Acurácia da reação em cadeia da polimerase em amostras de saliva, swab nasal e papel filtro oral no diagnóstico da leishmaniose tegumentar americana : estudo clínico, revisão sistemática da literatura e meta-análise

Tese (doutorado)—Universidade de Brasília, Faculdade de Medicina, 2014Introdução: A técnica da reação em cadeia da polimerase (PCR) aumenta a sensibilidade do diagnóstico da leishmaniose tegumentar americana (LTA), especialmente na forma mucosa (LM). Teve-se por objetivo avaliar a acurácia dos resultados de PCR em amostras da mucosa nasal, oral e de saliva no diagnóstico da LM e da leishmaniose cutânea (LC). Métodos: Pacientes atendidos no Hospital Universitário de Brasília foram inclusos de forma consecutiva em amostra de conveniência. Intradermorreação de Montenegro (IDRM), imunofluorescência indireta (IFI), imprint em lâmina, cultura, exame histopatológico e PCR em papel filtro da lesão foram utilizados em paralelo para alocação dos casos nos grupos de LM, LC e controles. As amostras mucosas avaliadas por PCR foram coletadas por swab nasal (SN), microtubo de 1,5mls (saliva) e esfregaço oral na forma de imprint em papel de filtro (PFO). Para a PCR, utilizou-se par de iniciadores que amplificam sequência de 120pb do DNA mitocondrial de Leishmania spp. Para a identificação do subgênero, empregou-se digestão pelas enzimas de restrição HaeIII e Bsr1. Realizou-se ainda revisão sistemática da literatura com o objetivo de agregação com os dados encontrados na pesquisa clínica. Resultados: Foram incluídos 69 pacientes, sendo 17 (25%) com LM, 19 (28%) com LC e 33 (48%) controles. Para o diagnóstico da LM, em comparação aos controles, a melhor acurácia foi alcançada pela PCR do SN 86% (IC-95%=73,81-93,05), seguido da saliva 74% (IC-95%=60,45-84,13) e PFO 68% (IC-95%=54,19-79,24). As especificidades do SN e PFO foram completas, negativas em todos os controles sem LTA. Dois casos de LC tiveram SN e PFO simultaneamente positivos. A revisão sistemática da literatura resultou na inclusão de 14 referências. Análise dos dados por meta-análise, possível apenas para amostras de PCR de fragmento da lesão em 2 dos artigos selecionados, demonstrou uma sensibilidade de 70% (IC-95%=0,57-0,81), especificidade de 97% (IC-95%=0,89-1), e razão de chances de 40,34 (IC-95%=11,06-147,08) no diagnóstico da LM. Identificou-se Leishmania do subgênero Viannia em 12 casos de LM e 11 casos da LC. Em apenas um caso de LC foi identificado o subgênero Leishmania. Conclusões: O SN demonstrou a melhor acurácia entre os exames de PCR na mucosa. Os resultados da PCR nas três formas de coleta nasal, oral e de saliva apresentaram maior especificidade que a IDRM e IFI. Estes mostraram ainda sensibilidade comparável aos exames de cultura e imprint em lâmina, com a vantagem da coleta menos invasiva. _____________________________________________________________________________ ABSTRACTIntroduction: The technique of polymerase chain reaction (PCR) increases the sensitivity ofthe etiological diagnosis of american cutaneous leishmaniasis (ACL), especially in themucocutaneous form (MCL). The aim of the study was to evaluate the accuracy of PCR in thenasal cavity, oral mucosa and saliva in the diagnosis of MCL and cutaneous leishmaniasis(CL). Methods: Patients attending the University Hospital of Brasilia were consecutivelyincluded in a convenience sample. Montenegro skin test (MST), indirect immunofluorescence(IIF), smear, culture, histopathology and PCR from filter paper imprints of lesion biopsy(FPIL) were used in parallel for allocation in groups of MCL, CL and controls. Mucosalsamples evaluated by PCR were collected by nasal swab (NS), 1.5mls microtubes (saliva) andoral filter paper imprints (OFPI). The primers used resulted on a 120-bp sequence present inthe mitocondrial DNA of Leishmania spp. Digestion with the restriction enzymes HaeIII andBSR1 were used for subgenus identification. A systematic review of the literature wasconducted with the goal of aggregation with data found in the present clinical research.Results: 69 patients were included, 17 (25%) with MCL, 19 (28%) with CL and 33 (48%)controls . For the diagnosis of MCL, compared to controls, the best accuracy was achieved byNS 86% (95%CI=73.81-93.05), followed by saliva 74% (95%CI=60.45-84.13) and OFPI68% (95%CI=54.19-79.24). The specificity of the NS and OFPI were complete, negative inall controls without ACL. Two cases of isolated CL showed positivity for both NS and OFPI.The systematic review of the literature resulted in the inclusion of 14 previous references.Analysis of aggregated data by meta-analysis, possible only for tissue samples in 2 of thepreviously selected articles showed a sensitivity of 70% (IC-95%=0.57-0.81), a specificity of97% (IC-95%=0.89-1) and an odds-ratio of 40.34 (IC-95%=11.06-147.08) in the diagnosis ofMCL. We identified the Leishmania subgenus Viannia in 12 cases of MCL and in 11 cases ofCL. In only one case of CL the subgenus Leishmania was identified. Conclusions: NSshowed the best accuracy among the PCR tests in the mucosa. PCR results in all three formsof nasal, oral and saliva samples showed higher specificity than the MST and IIF. Themethods also show a sensitivity comparable to culture and smears, with the advantage of aless invasive collection

