CROMOBLASTOMICOSE: Apresentação clínica, evolução terapêutica e associação com achados histopatológicos no Maranhão / CHROMOBLASTOMYCOSIS: Clinical presentation, therapeutic Evolution

Introdução: A Cromoblastomicose é uma doença crônica e de evolução lenta que acomete o tecido celular cutâneo e subcutâneo, tendo como principal agente etiológico, Fonsecaea pedrosoi. Podendo apresentar aspecto polimórfico, de evolução lenta, atingindo principalmente os membros inferiores de trabalhadores rurais. Objetivo: Analisar os achados histopatológicos correlacionando com tipo lesional, gravidade e terapias realizadas em pacientes portadores de agentes da CBM. Metodologia: É um estudo descritivo, analítico, longitudinal dos casos confirmados, com amostra de conveniência, realizado no Centro de Referência Infecciosa e Parasitária da Universidade Federal do Maranhão entre fevereiro/2017 a agosto/2018. Os testes de pesquisa direta, a cultura do fungo e microcultivo foram utilizados para confirmar o diagnóstico e o histopatológico para realizar as correlações e análises deste estudo. O tratamento foi realizado com itraconazol, para os pacientes com doença leve (200mg/dia), e em doença moderada e grave, itraconazol (400mg/dia). Em pacientes com lesões infiltrativas, associou-se imiquimode, tópico, 3 vezes por semana e nos pacientes com baixa resposta terapêutica e os que puderam comparecer no ambulatório a cada 15 dias, associou-se nitrogênio líquido. Resultados: A investigação clínica e epidemiológica dos 52 casos apresentou variação de idade entre 50 a 60 anos (n=21;40%); predominância: do sexo masculino (n=48; 92%), de trabalhadores rurais, de gravidade moderada (n=25;48%), de lesão em placa (n=38;73,08%), de granulomas supurativos (n=20;38,46%) e oriundos em sua maioria da Baixada Maranhense. Nas associações de achados histopatológicos e lesões, houve maiores percentuais para polimorfonuclear, linfócitos e hiperplasia pseudoepiteliomatosa, apontando para uma tentativa de eliminação do fungo (p<0,0001). Na correlação entre os achados histopatológicos e o tratamento, a proliferação vascular apresentou em menor quantidade nos locais das lesões, podendo prejudicar assim a concentração do antifúngico utilizado no tratamento. A carga fúngica apresentou redução nos tratamentos com itraconazol e itraconazol associado com nitrogênio líquido. Discussão: O itraconazol é um medicamento utilizado nas terapias de CBM que pode alcançar curas e melhoras dos quadros clínicos da maioria dos pacientes, principalmente nos que apresentam gravidade leve a moderada, após longos períodos de tratamento. Já em pacientes com lesões graves nota-se uma resposta diferenciada, isto talvez, ocasionada pela diminuição das concentrações teciduais de itraconazol. Os fatores que podem estar envolvidos nestas reduções das concentrações teciduais são as fibroses teciduais, edemas e coinfecções bacterianas, muito encontradas nos tecidos subcutâneos. É nesse momento que outras estratégias terapêuticas podem ser utilizadas como as associações com o nitrogênio líquido local ou o imiquimode. Conclusão: A cromoblastomicose tem comportamento endêmico no estado do Maranhão. O itraconazol em monoterapia apresentou os melhores resultados em termos de cura e redução de intensidade da carga fúngica do que em associação com nitrogênio líquido. O nitrogênio líquido apesar de apresentar reduções na intensidade da carga fúngica, tem que ser avaliado seu custo benefício. E a associação de itraconazol com imiquimode não apresentaram boa evolução, sendo evidenciada com aumento da intensidade da carga fúngica

Population-based seroprevalence of SARS-CoV-2 and the herd immunity threshold in Maranhão

OBJECTIVE: To estimate the seroprevalence of SARS-CoV-2 in the state of Maranhão, Brazil. METHODS: A population-based household survey was performed, from July 27, 2020 to August 8, 2020. The estimates considered clustering, stratification and non-response. Qualitative detection of IgM and IgG antibodies was performed in a fully-automated Elecsys® Anti-SARS-CoV-2 electrochemiluminescence immunoassay on the Cobas® e601 analyzer (Roche Diagnostics). RESULTS: In total, 3,156 individuals were interviewed. Seroprevalence of total antibodies against SARS-CoV-2 was 40.4% (95%CI 35.6-45.3). Population adherence to non-pharmaceutical interventions was higher at the beginning of the pandemic than in the last month. SARS-CoV-2 infection rates were significantly lower among mask wearers and among those who maintained social and physical distancing in the last month compared to their counterparts. Among the infected, 26.0% were asymptomatic. The infection fatality rate (IFR) was 0.14%, higher for men and older adults. The IFR based on excess deaths was 0.28%. The ratio of estimated infections to reported cases was 22.2. CONCLUSIONS: To the best of our knowledge, the seroprevalence of SARS-CoV-2 estimated in this population-based survey is one of the highest reported. The local herd immunity threshold may have been reached or might be reached soon.OBJECTIVE: To estimate the seroprevalence of SARS-CoV-2 in the state of Maranhão, Brazil. METHODS: A population-based household survey was performed, from July 27, 2020 to August 8, 2020. The estimates considered clustering, stratification and non-response. Qualitative detection of IgM and IgG antibodies was performed in a fully-automated Elecsys® Anti-SARS-CoV-2 electrochemiluminescence immunoassay on the Cobas® e601 analyzer (Roche Diagnostics). RESULTS: In total, 3,156 individuals were interviewed. Seroprevalence of total antibodies against SARS-CoV-2 was 40.4% (95%CI 35.6-45.3). Population adherence to non-pharmaceutical interventions was higher at the beginning of the pandemic than in the last month. SARS-CoV-2 infection rates were significantly lower among mask wearers and among those who maintained social and physical distancing in the last month compared to their counterparts. Among the infected, 26.0% were asymptomatic. The infection fatality rate (IFR) was 0.14%, higher for men and older adults. The IFR based on excess deaths was 0.28%. The ratio of estimated infections to reported cases was 22.2. CONCLUSIONS: To the best of our knowledge, the seroprevalence of SARS-CoV-2 estimated in this population-based survey is one of the highest reported. The local herd immunity threshold may have been reached or might be reached soon

