Are the neglected tropical diseases under control in the tri-border region between Brazil, Argentina, and Paraguay?

INTRODUCTION: Implementation of prevention and control measures for communicable diseases in border regions can be challenging and lead to inefficient attempts to control them. We describe evidences on the strengths, weaknesses, opportunities and challenges regarding implementation of health interventions for control, prevention and treatment of selected neglected tropical diseases (NTD), a group of transmissible diseases typically prevalent in tropical countries and vulnerable populations, in the tri-border between Brazil, Argentina, and Paraguay. METHODOLOGY: A systematic literature review of observational and experimental studies was conducted, using PubMed and Bireme databases. Eligibility criteria were location (tri-border area) and subject (health interventions). RESULTS: Of a total of 595 references identified, 34 studies were included (18 pertaining to leishmaniasis, 11 to dengue, 2 to leprosy, 2 to soil-transmitted helminthiases and 1 to Chagas' disease), with an inclusion rate of 6.4%. The main strengths were the similarity of health interventions between countries and easiness of mobility and communication flows. The main weaknesses were access to rural areas and discrepancies in the number of studies between countries. As for opportunities, we identified increased tourism, economic development and recent increasing research in this field. The main challenges were the absence of studies regarding other prevalent NTD in the region and movement of goods, animals and people across borders. CONCLUSIONS: Although epidemiological studies are still needed to better understand and assess the prevalence of NTD in the area, mainly in Paraguay, these findings can inform decision-makers and health managers to plan a common strategy to address NTD.

[Delay in diagnosis as a prognostic factor for disability in patients with leprosy in Paraguay. Case and control study]. / Retraso en el diagnóstico como factor pronóstico de discapacidad en pacientes con lepra en Paraguay. Estudio de casos y controles.

BACKGROUND: Leprosy, a chronic infectious disease, is one of the major causes of preventable disability. Early treatment prevents neurological damage and disability. AIM: To identify prognostic factors of disability in individuals with multibacillary and paucibacillary leprosy who completed a drug treatment between 2011 and 2017 in Paraguay. METHODS: A case-control study was carried out on 34 patients, of them 9 were cases and 25 controls. Cases were those patients with Grade 1, presented lack of sensation in lower or upper limbs, and those of Grade 2 lagophthalmos, rigidity, visible deformity ulcerations, passive claw, active claw. Controls had no disabilities. RESULTS: Mean age of the patients was 53 ± 15.2 years, 55.9% were male, and 58.9% had primary education or no formal education. Multibacillary leprosy was found in 58.8% of patients; and 64.7% were diagnosed after consulting with two or more physicians. Diagnosis delay of more than one year was significantly (p = 0.047) greater in the cases than in the controls (77.8% vs 12%; OR: 7.44; 95% CI: 1.02-67.86). CONCLUSION: In this study, a diagnosis delay of more than one year is a prognostic factor for disability.

Bacillus of Calmette and Guérin (BCG) and the risk of leprosy in Ciudad del Este, Paraguay, 2016-2017.

OBJECTIVES: Paraguay has experienced a 35% reduction in the detected incidence of leprosy during the last ten years, as the vaccination coverage against tuberculosis (Bacillus of Calmette and Guérin [BCG] vaccine) reached ≥95% among infants. The objective of this case-control study was to evaluate the protective effect of BCG on the risk of leprosy. METHODS: We used a population-based case-control study of 20 leprosy confirmed cases reported among residents of Ciudad del Este, Paraguay, diagnosed in 2016-2017. Three controls were selected from a random sample of households from the city. We assessed vaccine effectiveness using 1- odds ratio [OR], and confounding for age, gender, education, occupation, and marital status using stratified and exact logistic regression, and explored if there was effect modification calculating the synergy factor (SF) and relative excess risk due to interaction (RERI). RESULTS: After controlling for age, gender, education, occupation and marital status, the OR of BCG scar on the risk of leprosy was 0.10 (95% confidence interval [CI], 0.02 to 0.45), for an estimate of vaccine effectiveness of 89.5% reduced risk of leprosy (95% CI, 55.2 to 98.1). There was evidence of heterogeneity by which the effectiveness of BCG seemed stronger among younger persons (Breslow-Day and Z-test of the SF had a p<0.05), and both the RERI and SF indicated a less then multiplicative and additive interaction of BCG and younger age. CONCLUSIONS: BCG vaccination was associated with a decreased risk of leprosy in the study population, particularly in persons born after 1980.

Retraso en el diagnóstico como factor pronóstico de discapacidad en pacientes con lepra en Paraguay: estudio de casos y controles / Delay in diagnosis as a prognostic factor for disability in patients with leprosy in Paraguay: case and control study

INTRODUCCIÓN: La lepra, una infección crónica, es una de las mayores causas de discapacidad prevenible. El inicio temprano del tratamiento previene el desarrollo de discapacidad. OBJETIVO: Identificar los factores pronóstico de discapacidad en individuos con lepra multibacilar y paucibacilar que culminaron el tratamiento farmacológico entre el 2011 y 2017 en Paraguay. PACIENTES Y MÉTODOS: Se realizó un estudio de casos y controles, con 34 pacientes, 9 casos, 25 controles. Los casos fueron pacientes con discapacidad Grado 1 que presentaban falta de sensibilidad en miembros inferiores o superiores, y los de Grado 2, lagoftalmos, rigidez, ulceraciones, garra pasiva, garra activa. Los controles no presentaron discapacidad. RESULTADOS: La edad media de los pacientes fue 53 ± 15,2 años, el 55,9% fue de sexo masculino y 58,9% tenía educación primaria o no tenía educación formal. El 58,8% de los pacientes presentó lepra multibacilar; y el 64,7% fue diagnosticado tras consultar con dos o más médicos. Retraso en el diagnóstico mayor a un año fue significativamente (p = 0,047) mayor en los casos que en los controles (77,8 vs 12%; OR: 7,44; IC95%: 1,02-67,86). CONCLUSIÓN: El retraso en el diagnóstico mayor a un año es un factor pronóstico de discapacidad.

