Also called visceral Leishmaniasis, caused by Leishmania donovani, a protozoan transmitted mostly through bite of sandfly. Endemic in areas of Bihar and Eastern Uttar Pradesh.

Diagnosis is suggested by clinical features, presence of pancytopenia, hypergammaglobulinemia and hypoalbuminemia and confirmed by demonstration of LD bodies in the bone marrow/splenic aspirate. Serological tests (ELISA) are useful for field diagnosis.

Treatment

Blood transfusion.

Nonpharmacological

Cold sponging, rest and high protein diet.

Pharmacological

Nonspecific

Specific
Inj. Sodium Stibogluconate 200 mg test dose followed by 20 mg/kg IM/slow IV injection for 28 days. IM injection is painful thus IV route is preferred although cough is the common side effect specially when the volume is high, as is the case for most adults.
Or
Inj. Amphotericin B 0.5-1 mg/kg/day with a total of 15-20 mg/kg.
Drug of choice in patients resistant to or intolerant to Sodium Stilbogluconate.

Other drugs that have been found useful are
Inj. Pentamidine isethionate 4 mg/kg/day x 15-30 days.
Or
Inj. Aminosidine (Aminoglycoside) 15 mg/kg/day x 21 days per-orally particularly in HIV positive patients.
Clinically, patient feels better and becomes afebrile during the first week of treatment. Return of pancytopenia, abnormal liver function, serum albumin, splenomegaly and weight gain may take weeks or months to improve.
Reassessment at 6 weeks and 6 months will usually detect any relapse.
Patient is said to be cured if no clinical relapse occurs during the first 6 months of follow-up. There is no need to prove absence of parasite as a marker for cure.

Treatment of relapse
Inj. Sodium Stibogluconate 20 mg/kg/day for at least 8 weeks with frequent monitoring for parasite count.
Or
Inj. Amphotericin B in doses mentioned above.
Or
Liposomal Amphotericin B 2-5 mg/kg/day IV on days 1-5,14 and 21 for a total of 21 mg/kg.

Special situations
Patients co-infected with HIV respond slowly, require longer treatment and are more liable to relapse

Monitoring for drug side-effects.

Infection is caused by Enterobius vermicularis (Pin worm). Adult pinworm is around 1 cm long and dwells in the bowel lumen in the small and large intestine around caecum area.

Treatment

Tab. Mebendazole 100 mg as a single dose in adults and children more than 2 years of age.
(Contraindicated in pregnancy and in children below one year of age).
Or
Tab. Pyrantel pamoate 11 mg/kg body weight as a single dose.
Or
Tab. Albendazole 400 mg as a single dose.
Children (1-2 years) Syp. Albendazole 200 mg as a single dose; More than 2 years 400 mg as a single dose.
Repeat treatment after two weeks.

Assessment of response of worm infestation to therapy

Ascariasis is caused by Ascaris lumbricoides, the largest intestinal nematode parasite of humans reaching up to 40 cm in length. The worm is usually located in the small intestine.

Treatment

Tab. Mebendazole 100 mg 12 hourly for 3 days.
(CAUTION: Contraindicated in children less than 2 years)
Or
Tab. Piperazine (Adults) 4 g once daily for 2 days; Syrup (750 mg/5 ml) 75 mg/kg once daily for 2 days.
Or
Tab. Pyrantel pamoate 11 mg/kg as a single dose.
Or
Tab. Albendazole 400 mg as a single dose. In heavy infestation, however, a 2-3 day course is indicated.
(CAUTION: Contraindicated in pregnancy)
In children between 1-2 years: Albendazole Susp (200 mg/5 ml) 200 mg as a single dose; in children more than 2 years Syp./Tab. Albendazole 400 mg as a single dose.
Partial intestinal obstruction may be managed with nasogastric suction, IV fluid administration and instillation of piperazine through nasogastric tube. Complete obstruction and other surgical complications require surgical referral for intervention.

Patient education

Worm Infestations

The majority of worm infestations are asymptomatic.

Hook Worm Infestation

Infection is caused by A. duodenale and N. americanus. The infective larvae penetrate through skin usually foot and travels through subcutaneous tissue to the intestines. The adult forms live in the jejunum and feed on blood thus, leading to chronic blood loss and anaemia.

Treatment

Tab. Mebendazole 100 mg 12 hourly for 3 days in children above 2 years of age.
(CAUTION: Contraindicated in children less than 2 years)
Or
Tab. Pyrantel Pamoate (250 mg); Syp. (250 mg/5 ml ) 10 mg/kg body weight once daily for 3 days.
(CAUTION: Not recommended in children below one year of age)
In children more than 1 year Susp Pyrantal pamoate 10 mg/kg as a single dose.
Or
Tab. Albendazole 400 mg as a single dose.
In children between 1-2 years of age Syp. Albendazole 200 mg as a single dose: In children more than 2 years Syp. Albendazole 400 mg as a single dose
For treatment of anaemia (see section on anaemia – in pregnancy & in children) and nutritional support.

Patient education

Intestinal disease caused by protozoal parasite – Giardia lamblia. The disease spreads by direct faeco-oral transmission.

Treatment

Tab. Tinidazole 2 g as a single dose in adults.
In children 50 mg/kg as a single dose.
Or
Tab. Metronidazole 400 mg every 8 hours for 7 days in adults.
In children 15 mg/kg divided in three doses for 7 days.

Patients education

References

Amoebiasis and giardiasis are the commonest intestinal protozoal infections. Patients of amoebiasis and giardiasis commonly present as asymptomatic carriers.

Amoebiasis (Intestinal)

Infection is caused by intestinal protozoa- Entamoeba histolytica. Infection usually spreads by infective cysts in stool which contaminate food and drinking water.

Treatment (Asymptomatic cyst passers)

Tab. Diloxanide furoate 500 mg 8 hourly for 10 days.

Treatment (Acute amoebic dysentery and chronic infections)