Treatment monitoring

Patients need to be followed for their clinical response, adverse drug reactions and complications. In a typically responding patient, fever resolves in the first week, 5-7 days of treatment initiation. The spleen starts to regress in the second week of treatment and becomes non-palpable/tipped by the end of one month. Returning to normal may take up to 6 months. Hematological profile usually deteriorates in the first week and starts to improve after the second week of treatment.

Relapse may occur in about 5% of the primary VL cases with no other underlying immunosuppressive conditions. Relapse is much higher in immunocompromised patients. Leishmanin skin test (LST) is negative in VL patients and conversion to positive is delayed upto one year. The LST is an indicator of cell mediated immunity. 

Investigations needed during follow up for treatment monitoring and adverse events are: hematology profile, renal function tests, liver function assessments, ECG, amylase, lipase and electrolytes.

At the end of treatment, clinical assessment is very important. Patients who have primary VL (first time disease) can be declared clinically cured if all sign and symptoms have resolved and there is clinical improvement (weight gain, no fever, regression of splenomegaly, improvement in anemia). Patients who have persistent symptoms and signs, patients with high risk for treatment failure (e.g. HIV co-infected patients) need a test of cure (ToC). ToC is checking for the presence of visible parasitemia in tissue aspirates under microscopy examination. ToC positive means that there are visible parasites and shows treatment failure. This will require prolonging the treatment or changing the regimen (see details on how to prolong the treatment for such patients in the section of management of treatment failures under VL-HIV co-infection). If a patient has persistent symptoms but ToC negative, alternative diagnosis has to be looked for.