==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2489478310.5144/0256-4947.2014.143asm-2-143Original ArticleVisceral leishmaniasis-hepatitis B/C coinfections: a rising necessity to triage patients for treatment Adam Abubakr O. A. Dafalla Mohamed M. M. Mohammed Hatim A. A. Elamin Mohamed Y. Younis Brima M. Elfaki Mona E. E. Musa Ahmed M. Elhassan Ahmed M. Khalil Eltahir A. G. From the Leishmaniasis Research Group/Sudan, Institute of Endemic Diseases, University of Khartoum, Khartoum, SudanCorrespondence: Professor Eltahir Awad Gasim Khalil, Department of Clinical Pathology & Immunology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan, PO Box 45235, T/F: +249 183 793267, eltahirk@iend.org; eltahirgasim@yahoo.caMar-Apr 2014 34 2 143 146 Copyright © 2014, Annals of Saudi Medicine2014This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.BACKGROUND AND OBJECTIVES Visceral leishmaniasis (VL) is a life-threatening infection caused by Leishmania species. In Sudan, VL is caused by L donovani. Most drugs used to treat VL, especially pentavalent antimony compounds (sodium stibogluconate, SSG), are potentially hepatotoxic. A number of fatal catastrophes happened because patients with VL-hepatitis B/C coinfection were indiscriminately treated with SSG in settings where VL and viral hepatitis coexist. This study aimed to study biochemical and hematological parameters of patients with VL-hepatitis B/C coinfections with the aim to modify treatment protocols to reduce coinfection-added morbidity and mortality. DESIGN AND SETTINGS This was a prospective analytical, hospital-based, and case-controlled study. The study was done at Kassab Hospital and Professor Elhassan Centre for tropical medicine during the period of February 2008 to April 2013. MATERIALS AND METHODS Following informed consent by the participants, 78 parasitologically confirmed VL patients with either hepatitis B or C or both and 528 sex- and age-unmatched VL patients without hepatitis B/C coinfection (control group) were enrolled sequentially. Diagnosis of hepatitis B or C was made using immunochromatographic test kits and confirmed by an enzyme-linked immunosorbent assay. RESULTS VL patients with hepatitis B/C coinfections had significantly increased levels of AST, ALT, and total bilirubin compared to the control group (P=.0001 for all), with significantly decreased levels of albumin and platelets counts (P=.0029 for both). CONCLUSION VL-hepatitis B/C coinfections are an emerging entity that needs anti-leishmanial treatment modification. Alternative treatments like paromomycin and amphotericin B (AmBisome) could be reserved for these patients. ==== Body Visceral leishmaniasis (VL) is a life-threatening disease caused by Leishmania species. In Sudan, VL is caused by L donovani. The typical clinical findings are fever, hepatosplenomegaly, and cachexia. More than 90% of global VL cases occur in 6 countries: India, Bangladesh, Sudan, South Sudan, Ethiopia, and Brazil.1,2 Children are mostly affected with an equal male-to-female ratio. In endemic areas, in Sudan, the mean age of VL patients has been reported as 8.6 years (range 2–32 years).3 Sodium stibogluconate (SSG) is the drug most widely used in East Africa. SSG is associated with significant hepatocellular damage and hepatic functional impairment. However, this is rapidly reversible after drug withdrawal.4 Recently, combination treatment using paromomycin with SSG for shorter treatment courses to reduce cost and toxicity were introduced.5–7 Liposomal amphotericin B (AmBisome) is less hepatotoxic and is safer in VL patients with deranged liver function.8–12 The most common causes of viral hepatitis are the 5 unrelated hepatotropic viruses: hepatitis A, B, C, D, and E.13,14 Hepatitis B virus (HBV) and hepatitis C virus (HCV) affect more than 300 million people worldwide.15 The HCV prevalence varies widely among countries, being highest in several African and Eastern Mediterranean countries.16 They represent common causes of a wide spectrum of liver diseases ranging from acute (including fulminant hepatic failure) to chronic hepatitis, cirrhosis, and hepatocellular carcinoma. Acute HBV and HCV infections can be either asymptomatic or present with symptomatic acute hepatitis. Extrahepatic