Postorotracheal intubation dysphagia in patients with COVID-19: A retrospective study.

BACKGROUND: The cause of oropharyngeal dysphagia in patients with coronavirus disease (COVID-19) can be multifactorial and may underly limitations in swallowing rehabilitation. OBJECTIVE: Analyze the factors related to dysphagia in patients with COVID-19 immediately after orotracheal extubation and the factors that influence swallowing rehabilitation. DESIGN AND SETTING: A retrospective study. METHODS: The presence of dysphagia was evaluated using the American Speech-Language Hearing Association National Outcome Measurement System (ASHA NOMS) scale and variables that influenced swallowing rehabilitation in 140 adult patients who required invasive mechanical ventilation for >48 h. RESULTS: In total, 46.43% of the patients scored 1 or 2 on the ASHA NOMS (severe dysphagia) and 39.29% scored 4 (single consistency delivered orally) or 5 (exclusive oral diet with adaptations). Both the length of mechanical ventilation and the presence of neurological disorders were associated with lower ASHA NOMS scores (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.74-0.87 P < 0.05; and OR: 0.13, 95% CI: 0.61-0.29; P < 0.05, respectively). Age and the presence of tracheostomy were negatively associated with speech rehabilitation (OR: 0.92; 95% CI: 0.87--0.96; OR: 0.24; 95% CI: 0.80--0.75), and acute post-COVID-19 kidney injury requiring dialysis and lower scores on the ASHA NOMS were associated with longer time for speech therapy outcomes (ß: 1.62, 95% CI, 0.70-3.17, P < 0.001; ß: -1.24, 95% CI: -1.55--0.92; P < 0.001). CONCLUSION: Prolonged orotracheal intubation and post-COVID-19 neurological alterations increase the probability of dysphagia immediately after extubation. Increased age and tracheostomy limited rehabilitation.

Impact of antivenom administration on the evolution of cutaneous lesions in loxoscelism: a prospective observational study

Background Spiders of the genus Loxosceles are distributed throughout tropical and temperate regions worldwide. Loxosceles spp. bites may evolve to necrosis, with or without intravascular hemolysis. There is no consensus regarding the best treatment to prevent necrosis. The objective of this study was to evaluate the factors associated with the development of necrosis and the impact that antivenom administration has on the evolution of cutaneous loxoscelism. Methodology/Principal findings This was a prospective observational study carried out at a referral center for envenoming. Over a 6-year period, we included 146 patients with a presumptive or definitive diagnosis of loxoscelism. Depending on the symptom severity, a polyvalent anti-arachnid antivenom was administered or not—in 74 cases (50.7%) and 72 cases (49.3%), respectively. Cutaneous and systemic manifestations were assessed at admission and weekly thereafter. Adverse reactions to the antivenom were also evaluated. Cutaneous loxoscelism was observed in 141 cases (96.6%), and the spider was identified in 29 (19.9%). The mean time from bite to antivenom administration was 41.6 ± 27.4 h. After discharge, 130 patients (90.9%) were treated with corticosteroids, antihistamines and analgesics being prescribed as needed. The probability of developing necrosis was significantly lower among the patients who were admitted earlier, as well as among those who received antivenom (p = 0.0245). Among the 74 patients receiving antivenom, early and delayed adverse reactions occurred in seven (9.5%) and four (5.4%), respectively. Local infection was observed only in three (2.3%) of the 128 patients for whom that information was available. Conclusions/Significance Necrosis after a Loxosceles sp. bite appears to more common when hospital admission is delayed or when antivenom is not administered. In addition, the administration of a polyvalent anti-arachnid antivenom appears to be safe, with a relatively low rate of adverse reactions.

Intensive care unit staff preparedness as an independent factor for death of patients during COVID-19 pandemic: An observational cohort study.

