Serum hyaluronan and collagen IV as non-invasive markers of liver fibrosis in patients from an endemic area for schistosomiasis mansoni: a field-based study in Brazil.

Non-invasive markers of fibrosis have been used to diagnose liver fibrosis in a variety of diseases. Hyaluronic acid (HA) and collagen IV (C-IV) levels were measured in the sera of patients from an endemic area for schistosomiasis in Brazil to diagnose and to rank the intensity of liver fibrosis. Seventy-nine adult patients with schistosomiasis, in the age range of 21-82 years (49 +/- 13.4) were submitted to clinical and ultrasonographic examinations. Ultrasound was employed to diagnose and categorise liver fibrosis according to World Health Organization patterns. Serum HA and C-IV levels were measured using commercial ELISA kits. Ultrasound revealed six patients with intense liver fibrosis, 21 with moderate, 23 with light and 29 without. Serum HA was able to separate individuals with fibrosis from those without (p < 0.001) and light from intense fibrosis (p = 0.029), but C-IV was not (p = 0.692). The HA diagnostic accuracy for fibrosis was 0.89. The 115.4 ng/mL cut-off level diagnosed patients with fibrosis (sensitivity 0.98, specificity 0.64). HA correlated positively with portal hypertension. Periportal fibrosis (subjective evaluation), age and collateral circulation predicted HA increase. In conclusion, we propose that serum HA can be used to identify patients with liver fibrosis in an endemic area for schistosomiasis mansoni in Brazil.

Failure of both azithromycin and antimony to treat cutaneous leishmaniasis in Manaus, AM, Brazil.

A non-randomized controlled clinical trial was carried out in order to evaluate both azithromycin and antimony efficacy in cutaneous leishmaniasis in Manaus, AM, Brazil. Forty nine patients from both genders, aged 14 to 70, with cutaneous ulcers for less than three months and a positive imprint for Leishmania spp. amastigotes were recruited into two groups. Group I (26 patients) received a daily-single oral dose of 500 mg of azithromycin for 20 days and Group II (23 patients) received a daily-single intramuscular dose of 20 mg/kg of meglumine antimony, also for 20 days. Azithromycin cured three of 24 (12.5%) patients on days 60, 90 and 120 respectively whereas therapeutic failure was considered in 21 of 24 (87.5%) cases. In group II, antimony cured eight of 19 (42.1%) cases as follows: three on day 30, one each on day 60 and day 90, and three on day 120. Therapeutic failure occurred in 11 of 19 (57.9%) individuals. The efficacy of antimony for leishmaniasis was better than azithromycin but analysis for the intention-to-treat response rate did not show statistical difference between them. Although azithromycin was better tolerated, it showed a very low efficacy to treat cutaneous leishmaniasis in Manaus.

Problems and perspectives for Chagas disease control: in search of a realistic analysis.

Chagas disease was an important medical and social problem in almost all of Latin America throughout the twentieth century. It has been combated over a broad swath of this continent over recent decades, with very satisfactory results in terms of vector and transfusional transmission. Today, a surveillance stage still remains to be consolidated, in parallel with appropriate care required for some millions of infected individuals who are today living in endemic and non-endemic areas. Contradictorily, the good results attained have generated excessive optimism and even disregard among health authorities, in relation to this disease and its control. The loss of visibility and priority may be a logical consequence, particularly in Latin American healthcare systems that are still disorganized and overburdened due to insufficiencies of financial and human resources. Consolidation of the victories against Chagas disease is attainable but depends on political will and continual attention from the most consequential protagonists in this struggle, especially the Latin American scientific community.

Virological and histological re-evaluation of Labrea hepatitis.

