This is the first published data on VL among children in Gadarif, eastern Sudan which is populated by 1,7 million inhabitants. The current study showed significant association between residence, male gender and VL among children and nearly one half (48.9%) of VL patients had severe anaemia.. Severe VL epidemics are reported in poor communities and poor people in developing and middle income countries such as Nepal and India [
7]. Anaemia is a common public health problem in eastern Sudan where 36.2% of the adults had anaemia [
8]; the common causes of anaemia in this area include: chronic illness, followed by nutritional and repeated malaria infection [
9]. Severe VL epidemics have been reported in the past: in Southern Sudan, in a context of civil war and at that time VL killed an estimated 100,000 people out of a population of 280,000 between 1984 and 1994 [
10]. Rapid urbanization, and human migration are known risk factors that potentiate the spread of the disease. Gadarif state is bordering two neighbouring countries (Ethiopia and Eretria) and characterized by poverty with nomads and refugees and this might explain the prevalence of the infection in this area of Sudan. Interestingly 25.8% of the patients were initially misdiagnosed and mistreated as cases of febrile illness such as malaria. This is attributed to the lack of proper diagnostic facilities and low priority of leishmaniasis in our setting. Furthermore this may be another problem added to the probability of relapses due to loss of follow up and clinical complications. Thus health care providers generally need high clinical suspicion to diagnose VL. The clinical presentation of VL in children in the majority of the cases is more severe than in adults, commonly with severe anaemia. In our cases, fever and pallor, weight loss and lymphadenopathy were the most common clinical presentations. The clinical presentation of VL is similar in the various endemic areas. However lymphadenopathy is rarely found in Indian VL patients but it is frequent in Sudanese VL patients [
11]. In a study conducted by
Rai et al., majority of the patients (98%) presented with fever followed by abdominal distension (47%), pallor (44%), weight loss (43%), diarrhoea (17%), vomiting (15%) and hepatosplenomegaly (83%) [
12]. Again and in consistent with our results, weight loss, hepatosplenomegaly, lymphadenopathy and prolonged fever were the most common clinical signs reported by
Walyeldin and his colleagues in Omdurman Emergency Hospital for Children (OEHC), Sudan, 2006–2008 [
6]. The severity of anaemia in children with VL in this study is also seen in other studies [
13].
Alvar J et al. also mentioned that children with VL suffer more severe anaemia than adults [
14]. In our study anaemia was seen in all patients while severe anaemia was reported in 23 cases which is in line with studies conducted in Kashmir and Peshawar where anaemia was seen in all (100%) cases of VL [
15,
16]. The reported complications of VL among our investigated children in this study include: pneumonia, otitis media, septicaemia, urinary tract infection, parasitic infestation and PKDL. While PKDL is not rare in Sudanese VL patients, liver impairment and jaundice are a rare finding [
13]. Complications in eyes and mucous membranes were seen but rare. The interval between treated VL and PKDL is 0–6 months in Sudan and 6 months to 3 years in India [
17]. In this study 85% respond to sodium stibogluconate (Pentostam ®) which is not different from studies in other areas, for example studies conducted by
Kirk and
Satti early in 1940 [
18] and
Khalil et al. in 1998 [
19]. In agreement with our study
Ali Shah et al. in Peshawar [
16] and a study from Muzaffarabad [
20] showed a male to female ratio of 2:1. However in contrast to our study
Qasmi et al., in Morocco, reported a higher mean age and a female predominance in children with leishmaniasis [
20]. Male predominance in our study could be easily justified by the fact that the male children usually work with their fathers in the farms and thus there is greater chance to be exposed to the sand fly. In our study there was significant correlation between VL and rural residence. Visceral leishmaniasis affects poor communities, generally in remote rural areas. Patients and families affected by VL become poorer because of the high direct costs (for example, the costs of VL diagnosis and treatment) and indirect costs (for example, loss of household income) of the disease [
7,
21].