Impact of El Niño on the dynamics of American cutaneous leishmaniasis in a municipality in the western Amazon.

Vector-borne diseases are some of the leading public health problems in the tropics, and their association with climatic anomalies is well known. The current study aimed to evaluate the trend of American cutaneous leishmaniasis cases in the municipality of Manaus, Amazonas-Brazil, and its relationship with climatic extremes (ENSO). The study was carried out using a series of secondary data from notifications on the occurrence of several American cutaneous leishmaniasis cases in the municipality of Manaus between 1990 and 2017 obtained through the Sistema de Informação de Agravos de Notificação. Data regarding temperature, relative humidity, and precipitation for this municipality were derived from the Instituto Nacional de Meteorologia (INMET) and the National Oceanic and Atmospheric Administration (NOAA) websites. Coherence and wavelet phase analysis was conducted to measure the degree of relationship of the occurrence of the cases of cutaneous leishmaniasis and the El Niño-Southern Oscillation (ENSO). The results show that during La Niña events, an increase in American cutaneous leishmaniasis (ACL) cases is anticipated after the increase in rainfall from November, resulting in a more significant number of cases in January, February, and March. It was observed that in the municipality of Manaus, the dynamics of ACL cases are directly influenced by ENSO events that affect environmental variables such as precipitation, temperature, and humidity. Therefore, climatic variations consequently change the ACL incidence dynamics, leading to subsequent increases or decreases in the incidence of ACL cases in the area.

The Selvester QRS score as an estimative of myocardial injury in acute chagasic patients from the Brazilian Amazon.

BACKGROUND: In the Brazilian Amazon, a new epidemiological profile of Chagas disease transmission, the oral route, has been detected and cited as being responsible for the increase in acute cases in Brazil. The clinical evaluation of acute Chagas disease (ACD) has been a challenge since it can progress to a chronic phase with cardiac alterations, and the follow-up by modern diagnostic methods is very difficult due to the socio-geographical characteristics of the Brazilian Amazon. Thus, alternatives should be sought to alleviate this problem. We conducted a study to evaluate subjects with ACD using the 12-lead ECG QRS score (Selvester score) as an estimative of myocardial injury progression before and after ACD treatment. METHODS: The study included indigenous subjects from the Amazon region with ACD in clinical follow-up at the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD) Chagas Disease outpatient clinic in the state of Amazonas, Brazil. The control group consisted of 31 healthy volunteers with no history of heart disease and no reactive serology for Chagas disease. Baseline ECG was performed in all subjects. The Selvester scoring method was performed according to the standardized guide (< 3 points: no myocardial injury,> 3: points × 3% = % of the predicted LV infarction). RESULTS: A total of 62 subjects were included, 31 as cases and 31 as controls. The mean follow-up of the case group was 17 months. The control group presented normal ECG. The case group presented 13 alterations before treatment and 11 after. Nineteen individuals presented scores > 3 points, 6 before and 13 after. In 19.36% of subjects, myocardial injury was found before treatment and in 41.94% after treatment. CONCLUSION: This is the first study that uses the Selvester score (SS) to predict myocardial injury in subjects with ACD. The results of this study suggest the significant presence of myocardial injury from the beginning of treatment to the period post treatment of ACD, which demonstrates that the SS can be applied for stratification and follow-up of Chagas disease in the Amazon region.

Association of miltefosine with granulocyte and macrophage colony-stimulating factor (GM-CSF) in the treatment of cutaneous leishmaniasis in the Amazon region: A randomized and controlled trial.

OBJECTIVES: To compare topical granulocyte and macrophage colony-stimulating factor (GM-CSF) and miltefosine (G + M) versus placebo and miltefosine (P + M) or parenteral meglumine antimoniate (MA) in the treatment of 150 patients with cutaneous leishmaniasis (CL) caused by Leishmania guyanensis in the Amazon. DESIGN: A randomized and double-blinded clinical trial. RESULTS: At 90 days after the initiation of therapy, the cure rates were 66%, 58%, and 52% for the groups P + M, G + M, and MA, respectively (p > 0.05). Cure rates at 180 days did not differ. Healing time was similar in the 3 groups, but faster in the MA group as compared to the G + M group (p = 0.04). Mild and transitory systemic adverse events were frequent in all groups (above 85%). Nausea (85%) and vomiting (39%) predominated in the miltefosine groups and arthralgia (51%) and myalgia (48%) in the MA group. One patient (group MA) stopped treatment after presenting with fever, exanthema, and severe arthralgia. CONCLUSIONS: Miltefosine did not present a higher cure rate than MA, and the association of GM-CSF did not improve the therapeutic response. Nevertheless, because of its less toxicity, easier administration, and a similar cure rate when compared with MA, miltefosine should remain as one of the main drugs for treating CL due to L. guyanensis. (Clinicaltrials.gov Identifier NCT03023111).

Cardiac Evaluation in the Acute Phase of Chagas' Disease with Post-Treatment Evolution in Patients Attended in the State of Amazonas, Brazil.

