Uma nova possibilidade de vigilância: identificamos todos os casos de leptospirose?

Leptospirosis is a febrile disease with a typically underestimated global incidence, especially in regions where dengue is endemic. Therefore, it is difficult to accurately determine the number of leptospirosis cases in these areas, which contributes to significant under-reporting this disease. In this study, we estimated the number of possible leptospirosis cases among dengue-like cases that were reported during 2008, 2010, and 2012 in the city of Fortaleza, northeast Brazil. Patients were evaluated for dengue and leptospirosis using immunoenzymatic tests for IgM antibodies that were specific to each pathogen. Among the suspected cases of dengue that resulted as negative in laboratory tests, 10.8% (2008), 19.2% (2010), and 30.8% (2012) were confirmed to be leptospirosis. Considering the cases reported by the surveillance authority as dengue that were subsequently discarded based on the laboratory test results, we estimate that the number of actual leptospirosis cases may be 26 to 49 times higher than those diagnosed and reported by the Health Services. Furthermore, we believe that approximately 20% of dengue-like cases may be leptospirosis cases in areas where the two diseases are endemic.A leptospirose é doença febril tipicamente subestimada em todo o mundo, principalmente em áreas que a dengue se apresenta de forma endêmica. Desta forma, há limitações importantes na compreensão do número de casos de leptospirose nessas áreas, o que proporciona maior subnotificação. Neste estudo, apresentamos estimativa de possíveis casos de leptospirose a partir de casos de dengue-símile na cidade de Fortaleza, nordeste do Brasil, durante os anos de 2008, 2010 e 2012. Os pacientes foram investigados para dengue e leptospirose utilizando testes imunoezimáticos para detecção do anticorpo, da classe IgM, específicos para cada patologia. Entre os casos suspeitos de dengue, mas que não apresentaram resultado laboratorial positivo, 10,8%; 19,2% e 30,8% foram confirmados como leptospirose nos anos de 2008, 2010 e 2012; respectivamente. Considerando os casos notificados pela vigilância de dengue e que foram, posteriormente, descartados, baseados nos resultados dos testes laboratoriais, estimamos que o número atual de casos de leptospirose pode ser de 26 a 49 vezes mais do que o detectado e notificado pelos serviços de saúde. Além disso, acreditamos que aproximadamente 20% dos casos de dengue-símile podem ser de leptospirose, em áreas onde as duas doenças ocorram de forma endêmica

Dengue: 30 years of cases in an endemic area

The present study aimed to review literature on studies of dengue cases conducted over 30 years in the state of Ceara´. Between November 2015 and January 2016, articles published in Portuguese and English in 7 databases were searched using keywords and a Boolean operator. A total of 191 articles were identified in the databases; 133 were excluded according to the exclusion criteria, and 58 were included in the study. Of the 58 articles analyzed, 6 reported data from Brazil; including the Northeast region and the state of Ceara´; 41 reported data for only the city of Fortaleza; 7 reported data for the state of Ceara´; 4 reported data for cities in the interior of the state; and 3 included only children. The studies adopted different approaches and focused on different aspects of the disease. Study outcomes included the identification of serological, epidemiological, clinical, and laboratory characteristics; potential larvicides and biological predators of mosquitoes; potential antiviral agents; vector density characteristics; and educational dengue prevention and control strategies. Additionally, one vaccine trial was included. Although studies on dengue in the state of Ceara´ are scarce, they are encompassing, including several lines of research, and the number of studies and reports on dengue in the state of Ceara´ continues to increase

Diagnosis of esophageal lesions in HIV-positive patients by the polymerase chain reaction (PCR).

