229.3 🩺 內科專科考前版

229.3.0.1 1⃣ VL Returning Traveler / Immigrant

  • Prolonged fever + massive splenomegaly + pancytopenia in immigrant from endemic → consider VL
  • rK39 rapid test screening
  • Bone marrow aspirate definitive
  • Hematology + ID consultation
  • Hospitalization + treatment

229.3.0.2 2⃣ Bone Marrow vs Splenic Aspirate

  • Bone marrow: standard, sensitivity 60-85%, safe
  • Splenic aspirate: highest sensitivity (95%) but bleeding risk
  • Reserved for treatment failures or refractory diagnosis
  • Imaging-guided splenic aspirate to minimize bleeding

229.3.0.3 3⃣ Liposomal AmB Single Dose Strategy

  • 10 mg/kg single IV dose for Indian VL (WHO endorsement)
  • Used in mass campaigns + India elimination
  • Safer than antimony (less cardiac toxicity)
  • Cost-effectiveness analyses positive
  • Adopted in endemic countries

229.3.0.4 4⃣ MCL Workup + Treatment

  • Always systemic treatment (not local)
  • Pentavalent antimony × 28+ days or liposomal AmB
  • Surgical reconstruction after parasite cure
  • Ophthalmology / ENT involvement for complications
  • Long follow-up + counseling

229.3.0.5 5⃣ PKDL Implications

  • Reservoir → continued transmission
  • L. donovani anthroponotic regions
  • Treatment of PKDL → outbreak control
  • WHO recommendation to identify + treat all PKDL

229.3.0.6 6⃣ HIV + VL Co-Infection Algorithm

  • More severe initial presentation
  • Atypical features (less fever, atypical lab)
  • Relapsing course common
  • Treatment: liposomal AmB 40 mg/kg total (longer)
  • Maintenance / secondary prophylaxis: monthly liposomal AmB until CD4 > 350 sustained
  • ART critical

229.3.0.7 7⃣ India Elimination Program

  • WHO 2030 target
  • Mass screening + treatment
  • Liposomal AmB mass deployment
  • Vector control + bed nets
  • PKDL identification + treatment
  • 90%+ reduction in cases over past decade

229.3.0.8 8⃣ 健保 / Taiwan

  • 眕芋 endemic; imported cases
  • 通報 mandatory
  • 健保 antimonials, miltefosine, liposomal AmB for confirmed cases
  • ID consult + reference labs

229.3.0.9 9⃣ Sandfly + Climate Change

  • Sandfly range expanding northward (Mediterranean basin spreading north Europe)
  • Climate change impact on transmission
  • Surveillance ongoing
  • Increasing autochthonous CL cases in N Italy + S France

229.3.0.10 10. Future + Vaccines

  • LEISH-F2 (recombinant) — Phase 2/3
  • LEISH-F3 candidates
  • Whole-killed + DNA + mRNA candidates
  • ChAd vector vaccines
  • Combined CL + VL vaccines researched