BEDSIDE CLINICS 9TH EDITION

236 Bedside Clinics in Medicine
6. Skin—Increased black pigmentation (so the name kala-azar, which is Hindi version of ‘blacksickness’)
or rarely cancrum oris (ulcerative lesion around mouth).
7. Reticulo-endothelial system—Rarely, there are presence of sternal tenderness (due to severe
anaemia) and palpable lymph nodes (very rare in India, found in African form).
What is cancrum oris (noma) ?
This is a form of sloughing ulcerative gingivitis which spread to buccal mucosa, cheek, mandible or
maxilla resulting in widespread destruction of bone and soft tissue. It is thought to be due to invasion of
tissues by Bacteroids. Fusobacterium and other normal commensals of the mouth. The causes are,
1. Kala-azar (due to neutropenia) 2. Acute leukaemia 3. Measles 4. Enteric fever 5. Immunosuppression.
Points in the past history you have enquired for :
1. Jaundice (as cirrhosis of liver and thalassaemia may be present with hepatosplenomegaly).
2. Repeated blood transfusions (indicates thalassaemia).
3. Haematemesis or melaena (indicates cirrhosis of liver).
4. Tuberculosis (kala-azar may be complicated by tuberculosis).
5. Swelling anywhere in neck, axilla or groin (indicates lymphoma).
6. I.V drug abuse (may give rise to prolonged fever).
7. Diabetes mellitus and hypertension as a routine enquiry.
Importance of treatment history :
Whether the patient has received any injection for 21-28 days (sodium antimony gluconate) or
directly ask the patient if he knows the name of the drugs used so far. Usually a patient of chronic kalaazar
is treated by too many doctors with too many drugs.
Describe the splenic enlargement :
It is just like thalassaemic spleen (read the section on Thalassaemia’). The difference is that the
spleen of chronic kala-azar is ‘soft’ to firm in consistency and not very firm like thalassaemia. At the end
of 1 month of illness, splenic enlargement is about 2-3 cm below the left costal margin and then the
spleen enlarges at the rate of 1 cm per month. Spleen may be tender; in splenic infarction. [In case of
acute malaria, spleen is usually palpable after second paroxysm of fever (i.e.. after 3rd day of illness) and
the spleen of enteric fever is palpable after 7 days of illness. 1 The spleen of chronic kala-azar is not so
firm like chronic malarial spleen.
The spleen of acute kala-azar (and acute malaria) is always soft in consistency.
Anaemia in kala-azar :
1. Hypoproteinaemia (malnutrition).
2. Bone marrow depression (due to proliferation of parasitised reticulo-endothelial cells).
3. Haemolysis (autoimmune and rare).
4. Hypersplenism (sequestration and splenic pooling).
Causes of jaundice in kala-azar (though rare) :
1. Blood transfusion causing jaundice by hepatitis B or C virus.
2. Portal hypertension with cirrhotic change in liver.
Why there is bleeding kala-azar ?
X. Before treatment : due to thrombocytopenia.
2. During treatment : with sodium stibogluconate.
How kala-azar is produced ?
I) Kala-azar is also known as visceral leishmaniasis and is caused by Leishmania donovani.
II) Incubation period averages 1-2 months, but may be several years.
III) Transmitted by—
1. Bite of female sand fly (Phlebotomus argentipes, the Indian vector).
2. Blood transfusion (very rare).
3. Rarely, inoculation of cultures of Leishmania donovani.
* The term ‘leishmaniasis’ encompasses multiple clinical syndromes, i.e., visceral, cutaneous and
mucosal leishmaniasis.