New Genetic Variants of Leptospira spp Characterized by MLST from Peruvian Isolates.

Leptospirosis is a zoonotic disease caused by the genus Leptospira, presenting complex and dynamic epidemiology. To determine the genetic variability and its phylogenetic relationship of Leptospira spp isolates from three sources in Iquitos (Peruvian Amazon) from 2002 to 2013, seven MLST genes were analyzed to obtain the Sequence Type (ST) and these sequences were concatenated for phylogenetic analysis. The genetic relationship between STs was determined with the goeBURST algorithm and genetic diversity was determined using DnaSP. Of 51 isolates, 48 were pathogenic belonging to five different species: Leptospira interrogans Nascimento 2004, Leptospira santarosai Feil 2004, Leptospira noguchii Haake 2021, Leptospira borgpetersenii Levett 2021, and Leptospira kirschneri Levett 2021. Of 20 STs identified, 60% corresponded to new genotypes circulating only in Peru. The genotypes ST17, ST37, and ST301 were recorded in rodents and humans. A high intraspecific genetic diversity was demonstrated in L. noguchi. The goeBURST analysis revealed three clonal complexes (CCs) and 16 singletons. The STs were found to show high genetic variability and phylogenetic and goeBURST analysis determined that the genotypes found did not form specific groups according to the source of infection or origin, which confirms the zoonotic potential of these STs in an area highly endemic for leptospirosis.

Serologic Evidence of Scrub Typhus in the Peruvian Amazon.

Using a large, passive, febrile surveillance program in Iquitos, Peru, we retrospectively tested human blood specimens for scrub typhus group orientiae by ELISA, immunofluorescence assay, and PCR. Of 1,124 participants, 60 (5.3%) were seropositive, and 1 showed evidence of recent active infection. Our serologic data indicate that scrub typhus is present in the Peruvian Amazon.

Rickettsial Disease in the Peruvian Amazon Basin.

Using a large, passive, clinic-based surveillance program in Iquitos, Peru, we characterized the prevalence of rickettsial infections among undifferentiated febrile cases and obtained evidence of pathogen transmission in potential domestic reservoir contacts and their ectoparasites. Blood specimens from humans and animals were assayed for spotted fever group rickettsiae (SFGR) and typhus group rickettsiae (TGR) by ELISA and/or PCR; ectoparasites were screened by PCR. Logistic regression was used to determine associations between patient history, demographic characteristics of participants and symptoms, clinical findings and outcome of rickettsial infection. Of the 2,054 enrolled participants, almost 2% showed evidence of seroconversion or a 4-fold rise in antibody titers specific for rickettsiae between acute and convalescent blood samples. Of 190 fleas (Ctenocephalides felis) and 60 ticks (Rhipicephalus sanguineus) tested, 185 (97.4%) and 3 (5%), respectively, were positive for Rickettsia spp. Candidatus Rickettsia asemboensis was identified in 100% and 33% of the fleas and ticks tested, respectively. Collectively, our serologic data indicates that human pathogenic SFGR are present in the Peruvian Amazon and pose a significant risk of infection to individuals exposed to wild, domestic and peri-domestic animals and their ectoparasites.

BAES Scrotal flap: anatomical bases and usefulness in complex urethral reconstruction.

OBJECTIVE: To describe the anatomical characteristics and vascularization of the biaxial hair free scrotal flap (BAES-flap) and to detail its surgical application to reconstruction of the more complex urethral strictures. METHODS: We performed macro and micro anatomical dissections of the scrotum in 15 cryopreserved cadavers for the study of the arterial microvascularization of the BAES flap, and this anatomical knowledge has been implemented with the aim to improve the anterior and posterior urethra reconstructive surgical technique. For scrotal skin conditioning we performed definitive hair removal with the alexandrite laser. RESULTS: The BAES flap, thanks to its rich biaxial vascularization, its anatomical disposition over the urethral axis, and the suitable characteristics of hair free scrotal skin, has allowed us to perform successful one-step urethral reconstruction in complex cases such as panurethral disease, multioperated hypospadias, failed urethroplasties and obliterative stenosis. CONCLUSIONS: Detailed study of scrotal skin arterial vascularization is essential to design reliable and versatile genital skin flaps that result appropriate for the most complex reconstructive urethral surgery. The BAES scrotal flap complies with these requirements offering the patient a one step reconstructive option with a very satisfactory surgical experience over more than 20 years.

