Thrombocytopenia in patients with dengue virus infection in the Brazilian Amazon.

Thrombocytopenia may be occasionally observed in dengue fever (DF) but is a constant feature and one of the diagnostic criteria of dengue hemorrhagic fever (DHF). Its clinical presentation and relevance is still poorly described in the literature. Patients with fever and bleeding were referred to a tertiary care center in Manaus, in the Western Brazilian Amazon during the outbreak of dengue in 2001. They were hospitalized for clinical observation and supportive care. Platelet counts were performed on admission and throughout the hospitalization. Only patients with a serological confirmation or viral isolation of the dengue virus were included. One hundred and seventy eight patients were enrolled in the study (118 with DF and 60 with DHF). There was no association between the presence of active bleeding and the degree of thrombocytopenia on admission (P = 0.302). A positive tourniquet test, hematemesis and ecchymoses were more frequent in DHF patients (P < 0.05). Patients with DHF had lower platelet counts than patients with DF (P < 0.001). There was a positive correlation between platelet counts and plasma albumin levels (r = 0.217; P = 0.016) and a negative correlation with ALT values (r = -0.3; P = 0.001). Clinical manifestations of thrombocytopenia are not related only to the number of peripheral platelets in dengue infection, but its recovery is associated with clinical improvement. The level of platelets correlates with the vascular leakage of proteins and liver damage.

The rarity of infection with Leishmania (Viannia) braziliensis among patients from the Manaus region of Amazonas state, Brazil, who have cutaneous leishmaniasis.

The frequency of Leishmania ( Viannia) braziliensis infection was assessed in 79 of the 138 patients with cutaneous leishmaniasis who attended a reference outpatient unit in Manaus, Amazonas state, between the August and December of 1997. The disease was characterized by one or more cutaneous ulcers, the skin lesions being frequently associated with satellite lymph-node enlargement. All parasite isolates were identified using monoclonal antibodies and enzyme electrophoresis. Only two (2.8%) of the 71 patients from whom parasites were successfully isolated were found to be infected with L. ( V.) braziliensis, the other 69 isolates being identified, from their isoenzyme profiles, as L. ( V.) guyanensis. In the Manaus region, therefore, almost all human cutaneous leishmaniasis is the result of infection with L. (V.) guyanensis, and L. ( V.) braziliensis is a relatively rare cause of the disease.

Comparison of cutaneous leishmaniasis due to Leishmania (Viannia) braziliensis and L. (V.) guyanensis in Brazil: therapeutic response to meglumine antimoniate.

We conducted a quasi-experimental study to compare the response to meglumine antimoniate in patients with localized cutaneous leishmaniasis from two endemic areas of Brazil that were infected by two Leishmania species. Sixty-one were infected by Leishmania (Viannia) braziliensis (group B) and 57 by L. (V.) guyanensis (group G). All had a parasitologically proven diagnosis and were treated with 20 mg of pentavalent antimonial (SbV)/kg/day given intravenously or intramuscularly for 20 days. Main outcomes were diagnosed using clinical criteria three months after treatment and patients were followed for six months. Intention-to-treat analysis showed a higher failure rate in group G (relative risk [RR] = 1.5, 95% confidence interval [CI] = 1.1-2.0, chi2 = 7.44, P = 0.006). The analysis using an explanatory approach including 52 patients from group B and 49 from group G, who were regularly treated and followed for six months, showed a low cure rate (50.8% in group B and 26.3% in group G) with a greater risk of failure in the latter group (RR = 1.7, 95% CI = 1.2-2.5, chi2 = 8.56, P = 0.003). The effect of the etiologic agent remained significant after adjusting for age, disease duration, and site and number of lesions that were identified as predictors of failure in a logistic regression model. We concluded that Leishmania species constitute an important factor in predicting the outcome of cutaneous leishmaniasis treated with a pentavalent antimonial.

[Evaluation of secondary bacterial infection's influence on the course of cutaneous leishmaniasis in Corte de Pedra, Bahia]. / Avaliação da influência da infecção bacteriana secundária na evolução da leishmaniose cutânea em Corte de Pedra, Bahia.