BACKGROUND: a peculiar form of fulminant hepatitis known as Labrea hepatitis, probably related to hepatitis B and D, has been reported in Brazilian Amazon as early as the 1930s. METHODS: we reviewed the postmortem liver biopsies of 9 patients with Labrea Hepatitis. Immunostaining for HBV and HDV antigens were performed. RESULTS: we found several important characteristics in the liver tissues: 1) moderate hepatocellular necro-inflammation, 2) hepatocellular ballooning, 3) ballooned hepatocytes with fat droplets surrounding the nucleus (morula-like cells or spongiocytes), 4) mild to moderate necrosis and/or mild portoseptal fibrosis. Hepatitis B surface antigen (HBsAg) was identified in 7 of the 9 cases and was concentrated in the Morula-like cells. Hepatitis B core antigen (HBcAg) was present in 5 cases, mostly in the hepatocyte's nucleous. The hepatitis D virus antigen (HDV Ag) was present in 5 cases, mostly in the cytoplasm and concentrated in the Morula-like cells. CONCLUSION: labrea hepatitis is a fatal disease mostly affecting isolated communities in the Amazon. Evidence implicates HBV and HDV in the etiology of this disease, but this hypothesis needs to be confirmed with genotyping and sequencing research on HBV DNA and HDV RNA extracted from the liver and sera of these patients.

Cardiac autonomic function in chagasic elderly patients in an endemic area: A time and frequency domain analysis approach.

Chagas' disease is a common cause of cardiac autonomic impairment. In an endemic area there is a predominance of the indeterminate form and the number of elderly individuals committed by the disease is increasing. This study aimed to investigate the profile of heart rate variability (HRV) in elderly chagasic patients. 28 aged chagasic (CH), 28 non-chagasic (NC) aged individuals and 28 adults between 20 and 40 years old (YG) were studied. R-R intervals were assessed in time and frequency domains applying an autoregressive algorithm. There was no difference regarding temporal and spectral indices among the elderly groups in baseline. The values of the variance in CH, NC and YG individuals were 891.80, 283.60, 2557.00, showing a reduction of the total HRV in the aged groups when compared to the young control (p < 0.001). During the cold face test, the pNN50 response was significantly different only in the young group (p < 0.001). The temporal and spectral indices were not different among the elderly groups. The percentile changes of the R-R intervals induced by the tilt test in CH, NC and YG were respectively -7.04%, -9.35%, -15.81%, being significantly higher in the young individuals (p < 0.001). There was no difference regarding the percentile changes of the temporal and spectral indices between CH and NC elderly patients. The cardiac autonomic function assessed by HRV parameters presented no differences among the elderly individuals (CH and NC) living in an endemic area.

Low efficacy of azithromycin to treat cutaneous leishmaniasis in Manaus, AM, Brazil.

An open trial to evaluate the azithromycin efficacy in cutaneous leishmaniasis patients was carried out in Manaus (AM), where Leishmania (Viannia) guyanensis is the main etiologic agent. Forty-one patients with skin lesions of less than 12 weeks duration, without specific treatment for the last three months and a positive imprint to Leishmania sp. were included. From these, 31 (75.6%) were male with median age of 30.2. All of them received a daily-single oral dose of 500 mg of azithromycin for ten days. At 25th day, 16 (39%) presented therapeutic failure and received intramuscular pentavalent antimonial, four were considered lost, 21, that had improved or were inaltered received another ten-day series of azithromycin and were monthly followed, but nine (21.9%) of them presented a poor clinical response and switched to intramuscular pentavalent antimonial on day 55. Of the 12 remaining cases evaluated on day 55, despite of clinical improvement, three asked for antimony therapy and 9 (21.9%) continued the follow-up but, only three were cured on 55th, 85th and 115 th days, and six did not come back for final evaluation. The intention-treatment overall response rate was 22% and whole cure was seen in three (7.3%) of cases. Thus, azithromycin showed a low efficacy to treat cutaneous leishmaniasis in Manaus.

Immunologic tests in patients after clinical cure of visceral leishmaniasis.