Os pacientes infectados pelo vírus da imunodeficiência humana (HIV) freqüentemente apresentam alterações digestivas, sendo o esôfago um alvo comum de lesões estruturais. A etiologia infecciosa é a mais freqüente neste grupo de pacientes. Múltiplos agentes já foram implicados como causadores de lesões esofágicas. As infecções virais são uma das principais causas de tais lesões, sendo os vírus mais implicados o citomegalovirus (CMV) e o vírus herpes simples (HSV). Muitas lesões ulceradas permanecem sem diagnóstico etiológico, mesmo após exaustiva investigação, sendo denominadas úlceras idiopáticas ou aftosas. Os métodos de diagnóstico usuais são demorados e pouco sensíveis. Assim, nosso estudo tem como principal objetivo estudar o papel do método da reação em cadeia da polimerase (PCR) no diagnóstico destas lesões. Durante o período de outubro de 1996 a outubro de 1997, foram estudados 79 pacientes HIV-positivos, que foram submetidos ao exame de endoscopia digestiva alta por indicação clínica. Estes foram submetidos a 89 exames endoscópicos, sendo colhidas 96 biópsias, as quais foram armazenadas em nitrogênio líquido (50) ou em freezer a 70oC (46). O DNA foi extraído usando método baseado na lise hipotônica, digestão com proteinase K, extração com fenol-clorofórmio e precipitação em etanol. Uma quantidade fixa foi usada para amplificação em ciclador térmico, utilizando primers específicos para CMV, Herpesvirus, HPV, HIV, Haemophilus ducreyi, Treponema pallidum e as micobactérias M. tuberculosis, M. avium e M. intracellulare. O produto final foi submetido a uma eletroforese em gel de agarose e corado com brometo de etídeo. A endoscopia não revelou alterações esofágicas em 26 exames (29,2%). As alterações observadas foram monilíase esofágica em 33 exames (37,1%), úlceras em 22 (24,7%); esofagite em 10 (11,2%) e áreas lugol-negativas em 9 (10,1%). A PCR resultou positiva para o CMV em 19 amostras (19,8%), para o Herpes em 4 (4,2%), para o HPV em 17 (17,7%), para o HIV em 37 (38,5%) e para o H. ducreyi em 3 (3,1%). Nenhuma amostra foi positiva para o T. pallidum e para micobactérias. No estudo de 29 amostras de 22 úlceras esofágicas a PCR detectou o CMV em 9 amostras (31%), o Herpes em 3 (10,3%), o HPV em 6 (20,7%), o HIV em 19 (65,5%) e o H. ducreyi em 2 (6,9%) e em 8 (36,4%) não foi detectado nenhum agente. O CMV foi detectado com freqüência nas úlceras esofágicas, sendo difícil diferenciar se havia infecção ativa ou latente. O HIV teve uma incidência elevada nas biópsias de úlceras, o que pode sugerir um possível papel etiológico deste agente em tais lesões. O HPV foi o terceiro agente mais freqüente, mas não foi possível caracterizá-lo como causador de lesões esofágica ulceradas. A PCR apresentou potencial para tornar-se um método útil na investigação das lesões esofágicas em pacientes infectados pelo HIV.Patients infected by Human Immunodeficiency Virus (HIV) usually present digestive abnormalities and the esophagus is a common target of structural lesions. Infections are the most frequent cause of esophageal lesions in these patients. Several agents were already implied in this process. Viral infections are one of the main causes of such lesions and cytomegalovirus (CMV) and herpes simplex virus (HSV) were the most involved agents. Many ulcerated lesions persist without etiologic diagnosis even after exhaustive investigation, being denominated idiopathic or aphthous ulcers. The usual diagnostic methods are difficult and have low sensitivity. Thus, the main objective of our study was to evaluate the role of the polimerase chain reaction (PCR) method in the diagnosis of these lesions. During the period of October of 1996 to October of 1997, 79 HIV-positive patients were studied. They were submitted to upper digestive endoscopies, which were indicated on clinical basis. These patients were submitted to 89 upper digestive endoscopies, being obtained 96 biopsies, which were stored in liquid nitrogen or in a 70oC freezer. DNA was extracted using a method based on hypotonic lyses, proteinase K digestion, extraction with phenol-chloroform and precipitation in ethanol. A fixed amount was used for amplification in thermal cycler, using specific primers for CMV, herpesvirus, human papillomavirus (HPV), HIV, Haemophilus ducreyi, Treponema pallidum, Mycobacterium tuberculosis, Mycobacterium avium and Mycobacterium intracellulare. The final products were submitted to an electrophoresis in agarose gel and stained with ethidium bromide. The endoscopies did not reveal esophageal alterations in 26 exams(29,2%). The abnormalities observed were esophageal candidiasis in 33 exams (37,1%), ulcers in 22 (24,7%); esophagitis in 10 (11,2%) and lugol-negative areas in 9 (10,1%). The PCR was positive to CMV in 19 samples (19,8%), for Herpes in 4 (4,2%), for HPV in 17 (17,7%), for HIV in 37 (38,5%) and for the H. ducreyi in 3 (3,1%). No sample was positive for T. pallidum or micobacterium. In the study of the esophageal ulcers by PCR, CMV was detected in 9 samples (31%), Herpes in 3 (10,3%), HPV in 6 (20,7%), HIV in 19 (65,5%), H. ducreyi in 2 (6,9%) and any agent was detected in 8 samples (36,4%). CMV was frequently detected in esophageal ulcers, being difficult to differentiate between active and latent infections. The HIV had an elevated incidence in ulcer biopsies, which may suggest a possible etiologic role of this virus in such lesions. HPV was the third more frequent agent, but it was not possible to attribute the esophageal lesions to that virus. In conclusion, this study suggests that the PCR can be an useful method in the investigation of esophageal lesions in HIV infected patients

