Venezuela's humanitarian crisis, resurgence of vector-borne diseases, and implications for spillover in the region.

In the past 5-10 years, Venezuela has faced a severe economic crisis, precipitated by political instability and declining oil revenue. Public health provision has been affected particularly. In this Review, we assess the impact of Venezuela's health-care crisis on vector-borne diseases, and the spillover into neighbouring countries. Between 2000 and 2015, Venezuela witnessed a 359% increase in malaria cases, followed by a 71% increase in 2017 (411 586 cases) compared with 2016 (240 613). Neighbouring countries, such as Brazil, have reported an escalating trend of imported malaria cases from Venezuela, from 1538 in 2014 to 3129 in 2017. In Venezuela, active Chagas disease transmission has been reported, with seroprevalence in children (<10 years), estimated to be as high as 12·5% in one community tested (n=64). Dengue incidence increased by more than four times between 1990 and 2016. The estimated incidence of chikungunya during its epidemic peak is 6975 cases per 100 000 people and that of Zika virus is 2057 cases per 100 000 people. The re-emergence of many vector-borne diseases represents a public health crisis in Venezuela and has the possibility of severely undermining regional disease elimination efforts. National, regional, and global authorities must take action to address these worsening epidemics and prevent their expansion beyond Venezuelan borders.

Enseñanza de la medicina tropical mediante la discusión de casos clínicos / Teaching tropical medicine through discussion of clinical cases

En los últimos años se han propuestos cambios en la enseñanza de la medicina tropical, basando la docencia en el estudiante. El objetivo de la investigación fue utilizar la metodología de la discusión organizada y razonada de casos clínicos, con la participación activa del estudiante, a fin de llegar a un diagnóstico prsuntivo de las patologías presentadas. Se describe el proceso de discusción con los estudiantes de medicina tropical, de cinco pacientes con enfermedades infecciosas bacterianas (fiebre tifoidea, brucelosis, leptospirosis, cólera y shigellosis), diagnósticados y tratados en la consulta de Endemias Rurales del Instituto de Medicina Tropical y en los servicios de Pediatría Médica Infecciosa y de Enfermedades Infecciosas del Adulto del Hospital Universitario de Caracas, Universidad Central de Venezuela, relacionado sus manifestaciones clínicas y de laboratorio con sus antecedentes epidemiológicos para establecer los diagnósticos e iniciar el tratamiento específico. En cada uno de los casos, siguiendo la metodología descrita se llegó al diagnóstico definitivo permitiendo el tratamiento oportuno de los pacientes de acuerdo a los agentes etiológicos. Mediante la discusión de casos clínicos y la utilización de la medicina basada en evidencia incluyendo al estudiante como ente activo es posible transmitir el conocimiento de la medicina tropical, llegando a los diagnósticos etiológicos de las enfermedades.

In recent years changes have been proposed in the teaching of tropical medicine, basing the teaching on the student. To use the methodology of organized and reasoned discussion of clinical cases, with active student participation in order to reach a presumptive diagnosis of pathology present. We describe the process of discussion with students of tropical medicine, five patients with baceterial infectious diseases (typhoid fever, brucellosis, leptospirosis, cholera and shigellosis), diagnosed and treated at the Outpatient Clinic of Rural Endemic Disease, Institute of Tropical Medicine, and Services of Pediatrics and Adult Infectious Diseases, Hospital Universitario de Caracas, Universidad Central de Venezuela, Relating clinicial manifestations and laboratory findings to epidemiological background to establish the diagnosis and initiate specific treatment. In each case, following the methodology described definitive diganosis was reached allowing timely tratment of tatients accoring to etiologic agents. Trough discussion of clinical cases and the use of evidence-based medicine including the student as an active entity the knowledge of tropical medicine may be transmitted, reaching the etiologic diagnosis of disease, and getting publications of articles.

Meglumina en series terapéuticas de 10 días en niños con leishmaniosis tegumentaria americana / Meglumine therapeutic series of 10 days in children with american tegumentary leishmaniasis

La cátedra de Medicina Tropical de la Universidad Central de Venezuela viene empleando el antimoniato de meglumina en series terapéuticas de 10 días en el tratamiento de leishmaniosis tegumentaria americana, la cual continúa como problema de salud del medio rural venezolano. Se evalúa una experiencia con una dosis de 70 mg/kg/día de meglumina en niños con la enfermendad. A los pacientes con presunción diagnóstica de leishmaniosis tegumentaria americana (clínica y antecedentes epidemiológicos) se les efectuó la prueba de leishmania, la demostración de anticuerpos flurescentes antileishmania y la visualización de amastigotes en frotis teñidos con Giemsa. Los casos identificados ingresaron al Hospital Universitario (Pediatría médica infecciosa), recibieron 70 mg/kg/día de antimoniato de meglumina en series terapéuticas de 10 días con reposo intercalados por el mismo número de días. Se incluyeron 33 niños con la enfermedad, 21 de género femenino (64%) con promedio de edad 7,12 años y predominio de escolar (70%). Del Estado Miranda procedía el 85%, una sola úlcera la tenía el 88%, localizada en miembros inferiores (49%). La Leishmanina y los anticuerpos fluorescentes antileishmania fueron positivos en todos los pacientes y el frotis para amastigotes en 45%. Dos series de antimoniato de meglumina las recibió 91% de los pacientes; una de 10 días 6%. Egresaron con cicatrizaciones de sus procesos ulcerosos y fueron evaluados durante seis meses en la consulta de endemias rurales y no se evidenciaron recaídas. La variedad cutánea localizada de la enfermedad fue la única identificada, el Estado Miranda continúa aportando la mayoría de los pacientes atendidos en medicina tropical. El antimoniato de meglumina en leishmaniosis tegumentaria americana a la dosis de 70 mg/kg/día en series terapéuticas fue tan eficaz como la anterior de 100 mg/kg/día que dejó de administrarse hace ocho años.

