Mucosal leishmaniasis: description of case management approaches and analysis of risk factors for treatment failure in a cohort of 140 patients in Brazil.

BACKGROUND: Mucosal leishmaniasis is caused mainly by Leishmania braziliensis and it occurs months or years after cutaneous lesions. This progressive disease destroys cartilages and osseous structures from face, pharynx and larynx. OBJECTIVE AND METHODS: The aim of this study was to analyse the significance of clinical and epidemiological findings, diagnosis and treatment with the outcome and recurrence of mucosal leishmaniasis through binary logistic regression model from 140 patients with mucosal leishmaniasis from a Brazilian centre. RESULTS: The median age of patients was 57.5 and systemic arterial hypertension was the most prevalent secondary disease found in patients with mucosal leishmaniasis (43%). Diabetes, chronic nephropathy and viral hepatitis, allergy and coagulopathy were found in less than 10% of patients. Human immunodeficiency virus (HIV) infection was found in 7 of 140 patients (5%). Rhinorrhea (47%) and epistaxis (75%) were the most common symptoms. N-methyl-glucamine showed a cure rate of 91% and recurrence of 22%. Pentamidine showed a similar rate of cure (91%) and recurrence (25%). Fifteen patients received itraconazole with a cure rate of 73% and recurrence of 18%. Amphotericin B was the drug used in 30 patients with 82% of response with a recurrence rate of 7%. The binary logistic regression analysis demonstrated that systemic arterial hypertension and HIV infection were associated with failure of the treatment (P < 0.05). CONCLUSION: The current first-line mucosal leishmaniasis therapy shows an adequate cure but later recurrence. HIV infection and systemic arterial hypertension should be investigated before start the treatment of mucosal leishmaniasis. Conflicts of interest The authors are not part of any associations or commercial relationships that might represent conflicts of interest in the writing of this study (e.g. pharmaceutical stock ownership, consultancy, advisory board membership, relevant patents, or research funding).

Glomerular involvement in human kala-azar. A light, immunofluorescent, and electron microscopic study based on kidney biopsies.

Glomerular involvement characterized by mesangial cell proliferation with fibrillar thickening of the axial region and deposits of immune complexes is reported in three human cases of kala-azar. IgG was seen in all 3 and Igm in 2 patients. Complement (C3) was detected in the glomeruli in all cases and fibrinogen in the only case in which it was tested for. The deposits appeared mainly along the mesangium and their staining was particularly strong for complement and IgG. Electron microscopy detected granular electron dense deposits mainly close to mesangial cells. In one case clumps made us of electron dense lamellae were seen in the glomerular basal membrane interpreted as evidence of focal membranolysis. No granulocytes were seen in the glomeruli. Attempts to demonstrate antigen were unsuccessful. The pattern of the lesion resembles that described in the kidney of human cases of hepatosplenic schistosomiasis, and the distribution of the deposits suggests that relatively large, poorly soluble complexes formed either in the presence of excess antigen or, under certain circumstances, in the presence of excess antibody, are trapped in the glomerular capillaries. The aggregates are partially shunted to the mesangial cells, which enlarge and proliferate.

Use of itraconazole in the treatment of mucocutaneous leishmaniasis: a pilot study.

OBJECTIVE: Mucocutaneous leishmaniasis is widely distributed in Brazil, with Leishmania (Viannia) braziliensis being the major etiologic agent. The currently recommended therapy is limited by its parenteral use, high toxicity, and variable efficacy. A clinical pilot study was conducted to analyze itraconazole as an oral alternative for the treatment of mucocutaneous leishmaniasis. METHODS: Ten patients were enrolled to receive 4 mg/kg per day (up to 400 mg/d) itraconazole for 6 weeks on an outpatient regimen. Diagnosis was based on clinical otorhinolaryngologic examination, followed by a specific serologic reaction, the Montenegro test and pathologic analysis with immunohistochemical reaction. Healing of the lesions was confirmed by clinical otorhinolaryngologic examination. Side effects were monitored by general clinical assessment, hemoglobin determination, leukocyte counts, and liver function tests, all performed before, during, and 1 month after the end of treatment. RESULTS: Six of 10 patients presented healed lesions 3 months after treatment, with a sustained therapeutic response for at least a median period of 14.5 months (range, 12-18 mo). Side effects were not observed. CONCLUSIONS: This pilot study demonstrated that itraconazole can be an effective and well-tolerated alternative for the treatment of mucocutaneous leishmaniasis. Further randomized studies and double blind controlled trials are needed to assess the benefits of this drug in the treatment of mucocutaneous leishmaniasis.