The pandemic of COVID-19 brought to the world an unprecedented challenge. This single center observational study aimed to evaluate the impact of staff preparedness by comparing the outcomes between two intensive care units (ICUs) from a hospital that had to expand ICU beds to deal with an incremented volume of critical patients. Patients consecutively admitted to these ICUs with suspected COVID-19, from March 1st until April 30th, 2020, were included. Both ICUs attended a similar population and had the same facilities, what differed was the staff: one previously well-established (ICU-1) and another recently assembled (ICU-2). 114 patients with severe respiratory syndrome were included. In-hospital mortality was 40%. Compared with patients in the well-established ICU-1, patients in the recently assembled ICU-2 were older (54 versus 61.5, p=0.045), received more antibiotics (93% versus 98%, p=0.001) and chloroquine/hydroxychloroquine 6% versus 30%, p=0.001), had a higher proportion of invasive mechanical ventilation (44% versus 52%, p=0.008) and had greater in-hospital mortality (30% versus 50%, p=0.017). The proportion of patients considered at high risk for death according to PSI was similar between the two ICU populations. Age ≥ 60 years (adjusted OR 2.33; 95% CI 1.02-5.31), need of invasive mechanical ventilation (adjusted OR 2.79; 95% CI 1.22-6.37), and ICU type (recently assembled) (adjusted OR 2.38; 95% CI 1.04-5.44) were independently associated with in-hospital mortality . This finding highlights the importance of developing support strategies to improve preparedness of staff recently assembled to deal with emergencies.

Prone positioning to improve oxygenation and relieve respiratory symptoms in awake, spontaneously breathing non-intubated patients with COVID-19 pneumonia.

Emergency departments are facing an unprecedented challenge in dealing with patients who have coronavirus disease 2019 (COVID-19). The massive number of cases evolving to respiratory failure are leading to a rapid depletion of medical resources such as respiratory support equipment, which is more critical in low- and middle-income countries. In this context, any therapeutic and oxygenation support strategy that conserves medical resources should be welcomed. Prone positioning is a well-known ventilatory support strategy to improve oxygenation levels. Self-proning can be used in the management of selected patients with COVID-19 pneumonia. Here, we describe our experience with two COVID-19-positive patients who were admitted with respiratory failure. The patients were successfully managed with self-proning and noninvasive oxygenation without the need for intubation.

Prone positioning to improve oxygenation and relieve respiratory symptoms in awake, spontaneously breathing non-intubated patients with COVID-19 pneumonia

Emergency departments are facing an unprecedented challenge in dealing with patients who have coronavirus disease 2019 (COVID-19). The massive number of cases evolving to respiratory failure are leading to a rapid depletion of medical resources such as respiratory support equipment, which is more critical in low- and middleincome countries. In this context, any therapeutic and oxygenation support strategy that conserves medical resources should be welcomed. Prone positioning is a well-known ventilatory support strategy to improve oxygenation levels. Self-proning can be used in the management of selected patients with COVID-19 pneumonia. Here, we describe our experience with two COVID-19-positive patients who were admitted with respiratory failure. The patients were successfully managed with self-proning and noninvasive oxygenation without the need for intubation

Efficacy of sofosbuvir as treatment for yellow fever: protocol for a randomised controlled trial in Brazil (SOFFA study).

INTRODUCTION: An ongoing outbreak of yellow fever (YF) has been reported in Brazil with 1261 confirmed cases and 409 deaths since July 2017. To date, there is no specific treatment available for YF. Recently published papers describing in vitro and animal models suggest a potential effect of antiviral drugs (approved for the treatment of hepatitis virus) against flaviviruses, including YF. The primary aim of this study is to analyse the effect of sofosbuvir on viral kinetics and clinical outcomes among patients presenting with YF. This is a multicentre open-label randomised controlled trial with 1:1 individual allocation, stratified by severity and by recruiting centre. METHODS AND ANALYSIS: Adults with suspected or confirmed YF infection and symptoms lasting up to 15 days are screened. Eligible and consenting patients are randomised to receive oral sofosbuvir 400 mg daily for 10 days or to receive standard clinical care. Viral kinetics are measured daily and the reduction in YF plasma viral load from the sample at inclusion to 72 hours after randomisation will be compared between active and control groups. Clinical outcomes include severity meeting criteria for intensive care support, liver transplantation, in-hospital mortality and mortality within 60 days. ETHICS AND DISSEMINATION: Ethics approval was obtained at the participating sites and at the national research ethics committee (CAAE 82673018.6.1001.0068). The trial has been submitted for ethical approval at additional potential recruiting centres. Results of the study will be published in journals and presented at scientific meetings. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (RBR-93dp9n).

