Update on oral Chagas disease outbreaks in Venezuela: epidemiological, clinical and diagnostic approaches.

Orally transmitted Chagas disease has become a matter of concern due to outbreaks reported in four Latin American countries. Although several mechanisms for orally transmitted Chagas disease transmission have been proposed, food and beverages contaminated with whole infected triatomines or their faeces, which contain metacyclic trypomastigotes of Trypanosoma cruzi, seems to be the primary vehicle. In 2007, the first recognised outbreak of orally transmitted Chagas disease occurred in Venezuela and largest recorded outbreak at that time. Since then, 10 outbreaks (four in Caracas) with 249 cases (73.5% children) and 4% mortality have occurred. The absence of contact with the vector and of traditional cutaneous and Romana's signs, together with a florid spectrum of clinical manifestations during the acute phase, confuse the diagnosis of orally transmitted Chagas disease with other infectious diseases. The simultaneous detection of IgG and IgM by ELISA and the search for parasites in all individuals at risk have been valuable diagnostic tools for detecting acute cases. Follow-up studies regarding the microepidemics primarily affecting children has resulted in 70% infection persistence six years after anti-parasitic treatment. Panstrongylus geniculatus has been the incriminating vector in most cases. As a food-borne disease, this entity requires epidemiological, clinical, diagnostic and therapeutic approaches that differ from those approaches used for traditional direct or cutaneous vector transmission.

Ten years follow-up of the largest oral Chagas disease outbreak: Cardiological prospective cohort study.

BACKGROUND: Chagas disease (ChD) is the most important endemy in Latin America. Some patients, develop chronic Chagasic cardiopathy (CCC) years after the acute phase. It is unknown if patients infected by the oral route have higher risk of developing early CCC. METHODS AND FINDINGS: A prospective cohort study was conducted to assess morbidity and mortality during 10 years observation in 106 people simultaneously infected and treated in the largest known orally transmitted ChD outbreak in 2007. A preschooler died during the acute phase, but thereafter was no mortality associated to ChD. All acute phase findings improved in the first-year post-treatment. Each person was evaluated 8.7 times clinically, 6.4 by electrocardiogram (ECG)/Holter, and 1.7 by echocardiogram. Based on prevalence, the number of people who had any abnormalities (excluding repolarization abnormalities and atrial tachycardia which decreased) was higher than 2007, since they were found at least once between 2008-2017. However, when we evaluated incidence, except for clinical bradycardia and dizziness, it was observed that the number of new cases of all clinical and ECG findings decreased at the end of the follow-up. Between 2008-2017 there was not incidence of low voltage complex, 2nd degree AV block, long QT interval, left bundle branch block or left ventricular dysfunction that allowed the diagnosis of CCC. Total improvement prevailed over the persistence of all clinical and ECG/Holter findings, except for sinus bradycardia. Incomplete right bundle branch block, sinus bradycardia and/or T-wave inversion were diagnosed persistently in 9 children. The second treatment did not have significant influence on the incidence of clinical or ECG/Holter findings. CONCLUSIONS: At the end of the 10-year follow-up, there were not clinical or ECG/Holter criteria for classifying patients with CCC. The incidence of arrhythmias and repolarization abnormalities decreased. However, special attention should be paid on findings that not revert as sinus bradycardia, or those diagnosed persistently in all ECG as sinus bradycardia, incomplete right bundle branch block or T-wave inversion. Early diagnosis and treatment may have contributed to the rapid improvement of these patients. In ChD follow-up studies prevalence overestimates the real dimension of abnormalities, the incidence looks as a better indicator.

The performance of laboratory tests in the management of a large outbreak of orally transmitted Chagas disease.

Orally transmitted Chagas disease (ChD), which is a well-known entity in the Brazilian Amazon Region, was first documented in Venezuela in December 2007, when 103 people attending an urban public school in Caracas became infected by ingesting juice that was contaminated with Trypanosoma cruzi. The infection occurred 45-50 days prior to the initiation of the sampling performed in the current study. Parasitological methods were used to diagnose the first nine symptomatic patients; T. cruzi was found in all of them. However, because this outbreak was managed as a sudden emergency during Christmas time, we needed to rapidly evaluate 1,000 people at risk, so we decided to use conventional serology to detect specific IgM and IgG antibodies via ELISA as well as indirect haemagglutination, which produced positive test results for 9.1%, 11.9% and 9.9% of the individuals tested, respectively. In other more restricted patient groups, polymerase chain reaction (PCR) provided more sensitive results (80.4%) than blood cultures (16.2%) and animal inoculations (11.6%). Although the classical diagnosis of acute ChD is mainly based on parasitological findings, highly sensitive and specific serological techniques can provide rapid results during large and severe outbreaks, as described herein. The use of these serological techniques allows prompt treatment of all individuals suspected of being infected, resulting in reduced rates of morbidity and mortality.

