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Miltefosine in the treatment of a case of visceral leishmaniasis with renal dysfunction

In human visceral leishmaniasis (VL), also known as kala-azar, infection of liver, spleen and bone-marrow macrophages with the causative parasites results in a spectrum of disease that ranges from asymptomatic to full-blown VL, with fever, weight loss, hepato–splenomegaly and pancytopenia (Badaro et al.,1986). Although pentavalent antimonials remain the mainstay of treatment globally, they are toxic to humans and resistance to them is an increasing problem, especially in the hyper-endemic areas of the Indian state of Bihar, where 65% of cases now harbour antimony-resistant parasites (Sundar et al., 2000). Amphotericin B has become the standard second-line treatment but is expensive and may cause nephrotoxicity and electrolyte imbalance (Jha et al., 1995). In this context, the development of miltefosine, the first orally active antileishmanial agent with minimal side-effects, is a great advance (Sundar et al., 2002). The drug has recently been used successfully to treat an Indian case of VL who, because of pre-existing renal dysfunction, would have been difficult to treat with any of the more nephrotoxic drugs. This case is described and discussed below.