Efficacy of sofosbuvir as treatment for yellow fever: protocol for a randomised controlled trial in Brazil (SOFFA study)

INTRODUCTION: An ongoing outbreak of yellow fever (YF) has been reported in Brazil with 1261 confirmed cases and 409 deaths since July 2017. To date, there is no specific treatment available for YF. Recently published papers describing in vitro and animal models suggest a potential effect of antiviral drugs (approved for the treatment of hepatitis virus) against flaviviruses, including YF. The primary aim of this study is to analyse the effect of sofosbuvir on viral kinetics and clinical outcomes among patients presenting with YF. This is a multicentre open-label randomised controlled trial with 1:1 individual allocation, stratified by severity and by recruiting centre. METHODS AND ANALYSIS: Adults with suspected or confirmed YF infection and symptoms lasting up to 15 days are screened. Eligible and consenting patients are randomised to receive oral sofosbuvir 400 mg daily for 10 days or to receive standard clinical care. Viral kinetics are measured daily and the reduction in YF plasma viral load from the sample at inclusion to 72 hours after randomisation will be compared between active and control groups. Clinical outcomes include severity meeting criteria for intensive care support, liver transplantation, in-hospital mortality and mortality within 60 days. ETHICS AND DISSEMINATION: Ethics approval was obtained at the participating sites and at the national research ethics committee (CAAE 82673018.6.1001.0068). The trial has been submitted for ethical approval at additional potential recruiting centres. Results of the study will be published in journals and presented at scientific meetings. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (RBR-93dp9n)

Severe yellow fever and extreme hyperferritinemia managed with therapeutic plasma exchange

A 43-year-old man was admitted to the intensive care unit and diagnosed with yellow fever. He presented with refractory bleeding, extreme hyperferritinemia, and multiple organ dysfunction syndrome, requiring renal replacement therapy, mechanical ventilation, and treatment with vasoactive drugs. Because the bleeding did not respond to fresh-frozen plasma administration, the patient received therapeutic plasma exchange, which was accompanied by a marked improvement of the clinical and biochemical parameters, including a significant decline in serum ferritin levels

Yellow fever: factors associated with death in a hospital of reference in infectious diseases, São Paulo, Brazil, 2018

Faced with the reemergence of yellow fever (YF) in the metropolitan region of São Paulo, Brazil, we developed a retrospective study to describe the cases of YF attended at the Institute of Infectology Emilio Ribas from January to March 2018 and analyze the factors associated with death, from the information obtained in the hospital epidemiological investigation. A total of 72 cases of sylvatic YF were confirmed, with 21 deaths (29.2% lethality rate). Cases were concentrated in males (80.6%) and in the age group of 30 to 59 years (56.9%). Two logistic regression models were performed, with continuous variables adjusted for the time between onset of symptoms and hospitalization. The first model indicated age (odds ratiosadjusted [ORadj]: 1.038; CI 95%: 1.008-1.212), aspartate aminotransferase (AST) (ORadj: 1.038; CI 95%: 1.005-1.072), and creatinine (ORadj: 2.343; CI 95%: 1.205-4.553) were independent factors associated with mortality. The second model indicated age (ORadj: 1.136; CI 95%: 1.013-1.275), alanine aminotransferase (ALT) (ORadj: 1.118; CI 95%: 1.018-1.228), and creatinine (ORadj: 2.835; CI 95%: 1.352-5,941). The risk of death in the model with continuous variables was calculated from the increase of 1 year (age), 1 mg/dL (creatinine), and 100 U/L for AST and ALT. Another logistic regression analysis with dichotomous variables indicated AST > 1,841 IU/L (ORadj: 12.92; CI 95%: 1.50-111.37) and creatinine > 1.2 mg/dL (ORadj: 81.47; CI 95%: 11.33-585.71) as independent factors associated with death. These results may contribute to the appropriate clinical management of patients with YF in health-care services and improve the response to outbreaks and public health emergencies

The role of dexamethasone in scorpion venom-induced deregulation of sodium and water transport in rat lungs.