The results of five serologic tests (ELISA using promastigote antigen [ELISAp] and recombinant K39 [ELISArK39] and K26 [ELISArK26] antigens, indirect immunofluorescence test using promastigote antigen [IIFT], and immunochromatographic tests using the rK39 antigen [TRALd]) and of the Montenegro skin test (MST) were analyzed in 41 individuals treated for kala-azar and living in Porteirinha, Minas Gerais, Brazil. The tests were carried out 1 week to 12 years after specific treatment. All MSTs during the 8 months after treatment were negative, whereas after 1 year, 28 (84.8%) were positive. Negativity in all serologic tests was observed for 11 (26.8%) of the 41 individuals, whereas positivity in at least one test was observed for 70.3% of subjects evaluated > or = 2 years after treatment. With respect to each exam, positivity was 38.0% for TRALd, 61.9% for ELISA rK39, 47.6% for ELISA rK26, 38.0% for ELISAp, and 40.5% for IIFT. None of the individuals presented recurrence of the disease during the 4 years of follow-up. The tests were repeated in 24 of the 41 individuals, after some time, and the results were the same in 33.3% of the cases. We conclude that serological tests for kala-azar might continue to be positive after treatment of the disease, although this does not indicate a poor prognosis or a poor therapeutic response.

Cardiac autonomic modulation in hypertensive patients with Chagas' disease.

BACKGROUND: Arterial hypertension and Chagas' disease are prevalent pathologies in Latin America. It has been demonstrated that each one of them may cause cardiac autonomic dysfunction. This study aimed to investigate the pattern of cardiac autonomic modulation in chagasic-hypertensive patients. METHODS: Subjects (n=120) without left ventricular dysfunction were distributed in four groups: healthy control (n=30); hypertensive (n=30); chagasic (n=30) and chagasic-hypertensive (n=30). Patients were evaluated by autoregressive spectral analysis of heart rate variability in three different conditions: baseline, cold face and passive tilt tests. Power spectral densities in low (0.04-0.15 Hz) and high (0.15-0.50 Hz) frequency bands were estimated in both absolute and normalized units. RESULTS: Baseline median values (percentile 25 to percentile 75) of mean arterial pressure (in mmHg) were 93.3 (85.0-96.7), 116.7 (*, #) (110.0-129.2), 86.7 (83.3-92.5) and 106.7 (*, #) (106.7-110.0) for healthy control, hypertensive, chagasic and chagasic-hypertensive patients, respectively (*p<0.05 versus healthy control, #p<0.05 against chagasic group). Heart rate at rest did not differ among groups. Regarding to spectral parameters in baseline conditions, the absolute power of high frequency component of heart rate variability of the chagasic-hypertensive group was significantly lower than that found in healthy control and hypertensive patients. There were no differences in spectral parameters responses during cold face test. After passive tilt test, however, decreases in high frequency oscillations and increases in sympathovagal balance (low and high frequency ratio) were significantly lower in hypertensive, chagasic and chagasic-hypertensive patients as compared with healthy control. CONCLUSIONS: These data indicate that chagasic-hypertensive patients presented an impairment of cardiac parasympathetic modulation at baseline conditions as well as in response to passive orthostatic stress.

[Radiographic study of the oesophagus of chagasic patients in 25 years of the Mambaí Project]. / Estudo radiológico do esôfago de chagásicos, em 25 anos do Projeto Mambaí

This work describes radiography studies of the esophagus in chagasic patients of the Mambaí project over a 25 year period. Each person realized two radiographs in four different periods (1975-1976, 1980-1982, 1988-1991 and 1998-2000). The first radiograph was realized in the right anterior oblique position after swallowing 75 ml of barium sulphate solution and another 60 seconds later. In all periods the same methodology was used. The radiographs were read by the same researcher, and the megaesophagus was classified in four groups according to Rezende and colleagues. The prevalence of megaesophagus was 5.2%; 5.0%; 18.6% and 13.9% in 1975-1976, 1980-1982, 1988-1991 and 1998-2000 respectively. The incidence of megaesophagus from 1975 to 2000 was 11.5% (51/445). During 25 year, 394 (84.2%) patients presented radiographs normal of esophagus, 11 (2.3%) diagnosed as megaesophagus in 1975-1976 did not progress, 61 (13%) that were normal, doubtful or already presented megaesophagus in 1975-1976, progressed and 2 (0.4%) presented regression of group I megaesophagus, diagnosed in previous studies.

[Epidemiological aspects of American tegumentary leishmaniasis in Varzelândia, Minas Gerais, Brazil]. / Aspectos epidemiológicos da leishmaniose tegumentar americana em Varzelândia, Minas Gerais, Brasil.