Colgajo escrotal "BAES": Bases anatómicas y utilidad en reconstrucción uretral compleja / BAES Scrotal flap: Anatomical bases and usefulness in complex urethral reconstruction

OBJETIVO: Describir las características anatómicas y la vascularización del colgajo escrotal biaxial depilado ("BAES-flap"), y detallar su aplicación quirúrgica en la reconstrucción de las estenosis uretrales más complejas. MÉTODOS: Se han realizado macro y microdisecciones anatómicas de la bolsa escrotal en 15 cadáveres criopreservados para estudiar la microvascularización arterial que posee el colgajo "BAES", y este conocimiento anatómico ha sido implementado con la intención de mejorar la técnica quirúrgica reconstructiva de la uretra anterior y posterior. Para el acondicionamiento cutáneo escrotal se ha empleado la técnica de depilación definitiva con láser de Alejandrita. RESULTADOS: El colgajo "BAES" gracias a su abundante vascularización bi-axial, a su disposición anatómica sobre el eje uretral y a las características idóneas de la piel escrotal depilada, nos ha permitido desde el año 1989 reconstruir con éxito la uretra en un tiempo quirúrgico en casos complejos como son la enfermedad panuretral, los hipospadias multioperados, las uretroplastias fracasadas y las estenosis obliterantes. CONCLUSIONES: El estudio detallado de la vascularización cutánea arterial es fundamental para diseñar colgajos de piel genital fiables y versátiles que resulten aptos para la cirugía reconstructiva uretral más compleja. El colgajo escrotal "BAES" cumple con estos requisitos ofreciendo al paciente una opción reconstructiva en un solo tiempo con una experiencia quirúrgica muy satisfactoria de más de 20 años

OBJECTIVE: To describe the anatomical characteristics and vascularization of the biaxial hair free scrotal flap (BAES-flap) and to detail its surgical application to reconstruction of the more complex urethral strictures. METHODS: We performed macro and micro anatomical dissections of the scrotum in 15 cryopreserved cadavers for the study of the arterial microvascularization of the BAES flap, and this anatomical knowledge has been implemented with the aim to improve the anterior and posterior urethra reconstructive surgical technique. For scrotal skin conditioning we performed definitive hair removal with the alexandrite laser. RESULTS: The BAES flap, thanks to its rich biaxial vascularization, its anatomical disposition over the urethral axis, and the suitable characteristics of hair free scrotal skin, has allowed us to perform successful one-step urethral reconstruction in complex cases such as panurethral disease, multioperated hypospadias, failed urethroplasties and obliterative stenosis. CONCLUSIONS: Detailed study of scrotal skin arterial vascularization is essential to design reliable and versatile genital skin flaps that result appropriate for the most complex reconstructive urethral surgery. The BAES scrotal flap complies with these requirements offering the patient a one step reconstructive option with a very satisfactory surgical experience over more than 20 years

A foodborne outbreak of brucellosis at a police station cafeteria, Lima, Peru.

Brucella melitensis is highly infectious for humans and can be transmitted to humans in a number of epidemiological contexts. Within the context of an ongoing brucellosis surveillance project, an outbreak at a Peruvian police officer cafeteria was discovered, which led to active surveillance (serology, blood culture) for additional cases among 49 police officers who had also eaten there. The cohort was followed up to 18 months regardless of treatment or symptoms. Active surveillance estimated the attack rate at 26.5% (13 of 49). Blood cultures from four cases were positive; these isolates were indistinguishable using multiple locus variable number tandem repeat analysis. This investigation indicates the importance of case tracking and active surveillance for brucellosis in the context of potential common source exposure. These results provide rationale for public health investigations of brucellosis index cases including the bioterrorism-related dissemination of Brucella.

Diversidad genética de aislamientos peruanos de Leptospira spp. mediante electroforesis en gel de campo pulsado / Genetic diversity of Peruvian isolates of Leptospira spp. through pulsed field gel electrophoresis