In order to study the prevalence of secondary bacterial infection in ulcerated lesions and its relationship to the healing process, 84 leishmaniotic patients were evaluated. Diagnosis of the secondary infection was made by bacterial aerobic culture of peripheral tissue specimen of the ulcer. All patients received antimonial therapy during 20 days and washed their ulcers with common soap. Cases were composed mainly of adolescent and adult farmer patients with single lesions. The evaluated ulcers were encountered on legs and feet in 47.6%. Secondary bacterial infection was found in 45/83 (54.2%), and was more frequent in lesions located below the knee. Staphylococcus aureus predominated (89%). The ulcers' healing process, evaluated in 79 patients one month after finishing treatment, was not influenced by the secondary bacterial infection.

Sensitivity of the polymerase chain reaction for the diagnosis of cutaneous leishmaniasis due to Leishmania (Viannia) guyanensis.

The sensitivity of the polymerase chain reaction (PCR) in 35 consecutive outpatients with cutaneous leishmaniasis caused by Leishmania (Viannia) guyanensis was evaluated using, as gold standard, the in vitro isolation of the parasite through culture of aspirates of the cutaneous ulcers. All isolates were identified using electrophoretic enzyme analysis. Patients were mainly young males with recent onset disease without prior specific treatment. PCR was performed using DNA extracted from fresh frozen biopsies of cutaneous ulcers. The reaction used a pair of oligonucleotides that amplify the conserved region of the minicircle molecule. PCR showed 100% sensitivity (95% CI from 90.0 to 100.0). These results were similar to the visualization of amastigotes in imprint preparations of cutaneous biopsy tissue and the inoculation of biopsy material in golden hamsters. Despite the high sensitivity of the PCR, in this particular clinical setting of cutaneous leishmaniasis caused by L. (V.) guyanensis in the Brazilian Amazon, it appears that the method of choice for diagnosis should be the direct visualization of amastigotes using imprint preparations and the PCR reserved for those patients with negative imprint results.

Avaliação da influência da infecção bacteriana secundária na evolução da leishmaniose cutânea em Corte de Pedra, Bahia / Evaluation of secondary bacterial infection's influence on the course of cutaneous leishmaniasis in Corte de Pedra, Bahia

In order to study the prevalence of secondary bacterial infection in ulcerated lesions and its relationship to the healing process, 84 leishmaniotic patients were evaluated. Diagnosis of the secondary infection was made by bacterial aerobic culture of peripheral tissue specimen of the ulcer. All patients received antimonial therapy during 20 days and washed their ulcers with common soap. Cases were composed mainly of adolescent and adult farmer patients with single lesions. The evaluated ulcers were encountered on legs and feet in 47.6%. Secondary bacterial infection was found in 45/83 (54.2%), and was more frequent in lesions located below the knee. Staphylococcus aureus predominated (89%). The ulcers' healing process, evaluated in 79 patients one month after finishing treatment, was not influenced by the secondary bacterial infection.

Foram avaliados 84 pacientes leishmanióticos com o objetivo de verificar a prevalência de infecção bacteriana secundária das úlceras cutâneas e de estudar sua relação com a cicatrização das lesões. A infecção secundária foi diagnosticada mediante cultura bacteriana aeróbica de amostra de tecido da lesão. Todos os pacientes receberam tratamento antimonial durante 20 dias e fizeram lavagem da úlcera com água e sabão comum. A casuística foi composta principalmente de adolescentes e de adultos dedicados à lavoura, apresentando lesão única. Em 47,6%, as úlceras estudadas estavam localizadas nas pernas e nos pés. Verificou-se infecção secundária em 45/83 (54,2%), sendo mais freqüente nas lesões localizadas abaixo dos joelhos. O Staphylococcus aureus predominou (88,9%). A reepitelização completa das úlceras, avaliada em 79 pacientes um mês após o fim do tratamento, não foi influenciada pela infecção secundária.

[Socioeconomic factors and attitudes towards household prevention of American cutaneous leishmaniasis in an endemic area in Southern Bahia, Brazil]. / Fatores sócio-econômicos e atitudes em relação à prevenção domiciliar da leishmaniose tegumentar americana, em uma área end emica do sul da Bahia, Brasil.

A survey was conducted to identify socioeconomic conditions and attitudes towards household prevention of American cutaneous leishmaniasis in Corte de Pedra, located in the county of Tancredo Neves, an endemic region in southern Bahia, Brazil. A questionnaire was applied in July 1997, focusing on social and economic variables, habits, and attitudes towards prevention of arthropod bites. All families (100%) living in the study area were surveyed, comprising 168 households with 851 individuals. Approximately 66.7% of the families earned up to one minimum wage, supporting an average of 5.1 residents per household. Most (57.2%) of the families did not use any type of protection against bites. Fumigation by burning various types of materials was the most customary form of prevention. Individual protection measures were rarely used. Since there was evidence of household and peridomiciliary transmission in the study area, use of impregnated bed nets is an alternative for intradomiciliary protection.