To characterize an area of endemic leishmaniasis, aiming to test a candidate leishmania vaccine, a prospective epidemiological survey was implemented in 1999 in a rural area of Varzelândia, Minas Gerais, Brazil. From a total of 1,253 persons in 246 households, 1,170 were included, of whom 593 (50.6%) were males and 662 (56.5%) were under 21 years of age. A Montenegro intradermal test performed in 1,120 individuals and evaluated in 1,020 was reactive in 282 (27.6%). Serological testing through indirect immunofluorescence and ELISA was performed in 970 individuals (82.9%). Antibodies to Leishmania sp. were detected in 117 (13.1%) and 170 (17.5%), respectively, by the two tests. Cutaneous scars similar to those seen in American tegumentary leishmaniasis were found in 297 individuals (25.4%), 282 of whom were submitted to the intradermal test, while only 168 (59.6) were reactive. Initial leishmaniasis prevalence of 5.8% was recorded, and an annual leishmaniasis incidence rate of 4.6% was observed after one year of follow-up. The epidemiological characteristics observed in this location are suggestive of an endemic area with old colonization.

[The influence of the parasitemia on the evolution of the chronic Chagas' disease]. / Influência da parasitemia na evolução da doença de Chagas crônica.

During 13 years, 190 individuals with chagasic infection were submitted to clinical and parasitological examinations to investigate the relationship between parasitemia and the evolution of chronic chagasic infection. Fifty-six patients with positive xenodiagnosis and 134 with negative exams were compared from 1988 to 91, it was found that 22 (39.3%) and 50 (37.3%), respectively, presented disease progression. The parasitemia was stratified into high, medium and low and the relation with the disease evolution showed that 5 (62.5%), 10 (41.7%) and 57 (36.1%), respectively, presented progressive disease, though without a statistically significant difference (p>0.05). When 20 patients with persistent parasitemia in 1976/91, were compared with 59 with negative xenodiagnosis, a progressive evolution was observed in 6 (30%) and 17 (28.8%), respectively. Comparing six patients with high parasitemia and 59 with negative exams, it was verified that 3 (50%) and 17 (28.8%), respectively, showed progressive disease, but this was not statistically significant, (p>0.05). Mean age with high, medium and low parasitemia were 39.6, 45.3 and 41.5 years, respectively, (p>0.05). Mean age in patients showing progressive, unaltered and regressive evolution was 46.4, 39.8 and 32.6 years, respectively, with a statistically significant difference between progressive and regressive evolution (p<0.05). It is suggested that high parasitemia did not have an influence on the evolution of the chronic infection.

[Diagnosis and treatment of congenital infection caused by Trypanosoma cruzi in Brazil]. / Diagnóstico y tratamiento de la infección congénita por Trypanosoma cruzi en Brasil.

Diagnosis of congenital infection should be performed preferentially by the search of the parasite, through microhematocrit. Nevertheless, most of the infected mothers are living now in non-endemic areas, where the expertise for identification of the parasite is low. Furthermore, transmission near delivery or even at delivery do not allow that enough parasites will be detected when the baby is at the maternity. So, if parasites are not found or not searched, it is imperative that, in serologically confirmed mothers (two positive tests), the babies are recalled at six/eight months of age, to look for IgG antibodies. If they are present, the baby is infected and should be treated. Treatment in Brazil is with benznidazol, 10 mg/Kg/day, during 60 days. Certification of cure is obtained once a negative serology is obtained, as a rule after one year. A follow up each six months is suggested.

Very low prevalence of hepatitis C virus infection in rural communities of northeastern Brazil with a high prevalence of schistosomiasis mansoni.

