First Case of Indigenous Visceral Leishmaniasis from Central India Ayan Dey, Umakant Sharma, and Sarman Singh* Division of Clinical Microbiology, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India Abstract. Visceral leishmaniasis is endemic in the eastern states of India, but central India remains free of leishma- niais. This report describes the first indigenous case of visceral leishmaniasis in a seven-year-old girl from central India. The child presented with fever for 10 days and was diagnosed by bone marrow examination, serology using rKE16 and rK39 antigens, and a polymerase chain reaction specific for the kinesin gene. Sequencing of the immunodominant region of the kinesin gene of the parasite showed four tandem repeats, each 117 basepairs. The first tandem repeat of this strain had 97% homology with the corresponding first tandem repeat of the Leishmania donovani KE16 strain and 92% homology with the L. chagasi BA-2 strain. The second, third, and fourth tandem repeats had 97%, 98%, and 99% homology, respectively, with the L. donovani KE16 strain, and 89%, 96%, and 92% homology, respectively, with the L. chagasi BA-2 strain. This case shows that more than one genetic variant of L. donovani is circulating in various parts of India. INTRODUCTION Leishmaniasis is a major public health problem causing sig- nificant morbidity and mortality in Africa, Asia, and Latin America. It has three clinical forms, of which visceral leish- maniasis (VL) (kala-azar) is the most severe. Recent out- breaks of VL in India and the epidemic of human immuno- deficiency virus (HIV) make VL a re-emerging problem in India. 1 Visceral leishmaniasis spreads from person to person through sand fly bites. Anthroponotic VL is endemic in the tropical and sub-tropical regions of Africa, Asia, southern Europe, and South and Central America. However, distribu- tion of anthroponotic VL in these areas is patchy and often associated with areas of drought, famine, and densely popu- lated villages with little or no sanitation. 2 Outbreaks and epi- demics of leishmaniasis have been associated with urban de- velopment, deforestation, environmental changes, and popu- lation migrations. Risk factors for this disease include HIV and malnutrition, and genetic factors are also responsible for the epidemiologic diversity of leishmaniasis. 3 India accounts for half of the 500,000 VL infections that are reported annually worldwide. Most cases in India are re- ported from the northeastern states of Bihar, eastern Uttar Pradesh, West Bengal, and Assam. 4 Sporadic cases have also been reported from Gujarat (western India), Tamil Nadu and Kerala (southern India), and sub-Himalayan parts of north- ern India including Uttar Pradesh, Himachal Pradesh, Jammu, and Kashmir. 4–7 To the best of our knowledge and available literature, VL has not been reported from Madhya Pradesh (central India), although a sand fly vector (Phleboto- mus argentipes) has been reported from this area. 8 This case report is unique and significant because possible spread of VL in this region may affect the health of local inhabitants as well as tourism and the economy of this state. CASE REPORT A seven-year-old girl from Morena (26°30N, 78°04E) in Madhya Pradesh in central India was referred to our institute. She had a high-grade fever (105°F) with chills and rigors for three weeks and did not respond to standard treatment. Ini- tially, for her febrile illness, she was tested locally for malaria (peripheral blood smear examination and Plasmodium falci- parum and P. vivax antigen detection) and typhoid fever (Widal and TyphiDot test) but results were negative. Results of routine serum biochemical and hematologic investigations were also negative. When no conclusive diagnosis could be made and she did not respond to treatment with anti-malarial drugs and third-generation cephalosporine antibiotics, she was transferred from Madhya Pradesh to a nursing home in Delhi. She was again tested for malaria and other causes of fever of unknown origin by blood culture (BacTec 460; Bec- ton Dickinson, Heidelberg, Germany), chest radiograph, and abdominal ultrasonography. Results of blood cultures and chest radiographs were negative. However, ultrasound showed moderate hepatosplenomegaly, with both the liver and spleen palpable below costal margins. Results of routine and culture examinations of urine were normal. Hematologic examination showed mild normocytic hypochromic anemia with hemoglobin levels of 11 g%, a total leukocyte count of 9,000/mm 3 with slight lymphocytosis (40%). Her liver enzyme levels were within normal limits, and she had a moderately low total serum protein level (7 g%) and increased globulin levels (5 g%). Her past and family history showed that she was a full-term normal delivery through the vaginal route. She and her family members had never traveled to any areas endemic for kala- azar, including the endemic districts of eastern Uttar Pradesh and Bihar located approximately 620 km from Morena. She did not have any prolonged illness and had not received any blood transfusions. Her bone marrow, other clinical samples, and all clinical and laboratory details were referred to us for the expert opin- ion of the senior author of this report (SS). Her bone marrow smears were examined by staining with Giemsa and showed numerous plasma cells and an overall reactive pattern. The smear also showed Leishman-Donovan body-like structures. Her serum samples were tested with the anti-rK-39 dipstick test (Insure™; Inbios, Seattle, WA) anti-rKE16 spot test (Sig- nal KA™; Span Diagnostics Ltd., Surat, India), and the rKE16 latex agglutination test (up to a dilution of 1:16). All three tests showed strongly positive results. The novel recom- binant antigen (rKE16) has recently been prepared in our laboratory from KE16 (MHOM/IN/1998/KE16) isolate of * Address correspondence to Sarman Singh, Division of Clinical Mi- crobiology, All India Institute of Medical Sciences, PO Box 4398, Ansari Nagar, New Delhi 110029, India: E-mail: sarman_singh@ yahoo.com Am. J. Trop. Med. Hyg., 77(1), 2007, pp. 95–98 Copyright © 2007 by The American Society of Tropical Medicine and Hygiene 95