Avaliação de Sintomas Depressivos e Associação com a Limitação de Atividade em Pacientes Acometidos por Hanseníase em uma Unidade de Referência / Evaluation of Depressive Symptons and Association with Limitation of Activity in Patients Affected by Leprosy at Reference Unit

Objetivos: analisar a frequência de sintomas depressivos em pacientes acometidos por Hanseníase em uma unidade de referência no estado do Pará, além de correlacionar a incidência de sintomas depressivos em pacientes acometidos por Hanseníase com o grau de limitação de atividades e com o grau de incapacidade física. Metodologia: estudo transversal, observacional e descritivo, com o uso da escala de depressão de Beck e do Screening of Activity Limitation and Safety Awareness (Triagem de Limitação de Atividade e Consciência de Risco), que levou em consideração os pacientes acometidos pela hanseníase que fazem acompanhamento na Unidade de Referencia Especializada Marcello Candia. A casuística foi composta por 104 pacientes, de ambos os sexos. Resultados: presença de sintomas depressivos em 66,3% dos pacientes analisados, considerando um total de 14,4% com sintomas graves. Em relação à limitação de atividade, 73% dos pesquisados apresentavam algum grau de limitação de atividade, sendo que maior parte apresentava grau leve de limitação. Discussão: Houve correlação significativa entre o grau de incapacidade e a limitação física pela escala, visto que os pacientes com Grau II de incapacidade apresentavam uma média superior na escala quando comparados a pacientes com Grau 0. Conclusões: Os dados obtidos nesta pesquisa contribuem para que haja uma preocupação para além da integridade física do paciente com hanseníase, sinalizando a necessidade de um cuidado psicossocial e integral, o que deve incluir o rastreio de sintomas depressivos, além de intervenções clinicas e psicoterápicas no combate à depressão.Objetivos: analisar a frequência de sintomas depressivos em pacientes acometidos por Hanseníase em uma unidade de referência no estado do Pará, além de correlacionar a incidência de sintomas depressivos em pacientes acometidos por Hanseníase com o grau de limitação de atividades e com o grau de incapacidade física. Metodologia: estudo transversal, observacional e descritivo, com o uso da escala de depressão de Beck e do Screening of Activity Limitation and Safety Awareness (Triagem de Limitação de Atividade e Consciência de Risco), que levou em consideração os pacientes acometidos pela hanseníase que fazem acompanhamento na Unidade de Referencia Especializada Marcello Candia. A casuística foi composta por 104 pacientes, de ambos os sexos. Resultados: presença de sintomas depressivos em 66,3% dos pacientes analisados, considerando um total de 14,4% com sintomas graves. Em relação à limitação de atividade, 73% dos pesquisados apresentavam algum grau de limitação de atividade, sendo que maior parte apresentava grau leve de limitação. Discussão: Houve correlação significativa entre o grau de incapacidade e a limitação física pela escala, visto que os pacientes com Grau II de incapacidade apresentavam uma média superior na escala quando comparados a pacientes com Grau 0. Conclusões: Os dados obtidos nesta pesquisa contribuem para que haja uma preocupação para além da integridade física do paciente com hanseníase, sinalizando a necessidade de um cuidado psicossocial e integral, o que deve incluir o rastreio de sintomas depressivos, além de intervenções clinicas e psicoterápicas no combate à depressão.

The expression of FOXP3 in lesions of several forms of leprosy in patients co-infected with HIV.