Objetivos. Determinar la diversidad genética de aislamientos peruanos de Leptospira spp. mediante electroforesis en gel de campo pulsado (PFGE). Materiales y métodos. Se estandarizó la metodología de PFGE propuesta por Galloway y Levett (2008). Se elaboró una base de datos con los perfiles de PFGE de 65 cepas de referencia y se aplicó la técnica en 111 aislamientos de Leptospira spp. obtenidos en Perú entre 2002 y 2010. Resultados. Se determinó gran diversidad genética de serovares de Leptospira spp. circulantes en nuestro país. Se identificaron 57 serovares, 47 en 97 aislamientos patógenos. Los serovares más frecuentes fueron Icterohaemorrhagiae/Copenhageni (n=24) y Canicola (n=7). Las especies más frecuentes fueron L. santarosai (49,5%) y L. interrogans (37,1%). La distribución de especies, clusters y serovares varió según la fuente del aislamiento, el contexto ambiental y la procedencia. Conclusiones. Existe gran diversidad de serovares circulantes en el Perú, la cual está relacionada a la especie, el reservorio, el contexto ambiental y la procedencia del aislamiento. Se evidencia las relaciones genéticas y epidemiológicas entre aislamientos de diferentes fuentes, lo cual está relacionada a la especie, el reservorio, el contexto ambiental y la procedencia del aislamiento.

Objectives. Determine the genetic diversity of Peruvian isolations of Leptospira spp. through Pulsed Field Gel Electrophoresis (PFGE). Materials and methods. The PFGE methodology proposed by Galloway and Levett (2008) was standardized. A database including the PFGE profiles of 65 reference strains was prepared, and the technique was applied in 111 isolates of Leptospira spp. obtained in Peru between 2002 and 2010. Results. A great generic diversity of serovars of circulating Leptospira spp. was determined in our country. 57 serovars were identified, 47 out of 97 pathogen isolates. Most frequent serovars were Icterohaemorrhagiae/Copenhageni (n=24) and Canicola (n=7). The most frequent species were L. santarosai (49,5%) and L. interrogans (37,1%). The distribution of species, clusters and serovars changed according to the source of isolate, the environmental context and the origin. Conclusions. There is great diversity of circulating serovars in Peru. There are genetic and epidemiological relations among isolates of different sources, and this is related to species, reservoir, environmental context and the origin of the isolate.

[Genetic diversity of Peruvian isolates of Leptospira spp. through pulsed field gel electrophoresis]. / Diversidad genética de aislamientos peruanos de Leptospira spp. mediante electroforesis en gel de campo pulsado.

OBJECTIVES: Determine the genetic diversity of Peruvian isolations of Leptospira spp. through Pulsed Field Gel Electrophoresis (PFGE). MATERIALS AND METHODS: The PFGE methodology proposed by Galloway and Levett (2008) was standardized. A database including the PFGE profiles of 65 reference strains was prepared, and the technique was applied in 111 isolates of Leptospira spp. obtained in Peru between 2002 and 2010. RESULTS: A great generic diversity of serovars of circulating Leptospira spp. was determined in our country. 57 serovars were identified, 47 out of 97 pathogen isolates. Most frequent serovars were Icterohaemorrhagiae/Copenhageni (n=24) and Canicola (n=7). The most frequent species were L. santarosai (49,5%) and L. interrogans (37,1%). The distribution of species, clusters and serovars changed according to the source of isolate, the environmental context and the origin. CONCLUSIONS: There is great diversity of circulating serovars in Peru. There are genetic and epidemiological relations among isolates of different sources, and this is related to species, reservoir, environmental context and the origin of the isolate.

Iquitos virus: a novel reassortant Orthobunyavirus associated with human illness in Peru.

Oropouche (ORO) virus, a member of the Simbu serogroup, is one of the few human pathogens in the Orthobunyavirus genus in the family Bunyaviridae. Genetic analyses of ORO-like strains from Iquitos, Peru, identified a novel reassortant containing the S and L segments of ORO virus and the M segment of a novel Simbu serogroup virus. This new pathogen, which we named Iquitos (IQT) virus, was first isolated during 1999 from a febrile patient in Iquitos, an Amazonian city in Peru. Subsequently, the virus was identified as the cause of outbreaks of "Oropouche fever" during 2005 and 2006 in Iquitos. In addition to the identification of 17 isolates of IQT virus between 1999 and 2006, surveys for neutralizing antibody among Iquitos residents revealed prevalence rates of 14.9% for ORO virus and 15.4% for IQT virus. Limited studies indicate that prior infection with ORO virus does not seem to protect against disease caused with the IQT virus infection. Identification of a new Orthobunyavirus human pathogen in the Amazon region of Peru highlights the need for strengthening surveillance activities and laboratory capabilities, and investigating the emergence of new pathogens in tropical regions of South America.

[Primary pneumonic plague with nosocomial transmission in La Libertad, Peru 2010]. / Peste neumónica primaria con transmisión intrahospitalaria en La Libertad, Perú 2010.

