Shekhar Koirala

Treatment of visceral leishmaniasis in south-eastern Nepal: decreasing efficacy of sodium stibogluconate and need for a policy to limit further decline

Sodium stibogluconate (SSG) is the first-line therapy for visceral leishmaniasis (VL) in south-eastern Nepal. Recent studies from the neighbouring state of Bihar, India, have shown a dramatic fall in cure rates with treatment failure occurring in up to 65% of VL patients treated with SSG. A prospective study was conducted at a tertiary-level hospital located in south-eastern Nepal from July 1999 to January 2001. Parasitologically proven kala-azar patients with no previous history of treatment for VL were treated with SSG 20 mg/kg/d for 30 d which was extended to 40 d in those with persistent positive parasitology. Of the 110 patients who completed SSG therapy and were assessed at 1 and 6 months, definite cure was achieved in 99 patients (90%) and SSG failure occurred in 11 patients (10%). Except for the presence of hepatomegaly and a lower platelet count there was no clinical or laboratory baseline characteristic associated with treatment failure. A significantly lower cure rate (76%, P = 0.03) was observed in patients from the district of Saptari, which borders the antimony-resistant VL areas of Bihar. The efficacy of SSG as a first-line treatment for VL in south-eastern Nepal was still satisfactory, except for the patients living closer to the antimony-resistant VL areas of India. These findings indicate that the spread of resistance to antimonials is already taking place in Nepal and that a policy to control further spread should be urgently implemented.

Prospective evaluation and comparison of the direct agglutination test and an rK39‐antigen‐based dipstick test for the diagnosis of suspected kala‐azar in Nepal

The diagnosis of visceral leishmaniasis (kala‐azar) remains difficult in rural endemic areas and practical and reliable tests are badly needed. Two serological tests, the Direct Agglutination Test (DAT) and an rK39‐antigen‐based dipstick test, were compared to parasitological diagnosis in a group of 184 patients presenting at a tertiary care centre in south‐eastern Nepal with a history of fever ≥14 days and splenomegaly; 139 patients had a parasitologically proven kala‐azar and 45 patients had a negative parasitological work‐up. The rK39 dipstick showed a sensitivity of 97% and a specificity of 71%. The DAT was up to 99% sensitive with a low cut‐off titre (1:400) but its specificity did not exceed 82% even with a high cut‐off titre (1:51 200). Both tests could be used for screening suspect patients in endemic areas. However, their use as confirmatory tests should be restricted to situations where the proportion of kala‐azar among clinical suspect patients is high. The rK39 dipstick is cheaper and easier to use than the DAT and could be used widely provided that both its performance and production remain stable.

Visceral leishmaniasis in southeastern Nepal: A cross-sectional survey on Leishmania donovani infection and its risk factors

Objective  To document the frequency of Leishmania donovani infection at community level in a highly endemic region in southeastern Nepal, and to assess socioeconomic and environmental risk factors.

A clinico-epidemiological study of snake bite in Nepal.

Envenoming from snake bite is an important medical condition, frequently encountered at the emergency department of BPKIHS hospital (Dharan, Nepal). This is a retrospective study of 52 cases of suspected snake bite who presented at the department from August 1993 to November 1994. Analysis of the data showed that snake bite was more frequent between the ages of 11 to 20 years (36.7%) and 2.5 times more common in males. Fifty-seven per cent of the bites occurred between 1600 h and midnight with highest incidence (51%) occurring during the monsoon (August–October). Twenty per cent of the patients were able to identify the snake species as venomous and 90% of them presented to the hospital within 3 h of being bitten. Sixty per cent of the bites were in the lower limb. Neurotoxicity due to envenoming was recorded in nine patients (17%). No case of coagulopathy was recorded. The overall case fatality was 3.8% but mortality amongst those exhibiting signs of neurotoxicity was 22%.

Field validity, reproducibility and feasibility of diagnostic tests for visceral leishmaniasis in rural Nepal

Objectives  To assess the field accuracy, reproducibility and feasibility of the formol gel test (FGT), the urine latex agglutination test (KAtex) and a rK39 antigen‐based dipstick for the diagnosis of visceral leishmaniasis (VL) in rural Nepal.