BACKGROUND: Leprosy, a chronic infectious disease, is one of the major causes of preventable disability. Early treatment prevents neurological damage and disability. AIM: To identify prognostic factors of disability in individuals with multibacillary and paucibacillary leprosy who completed a drug treatment between 2011 and 2017 in Paraguay. METHODS: A case-control study was carried out on 34 patients, of them 9 were cases and 25 controls. Cases were those patients with Grade 1, presented lack of sensation in lower or upper limbs, and those of Grade 2 lagophthalmos, rigidity, visible deformity ulcerations, passive claw, active claw. Controls had no disabilities. RESULTS: Mean age of the patients was 53 ± 15.2 years, 55.9% were male, and 58.9% had primary education or no formal education. Multibacillary leprosy was found in 58.8% of patients; and 64.7% were diagnosed after consulting with two or more physicians. Diagnosis delay of more than one year was significantly (p = 0.047) greater in the cases than in the controls (77.8% vs 12%; OR: 7.44; 95% CI: 1.02-67.86). CONCLUSION: In this study, a diagnosis delay of more than one year is a prognostic factor for disability.

Leprosy in urban space, areas of risk for disability and worsening of this health condition in Foz Do Iguaçu, the border region between Brazil, Paraguay and Argentina.

BACKGROUND: Leprosy is a public health problem and a challenge for endemic countries, especially in their border regions where there are intense migration flows. The study aimed to analyse the dynamics of leprosy, in order to identify areas of risk for the occurrence of the disease and disability and places where this health condition is worsening. METHOD: This ecological study considered the new cases of leprosy reported in the municipality of Foz do Iguaçu from 2003 to 2015. Spatial and spatial-temporal scan statistics were used to identify the risk areas for the occurrence of leprosy, as well as the Getis-Ord Gi and Getis-Ord Gi* methods. Areas of risk for disabilities were identified by the scan statistic and kernel density estimation. RESULTS: A total of 840 cases were reported, of which 179 (21.3%) presented Grade 1 or 2 disabilities at the time of diagnosis. Leprosy risk areas were concentrated in the Southern, Eastern and Northeastern Health Districts of the municipality. The cases of Grade 2 disability were observed with higher intensity in regions characterized by high population density and poverty. CONCLUSION: The results of the study have revealed changes in the pattern of areas at risk of leprosy according to the investigated periods. In addition, it was possible to verify disabilities as a condition present in the investigated cases, or that may be related to the late diagnosis of the disease. In the areas of risk identified, patients have reported worse physical disability after diagnostic confirmation, or indicate inadequate clinical examination, reinforcing the need for structuring leprosy control services in a qualified manner.

Leprosy in Brazilian counties bordering Paraguay: Mato Grosso do Sul State, 2001-2011.

BACKGROUND: In Mato Grosso do Sul state, Brazil, the dry border shared with Paraguay is a territory marked by facilities in the flow of goods, services and people, bringing difficulties for surveillance of communicable diseases. PURPOSE: The purpose of this study is to characterise leprosy epidemiologically in dry border municipalities of Mato Grosso do Sul in Brazil with contiguous urban areas with neighbouring Paraguayan counties, in the period 2001-2011. METHODS: This is an exploratory descriptive investigation that includes the four dry border municipalities of Mato Grosso do Sul (Coronel Sapucaia, Paranhos, Ponta Porã, and Sete Quedas) in Brazil whose urban areas are contiguous with Paraguay. Data comprised the period 2001-2011. RESULTS: The rates of leprosy detection and prevalence oscillated along the study period, increasing in the last 2 years investigated. The detection rate was 3.3/10,000 in 2011, up from 1.7/10,000 in 2009. Prevalence was 5.3/10,000 in 2011, up from 2.5/10,000 in 2009. The Virchowian disease form was predominant in 8 of the 11 years investigated. Most patients were male, with limited formal education (44.2% with less than 4 years of study). CONCLUSION: In the border of Brazil, most (greater than 70%) of the cases detected were classified as multibacillary. The higher coefficient found in Brazilian municipalities was the Virchowian clinical form, which can influence the operational classification in multibacillary. The predominance of the Virchowian clinical form, larger number of patients in rural areas and children under 15 years of age provides new information on the manifestations of the disease in the border territories. The study revealed that municipalities with contiguous cross-border urban areas with Paraguay have unique epidemiological features that need to be addressed by policies focusing leprosy as a public health priority.

The context of leprosy in Brazil-Paraguay border.

In Brazil, leprosy is endemic in three regions: the North, Northeast, and Mid-West. Counties with contiguous binational urban areas are characterized by a constant flow of people, goods, and services, which facilitates the transmission of diseases and influences the epidemiological profile of leprosy. The purpose of this study was to examine territorial differences in relation to the incidence of leprosy, focusing on border counties with contiguous binational urban areas or otherwise. Each county was taken as an information unit for leprosy cases reported during 2001-2011, based on data from original notification records of the state's Department of Health. In counties with contiguous binational urban areas detection rates showed tendency to increase, Virchowian (lepromatous) disease and disability grade II predominated when compared with Groups II and III: 0.64 and 0.54/100,000 inhabitants for Virchowian disease and 0.14 and 0.27/100,000 inhabitants for disability grade II respectively, and were associated with higher transmission rates. The findings demonstrate the role of border areas in maintaining the endemicity of leprosy.