The Tropical Medicine Department of the Universidad Central de Venezuela employs the meglumine pentavalent antimonial in series of 10 days of treatment for American Tegumentary Leishmaniosis, which continues being a health problem in the Venezuelan rural areas. We are reporting a clinical experience of treatment in children at a dose of 70 mg/kg/day. Patients with diagnostic suspición of American Tegumentary Leishmaniosis (clinical and epidemiologic antecedents) who attended the Rural Endemics Clinic at the Instituto de Medicina Tropical of the Universidad Central de Venezuela and to the Medical Infectious Pediatrics Service at the Hospital Universitario de Caracas (HUC), were tested for leishmanine, fluorescent antileishmania antibodies and for the presence of amastigotes of the parasite in smear for apposition from the ulcer that were treated by the Giemsa method. Patients hospitalized at the Medical Infectious Pediatric Service (Hospital Universitario de Caracas) received 70 mg/kg/day of meglumine pentavalent antimonial during 10 days, a rest period of 10 days without treatment and, if 20 days after ulcers were unhealed, was administred a new 10 days meglumine pentavalent antimonial series. We included 33 children with the disease with a mean age of 7,12 years, 70% in school age and 30% preschool children, and 21 (64%) were girls. The 85% of patients came from Miranda`s state, 88% had only ulcer and in 49% of them the lesions where localized in the legs. The apposition smear showed Leishmania amastigotes in 45% od cases. One series of treatment was given to 91% of cases, two children received two series and one three. At discharge from the hospital all ulcers were healed and follow-up control for a 6 months period showed no relapses. The cutaneous localized from was the clinical form of presentation in the children studied. The great majority of patients that assits to the Tropical Medicine Institute come from the Miranda`s state area...

Leishmaniasis tegumentaria americana en brotes epidérmicos familiares diagnóstico y terapèutica / Cutaneous leishmaniasis in epidermal outbreaks diagnostic and therapeutic family

Describir y evaluar cinco brotes epidémicos de leishmaniasis tegumentaria americana (LTA) en grupos familiares de los estados Miranda y Aragua y de la República de Colombia. Trece pacientes de grupos familiares diferentes acudieron al Instituto de Medicina Tropical por lesiones ulcerosas en regiones anatómicas expuestas; siete del sexo masculino en edades entre 2 y 66 años. La leishmanina, los anticuerpos fluorescentes anti-leishmania y los frotis por aposición de segmentos de piel de las úlceras revelaron la presencia del parásito leishmania spp. Se efectuaron exámenes bioanalíticos y cardiovasculares recomendados para el tratamiento con antimoniatos pentavalentes. Siete pacietes fueron tratados ambulatoriamente con meglumina intramuscular a la dosis de 3000 mg/día en series terapéuticas de 10 días con una segunda serie luego del reposo de 10 días. Una paciente adulta recibió tres series de AM, la última de ellas de 4500 mg/kg/día 10 días en hospitalización. Cinco niños fueron hospitalizados y recibieron AM a la dosis de 70 mg/día/10 días con reposo intermedio y una segunda serie. Los pacientes respondieron adecuadamente a la terapia empleada con la cicatrización completa de los procesos ulcerosos. La LTA siguen adquiriéndola pobladores y viajeros de las áreas rurales de Venezuela y Colombia y frecuentemente se presenta como brotes epidémicos familiares, lo cual facilita el diagnóstico presuntivo. El caso índice permite el diagnóstico de la enfermedad entre otros familiares. Los casos tratados comprueban una vez más las ventajas terapéuticas de la meglumina en LTA.

Leishmaniasis is an infectious disease acquired with relative frequency in the rural areas of Venezuela and Colombia. When there is the antecedent of another member of the family with a similar symptom "at home there is somebody with a similar ulcer" is a frequent statement that facilitates the diagnosis. To describe and evaluate five epidemic autbreaks of cutaneous leishmaniasis of the New World (CLNW) in family groups of Miranda and Aragua states in Venezuela and North Santander Department in Colombia, including diagnosis and treatment with meglumine. This disease is relatively frequently acquired by inhabitants and travelers to these geographical regions. Thirteen patients of different family groups, attended to the "Instituto de Medicina Tropical" (IMT) and to the "Hospital Universitario de Caracas" (HUC) presenting an ulcerative lesión on an exposed area of skin, compatible with the clínical diagnosis of this parasitic disease. Seven patients were females with age between 2 and 66 years. Laboratory diagnostic exams included the intradermal reaction test "leishmanina" serology tests for determination of antibodies anti-leismania and apposition smear from the ulcers stained by the Giemsa method, resulted positive for the infection produced by parasites of the species Leishmania spp. Six patients adults received treatment as outpatients with two series of the pentavalent antimony meglumine at a dose of 3000 mg/day during 10 days, one patient received the dose of 4500 mg/day as a last series of treatment. Children were given a dose of meglumine of 70 mg/kg/day, in series of treatment with their respective rest period. All patients responded adequately. Once again, we can demonstrate the advantages of the treatment of CLNW with the pentavalent antimony meglumine.