Large urban outbreak of orally acquired acute Chagas disease at a school in Caracas, Venezuela.

BACKGROUND: Trypanosoma cruzi oral transmission is possible through food contamination by vector's feces. Little is known about the epidemiology and clinical features of microepidemics of orally acquired acute Chagas disease (CD). METHODS: A case-control, cohort-nested, epidemiological study was conducted during an outbreak of acute CD that affected a school community. Structured interviews were designed to identify symptoms and sources of infection. Electrocardiograms were obtained for all patients. Specific serum antibodies were assessed by immunoenzimatic and indirect hemagglutination tests. In some cases, parasitemia was tested directly or by culture, animal inoculation, and/or a polymerase chain reaction technique. RESULTS: Infection was confirmed in 103 of 1000 exposed individuals. Of those infected, 75% were symptomatic, 20.3% required hospitalization, 59% showed ECG abnormalities, parasitemia was documented in 44, and 1 child died. Clinical features differed from those seen in vectorial transmission. The infection rate was significantly higher among younger children. An epidemiological investigation incriminated contaminated fresh guava juice as the sole source of infection. CONCLUSIONS: This outbreak was unique, because it affected a large, urban, predominantly young, middle-class, otherwise healthy population and resulted in an unprecedented public health emergency. Rapid diagnosis and treatment avoided higher lethality. Food-borne transmission of T. cruzi may occur more often than is currently recognized.

Ten-year follow-up of the largest oral Chagas disease outbreak. Laboratory biomarkers of infection as indicators of therapeutic failure.

Trypanosoma cruzi uses various mechanisms of infection to access humans. Since 1967, food contaminated with metacyclic trypomastigotes has triggered several outbreaks of acute infection of Chagas disease by oral transmission. Follow-up studies to assess the effectiveness of anti-parasitic treatment of oral outbreaks are rather scarce. Here, we report a 10-year laboratory follow-up using parasitological, serological, and molecular tests of 106 individuals infected in 2007 of the largest known outbreak of orally transmitted Chagas disease, which occurred in Caracas city, Venezuela. Before treatment (2007), specific IgA, IgM and IgG, were found in 71% (75/106), 90% (95/106) and 100% (106/106), respectively, in addition to 21% (9/43) parasitemia, Complement Mediated Lysis (CML) in 98% (104/106) and 79% (34/43) parasitic DNA for PCR. Blood culture detected parasitemia up to 18 months post-treatment in 6% (6/106) of the patients. In 2017, the original number of cases in the follow-up decreased by 46% and due to the country's economic situation, not all the trials could be carried out in the entire population. During follow-up, IgA and IgM disappeared promptly, with IgM persisting in 19% (20/104) of the patients three years after treatment. The anti-T. cruzi IgG remained positive 10 years later in 41% (20/49) of the individuals evaluated. CML remained positive seven years later in 79% (65/82) of the cases. PCR positive cases decreased after treatment but progressively recovered, being positive in 69% (32/46) of the individuals evaluated in 2017. The group of children (under 18 years of age) showed the highest PCR positivity with 76% (26/34) of the cases, but their parasitic load tended to diminish, while in adults the parasitic load regained their initial values. The simultaneous evaluation of serological tests and PCR of the patients allowed us to separate patients among responders and non-responders to the anti-parasitic treatment, and this information prompted us to apply a second anti-parasitic treatment in the group of non-responders. In this population not subjected to the like lihood of re-infection, adult patients were more likely to be non-responders when compared to children. These results suggest that rigorous laboratory follow-up with T. cruzi infectious biomarkers is essential to detect cases of parasite persistence.

Serum hyaluronan and collagen IV as non-invasive markers of liver fibrosis in patients from an endemic area for schistosomiasis mansoni: a field-based study in Brazil.