HIV e demência: prevalência e fatores de risco

Objective: To determine the prevalence of patients at risk of developing HIV-associated neurocognitive disorder (HAND) and identify factors possibly associated with its occurence. Methods: Quantitative cross-sectional study conducted at the Specialized Care Service (Serviço de Atendimento Especializado - SAE) for HIV/Aids of the Integrated Medical Care Center (Núcleo de Atendimento Médico Integrado - NAMI) of the University of Fortaleza (Universidade de Fortaleza - UNIFOR), Fortaleza, Ceará, Brazil. We reviewed medical records of all 249 patients that started medical follow-up at SAE/NAMI since its foundation (August/2010) until January/2014, including in the analysis those who completed the international HIV dementia scale - IHDS during routine medical visits. Epidemiological, clinical and laboratory variables were collected in addition to IHDS score and the sample was classified in two groups: patients with IHDS≥10 (Group 1) and IHDSObjetivo: Determinar la prevalencia de pacientes con riesgo para el desarrollo del desorden cognitivo relacionado al VIH (HAND – HIV associated neurocognitive disorder) y identificar los factores que posiblemente estarían asociados a su ocurencia.Métodos: Estudio cuantitativo, transversal realizado en el Servicio de Atención Especializada (SAE) en VIH/SIDA del Núcleo de Atención Médica Integrada (NAMI), Universidad de Fortaleza (UNIFOR), Fortaleza/Ceará/Brasil. Se revisó todos los 249 historiales clínicos de pacientes que iniciaron seguimiento em el SAE/NAMI desde su creación (agosto/2010) hasta enero/2014, incluyéndose en el analisis aquellos que presentabam el registro de la aplicación de la escala de demencia del VIH (IHDS – international HIV dementia scale) en las consultas de rutina. Se recogieron variables epidemiológicas, clinicas y de laboratório además del valor del IHDS clasificando la muestra en dos grupos: pacientes con IHDS≥10 (Grupo 1) y IHDSObjetivo: Determinar a prevalência de pacientes sob risco de desenvolver desordem cognitiva relacionada ao HIV (HAND – HIV associated neurocognitive disorder) e identificar fatores que possivelmente estariam associados à sua ocorrência. Métodos: Estudo quantitativo, transversal, conduzido no Serviço de Atendimento Especializado (SAE) em HIV/AIDS do Núcleo de Atenção Médica Integrada (NAMI), Universidade de Fortaleza (UNIFOR), Fortaleza/Ceará/Brazil. Foram revisados todos os 249 prontuários de pacientes que iniciaram acompanhamento no SAE/NAMI desde a sua criação (agosto/2010) até janeiro/2014, incluindo-se na análise aqueles que apresentavam o registro da aplicação da escala de demência do HIV (IHDS – international HIV dementia scale) nas consultas de rotina. Coletaram-se variáveis epidemiológicas, clínicas e laboratoriais, além do valor do IHDS, classificando-se a amostra em dois grupos: pacientes com IHDS≥10 (Grupo 1) e IHD

Serological evidence of leptospirosis in patients with a clinical suspicion of dengue in the State of Ceará, Brazil.

