the female child is six - years - old and comes from fortaleza in the state of ceara in brazil . initial symptoms began six months ago and included fever , asthenia , and weight loss . tests findings include : cbc : normochromic and very microcytic anemia ( hb : 7.1 g ) , leucopenia ( 3,300 wbc ) , and thrombopenia ( 70,000 platelets / mm ) ; esr : 77 mm for first hour ; serology of leishmaniasis : positive ( 1/1600 using immunofluorescence and 5 archs in electrosyneresis ) ; bone marrow biopsy : the medulla is rich , but no leishmania are seen . the patient is given a meglumine antimoniate treatment with increasing doses reaching 60 mg / kg / day after three days . transient hepatic cytolysis emerges with alanine transaminasi ( alt ) and aspartate aminotransferase ( ast ) 1.5 times above upper normal limit . according to the world health organization , leishmaniasis is a poverty - related disease whose public health impact has been , until recently , grossly underestimated . the disease is caused by protozoan parasites belonging to the genus leishmania that are transmitted by the bite of a phlebotomine sandfly . there are approximately two million new cases each year  1.5 million of cutaneous leishmaniasis and 500,000 of visceral leishmaniasis or kala - azar . kala - azar is endemic to south america , east africa , the mediterranean basin , the middle east , india , and china . the cardinal sign of kala - azar is an anarchic type of fever resisting all forms of treatment . the disease always yields splenomegaly and is thought by many to produce the largest spleens in parasitology . contrary to adult manifestations , cutaneous signs such as erythematous , hyper- or hypopigmented papules and nodules of various sizes are rare in children . although not performed in the case reported , protein immunoelectrophoresis reveals hypergammaglobulinemia with an igg peak in patients with kala - azar . serological tests , which are useful for the diagnosis of kala - azar , include elisa ( enzyme linked immunosorbent assay ) , direct agglutination test ( dat ) , indirect fluorescent antibody test ( ifat ) , and the rk39 dipstick test . elisa is widely performed , particularly in epidemiological studies , because it is very simple . anemia secondary to kala - azar is aregenerative because of bone medullar parasitic invasion . even without direct evidence of leishmania , this child s poor health condition coupled with the epidemiological , clinical , and biological presentations called for immediate treatment . in brazil , side - effects of this case s treatment drug of choice , meglumine antimoniate , include the following : i ) intolerance that usually appears after the first injections and consists of fever , chills , cough , myalgia , and/or skin rash . treatment discontinuation is mandatory if such intolerance occurs ; ii ) intoxication resulting in fever , cough , skin rash , polyneuritis , hepatitis , cardiac , and renal signs . alternative treatments for kala - azar include sodium stibogluconate , amphotericin b , liposomal amphotericin b , pentamidine , and paromycin . the cardinal sign of kala - azar is an anarchic type of fever resisting all forms of treatment . the disease always yields splenomegaly and is thought by many to produce the largest spleens in parasitology . contrary to adult manifestations , cutaneous signs such as erythematous , hyper- or hypopigmented papules and nodules of various sizes are rare in children . although not performed in the case reported , protein immunoelectrophoresis reveals hypergammaglobulinemia with an igg peak in patients with kala - azar . serological tests , which are useful for the diagnosis of kala - azar , include elisa ( enzyme linked immunosorbent assay ) , direct agglutination test ( dat ) , indirect fluorescent antibody test ( ifat ) , and the rk39 dipstick test . elisa is widely performed , particularly in epidemiological studies , because it is very simple . anemia secondary to kala - azar is aregenerative because of bone medullar parasitic invasion . even without direct evidence of leishmania , this child s poor health condition coupled with the epidemiological , clinical , and biological presentations called for immediate treatment . in brazil , the etiological agent of kala - azar is leishmania donovani . without treatment , side - effects of this case s treatment drug of choice , meglumine antimoniate , include the following : i ) intolerance that usually appears after the first injections and consists of fever , chills , cough , myalgia , and/or skin rash . treatment discontinuation is mandatory if such intolerance occurs ; ii ) intoxication resulting in fever , cough , skin rash , polyneuritis , hepatitis , cardiac , and renal signs . alternative treatments for kala - azar include sodium stibogluconate , amphotericin b , liposomal amphotericin b , pentamidine , and paromycin .