Leprosy and Lobomycosis: First report from the Amazon Region.

Leprosy is still a relevant health problem in Brazil with 31 044 new cases diagnosed in 2013, of which 781 new cases diagnosed in the State of Amazonas. Lobomycosis is a cutaneous-subcutaneous mycosis caused by Lacazia loboi, an in vitro uncultivable fungus. Lobomycosis has been mainly reported in the Amazon region of Brazil and Colombia affecting mainly male farmers and workers in extraction of rubber. Lobomycosis is clinically characterised by keloid-like lesions and chronic evolution. Even if lobomycosis does not represent a major public health problem, it remains a serious condition for patients due to unsatisfactory treatment. We report a case of an old man with lepromatous leprosy diagnosed in 1983, treated with multidrug therapy until 1989 and presenting a leprosy relapse 15 years after treatment. At this time a lobomycosis was also diagnosed in a keloid-like lesion evolving for more than 30 years. This co-infection has been only rarely reported and this is the first detailed case report in the English literature.

Risk factors for leprosy reactions in three endemic countries.

The objective of this study was to ascertain risk factors for complications (reactions or neuritis) in leprosy patients at the time of diagnosis in three leprosy-endemic countries. Newly diagnosed patients were enrolled in Brazil, the Philippines, and Nepal, and risk factors for reactions and neuritis were assessed using a case-control approach: "cases" were patients with these complications, and controls were patients without complications. Of 1,972 patients enrolled in this study, 22% had complications before treatment. Type 1 reaction was diagnosed in 13.7% of patients, neuritis alone in 6.9.%, and type 2 reaction in 1.4%. The frequency of these complications was higher in Nepal, in lepromatous patients, in males, and in adults versus children. Reactions and neuritis were seen in patients at diagnosis, before treatment was started. Reactions were seen in adults and children, even in patients with only a single lesion. Neuritis was often present without other signs of reaction. Reactions and neuritis were more likely to occur in lepromatous patients, and were more likely to be seen in adults than in children.

Case for diagnosis.

We report the case of a 81-year-old female patient who had a two-year history of violet-colored erythematous tumors on both legs. Histopathological and immunohistochemical examinations confirmed the diagnosis of primary cutaneous large B-cell lymphoma, leg type. This rare, cutaneous lymphoma affects predominantly elderly females. Clinically, patients present with tumoral lesions on one or both legs (worst prognosis). Diagnosis is based on clinical, histopathological and immunohistochemical findings. The strong expression of BCL2, BCL6, MUM-1 and CD20, and the positivity for Ki67 antigen confirm the diagnosis. R-CHOP chemotherapy regimen (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) is the most widely accepted treatment.

Case for diagnosis

We report the case of a 81-year-old female patient who had a two-year history of violet-colored erythematous tumors on both legs. Histopathological and immunohistochemical examinations confirmed the diagnosis of primary cutaneous large B-cell lymphoma, leg type. This rare, cutaneous lymphoma affects predominantly elderly females. Clinically, patients present with tumoral lesions on one or both legs (worst prognosis). Diagnosis is based on clinical, histopathological and immunohistochemical findings. The strong expression of BCL2, BCL6, MUM-1 and CD20, and the positivity for Ki67 antigen confirm the diagnosis. R-CHOP chemotherapy regimen (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) is the most widely accepted treatment.

Síndrome inflamatória da recuperação imune em hanseníase: relato de caso clínico / Immune reconstitution inflammatory syndrome in leprosy: report of a clinical case

Relatamos a ocorrência da Síndrome Inflamatória da RecuperaçãoImune (IRIS), após reversão de agranulocitose, induzida por poliquimioterapia,em paciente do sexo feminino acometida por hanseníasedimorfa-virchowiana. Propomos que em todos os pacientes submetidosà poliquimioterapia para hanseníase sejam efetuados periodicamenteexames laboratoriais que possam identificar precocementedistúrbios hematológicos graves

We report the occurrence of Immune Reconstitution InflammatorySyndrome (IRIS) after reversal of agranulocytosis provoked by drugor drugs used in the treatment of leprosy. After suspension of thedrugs under suspicion and the recovery of the hematologic disturbanceand as consequence the restoration of the immune conditionwe started an alternate treatment for Hansen’s disease. Takingthis case as an example, we propose that all patients with leprosyand under treatment with drugs such as dapsone and/ or rifampicinshould have a periodical hemogram to identify premature hematologicanomalies.