Sodium stibogluconate cardiotoxicity and safety of generics

Between April 9 and May 5 2000, an outbreak of fatal cardiotoxicity occurred in Nepal amongst visceral leishmaniasis patients treated with a recently introduced batch of generic sodium stibogluconate (SSG) from GL Pharmaceuticals, Calcutta, India. Eight (36%) of 23 patients treated with this batch died, and in 5 (23%) death was attributed to the cardiotoxicity of the drug. This contrasts with the low total death rate (3.2%) and death rate due to cardiotoxicity (0.8%) observed among 252 patients treated between August 1999 and December 2001 with generic SSG from Albert David Ltd, Calcutta, India. These data show that every batch of generic SSG should be subject to rigorous quality control prior to use.

Snakebite-reappraisal of the situation in Eastern Nepal

Four thousand and seventy eight cases of snakebite, occurring between January and December 2000, were analysed for clinical and epidemiological features. Cases of about 379 had features of envenoming and 81 died. All the victims with systemic envenoming had neurotoxicity. No case with coagulopathy was recorded. Snakebite was more frequent between the ages of 10 and 40 years (76%) and in males (73%). The majority (80%) of the snakebites were observed during the monsoon. Seventy percent of the bites with clinical features of envenoming occurred between 1400 and 2200 h. Five thousand eight hundred and fifty nine vials of polyvalent antisnake venom were used. Case fatality rate varied in the ten centres surveyed. It was as low as 3% in some to as high as 58% in others. Overall death rate among all snakebite cases was 2%.

Post-kala-azar dermal leishmaniasis in Nepal.

Abstract

Epidemiological study of kala-azar by direct agglutination test in two rural communities of eastern Nepal.

We conducted a sero‐epidemiological study of kala‐azar in two endemic communities (Kasaini and Gidhaniya) situated in the Terai (plain) of eastern Nepal. Direct agglutination test (DAT) was used as a serological test for screening. Capillary blood samples were collected by filter paper method from 601 (96%) people of a total population of 628 in Kasaini and from 482 (94%) people of 515 in Gidhaniya. Positive DAT titres (1:2000) were found in 66 (6.09%) of 1083 sera tested. The male–female sero‐prevalence ratio was 1.44:1 and the age group of 15 years and above was most affected. Among the bone marrow aspirates collected from 66 DAT seropositive cases, only 19 were positive for Leishmania donovani (LD bodies). Of the 47 DAT seropositive but LD bodies’ negative cases, three were clinically active cases of kala‐azar. Another nine developed clinical symptoms of kala‐azar during 6 months follow‐up and 23 were cases that had received prior treatment for kala‐azar (within 1 year). The results of this study show the potential of the DAT on filter paper as a screening test for the surveillance of kala‐azar at a community level.

A clinico-epidemiological study of organophosphorus poisoning at a rural-based teaching hospital in eastern Nepal

Thirty-seven patients with severe organophosphorus poisoning (OPP) presented to the emergency ward of BP Koirala Institute of Health Sciences between January 1995 and December 1996. The mean age of patients was 26.9 years. There were 17 (46%) males and 20 (54%) females, with male: female ratio being 1:1.2. Twenty-three (62%) patients were unmarried with 16 (46%) of them students. The most common reason for poisoning was suicide − 32 patients (86.5%). The most commonly involved compound was Metacid (methyl-parathion) − 23 (62%) patients. Ninety per cent of the patients presented within 2 h of ingestion. All patients were managed with intravenous atropine. Pralidoxime was given to patients with nicotinic symptoms and mechanical ventilation initiated in patients with respiratory distress. The mean dose of atropine used in the first 24 h and during the hospital stay was 30.6 mg and 136.7 mg, respectively. The mean duration of treatment was 5.5 days (range 2–20 days). Two patients developed intermediate syndrome and the overall mortality among hospitalized patients was 8%.