BACKGROUND: Severe scorpion envenomation can evolve to lung injury and, in some cases, death. The lung injury could be attributed to acute left ventricular failure and increased pulmonary vascular permeability secondary to the release of inflammatory mediators. In clinical practice, corticosteroids have been administered to reduce the early side effects of the anti-venom. We propose to study the effects of Tityus serrulatus venom and dexamethasone on pulmonary expression of sodium and water transporters, as well as on the inflammatory response. METHODS: Wistar rats were injected intraperitoneally with saline (control group), dexamethasone, and saline (2.0 mg/kg body weight-60 min before saline injection; dexamethasone + saline group), venom (T. serrulatus venom-3.8 mg/kg body weight), or dexamethasone and venom (2.0 mg/kg body weight-60 min before venom injection; dexamethasone + venom group). At 60 min after venom/saline injection, experiments were performed in ventilated and non-ventilated animals. We analyzed sodium transporters, water transporters, and Toll-like receptor 4 (TLR4) by Western blotting, macrophage infiltration by immunohistochemistry, and serum interleukin (IL) by cytokine assay. RESULTS: In the lung tissue of non-ventilated envenomed animals, protein expression of the epithelial sodium channel alpha subunit (α-ENaC) and aquaporin 5 (AQP5) were markedly downregulated whereas that of the Na-K-2Cl cotransporter (NKCC1) and TLR4 was elevated although expression of the Na,K-ATPase alpha 1 subunit was unaffected. Dexamethasone protected protein expression of α-ENaC, NKCC1, and TLR4 but not that of AQP5. We found that IL-6, IL-10, and tumor necrosis factor alpha were elevated in the venom and dexamethasone + venom groups although CD68 expression in lung tissue was elevated only in the venom group. Among the ventilated animals, both envenomed groups presented hypotension at 50 min after injection, and the arterial oxygen tension/fraction of inspired oxygen ratio was lower at 60 min than at baseline. CONCLUSIONS: Our results suggest that T. serrulatus venom and dexamethasone both regulate sodium transport in the lung and that T serrulatus venom regulates sodium transport via the TLR4 pathway.

Estudo da ação do veneno de Tityus serrulatus sobre a expressão de transportadores de sódio e água em epitélio alveolar de rato / Effect of Tityus serrulatus venom on sodium and water trasporters in rat alveolar epithelium

Acidentes escorpiônicos podem evoluir com edema pulmonar de origem cardiogênica e não cardiogênica. O clearance de edema pulmonar está relacionado principalmente ao transporte ativo de sódio do espaço alveolar para o interstício. O objetivo deste trabalho foi avaliar os efeitos do veneno de Tityus serrulatus e da dexametasona sobre a expressão dos transportadores de sódio e água e do TLR4 em pulmão de ratos. Foram utilizados ratos Wistar, divididos em três grupos: controle (salina); grupo Vn, que recebeu o veneno de T. serrulatus (3.8 mg/kg) por via intraperitoneal (ip), e o grupo Dx+Vn, que recebeu dexametasona (2.0 mg/kg) por via ip, uma hora antes da injeção do veneno. Os experimentos foram realizados uma hora após a injeção do veneno. Foram realizadas análise bioquímica e dosagens de citocinas no plasma. Nos pulmões foram estudados a expressão de -ENaC, Na+-K+- ATPase, NKCC1, AQP-5 e TRL4 através de western blotting, e a expressão do NF-kB e infiltração de células CD68+ (monócitos/macrófagos) e neutrófilos, através de imunoistoquímica. O veneno de T. serrulatus diminuiu a expressão pulmonar de -ENaC e AQP-5, enquanto aumentou a expressão do NKCC1. A dexametasona preveniu os efeitos do veneno sobre a expressão da -ENaC e NKCC1, mas não da AQP5. Não foi observada alteração da expressão da 1- Na+-K+-ATPase . A expressão do TLR4 foi maior nos animais envenenados que nos grupos Cont e Dx+Vn. O níveis plasmáticos de IL-6, IL-10 e TNF- estavam aumentados nos grupo Vn e Dx+Vn em relação ao controle. O infiltrado de células CD68+ foi maior no grupo Vn. A expressão de NF-kB e o infiltrado ne neutrófilos no tecido pulmonar foi semelhantes nos três grupos avaliados. Os resultados encontrados sugerem que o veneno de T. serrulatus tem efeito sobre as proteínas transportadoras de sódio em células do epitélio alveolar e também sobre a expressão do TLR4 em pulmão; a dexametasona pode regular essas ações...