Clinico-immunological spectrum of American tegumentary leishmaniasis and leprosy coinfection: A case series in Southeastern Brazil

INTRODUCTION: American tegumentary leishmaniasis (ATL) and leprosy share common areas of prevalence, but reports of coinfection are scarce. METHODS: We report a series of 9 ATL-leprosy cases and discuss the association. An integrative diagram to analyze the clinico-immunological features of coinfection with both diseases. RESULTS: Nine patients with leishmaniasis (5 cutaneous, 3 mucocutaneous, 1 disseminated case) exhibited concurrent infection with distinct clinical forms of leprosy. Our diagram-based analysis evidenced a divergent clinico-immunological spectrum for each disease in 8 out of 9 cases. CONCLUSIONS: The spectrum of ATL-leprosy comorbidity suggests that the host has a specific immune response against each pathogen

American cutaneous leishmaniasis triggered by electrocoagulation

Cutaneous leishmaniasis is usually transmitted by infected phlebotomine sand fly bites that initiate local cutaneous lesions. Few reports in the literature describe other modes of transmission. We report a case of a previously healthy 59-year-old woman who underwent electrocoagulation to remove seborrheic keratosis confirmed by dermatoscopy. Three months later, a skin fragment tested positive for Leishmania culture; the parasite was identified as L. (V.) braziliensis. Trauma may generate inflammatory cascades that favor Leishmania growth and lesion formation in previously infected patients. American cutaneous leishmaniasis is a dynamic disease with unclear pathophysiology because of continually changing environments, demographics, and human behaviors

Upper limb revascularization with reversed vein graft and microvascular anastomoses after brachial artery aneurysm resection in a child with tuberous sclerosis

The authors present an unusual case of a 3-year-old girl who was diagnosed with a fast-growing brachial aneurysm due to tuberous sclerosis. The patient underwent aneurysm resection and microsurgical reconstruction with reversed greater saphenous vein graft at the same time. She had a favorable outcome, without neuromuscular deficits. Doppler ultrasonography was performed for diagnosis, vein graft selection, and postoperative follow-up. The authors believe that such combined approach may be the routine for pediatric vascular reconstructions. Finally, this reconstruction has been rarely reported in tuberous sclerosis patients

Leishmaniose recidiva cútis

Paciente do sexo masculino, 18 anos. Dois anos após tratamento insuficiente para leishmaniose tegumentar americana, apresentou, na mesma localização, lesão formada por cicatriz atrófica central e nódulos verrucosos na periferia. Era imunocompetente, hígido e negava qualquer trauma local. O diagnóstico de leishmaniose recidiva cutis foi feito através de cultura do aspirado da lesão. Realizou tratamento com N-metilglucamina (20mgSbV/kg/dia) associado à pentoxifilina (1200mg/dia) durante 30 dias alcançando cura clínica. Os casos semelhantes requerem atenção diferenciada pela dificuldade ao tratamento.We present a case of an 18-year-old male patient who, after two years of inappropriate treatment for cutaneous leishmaniasis, began to show nodules arising at the edges of the former healing scar. He was immune competent and denied any trauma. The diagnosis of recurrent cutaneous leishmaniasis was made following positive culture of aspirate samples. The patient was treated with N-methylglucamine associated with pentoxifylline for 30 days. Similar cases require special attention mainly because of the challenges imposed by treatment

Complementary exams in the diagnosis of american tegumentary leishmaniasis

The diagnosis of American Tegumentary Leishmaniasis is a difficult but essential task when considering the high toxicity profile of the drugs available. Since the discovery of its etiologic agent, numerous diagnostic tests have been developed. None of the tests available today can be considered as the gold standard, since they do not add enough accuracy for the disease detection. Good epidemiological and clinical knowledge of the disease are fundamental precepts of the dermatology practice and precede the rational use of existing diagnostic tests. In this article we aim, through extensive literature review, to recall fundamental concepts of any diagnostic test. Subsequently, based on this information, we will weave important comments about the characteristics of existing diagnostic tests, including immunological tests such as Montenegro's skin test, serology and detection of parasites by direct examination, culture or histopathology. Finally we will discuss the new technologies and options for the diagnosis of Cutaneous Leishmaniasis. The molecular biology technique is considered a promising tool, promoting the rapid identification of the species involved. We also aim to educate dermatologists about a disease with high morbidity and assist in its difficult recognition

Infection of the lymphatic system by Aureobasidium pullulans in a patient with erythema nodosum leprosum

Aureobasidium pullulans is a causal agent of phaeohyphomycosis, occasionally found in men and animals. As an agent of different opportunistic fungal processes, it may cause fungemia, systemic infections and abscesses in different viscera. This paper aims to report a case of a patient with infection of the lymphatic system by A. pullulans. A 23-year-old patient being treated for erythema nodosum leprosum presented a 60-day complaint of daily fever, hoarseness, odynophagia and weight loss. Laboratory tests showed pancytopenia with severe neutropenia, cervical adenomegaly and solid contrast uptake lesion in the oropharyngeal region. Due to neutropenia and sepsis the patient was initially treated with cefepime and vancomycin, but there was no clinical improvement. Lymph node puncture-aspiration showed yeast-form fungus identified as A. pullulans by sequencing ITS region. The patient was treated with amphotericin B deoxycholate, leading to complete recovery of bone marrow function and regression of adenomegaly and the oropharyngeal lesion