BACKGROUND: In the past two decades, a new epidemiological profile of Chagas' disease (CD) has been registered in the Brazilian Amazon where oral transmission has been indicated as responsible for the increase of acute cases. In the Amazonas state, five outbreaks of acute CD have been registered since 2004. The cardiac manifestations in these cases may be characterized by diffuse myocarditis, with alteration in the electrocardiogram (ECG) and transthoracic echocardiogram (TTE). OBJECTIVE: To perform a cardiac evaluation in autochthonous patients in the acute phase and at least one year after submitted to treatment for acute CD and evaluate the demographic variables associated with the presence of cardiac alterations. METHODS: We evaluated patients diagnosed with acute CD through direct parasitological or serological (IgM) methods from 2007 to 2015. These patients were treated with benznidazole and underwent ECG and TTE before and after treatment. We assumed a confidence interval of 95% (CI 95%, p < 0.05) for all variables analyzed. RESULTS: We observed 63 cases of an acute CD in which oral transmission corresponded to 75%. Cardiac alterations were found in 33% of the cases, with a greater frequency of ventricular repolarization alteration (13%), followed by pericardial effusion (10%) and right bundle branch block and left anterior fascicular block (2%). The follow-up occurred in 48 patients with ECG and 25 with TTE for a mean period of 15.5 ± 4.1 months after treatment. Of these, 8% presented normalization of the cardiac alterations in ECG, 62.5% remained with the normal exams. All of the patients presented normal results in TTE in the post-treatment period. As for the demographic variables, isolated cases presented more cardiac alterations than outbreaks (p = 0.044) as well as cases from Central Amazonas mesoregion (p = 0.020). CONCLUSIONS: Although cardiac alterations have not been frequent in most of the studied population, a continuous evaluation of the clinical-epidemiological dynamics of the disease in the region is necessary in order to establish preventive measures.

Cardiac Evaluation in the Acute Phase of Chagas' Disease with Post-Treatment Evolution in Patients Attended in the State of Amazonas, Brazil / Avaliação Cardíaca na Fase Aguda da Doença de Chagas com Evolução Pós-Tratamento em Pacientes Atendidos no Estado do Amazonas, Brasil

Abstract Background: In the past two decades, a new epidemiological profile of Chagas' disease (CD) has been registered in the Brazilian Amazon where oral transmission has been indicated as responsible for the increase of acute cases. In the Amazonas state, five outbreaks of acute CD have been registered since 2004. The cardiac manifestations in these cases may be characterized by diffuse myocarditis, with alteration in the electrocardiogram (ECG) and transthoracic echocardiogram (TTE). Objective: To perform a cardiac evaluation in autochthonous patients in the acute phase and at least one year after submitted to treatment for acute CD and evaluate the demographic variables associated with the presence of cardiac alterations. Methods: We evaluated patients diagnosed with acute CD through direct parasitological or serological (IgM) methods from 2007 to 2015. These patients were treated with benznidazole and underwent ECG and TTE before and after treatment. We assumed a confidence interval of 95% (CI 95%, p < 0.05) for all variables analyzed. Results: We observed 63 cases of an acute CD in which oral transmission corresponded to 75%. Cardiac alterations were found in 33% of the cases, with a greater frequency of ventricular repolarization alteration (13%), followed by pericardial effusion (10%) and right bundle branch block and left anterior fascicular block (2%). The follow-up occurred in 48 patients with ECG and 25 with TTE for a mean period of 15.5 ± 4.1 months after treatment. Of these, 8% presented normalization of the cardiac alterations in ECG, 62.5% remained with the normal exams. All of the patients presented normal results in TTE in the post-treatment period. As for the demographic variables, isolated cases presented more cardiac alterations than outbreaks (p = 0.044) as well as cases from Central Amazonas mesoregion (p = 0.020). Conclusions: Although cardiac alterations have not been frequent in most of the studied population, a continuous evaluation of the clinical-epidemiological dynamics of the disease in the region is necessary in order to establish preventive measures.

Resumo Fundamento: Nas últimas duas décadas, um novo perfil epidemiológico da Doença de Chagas (DC) foi registrado na Amazônia brasileira, onde a transmissão oral foi indicada como responsável pelo aumento dos casos agudos. No estado do Amazonas, foram registrados cinco surtos da doença desde 2004. As manifestações cardíacas nesses casos podem ser caracterizadas por miocardite difusa, com alteração nos resultados eletrocardiograma (ECG) e ecocardiografia transtorácica (ETT). Objetivo: avaliar parâmetros cardíacos em pacientes autóctones com DC na fase aguda e em um ano ou mais após tratamento, e avaliar as variáveis demográficas associadas com a presença de alterações cardíacas. Métodos: Avaliamos os pacientes diagnosticados com DC aguda por método direto parasitológico e exame sorológico (IgM) entre 2007 e 2015. Os pacientes foram tratados com benzonidazol e submetidos à ECG e ETT antes e após tratamento. Assumimos um intervalo de confiança de 95% (p < 0,05) para todas as variáveis analisadas. Resultados: Observamos 63 casos de DC aguda em que a transmissão oral ocorreu em 75% dos casos. Alterações cardíacas foram encontradas em 33% dos casos, com maior frequência de repolarização ventricular (13%), seguida de derrame pericárdico (10%), e bloqueio do ramo direito e bloqueio fascicular anterior esquerdo (2%). O acompanhamento foi realizado com 48 pacientes com ECG e 25 com ETT por um período médio de 15,5±4,1 meses após o tratamento. Desses pacientes, observou-se normalização das alterações eletrocardiográficas em 8% dos pacientes, e 62,5% continuaram com os parâmetros normais. Todos os pacientes apresentaram resultados da ETT normais no período pós-tratamento. Quanto às variáveis demográficas, os casos isolados apresentaram mais alterações cardíacas em comparação aos casos de surtos (p=0,044) e os casos identificados na mesorregião do Amazonas Central (p = 0,020). Conclusões: Apesar de as alterações cardíacas não terem sido frequentes na maioria da população do estudo, é necessária uma avaliação contínua da dinâmica clínica-epidemiológica da doença na região para se estabelecer medidas preventivas.