The context of leprosy in Brazil-Paraguay border / O contexto da hanseníase na fronteira Brasil/Paraguai

Abstract In Brazil, leprosy is endemic in three regions: the North, Northeast, and Mid-West. Counties with contiguous binational urban areas are characterized by a constant fow of people, goods, and services, which facilitates the transmission of diseases and influences the epidemiological profile of leprosy. The purpose of this study was to examine territorial differences in relation to the incidence of leprosy, focusing on border counties with contiguous binational urban areas or otherwise. Each county was taken as an information unit for leprosy cases reported during 2001-2011, based on data from original notification records of the state's Department of Health. In counties with contiguous binational urban areas detection rates showed tendency to increase, Virchowian (lepromatous) disease and disability grade II predominated when compared with Groups II and III: 0.64 and 0.54/100,000 inhabitants for Virchowian desease and 0.14 and 0.27/100,000 inhabitants for disability grade II respectively, and were associated with higher transmission rates. The findings demonstrate the role of border areas in maintaining the endemicity of leprosy.

Resumo A hanseníase no Brasil é endêmica em três regiões: norte, nordeste e centro-oeste. As cidades com áreas urbanas contíguas entre o Brasil e Paraguai têm como característica intenso fluxo de pessoas, bens e serviços, cuja mobilidade favorece a transmissão de doenças e influencia no perfil epidemiológico da hanseníase. O objetivo do estudo é analisar as diferenças territoriais relacionadas aos casos de hanseníase, considerando os municípios da linha de fronteira com e sem áreas urbanas contiguas e demais municípios de Mato Grosso do Sul. Cada município foi tratado como unidade de informação para os casos de hanseníase notificados no período de 2001 a 2011, sendo os dados obtidos a partir da base de dados composta pelas fichas de notificação originais da Secretaria de Estado de Saúde. Em municípios com áreas urbanas contiguas, a detecção de casos mostra tendência de aumento, maior coeficientes da forma clínica virchowiana e grau de incapacidade II, em relação aos grupos II e III, que apresentaram 0,64 e 0,54/100.000 da forma clínica virchowiana, respectivamente, e 0,14 e 0,27/100.000, respectivamente, para o grau II de incapacidade. Situação que implica no aumento da transmissão da doença e configura o território de fronteira como cidade urbana contigua importante na manutenção da hanseníase como endêmica.

Reacciones lepromatosas en pacientes adultos y pediátricos en un centro de referencia. Programa Nacional de Lepra, Paraguay / Lepromatous reactions in adults and pediatric outpatients in a reference center. National Lepra Program, Paraguay

Introducción la lepra, llamada también enfermedad de Hansen, es una afección de la piel y de los nervios periféricos, infectocontagiosa, causada por Mycobacterium leprae. Las reacciones lepromatosas se presentan aún con tratamiento y son expresiones de respuesta inmunitaria. Conocerlas es importante a fin de facilitar el abordaje. Objetivo determinar la frecuencia y tipo de reacciones lepromatosas en pacientes con diagnóstico de lepra que acuden al centro de referencia de Enfermedad de Hansen en el Hospital Distrital de San Lorenzo, de enero 2013 a diciembre 2015. Metodología observacional, descriptivo, retrospectivo de corte transverso. Resultados se incluyeron 217 pacientes, 72% presentaban lepra MB y 63% era de sexo masculino. La prevalencia de reacción lepromatosa fue 44%, siendo más frecuentes las de tipo 2 (65%). Se presentó reacción lepromatosa como debut de la enfermedad en 27 %. Treinta y tres pacientes presentaron de tres a doce episodios de reacción lepromatosa. El tratamiento fue talidomida y corticoides. Conclusiones la prevalencia de leprorreacciones fue cercana al 50%, predominando las de tipo 2. El tratamiento utilizado fue talidomida y/o corticoides dependiendo del tipo de reacción lepromatosa.

Introduction leprosy, wich is cause by Mycobacterium leprae, also known as Hansen's Disease, affects skin and peripheral nerves. Lepromatous reactions (LRs) are expressions of an immune reaction and remain as a major persistent problem. LRs are present even with appropriated treatment. Emphasis must be made in early diagnosis and prevention of the catastrophic consequences of LRs. Objective to determine the frequency and type of lepromatous reactions in leprosy patients with leprosy attending to reference center of Hansen´s Disease in the District Center Hospital in San Lorenzo, from January 2013 to December 2015. Methodology observational, retrospective cross sectional study. Results 217 patients were included, 72% with multibacillary leprosy. 63% were male. Lepromatous reactions were found in 44%, been more frequent Type II reaction, in 65% of cases. LRs as oset disease occurred in 27%. 33 patients presented from 3 to 12 episodes of lepromatous reaction. The number of LRs episodes per patient were 3 to 12. Thalidomide was used as treatment in Erithema Nodosum Leprosum (ENL) and corticosteroids for the other types de LRs. Conclusions prevalence of PRs were 50%, been more frecuent the type II. Reaction the treatment used was Thalidomide and/or corticosteroids depending on the type of lepromatosus reaction.