BACKGROUND: Brazil remains endemic for infection by the human immunodeficiency virus (HIV) and leprosy, having a major impact on public health and the life quality of affected patients. Although the relevance of this co-infection is recognized, several aspects, such as the immune response, are not yet fully understood. The objective of this study was to investigate the expression of FOXP3+ Treg cells in leprosy skin lesions and to correlate their clinical forms, laboratory characteristics (CD4, CD8, and CV), and the immune reconstitution syndrome in HIV-leprosy co-infection. METHODOLOGY/PRINCIPAL FINDINGS: An observational, cross-sectional, and analytical study was carried out comparing four groups of patients: those with concomitant diagnosis of leprosy and HIV infection without a leprosy reaction, those with leprosy and HIV co-infection patients with a reverse reaction (RR), those with leprosy without HIV and without reaction, and those with leprosywithout HIV and with RR. The patients were diagnosed at a dermatology outpatient clinic located in Belém, Pará, Brazil, from 2003 to 2017. In the sample studied, there was a positive correlation between FOXP3+ cell density and viral load, negative correlation with blood CD4+ (not statistically significant), significant positive correlation in CD8 count in patients with leprosy reaction, and positive relationship in patients with IRIS. The density of cells expressing FOXP3 was higher in the BL/LL forms in patients without HIV, although the difference was not statistically significant. However, the cell mean was higher in the TT/BT forms in patients co-infected with leprosy and HIV, showing contradictory results. CONCLUSIONS/SIGNIFICANCE: These findings support that higher activity of the HIV may stimulate or result in a higher expression of FOXP3-Tregs and that they may be involved in active immunosuppression observed at the infection site at the tissue level. This supports the need to expand studies on FOXP3+ Treg cells in co-infected patients.

Expression of interleukin-1ß and interleukin-6 in leprosy reactions in patients with human immunodeficiency virus coinfection.

Previous studies suggest that coinfection of leprosy and human immunodeficiency virus (HIV) does not decrease the frequency and intensity of leprosy reactions. However, the immunological aspects of leprosy reactions in coinfected patients remain obscure, with a limited number of studies showing contradictory results. Observational study using tissue samples collected during leprosy reactions from 15 patients coinfected with leprosy and HIV and from 15 patients with leprosy alone. Patients were part of a prior larger cohort study of leprosy patients with and without HIV coinfection. Specific antibodies were used to detect IL-1ß and IL-6 expression in skin biopsy tissue cells. IL-1ß and IL-6 expression was similar between leprosy patients with and without HIV coinfection (p>0.05). Coinfected and non-coinfected tissues showed similar levels of IL-1ß and IL-6 expression for type 1 reactions. A trend towards increased levels of IL-1ß and IL-6 expression was observed in tissue from coinfected patients (p=0.0024). The expression of IL-1ß and IL-6 during leprosy reactions did not differ significantly between tissues obtained from leprosy patients with and without HIV coinfection. Therefore, we conclude that HIV coinfection does not affect the immunological pattern of leprosy reactions.

Leprosy Reactions in Patients Coinfected with HIV: Clinical Aspects and Outcomes in Two Comparative Cohorts in the Amazon Region, Brazil.

BACKGROUND: Leprosy, caused by Mycobacterium leprae, can lead to scarring and deformities. Human immunodeficiency virus (HIV), a lymphotropic virus with high rates of replication, leads to cell death in various stages of infection. These diseases have major social and quality of life costs, and although the relevance of their comorbidity is recognized, several aspects are still not fully understood. METHODOLOGY/PRINCIPAL FINDINGS: Two cohorts of patients with leprosy in an endemic region of the Amazon were observed. We compared 40 patients with leprosy and HIV (Group 1) and 107 leprosy patients with no comorbidity (Group 2) for a minimum of 2 years. Group 1 predominantly experienced the paucibacillary classification, accounting for 70% of cases, whereas Group 2 primarily experienced the multibacillary classification (80.4% of cases). There was no significant difference in the prevalence of leprosy reactions among the two groups (37.5% for Group 1 vs. 56.1% for Group 2), and the most frequent reaction was Type 1. The appearance of Group 1 patients' reversal reaction skin lesions was consistent with each clinical form: typically erythematous and infiltrated, with similar progression as those patients without HIV, which responded to prednisone. Patients in both groups primarily experienced a single episode (73.3% in Group 1 and 75% in Group 2), and Group 1 had shorter reaction periods (≤3 months; 93.3%), moderate severity (80%), with 93.3% of the patients in the state of acquired immune deficiency syndrome, and 46.7% presenting the reaction at the time of the immune reconstitution inflammatory syndrome. CONCLUSIONS/SIGNIFICANCE: This study used a large sample and makes a significant contribution to the clinical outcomes of patients in the reactive state with comorbid HIV and leprosy. The data indicate that these diseases, although concurrent, have independent courses.

