Evaluation of N95 respirator use as a tuberculosis control measure in a resource-limited setting.

SETTING: A 150-bed public Brazilian hospital that serves as reference hospital for tuberculosis (TB) patients. OBJECTIVE: To evaluate the use of personal respiratory protection by health care workers (HCWs) as a measure to reduce TB occupational risk. DESIGN: One hundred and forty-five HCWs were randomly observed for the use of a N95 respirator when entering high-risk areas or performing high-risk procedures. RESULTS: N95 respirators were infrequently used, even for high-risk procedures such as endotracheal intubation (25%) and respiratory aspiration (12%), and in high-risk areas such as the respirology ward (69.2%), emergency department (29.5%), intensive care unit (8.8%), and TB room isolation (39.5%). Facial-seal leakage was observed in 39% of HCWs due to failure to wear the mask with a tight facial fit as directed. CONCLUSION: Respirator use as a sole control measure is inadequate in any setting and is not cost-effective in resource-limited settings. Alternative or additional measures are clearly needed in hospitals with a high incidence of active TB admissions, specially following recent recommendations from the WHO, which consider personal respiratory protection as the third line of defense for TB control, indicated when TB risk cannot be adequately reduced by administrative and engineering controls.

[Tetanus in Brazil: a disease of the elderly?]. / Tétano no Brasil: doença do idoso?

Epidemiological data regarding the age distribution of tetanus in Brazil is scarce. This work analyzed the historical evolution of tetanus in Brazil, between 1980 and 1991, according to the Mortality Information System and established the age distribution for this disease. The data used was that provided by FUNASA-CENEPI, DATASUS and IBGE. Between 1980 and 1991, the coefficient of general incidence dropped from 2.6 to 1.0 case per 100,000 inhabitants. There was a decline in the mortality coefficients within all the age groups, except in the elderly. In the North and South regions, there was an increase in the mortality coefficient among the elderly. Infantile tetanus is disappearing, particularly, in the developed areas. However, the overall lethality tended to rise in this period and, in 1991, it reached 32.5%. In Brazil, tetanus presents epidemic behavior similar to that observed in the developed countries, where the elderly represent the main risk group to contract and die from the disease.

Pathogenetic factors of acute schistosomiasis mansoni: correlation of worm burden, IgE, blood eosinophilia and intensity of clinical manifestations.

A clinical study of 34 previously healthy young patients simultaneously infected in an endemic area of schistosomiasis mansoni is presented, emphasizing the initial phase of the infection. Its intensity was established according to the occurrence, intensity, and duration of the signs and symptoms in order to investigate the possible correlations between the worm burden (estimated by the number of eggs in faeces), the blood eosinophilia and specific levels of IgE (estimated by the area of immediate intradermal reaction), with the clinical manifestations. A significant but low-level association was found between the worm burden and morbidity, suggesting that multiple factors, besides worm burden itself, may contribute to the pathogenesis of the disease.

A propósito de um paciente com leucemia mielóide crônica evoluindo com tromboembolismo pulmonar de repetiçäo simulando choque séptico / A case of recurrent pulmonary thromboembolism in patient with chronic myeloid leukemia like septic shock

Trata-se de paciente no limiar da idade senil, com diagnóstico recente de Leucemia Mielóide Crônica e instabilidade hemodinâmica de difícil tratamento. Embora tivesse outras doenças que pudessem explicar estas manifestaçSes, como miocardiopatia chagásica e insuficiência cardíaca congestiva, foi necessário buscar novas possibilidades diagnósticas. O objetivo do tratamento é evidenciar a importância de buscar novas hipóteses, baseando-se na lógica e raciocínio clínico. Usar com discernimento a propedêutica complementar. Estar pronto para reconhecer erros e mudar condutas. Tudo isso para proporcionar o melhor atendimento, evitando agressSes e riscos desnecessários ao paciente.

Secondary cutaneous manifestations of acute schistosomiasis mansoni.