manifestations of HBV infection are rare whereas HCV infection is more frequent, and both HBV and HCV infections can be difficult to diagnose and manage.15 Wide interindividual variation in the natural history of both acute and chronic hepatitis B/C exists, which is explained by a combination of various host, viral, and environmental factors.17 Sudan is classified among the countries with high HBV seroprevalence and exposure to the virus varied from 47% to 78%, with a hepatitis B surface antigen (HBsAg) prevalence ranging from 6.8% in central Sudan to 26% in southern Sudan. Studies of HCV showed a low seroprevalence of 2.2% -to 4.8%.18 VL-hepatitis B/C coinfection is an emerging entity with a cumulative effect on the liver in areas where both conditions coexist. Hepatic involvement because of either leishmaniasis or coexisting viral infection sometimes poses a dilemma in diagnosis and management.19 A number of fatal catastrophes happened at our settings when patients with VL-hepatitis B/C coinfection were treated with SSG. This study was conducted to analyze biochemical and hematological profiles of patients with VL-hepatitis B/C coinfections aiming to modify treatment modalities to reduce morbidity and mortality. MATERIALS AND METHODS Study design This was a prospective, analytical, hospital-based, and case-controlled study. Following informed consent, 78 parasitologically confirmed VL patients with either hepatitis B or C or both and 528 sex- and age-unmatched VL patients without hepatitis B/C coinfection (control group) were enrolled sequentially, who presented to Kassab Rural Hospital and Professor ELHassan’s Centre for Tropical Medicine, Gedarif State. Reference hematological and biochemical values for African population were based on the report of Karita and colleagues as follows: hemoglobin in males 12.2–17.7 g/dL, hemoglobin in females 9.5–15.8 g/dL, platelets count (126–438) × 103 cells/μL, aspartate aminotransferase (AST) 14–60 IU/L, alanine aminotransferase (ALT) 8–61 IU/L, total bilirubin 2.9–37.0 μmol/L, and total albumin 35–52 g/L.20 Clinical data and samples Study VL patients consented to lymph node/bone marrow aspiration and hepatitis screening (HBV, HCV). Pretreatment blood samples were collected for hematologic and chemical assessment (AST, ALT, total bilirubin and albumin). Diagnosis of hepatitis B or C was done using immunochromatographic test kits and confirmed by an enzyme-linked immunosorbent assay. HBV infection in this situation was defined as patients with HBsAg positivity that was confirmed by molecular techniques, and HCV infection defined as anti-HCV antibody positivity that was confirmed by molecular techniques. Data were analyzed using IBM SPSS, version 20 (The International Business Machines Corporation [IBM], USA). Results were expressed as mean (standard deviation). The Significance of difference between 2 mean values among cases and controls were determined by Student independent t test with P<.05 considered significant. RESULTS The mean age of VL patients with hepatitis B/C coinfections was 16.5 (9.8) years with a male-to-female ratio of 2.9, while the mean age of VL patients without hepatitis B/C coinfection was 15.0 (9.7) years (P=.2) and a male-to-female ratio of 1.68. About two thirds (52/78; 66.7%) of the 78 VL-hepatitis B/C–coinfected patients had hepatitis B, with 1 patient having HIV in addition. A total of 27% (21/78; 26.9%) had hepatitis C, with 1 patient having HIV also. Five patients (5/78; 6.4%) had both hepatitis B and C. ALT levels among VL-hepatitis B/C coinfections ranged from 6 to 371 IU/L with a mean concentration of 90.4 (94.1) IU/L compared to 19.8 (12.7) IU/L in the control group (P=.0001). More than half (52.5%) of VL-hepatitis B/C–coinfected patients had normal levels of ALT (8–61 IU/L) with 45% having high levels (>61 IU/L) and 2.5% showing low levels (<8 IU/L). The mean AST level was 143.6 (115.8) IU/L compared to 25.5 (18.1) IU/L in the control group (P=.0001). Most (71%) of VL-hepatitis B/C–coinfected patients had high levels of AST (>60 IU/L) with 29% showing normal levels (14–60 IU/L). The mean total bilirubin concentration among VL-hepatitis B/C–coinfected patients was 1.1 (1.0) mg/dL compared to 0.5 (0.4) mg/dL in