Introduction: Dengue and leptospirosis are two febrile illnesses of great clinical and epidemiological importance in Brazil. Their significant degree of symptomatic similarity makes clinical diagnosis difficult.Objective: To diagnose leptospirosis differentially in patients with clinically suspected dengue.Materials and methods: In this study, 86 patients with clinically suspected dengue underwent virological and serological diagnostic evaluations for dengue (reverse transcriptase polymerase chain reaction, NS1 immunochromatographic test, and NS1 enzyme-linked immunosorbent assay, ELISA), as well as tests to detect immunoglobulin M (IgM; IgM/IgG Rapid Test and IgM ELISA). The same patients were subsequently evaluated for leptospirosis using Rapid Test IgG/IgM (Bioeasy®) and Leptospira IgM ELISA (PanBio®).Results: Of the 86 patients, 48 (55.8%) had positive results for dengue in at least one of the tests and five (7.35%) showed positive reactions for leptospirosis.Conclusion: During dengue epidemics, this disease may be misdiagnosed as other infections, including leptospirosis, when diagnosis is based on nonspecific clinical and laboratory criteria alone.Introducción. El dengue y la leptospirosis son dos enfermedades febriles de gran importancia clínica y epidemiológica en Brasil, y presentan una similitud sintomatológica significativa, lo cual dificulta el diagnóstico clínico.Objetivos. Hacer el diagnóstico diferencial para leptospirosis en pacientes con sospecha clínica de dengue.Materiales y métodos. En este estudio, 86 pacientes con sospecha clínica de dengue fueron sometidos a examen para el diagnóstico de dengue mediante pruebas de virología y serología (RT-PCR, prueba de inmunocromatografía NS1 y ELISA-NS1) y pruebas para la detección de IgM (prueba rápida IgM/IgG y ELISA-IgM). En los mismos pacientes también se evaluó la presencia de leptospirosis mediante la prueba rápida IgG/IgM (Bioeasy®) y ELISA IgM-Leptospira (PanBio®).Resultados. De los 86 pacientes, 48 (55,8 %) fueron positivos para dengue en, por lo menos, una de las pruebas y 5 (7,35 %) presentaron reacciones positivas para leptospirosis.Conclusión. Durante las epidemias de dengue, otras infecciones y entre ellas la leptospirosis, pueden dar lugar a confusiones cuando se el diagnóstico se hace únicamente con base en criterios inespecíficos clínicos y de laboratorio.Introduction: Dengue and leptospirosis are two febrile illnesses of great clinical and epidemiological importance in Brazil, demonstrating significant symptomatic similarity that makes clinical diagnosis difficult.Objectives: To differentially diagnose leptospirosis in patients with clinically suspected dengue.Materials and methods: In this study, 86 patients with clinically suspected dengue underwent virological and serological diagnostic evaluations for dengue (reverse transcriptase polymerase chain reaction, NS1 immunochromatographic test, and NS1 enzyme-linked immunosorbent assay [ELISA]), and tests to detect immunoglobulin M (IgM; IgM/IgG Rapid Test and IgM ELISA). Then, the same patients were also evaluated for leptospirosis using Rapid Test IgG/IgM (Bioeasy®) and Leptospira IgM ELISA (PanBio®).Results: Of the 86 patients, 48 (55.8%) had positive results for dengue in at least one of the tests and 5 (7.35%) showed positive reactions for leptospirosis.Conclusion: During dengue epidemics, diagnosis of dengue may be confused with other infections, among which is leptospirosis, when diagnosed only by using nonspecific clinical and laboratory criteria

Is early HIV infection diagnosis at a reference center a reality in the state of Ceara?

Abstract INTRODUCTION: Early diagnosis of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) can decrease transmission and significantly affect morbidity and mortality; however, Brazil still confronts the reality of late HIV diagnosis. METHODS: Medical records of 284 HIV-positive patients were reviewed in this cross-sectional study. RESULTS: Of all patients, 28% were diagnosed in the context of health assessments, whereas 27% were symptomatic at diagnosis. Early HIV infection (Group 1) was diagnosed in 60.2% of participants. They were younger than those with late diagnosis (Group 2) (p = 0.002). CONCLUSIONS: These findings highlight the need for strategies to increase HIV testing in asymptomatic individuals and older patients

Is Visceral Leishmaniasis the same in HIV-coinfected adults?

Introduction: Visceral Leishmaniasis is the most severe form of disease caused by the Leishmania donovani complex, with significant morbidity and mortality in developing countries. Worse outcomes occur among HIV-positive individuals coinfected with Leishmania. It is unclear, however, if there are significant differences on presentation between Visceral Leishmaniasis patients with or without HIV coinfection. Methods: We reviewed medical records from adult patients with Visceral Leishmaniasis treated at a reference healthcare center in Fortaleza – Ceará, Brazil, from July 2010 to December 2013. Data from HIV-coinfected patients have been abstracted and compared to non-HIV controls diagnosed with Visceral Leishmaniasis in the same period. Results: Eighty one HIV-infected patients and 365 controls were enrolled. The diagnosis in HIV patients took significantly longer, with higher recurrence and death rates. Kala-azar's classical triad (fever, constitutional symptoms and splenomegaly) was less frequently observed in Visceral Leishmaniasis-HIV patients, as well as jaundice and edema, while diarrhea was more frequent. Laboratory features included lower levels of hemoglobin, lymphocyte counts and liver enzymes, as well as higher counts of blood platelets and eosinophils. HIV-infected patients were diagnosed mainly through amastigote detection on bone marrow aspirates and treated more often with amphotericin B formulations, whereas in controls, rK39 was the main diagnostic tool and pentavalent antimony was primarily used for treatment. Conclusions: Clinical and laboratory presentation of Visceral Leishmaniasis in HIV-coinfected patients may differ from classic kala-azar, and these differences may be, in part, responsible for the delay in diagnosing and treating leishmaniasis, which might lead to worse outcomes. Keywords: Leishmaniasis, HIV, Coinfectio