Immunoenzymatic assay for the diagnosis of American tegumentary leishmaniasis using soluble and membrane-enriched fractions from infectious Leishmania (Viannia) braziliensis.

The diagnosis of American tegumentary leishmaniasis (ATL) is based on the visualization or isolation of the parasite, which is a time-consuming and poorly sensitive method. In this study, we evaluated the accuracy and reliability of ELISA for the diagnosis of ATL using soluble (SF) and membrane-enriched (MF) antigen fractions obtained from an infectious strain of Leishmania (Viannia) braziliensis. A total of 152 serum samples investigated at a referral center in Rio de Janeiro, Brazil, between 2005 and 2007 were studied. Each sample was tested twice with each fraction for the calculation of reliability (intraclass coefficient (ICC)). Cut-off values of 0.22 (SF) and 0.33 (MF) were defined. The use of the fractions resulted in good discrimination between patients, with a large area under the curve (P<0.0001), but no difference was observed between the two fractions (P=0.45). Sensitivity was 89.5% for each fraction, specificity was 89.5% for SF and 93.4% for MF, and the positive likelihood ratio was 8.5 for SF and 13.6 for MF. The ICCs were excellent (SF: 0.96 and MF: 0.90). The antigens tested provided precision and accuracy for the diagnosis of ATL, with SF being recommended due to its lower cost and greater practicality.

Favorable responses to treatment with 5 mg Sbv/kg/day meglumine antimoniate in patients with American tegumentary leishmaniasis acquired in different Brazilian regions.

INTRODUCTION: Favorable responses in American tegumentary leishmaniasis (ATL) patients to treatment with 5 mg Sbv/kg/day meglumine antimoniate (MA) has been reported in Rio de Janeiro, but little is known regarding the therapeutic response to low doses in patients from other locations. METHODS: A retrospective review of medical records was conducted to compare the therapeutic response to 5 mg Sbv/kg/day MA treatment among 36 patients who acquired ATL in Brazilian states other than Rio de Janeiro (OS group) and 72 patients from Rio de Janeiro (RJ group). RESULTS: One course of 5 mg Sbv/kg/day MA cured 72.8% of 81 cutaneous (CL) and 66.6% of 27 mucosal (ML) leishmaniasis-infected patients: 70% in the CL/RJ group, 81% in the CL/OS group, 50% in the ML/RJ group, and 80% in the ML/OS group. After up to two additional treatment courses at the same dose, 88.9% and 85.2% of the CL and ML patients were cured, respectively. Adverse events were observed in 40% of patients in the CL/RJ group, 57% of the CL/OS group, 58% of the ML/RJ group, and 80% of the ML/OS group. No significant differences were observed in the cure rates or adverse effects between the RJ and OS groups. No patients required permanent discontinuation of treatment due to adverse events. CONCLUSIONS: Patients with ATL acquired in both RJ and OS may respond to low-dose MA. While high-dose MA should remain the standard treatment for ATL, low-dose MA might be preferred when toxicity is a primary concern.

Intestinal helminth coinfection is associated with mucosal lesions and poor response to therapy in American tegumentary leishmaniasis.

The most severe clinical form of American tegumentary leishmaniasis (ATL) due to Leishmania braziliensis is mucosal leishmaniasis (ML), characterized by destructive lesions in the facial mucosa. We performed a retrospective cohort study of 109 ATL patients from Rio de Janeiro State, Brazil, where ATL is caused by L. braziliensis, to evaluate the influence of intestinal parasite coinfections in the clinical course of ATL. Parasitological stool examination (PSE) was performed with samples from all patients by the sedimentation, Kato-Katz and Baermann-Moraes methods. The diagnosis of ATL was made from lesion biopsies by direct observation of amastigotes in Giemsa-stained imprints, isolation of Leishmania promastigotes or histopathological examination. All patients were treated with meglumine antimoniate. Patients with positive PSE had a frequency of mucosal lesions significantly higher than those with negative PSE (p<0.005). The same was observed for infections with helminths in general (p<0.05), with nematodes (p<0.05) and with Ascaris lumbricoides (p<0.05), but not for protozoan infections. Patients with intestinal parasites had poor response to therapy (therapeutic failure or relapse) significantly more frequently than the patients with negative stool examination (p<0.005). A similar difference (p<0.005) was observed between patients with positive and negative results for intestinal helminths, but not for intestinal protozoa. Patients with positive PSE took significantly longer to heal than those with negative PSE (p<0.005). A similar difference was observed for intestinal helminth infections (p<0.005), but not for protozoan infections. Our results indicate a deleterious influence of intestinal helminth infections in the clinical course of ATL and evidence for the first time an association between ML and these coinfections, particularly with nematodes and A. lumbricoides.