Comparison between histopathologic features of leprosy in reaction lesions in HIV coinfected and non-coinfected patients.

BACKGROUND: Leprosy and HIV are diseases that have a major impact on public health in Brazil. Patients coinfected with both diseases, appear to be at higher risk to develop leprosy reactions. OBJECTIVE: The aim of this study is to describe the histopathological aspects of cutaneous lesions during reactional states in a group of patients with HIV-leprosy coinfection, compared to patients with leprosy, without coinfection. METHODS: Two groups were established: group 1 comprised of 40 patients coinfected with HIV-leprosy; group 2, comprised of 107 patients with leprosy only. Patients presenting reactional states of leprosy had their lesions biopsied and comparatively evaluated. RESULTS: Reversal reaction was the most frequent feature in both groups, with dermis edema as the most common histopathological finding. Giant cells were seen in all group 1 histopathological examinations. Dermis edema was the most common finding in patients with erythema nodosum leprosum. CONCLUSION: Few histopathological differences were found in both groups, with reversal reaction as the most significant one, although this fact should be analyzed considering the predominant BT clinical form in the coinfected group and BB form in the group without HIV. Larger prospective studies in patients with HIV-leprosy coinfection are needed to confirm and broaden these results.

Comparison between histopathologic features of leprosy in reaction lesions in HIV coinfected and non-coinfected patients*

BACKGROUND: Leprosy and HIV are diseases that have a major impact on public health in Brazil. Patients coinfected with both diseases, appear to be at higher risk to develop leprosy reactions. OBJECTIVE: The aim of this study is to describe the histopathological aspects of cutaneous lesions during reactional states in a group of patients with HIV-leprosy coinfection, compared to patients with leprosy, without coinfection. METHODS: Two groups were established: group 1 comprised of 40 patients coinfected with HIV-leprosy; group 2, comprised of 107 patients with leprosy only. Patients presenting reactional states of leprosy had their lesions biopsied and comparatively evaluated. RESULTS: Reversal reaction was the most frequent feature in both groups, with dermis edema as the most common histopathological finding. Giant cells were seen in all group 1 histopathological examinations. Dermis edema was the most common finding in patients with erythema nodosum leprosum. CONCLUSION: Few histopathological differences were found in both groups, with reversal reaction as the most significant one, although this fact should be analyzed considering the predominant BT clinical form in the coinfected group and BB form in the group without HIV. Larger prospective studies in patients with HIV-leprosy coinfection are needed to confirm and broaden these results. .

Tufted angioma in ear auricle: importance of the differential diagnosis.

Tufted angioma is an acquired vascular proliferation with specific histological characteristics. The most common clinical features are erythematous macules. It occurs predominantly in children and young adults, especially in the chest and neck. We report the case of a male patient, 12 years old, with an increased right ear auricle associated with erythematous macules and increased local temperature, referred with a diagnosis of lepromatous leprosy; however, this diagnosis was questioned. Histopathology was consistent with tufted angioma.

Tufted angioma in ear auricle: importance of the differential diagnosis / Hemangioma em penacho no pavilhao auricular: importancia do diagnostico diferencial

Tufted angioma is an acquired vascular proliferation with specific histological characteristics. The most common clinical features are erythematous macules. It occurs predominantly in children and young adults, especially in the chest and neck. We report the case of a male patient, 12 years old, with an increased right ear auricle associated with erythematous macules and increased local temperature, referred with a diagnosis of lepromatous leprosy; however, this diagnosis was questioned. Histopathology was consistent with tufted angioma.

O Hemangioma em penacho é uma proliferação vascular adquirida de características histológicas peculiares. Sua característica clínica mais comum são máculas eritematosas. Ocorre predominantemente em crianças e adultos jovens, principalmente no tórax e pescoço. Relata-se o caso de paciente do sexo masculino, 12 anos, com aumento do pavilhão auricular direito associado a máculas eritematosas e aumento da temperatura local, encaminhado com diagnóstico de Hanseníase Virchowiana, entretanto, tal diagnóstico foi questionado. Histopatologia compatível com Hemangioma em penacho.