Eritema Nodoso Leproso Forunculoide: Presentación de un caso / No disponible

La Lepra es una enfermedad infectocontagiosa crónica de larga evolución que puede presentar episodios sintomáticos agudos, en ocasiones muy severos, que obligan a buscar atención médica y que se conocen con el nombre de lepra reaccional o leprorreacciones. Diagnosticar lepra reaccional no es dificultoso frente a un paciente con diagnóstico previo de la enfermedad. Aún así, se deberá estar alerta ante la aparición de síntomas generales y/o manifestaciones viscerales, en ausencia de otros signos cutáneos de reacción. Por el contrario, su reconocimiento como primer motivo de consulta puede ser, en ocasiones, un desafío diagnóstico tanto para el dermatólogo como para el médico clínico. Presentamos un raro caso de un paciente de 84 años de edad, procedente de medio rural del Paraguay, diabética, que debutó con lesiones compatibles con forúnculos, tratada previamente como tal por internista y ante falta de mejoría remitida a nuestro servicio, llegando al diagnóstico clínico, histopatológico y baciloscópico de lepra reaccional: eritema nodoso leproso atípico, de tipo forunculoide

Leprosy is a chronic infectious disease that can have longstanding acute symptomatic episodes, in severe cases, requiring them to seek medical attention and are known by the name of leproreactions of leprosy reactions. Diagnosing leprosy reaction is not difficult compared to a patient with a previous diagnosis of the disease, Still, should be alert to the appearance of general symptoms and/or visceral manifestations, in the absence of other signs o skin reaction. On the contrary its recognition as a first reason for consultation can sometimes be a diagnostic challenge for the dermatologist to the clinician. We present rare case a 84 year old female from rural area of Paraguay, diabetic, which debuted with furunculoid lesions and consistent with that was previously treated by an Internist and because the lack of improvement she was referred to our department, arriving at clinical and histopathological diagnosis of atypical erythema nodosum of furunculoid type

Características clínico epidemiológicas de la lepra en la cátedra de dermatología del Hospital de clínicas - Paraguay. Períodod 2003 - 2013 / No disponible

Objetivo: Conocer las características clínicas y epidemiológicas de la Lepra en la Cátedra de Dermatología del Hospital de Clínicas - Paraguay. Material y método: Estudio observacional, descriptivo y retrospectivo. Se estudiaron 250 pacientes con diagnóstico clínico y anatomapatológico de lepra de consultaron en la Cátedra de Dermatología del Hospital de Clínicas entre los años 2003 a 2013 y se realizó el análisis estadístico de las variables estudiadas para lo cual se utilizaron los datos de las historias clínicas. Resultados: la frecuencia en el diagnóstico de lepra fue de 0,57%. El 65% de los pacientes era del sexo masculino. La edad promedio fue de 46,5 ± 16 años; con una edad mínima de 3 años y la máxima de 86 años. En relación a la procedencia el 68% pertenecía al departamento Central y a Asunción. El tiempo de evolución entre la aparición del cuadro clínico y la consulta fue de 1 a 12 meses en el 62% de los pacientes. El 12% de los pacientes presentaba antecedentes de la enfermedad en la familia. El motivo de consulta más frecuente fue la presencia de placas en el 46%. Según la clasificación de la OMS se encontró que el 87% correspondía a la forma multibacilar y la forma clínica más frecuente fue la lepra lepromatosa en el 59% de pacientes. Se encontró que el 30% de los pacientes presentó una reacción lepromatosa, siendo la tipo 2 la de mayor frecuencia. El 50% de los pacientes completó el tratamiento propuesto por la OMS. Se realizó seguimeinto en el 28% de los casos. Conclusión: El programa de lucha contra la lepra debería intensificar la formación de los profesionales, intensificar el seguimiento de los pacientes y difundir información acerca de la enfermedad con el fin de lograr diagnósticos tempranos y la disminución de la prevalencia de la enfermedad (AU)

Objective: To determine the clinical and epidemiological characteristics of Leprosy in the Department of Dermatology, Clinicas Hospital-Paraguay. Methods: An observational, descriptive and retrospective study. We studied 250 patients with clinical and pathological diagnosis of leprosy who consulted at the Department of Dermatology, between the years 2003-2013 and performed the statistical analysis of the variables for which we used data from the medical records. Results: The frequency in the diagnosis of leprosy was 0.57%. The 65% of patients were male. The average age was 46.5 ± 16 years, with a minimum age of 3 years and maximum of 86 years. In relation to the origin 68% belonged to the Central Department and Asuncion. The mean time to interval between the onset of clinical and consultation was 1 to 12 months in 62% of patients. 12% of patients had a history of family illness. The most frequent reason for consultation was the presence of plaques in 46%. According to the WHO classification 87% were of multibacillary form and the most frequent clinical presentation was lepromatous leprosy in 59% of patients. It was found that 30% of patients had a lepromatous reaction type 2. The 50% of the patients completed the treatment proposed by the WHO. Monitoring was performed in 28% of cases. Conclusion: The program of leprosy should intensify the training of professionals, step up monitoring of patients and disseminate information about the disease in order to achieve early diagnosis and decrease the prevalence of the disease (AU)

Hansen lepromatosos histioide. Características clínicas y Epidemiológicas en pacientes de la cátedra de dermatología del Hospital de clínicas, Facultad de ciencias médicas-Universidad Nacional. Asunción-Paraguay. Estudio retrospectivo de 7 años / No disponible

