<div dir="ltr"><div class="gmail_default" style="font-family:verdana,sans-serif;font-size:small;color:rgb(0,0,0)">Anthony Bryceson is probably right when he suggests that a good review (systematic?) should be undertaken on the effect of splenectomy for the cure of kala-azar patients resistant to drug therapy.<br>
<br></div><div class="gmail_default" style="font-family:verdana,sans-serif;font-size:small;color:rgb(0,0,0)">The references bellow show that: (1) Many drug resistant patients are cured after splenectomy, including patients with HIV infection; (b) One previously splenectomized patient under immunosuppresive therapy acquired kala-azar, suggesting that immunosupression is necessary for bone marrow parasitism in the absence of spleen. (c) There is no evidence that splenectomy without additional drug therapy is efficient.<br>
<br></div><div class="gmail_default" style="font-family:verdana,sans-serif;font-size:small;color:rgb(0,0,0)">Additionally, the comments by Sinha and Bryceson suggest that the response of L. donovani kala-azar may be different from those with L. infantum kala-azar.<br>
<br></div><div class="gmail_default" style="font-family:verdana,sans-serif;font-size:small;color:rgb(0,0,0)">The subject is hot and enlightening.<br></div><div class="gmail_default" style="font-family:verdana,sans-serif;font-size:small;color:rgb(0,0,0)">
<br></div><div class="gmail_default" style="font-family:verdana,sans-serif;font-size:small;color:rgb(0,0,0)">PS. I was unable to access and check the paper cited by Dutra et al: Mukhopadhyay B, Sarkar AK, Dasgupta A, Mukhopadhyay M, Chowdhury MM, Sarkar S. Drug - resistant childhood visceral leishmaniasis. Is splenectomy a solution? Pediatr Surg Int 1993; 8:314-315 </div>
<div class="gmail_default" style="font-family:verdana,sans-serif;font-size:small;color:rgb(0,0,0)"><div class="">
<div><h2 class="">Results: 4</h2><span id="result_sel" class=""></span></div>
</div>
<div class=""><div class=""><input name="EntrezSystem2.PEntrez.PubMed.Pubmed_ResultsPanel.Pubmed_RVAbstract.uid" id="UidCheckBox22581957" value="22581957" type="checkbox"><span>1.</span></div><div class=""><div class="">
<span><a href="http://www.ncbi.nlm.nih.gov/pubmed#" title="International journal of STD & AIDS.">Int J STD AIDS.</a></span> 2012 Apr;23(4):289-90. doi: 10.1258/ijsa.2009.009234.</div><h1><a href="http://www.ncbi.nlm.nih.gov/pubmed/22581957">Successful therapeutic <span class="" style>splenectomy</span> in an HIV patient with relapsing <span class="" style>visceral leishmaniasis</span>.</a></h1>
<div class=""><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Alon%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Alon D</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Chowers%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Chowers M</a>.</div>
<div class=""><h3 class="">Source</h3><p>Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel. <a href="mailto:dr.danny.alon@gmail.com">dr.danny.alon@gmail.com</a></p></div><div class=""><h3>Abstract</h3><div class="">
<p>A 43-year-old HIV-positive Ethiopian immigrant presented with persistent diarrhoea, hepatosplenomegaly and pancytopaenia. <span class="" style>Visceral leishmaniasis</span>
was diagnosed by multiple gastrointestinal tract biopsies. Blood
polymerase chain reaction (PCR) was positive for Leishmania donovani.
