presenting symptom and the spleen was appreciably enlarged.
Ahmad et al¹ described lymph node enlargement in 52% of cases in Baltistan and anaemia in 50%. In present case lymph nodes were not enlarged, anaemia was present and leukocyte count was normal. Bone marrow examination helps in diagnosing 80-90% of the cases, as it did in our case. Spontaneous remission is noticed in 17% of cases.

1. Ahmed, N., Burney, M.I. and Wazir, Y. A. Preliminary report on the study of Kala-azar in Baltistan (Pakistan). Armed Forces Med. J., 1960; 10: 1
2. Burney, M.l., Wazir, Y. and Lari, F.A. A longitudinal study of visceral leishmaniasis in northern areas of Pakistan. Trop. Doct., 1979; 30:66.
3. Fenech, F.F. Visceral leishmaniasis in the Mediterranean. J. Trop. Med. Hyg., 1976; 79:85.
4. Wright, M.A. Kala-azar of unusual duration associated with agammaglobulinaemia. Br. Med. J., 1218.