A comparison of intercostal and abdominal routes of splenic aspiration and bone marrow aspiration in the diagnosis of visceral leishmaniasis.

Two hundred and seventy patients with febrile splenomegaly and coming from areas where visceral leishmaniasis (VL; kala-azar) is endemic and in whom the diagnosis of kala-azar was strongly suspected were randomly divided into 3 groups, subjected to splenic aspiration by the intercostal route, splenic aspiration by the abdominal route, and bone marrow aspiration, respectively, for demonstration of amastigotes. Pain immediately after aspiration, requiring a few analgesic tablets, occurred in 8, 16 and 20 patients of the 3 groups, respectively. Pain on the day after aspiration was reported by 2, 4 and 6 patients, respectively. One patient, in the abdominal group, developed gastro-intestinal haemorrhage but this was managed with blood transfusion; he was not suffering from VL. No patient died. The abdominal route of splenic aspiration was not feasible in 12 patients (13%), as their spleen size was less than 3 cm, and they were subsequently aspirated by the intercostal route. On the first aspiration, amastigotes were seen in 68 patients (76%) in the intercostal group, 64 patients (71%) in the abdominal group and 42 patients (46%) in the bone marrow group. Two weeks later, 15 patients (17%) in the bone marrow group and in whom amastigotes had not been detected, but whose fever continued, were subjected to intercostal splenic aspiration and amastigotes were detected. After 2 months, 3 patients in the intercostal group and 4 patients in the abdominal group gave positive aspirates, and 2 patients in the intercostal group, one in the abdominal group, and one in the bone marrow group did so at the third aspiration. Thus only 200 (74%) of 270 patients were suffering from VL. It was concluded that, with some precautions, splenic aspiration is a safe and easy method for the diagnosis of VL, and the intercostal route is preferred because it is feasible in a larger proportion of cases and anatomically safer than the abdominal route, and it gives a positive result more often than bone marrow aspiration.