BCG revaccination does not protect against leprosy in the Brazilian Amazon: a cluster randomised trial.

BACKGROUND: Although BCG has been found to impart protection against leprosy in many populations, the utility of repeat or booster BCG vaccinations is still unclear. When a policy of giving a second BCG dose to school children in Brazil was introduced, a trial was conducted to assess its impact against tuberculosis, and a leprosy component was then undertaken in parallel. OBJECTIVE: to estimate the protection against leprosy imparted by a second dose of BCG given to schoolchildren. METHODS AND FINDINGS: This is a cluster randomised community trial, with 6 years and 8 months of follow-up. STUDY SITE: City of Manaus, Amazon region, a leprosy-endemic area in Brazil. PARTICIPANTS: 99,770 school children with neonatal BCG (aged 7-14 years at baseline), of whom 42,662 were in the intervention arm (revaccination). INTERVENTION: BCG given by intradermal injection. MAIN OUTCOME: Leprosy (all clinical forms). RESULTS: The incidence rate ratio of leprosy in the intervention over the control arm within the follow-up, in schoolchildren with neonatal BCG, controlled for potential confounders and adjusted for clustering, was 0.99 (95% confidence interval: 0.68 to 1.45). CONCLUSIONS/SIGNIFICANCE: There was no evidence of protection conferred by the second dose of BCG vaccination in school children against leprosy during the trial follow-up. These results point to a need to consider the effectiveness of the current policy of BCG vaccination of contacts of leprosy cases in Brazilian Amazon region.

Vitamin A and lipid peroxidation in patients with different forms of leprosy.

Leprosy, a chronic infectious disease, is caused by a Mycobacterium leprae infection. After India, Brazil has the second greatest number of cases in the world. Increase of oxidative stress and antioxidant deficiency are present in infected subjects and can be related to infection progression. We studied alterations in serum levels of lipid peroxidation (LPO) and vitamin A in patients with different forms of leprosy. Four groups of leprosy patients and a control group (healthy subjects) were selected, and their vitamin A serum levels and LPO profile, measured as malonaldehyde (MDA) were measured by spectrophotometric assays. The mean MDA serum levels (micromol/L) were 3.80 +/- 0.5 for control group and 10.54 +/- 1.1 in the leprosy patients and this increase was gradual, being more accentuated in severe forms of the disease. Also, the vitamin A serum levels (microg/dL) were diminished in the infected subjects (38.51 +/- 4.2), mainly in lepromatous form, when compared with the control group (53.8 +/- 5.6). These results indicate that LPO can be an important factor in Mycobacterium leprae infection, which can be related to increases in phagocytic activity and the general breakdown of antioxidants, contributing to an increase of LPO during infection progression. The evaluation of oxidant/antioxidant status in these patients can be an important factor in the treatment, control, and/or prognosis of this disease.

