Clinico-epidemiological analysis of Post kala-azar dermal leishmaniasis (PKDL) cases in India over last two decades: a hospital based retrospective study

Abstract

Background: Patients with Post kala-azar dermal leishmaniasis (PKDL) are considered a reservoir of Leishmania donovani. It is imperative to identify and treat them early for control of visceral leishmaniasis (VL), a current priority in the Indian subcontinent. We explored trends in clinico-epidemiological features of PKDL cases over last two decades, for improving management of the disease.

Methods: Clinically suspected cases were diagnosed with rK39 strip test followed by parasitological confirmation by microscopy and/or PCR/qPCR in skin tissue/slit aspirates. Patients were treated with antimonials till 2008 and subsequently with miltefosine.

Results: The study indicated higher incidence of PKDL cases in areas of high endemicity for VL, with 20 % cases reporting no history of VL. Approximately 26 % cases of PKDL were initially misdiagnosed at primary health centers. Duration between onset of PKDL and diagnosis was above 12 months in 80 % cases. Diagnostic sensitivity was 32-36 % with microscopy and 96-100 % with PCR/qPCR. Compliance to treatment was over 85 % with miltefosine while 15 % with antimonials. Relapse rate with miltefosine was up to 13.2 %.

Conclusions: PKDL patients tend to delay reporting and are often misdiagnosed. Confirmatory diagnosis using minimally invasive skin slit aspirate samples would help overcome such issues. There was a paradigm shift in compliance with miltefosine; however, increasing relapse rate indicated the need for newer therapies with oral formulations.

Fig. 1

Distribution of PKDL cases in Bihar and the adjoining states. Map showing the distribution of PKDL cases in the state of Bihar and adjoining states, based on the area of high, moderate and low endemicity for VL, designated as per Sundar et al. [19]. Number shown in the figure is the number of PKDL cases from the district

Fig. 2

Incidence of PKDL in the reported period. Number of cases reported to Safdarjung Hospital, New Delhi, India per five year block duration since 1995

Fig. 3

Diagnosis of PKDL based on minimally invasive sampling technique. The proposed flowchart for the confirmatory diagnosis of PKDL