The association of hepatitis C virus infection and the hepatosplenic form of schistosomiasis mansoni has been claimed to result in the concomitant evolution of the two pathologies, with a poor prognosis due to aggravated liver disease. Recently, however, some authors have begun to reject the hypothesis of a higher susceptibility of hepatosplenic schistosomal patients to HCV. The aim of the present transverse study carried out between July and August 1990 was to determine the possible association between SM and HCV markers in residents of Catolândia, Bahia State. Anti-HCV markers were assayed by ELISA-II and RIBA-II in serum samples obtained from 1,228 residents (85.8%). The anti-HCV antibody (ELISA-II) was positive in six (0.5%) individuals, eight (0.6%) cases were inconclusive and 1,214 (98.9%) were negative. However, only in one ELISA-positive serum sample (0.08%) were antibodies confirmed by RIBA-II, while two other samples assayed by RIBA-II were indeterminate. These three patients presented the hepatointestinal form of SM during the follow-up period (1976 to 1996). In conclusion, no association was observed between HCV and SM in the endemic area studied, especially among patients with the hepatosplenic form of the disease.

[Congenital transmission of Trypanosoma cruzi in Brazil: estimation of prevalence based on preliminary data of national serological surveys in children under 5 years old and other sources]. / Transmisión congénita del Trypanosoma cruzi en Brasil: estimativa de prevalencia baseada en resultados preliminares de la encuesta nacional serológica en niños menores de cinco años, así como otras fuentes.

A prevalence estimation of congenital transmission in Brazil is performed, based on several sources of recent data. From a serological survey conducted now in Brazil, with children below 5 years old, preliminary data from the state of Minas Gerais only 19/9,556 children did have antibodies against Trypanosoma cruzi. All 19 mothers were infected, but only one child persisted with antibodies on a second blood collection, hence diagnosed as congenital. The other were just passive transference of maternal antibodies. From a recent publication, 278 children born from 145 infected mothers were studied. Two cases (0.7%) were congenital. In other source, from 1,348 blood donors, 35 were born in non endemic areas. When 10 of them were called, 8 were born from infected mothers and five may be congenital. Finally, no infection was detected in 93 children born from 78 infected mothers. The reasons for this low prevalence are discussed, are lower than in other countries of the South Cone, that harbor also T. cruzi 2, but are unrecognized up to now.

[Aspects of the ecology and behaviour of phlebotomines in endemic area for visceral leishmaniasis in State of Minas Gerais]. / Aspectos da ecologia e do comportamento de flebotomíneos em área endêmica de leishmaniose visceral, Minas Gerais.

Studies on the behavioral and feeding habits of some species of phlebotominae sand flies have contributed to the comprehension of the epidemiology of leishmaniasis. In the present work, systematic captures were performed monthly in the municipality of Porteirinha (MG) using 28 light traps (CDC) from January to December 2002. Fourteen different species of phlebotomine were captured in a total of 1,408 specimens. The highest percentage of individuals (53.3%) was collected in the peridomicile against 46.7% in the intradomicile. Lutzomyia longipalpis was the predominant species in that region. The blood feeding of 38 females of this species from the field was analyzed by precipitin reaction. The results indicated that Lutzomyia longipalpis is an opportunist (65.1%) species that feeds on a wide variety of vertebrates in nature.

Comparative clinical and ultrasound study of egg-negative and egg-positive individuals from Schistosoma mansoni low morbidity endemic areas, and hospitalized patients with hepatosplenic disease.

Two hundred and twenty three subjects from a Schistosoma mansoni low morbidity endemic area and nine hospitalized hepatosplenic patients were submitted to stool test and clinical examination and abdomen ultrasound assessments. According to stool examination and ultrasound results, they were grouped as follows: G1 -- 63 Schistosoma mansoni egg-negative individuals; G2 -- 141 egg-positive patients and without evidence of periportal fibrosis; G3 -- 19 egg-positive patients with periportal echogenicity (3-6 mm); and G4 -- 9 hepatosplenic patients with periportal echogenicity (> 6 mm). Hepatomegaly detected by physical examination of the abdomen evaluated in the midclavicular line was verified in G1, G2 and G3, respectively, in 11.1, 12.1 and 26.3%. In G1, G2 and G3, periportal thickening occurred only in schistosomal patients (8.5%). Mild pathological alterations in patients that cannot yet be detected by clinical examination were detectable in the liver by ultrasound and can be due to fibrosis. The degree of mild periportal fibrosis was diminished in 57.9% of patients 12 months after treatment of schistosomiasis with oxamniquine. At ultrasonography, the mean liver left lobe measurement of G3 was larger than that of G1, and that of G4 larger than that of G1 and G2. The mean size of the spleen of G4 was significantly larger than that of the other three groups, and that of G3 larger than that of G1 and G2.

