Black Rebing (Kala-azar) is a chronic endemic pestilence caused by Leishmania donovani transmitted through sandfly bites. It is mainly characterized by irregular fever, emaciation, progressive splenomegaly, and pancytopenia.

bubble_chart Clinical Manifestations

The onset is slow, with irregular fever that may resolve spontaneously after several weeks, only to recur with irregular fever again (some children may exhibit a biphasic fever pattern). After 3 to 6 months, in addition to fever, the child may experience weight loss, anemia, lack of strength, epistaxis, and gum bleeding. Symptoms such as abdominal pain, abdominal distension and fullness, and gradual splenomegaly develop, with the spleen enlarging to the level of the umbilicus within six months—initially soft but later becoming firm. The liver also enlarges. Enlarged lymph nodes can often be palpated throughout the body. In the advanced stage, approximately 10% of older children may develop a yellowish-brown skin pigmentation.

bubble_chart Auxiliary Examination

1. Pancytopenia, anemia.
2. Globulin water test and globulin formaldehyde test are positive.
3. The blood moistening and tonifying body binding test is positive in the early stages of the disease. Other immunofluorescence tests, enzyme-linked immunosorbent assay, counterimmunoelectrophoresis, and indirect hemagglutination are also helpful for diagnosis.
4. Confirmation relies on bone marrow puncture to search for Leishman-Donovan bodies, with about 85–90% being positive. Leishman-Donovan bodies are also present in the liver, spleen, and lymph nodes.

bubble_chart Diagnosis

Epidemiological history: A history of living in an endemic area during the sandfly activity season (May to September).

﹝Treatment﹞

(1) General Treatment The patient should rest in bed and maintain oral hygiene. Provide a nutritious diet. For severe cases, multiple small blood transfusions may be considered. (2) Etiological Treatment 1. Sodium stibogluconate is the drug of choice. This is a 10% injectable solution. The total dose is 150–180 mg/kg, divided into 6 doses, administered intravenously once daily. For weak or severely ill children, injections may be given twice weekly for a 3-week course. This drug has low toxicity and high efficacy, with a cure rate of 98%. Use with caution in patients with heart or liver disease. For relapses, repeat the same dose for another course, but monitor closely to prevent antimony poisoning. 2. For cases unresponsive or allergic to antimony therapy, or those developing agranulocytosis during treatment, aromatic diamidines may be used. (1) Pentamidine: Due to its highly unstable aqueous solution, prepare a fresh 10% solution immediately before intramuscular injection. The dose is 3–5 mg/kg per day for 15 days, with a total dose of 60 mg/kg. Local reactions such as redness, swelling, induration, and pain may occur, along with headache, vomiting, nausea, palpitations, and hypotension. (2) Diamidine: Dilute with 10% glucose solution to 0.1%–0.2% before intravenous drip or slow injection. The dose is 1–2 mg/(kg·d) once daily, with a total dose of 50 mg/kg. Local reactions like redness, swelling, induration, and pain may occur, along with hypotension, vertigo, vomiting, sweating, and dyspnea. Due to high toxicity, use with caution. 3. Amphotericin B may be used when the above drugs fail. Prepare a 0.01% solution with 5% glucose for slow intravenous drip, administered every other day. For adults, start with 0.1 mg/kg per dose, gradually increasing to a maximum of 1 mg/kg daily. Continue for 3–8 weeks. Due to high toxicity, use cautiously. Reduce the dose for children. (3) Splenectomy Consider splenectomy for patients with hypersplenism, but do not neglect drug therapy.

Conduct comprehensive surveys and treatment in endemic areas to eliminate the source of pestilence. Eradicate sandflies and manage infected animals (such as sick dogs, etc.).

bubble_chart Differentiation

It should be differentiated from cold-damage disease, subcutaneous node disease, malaria, schistosomiasis, and blood diseases presenting with chronic splenomegaly and pancytopenia.