the control group (P=.0001). The mean albumin concentration among VL-hepatitis B/C–coinfected patients was 2.6 (0.7) g/dL compared to 3.0 (0.7) g/dL in the control group (P=.003). The mean platelet count among VL-hepatitis B/C coinfections was 105×103 (68×103)/μL compared to (147×103 [99×103)/μL in the control group (P=.003). The mean hemoglobin concentration was comparable in the 2 groups with a mean of 75 (20) g/L among VL-hepatitis B/C coinfections and a mean of 82 (41) g/L in the control group (P=.2). DISCUSSION The increased male preponderance (3× females) in VL-hepatitis B/C coinfection can be partly explained by increased male preponderance in VL patients in general. VL-hepatitis B/C coinfection appears to be affecting young age groups, which is partly expected because VL is mainly a disease of children in Sudan. Alternatively, this may reflect a widespread reuse of needles in primary health care settings because in India hepatitis B and C viral infections were found to be significantly more prevalent in those who received multiple injections specially through the shared use of unsterile injection needles.21 VL-hepatitis B coinfection was more prevalent than VL-hepatitis C infection, which simply reflects the national situation of increased hepatitis B. A considerable number of VL-hepatitis B/C coinfection (45.0%) had high ALT levels, probably indicating ongoing hepatic damage, while a minority (2.5%) had low ALT levels probably indicating a reduced liver function reserve. The reduced serum albumin levels could further point to affected liver productive function. These groups of coinfected patients certainly need treatment modification, using drugs like liposomal amphotericin B. However, the high percentage of VL-hepatitis B/C patients with high AST could point to the ongoing hepatic damage mentioned above. Alternatively, AST could be fortuitously raised as a result of mild hemolysis.22,23 Reduced platelet count in VL-hepatitis B/C coinfection could be because of the effects of megakaryocytes rather than a pan bone marrow depression, as evidenced by the comparable hemoglobin concentrations in the study groups. In conclusion, VL-hepatitis B/C coinfection is an emerging entity that needs anti-leishmanial treatment modification. Care should be taken with the use of SSG. Biochemical parameters can help triaging VL patients to the appropriate treatment regimen. Acknowledgments We acknowledge the support of all during the process of this work. We would like to thank to medical assistants Mohammed A. M. Sha-eldin, Khalifa M. G. Mohammed, and Abdalrahman M. E. Mofarah and to lab technologists Eltahir F. Khamees, Mohammed A. A. Idris, Khalid S. M. Salman, Mohammed A. Saeed, Ahmed J. Suliman, AlaEldin M. A. Merghani, Suliman A. M. Elsafi, and Hikma B. A. Mohammed. ==== Refs REFERENCES 1 Alvar J Velez ID Bern C Herrero M Desjeux P Cano J Jannin J den Boer M 2012 Leishmaniasis worldwide and global estimates of its incidence PloS one 7 e35671 22693548 2 Tunccan OG Tufan A Telli G Akyurek N Pamukcuoglu M Yilmaz G Hizel K 2012 Visceral leishmaniasis mimicking autoimmune hepatitis, primary biliary cirrhosis, and systemic lupus erythematosus overlap The Korean journal of parasitology 50 13 136 3 Zijlstra EE el-Hassan AM 2001 Leishmaniasis in Sudan Visceral leishmaniasis Transactions of the Royal Society of Tropical Medicine and Hygiene 95 Suppl 1 S27 58 11370250 4 Hepburn NC Siddique I Howie AF Beckett GJ Hayes PC 1994 Hepatotoxicity of sodium stibogluconate therapy for American cutaneous leishmaniasis Transactions of the Royal Society of Tropical Medicine and Hygiene 88 453 455 7570843 5 Musa AM Younis B Fadlalla A Royce C Balasegaram M Wasunna M Hailu A Edwards T Omollo R Mudawi M Kokwaro G El-Hassan A Khalil E 2010 Paromomycin for the treatment of visceral leishmaniasis in Sudan: a randomized, open-label, dose-finding study PLoS neglected tropical diseases 4 e855 21049063 6 Musa A Khalil E Hailu A Olobo J Balasegaram M Omollo R Edwards T Rashid J Mbui J Musa B Abuzaid AA Ahmed O Fadlalla A El-Hassan A Mueller M Mucee G Njoroge S Manduku V Mutuma G Apadet L Lodenyo H Mutea D Kirigi G Yifru S Mengistu G Hurissa Z Hailu W Weldegebreal T Tafes H Mekonnen Y Makonnen E Ndegwa S Sagaki P Kimutai R Kesusu J