Vitamin A and lipid peroxidation in patients with different forms of leprosy

Leprosy, a chronic infectious disease, is caused by a Mycobacterium leprae infection. After India, Brazil has the second greatest number of cases in the world. Increase of oxidative stress and antioxidant deficiency are present in infected subjects and can be related to infection progression. We studied alterations in serum levels of lipid peroxidation (LPO) and vitamin A in patients with different forms of leprosy. Four groups of leprosy patients and a control group (healthy subjects) were selected, and their vitamin A serum levels and LPO profile, measured as malonaldehyde (MDA) were measured by spectrophotometric assays. The mean MDA serum levels (μmol/L) were 3.80 ± 0.5 for control group and 10.54 ± 1.1 in the leprosy patients and this increase was gradual, being more accentuated in severe forms of the disease. Also, the vitamin A serum levels (μg/dL) were diminished in the infected subjects (38.51 ± 4.2), mainly in lepromatous form, when compared with the control group (53.8 ± 5.6). These results indicate that LPO can be an important factor in Mycobacterium leprae infection, which can be related to increases in phagocytic activity and the general breakdown of antioxidants, contributing to an increase of LPO during infection progression. The evaluation of oxidant/antioxidant status in these patients can be an important factor in the treatment, control, and/or prognosis of this disease.

A hanseníase, doença infecciosa crônica, é causada pelo Mycobacterium leprae. Depois da índia, o Brasil possui o segundo maior número de casos no mundo. O aumento do estresse oxidativo e da deficiência das defesas antioxidantes estão presentes em indivíduos infectados e podem associar-se à progressão da infecção. Foram estudadas alterações nos níveis séricos da peroxidação lipídica e vitamina A em pacientes com diferentes formas de hanseníase. Foram selecionados para o estudo quatro grupos de pacientes com hanseníase e um grupo controle (indivíduos saudáveis) e os níveis séricos de vitamina A e a peroxidação lipídica, medida através do malondialdeído (MDA), foram determinados por métodos espectrofotométricos. Os níveis séricos médios de MDA (μmol/L) foram 3,80 ± 0,5 no grupo controle e 10,54 ± 1,1 nos pacientes com hanseníase. Sendo este aumento gradual e exacerbado nas formas mais severas da doença. Quanto à vitamina A, os níveis séricos (μg/dL) encontraram-se diminuídos nos indivíduos infectados (38.51 ± 4.2), principalmente na forma lepromatosa, quando comparados com o grupo controle (53.8 ± 5.6). Estes resultados indicam que a peroxidação lipídica pode ser um fator importante na infecção mediada pelo Mycobacterium leprae podendo estar relacionada ao aumento da atividade fagocítica pelos macrófagos contribuindo para um aumento da LPO durante a progressão da infecção. A avaliação do perfil oxidante/antioxidante nestes pacientes pode ser um fator importante no tratamento, controle e/ou prognóstico desta doença.

Talidomida no tratamento do eritema nodoso hansênico: revisão sistemática dos ensaios clínicos e perspectivas de novas investigações / Thalidomide in the treatment of erythema nodosum leprosum (ENL): systematic review of clinical trials and prospects of new investigations

FUNDAMENTOS: A hanseníase persiste como problema de saúde pública, e episódios de ENH são eventos agudos que ocorrem antes, durante e após PQT. Na última década, o uso da talidomida como agente imunomodulador foi expandido a outras doenças. OBJETIVOS: realizar revisão sistemática dos ensaios clínicos publicados sobre a eficácia e efeitos colaterais da talidomida no ENH. Descrever metodologia e resultados da triagem para recrutamento de ensaio clínico visando avaliar dose-resposta da talidomida seguida de desmame no ENH moderado e grave, realizado no Brasil. MÉTODOS: Analisaram-se ensaios publicados sobre talidomida no ENH. Foi delineado um ensaio clínico duplo-cego randomizado para avaliar dose de 100 thalid 300mg/dia de talidomida durante fase aguda de ENH, seguida de desmame da talidomida, thalid placebo. Para este ensaio clínico descreve-se metodologia e dados de recrutamento de pacientes, com ênfase na gravidade dos episódios de ENH. RESULTADOS: Os seis ensaios clínicos publicados nas décadas de 1960 e 1970 apontam para o benefício da talidomida no ENH, embora diferenças metodológicas dificultem a comparação. Na fase de recrutamento do ensaio brasileiro, dos 143 pacientes de ENH triados, 65 por cento eram potencialmente elegíveis. A associação com neurite em 56,4 por cento dos ENH moderados e graves exigiu co-intervenção com corticosteróide. CONCLUSÃO: O padrão de recrutamento dos pacientes evidenciou alta freqüência de neurite nos episódios de ENH. O esquema de talidomida isolada no ENH foi avaliado como infreqüente na prática clínica brasileira. O desafio atual é acumular evidências sobre a eficácia e efeitos colaterais da talidomida em associação com corticosteróides.