Scorpion envenomation can cause cardiogenic and noncardiogenic pulmonary edema. Pulmonary edema clearance is largely related to active Na+ transport out of the alveoli, rather than to reversal of Starling forces. Our objective was determine the effects of Tityus serrulatus venom and dexamethasone on the pulmonary expression of sodium and water transporters, and Toll-like receptor 4. Wistar rats were divided into groups and injected intraperitoneally: control (saline only); venom (T. serrulatus venom3.8 mg/kg body weight); and dexamethasone+venom (dexamethasone2.0 mg/kg body weight60 min before venom inoculation). At 60 min after venom inoculation, interleukin-6 and -10, together with tumor necrosis factor alpha, were analyzed in plasma. In lungs, we determined expression of the epithelial sodium channel alpha subunit; Na,K-ATPase alpha 1 subunit; Na-K-2Cl cotransporter, NKCC1; aquaporin 5; Toll-like receptor 4 (by Western blotting); and nuclear factor-kappa B. We determined CD68 and neutrophil counts by immunohistochemistry. In venom group lungs, the epithelial sodium channel alpha subunit and aquaporin 5 were markedly downregulated, whereas NKCC1 was elevated, although the Na,K-ATPase alpha 1 subunit was unaffected. Dexamethasone protected the epithelial sodium channel alpha subunit, NKCC1, and Toll-like receptor 4 but not aquaporin 5. Serum interleukin 6, interleukin 10, and tumor necrosis factor alpha were elevated in both groups, as was CD68 expression. Neutrophil counts and nuclear factor-kappa B expression were comparable across groups. Our data show that T. serrulatus venom alters sodium transport in alveolar epithelial cells and increases Toll-like receptor 4 expression. Dexamethasone appears to partially protect against those effects...

Human heterophilic antibodies against equine immunoglobulins: assessment of their role in the early adverse reactions to antivenom administration.

The presence of human heterophilic antibodies against horse immunoglobulins (HHA-HI) was determined by ELISA in sera from healthy volunteers and from patients who received equine antivenom for therapy of snake bite envenoming. These patients were selected from two independent clinical studies: one in Colombia in which patients received antivenom constituted by whole IgG (n=25); and the other in Brazil where an antivenom constituted by F(ab')(2) fragments was administered (n=31). Results show that healthy volunteers have antibodies, mainly of the IgG class, able to react with whole equine IgG. Additionally, patients have IgG antibodies that react both with whole equine IgG and F(ab')(2) fragments. In both clinical studies, no significant differences were observed in the HHA-HI titres between the patients who presented early adverse (anaphylactoid) reactions and those who did not develop them. In addition, no variation in titre was observed in samples collected before and after antivenom administration. These results do not support the hypothesis that the incidence of early adverse reactions to antivenom administration correlates with the titre of HHA-HI in the serum of patients. Nevertheless, participation of these antibodies as part of a multifactorial pathogenic mechanism associated with these reactions cannot be ruled out.

Clinical and epidemiological features of definitive and presumed loxoscelism in São Paulo, Brazil.