Owiti R Ellis S Wasunna M 2012 Sodium stibogluconate (SSG) & paromomycin combination compared to SSG for visceral leishmaniasis in East Africa: a randomised controlled trial PLoS neglected tropical diseases 6 e1674 22724029 7 Sundar S Agrawal N Arora R Agarwal D Rai M Chakravarty J 2009 Short-course paromomycin treatment of visceral leishmaniasis in India: 14-day vs 21-day treatment Clinical infectious diseases: an official publication of the Infectious Diseases Society of America 49 914 918 19663597 8 Sundar S Chakravarty J Agarwal D Rai M Murray HW 2010 Single-dose liposomal amphotericin B for visceral leishmaniasis in India The New England journal of medicine 362 504 512 9 Ritmeijer K ter Horst R Chane S Aderie EM Piening T Collin SM Davidson RN 2011 Limited effectiveness of high-dose liposomal amphotericin B (AmBisome) for treatment of visceral leishmaniasis in an Ethiopian population with high HIV prevalence Clinical infectious diseases: an official publication of the Infectious Diseases Society of America 53 e152 158 22016502 10 Berman JD Badaro R Thakur CP Wasunna KM Behbehani K Davidson R Kuzoe F Pang L Weerasuriya K Bryceson AD 1998 Efficacy and safety of liposomal amphotericin B (AmBisome) for visceral leishmaniasis in endemic developing countries Bulletin of the World Health Organization 76 25 32 9615494 11 Seaman J Boer C Wilkinson R de Jong J de Wilde E Sondorp E Davidson R 1995 Liposomal amphotericin B (AmBisome) in the treatment of complicated kala-azar under field conditions Clinical infectious diseases: an official publication of the Infectious Diseases Society of America 21 188 193 7578729 12 Davidson RN Di Martino L Gradoni L Giacchino R Russo R Gaeta GB Pempinello R Scott S Raimondi F Cascio A 1994 Liposomal amphotericin B (AmBisome) in Mediterranean visceral leishmaniasis: a multi-centre trial The Quarterly journal of medicine 87 75 81 8153291 13 Jain P Prakash S Gupta S Singh KP Shrivastava S Singh DD Singh J Jain A 2013 Prevalence of hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus as causes of acute viral hepatitis in North India: a hospital based study Indian journal of medical microbiology 31 261 265 23883712 14 Tsega E Hansson BG Krawczynski K Nordenfelt E 1992 Acute sporadic viral hepatitis in Ethiopia: causes, risk factors, and effects on pregnancy Clinical infectious diseases: an official publication of the Infectious Diseases Society of America 14 961 965 1576296 15 Liang TJ 2009 Hepatitis B: the virus and disease Hepatology 49 S13 21 19399811 16 Papatheodoridis G Hatzakis A 2012 Public health issues of hepatitis C virus infection, Best practice & research Clinical gastroenterology 26 371 380 23199497 17 Maasoumy B Wedemeyer H 2012 Natural history of acute and chronic hepatitis C, Best practice & research Clinical gastroenterology 26 401 412 23199500 18 Mudawi HM 2008 Epidemiology of viral hepatitis in Sudan Clinical and experimental gastroenterology 1 9 13 21677820 19 Salma Umma AHK Ur Rahaman Mohammad Ferdous Irshadullah Naseeb Muhammad Shumy Farzana MJC 2012 Leishmanial Hepatitis with Chronic Hepatitis B Infection Treated Successfully with Liquid Form of Liposomal Amphotericin B - A Case Report BSMMU 5 55 56 20 Karita E Ketter N Price MA Kayitenkore K Kaleebu P Nanvubya A Anzala O Jaoko W Mutua G Ruzagira E Mulenga J Sanders EJ Mwangome M Allen S Bwanika A Bahemuka U Awuondo K Omosa G Farah B Amornkul P Birungi J Yates S Stoll-Johnson L Gilmour J Stevens G Shutes E Manigart O Hughes P Dally L Scott J Stevens W Fast P Kamali A 2009 CLSI-derived hematology and biochemistry reference intervals for healthy adults in eastern and southern Africa PloS one 4 e4401 19197365 21 Singh S Kumar J Singh R Dwivedi SN 2000 Hepatitis B and C viral infections in Indian kala-azar patients receiving injectable anti-leishmanial drugs: a community-based study International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases 4 203 208 11231183 22 Koseoglu M Hur A Atay A Cuhadar S 2011 Effects of hemolysis interferences on routine biochemistry parameters Biochemia medica 21 79 85 22141211 23 Lippi G Salvagno GL Montagnana M Brocco G Guidi GC 2006 Influence of hemolysis on routine clinical chemistry testing Clinical chemistry and laboratory medicine: CCLM/FESCC 44 311 316