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Clinical manifestations and diagnosis of visceral leishmaniasis

Caryn Bern, MD, MPH
Section Editor
Peter F Weller, MD, FACP
Deputy Editor
Elinor L Baron, MD, DTMH


Visceral leishmaniasis (VL), also known as kala-azar, black fever, and Dumdum fever, is primarily caused by Leishmania donovani and L. infantum (synonym L. chagasi) (table 1). Rarely, visceral disease has been reported in patients infected with leishmanial species usually associated with cutaneous disease, in particular, L. mexicana and L. tropica [1-4]. The major clinical manifestations caused by L. donovani and L. infantum are not generally distinguishable, and specialized techniques are needed to identify the species. However, treatment decisions for VL usually do not require species identification since they are based on disease severity, geographic origin, and the presence of HIV and other coinfections.

Issues related to clinical manifestations and diagnosis of visceral leishmaniasis will be reviewed here. Issues related to treatment of VL are discussed separately. (See "Treatment of visceral leishmaniasis".)


Leishmania invade and replicate within host macrophages, evading innate and cell-mediated immune responses. Infection generally appears to persist after clinical cure of the primary infection [5,6]. Evasion and persistence are achieved through a combination of strategies including neutralization of complement components, preventing release of macrophage superoxide and nitric oxide, and suppressing induction of antigen-specific CD4+ T helper lymphocytes [6,7]. Spontaneous recovery is rare, although some relatively mild, self-limited cases of visceral leishmaniasis have been reported in a cohort of Brazilian children [8].


Asymptomatic infection — Many leishmaniasis infections are asymptomatic, reflecting the ability of the host immune system to control the parasite [9,10]. The ratio of asymptomatic infection to clinically manifest disease varies widely, from >30:1 in Europe to 6:1 in Brazilian children and 4:1 in Bangladesh. This may reflect differences in parasite virulence, human genetic predisposition, nutritional status, and other factors [10-17].

Subclinical infections can be detected early in their course with serologic testing. The later development of a protective cell-mediated immune response can be detected via leishmanin skin testing (see 'Diagnosis' below). The majority of patients with subclinical infection harbor viable parasites lifelong and can develop reactivation disease if immunosuppression occurs, although there does not appear to be a role for primary prophylaxis [5,18].


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