Despite highly active antiretroviral therapy (HAART) and multiple
courses of antileishmanial treatments, including liposomal amphotericin
and sodium stibogluconate, the patient had multiple relapses. CD4 counts
remained at 40-60 cells/µL although viral loads were undetectable. <span class="" style>Splenectomy</span> resulted in resolution of the patient's pancytopaenia and in rising CD4 levels, which enabled a long-lasting remission.</p>
</div></div><div class=""><div class=""><dl class=""><dt>PMID:</dt><dd>22581957</dd><dd> [PubMed - indexed for MEDLINE] </dd><dd> <br></dd></dl></div><div class=""><a class="" href="http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=22581957">Related citations</a></div>
</div><div class=""><h3><a title="Supplemental information" class="" href="http://www.ncbi.nlm.nih.gov/pubmed#"><span class="">Publication Types, MeSH Terms, Substances</span><span class=""></span></a></h3></div></div><ul class="">
<li><br></li></ul></div><div class=""><div class=""><input name="EntrezSystem2.PEntrez.PubMed.Pubmed_ResultsPanel.Pubmed_RVAbstract.uid" id="UidCheckBox22370845" value="22370845" type="checkbox"><span>2.</span></div><div class="">
<div class=""><span><a href="http://www.ncbi.nlm.nih.gov/pubmed#" title="Revista da Sociedade Brasileira de Medicina Tropical.">Rev Soc Bras Med Trop.</a></span> 2012 Feb;45(1):130-1.</div><h1><a href="http://www.ncbi.nlm.nih.gov/pubmed/22370845"><span class="" style>Splenectomy</span> in a patient with treatment-resistant <span class="" style>visceral leishmaniasis</span>: a case report.</a></h1>
<div class=""><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Dutra%20RA%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Dutra RA</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Dutra%20LF%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Dutra LF</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Reis%20Mde%20O%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Reis Mde O</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Lambert%20RC%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Lambert RC</a>.</div>
<div class=""><h3 class="">Source</h3><p>Departamento de Cirurgia Pediátrica, Santa Casa de Franca, Franca, SP.</p></div><div class=""><h3>Abstract</h3><div class=""><p><span class="" style>Visceral leishmaniasis</span> (VL), also known as <span class="" style>Kala-azar</span>,
is a systemic infection caused by a protozoan (Leishmania) and, in its
classic form, is a serious illness associated with malnutrition, anemia,
hepatosplenomegaly, infectious processes and coagulopathies. The effect
of <span class="" style>splenectomy</span> in patients with <span class="" style>visceral leishmaniasis</span>
is not well defined; however, it is known that the spleen is the
largest reservoir of infected cells belonging to the reticulo
endothelial system. Therefore, the surgical procedure is an option for
the debulking of parasites, providing a cure for refractory VL and
minimizing the complications of hypersplenism.</p></div></div><div class=""><div class=""><dl class=""><dt>PMID:</dt><dd>22370845</dd><dd> [PubMed - indexed for MEDLINE] </dd><dd> <br></dd></dl><span class="">Free full text</span></div>
<div class=""><a class="" href="http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=22370845">Related citations</a></div><div class=""><div><a href="http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0037-86822012000100027&lng=en&nrm=iso&tlng=en" target="_blank"><img alt="Icon for Scientific Electronic Library Online" title="Read full text in Scientific Electronic Library Online" src="http://www.ncbi.nlm.nih.gov/corehtml/query/egifs/http:--www.scielo.br-img-scielo.gif" border="0"></a> </div>
</div></div><div class=""><h3><a title="Supplemental information" class="" href="http://www.ncbi.nlm.nih.gov/pubmed#"><span class="">Publication Types, MeSH Terms</span><span class=""></span></a></h3></div></div><ul class="">
<li><br></li></ul></div><div class=""><div class=""><input name="EntrezSystem2.PEntrez.PubMed.Pubmed_ResultsPanel.Pubmed_RVAbstract.uid" id="UidCheckBox19579705" value="19579705" type="checkbox"><span>3.</span></div><div class="">
<div class=""><span><a href="http://www.ncbi.nlm.nih.gov/pubmed#" title="The new microbiologica.">New Microbiol.</a></span> 2009 Apr;32(2):223-7.</div><h1><a href="http://www.ncbi.nlm.nih.gov/pubmed/19579705"><span class="" style>Visceral leishmaniasis</span> in a patient with common variable immunodeficiency and evans syndrome: clinical remarks.</a></h1>