Exercise testing in the latent phase of Chagas' disease.

Exercise stress testing was performed in 50 completely asymptomatic patients in the latent phase of Chagas' disease. In 32 (64%) abnormalities were found consisting of either abnormal ST depression, exercise-induced arrhythmias, or chronotropic incompetence. The latter was determined by comparing the heart rate response to 50 age- and sex-matched control patients without serologic evidence of Chagas' disease. In the absence of an adequate control population we can only speculate as to the significance of the ST depression and arrhythmias during exercise. However, chronotropic incompetence may be a specific marker for Trypanosomal infestation in an endemic area. It probably is an early manifestation of autonomic dysfunction secondary to Chagas' disease.

[Evaluation of antiparasitic activity of allopurinol, against Trypanosoma cruzi, in experimental system using infected triatomines]. / Avaliação da atividade antiparasitária do alopurinol, referente ao Trypanosoma cruzi, em sistema experimental que utiliza triatomíneos infectados.

The antiparasitic activity of allopurinol, against Trypanosoma cruzi, was evaluated by a procedure using infected triatomines. This methodology indicated that the drug was unable to eliminate the protozoa in the digestive tract of the insects. Therefore, further knowledge to improve our understanding of allopurinol in the context of the etiologic treatment of infection by T. cruzi was not acquired. Despite this finding the drug continues to be used, even though its performance appears to be full of divergences and contradictions.

[Nifurtimox as a prophylactic drug to prevent reactivation in chronic chagasic patients treated with corticoid for associated diseases]. / Efeito protetor do nifurtimox contra a reativação parasitária em pacientes cronicamente infectados pelo Trypanosoma cruzi e tratados com corticoide em virtude de afecções associadas.

Patients in the chronic phase of Chagas' disease and receiving corticoid because of concommitant diseases were treated with nifurtimox. We proved in another paper that in the chronic phase of Chagas' disease corticoid use is associated with increased parasitemia, as evaluated by xenodiagnosis. In this study nifurtimox use prevented this increase, and we suggest that in immunocompromised patients with chronic Chagas' disease the use of this drug could be useful.

[Infective endocarditis in 100 patients subjected to heart transplantation]. / Endocardite infecciosa em 100 pacientes submetidos a transplante cardíaco.

PURPOSE: An analysis of occurence, etiology, clinical aspects and death rate of infectious endocarditis cases involving patients who underwent heart transplantation. METHODS: 100 consecutive heart transplant patients were analysed; follow-up varied from three to 90 (medium of 25.38, SD +/- 27.97) months. Diagnostic criteria for endocarditis were those of the epidemiology and quality control service, Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, that agree with those of the Center for Disease Control. Diagnosis was established mostly by blood cultures, echocardiograms, either transthoracic or esophageal and autopsy. RESULTS: Six cases of endocarditis were recognized, with four deaths; in three of those we found severe systemic compromise. All cases had fever as an important symptom. CONCLUSION: Death risk seems high of infectious endocarditis after heart transplantation. The cause of this high risk appears to be linked to the bacteria themselves, to association with other clinical situations and to the use of immunosuppresive agents. We recommend a high index of suspition when risk factors are present in order to make a rapid diagnosis soon enough in the natural history of the disease; treatment has to be started as soon as possible.