Favorable responses to treatment with 5 mg Sbv/kg/day meglumine antimoniate in patients with American tegumentary leishmaniasis acquired in different Brazilian regions

Abstract INTRODUCTION: Favorable responses in American tegumentary leishmaniasis (ATL) patients to treatment with 5 mg Sbv/kg/day meglumine antimoniate (MA) has been reported in Rio de Janeiro, but little is known regarding the therapeutic response to low doses in patients from other locations. METHODS: A retrospective review of medical records was conducted to compare the therapeutic response to 5 mg Sbv/kg/day MA treatment among 36 patients who acquired ATL in Brazilian states other than Rio de Janeiro (OS group) and 72 patients from Rio de Janeiro (RJ group). RESULTS: One course of 5 mg Sbv/kg/day MA cured 72.8% of 81 cutaneous (CL) and 66.6% of 27 mucosal (ML) leishmaniasis-infected patients: 70% in the CL/RJ group, 81% in the CL/OS group, 50% in the ML/RJ group, and 80% in the ML/OS group. After up to two additional treatment courses at the same dose, 88.9% and 85.2% of the CL and ML patients were cured, respectively. Adverse events were observed in 40% of patients in the CL/RJ group, 57% of the CL/OS group, 58% of the ML/RJ group, and 80% of the ML/OS group. No significant differences were observed in the cure rates or adverse effects between the RJ and OS groups. No patients required permanent discontinuation of treatment due to adverse events. CONCLUSIONS: Patients with ATL acquired in both RJ and OS may respond to low-dose MA. While high-dose MA should remain the standard treatment for ATL, low-dose MA might be preferred when toxicity is a primary concern.

Molecular identification and typing of Mycobacterium massiliense isolated from postsurgical infections in Brazil.

OBJECTIVE: One hundred thirty-one cases of postsurgical infections were reported in Southern Region of Brazil between August 2007 and January 2008. Thirty-nine (29.8%) cases were studied; this report describes epidemiological findings, species identification, antimicrobial susceptibility and clonal diversity of rapidly growing mycobacteria isolated in this outbreak. METHODS: All 39 isolates were analyzed by Ziehl-Nielsen stained smear, bacterial culture and submitted to rpoB partial gene sequencing for identification. The isolates were also evaluated for their susceptibility to amikacin, cefoxitin, clarithromycin, ciprofloxacin, doxycycline, tobramycin and sulfamethoxazole. RESULTS: Thirty-six isolates out of the confirmed cases were identified as Mycobacterium massiliense and the remaining three were identified as Mycobacterium abscessus, Mycobacterium chelonae and Mycobacterium fortuitum. All M. massiliense isolates were susceptible to amikacin (MIC90 = 8 µg/mL) and clarithromycin (MIC90 = 0.25 µg/mL) but resistant to cefoxitin, ciprofloxacin, doxycycline, tobramycin and sulfamethoxazole. Molecular analysis by pulsed-field gel electrophoresis clustered all 36 M. massiliense isolates and showed the same pattern (BRA 100) observed in three other outbreaks previously reported in Brazil. CONCLUSIONS: These findings suggest a common source of infection for all patients and reinforce the hypotheses of spread of M. massiliense BRA100 in Brazilian hospital surgical environment in recent years.

Avaliação da influência da espécie de Leishmania e da coinfecção por parasitos intestinais no curso clínico e resposta terapêutica da leishmaniose tegumentar americana em pacientes tratados com 5mg SbV/Kg/dia de antimoniato de meglumina