Introducción: El Hansen lepromatosos (HL) histoide de Wade es una forma de presentación de lepra multibacilar con características clínicas, histopatológicas y bacteriológicas específicas, que puede surgir de novo o después de un tratamiento inadecuado e irregular con la monoterapia con dapsona o la poliquimioterapia. Presenta escasa frecuencia de observación, que se estima entre 1,2-3,5% de los casos de lepra y de mayor ocurrencia en el sexo masculino. Objetivos: General: Describir las características clínico-epidemiológicas de pacientes con Hansen lepromatoso variedad Histiodide de la Cátedra de Dermatología del Hospital de Clinicas (HC), Facultad de Ciencias Médicas de la Universidad Nacional de Asunción Paraguay (FCM-UNA) en el período comprendido entre enero de 206 a diciembre de 2012. Específicos: 1. Establecer las características epidemiológicas de la población estudiada. 2. Describir las características clínicas observadas; 3. Determinar los casos surgidos de novo y la adhesión al tratamiento; 4. Describir el índice bacilifero y los episodios reacionales en la población estudiada. Material y Método: Estudio descriptivo observacional, retrospoectivo, de corte transversal. Criterio de inclusión. Pacientes de cualquier edad y sexo con HL: histioide diagnosticados clínica e histopatológicamente de la Cátedra de Dermatología, FCM-UNA, entre de enero de 2006 a diciembre de 2012. Criterios de exclusión: Pacientes con HL con diagnóstico clínico presuntivo peros in confirmación histopatológica y pacientes con HL de variantes diferentes a la histioide. Resultados: Se encontraton 6,7% de pacientes con HL histioide sobre el total de pacientes con Hansen en el periodo de estudio, lo que corresponde al 20,3% de pacientes con HL, con predominio del sexo masculino y en zonas rurales. La franja etaria predominante fue la de 41 a 50 años, con un período de evolución de 1 a 3 años en el 38%. Solo un 10% de pacientes contaban con antecedentes familiares de la enfermedad. La clínica predominante fue de lesiones nodulares con afectación de tronco, abdomen y miembros. Todos los casos fueron de novo, sin tratamiento previo y el 20% presentó eritema nodoso reaccional. Todos fueron tratados con el esquema multibacilar (MB) de la OMS, con un 9,5% de abandono. Conclusión: esta variedad de HL a es poco frecuente, obligando a varios diagnósticos diferenciales. Debemos resaltar: 1. La importancia del diagnóstico y tratamiento precoz, ya que debido a la alta carga bacilifera, el paciente constitutye un importante reservorio de la enfermedad, y 2. La importancia del seguimiento a largo plazo durante y después del tratamiento de pacientes con Hansen lepromatoso variedad histiode (AU)

Introduction: Lepromatous leprosy (LL) histioid variant of Wade is a form of multibacillary leprosy presenting with specific clinical, histopathological and bacteriological features, which may arise de novo or after inadequate and irregular treatment with dapsone monotherapy or combination polichemotherapy. It is infrequent, which is estimated at 1.2-3.6% of cases of leprosy and with higher occurrence in males. Objectives: General. To describe the clinical and epidemiological characteristics of patients with LL histioid variant at the Department of Dermatology, Hospital de Clinicas (HC), Faculty of Medical Sciences of the National University of Asunción, Paraguay (FCM-UNA) in the period from January 2006 to December 2012. Specific: 1. To describe the epidemiological characteristics of the study population. 2. To describe the clinical features observed. 3. Determine cases arising de novo and treatment adherence. 4. To describe the bacillary index smear and reactional episodes in the study population. Material and Methods. A descriptive, observational, retrospective, cross-sectional study. Inclusion criteria. Patients of any age and sex with histioid LL clinically and histologically diagnosed at Department of Dermatology, HC, ECM-UNA, between January 2006 to December 2012. Exclusion criteria: Patients with presumptive clinical diagnosis of LL but without histopathological confirmation and patients with LL with different variants rather than histioid. Results: We found 8.7% of patients with histioid LL of the total patients with leprosy in he study period, corresponding to 20.3% of patients with LL, predominantly males and in rural areas. The predominant age group was 41 to 50 years, with a period of evolution of 1-3 years in the 38%. Only 10% of patients had a family history of the disease. The clinic was of nodular lesions with involvement of the trunk, abdomen and limbs. All cases were de novo, without prior treatment and 29% had erythema nodosum reaction. All were treated with the multibacillary WHO scheme (MB), with 9,5% drop. Conclusion: This variety is rare and raises many differential diagnoses. We should point our: 1. The importance of early diagnosis and treatment, as the high load of B1 in the smears, the patient is a significant reservoir of the disease, and 2. The importance of long term monitoring during and after treatment of patients with histoid LL (AU)

Características clínico-epidemiológicas del fenómeno de lucio en la cátedra de dermatología del hospital de clínicas de Asunción-Paraguay. Estudio de 8 años / No disponible