The secondary cutaneous manifestations of the initial phase of schistosomiasis mansoni were studied in 34 patients who had been infected simultaneously in the same location. Sixteen of the patients developed angioedema and/or urticaria, generally of short duration and of mild intensity and usually about 30 days post-infection. There was no apparent association between the occurrence of these skin manifestations and the patients' worm burdens, blood eosinophilias or areas of immediate reaction to an intradermal inoculation with worm antigen. Other factors, particularly host immunological reactivity, are thought to be important elements in the genesis of the manifestations.

Pulmonary manifestations in the initial phase of schistosomiasis mansoni.

The clinical and radiological pulmonary manifestations in the initial phase of schistosomiasis mansoni were studied in thirty previously healthy individuals who were simultaneously infected. The findings were compared with those concerning a control group and related to possible pathogenetic factors. The respiratory manifestations were of light or of moderate intensity, the dry cough being the most common symptom. The significant radiological alterations were: thickening of bronchial walls and beaded micronodulation, predominantly localized in the lower pulmonary fields. It was observed significant association between wheezing and IgE levels, estimated by the area of immediate intradermal reaction, as well as between the number of blood eosinophils and the occurrence of radiological changes. Moreover, there was correlation between the worm burden and the presence of wheezing, thoracic pain and beaded micronodulation. Thus, the clinical and radiological pulmonary manifestations described are significant part of the initial phase of schistosomiasis mansoni and present the worm burden, eosinophilia and levels of IgE as probable pathogenetic factors.

Egg excretion in the initial phase of experimental murine schistosomiasis mansoni: stability and association with worm burden.

Stability of faecal egg excretion and correlation with results related to worm burden at the initial phase of schistosomiasis mansoni were observed in two groups of mice infected with different Schistosoma mansoni cercarial burdens, by means of analysis of quantitative parasitological studies and schistosome counts after perfusion. Thus, it may be stated that few quantitative parasitological stool examinations could be sufficient to express the infection intensity at the initial phase, on the same grounds that it was already demonstrated at the chronic phase. Furthermore, it is confirmed that the use of the number of eggs passed in the faeces as a tool to estimate the worm burden at the initial phase of schistosome infection is adequate.

Gastro-intestinal manifestations of the initial phase of schistosomiasis mansoni.

Clinical gastro-intestinal manifestations were studied in 34 patients in the initial phase of schistosomiasis mansoni. The patients, all men, were of similar age and in similar nutritional condition and had been infected simultaneously at the same transmission site. Most (85%) showed some gastro-intestinal sign or symptom, generally of light or moderate intensity; 56% had liquid or pasty diarrhoea, 41% abdominal pain, 29% hepatomegaly, 21% dysentery, 15% anorexia, 12% pain on colon palpation and 9% nausea and/or vomiting. High worm burden was associated with blood in faeces but apparently not with any other clinical manifestation. There was no apparent association between any clinical manifestation and peripheral-blood eosinophil counts or titres of IgE specific for Schistosoma mansoni (evaluated by the area of immediate intradermal reaction to injected adult worm antigen). The absence of association between worm burden and nearly all the clinical gastro-intestinal manifestations strengthens the concept that factors other than worm burden, such as host reactivity, constitute important pathogenetic elements in the initial phase of schistosomiasis mansoni.

Characterization of the non-apparent clinical form in the initial phase of schistosomiasis mansoni.

In this paper the history of 115 recruits that had bathed simultaneously in streams contaminated with Schistosoma mansoni, during military maneuvers, is reported. Thirty four of the infected patients presented the initial phase of the infection diagnosed through epidemiologic, clinical and laboratory parameters. Three out of the 34 patients did not reveal the clinical picture of the infection, thus being considered representatives of the non-apparent form of the disease. Differences between the intensity of blood eosinophilia, the area of immediate cutaneous reaction and the number of Schistosoma eggs eliminated in the stools proved not to be statistically significant (p > 0.05) when the non-apparent and acute cases of schistosomiasis were compared. These cases actually may be considered evidences of the non-apparent form hitherto merely taken for granted in the literature.