Non-invasive markers of fibrosis have been used to diagnose liver fibrosis in a variety of diseases. Hyaluronic acid (HA) and collagen IV (C-IV) levels were measured in the sera of patients from an endemic area for schistosomiasis in Brazil to diagnose and to rank the intensity of liver fibrosis. Seventy-nine adult patients with schistosomiasis, in the age range of 21-82 years (49 +/- 13.4) were submitted to clinical and ultrasonographic examinations. Ultrasound was employed to diagnose and categorise liver fibrosis according to World Health Organization patterns. Serum HA and C-IV levels were measured using commercial ELISA kits. Ultrasound revealed six patients with intense liver fibrosis, 21 with moderate, 23 with light and 29 without. Serum HA was able to separate individuals with fibrosis from those without (p < 0.001) and light from intense fibrosis (p = 0.029), but C-IV was not (p = 0.692). The HA diagnostic accuracy for fibrosis was 0.89. The 115.4 ng/mL cut-off level diagnosed patients with fibrosis (sensitivity 0.98, specificity 0.64). HA correlated positively with portal hypertension. Periportal fibrosis (subjective evaluation), age and collateral circulation predicted HA increase. In conclusion, we propose that serum HA can be used to identify patients with liver fibrosis in an endemic area for schistosomiasis mansoni in Brazil.

Clinical and ultrasound findings before and after praziquantel treatment among Venezuelan schistosomiasis patients.

Abdominal ultrasound can be a useful tool for diagnosing periportal fibrosis related to Schistosoma mansoni infection, and also for planning and monitoring the evolution of hepatic morbidity following control measures. We evaluated the standardized ultrasound methodology proposed by the World Health Organization for detecting periportal fibrosis and portal hypertension, among patients from an endemic area in Venezuela, and the impact of praziquantel treatment 3-5 years later. After chemotherapy, complete reversal of periportal lesions was observed in 28.2% of the cases and progression of the disease in 5.1%. Improvement in the hepatic disease started with a reduction in the periportal thickening followed by a decrease in the size of the left hepatic lobe, spleen and mesenteric and spleen veins. Ultrasound confirmed the clinical findings after chemotherapy among the patients with reversal of the disease. However, in patients with more advanced disease, these findings were contradictory. There was no correlation between evolution of the disease seen on ultrasound and age, intensity of infection or serological findings.

Long-term comparative pharmacovigilance of orally transmitted Chagas disease: first report.

BACKGROUND: Two old drugs are the only choice against Trypanosoma cruzi and little is known about their secondary effects in the acute stage of oral-transmitted Chagas disease (ChD). METHODS: A cross-sectional analytical surveillance study was conducted in a sizable cohort of patients seen during the largest acute foodborne ChD microepidemic registered so far. Individuals were treated with benznidazole (BNZ) or nifurtimox (NFX). 'Common Terminology Criteria for Adverse Events' was assessed to categorize side effects according to severity. RESULTS: Out of 176 treatments applied, 79% had one or more adverse effects, which predominated in adults (97.8%) as compared to children (75.5%). Risk of side effects with NFX was significantly higher than BNZ. Four adults and a child treated with NFX had severe side effects (pulmonary infarction, facial paralysis, neutropenia, blurred vision, bone marrow hypoplasia) warranting hospitalization, and drug suspension. Adverse effects frequently reported with NFX were abdominal pain, hyporexia, weight loss, headache, nausea and lymphocytosis, whereas skin rash, neurosensory effects, hyporexia, fatigue, pyrosis, abdominal pain and eosinophilia were observed with BNZ. CONCLUSIONS: Frequency and severity of side effects during treatment of acute oral infection by T. cruzi demand direct supervision and close follow-up, even in those asymptomatic, to prevent life-threatening situations.

Orally-transmitted Chagas disease: Epidemiological, clinical, serological and molecular outcomes of a school microepidemic in Chichiriviche de la Costa, Venezuela.

Oral transmission of Trypanosoma cruzi is a frequent cause of acute Chagas disease (ChD). In the present cross-sectional study, we report the epidemiological, clinical, serological and molecular outcomes of the second largest outbreak of oral ChD described in the literature. It occurred in March 2009 in Chichiriviche de la Costa, a rural seashore community at the central littoral in Venezuela. The vehicle was an artisanal guava juice prepared at the local school and Panstrongylus geniculatus was the vector involved. TcI genotype was isolated from patients and vector; some showed a mixture of haplotypes. Using molecular markers, parasitic loads were high. Eighty-nine cases were diagnosed, the majority (87.5%) in school children 6-15 years of age. Frequency of symptomatic patients was high (89.9%) with long-standing fever in 87.5%; 82.3% had pericardial effusion detected by echocardiogram and 41% had EKG abnormalities. Three children, a pregnant woman and her stillborn child died (5.6% mortality). The community was addressed by simultaneous determination of specific IgG and IgM, confirmed with indirect hemagglutination and lytic antibodies. Determination of IgG and IgA in saliva had low sensitivity. No individual parasitological or serological technique diagnosed 100% of cases. Culture and PCR detected T. cruzi in 95.5% of examined individuals. Based on the increasing incidence of oral acute cases of ChD, it appears that food is becoming one of the most important modes of transmission in the Amazon, Caribbean and Andes regions of America.

