LEISHMANIOSE TEGUMENTAR AMERICANA - APRESENTAÇÃO ATÍPICA DIAGNOSTICADA COM TÉCNICA DE BIOLOGIA MOLECULAR

American cutaneous leishmaniasis is an infectious, not contagious disease, caused by a protozoa from genus Leishmania and affects skin and mucosal tissue. The clinical symptoms is varied and it is related with the Leishmania species and the immune response of the host; Most common symptoms are single or multiples ulcerated lesions, however, we will present an atypical case of the disease. The patient presented mainly verrucous lesions in lower limbs, the polymerase chain reaction confirmed American cutaneous leishmaniasis diagnosis. After meglumine antimoniate treatment, the patient evolved with clinical improvement of the lesions, which supports the diagnosis. This case relevance is the need of knowledge of the disease atypical forms, in order to establish an early diagnosis and also an appropriate therapy.Leishmaniose tegumentar Americana é uma doença infecciosa, não contagiosa, causada por protozoários do gênero Leishmania, que acomete pele e mucosa. A clínica é variada e relaciona-se com a espécie de Leishmania e a resposta imune do hospedeiro; o quadro clássico são lesões ulceradas únicas ou múltiplas, porém mostraremos um caso atípico da doença. Paciente apresentava lesões predominantemente verrucosas em membros inferiores, a reação em cadeia da polimerase confirmou o diagnóstico de leishmaniose tegumentar Americana. Este paciente, após inicio do antimoniato de meglumina, evoluiu com melhora clínica das lesões, corroborando para o diagnóstico. A importância se deve a necessidade do conhecimento das formas atípicas da doença, a fim de se estabelecer um diagnóstico precoce e uma terapêutica correta

Failure of fluconazole in treating cutaneous leishmaniasis caused by Leishmania guyanensis in the Brazilian Amazon: An open, nonrandomized phase 2 trial.

The treatment of Leishmaniasis caused by Leishmania (Viannia) guyanensis is based on a weak strength of evidence from very few clinical trials and some case series reports. Current treatment guidelines recommend pentamidine isethionate or meglumine antimoniate (Glucantime) as the first-line choices. Both are parenteral drugs with a low therapeutic indexes leading to a high risk of undesired effects. Imidazole derivatives interfere with the production of leishmanial ergosterol, an essential component of their membrane structure. One drug that has been studied in different clinical presentations of Leishmania is fluconazole, a hydrophilic bis-triazole, which is easily absorbed through the oral route with a low toxicity profile and is considered safe for children. This drug is readily available in poor countries with a reasonable cost making it a potential option for treating leishmaniasis.An adaptive nonrandomized clinical trial with sequential groups with dose escalation of oral fluconazole was designed to treat adult men with localized cutaneous leishmaniasis (LCL) in Manaus, Brazil. Eligible participants were patients with LCL with confirmed Leishmania guyanensis infection.Twenty adult male patients were treated with 450 mg of fluconazole daily for 30 days. One patient (5%) was cured within 30 days of treatment. Of the 19 failures (95%), 13 developed a worsening of ulcers and six evolved lymphatic spreading of the disease. Planned dose escalation was suspended after the disappointing failure rate during the first stage of the trial.Oral fluconazole, at the dose of 450mg per day, was not efficacious against LCL caused by Leishmania guyanensis in adult men.Brazilian Clinical Trial Registration (ReBec)-RBR-8w292w; UTN number-1158-2421

Flow diagram of the progress through the phases: enrolment, intervention allocation, follow-up, and data analysis.

<p>Flow diagram of the progress through the phases: enrolment, intervention allocation, follow-up, and data analysis.</p

Local inflammatory reactions, all cases of the lymphatic spread of the disease and the adverse events related to fluconazole treatment.

<p>Local inflammatory reactions, all cases of the lymphatic spread of the disease and the adverse events related to fluconazole treatment.</p

Multi-series line chart representing the size of each ulcer before treatment, at 30 days of treatment and after 30 days after the completion of treatment.

<p>The red lines represent increasing ulcer size, and the blue lines represent decreasing ulcer size. The lines that stop at day 30 represent the lesions of patients who suffered treatment failure and requested rescue treatment. Lesions that appeared after 30 days of completing treatment were new lesions.</p

Two examples of clinical worsening with fluconazole 450 mg administered once daily.

<p>Picture A shows two lesions on the right hand of the patient before treatment, and picture B shows the same lesions after 30 days of fluconazole. Picture C shows new lesions caused by lymphatic spread in another patient after treatment with fluconazole.</p

“Programa Saúde e Cidadania”: the contribution of university extension in Amazonia for medical education

With emphasis to the importance in medical education, it reports the experience lived by the academics and teachers of medicine in partnership with the pupils of Health Multiprofissional Residence in an extension program in the interior of the Amazon. The result of the immersion of these authors in community reality and of their individual and collective experiences within the “Programa Saúde e Cidadania” in municipalities of Amazonas, between February 2012 and July 2015, is described in a qualitative approach of the type experience report. Since 2012, more than 50 academics were able to be present in field trips, planned and executed by the students themselves under the guidance of the team of coordinators and teachers of the extension program in partnership of Helth Multiprofissional Residence from Ufam. The academics of medical school has the opportunity of immersing in the reality of these communities and thus glimpse the social context, the territorial peculiarities and Health Social Determinants which influence the health-disease process. The experiences in this extension program cooperated to integrate criticality, humanization and team work to technical training of curriculum providing the possibility of forming doctors more sensitive to the proposals of the Public Health Sistem.Com destaque à importância na formação médica, relata-se a experiência vivida por discentes e docentes de medicina em parceria com os residentes multiprofissionais em saúde num programa de extensão no interior do Amazonas. O resultado da imersão destes autores na realidade comunitária e de suas vivências práticas, individuais e coletivas, dentro do “Programa Saúde e Cidadania” em municípios do interior do Amazonas, entre fevereiro de 2012 e julho de 2015, é descrito numa abordagem qualitativa do tipo relato de experiência. Desde 2012, mais de 50 acadêmicos puderam estar presentes nas viagens de campo, programadas e executadas pelos próprios alunos sob orientação da equipe de coordenadores e docentes do Programa, em parceria com multiprofissionais da Residência Multiprofissional em Saúde da Universidade Federal do Amazonas (UFAM). Os graduandos do curso de medicina têm a oportunidade de imergir na realidade destas comunidades e, assim, vislumbrar o contexto social, as peculiaridades territoriais e os Determinantes Sociais em Saúde que influenciam no processo saúde-doença. As vivências neste programa de extensão colaboraram para integrar criticidade, humanização e trabalho em equipe à formação técnica da grade, possibilitando que se formem médicos mais sensíveis às propostas do Sistema Único de Saúde