Editor,—We read with interest the report by Grechet al.1 From their population based study, it seems that the annual incidence of visceral leishmaniasis (VL) declined considerably in Malta as a result of the eradication of stray dogs. VL is still endemic around the Mediterranean Sea and sporadic cases are reported in children living in Northern Europe. It seems likely that with increasing tourism the incidence of VL will also increase in areas where until recently this condition would not even be thought of. During the last 18 months, we have diagnosed three children with VL. As the presentation features can be fairly dramatic and physicians in Northern Europe are not always alert to the possibility of this condition, we would like to call attention again to the possibility of VL in non-endemic countries.

The main clinical features of the patients are shown in table 1. All three children presented with spiking high fevers, anorexia, hepatosplenomegaly, and pancytopenia. The onset of the symptoms was insidious and it took 3–12 weeks to establish the diagnosis. In all three patients this was achieved through bone marrow aspiration and the demonstration of the typical amastigotes in macrophages. The diagnosis was further confirmed through the demonstration of antibodies to the leishmania parasite. All three patients needed erythrocyte transfusions and patient three also needed platelet transfusions. A 5–10 day course of liposomal amphotericin-B was given to all three children. The treatment was well tolerated, and they all became afebrile within a week. Pancytopenia subsided over the ensuing 2–3 weeks and the children gradually returned to normal activity.

Naturally, we cannot draw epidemiological conclusions from such a small number of patients, but it is intriguing to find three unrelated cases within a relatively short time. While the eradication of stray dogs may go a long way to reduce the incidence of VL, vaccination would be more desirable.2 Although resistance and immunity against the leishmania parasites is not well understood, the seemingly increasing incidence of VL in children travelling from Northern Europe might be because they have no transplacental immunity against the parasite and are therefore more prone to develop this condition than local children. There is much in common between the presentation features of the haemophagocytic syndromes and VL. It is noteworthy that all three of our patients showed signs of macrophage activation and haemophagocytosis was observed in their bone marrow smears. With increased awareness of this condition by physicians in non-endemic countries, the time required to reach the correct diagnosis and institute treatment should be reduced.