Update on oral Chagas disease outbreaks in Venezuela: epidemiological, clinical and diagnostic approaches

Orally transmitted Chagas disease has become a matter of concern due to outbreaks reported in four Latin American countries. Although several mechanisms for orally transmitted Chagas disease transmission have been proposed, food and beverages contaminated with whole infected triatomines or their faeces, which contain metacyclic trypomastigotes of Trypanosoma cruzi, seems to be the primary vehicle. In 2007, the first recognised outbreak of orally transmitted Chagas disease occurred in Venezuela and largest recorded outbreak at that time. Since then, 10 outbreaks (four in Caracas) with 249 cases (73.5% children) and 4% mortality have occurred. The absence of contact with the vector and of traditional cutaneous and Romana’s signs, together with a florid spectrum of clinical manifestations during the acute phase, confuse the diagnosis of orally transmitted Chagas disease with other infectious diseases. The simultaneous detection of IgG and IgM by ELISA and the search for parasites in all individuals at risk have been valuable diagnostic tools for detecting acute cases. Follow-up studies regarding the microepidemics primarily affecting children has resulted in 70% infection persistence six years after anti-parasitic treatment. Panstrongylus geniculatus has been the incriminating vector in most cases. As a food-borne disease, this entity requires epidemiological, clinical, diagnostic and therapeutic approaches that differ from those approaches used for traditional direct or cutaneous vector transmission.

Comparison between clinical and ultrasonographic findings in cases of periportal fibrosis in an endemic area for schistosomiasis mansoni in Brazil.

INTRODUCTION: Abdominal palpation and ultrasound findings among patients from an endemic area for schistosomiasis in Brazil who had been followed up for 27 years were compared. METHODS: In 2004, 411 patients from Brejo do Espírito Santo, in the State of Bahia, were selected for the present investigation after giving their written informed consent. Based on clinical data, they were divided into three groups: 41 patients with evidence of liver fibrosis in 2004 (Group 1); 102 patients with evidence of liver fibrosis in the past (1976-1989) but not in 2004 (Group 2); and 268 patients without evidence of liver fibrosis at any time during the 27-year follow-up (Group 3). All of the patients underwent abdominal ultrasound in which the examiner did not know the result from the clinical examination. The data were stored in a database. RESULTS: The prevalence of periportal fibrosis on ultrasound was 82.9%, 56.9% and 13.4% in Groups 1, 2 and 3, respectively. In the presence of hard, nodular liver or prominent left lobe and a hard palpable spleen, ultrasound revealed periportal fibrosis in 70.9%. However, periportal fibrosis was diagnosed using ultrasound in 25.4% of the patients in the absence of clinical evidence of liver involvement. Thus, ultrasound diagnosed periportal fibrosis 3.1 times more frequently than clinical examination did. CONCLUSIONS: Although clinical examination is important in evaluating morbidity due to Manson's schistosomiasis in endemic areas, ultrasound is more accurate in diagnosing liver involvement and periportal fibrosis.

Evaluación clínica y de laboratorio de pacientes hospitalizados durante el primer brote urbano de enfermedad de chagas de transmisión oral en Venezuela / Clinical and laboratory evaluation of hospitalized patients from the first oral transmitted urban outbreak of Chagas disease in Venezuela

La mayor microepidemia de Enfermedad de Chagas (ECh) de transmisión oral (103 afectados) se detectó en 2007 en una escuela en Caracas, Venezuela. Este trabajo describe los hallazgos clínicos yde laboratorio en 22 personas hospitalizadas. Se investigó la presencia de parásitos y de anticuerposespecíficos IgM e IgG (ELISA y Hemaglutinación Indirecta). Se encontraron parásitos en 22,7por cento(5/22) individuos y anticuerpos anti-Trypanosoma cruzi en 86,3por cento (19/22). Los diagnósticosdiferenciales de ingreso fueron dengue, infección urinaria, histoplasmosis, polimiositis, enfermedad autoinmune y mononucleosis. Se encontró fiebre diaria y prolongada en 18/22 (81,8por cento) y edema en 9 (40,9por cento) personas. En 13/19 casos confirmados hubo afectación cardíaca, 7 (31,8por cento) con derrame pericárdico y uno (4,5por cento) con fibrilación auricular que ameritó cardioversión. Otros hallazgos fueron astenia, mialgias, cefalea, dolor precordial y abdominal. Hubo alteraciones en los valoresde troponina (8/11), VSG (8/14), PCR (14/16), LDH (8/9) y leucocitos (8/21). Tres personas no presentaron anticuerpos para T. cruzi y un caso confirmado falleció. La sospecha clínica de ECh transmitida por vía oral es difícil pues no hay asociación con el vector ni puerta de entrada del parásito y los síntomas que eventualmente pueden orientar el caso, usualmente son inespecíficos. La enfermedad aguda puede progresar a enfermedad severa cuando el diagnóstico y tratamientooportunos se retrasan.