Campaña para la eliminación de la lepra Amazonas-Brasil. 1997

Se llevó a cabo una campaña para la eliminación de la lepra (LEC) en 15 áreas endémicas del Estado de Amazonas, Brasil, en 1997. La LEC concentró sus esfuerzos en la detección de lepra durante una campaña nacional de multivacunación de otros problemas sanitarios graves, como polio, difteria, hepatitis, sarampión, etc. La campanã nacional exigió una movilización de población muy intensa, proporcionando una valiosa oprotunidad para, al mismo tiempo, detectar nuevos casos de lepra. El personal de la LEC incluye 2.964 individuos (trabajadores sanitarios municipales y estatales y voluntarios de la comunidad), distribuidos en 688 unidades sanitarias y 53 centros sanitarios de referencia. Como resultado de la LEC se dieron 74.814 contactos directos persona a persona, 10.297 exámenes dermatológicos y se detectaron 40 nuevos casos de lepra el día de campaña en las z/onas urbanas de los municipios. Este resultado comparado con otros estados de Brasil es bajo, posiblemente debido al desarrollo de actividades educacionais sanitarias y servicios comunitarios en el estado de Amazonas desde 1987 y a la implantación de la multiterapia (MDT) de la OMS desde 1982. A pesar del hecho de que la LEC se llevó a cabo solamente en áreas urbanas de los municipios, al no encontrar casos de lepra en 7 de 15 municipios resultó sorprendente y puede indicar que la prevalencia de los casos ocultos no sea tan elevado, al menos en estas zonas del Estado de Amazonas.

Tuberculose cutânea no Brasil / Cutaneous tuberculosis in Brazil

Os aspectos clínicos, a epidemiologia, a etiopatologia e o diagnóstico da doença foram apresentados e debatidos pelos relatores do grupo de trabalho e médicos que participaram da reuniäo na qualidade de assistidos. As formas clínicas mais comuns no Brasil foram mencionadas, destacando-se o escofuloderma, a tuberculose cutânea indurativa de Bazin e a tuberculide papulóide necrótica. Criticou-se a ficha epidemiológica da Divisäo de Pneumologia Sanitária do Ministério da Saúde, em que a tuberculose cutânea näo aparece especificada, sendo registrada no item Outros. Uma revisäo dos principais estudos etiopatogênicos, o polimorfismo lesional e o grande acontecimento dos imunodeprimidos, principalmente os portadores da Aids, mereceram atençäo especial dos participantes. No diagnóstico foi ressaltada a grande contribuiçäo da técnica da PCR, que permite identificar a presença de raríssimas micobactérias, contribuindo para a precisäo diagnóstica.

Tinea pedis na cidade de Manaus-AM, Brasil / Tinea pedis in city of Manaus-AM, Brazil

De 1981 a 1985, foram atendidos 96 pacientes nas unidades de saude:Instituto de Dermatologia Tropical e Venereologia "Alfredo da Mata" IDIV-AM e Servico Medico do Instituto Nacional de Pesquisas da Amazonia (INPA), Manaus-Am. Os portadores de diagnostico clinico de Tinea Pedis (pe-de-atleta),foram submetidos ao exame micologico, os quais revelaram que dos segmentos podais mais afetados foram os da Regiao plantar (42,0%) e interdigital (26%). Das 99 especies fungicas isoladas, 74% eram dermatofitos e 26% de leveduras. Dentre as especies observadas, verificou-se que as mais frequentes por numero de ocorrencias foram: Trichophyton rubrum (35,5%), Trichophyton mentagrophytes (25%) e Candida sp. (25%)