A retrospective study analysed 359 proven or presume cases of loxoscelism seen at the Hospital Vital Brazil, Instituto Butantan, São Paulo, Brazil, between 1985 and 1996. The spider was identified in 14%. The bites occurred predominantly in the urban areas (73%) between September and February. Patients > 14 years were commonest inflicted (92%) and 41% were bitten while getting dressed. Only 11% sought medical care within the first 12 hours post bite. Cutaneous loxoscelism was the commonest form presenting (96%); commonest manifestations were: pain (76%), erythema (72%), edema with enduration (66%), ecchymosis (39%). Skin necrosis occurred in 53% of patients, most frequently seen on trunk, thigh and upper arm, and when patients seek medical care more than 72 hours after bite. Local infection was detected in 12 patients (3%). Hemolysis was confirmed in 4 cases (1.1%). Generalised cutaneous rash, fever and headache were also observed in 48% of the total of patients. None of them had acute renal failure or died. Treatment usually involved antivenom administration (66%), being associated with corticosteroids (47%) or dapsone (30%). Presumptive diagnosis of loxoscelism may be established based on clinical and epidemiological findings. Further investigations are required to prove the value of antivenom and other treatment schedules.

Influência das alterações ambientais na epidemiologia dos acidentes ofídicos e na distribuição geográfica das serpentes de importância médica nos estados de São Paulo e Paraná: (Nota Prévia) / Influence of environmental changes in the epidemiology of snakebites and geographical distribution of snakes of medical importance in São Paulo and Paraná States, 1988-1997

BACKGROUND: Geographical distribution of snakebites and snakes of medical importance has a strong correlation with changes in the vegetation cover as a consequence of the expansion of agricultural frontiers. In São Paulo (SP) and Paraná (PR) the process of land occupation has led to a radical transformation in the natural landscape. The objective of this study was to analyze a historical series of snakebites and the geographical distribution of the main species of snakes, taking into account environmental changes of the landscape. MATERIAL AND METHODS: An observational study was conducted. A historical series (1988-1997) of snakebites was obtained from the notification records sent to the Health Secretaries of São Paulo (SP) and Paraná (PR) States. Registries of the herpetological collections were obtained from the Butantan Institute (SP), the Natural History Museum (PR) and from the Production and Research Center in Immunebiologics (PR). Data regarding vegetation cover and percentage of land occupation with the main agricultural practices were analyzed by the Pearson correlation coefficient. The sites of snakebites occurrence and capture of snakes were identified at the municipality level. Maps were obtained using a geographical information system using the software ArqView v.3.0. RESULTS: From the Bothrops species, B. jararaca showed a wide distribution in open fields, forests, and even in regions under anthropic influence, while B. moojeni and B. neuwiedi were found predominantly in open fields. Crotalus occupied areas originally constituted by semidecidual estacional forest and "cerrado". The annual incidence of snakebites varied from 4.31 to 10.57 cases per 100,000 population, decreasing through the period for both Bothrops (88%) and Crotalus (11%). Micrurus accidents were rare (1%) in São Paulo and absent in Paraná. The areas of greater risk for snakebites were coincident with the snakes distribution areas: the administrative regions of Registro and Sorocaba, in São Paulo, and União da Vitória, in Paraná, for Bothrops accidents, and Bauru and Presidente Prudente in Sao Paulo, Cascavel and Ivaiporã in Paraná, for Crotalus accidents. No correlation between snake distribution and vegetation cover was observed, except for B. jararacussu in the remaining forest at the Vale do Ribeira. No correlation was observed between land occupation and Bothrops snakebites. A small negative correlation was observed between Crotalus accidents and areas with sugar cane. CONCLUSIONS: A decreasing tendency was observed in the number of snakebites and snakes of medical importance. Maps of the distribution of poisonous snakes and snakebites allowed a better definition of risk areas. The anthropic pressure probably had influence on the result of no correlation between areas of distribution of snakes with the vegetation cover, while some agricultural practices may had resulted in changes in the risk areas for snakebites.