<div class=""><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Maio%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Maio P</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Leone%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Leone S</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Volpe%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Volpe S</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=dell%27Aquila%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">dell'Aquila G</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Giglio%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Giglio S</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Magliocca%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Magliocca M</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Nigro%20FS%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Nigro FS</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Pacifico%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Pacifico P</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Acone%20N%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Acone N</a>.</div>
<div class=""><h3 class="">Source</h3><p>Infectious Diseases Department, A.O.R.N. S.G. Moscati, Avellino, Italy. <a href="mailto:patriziamaio@yahoo.it">patriziamaio@yahoo.it</a></p></div><div class=""><h3>Abstract</h3><div class="">
<p><span class="" style>Visceral Leishmaniasis</span>
(VL) is a vector-borne zoonosis endemic in Southern Italy whose usual
clinical features include fever, splenomegaly, pancytopenia and
hypergammaglobulinemia. The clinical and biochemical picture may be
misleading in patients with immunodeficiency diseases hampering the
diagnosis. We describe a VL case in a patient whose spleen had been
removed and who had Common Variable Immunodeficiency and Evans syndrome.</p></div></div><div class=""><div class=""><dl class=""><dt>PMID:</dt><dd>19579705</dd><dd> [PubMed - indexed for MEDLINE] </dd><dd> <br></dd></dl>
<span class="">Free full text</span></div><div class=""><a class="" href="http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=19579705">Related citations</a></div><div class=""><div><a href="http://www.newmicrobiologica.org/PUB/allegati_pdf/2009/2/223.pdf" target="_blank"><img alt="Icon for Italian Society for Medical, Odontoiatric, and Clinical Microbiology" title="Read full text in Italian Society for Medical, Odontoiatric, and Clinical Microbiology" src="http://www.ncbi.nlm.nih.gov/corehtml/query/egifs/http:--www.newmicrobiologica.org-PUB-allegati_pdf-NewmicroFullText.jpg" border="0"></a> </div>
</div></div><div class=""><h3><a title="Supplemental information" class="" href="http://www.ncbi.nlm.nih.gov/pubmed#"><span class="">Publication Types, MeSH Terms, Substances</span><span class=""></span></a></h3></div></div>
<ul class=""><li><br></li></ul></div><div class=""><input name="EntrezSystem2.PEntrez.PubMed.Pubmed_ResultsPanel.Pubmed_RVAbstract.uid" id="UidCheckBox17156583" value="17156583" type="checkbox"><span>4.</span></div><div class="">
<span><a href="http://www.ncbi.nlm.nih.gov/pubmed#" title="Parasitology.">Parasitology.</a></span> 2007 May;134(Pt 5):621-4. Epub 2006 Dec 11.</div><h1><a href="http://www.ncbi.nlm.nih.gov/pubmed/17156583">The role of <span class="" style>splenectomy</span> in HIV-infected patients with relapsing <span class="" style>visceral leishmaniasis</span>.</a></h1>
<div class=""><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Troya%20J%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Troya J</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Casquero%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Casquero A</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Mu%C3%B1iz%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Muñiz G</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Fern%C3%A1ndez-Guerrero%20ML%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Fernández-Guerrero ML</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=G%C3%B3rgolas%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22581957">Górgolas M</a>.</div>
<div class=""><h3 class="">Source</h3><p>Division
of Infectious Diseases, Fundación Jiménez Díaz-UTE, Universidad
Autónoma de Madrid, Avda. de Reyes Católicos 2, 28040 Madrid, Spain.