[Treatment of mucosal leishmaniasis with aminosidine sulfate: results of two year follow-up]. / Tratamento da leishmaniose mucosa com sulfato de aminosidine: resultados de dois anos de acompanhamento.

In 1996, 20 of 21 patients with mucosal leishmaniasis, treated in 1994 with aminosidine sulfate, 16mg/kg/day salt, by intramuscular injection for 20 days, were clinically evaluated. One patient died due to disease not related to mucosal leishmaniasis. Seven of 14 patients (66.7% N = 21) who achieved complete remission three months after treatment remained clinically cured 24 months later and seven relapsed in the same period (50% N = 14). Sorological follow-up showed poor correlation with the results of clinical examination.

Tratamento da leishmaniose mucosa com sulfato de aminosidine: resultados de dois anos de acompanhamento / Treatment of mucosal leishmaniasis with aminosidine sulfate: results of two year follow-up

In 1996, 20 of 21 patients with mucosal leishmaniasis, treated in 1994 with aminosidine sulfate, 16mg/kg/day salt, by intramuscular injection for 20 days, were clinically evaluated. One patient died due to disease not related to mucosal leishmaniasis. Seven of 14 patients (66.7% N = 21) who achieved complete remission three months after treatment remained clinically cured 24 months later and seven relapsed in the same period (50% N = 14). Sorological follow-up showed poor correlation with the results of clinical examination.

Em 1996 foram avaliados clinicamente 20 dos 21 pacientes com leishmaniose mucosa, tratados em 1994 com sulfato de aminosidine 16mg do sal/kg/dia, intramuscular, por 20 dias. Um paciente foi a óbito por causas não relacionadas com a leishmaniose mucosa. Dos 14 pacientes (66,7% N = 21) que inicialmente alcançaram a remissão completa dos sinais e sintomas durante os três primeiros meses de seguimento, sete (50% N = 14) permaneceram livres de doença por 24 meses e sete pacientes apresentaram recidiva neste período. O acompanhamento sorológico mostrou pobre correlação com a avaliação clínica.

Clinical observations of unresponsive mucosal leishmaniasis.

We report the long-term clinical follow-up of two patients with unresponsive mucosal leishmaniasis due to Leishmania (Viannia) braziliensis from the Três Braços area in Bahia State, Brazil. Both were agricultural male workers with extensive upper respiratory mucosal involvement that was not cured with conventional and experimental therapy.

[Open therapeutic study with aminosidine sulfate in mucosal leishmaniasis caused by Leishmania (Viannia) braziliensis]. / Estudo terapêutico aberto com sulfato de aminosidine na leishmaniose mucosa causada por Leishmania (Viannia) braziliensis.

From September to November 1994. 21 patients with active mucosal leishmaniasis were treated with aminosidine sulphate 16 mg/kg/day by intramuscular injection for 20 days. They were principally adult male agricultural workers. Thirteen patients had not received specific treatment and eight had failed to respond to Glucantime therapy. Diagnosis was based on clinical and epidemiological observations, a search for the parasite, leishmanin skin sensitivity and indirect fluorescent antibody serological tests. Sixty seven percent of patients had leishmania parasites isolated from inoculated hamsters or visualized in imprints or histopathological sections. The mean follow-up period was 12.6 months. All patients completed treatment. Side effects were pain at the injection site (86%); mild proteinuria (24%), elevated serum creatinine (.5%) and subclinical bearing loss in one of two patients who did audiometric tests. Clinical cure was achieved in 48% and the accumulated relapse rate was 29% (4/14).

[Comparative study of meglumine antimoniate, pentamidine isethionate and aminosidine sulfate in the treatment of primary skin lesions caused by Leishmania (Viannia) braziliensis]. / Estudo comparativo entre antimoniato de meglumina, isotianato de pentamidina e sulfato de aminosidine, no tratamento de lesões cutâneas primárias causadas por Leishmania (Viannia) braziliensis.