A leishmaniose tegumentar americana (LTA) é um agravo que apresenta ampla complexidade em diferentes aspectos, fato que pode ser resultante da interação entre a resposta imunológica do paciente, das características genéticas das espécies envolvidas na infecção, aspectos epidemiológicos da área endêmica e possíveis coinfecções. No estado do Rio de Janeiro a LTA é causada predominantemente por L. braziliensis, com quadros clínicos variados e boa resposta terapêutica ao antimoniato de meglumina, entretanto, o mesmo cenário não é observado em outras regiões do Brasil, onde circulam outras espécies de Leishmania. Além disso, pouco se sabe sobre a influência das coinfecções por parasitos intestinais no perfil clínico e resposta terapêutica na LTA. Com base nisto, objetivamos verificar a influência da espécie de Leishmania e a ocorrência de coinfecções por parasitos intestinais no curso clínico e terapêutico da LTA. A população do estudo foi constituída por 217 pacientes, provenientes de várias regiões do Brasil, tratados com baixa dose (5mg/Kg/dia) de SbV(antimonial pentavalente). Para caracterização das espécies de Leishmania foi utilizada a técnica de eletroforese de isoenzimas e os parasitos intestinais foram diagnosticados através das técnicas de Kato-Katz, sedimentação e Baermann-Moraes. Os resultados foram reunidos em dois artigos científicos. No artigo 1, comparamos o desfecho clínico de pacientes com LTA oriundos do estado do Rio de Janeiro (RJ) com pacientes infectados em outros estados (OE). Considerando a utilização de 5mg SbV/Kg/dia por 30 dias, cura foi observada em 72% (n=78) dos 108 pacientes estudados, dos quais 59% (n=64) estavam infectados por L. braziliensis Considerando todos os pacientes que necessitaram de cursos adicionais com a mesma dose, 88,9% dos pacientes curaram com 5mg SbV/Kg/dia. Não houve diferença estatisticamente significante entre os grupos RJ e OE (p=0,254). Uma maior variabilidade genética de L. braziliensis foi encontrada em isolados de OE quando comparados aos do RJ. Dados clínicos ou demográficos não foram associados à falha terapêutica. No artigo 2, 109 pacientes foram estudados, comparando casos de LTA coinfectados e não coinfectados por parasitos intestinais. Nos pacientes coinfectados por helmintos, foi observada uma freqüência maior de lesões mucosas e má resposta terapêutica (falha e recidiva) quando comparados aos casos com exame parasitológico de fezes negativo e os que tiveram infecções por protozoários. Dentro do grupo de helmintos, os nematódeos, em especial Ascaris lumbricoides, tiveram associação com o desenvolvimento da forma mucosa da LTA. Além disso, no grupo de pacientes coinfectados com helmintos, o tempo de cura das lesões foi maior em relação aos não parasitados. Como conclusão geral do nosso estudo, pacientes com LTA causada por L. braziliensis de OE responderam de forma satisfatória ao tratamento com SbV em baixa dose, quando comparados aos casos oriundos do RJ. Mesmo que preliminar, esse dado sugere que o esquema de baixa dose de SbV, utilizado há vários anos no RJ, possa ser estendido para outras regiões do Brasil. Já com relação ao parasitismo intestinal, concluímos que a infecção por helmintos exerce uma influência deletéria no curso clínico e terapêutico na LTA, devendo ser um aspecto a ser considerado durante o manejo do paciente.

Molecular identification and typing of Mycobacterium massiliense isolated from postsurgical infections in Brazil

OBJECTIVE: One hundred thirty-one cases of postsurgical infections were reported in Southern Region of Brazil between August 2007 and January 2008. Thirty-nine (29.8 percent) cases were studied; this report describes epidemiological findings, species identification, antimicrobial susceptibility and clonal diversity of rapidly growing mycobacteria isolated in this outbreak. METHODS: All 39 isolates were analyzed by Ziehl-Nielsen stained smear, bacterial culture and submitted to rpoB partial gene sequencing for identification. The isolates were also evaluated for their susceptibility to amikacin, cefoxitin, clarithromycin, ciprofloxacin, doxycycline, tobramycin and sulfamethoxazole. RESULTS: Thirty-six isolates out of the confirmed cases were identified as Mycobacterium massilienseand the remaining three were identified as Mycobacterium abscessus, Mycobacterium chelonae and Mycobacterium fortuitum. All M. massiliense isolates were susceptible to amikacin (MIC90 = 8 µg/mL) and clarithromycin (MIC90 = 0.25 µg/mL) but resistant to cefoxitin, ciprofloxacin, doxycycline, tobramycin and sulfamethoxazole. Molecular analysis by pulsed-field gel electrophoresis clustered all 36 M. massiliense isolates and showed the same pattern (BRA 100) observed in three other outbreaks previously reported in Brazil. CONCLUSIONS: These findings suggest a common source of infection for all patients and reinforce the hypotheses of spread of M. massiliense BRA100 in Brazilian hospital surgical environment in recent years.