Introducción: El Fenómeno de Lucio (FL), reacción cutánea grave y distintiva mediada por inmunocomplejos, es una afección cutánea necrosante que ocurre en pacientes portadores de Lepra no nodular [1]. La forma difusa de lepra se produce en aquellos pacientes con poca o nula resistencia a la infección. La literatura revisada muestra inadecuado uso de esta definición. Muchos autores identifican como FL las reacciones vasculonecróticas que ocurren en formas distintas a la Lepra difusa [2]. Objetivos: General: Conocer las características epidemiológicas y clínicas del FL en el Hospital de Clínicas de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción (HC, FCM-UNA). Específicos:1. Establecer las características epidemiológicas de la población en estudio; 2. Describir el número y características clínicas del FL; 3. Describir el tipo de tratamiento impartido y evolución. Material y Método: Diseño: Retrospectivo, observacional de corte transversal. El estudio se lleva a cabo en la Cátedra de Dermatología del HC, FCM-UNA, entre enero de 2003 y octubre de 2011. Criterios de inclusión: Todos los pacientes con Leprorracciones de tipo FL diagnosticados clínicamente y con confirmación anatomopatológica. Criterios de exclusión: Pacientes con Lepra que no hagan leprorreacción de tipo FL o que no tengan confirmación anatomo-patológica. Fuentes de información: Historias clínicas de pacientes con diagnóstico clínico de lepra, con reacciones tipo FL. Resultados: El total de pacientes con lepra del HC, FCM-UNA fue de 311, y de éstos, 52 (16.8%) presentaron leprorreacciones de los cuales 8 fueron de tipo FL(2.5% del total y 15.4% de las leprorreacciones). Predominio de pacientes de sexo masculino procedentes del medio urbano. La mayor franja etaria afectada es la de 70 a 80 años, presentando esta reacción previa al tratamiento antibacilar y por ende representando el debut de su enfermedad de base. El IB osciló de 1 a 6+. En la mayoría de los casos se inició tratamiento MB-OMS y prednisona, con buena evolución. El óbito fue el desenlace en uno de los casos. Conclusiones: Varios autores llaman FL a las reacciones vasculonecróticas (VN) que se presentan en otras formas de la lepra diferentes a la forma difusa, debido a que reacciones VN se describen en pacientes MB con formas diferentes a la lepra difusa (reacciones tipo II: eritema nodoso leproso o ENL), por lo que presentamos este estudio de pacientes con criterios estrictos, clínicos y anatomopatológicos de FL. Es de presentación infrecuente y el diagnóstico diferencial debe incluir vasculitis y vasculopatías de otras etiologías para hacer un diagnóstico correcto, evitando retrasos en el tratamiento y desenlaces fatales (AU)

Introduction: Lucio phenomenon (LP), severe and distinctive skin reaction mediated by immune complexes, is a necrotizing skin condition that occurs in patients with non nodular leprosy [1]. The diffuse form of leprosy occurs in patients with little or no resistance to infection. The literature reviewed shows improper use of this definition. Many authors have identified as LP, vasculonecrotic reactions (VN) that occur in non diffuse leprosy [2]. Objectives: General: To determine the epidemiological and clinical characteristics of the LP at the Clinicas Hospital of the Faculty of Medical Sciences, National University of Asunción (CH, FMC-NUA). Specific: 1. To establish the epidemiological characteristics of the study population, 2. Describe the number and clinical characteristics of LP; 3. Describe the type of treatment given and outcome. Methods: Design: Retrospective, observational, cross-sectional. The study was conducted at the Department of Dermatology of CH, FMC-NUA, between January 2003 and October 2011. Inclusion criteria: All patients with LP diagnosed clinically and with pathologic confirmation. Exclusion Criteria: Patients with Leprosy reactions different from LP and without tanatomo-pathological confirmation. Information sources: Clinical records of patients with clinical diagnosis of leprosy with LP. Results: The total number of leprosy patients was 311, and of these, 52 presented reactions and 8 were LP (2,5%). Predominance of male patients from the urban environment. Most affected age group was between 70 and 80 years, with this reaction before antibacilartreatment and thus represents the debut of their underlying disease. The BI was between 1 and 6+. In most cases, treatment was begun with MB-WHO and prednisone, with good evolution. The death was the outcome in one case. Conclusions: Several authors call LP to other vasculonecrotic reactions (VN) that occur in other forms of leprosy than the diffuse form, because VN reactions are described in MB patients with different forms of leprosy diffuse (type II reactions: eryhthemanodosum), so we present this study of patients with strict criteria, clinical and pathological of LP Presentation is uncommon and differential diagnosis should include vasculitis and vascular disease of other etiologies for making a correct diagnosis, avoiding delays in treatment and fatal outcomes (AU)

Lepra infantil: Estudio clinico y epidemiologico en dos servicios de dermatología del Paraguya. Periodo 2005-2011 / No disponible

Introducción: La lepra en niños es más frecuente de lo que se solía pensarse, sobre todo en países tropicales y subtropicales, como el Paraguay. Pediatras y dermatólogos deberían pensar en esta enfermedad para realizar de esta manera un diagnóstico precoz con el tratamiento específico. Objetivos: Generales: Conocer las características epidemiológicas y clínicas de la lepra infantil en dos Servicios de Dermatología del Paraguay. Específicos: Establecer las características epidemiológicas de la población en estudio. Determinar la frecuencia, tipo, características clínicas y estados reaccionales relacionando con el índice bacilar. Describir el manejo terapéutico que recibieron estos pacientes y su evolución. Material y Método: Diseño del estudio: Retrospectivo, observacional de cortetransversal. El estudio se lleva a cabo en la Cátedra de Dermatología del Hospital de Clínicas, Facultad de Ciencias Médicas-Universidad Nacional de Asunción y en el Servicio de Dermatología del Hospital Nacional de Itauguá, ambos de Paraguay. Población de estudio: Pacientes de ambos sexos dentro de la definición de edad pediátrica de la OMS (0-18 años) con diagnóstico confirmado de Lepra, durante el periodo de enero de 2005 a octubre de 2011. Criterios de inclusión: Todos los pacientes en edad pediátrica diagnosticados clínicamente y con confirmación anatomopatológica. Criterios de exclusión: Pacientes lepra que no estén comprendidos en la edad pediátrica en el momento del diagnóstico y que no tengan confirmación anatomopatológica. Fuentes de información: Historias clínicas de pacientes con diagnóstico de lepra.Resultados: Total de pacientes con lepra en ambos servicios fue de 416, y de éstos 9 estaban en edad pediátrica (2.2%). Predominio de pacientes de sexo masculino; la franja estaria más afectada es la de los escolares con 5 casos (56%) El IB osciló entre negativo a 3+. Seis de los nueve casos presentaron formas multibacilares, siendo la lepra lepromatosa la forma más frecuente. La evolución fue buena en todos los casos y tres desarrollaron leprorreacciones. Fue predominante la localización facial de las lesiones. Conclusiones: Los niños con lepra constituyen un grupo significativo de enfermos donde los contactos familiares probablemente representen un rol importante en su desarrollo. Las publicaciones actuales muestran un aumento de la incidencia de la lepra en niños (AU)