The performance of laboratory tests in the management of a large outbreak of orally transmitted Chagas disease

Orally transmitted Chagas disease (ChD), which is a well-known entity in the Brazilian Amazon Region, was first documented in Venezuela in December 2007, when 103 people attending an urban public school in Caracas became infected by ingesting juice that was contaminated with Trypanosoma cruzi. The infection occurred 45-50 days prior to the initiation of the sampling performed in the current study. Parasitological methods were used to diagnose the first nine symptomatic patients; T. cruzi was found in all of them. However, because this outbreak was managed as a sudden emergency during Christmas time, we needed to rapidly evaluate 1,000 people at risk, so we decided to use conventional serology to detect specific IgM and IgG antibodies via ELISA as well as indirect haemagglutination, which produced positive test results for 9.1%, 11.9% and 9.9% of the individuals tested, respectively. In other more restricted patient groups, polymerase chain reaction (PCR) provided more sensitive results (80.4%) than blood cultures (16.2%) and animal inoculations (11.6%). Although the classical diagnosis of acute ChD is mainly based on parasitological findings, highly sensitive and specific serological techniques can provide rapid results during large and severe outbreaks, as described herein. The use of these serological techniques allows prompt treatment of all individuals suspected of being infected, resulting in reduced rates of morbidity and mortality.

Clinical versus ultrasound examination in the evaluation of hepatosplenic schistosomiasis mansoni in endemic areas.

The best way to appraise the size of abdominal organs remains undefined. Herein we compare the size of liver and spleen in hepatosplenic schistosomiasis using clinical and ultrasound (US) examination, and the size of the organs measured by US with their visualization below the costal margin ("palpable by US"). For this study, 411 individuals from an endemic area for schistosomiasis mansoni in Brazil have been selected. We found that palpable spleens and left liver lobes are larger than non palpable ones. Also, 23% of normal spleens measured by US were palpable on clinical examination, and 22% of spleens increased in size on US were non palpable. A total of 21% of normal spleens were "palpable by US". We also found 54% of normal sized right liver lobes palpable on clinical examination, whilst 54% of the increased livers, measured by US, were non palpable. About 76% of normal right liver lobes were "palpable by US". We conclude that the association of clinical, ultrasound and magnetic resonance imaging (MRI) examinations, in the near future, should give the investigators the necessary tools to perform a more accurate clinical diagnosis of hepatosplenic schistosomiasis mansoni.

Serum hyaluronan and collagen IV as non-invasive markers of liver fibrosis in patients from an endemic area for schistosomiasis mansoni: a field-based study in Brazil

Non-invasive markers of fibrosis have been used to diagnose liver fibrosis in a variety of diseases. Hyaluronic acid (HA) and collagen IV (C-IV) levels were measured in the sera of patients from an endemic area for schistosomiasis in Brazil to diagnose and to rank the intensity of liver fibrosis. Seventy-nine adult patients with schistosomiasis, in the age range of 21-82 years (49 ± 13.4) were submitted to clinical and ultrasonographic examinations. Ultrasound was employed to diagnose and categorise liver fibrosis according to World Health Organization patterns. Serum HA and C-IV levels were measured using commercial ELISA kits. Ultrasound revealed six patients with intense liver fibrosis, 21 with moderate, 23 with light and 29 without. Serum HA was able to separate individuals with fibrosis from those without (p < 0.001) and light from intense fibrosis (p = 0.029), but C-IV was not (p = 0.692). The HA diagnostic accuracy for fibrosis was 0.89. The 115.4 ng/mL cut-off level diagnosed patients with fibrosis (sensitivity 0.98, specificity 0.64). HA correlated positively with portal hypertension. Periportal fibrosis (subjective evaluation), age and collateral circulation predicted HA increase. In conclusion, we propose that serum HA can be used to identify patients with liver fibrosis in an endemic area for schistosomiasis mansoni in Brazil.