[Chronic pulmonary form of schistosomiasis mansoni. Clinico-radiologic evaluation]. / Forma pulmonar crônica da esquistossomose mansoni. Avaliação clínico-radiológica.

One hundred and fifteen patients with schistosomiasis mansoni were studied: 31 with a normal chest x-rays and no signs of pulmonary hypertension (PH) and 84 with x-rays compatible with cardiopulmonary abnormalities (73 without symptoms and 11 with symptoms of PH). The chronic pulmonary form (CPF) without pulmonary hypertension is frequent and benign. There was no association between the CPF and the hepatosplenic form (HEF), nor with age, sex or patient origin. Pulmonary hilum alterations were the most common x-ray findings, followed by parenchymatous abnormalities (micronodules). The CPF was associated with a low to medium worm burden. The incidence of CPF with pulmonary hypertension is low but usually related to significant heart abnormalities. It is more common in patients over 12 years, with the HEF of the disease and has no correlation with sex, race or place of birth. Chest x-ray alterations are seen with similar frequency both in parenchymatous and hilar regions.

Afibrinogenemia secundária a acidente ofídico crotálico (Crotalus durissus terrificus) / Afibrinogenemia following snake bite (Crotalus durissus terrificus)

Relatam-se os casos de dois pacientes que desenvolveram afibrinogenemia sem consumo de plaquetas após terem sido picados por Crotalus durissus terrificus. Ambos também tiveram insuficiência renal aguda de alto débito e no caso n§2 foi feito o diagnóstico de rabdomiólise através da elevaçäo expressiva dos níveis séricos de CPK e DHL. O caso n§1 recebeu dose näo especificada de antiveneno e foi tratado com ácido épsilon-aminocaproico e transfusäo de sangue fresco total tendo apresentado normalizaçäo dos testes de coagulaçäo 40 horas após estas medidas. O caso n§2 recebeu dose adequada de antiveneno crotálico e 12 horas depois já evidenciava recuperaçäo do distúrbio da coagulaçäo. O caso n§1 evoluiu sem apresentar hemorragias. O caso n§2 apresentou sangramento persistente nos locais de venóclise e após remoçäo de crostas de impetigo nas pernas. Ambos receberam tratamento conservador para a insuficiência renal aguda e tiveram alta com recuperaçäo da funçäo renal

Pulmonary schistosomiasis mansoni: post-treatment pulmonary clinical-radiological alterations in patients in the chronic phase: a double-blind study.

A double blind trial was set up to study the pulmonary effects of specific treatment with oxamniquine of 40 patients with chronic schistosomiasis mansoni. Radiological alterations characterized by bronchopneumonitis were seen in 17.5% of the patients after treatment, but in none of the placebo group; non-migratory condensation occurred between 25 and 72 h after treatment, with a mean duration of 7 d. 86% of the patients showed spontaneous healing with no radiological sequelae after 30 d of follow-up. Slight pulmonary clinical manifestations without any functional repercussions were also seen. The alterations were probably related to the host-parasite interaction, and the lesions may have been caused by deposition of immune complexes in the lungs with local activation of complement.

Pulmonary involvement in schistosomiasis mansoni.

The post-treatment pulmonary alterations were evaluated in patients (Study 1) and in mice (Study 2) infected with Schistosoma mansoni. Study 1: the patients were examined pre and post-treatment (with ora oxamniquine) and the following exams were performed: sputum for eosinophils and chest x-ray. Study 2: four groups of mice (total = 64) were studied; Group I (infected and treated with oxamniquine); II (infected and not treated); III (not infected and treated) and IV (not infected and not treated). All were x-rayed to check for pulmonary abnormalities pre and post-treatment and lung specimens were studied by optical microscopy and immunofluorescence. We have found abnormalities in the parameters checked in both studies and the results suggest an immunological reaction, probably due to deposition of immune complexes in the lungs, with subsequent activation of the complement system. The experimental study showed that the alterations are not dependent of the presence of eggs and/or worms of S. mansoni in the lungs, thus corroborating the hypothesis of deposition of circulating material.