Avoid strenuous activity until spleen size normalizes
Risk of splenic rupture with trauma or contact sports during active disease
No contact sports until cleared by your doctor
Return to emergency department immediately for
Red flags requiring urgent return
Fever returning after initially resolving
Sudden severe abdominal pain (may indicate splenic rupture)
Heavy nosebleed not controlled with 15 minutes of pressure
Unusual bruising or skin bleeding
Confusion, difficulty thinking clearly, or extreme weakness
Difficulty breathing or chest pain
New skin lesions or spots appearing
Follow-up appointments
Scheduled follow-up with infectious disease specialist
Blood test at end of treatment to confirm response
Blood test again at 6 months to confirm cure
Contraception reminder if you received miltefosine
Use effective contraception during treatment and for 5 months after last dose
Do not become pregnant during this period — medication is harmful to a fetus
Prevent future sandfly bites
Use DEET-based repellent on exposed skin at dawn and dusk
Sleep under permethrin-treated bed nets
Wear long sleeves and pants in endemic areas
References
Guidelines and key sources
IDSA/ASTMH Clinical Practice Guidelines
Aronson N et al. Diagnosis and Treatment of Leishmaniasis: Clinical Practice Guidelines by IDSA and ASTMH. Clin Infect Dis. 2016
Foundational North American guideline for VL management
Covers drug selection, dosing, HIV-VL, and follow-up
IDSA/ASTMH guidelines recommend infectious disease consultation and CDC assistance for all US VL cases
WHO and international guidance
WHO control strategies: indoor residual spraying, active case detection, treatment access
Combination therapy now conditionally recommended for HIV-VL coinfection
van Griensven J et al. Status of Combination Therapy for VL: An Updated Review. Lancet Infect Dis. 2024
Current evidence base for combination regimens
Key clinical studies
Liposomal AmB and miltefosine evidence
Burza S et al. AmBisome Monotherapy and Combination AmBisome-Miltefosine for VL in HIV Patients in India. Clin Infect Dis. 2022
Randomized open-label phase 3 trial
Combination superior to monotherapy in HIV-VL
Sundar S et al. Short-Course Multidrug Treatment vs. Standard Therapy for VL in India. Lancet. 2011
Non-inferiority RCT supporting combination approaches in South Asia
Diagnostic studies
Boelaert M et al. Rapid Tests for Diagnosis of VL in Patients With Suspected Disease. Cochrane Database Syst Rev. 2014
rK39 RDT validated as best-performing rapid diagnostic tool
Sensitivity varies by region and immune status
Epidemiologic and surveillance
Pareyn M et al. Leishmaniasis. Nature Reviews Disease Primers. 2025
Comprehensive updated review of all forms of leishmaniasis
Burza S, Croft SL, Boelaert M. Leishmaniasis. Lancet. 2018
Seminal review with epidemiology, pathophysiology, and treatment
Coffeng LE et al. Effect of Indoor Residual Spraying on VL Incidence in India 2016–2022. Lancet Infect Dis. 2024
Demonstrated impact of vector control on VL incidence
Nutritional and HLH evidence
Custodio E et al. Nutritional Supplements for Patients With Active VL. Cochrane Database Syst Rev. 2018
Insufficient evidence for specific supplements; supportive nutrition recommended
Renna Bertoli M et al. VL as Cause or Mimicker of HLH: Diagnostic Challenges. Pediatr Infect Dis J. 2026
HLH-04 criteria limits in VL-HLH overlap — treat VL first
CDC resources
Abbott A, Chancey RJ, Roy SL. Leishmaniasis. CDC Yellow Book. 2025
Up-to-date travel medicine reference for VL diagnosis and treatment
CDC contact: parasiteslab@cdc.gov or 404-718-4175
Benson C et al. Guidelines for Prevention and Treatment of OIs in Adults With HIV. IDSA/OARAC. 2025
Secondary prophylaxis and ART considerations in HIV-VL
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.