With the aim of comparing the therapeutic efficacy, tolerability and toxicity of meglumine antimoniate, aminosidine sulphate and pentamidine isethionate, a field study was conducted on randomized treatment of patients with primary cutaneous leishmaniasis due to Leishmania (Viannia) braziliensis (L(V)b), in Corte de Pedra, BA, from October 1992 up to January 1993. Forty six patients were treated and distributed into three groups, two with 15 and one with 16 subjects. All patients were submitted to clinical examination, histopathological and immunological investigations, as diagnostic criterium. All patients were treated by intramuscular route. Group 1 received pentamidine 4 mg/kg/every 2 days, for 8 applications; Group 2 received aminosidine 20 mg/kg/day, for 20 days, and Group 3 received meglumine 10 mg Sbv/kg/day, for 20 days. Failure of therapy was defined as ulceration of the skin lesion four months after treatment. Such failure occurred in five cases as follows: two cases in patients of group 1 one case in patients of group 2, and two cases in group 3, after the first year of follow up. In the evaluation after three years we reviewed fifteen patients, five in each group; except for one in Group 3, all of them were cured. Statistical significance of the results between the three schedules used was not verified.

[The first 13 years of controlling Chagas' disease in Mambaí, Goiás, Brazil 1980-1992]. / Los 13 primeros años del control de la enfermedad de Chagas en Mambaí, Goiás, Brasil, 1980-1992.

The Mambaí Project was launched in 1980 for the purpose of making a longitudinal clinical-epidemiologic study of Chagas' disease and of serving as a pilot program for the Ministry of Health of Brazil. At the beginning of the project, a census was carried out, the housing units were evaluated, and clinical examination and laboratory tests were performed on the population. After a phase of massive attack with insecticides, ongoing epidemiologic surveillance was instituted in order to detect residual foci of triatomine bugs in all the housing units in the municipality. The campaign included a program of health education combined with community participation. All infested housing units were selectively fumigated. In 1988 a new census was carried out, together with a serologic survey of children born after the control program was initiated. This article describes the results of epidemiologic surveillance during the first 13 years of the program. The prevalence of T. infestans in the housing units diminished to levels that suggest that vector transmission of the disease in Mambaí has been stopped. However, the risk of reinfestation from neighboring areas without control programs and the risk of colonization by secondary T. sordida vectors are factors that should be carefully monitored.

Importancia da repeticao do xenodiagnostico para avaliacao da parasitemia na fase cronica da doenca de Chagas. / The importance of repetition of xenodiagnosis for evaluation of parasitemia in the chronic phase of Chagas' disease

Selecionamos em Mambai (GO) 303 chagasicos com sorologia reagente, para estudo da parasitemia, realizada atraves de tres xenodiagnosticos feitos com Dipetalogaster maximus e Triatoma infestans. Duzentos e dez (69,3%) pessoas apresentaram xenodiagnosticos positivos. O primeiro exame detectou parasitemia em 125 (41,2%) chagasicos, o segundo em outros 59 (19,5%). Classificamos os chagasicos em tres graus de parasitemia conforme a relacao de "pools" examinados. Deste modo, 28 (9,2%) tiveram alta parasitemia e 202 (66,7%) baixa parasitemia, 73 (24,1%) media parasitemia e 202 (66,7%) baixa parasitemia. Nos individuos de alta e media parasitemia o Trypanosoma cruzi foi detectado nos dois primeiros xenodiagnosticos, enquanto nos de baixa parasitemia, a positividade de 22,8% no primeiro exame elevou-se para 41,1% e 54% no segundo e terceiro xenodiagnosticos, respectivamente. A repeticao do xenodiagnostico, especialmente nos individuos de baixa parasitemia, mostrou uma elevacao significativa da positividade

[Peripheral neurological changes in chronic Chagas' disease]. / Alterações neurológicas periféricas na doença de Chagas crónica.

The authors review the literature about the cronic nervous form of Chagas' disease, directing their attention toward peripheral neurological aspects. Specifically, they analyse the results obtained from a "bind" research realized in a small community in the countryside of the state of Bahia, Brazil, where a high frequency of infection by Trypanosoma cruzi is reported. From 99 individuals examined, 50 showed a positive sorological test for Chagas' disease. The most frequent neurological findings in the total of 99 individuals were sensory loss and impairment of the deep reflexes. Among those with abolition of deep reflexes, there were 18 cases carrying a positive sorology for Chagas' disease, being that 15 from these 18 cases additionally presented a mild sensory deficit, characterizing a polyneuritic syndrome. In conclusion, they suggest that there is a neuritic form, as subdivision of a nervous form of Chagas' disease, particularly identified as a mixed polyneuritis.