<a href="mailto:jestrogar@hotmail.com">jestrogar@hotmail.com</a></p></div><div class=""><h3>Abstract</h3><div class=""><p>The treatment of <span class="" style>visceral leishmaniasis</span>
(VL) in HIV-infected patients is characterized by having a protracted
course and frequent relapses, despite the use of adequate
anti-leishmanial drugs and effective anti-retroviral therapy. A small
subset of patients with significant splenomegaly develops severe
cytopaenias and chronic leishmania infection. The use of elective <span class="" style>splenectomy</span>
is effective for restoring the haematological parameters and reduces
the need for blood transfusions but it does not avoid relapsing <span class="" style>visceral leishmaniasis</span>.</p></div></div><div class=""><div class=""><dl class=""><dt>PMID:</dt><dd>17156583</dd><dd> [PubMed - indexed for MEDLINE] </dd>
<dd> <br></dd></dl></div><div class=""><a class="" href="http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=17156583">Related citations</a></div><div class=""><div><a href="http://journals.cambridge.org/abstract_S0031182006002058" target="_blank"><img alt="Icon for Cambridge University Press" title="Read full text in Cambridge University Press" src="http://www.ncbi.nlm.nih.gov/corehtml/query/egifs/http:--journals.cambridge.org-images-cjo.gif" border="0"></a> </div>
</div></div><h3><a title="Supplemental information" class="" href="http://www.ncbi.nlm.nih.gov/pubmed#"><span class=""><br></span></a></h3><br></div></div><div class="gmail_extra"><br><br><div class="gmail_quote">2013/9/6 prabhat sinha <span dir="ltr"><<a href="mailto:pksinha18@yahoo.com" target="_blank">pksinha18@yahoo.com</a>></span><br>
<blockquote class="gmail_quote" style="margin:0 0 0 .8ex;border-left:1px #ccc solid;padding-left:1ex"><div><div style="font-size:12pt;font-family:bookman old style,new york,times,serif"><div><span>Dear All,</span></div>
<div style="font-size:16px;font-style:normal;background-color:transparent;font-family:bookman old style,new york,times,serif"><span>In Bihar,India I have seen patients of Kala azar (VL) with splencetomy without clinical cure and hepatic aspirates are laden with parasites. How can it be said that splenectomy cures VL?</span></div>
<div><span>Prabhat Kumar Sinha</span></div>
<div><span>Rajendra Memorial Research Instt. of Medical Sciences(ICMR).</span></div>
<div><span>Patna,India<var></var></span></div>
<div><br></div>
<div style="FONT-FAMILY:bookman old style,new york,times,serif;FONT-SIZE:12pt">
<div style="FONT-FAMILY:times new roman,new york,times,serif;FONT-SIZE:12pt">
<div dir="ltr">
<div style="BORDER-BOTTOM:#ccc 1px solid;BORDER-LEFT:#ccc 1px solid;PADDING-BOTTOM:0px;LINE-HEIGHT:0;MARGIN:5px 0px;PADDING-LEFT:0px;PADDING-RIGHT:0px;min-height:0px;FONT-SIZE:0px;BORDER-TOP:#ccc 1px solid;BORDER-RIGHT:#ccc 1px solid;PADDING-TOP:0px" readonly>
</div><font face="Arial"><b><span style="FONT-WEIGHT:bold">From:</span></b> Anthony Bryceson <<a href="mailto:a.bryceson@doctors.org.uk" target="_blank">a.bryceson@doctors.org.uk</a>><br><b><span style="FONT-WEIGHT:bold">To:</span></b> Carlos Costa <<a href="mailto:chncosta@gmail.com" target="_blank">chncosta@gmail.com</a>> <br>
<b><span style="FONT-WEIGHT:bold">Cc:</span></b> Leish-L <<a href="mailto:Leish-l@lineu.icb.usp.br" target="_blank">Leish-l@lineu.icb.usp.br</a>> <br><b><span style="FONT-WEIGHT:bold">Sent:</span></b> Friday, August 30, 2013 10:11 PM<br>
<b><span style="FONT-WEIGHT:bold">Subject:</span></b> Re: [Leish-l] spleen<br></font></div><div><div class="h5">
<div><br>
<div>
<div>Who says that splenectomy cures VL?