Valor relativo do exame direto, após concentraçäo e por cultivo de escarro no diagnóstico bacteriológico da tuberculose pulmonar no Amazonas / Relative values of the direct simear exam, concentrated simear and culture of sputum in the diagnosis of pulmonares tuberculosis in the Amazonas - Brazil

Realizou-se o estudo do valor da baciloscopia direta no diagnóstico da tuberculose pulmonar, comparativamente à baciloscopia após concentraçäo e cultivo, de 610 amostras de escarro de pacientes que apresentavam sinais ou sintomas indicativos da doença. Detectou-se que a baciloscopia após concentraçäo e o cultivo säo quatro e dez vezes, respectivamente, mais eficazes que a baciloscopia direta. Observaram-se também resultados baciloscópicos falsos positivos para tuberculose devido à presença de micobactérias outras que näo o bacilo da tuberculose (MOTT), sugerindo doença micobacteriana (micobacteriose pulmonar) ou colonizaçäo da orofaringe

Mycobacteria other than tubercle bacilli in sputum specimens from patients in Manaus (Amazonia, Brasil)

Mycobacteria which are most commonly isolated in pulmonary secretions of patients with respiratory symptoms living in the state of Amazonas are given. The high percentage of isolates (25,4%) and the species obtained indicate a strong relationship of contamination of man by the environment. Among the species isolated, seven of them are considered potentially pathogenic mycobacteria. Since some of these species may interfere with present and further vaccination programs against tuberculosis and leprosy, these investigations indicate a necessity of carrying out studies of population awareness against specific PPD's prepared from the same species

Dermatofitoses na cidade de Manaus, AM / Dermatophytoses in the city of Manaus, AM, Brazil

De 1981 a 1985, 384 pacientes atendidos no Centro de Dermatologia Tropical e Venereologia Alfredo da Matta e Serviço Médico do INPA na cidade de Manaus-AM, com diagnóstico clínico de dermatofitoses, foram submetidos a exame micológico. Doze espécies de fungos dermatófitos foram agentes dos casos de tinea humana. Fazem-se comentários sobre as espécies mais prevalentes e fatores determinantes

Porocarcinoma / Porocarcinoma

Descreve-se um caso de porocarcinoma em paciente do sexo masculino, de 65 anos. Justifica-se o relato pela raridade e pela dificuldade de diagnóstico clínico e, às vezes, histopatológico, que o tumor pode apresentar

Tinea capitis na cidade de Manaus - AM / Tinea capitis in the city of Manaus - AM

Cento e quinze pacientes atendidos no Centro de Dermatologia Tropical e Venereologia Alfredo da Matta, na Cidade de Manaus, Amazonas, com diagnóstico clínico de Tinea capitis, foram submetidos a exame micológico. A faixa etária esteve entre um mês e 54 anos e o aspecto clínico mostrou, em 70 (60,85%), eritema e descamaçäo; em 16 (14,0%), eritema, descamaçäo e cotos pilosos e, em 29 (25,15%), lesöes inflamatórias. Procedimentos laboratoriais constataram de exame direto com KOH a 30% do material retirado das lesöes, semeio em Micosel e incubaçäo à temperatura ambiente (28-C a 30-C). Maior número de fungos dermatófitos isolados ocorreu na faixa escolar (37,0%) e no sexo feminino (52,2%). Os fungos isolados foram: Trichophyton tonsurans (91,7%), Trichophyton mentagrophytes (3,7%), Microsporum canis (1,9%), Trichophyton rubrum (0,9%), Microsporum audouinii (0,9%) e Microsporum gypseum (0,9%). A prevalência de fungos antropofílicos nos isolamentos evidencia que, näo obstante o processo de industrializaçäo e urbanizaçäo que vem se verificando na cidade, as condiçöes socioeconômicas da populaçäo continuam baixas, sendo este um dos fatores que contribuem para a propagaçäo e permanência da Tinea capitis