Educação em saúde e busca ativa de casos de hanseníase em uma escola pública em Ananindeua, Pará, Brasil / Health education and active search for cases of leprosy in a public school in Ananindeua, Pará, Brazil / Educación para la salud y búsqueda activa de casos de lepra en una escuela pública en Ananindeua, Pará, Brasil

Objetivo: Descrever ação para o controle da hanseníase por meio da educação em saúde e da busca ativa de casos na faixa etária escolar, em uma instituição pública de ensino do município de Ananindeua, Pará. Métodos: Trata-se de estudo descritivo, conduzido em uma instituição pública de ensino, incluindo estudantes do ensino fundamental. Em outubro e novembro de 2010 foram realizadas palestras na escola sobre hanseníase e outras dermatoses e, em seguida, foi feita uma triagem com os alunos que apresentaram alguma mancha na pele. No total de 532 alunos envolvidos, foram identificados 55 alunos como casos suspeitos para hanseníase. Esses alunos foram conduzidos para consulta dermatológica, sendo realizados o exame clínico e a aplicação de questionários sociodemográficos. Resultados: A face (49%) e os membros superiores (45%) foram as principais regiões do corpo com lesões. Na maioria dos casos investigados tratava-se de pitiríase alba (42%) e pitiríase versicolor (31%). Entretanto, diagnosticou-se um caso de hanseníase (2%), na forma clínica tuberculóide. Conclusão: Considerando a abrangência do estudo, o número de casos de hanseníase encontrado é significativo e reafirma a alta taxa de detecção de hanseníase em menores de 15 anos no município. Ações de vigilância epidemiológica devem ser intensificadas, no sentido de detectar a doença mais precocemente, contribuindo para a redução de estigmas e da restrição à participação social.

Objectives: To describe action for leprosy control through health education and case active search among school age children in a public school in the municipality of Ananindeua, Pará state. Methods: This is a descriptive study conducted in a public school including elementary school students. In October and November 2010, lectures on leprosy and other skin lesions were given in this school and then screening was performed with students that presented skin spots. From the total of 532 students involved, 55 were identified as suspected to leprosy. These students were taken to dermatological appointment including clinical examination and application of socio-demographic questionnaire. Results: The face (49%) and upper limbs (45%) were the main body areas presenting lesions. In most of the cases investigated, pityriasis alba (42%) and pityriasis versicolor (31%) were diagnosed. However, one case of leprosy (2%) was also found, in tuberculoid clinical form. Conclusion: Considering the scope of the study, the number of leprosy cases found is significant and confirms the high detection rate of leprosy in children under age 15 in the city. Epidemiological surveillance actions should be intensified in order to detect the disease in its early stage, contributing to enhancement in social participation by reducing the disease-related stigma.

Objetivo: Describir la acción para el control de la lepra mediante la Educación para la Salud y la búsqueda activa de casos en niños en edad escolar en una escuela pública en la ciudad de Ananindeua, Pará. Métodos: Se trata de un estudio descriptivo, realizado en una escuela pública, con los estudiantes de primaria. En octubre y noviembre de 2010 se realizaron conferencias sobre lepra y otras enfermedades de la piel y luego se examinó a los estudiantes que tenían alguna mancha en la piel. Del total de 532 alumnos, 55 estudiantes fueron identificados como sospechosos de tener lepra. Esos estudiantes fueron derivados a consulta dermatológica, examen clínico y aplicación de cuestionarios socio-demográficos. Resultados: La cara (49%) y las extremidades superiores (45%) fueron las principales áreas del cuerpo con lesiones. En la mayoría de los casos se constató la pitiriasis alba (42%) y pitiriasis versicolor (31%). Sin embargo, se diagnosticó un caso de lepra (2%), en la forma clínica tuberculoide. Conclusión: Teniendo en cuenta el alcance del estudio, el número de casos de lepra encontrado es significativo y reafirma la alta tasa de detección de lepra en los niños menores de 15 años en la ciudad. Las acciones de vigilancia epidemiológica deben ser intensificadas, con el fin de detectar precozmente la enfermad, contribuyendo para la reducción del estigma y de la restricción de la participación social.