Comparison between clinical and ultrasonographic findings in cases of periportal fibrosis in an endemic area for schistosomiasis mansoni in Brazil / Comparação entre achados clínicos e ultrassonográficos no diagnóstico da fibrose periportal em uma área endêmica de esquistossomose no Brasil

INTRODUCTION: Abdominal palpation and ultrasound findings among patients from an endemic area for schistosomiasis in Brazil who had been followed up for 27 years were compared. METHODS: In 2004, 411 patients from Brejo do Espírito Santo, in the State of Bahia, were selected for the present investigation after giving their written informed consent. Based on clinical data, they were divided into three groups: 41 patients with evidence of liver fibrosis in 2004 (Group 1); 102 patients with evidence of liver fibrosis in the past (1976-1989) but not in 2004 (Group 2); and 268 patients without evidence of liver fibrosis at any time during the 27-year follow-up (Group 3). All of the patients underwent abdominal ultrasound in which the examiner did not know the result from the clinical examination. The data were stored in a database. RESULTS: The prevalence of periportal fibrosis on ultrasound was 82.9 percent, 56.9 percent and 13.4 percent in Groups 1, 2 and 3, respectively. In the presence of hard, nodular liver or prominent left lobe and a hard palpable spleen, ultrasound revealed periportal fibrosis in 70.9 percent. However, periportal fibrosis was diagnosed using ultrasound in 25.4 percent of the patients in the absence of clinical evidence of liver involvement. Thus, ultrasound diagnosed periportal fibrosis 3.1 times more frequently than clinical examination did. CONCLUSIONS: Although clinical examination is important in evaluating morbidity due to Manson's schistosomiasis in endemic areas, ultrasound is more accurate in diagnosing liver involvement and periportal fibrosis.

INTRODUÇÃO: Neste estudo, se comparou os achados da palpação abdominal e do ultrassom em pacientes de área endêmica de esquistossomose que foram acompanhados por 27 anos no Brasil. MÉTODOS: Em 2004, 411 pacientes de Brejo do Espírito Santo, no estado da Bahia, após consentimento informado e por escrito foram selecionados para o presente estudo. Baseando-se no exame clínico eles foram divididos em 3 grupos: 41 (Grupo 1) com evidência de fibrose hepática no ano de 2004; 102 (Grupo 2) com evidência de fibrose hepática no passado (1976-1989) mas não em 2004; e 268 (Grupo 3) sem evidência de fibrose hepática em 27 anos de seguimento. Todos foram submetidos a exame ultrassonográfico do abdome em que o examinador não sabia o resultado do exame clínico. Os dados foram armazenados em banco de dados. RESULTADOS: A prevalência de fibrose periportal ao ultrassom foi de 82,9 por cento, 56,9 por cento e 13,4 por cento nos Grupos 1, 2 e 3, respectivamente. Na presença de fígado duro, nodular ou lobo esquerdo proeminente e baço palpável duro, o ultra-som revelou fibrose periportal em 70,9 por cento. Porém, fibrose periportal foi diagnosticada através do ultrassom em 25,4 por cento dos pacientes, na ausência de evidência clínica de envolvimento hepático. Assim, o ultrassom diagnosticou fibrose periportal 3,1 vezes mais frequentemente que o exame clínico. CONCLUSÕES: O exame clínico tem importância na avaliação da morbidade da esquistossomose mansônica em áreas endêmicas, mas o ultrassom mostra-se mais preciso quando se pretende diagnosticar o envolvimento hepático e a fibrose periportal.

Aspectos ultrassonográficos e hemodinâmicos da esquistossomose mansônica: avaliação pela ultrassonografia Doppler em áreas endêmicas / Sonographic and hemodynamic findings of schistosomiasis mansoni: doppler sonography assessment in endemic areas

