I refer to the article on sandfly fever (The Sunday Times, July 15). The parasitic organism (not viral) responsible for the infection (leishmaniasis) is endemic in the Mediterranean and has been recorded in Malta since at least 1909, although, even before that, the local medical profession knew about a morbid condition in children, below the age of five, characterised by splenic enlargement and profound anaemia.
It was then, not surprisingly, often confused with tuberculosis because both infections are accompanied by an enlarged spleen and a low white blood cell count, although experienced doctors knew the temperature chart of sandfly fever characteristically had two spikes every 24 hours.
Leishmaniasis may be disseminated within the body (sandfly fever or Kala Azar) or localised to the skin. These two different manifestations are probably due to the infected individual’s immunity. The disseminated form is usually eventually fatal if not diagnosed correctly and treated. Up to some decades ago, the benign cutaneous form of leishmaniasis was thought not to exist in Malta, until local dermatologists proved that it does.
The dangerous systemic leishmaniasis was considered rare inMaltese adults and not described before 1931, but had been noted in British residents since 1913. A form of leishmanisis confined to enlarged lymph glands was first described in 1958 in British soldiers stationed in Malta. I personally diagnosed a similar lymph gland case in Malta a few years ago in a Belgian resident.
Leishmaniasis is most likely to be acquired in the rural setting, and its incidence in Malta declined after the war with increased urbanisation.
The possibility of tourists from central and northern Europe returning home with leishmaniasis from the Mediterranean is not something new, and came to particular prominence in the 1980s when it became clear that HIV-infected individuals (both locals and tourists) were at increased risk of acquiring this infection.
Round about that time, Dr Anthony Galea Debono was looking after a haemophiliac patient terminally ill with Aids acquired from repeated American blood product infusions. This patient was comatose from suspected toxoplasmosis brain infection when he started bleeding from his back passage, and a rectal biopsy sent to me in the UK diagnosed his disseminated leishmaniasis. This case was quoted in British medical literature to illustrate the HIV-leishmaniasis link in Mediterranean countries.