High levels of IgG4 to Schistosoma mansoni egg antigens in individuals with periportal fibrosis.

Specific IgG4 and IgE responses to adult worm antigen and soluble egg antigen (SEA) were examined in 267 individuals from an area in which schistosomiasis mansoni is endemic. Based on information obtained from clinical and sonographic examinations of this sample, the individuals were divided in three groups: 1) 204 individuals without periportal fibrosis, and liver and spleen enlargements; 2) 41 individuals without periportal fibrosis, but presenting with organopathy, with or without organomegaly; and 3) 22 individuals with periportal fibrosis, regardless of their status as having hepatomegaly and/or splenomegaly. Levels of IgG4 to SEA were significantly higher in sera from patients with fibrosis compared with the patients from the other two groups. We also found significantly higher levels of IgG4 against SEA in egg-negative patients with fibrosis compared with egg-negative patients from the other two groups. This report demonstrates a specific humoral response in patients presenting with initial fibrosis, a form of schistosomiasis transient between intestinal and severe hepatosplenic.

Human schistosomiasis mansoni: intensity of infection differentially affects the production of interleukin-10, interferon-gamma and interleukin-13 by soluble egg antigen or adult worm antigen stimulated cultures.

The effect of the intensity of infection (eggs per gram faeces, epg) on the production of interferon-gamma (INF-gamma), interleukin (IL)-10 and IL-13 by peripheral blood mononuclear cells (PBMCs) from individuals living in a Schistosoma mansoni-endemic area was evaluated. In vitro stimulation of PBMCs with soluble egg antigen (SEA) resulted in significantly higher secretion levels of IFN-gamma in egg-negative individuals compared with those with an intensity of infection of more than 100 epg. In contrast, the egg-positive group produced significantly higher amounts of IL-10. Levels of IL-13 did not differ significantly between egg-positive and egg-negative groups. These findings suggest that IL-10 is an important cytokine in the control of the T helper cell (Th) type 1 responses during human S. mansoni infection, shifting the immune response from Th0 in egg-negative individuals from an endemic area to a Th2 polarization in chronic infected individuals.

Azithromycin in the treatment of mucosal leishmaniasis.

This report describes three elderly patients with mucosal form of American tegumentary leishmaniasis associated with chronic cardiopathy. Due to the known toxicity of classical drugs with activity against Leishmania sp., the patients received three oral courses of azithromycin therapy in single 500 mg daily dose during ten days, every other month. All lesions healed after the third series. One of the patients relapsed and a new series of azithromycin was prescribed. Azithromycin may be an alternative drug for the treatment of leishmaniasis in special situations due to its optimal mucosal and intraphagocyte concentration, single daily posology, high tolerance and oral administration. The mechanism of this drug on Leishmania sp. is unknown at present.

[Schistosomiasis in hyperendemic area of Taquarendi: I- Schistosoma mansoni infection and severe clinical forms]. / Esquistossomose na área hiperendêmica de Taquarendi: I Infecção pelo Schistosoma mansoni e formas graves.

The study was carried out in Taquarendi (Bahia), a caatinga zone with a small irrigated strip of land, where Biomphalaria glabrata snails are found. From the 1,532 inhabitants, 1,105 (72.1%) were submitted to clinical examination and 1058 out of them (95.7%) made stool examinations. Prevalence of schistosomiasis was 73.1% and 16.2% of these patients eliminated more than 1,000 eggs per gram of stool. By clinical examination, the size and the consistency of the left liver lobe were increased in 54% of the individuals and the spleen was palpable in 21.8%. The diagnosis of hepatosplenomegaly and of the advanced hepatointestinal clinical form was made, respectively, in 9.8% and 3.7%. A direct relationship between such clinical forms of the disease and the worm load over 1.000 S. mansoni eggs/g of fezes was found.