OBJETIVO: Este estudo de campo objetivou identificar as alterações ultrassonográficas e hemodinâmicas indicativas da morbidade da esquistossomose mansônica em áreas endêmicas. MATERIAIS E MÉTODOS: Foram examinados pela ultrassonografia Doppler 554 pacientes esquistossomóticos em três áreas com níveis distintos de endemicidade: baixa endemicidade (n = 109); média endemicidade (n = 255) e alta endemicidade (n = 190). Para o estudo ultrassonográfico foi utilizado o protocolo da Organização Mundial da Saúde (Niamey Working Group, 2000). Pelo Doppler foram avaliados: vasos portais, artérias hepática e esplênica, veias hepáticas e vasos colaterais. RESULTADOS: Houve correlação significativa entre a frequência das alterações ultrassonográficas e o nível de endemicidade das áreas, exceto a hipertrofia do lobo esquerdo. As veias hepáticas apresentaram padrão de fluxo alterado em 23,7 por cento dos casos, alteração esta relacionada à presença e à intensidade de espessamento periportal. A artéria hepática não apresentou alterações nos parâmetros avaliados. Os vasos colaterais foram identificados apenas na área de alta endemicidade. A artéria esplênica apresentou alterações (aumento do calibre, da velocidade e do índice de resistência) mais frequentes na área de alta endemicidade, com diferença significativa entre os grupos. CONCLUSÃO: A ultrassonografia Doppler mostrou-se ferramenta auxiliar importante no estudo da morbidade relacionada à esquistossomose mansônica, contribuindo para definição mais precisa do perfil da doença nas áreas endêmicas.

OBJECTIVE: The present field research was aimed at identifying sonographic and hemodynamic findings indicative of the presence of schistosomiasis mansoni in endemic areas. MATERIALS AND METHODS: Doppler sonography was performed in 554 patients with schistosomiasis in three areas with different endemicity levels: low (n = 109), medium (n = 255) and high endemicity (n = 190). The World Health Organization (Niamey Working Group, 2000) protocol was adopted for sonographic evaluation. Doppler study included portal vessels, hepatic and splenic arteries, hepatic veins and collateral vessels. RESULTS: A significant correlation was observed between the frequency of sonographic findings, except for left lobe hypertrophy, and the areas endemicity levels. Altered hepatic veins flow pattern was observed in 23.7 percent of cases, such abnormality being related to the presence and intensity of periportal thickening. Hepatic arteries did not present any alteration as related to the evaluated parameters. Collateral vessels were identified only in the patients from the high-endemicity area. The splenic artery presented alterations (increase in caliber, flow velocity and resistive index), most frequently in the high-endemicity area, with significant difference between groups. CONCLUSION: Doppler sonography has shown to be a relevant auxiliary tool in the study of the morbidity related to schistosomiasis mansoni, contributing for a more accurate description of the disease profile in endemic areas.

Epidemia de chagas agudo adquirido por vía oral en una escuela de Caracas: descripción del caso índice / Epidemic outbreask of acute oral transmited chagas disease: description of the index case

La Enfermedad de Chagas (ECh) usualmente es transmitida al hombre por la penetración cutánea de parásitos contenidos en las heces de vectores hematófagos conocidos como chipos. Sin embargo existen otros mecanismos de transmisión. Se presenta el primer caso diagnosticado del brote de ECh agudo de transmisión oral, ocurrido en diciembre 2007 en una escuela de Caracas. Escolar de nueve años, femenino procedente de Caracas, hospitalizada con fiebre diaria 39-40°C y escalofríos de tres semanas de evolución, decaimiento, mareos, vómitos, astenia, mialgias, adenopatías cervicales, hepatomegalia, edema facial y en miembros inferiores. Los exámenes de laboratorio mostraron linfomonocitosis, serologías negativas para mononucleosis y dengue. En el frotis sanguíneo para el despistaje de malaria se encontró un tripomastigote de Trypanosoma cruzi. ELISA-IgM, ELISA-IgG, hemaglutinación indirecta, reacción en cadena de la polimerasa, cultivo e inoculación en ratones, fueron positivos para ECh. A los pocosdías se detectaron casos similares y se realizó el vínculo epidemiológico que permitió el reconocimiento de una epidemia urbana de ECh de transmisión oral. La paciente recibió nifurtimox y evolucionó satisfactoriamente. En la forma oral de transmisión de la ECh no existe signo de puerta de entrada, las manifestaciones clínicas, como la fiebre alta y prolongada y el edema, suelen ser comunes a otras patologías. En pacientes con fiebre de origen desconocido debe incluirse el frotis sanguíneo y la detección de IgM e IgG específicas para ECh como parte del plan diagnóstico. Se describe en forma pormenorizada el primer caso, considerado caso índice del brote de Chagas agudo adquirido por ingestión de alimentos en un colegio del municipio de Chacao en Caracas.

