Prognostic Factors and Scoring System for Death from Visceral Leishmaniasis: An Historical Cohort Study in Brazil

<div><p>Background</p><p>In Brazil, case-fatality rates attributable to visceral leishmaniasis (VL) are high and knowledge of the risk factors associated with death may help reduce mortality. The aim of this study was to construct and validate a scoring system for prognosis of death from VL by using all cases reported in Brazil from 2007 to 2011.</p><p>Methodology</p><p>In this historical cohort study, 18,501 VL cases were analyzed; of these, 17,345 cases were cured and 1,156 cases caused death. The database was divided into two series: primary (two-thirds of cases), to develop the model score, and secondary (one-third of cases), to validate the scoring system. Multivariate logistic regression models were performed to identify factors associated with death from VL, and these were included in the scoring system.</p><p>Principal Findings</p><p>The factors associated with death from VL were: bleeding (score 3); splenomegaly (score 1); edema (score 1); weakness (score 1); jaundice (score 1); <i>Leishmania</i>–HIV co-infection (score 1); bacterial infection (score 1); and age (≤0.5 years [score 5]; >0.5 and ≤1 [score 2]; >19 and ≤50 [score 2]; >50 and <65 [score 3]; ≥65 [score 5]). It was observed that patients with a score of 4 had a probability of death of approximately 4.5% and had a worse prognosis. The sensitivity, specificity, and accuracy of this score were 89.4, 51.2, and 53.5, respectively.</p><p>Conclusions/Significance</p><p>The scoring system based on risk factors for death showed good performance in identifying patients with signs of severity at the time of clinical suspicion of VL and can contribute to improving the surveillance system for reducing case fatalities. The classification of patients according to their prognosis for death may assist decision-making regarding the transfer of the patients to hospitals more capable of handling their condition, admission to the intensive care unit, and adequate support and specific treatment.</p></div

Factors associated with death from visceral leishmaniasis, Belo Horizonte, Brazil, 2002–2009.

a<p>Covering the period 2002–2009 and including the variables present in both versions of SINAN (111 death from VL and 777 cures).</p>b<p>Covering the period 2007–2009 and including the variables common to both versions of SINAN together with the new variables included in the Net version (49 death from VL and 327 cures).</p

Predictive scoring system for death from visceral leishmaniasis, Belo Horizonte, Brazil, 2007–2009.

<p>Scoring system based on the variables listed in the SINAN Net version.</p

Clinical variables according to death from visceral leishmaniasis, Belo Horizonte, Brazil, 2002–2009.

a<p>The total number of individuals listed in SINAN and included in the study were 888, of which 512 were registered in the Windows version and 376 in the Net version of the database.</p>b<p>Numerical information not applicable.</p>c<p>symbol equal to zero.</p

Flow diagram of the population evaluated.

<p>*Cases reported in Brazilian Reportable Disease Information System.</p

Comparison between the variables of Windows and Net versions of the SINAN database.

<p>Comparison between the variables of Windows and Net versions of the SINAN database.</p

Demographics and clinical characteristics of patients with visceral leishmaniasis according to primary and secondary series, Brazil 2007–2011.

<p>*Group used to develop the scoring system.</p>#<p>Group used to validate the scoring system.</p><p>**Time between the dates of onset of symptoms and notification (days). HIV, human immunodeficiency virus.</p><p>Demographics and clinical characteristics of patients with visceral leishmaniasis according to primary and secondary series, Brazil 2007–2011.</p

Prognostic scoring system and range of probability of death from visceral leishmaniasis.

<p>Prognostic scoring system and range of probability of death from visceral leishmaniasis.</p

Demographic and clinical variables according to death from visceral leishmaniasis, Belo Horizonte, Brazil, 2002–2009.

a<p>The total number of individuals listed in SINAN and included in the study (Belo Horizonte, Brazil) were 888, of which 512 were registered in the Windows version and 376 in the Net version of the database.</p>b<p>Numerical information not applicable.</p>c<p>Variable registered for VL cases occurring in the period 2007–2009 (Net version of SINAN).</p>d<p>Variable registered for VL cases occurring in the period 2002–2006 (Windows version of SINAN).</p

Univariate analysis of the prognostic factors for death in visceral leishmaniasis, Brazil 2007–2011.

<p>*Time between the dates of onset of symptoms and notification (days); CI, confidence interval; HIV, human immunodeficiency virus; OR, odds ratio.</p><p>Univariate analysis of the prognostic factors for death in visceral leishmaniasis, Brazil 2007–2011.</p