DELINEAMENTO DO PROBLEMA: A distribuição geográfica dos acidentes ofídicos e das serpentes de interesse médico guarda estreita correlação com as mudanças na cobertura vegetal, decorrentes da expansão de fronteiras agrícolas, notadamente em São Paulo (SP) e Paraná (PR), onde o processo de ocupação da terra levou a uma transformação radical da paisagem natural. O objetivo deste trabalho foi realizar levantamento de série histórica sobre a ocorrência de acidentes e a distribuição das espécies de serpentes, levando em conta as alterações ocorridas na cobertura vegetal. MATERIAL E MÉTODOS: Foi realizado levantamento de série história (1988-1997) dos acidentes ofídicos, a partir das fichas de notificação encaminhadas às Secretarias de Estado da Saúde do Paraná e São Paulo e registro das coleções herpetológicas do Instituto Butantan (SP), Museu de História Natural (PR) e Centro de Produção e Pesquisa em Imunobiológicos (PR). Dados sobre cobertura vegetal e percentual de ocupação do solo das principais práticas agrícolas foram correlacionados, utilizando-se o coeficiente de correlação de Pearson. As localidades de ocorrência dos acidentes e de coleta das serpentes foram identificadas por município. Foram obtidos mapas, por meio de um sistema de informação geográfica, no programa ArqView versão 3.0. RESULTADOS: Das espécies de Bothrops, a B. jararaca mostrou ampla distribuição em formações abertas, florestas e até regiões sob influência antrópica, enquanto que B. moojeni e B. neuwiedi foram encontradas em formações abertas. As Crotalus ocuparam áreas originalmente formadas por floresta estacional semidecidual e cerrado. A incidência anual dos acidentes ofídicos variou de 4,31 a 10,57 casos por cem mil habitantes, com queda ao longo do período, tanto dos acidentes botrópicos (88%) como dos crotálicos (11%). Os acidentes elapídicos foram raros (1%) em São Paulo e ausentes no Paraná. As áreas de maior risco para os acidentes foram coincidentes com as áreas de distribuição das serpentes, destacando-se, para os acidentes botrópicos, as regiões administrativas de Registro e Sorocaba em São Paulo e União da Vitória no sul do Paraná e, para os acidentes crotálicos, Bauru e Presidente Prudente em São Paulo, Cascavel e Ivaiporã no Paraná. Não houve relação entre áreas de ocorrência de serpentes e cobertura vegetal atual, com exceção da sobreposição de B. jararacussu nos remanescentes de mata no Vale do Ribeira. Não se observou correlação entre ocupação do solo e acidentes botrópicos, havendo, nos acidentes crotálicos, pequena correlação negativa com a ocupação por cana-de-açúcar. CONCLUSÕES: Observou-se tendência de queda no número de acidentes ofídicos e de serpentes de importância médica. Mapas de distribuição de serpentes peçonhentas e de acidentes ofídicos permitiram melhor definição das áreas de risco. A influência antrópica provavelmente influenciou a não-correlação com a cobertura vegetal atual, enquanto que práticas agrícolas podem ter determinado deslocamento nas áreas de maior risco de acidentes.

Clinical and epidemiological features of definitive and presumed loxoscelism in Säo Paulo, Brazil

A retrospective study analysed 359 proven or presume cases of loxoscelism seen at the Hospital Vital Brazil, Instituto Butantan, Säo Paulo, Brazil, between 1985 and 1996. The spider was identified in 14 percent. The bites occurred predominantly in the urban areas (73 percent) between September and February. Patients > 14 years were commonest inflicted (92 percent) and 41 percent were bitten while getting dressed. Only 11 percent sought medical care within the first 12 hours post bite. Cutaneous loxoscelism was the commonest form presenting (96 percent); commonest manifestations were: pain (76 percent), erythema (72 percent), edema with enduration (66 percent), ecchymosis (39 percent). Skin necrosis occurred in 53 percent of patients, most frequently seen on trunk, tigh and upper arm, and when patients seek medical care more than 72 hours after bite. Local infection was detected in 12 patients (3 percent). Hemolysis was confirmed in 4 cases (1.1 percent). Generalised cutaneous rash, fever and headache were also observed in 48 percent of the total of patients. None of them had acute renal failure or died. Treatment usually involved antivenom administration (66 percent), being associated with corticosteroids (47 percent) or dapsone (30 percent). Presumptive diagnosis of loxoscelism may be established based on clinical and epidemiological findings. Further investigations are required to prove the value of antivenom and other treatment schedules