Infantile kala-azar.—The symptoms on the whole are similar to those of the adult type of kala-azar and differ only to the extent that might be expected in a disease occurring in very young children instead of in those older.
The onset is insidious with some fever and gastro-intestinal upset. The spleen enlarges, the child becomes apathetic, anaemic and emaciated. Irregular attacks of fever occur and the child often suffers from epistaxis, bleeding from the gums or haemorrhages into the skin. According to Nicolle a peculiar pallor of the skin is characteristic. Ulcerations of the intestines and noma may bring about a fatal termination. The liver does not enlarge to the extent that the spleen does. The finding of the parasites is necessary for the distinction of this infantile splenomegaly from those of other origin. The lymphatic glands are not usually enlarged.
Symptoms in Detail
Onset and Fever Chart.—The disease commences in a rather indefinite manner, often with gastro-intestinal symptoms or possibly daily rigors. The fever chart is that of a remittent fever with rather marked oscillations and in particular a double rise in the 24 hours, which Rogers regards as characteristic. The absence of a high continued fever and this double daily rise assist in differentiating typhoid. Waves of fever separated by apyrexial periods often simulate the fever chart of Malta fever.
The Spleen, Liver and Lymphatic Glands.—The splenic enlargement, which may reach the umbilicus by the third month, is the most characteristic clinical sign of kala-azar. The diagnosis was formerly made by spleen puncture but owing to many fatalities the liver puncture is to be preferred, although the results of such exploratory examinations are often negative, the liver being involved to a less extent than the spleen and rarely showing appreciable enlargement before the third month. It is during the pyrexial periods that the spleen and liver enlarge.
Cochran has brought forward the importance of examining smears from excised lymph glands for the parasites and others have shown that gland puncture is of value. The glands in the infantile type of the disease often do not show enlargement.
The Blood.—Marked anaemia is only found in the later stages and the color index is about normal. The number of red cells rarely falls below 2,000,000.
Leucopenia is characteristically marked, this having been below 2000 in 62% of Rogers’ cases. This authority considers the finding of 1 white to 1000 red cells, in a case of fever, very significant of kala-azar.
There is also an increase in the large mononuclear percentage which would aid in differentiating typhoid.