Background: Leprosy among children is more common than usually thought, especially in tropical and subtropical countries like ours. Pediatricians and dermatologists should consider this disease for so early diagnosis with specific treatment. Objectives: General: To determine the epidemiological and clinical characteristics of Hansen’s disease in children in two Dermatology Services of Paraguay. Specific: To establish the epidemiological characteristics of the study population. Describe the frequency, type and clinical characteristics of Hansen’s disease. Relate the bacillary index with the type of reactions. Describe the therapeutic management of these patients. Material and Methods: Study design: Retrospective, observational cross-sectional. The study was conducted at the Department of Dermatology, Hospital de Clinicas, Faculty of Medical Sciences, National University of Asuncion and the Dermatology Service of the National Hospital Itauguá, both of Paraguay. Study population: Patients of both sexes within the definition of pediatric by the WHO (0-18 years) with confirmed diagnosis of leprosy during the period January 2005 to October 2011. Inclusion criteria: All pediatric patients clinically diagnosed with Hansen’s disease and pathologic confirmation. Exclusion Criteria: Patients with Hansen’s disease not included in the pediatric age at the diagnosis and who have no pathological confirmation. Information sources: Clinical records of pediatric patients with clinical diagnosis of Hansen’s disease, confirmed by smear and pathology. Results: Total patients with leprosy in both services was 416, and of these 9 children had Hansen’s disease (2.2%). Predominance of male patients, the most affected age group is school children with 5 cases (56%). The IB ranged from negative to 3+. Six of the nine cases had multibacillary forms (MB), the diagnosis of HL being the most frequent. The evolution was good in all cases and only three developed reactions. Facial location of the lesions was predominant. Conclusions: Children with leprosy are a significant group of patients where family contacts are likely to represent an important role in its development. Theexisting literature shows an increased incidence of childhood leprosy (AU)

Estudio clínico y epidemiológico de las leprorreacciones en dos servicios de dermatología del Paraguay. Periodo 2003-2009 / No disponible

Introducción: Las leprorreacciones constituyen episodios agudos en el curso de la enfermedad de Hansen debidas a cambios inmunitarios. Objetivos: Generales: Conocer las características epidemiológicas y clínicas de las leprorreacciones en dos Servicios de Dermatología del Paraguay. Específicos: Establecer las características epidemiológicas de la población en estudio. Describir la frecuencia, tipo y características clínicas de leprorreacciones. Relacionar el índice bacilar (IB) con el tipo de leprorreacciones. Describir el manejo terapéutico que recibieron estos pacientes. Material y Método: diseño del estudio: Retrospectivo, observacional de corte transversal. El estudio se lleva a cabo en la Cátedra de Dermatología del Hospital de Clínicas, Facultad de Ciencias Médicas-Universidad Nacional de Asunción y en el Servicio de Dermatología del Hospital Nacional de Itauguá, ambos de Paraguay. Población de estudio: Pacientes de ambos sexos y de cualquier edad con diagnóstico confirmado de Lepra que han tenido leprorreacciones en el transcurso de su evolución, durante el periodo de enero de 2003 a octubre de 2009. Criterios de inclusión: Todos los pacientes con leprorreacciones diagnosticados clínicamente, con o sin confirmación anatomopatológica. Criterios de exclusión: Pacientes con enfermedad de Hansen que no presenten leprorreacciones en su evolución y/o en el momento del diagnóstico. Fuentes de información: Historias clínicas de pacientes con diagnóstico clínico de Enfermedad de Hansen, confirmado con baciloscopía o anatomía patológica. Resultados: Total de pacientes con lepra en ambos servicios fue de 256, y de éstos 79 presentaron leprorreacciones (31%). Predominio de pacientes de sexo masculino; la franja etaria más afectada es entre los 20 y 60 años, con disminución en los extremos de vida. El IB fue alto (3-4+). En la mayoría de los casos se realizó tratamiento específico para la reacción. La evolución fue buena. El óbito fue el desenlace en un solo caso. Conclusiones: Las leprorreacciones representan una importante agudización dentro de la evolución crónica de la enfermedad, que obliga al paciente a buscar atención médica. Un poco más de un tercio de los casos la presentarán por lo que sería conveniente poner al paciente en conocimiento de esta complicación. En la gran mayoría de casos la evolución es buena y el paciente puede ser manejado ambulatoriamente. El médico dermatólogo está obligado a realizar una exhaustiva evaluación física a fin de detectar signos y síntomas de gravedad, que obliguen a una atención médica compleja, y así evitar secuelas o incluso un desenlace fatal si no se toman las medidas adecuadas en el momento oportuno (AU)

