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Anesthetic considerations in a patient with visceral leishmaniasis

[Éléments de l'anesthésie d'un patient atteint de leishmaniose viscérale]

Prakash K. Dubey, MD^*, Prabhat K. Sinha, MD and Kumar H. Raghwendra, MD^*

^* From the Department of Anesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna and the
Government Medical College, Chandigarh, India.

Address correspondence to: Dr. Prakash K. Dubey, 305, Janpriya Apartments, North S.K.Puri, Patna 800 013, India. E-mail: pkdubey{at}hotmail.com

Purpose: To describe the anesthetic problems in a patient with visceral leishmaniasis undergoing general anesthesia.

Clinical features: A 17-yr-old man with visceral leishmaniasis was booked for emergency appendectomy. He received parentral sodium stibogluconate 600 mg per day. The patient was pale, afebrile and had hepatosplenomegaly. Preoperative investigations showed a hemoglobin of 6.2 g•dL^•1, platelet count of 80 x 10⁹•L^–1 and serum albumin of 2.1 g•dL^–1. The electrocardiogram and chest x-ray were normal. Anesthesia was induced with 100 µg fentanyl and 50 mg propofol iv and tracheal intubation was facilitated with 3 mg vecuronium iv. Maintenance of anesthesia was done with intermittent positive pressure ventilation using 50% nitrous oxide and 0.4% isoflurane in oxygen. Reversal of neuromuscular blockade was achieved with 1.0 mg neostigmine and 0.2 mg atropine iv. 50 mg tramadol iv every six hours was used for postoperative analgesia. The perioperative course was uneventful.

Conclusion: Patients with visceral leishmaniasis have problems unique to them that may influence the anesthetic management. Of particular concern to an anesthesiologist are the presence of hematological abnormalities (anemia, leukopenia, thrombocytopenia), and hypoalbuminic malnutrition. The combination of low hemoglobin and thrombocytopenia may necessitate blood component therapy perioperatively. Drugs affecting coagulation should be used judiciously. Hypoalbuminemia may adversely affect the pharmacokinetics of agents that are highly protein bound. The anesthetic management in a patient with visceral leishmaniasis may be further complicated by the presence of coexisting infections like pneumonia and tuberculosis. Leishmaniasis is a recognized complication of infection with human immunodeficiency virus.