Conhecimento sobre hanseníase de contatos intradomiciliares na Atenção Primária em Ananindeua, Pará, Brasil / Knowledge of household contacts of leprosy in the Primary Care in Ananindeua, Pará, Brazil / Conocimiento sobre la lepra de contactos intra-domicilares en la Atención Primaria en Ananindeua, Pará, Brasil

Este relato buscou identificar o grau de conhecimento de contatos intradomiciliares de pacientes hansenianos tratados e acompanhados em uma Unidade de Saúde da Família (USF) no município de Ananindeua-Pará. Após visitas domiciliares, aplicação de protocolo de pesquisa e exame físico, nenhum caso suspeito de hanseníase foi encontrado, no entanto, o conhecimento sobre a doença ainda é escasso, pois apenas 20% dos contatos responderam que se tratava de uma "doença de pele com cura". Sobre a representação da doença para os entrevistados, 20% responderam ter "medo de contrair a doença". Metade da amostra sabia a forma de transmissão e 10% não souberam emitir nenhuma resposta; 60% dos contatos responderam que a hanseníase deve ser tratada na unidade de saúde com medicamentos orais. Aqueles que receberam orientações prévias possuíam melhores esclarecimentos sobre a doença (50%). É preciso um acompanhamento adequado desses contatos, além de uma atuação mais efetiva em educação em saúde.

This experience report sought to identify the degree of knowledge of household contacts of leprosy patients treated and monitored in a Family Health Center in the municipality of Ananindeua, state of Pará. After home visits, application of a research protocol, and physical examination, no suspected case of leprosy was found; however, knowledge about the disease is still scarce, since only 20% of the contacts answered that leprosy is a "treatable skin disease". Regarding the representation of the disease for the interviewees, 20% reported having "fear of contracting the disease". Half of the sample were aware of its mode of transmission and 10% were unable to give any answer; 60% of the contacts answered that leprosy should be treated at the health center with oral drugs. Those who had received advance directives were better informed about the disease (50%). A proper follow up of these contacts is needed, as well as a more effective health education.

Este relato de experiencia trató de determinar el grado de conocimiento de los contactos intra-domicilares de enfermos de lepra tratados y seguidos en una Unidad de Salud Familiar (USF) en la ciudad de Ananindeua-Pará. Después de las visitas domicilares, de la aplicación del protocolo de investigación y del examen físico, no fue encontrado ningún caso sospechoso de lepra, sin embargo el conocimiento sobre la enfermedad sigue siendo escaso, ya que sólo el 20% de los contactos respondió que se trataba de una "enfermedad curable de la piel". Sobre la representación de la enfermedad entre los encuestados, 20% informó tener "miedo a contraer la enfermedad". La mitad de la muestra conocía el modo de transmisión y el 10% no pudo dar ninguna respuesta; el 60% de los contactos respondió que la lepra debe ser tratada en una USF con medicamentos orales. Los que recibieron orientaciones previas tuvieron mayores conocimientos sobre la enfermedad (50%). Se necesita un acompañamiento adecuado de esos contactos, así como una actuación más efectiva en educación para la salud.

Trombose venosa profunda em um paciente com reação hansênica em uso de talidomida e corticóide: um raro efeito adverso? / Deep vein thrombosis in a patient with leprosy reaction in use of thalidomide and corticosteroids: a rare adverse effect?

Após re-introdução no mercado, a Talidomida tornou-se a droga mais eficaz no tratamento do eritema nodoso hânsenico, além de opção terapêutica para diversas doenças, como mieloma múltiplo. Contudo, o crescente uso desta, associado a corticóides sistêmicos e quimioterápicos, resultou em aumento de efeitos adversos pouco reconhecidos, como trombose venosa profunda.

After being reintroduced in the market, thalidomide has become the most effective drug in the treatment of erythema nodosum leprosum and a therapeutic option for several diseases, such as multiple myeloma. However, its increasing use, combined with systemic steroids and chemotherapy has also increased little recognized adverse effects, such as deep vein thrombosis.