Background: Leprosy reactions are acute episodes within Hansen´s disease due to impaired immunity. Objectives: General: To determine the epidemiological and clinical characteristics of leprosy reactions in two services of Dermatology in Paraguay. Specific: To establish the epidemiological characteristics of the population in study. To describe the frequency, type and clinical characteristics of leprosy reactions. To link the BI with the type of reaction. To describe the therapeutic management of these patients. Material and Methods: Study Design: Retrospective, observational cross-sectional. The study was conducted in the Dermatology, University Hospital, FCM-UNA and the Dermatology Service of the National Hospital of Itauguá. Population in study: Patients of both sexes and any age with a confirmed diagnosis of leprosy who have leprosy reactions in the course of its development during the period January 2003 to October 2009. Inclusion criteria: All patients with clinically diagnose of leprosy reaction, with or without pathological confirmation. Exclusion criteria: Patients with Hansen´s disease who do not submit leprosy reactions in their development and/or at the time of diagnosis. Sources of information: Clinical records of patients with clinical diagnosis of Hansen´s disease, confirmed or not with pathology. Results: Total number of patients with leprosy in both services was 256, and of these 79 had leprosy reactions (31%). Predominance of male patients, the most affected age group is between 20 and 60, with a decrease in end of life. The BI was high (3-4+). In most cases specific treatment was performed for the reaction. The outcome was good. The death was the outcome in the minority of cases. Conclusions: Leprosy reactions represent a significant worsening in the chronic course of the disease, which requires the patient to seek medical attention. A little more than a third of the cases presented, it would be appropriate to make the patient aware of this complication. In most cases the trend is good and the patient can be managed as outpatients. The dermatologist is required to conduct a thorough physical examination to detect signs and symptoms of severity, requiring complex medical care, thus avoiding a fatal outcome if not taken appropriate measures in due course (AU)

Lepra hoy: consideraciones epidemiológicas del Hospital Nacional / Leprosy today: epidemiologycal considerations of the National Hospital

La lepra o enfermedad de Hansen, enfermedad infectocontagiosa producida por el Mycobacterium leprae, sigue siendo un problema de salud pública en países como el nuestro. Se estudian aspectos epidemiológicos de la lepra en los casos registrados en el Servicio de Dermatología . Estudio retrospectivo observacional y descriptivo de los casos de Consultorio Externo e interconsultas hospitalarias registrados en el periodo de 1999 al 2009. La lucha contra la lepra, a pesar de algunas fortalezas como la distribución gratuita de los fármacos, sigue presentando grandes desafíos como el elevado número de abandono del tratamiento y el escaso y el escaso control de las personas contactantes, máxime considerando que el 80% son bacilíferos...

Polymorphism in the rpoT gene in Mycobacterium leprae isolates obtained from Latin American countries and its possible correlation with the spread of leprosy.

The genotypes of Mycobacterium leprae isolates originating from Mexico, Peru and Paraguay were analysed for the polymorphism of short tandem repeats in the rpoT gene. The genotype with four copies of the six-base tandem repeats in the rpoT gene was prominently predominant in Mexico, but the genotype of all isolates from Peru and Paraguay contained three copies of the six-base tandem repeats. These obvious different distributions might reflect the spread of leprosy by the different strains of M. leprae harboured by the various human races that moved to the American continent, as has been demonstrated in other infectious diseases.

Fenómeno de Lucio. Comunicación de 4 casos de lepra no difusa / Lucio’s phenomenon in nodular leprae. Report of 4 cases

El fenómeno de Lucio es una forma reactiva grave, de tipo 11, clásicamente descrita en la lepra lepromatosa difusa primaria. Esta variedad de lepra es más común en México y Costa Rica, aunque en algunos otros países se ha hallado de forma ocasional, y no se ha descrito en Paraguay. Este artículo tiene como objetivo comunicar la observación de 4 casos de fenómeno de Lucio en pacientes lepromatososnodulares (3 casos) y dimorfo próximo al polo lepromatoso (un caso). Se detallan los hallazgos clínicos, histológicos, de laboratorio, evolutivos y terapéuticos, y se plantean los principales diagnósticos diferenciales. Se concluye que el fenómeno de Lucio, si bien es poco frecuente en pacientes con lepra no difusa, presenta una importante morbimortalidad por la propia reacción y por las intercurrencias o complicaciones (AU)

The Lucio's phenomenon is a severe reactional form, of type 11, classically described in primary difuse lepromatous Leprosy. This variety of leprosy presents an important distribution in Mexico and Costa Rica, being occasional in some other countries, this variety was not described in Paraguay. The observation of 4 cases of Lucio's phenomenon in patients with nodular leprosy(3 cases) and bordeline next to the lepromatous pole (1 case) motivates this report. The clinical, histological, laboratorial and therapeutic findings are described and the main differential diagnosis are considered. We conclude that the Lucio's phenomenon, althougt less frequent in patients with non diffuse leprosy, presents an important morbimortality by the own reaction and the complications (AU)

[Hansen disease in Mercosur]. / Enfermedad de Hansen en el Mercosur.

In the context of the important changes of a political economic, social and health order upon which the Argentina, Brazil, Paraguay and Uruguay have now embarked in the framework of the commitment undertaken to create instruments for the Common Market of the South America (MERCOSUR), the importance of leprosy for public health in this new region is analysed. In this connection a description is given of the background and reasons which led to the creation of the MERCOSUR Committee for technical cooperation on leprosy, composed of the heads of the national leprosy control programmes of the countries in question, for the purpose of implementing the Protocol of Intention signed by the representatives of the Ministers of member countries, with the object of establishing policies of technical cooperation in activities to control this disease, with a view to attaining the goal proposed by WHO of eliminating leprosy as a public health problem by the year 2000. Using the data contributed by the different programmes, the epidemiological situation existing in this region in December 1995 is outlined, with analysis of certain epidemiological, demographic and operational variables, showing that MERCOSUR has a prevalence of 6.03 per 10,000 population, one of the highest rates in comparison with other WHO regions; a high percentage of cases lost to view (abandons); and a low rate of coverage with multidrug therapy. In this region a total of 33,654 new cases were detected during 1995, of which more than 50% were multibacillary forms, while nearly 10% of them were youngsters of less of 15 years of age. The action carried out jointly among the four countries, the successes achieved and the results to be achieved in the short term are also described.