<div>I last reviewed the literature in 1984 (<span style="FONT-SIZE:14px">"</span><span style="FONT-SIZE:14px"><i>Therapy in Man" i<u>n</u> Leishmaniasis in Biology and Medicine. Eds W Peters, R Killick-Kendrick, Academic Press, London, 1987, p 893)</i></span>, and there was not much to review (Napier 1949, Wang and Wu 1959, Das and Sen Gupta 1950, Sen Gupta and Chatterji 1961). I concluded that "splenectomy may cure VL without further chemotherapy in about 1 in 5 cases, and in a greater proportion with the aid of further chemotherapy, despite apparent unresponsiveness previously. The operation carries a mortality and may be followed by fatal septicaemia or further relapse". In 1984. Rees et al reported 5 cases in children in Nairobi, 3 improved and 2 died.</div>
<div><br></div>
<div>Is there a more recent review or collection of published cases?</div>
<div><br></div>
<div>There is still something of a mystery about the spleen in VL. The concentration of parasites is greatest there and parasites seem to remain longer in the spleen than in other organs following chemotherapy. What is the nature of the attraction? Is it immunological as "David et al" suggest, or due to cells that cannot respond as Farrokh suggests? Splenectomy might be of benefit in either instance, and it removes an immunosuppressive antigenic load. Suppression of antigenic load permitting the emergence of an immune response is the rationale for prolonged treatment of DCL. </div>
<div><br></div>
<div>I have two suggestions:</div>
<div>1. Someone collects all published and unpublished case reports and writes a review that includes indications, risks and precautions, bearing in mind that failed cases may not be reported, </div>
<div>2. An immunologist and a parasitologist be invited to join the physician and surgeon, whenever splenectomy is being considered for a patient with unresponsive VL.</div>
<div><br></div>
<div>Best wishes</div>
<div>Anthony</div>
<div><br></div>
<div><span style="FONT-SIZE:14px"><br></span></div>
<div><br></div>
<div>On 21 Aug 2013, at 13:52, Carlos Costa wrote:</div>
<div>
<div><br>
<blockquote type="cite">
<div dir="ltr">
<div style="font-size:small;font-family:verdana,sans-serif">Dear leishimmunologists,</div>
<div style="font-size:small;font-family:verdana,sans-serif"><br></div>
<div style="font-size:small;font-family:verdana,sans-serif">Do you have any guess on why splenectomy cures kala-azar? Would it be the absence of spleen-derived IL-10?</div>
<div style="font-size:small;font-family:verdana,sans-serif"><br></div>
<div style="font-size:small;font-family:verdana,sans-serif">All my best,</div>
<div style="font-size:small;font-family:verdana,sans-serif"><br></div>
<div style="font-size:small;font-family:verdana,sans-serif">Carlos.</div>
<div><br></div>-- <br>
<div dir="ltr">
<div style="TEXT-ALIGN:left"><span style="FONT-FAMILY:verdana,sans-serif">Carlos H. N. Costa, MD, DSc.</span></div>
<div style="TEXT-ALIGN:left"><span style="FONT-FAMILY:verdana,sans-serif">Coordenador</span></div>
<div style="TEXT-ALIGN:left"><span style="FONT-FAMILY:verdana,sans-serif">Laboratório de Leishmanioses - LabLeish</span></div>
<div style="TEXT-ALIGN:left"><span style="FONT-FAMILY:verdana,sans-serif">Universidade Federal do Piauí</span><br></div>
<div>
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<span style="font-family:verdana,sans-serif">Carlos H. N. Costa, MD, DSc.</span></div><div style="text-align:left"><span style="font-family:verdana,sans-serif">Coordenador</span></div><div style="text-align:left"><span style="font-family:verdana,sans-serif">Laboratório de Leishmanioses - LabLeish</span></div>
<div style="text-align:left"><span style="font-family:verdana,sans-serif">Universidade Federal do Piauí</span><br></div><div><div style="text-align:left"><span style="font-family:verdana,sans-serif">Instituto de Doenças Tropicais Natan Portella</span></div>
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Brazil</div><div style="text-align:left">Telephones: +55 86 3222-4377 (W), <div style="text-align:center;display:inline!important"><div style="text-align:center;display:inline!important">+55 86 3221-3062 (W), </div></div>
<div style="text-align:center;display:inline!important">+55 86 3237-1075 (R). </div></div><div style="text-align:left"><br></div><div style="text-align:left"><br></div><span style="font-size:x-small"><div style="text-align:left">
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