UNLABELLED: Pneumonic plague is one of the clinical forms of plague, of low frequency and high mortality, transmitted by direct inhalation of Yersinia pestis coming from an animal or from person to person. OBJECTIVE: To describe the clinical and epidemiological characteristics of the cases of primary pneumonic plague in an outbreak in the north of Peru. MATERIALS AND METHODS: The clinical records of the confirmed cases of primary pneumonic plague presenting in an outbreak occurring in La Libertad, in July 2010, were reviewed, also the search and contact investigation was performed. RESULTS: The index case was identified, as well as three additional cases, out of these, two were nosocomial infections related to the index case. The initial clinical presentation was characterized by sudden onset of fever, chills, myalgia and chest pain, which in less than 24 hours evolved to hypotension and cyanosis. The initiation of specific treatment varied from 2 to 12 days, and cases with prompt initiation of treatment had a better clinical outcome. The lethality was 50% (2/4). CONCLUSION: Nosocomial transmission of pneumonic plague in Peru is evidenced, with severe clinical manifestations and high lethality.

Peste neumónica primaria con transmisión intrahospitalaria en La Libertad, Perú 2010 / Primary pneumonic plague with nosocomial transmission in La libertad, Peru 2010

La peste neumónica es una forma clínica de peste, de baja frecuencia y alta letalidad, transmitida por la inhalación directa de Yersinia pestis proveniente de un animal o de persona a persona. Objetivo: Describir las características clínicas y epidemiológicas de los casos de un brote de peste neumónica primaria humana en el norte de Perú. Materiales y Métodos. Se revisaron las historias clínicas de los casos confirmados de peste neumónica primaria presentados en un brote ocurrido en la región de La Libertad, en el mes de julio de 2010, asimismo, se efectuó la búsqueda e investigación de contactos. Resultados: Se identificó el caso Índice y tres casos adicionales, de estos últimos, dos fueron infecciones intrahospitalarias relacionadas con el caso índice. La presentación clínica inicial se caracterizó por fiebre de inicio súbito, escalofríos, mialgias y dolor torácico y evolución en menos de 24 horas a hipotensión arterial y cianosis. El inicio del tratamiento específico varió de 2 a 12 días, observándose que los casos con inicio precoz de tratamiento tuvieron un mejor resultado clínico. La lealtad fue de 50 por ciento (2/4). Conclusión: Se evidenció la transmisión intrahospitalaria de peste neumónica en el Perú con manifestaciones graves y alta letalidad.

Pneumonic plague is one of the clinical forms of plague, of low frequency and high mortality, transmitted by direct inhalation of Yersinia pestis coming from an animal or from person to person. Objective. To describe the clinical and epidemiological characteristics of the cases of primary pneumonic plague in an outbreak in the north of Peru. Materials and methods. The clinical records of the confirmed cases of primary pneumonic plague presenting in an outbreak occurring in La Libertad, in July 2010, were reviewed, also the search and contact investigation was performed. Results. The index case was identified, as well as three additional cases, out of these, two were nosocomial infections related to the index case. The initial clinical presentation was characterized by sudden onset of fever, chills, myalgia and chest pain, which in less than 24 hours evolved to hypotension and cyanosis. The initiation of specific treatment varied from 2 to 12 days, and cases with prompt initiation of treatment had a better clinical outcome. The lethality was 50 percent (2/4). Conclusion. Nosocomial transmission of pneumonic plague in Peru is evidenced, with severe clinical manifestations and high lethality.

Arboviral etiologies of acute febrile illnesses in Western South America, 2000-2007.