Visceral leishmaniasis in Northeast Brazil: What is the impact of HIV on this protozoan infection?

BACKGROUND:The aim of this study was to compare cases of Visceral Leishmaniasis (VL) with and without HIV in a state in northeastern Brazil. METHODOLOGY:We performed a comparative study in the state's referral hospital for infectious/parasitic diseases located in Northeast Brazil between January 2007 and July 2017. The data obtained using this protocol were analyzed with SPSS. PRINCIPAL FINDINGS:In total, 252 patients were evaluated, including 126 with coincident VL/HIV and 126 with VL alone. Both groups primarily consisted of male patients. The most commonly affected ages were 30-39 years in the coinfected group and 19-29 years in the VL group (p < 0.001). Fever and anorexia (p = 0.001), which were more common in those with VL alone, were frequently observed, while diarrhea, vomiting, bleeding and dyspnea were more common in patients with VL/HIV coinfection (p<0.005). According to the hemogram results, leukocyte levels were lower in the VL group (p < 0.0001). Additionally, AST (aspartate aminotransferase) and ALT (alanine aminotransferase) levels differed between the groups, with higher levels in patients with VL (p < 0.001). On average, HIV was diagnosed 2.6 years before VL (p < 0.001), and VL relapse was observed only in the coinfection group (36.5% of cases). Fever (β = +0.17; p = 0.032) in the first VL/HIV episode was identified as a risk factor for relapse (R2 = 0.18). More deaths occurred in the VL/HIV group (11.1%) than in the VL group (2.4%). CONCLUSION/SIGNIFICANCE:VL/HIV was found to be prevalent among young adults, although the median patient age was higher in the VL/HIV group. The classic symptomatology of VL was more common in patients not coinfected with HIV; therefore, attention is needed in patients with HIV who present with any symptoms that suggest the presence of VL, especially in endemic areas. No cases of VL relapse occurred in patients without HIV, and death was more common in the VL/HIV co-infected group

Chromoblastomycosis and Chagas' disease: a case study in the Brazilian Northeast/ Cromoblastomicose e doença de Chagas: um estudo de caso no nordeste brasileiro

Background: Chromoblastomycosis is a disease caused by melanized fungi that have a slow evolution, and the disease may be chronic due to a lack of treatment at the onset of the disease. Besides chromoblastomycosis, other neglected diseases primarily affect people of low-income living in rural areas. The objective of this study was to analyze a case of coinfection with Trypanosoma cruzi and Fonsecaea pedrosoi in a patient with these agents. Methods: For the diagnosis of chromoblastomycosis, a biopsy of the lesion site was performed, and fungal tests were performed with KOH, cultured on Sabouraud Dextrose and Mycobiotic Agar. A microculture on the Potato Agar Dextrose was performed, followed by histopathology stained with hematoxylin-eosin. The diagnosis of Chagas disease, with the examination of gout on a slide, and staining using the Walker method. Results: The thick drop blood test was positive for Trypanosoma cruzi. Additionally, muriform brown corpuscles were visualized in the direct mycological biopsy, and also Fonsecaea pedrosoi was identified through the culture and microcultivation and sequencing, being thus diagnosed the chromoblastomycosis. Conclusions: Chromoblastomycosis and Chagas disease are neglected diseases in Brazil, especially in the states of the Northeast and North regions, where the prevalence of cases is still high

Environmental Screening of Fonsecaea Agents of Chromoblastomycosis Using Rolling Circle Amplification

Chromoblastomycosis is a chronic, cutaneous or subcutaneous mycosis characterized by the presence of muriform cells in host tissue. Implantation disease is caused by melanized fungi related to black yeasts, which, in humid tropical climates, are mainly members of the genus Fonsecaea. In endemic areas of Brazil, F. pedrosoi and F. monophora are the prevalent species. The current hypothesis of infection is traumatic introduction via plant materials, especially by plant thorns. However, isolation studies have demonstrated a low frequency of the agents in environmental substrates. The present study aimed to detect F. pedrosoi and F. monophora in shells of babassu coconuts, soil, plant debris, and thorns from endemic areas of chromoblastomycosis in Maranh&atilde;o state, northern Brazil, using Rolling Circle Amplification (RCA) with padlock probes as a new environmental screening tool for agents of chromoblastomycosis. In addition to molecular screening, the environmental samples were analyzed by fungal isolation using mineral oil flotation. The limit of detection of the RCA method was 2.88 &times; 107 copies of DNA per sample for the used padlock probes, indicating that this represents an efficient and sensitive molecular tool for the environmental screening of Fonsecaea agents. In contrast, with isolation from the same samples using several selective methods, no agents of chromoblastomycosis were recovered