Clinical features: The cardinal signs of VL in patients with HIV infection are unexplained fever, splenomegaly and pancytopenia (anaemia, leucopenia and thrombocytopenia). Presentation may not be typical. The bone marrow is packed with parasites but two-thirds of cases have no detectable anti Leishmanial antibodies. CD4+ cell count in co-infected patients is usually <300cells/ml. Diagnosis: Parasitological diagnosis: Isolation of the organism from material taken from reticuloendothelial tissue and examined with Giemsa, Wright’s or Leishmanial stain. Immunological diagnosis • Antibody detection • Leishmanial test is negative Treatment: Pentavalent antimonial 10-20mg/kg for 3-4 weeks, require longer treatment and more liable to relapse. Treatment of relapsed patients: These are patients who are slower to respond and have a higher chance of further relapse and of becoming unresponsive to antimonial. Treatment- 20mg Sb/kg daily for 8weeks; monitor by splenic aspirates.
5.1.3 Sepsis This diagnosis is formulated whenever patients with HIV present with high grade fever, tachycardia, tachypnea and low blood pressure. Though these signs are clinical evidence of infections, it is difficult to predict the aetiology without laboratory support. In clinical practice in Ethiopia nearly all patients with this type of presentation are empirically put on parentral ceftraixone. Although enteric fever and non typoidal salmonellosis can be common among AIDS patients, incidence of gram negative sepsis is not different from HIV negative individuals. Clinical features: symptoms suggesting onset of sepsis include fever, headache, sweating, chills and/or rigors, dyspnea, nausea and vomiting. Obviously these symptoms are non-specific although cough, dysuria or nuccal rigidity can suggest underlying pathology. Examination typically will elicit fever, tachycardia, tachypnea with low blood pressure and altered mental status. Fever can be absent and hypothermia can present concurrently in severe sepsis. A detailed examination is necessary to check the skins, lungs, rectum, female pelvis and full HEENT including the fundi.
Factors to consider before empirical treatment: 1. Do CBC including BF examinations to exclude haemo parasites. 2. Take three blood cultures if possible. 3. Do chest X-ray and abdominal sonography to determine sites of infection. 4. Identify if the source of sepsis is a community or hospital-acquired pathogen.
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