BACKGROUND: Arthropod-borne viruses (arboviruses) are among the most common agents of human febrile illness worldwide and the most important emerging pathogens, causing multiple notable epidemics of human disease over recent decades. Despite the public health relevance, little is know about the geographic distribution, relative impact, and risk factors for arbovirus infection in many regions of the world. Our objectives were to describe the arboviruses associated with acute undifferentiated febrile illness in participating clinics in four countries in South America and to provide detailed epidemiological analysis of arbovirus infection in Iquitos, Peru, where more extensive monitoring was conducted. METHODOLOGY/FINDINGS: A clinic-based syndromic surveillance system was implemented in 13 locations in Ecuador, Peru, Bolivia, and Paraguay. Serum samples and demographic information were collected from febrile participants reporting to local health clinics or hospitals. Acute-phase sera were tested for viral infection by immunofluorescence assay or RT-PCR, while acute- and convalescent-phase sera were tested for pathogen-specific IgM by ELISA. Between May 2000 and December 2007, 20,880 participants were included in the study, with evidence for recent arbovirus infection detected for 6,793 (32.5%). Dengue viruses (Flavivirus) were the most common arbovirus infections, totaling 26.0% of febrile episodes, with DENV-3 as the most common serotype. Alphavirus (Venezuelan equine encephalitis virus [VEEV] and Mayaro virus [MAYV]) and Orthobunyavirus (Oropouche virus [OROV], Group C viruses, and Guaroa virus) infections were both observed in approximately 3% of febrile episodes. In Iquitos, risk factors for VEEV and MAYV infection included being male and reporting to a rural (vs urban) clinic. In contrast, OROV infection was similar between sexes and type of clinic. CONCLUSIONS/SIGNIFICANCE: Our data provide a better understanding of the geographic range of arboviruses in South America and highlight the diversity of pathogens in circulation. These arboviruses are currently significant causes of human illness in endemic regions but also have potential for further expansion. Our data provide a basis for analyzing changes in their ecology and epidemiology.

Impacto de la implementación de medidas de gestión hospitalaria para aumentar la eficiencia en la gestión de camas y disminuir la saturación del servicio de urgencias / Impact of hospital management measures on improving the efficiency of bed allocation and reducing emergency department overcrowding

Objetivo: Analizar el impacto de la implementación de medidas para reducir el número de pacientes ubicados en urgencias en es pera de cama de hospitalización. Método: Tipo de estudio: comparativo con un análisis retrospectivo. Se compararon dos periodos: periodo 1 (nov 06-oct 07) y periodo 2 (nov 07-oct 08). Ámbito: Hospitalde Sant Boi, hospital general de 126 camas, en Sant Boi de Llobregat (Barcelona). Medidas implementadas: disminución de la estancia prequirúrgica, incremento de la cirugía mayor ambulatoria (CMA) y potenciación del ingreso en una unidad de corta estancia médica (UCE). Variables estudiadas: admisiones en el SUH, ingresos hospitalarios, ingresos de CMA, el número de días en que hay al menos 1 paciente pendiente de cama hospitalaria en el SUH a las 8:00 horas, estancia promedio hospitalaria, actividad y estancia promedio en la UCE. Resultados: El total de admisiones en el SUH fue de 57.140 en el periodo 1, y 71.280 en el periodo 2, con 4.840 (8,4%) y 5.385 (7,5%) ingresos, respectivamente. La estancia media de hospitalización disminuyó de 5,2 días a 4,5 días (p < 0,001). En 86 días del periodo 1, uno o más pacientes permanecían en el SUH pendientes de cama (307 pacientes/año), frente a 11 días en el período 2 (26 pacientes/año). Conclusiones: En nuestra experiencia, las medidas de gestión aplicadas fueron eficaces en la disminución del número de pacientes pendientes de cama en urgencias (AU)

Objective: To analyze the impact of hospital management measures to reduce the number of patients held in an emergency department while awaiting admission. Methods: Type of study: retrospective, comparing 2 periods, November 2006 to October 2007 and November 2007 to October 2008. Setting: Hospital de Sant Boi, a 126-bed general hospital in Sant Boi de Llobregat in the province of Barcelona. Management measures: decreased presurgical stay, increased use of ambulatory surgical procedures, and increased use of a medical short-stay unit. Variables studied: emergency department admissions, hospital ward admissions, admissions for ambulatory surgical procedures, number of days in which at least 1 patient was in the emergency department at 8 A.M. while waiting for a bed, mean hospital stay, and admissions and average time spent in the short-stay unit. Results: A total of 57140 patients were admitted to the emergency department in the first period and 71280 in the second period; 4840 (8.4%) were admitted to hospital in the first period and 5385 (7.5%) in the second. The average length of stay was 5.19 days in the first period and 4.54 days in the second (P<.001). At least 1 patient was waiting in the emergency department for a hospital bed to become available on 86 days in the first period (307 patients/year) and11 days in the second period (26 patients/year). Conclusions: The management measures applied in this case were effective in reducing the number of patients held in the emergency department while waiting for admission (AU)

Venezuelan equine encephalitis and 2 human deaths, Peru.

Studies have suggested that enzootic strains of Venezuelan equine encephalitis (VEE) subtype ID in the Amazon region, Peru, may be less pathogenic to humans than are epizootic variants. Deaths of 2 persons with evidence of acute VEE virus infection indicate that fatal VEEV infection in Peru is likely. Cases may remain underreported.