Chagas disease (ChD) is usually transmitted to man by cutaneous penetration of parasites contained in the feces of haematofagous vectors known as “kissing bugs or chipos”. However, other transmission mechanisms may occur. Herein, we report the first diagnosed case of an epidemic outbreak of acute oral transmitted ChD occurred in December 2007 in a school of Caracas. A 9 year old schoolgirl, coming from Caracas, was hospitalized with daily fever 39-40°C and chills of three weeks duration, sickness, vomitting, astenia, mialgias, cervical adenopathies, hepatomegaly, facial and inferior members edema. The laboratory tests showed lymphomonocytosis, negative serologies for mononucleosis and dengue. In the blood smear done to rule out malaria, tripomastigote of Trypanosoma cruzi was found. ELISA-IgM, ELISA-IgG, indirect hemaglutination, polymerase chain reaction, culture and mice inoculation were all positive for ChD. Few days after, similar cases were detected and it was carried out the epidemiological link that allowed the recognition of an urban outbreak of ChD of oral transmission. The patient evolved satisfactorily after being treated with nifurtimox. In the oral form of transmission of the ChD, signs of entrance do not exist, the clinical manifestations as high and prolonged fever and edema are common to other pathologies. In patients with fever of unknown origin, blood smear as well as search for specific IgM and IgG for ChD should be included as part of the diagnosis. The first case is described in detailed form, considered index case of the outbreak of acute Chagas acquired by food ingestion in a school of Chacao's county in Caracas.

Clinical and ultrasound findings before and after praziquantel treatment among Venezuelan schistosomiasis patients

Abdominal ultrasound can be a useful tool for diagnosing periportal fibrosis related to Schistosoma mansoni infection, and also for planning and monitoring the evolution of hepatic morbidity following control measures. We evaluated the standardized ultrasound methodology proposed by the World Health Organization for detecting periportal fibrosis and portal hypertension, among patients from an endemic area in Venezuela, and the impact of praziquantel treatment 3-5 years later. After chemotherapy, complete reversal of periportal lesions was observed in 28.2 percent of the cases and progression of the disease in 5.1 percent. Improvement in the hepatic disease started with a reduction in the periportal thickening followed by a decrease in the size of the left hepatic lobe, spleen and mesenteric and spleen veins. Ultrasound confirmed the clinical findings after chemotherapy among the patients with reversal of the disease. However, in patients with more advanced disease, these findings were contradictory. There was no correlation between evolution of the disease seen on ultrasound and age, intensity of infection or serological findings.

O ultra-som abdominal pode ser uma ferramenta útil para o diagnóstico da fibrose periportal relacionada à infecção por Schistosoma mansoni, e também para planejar e monitorar a evolução da morbidade hepática após medidas de controle. Nós avaliamos a metodologia padronizada no ultra-som, proposta pela Organização Mundial da Saúde, para a detecção da fibrose periportal e hipertensão porta, em pacientes de área endêmica da Venezuela e o impacto do tratamento com praziquantel 3-5 anos depois. Após quimioterapia, houve reversão completa das lesões periportais em 28,2 por cento dos casos e progressão da patologia em 5,1 por cento. A melhora da patologia hepática começou com a redução do espessamento periportal seguida pela diminuição do tamanho do lobo esquerdo, baço e veias mesentérica e esplênica. O ultra-som confirma os achados clínicos após quimioterapia em pacientes com reversão da patologia; contudo, naqueles com patologia mais avançada, estes achados foram contraditórios. Não houve correlação entre evolução da patologia ultra-sonográfica com idade, intensidade da infecção ou achados sorológicos.

Clinical versus ultrasound examination in the evaluation of hepatosplenic schistosomiasis mansoni in endemic areas

The best way to appraise the size of abdominal organs remains undefined. Herein we compare the size of liver and spleen in hepatosplenic schistosomiasis using clinical and ultrasound (US) examination, and the size of the organs measured by US with their visualization below the costal margin ("palpable by US"). For this study, 411 individuals from an endemic area for schistosomiasis mansoni in Brazil have been selected. We found that palpable spleens and left liver lobes are larger than non palpable ones. Also, 23 percent of normal spleens measured by US were palpable on clinical examination, and 22 percent of spleens increased in size on US were non palpable. A total of 21 percent of normal spleens were "palpable by US". We also found 54 percent of normal sized right liver lobes palpable on clinical examination, whilst 54 percent of the increased livers, measured by US, were non palpable. About 76 percent of normal right liver lobes were "palpable by US". We conclude that the association of clinical, ultrasound and magnetic resonance imaging (MRI) examinations, in the near future, should give the investigators the necessary tools to perform a more accurate clinical diagnosis of hepatosplenic schistosomiasis mansoni.