Tegumentary leishmaniasis in childhood

Very little has been published about tegumentary leishmaniasis in children and there are many controversies about this disorder in the literature. Therefore, we discuss the pathogenesis, clinical aspects, means to diagnosis, and treatment of this endemic disease.

PCR enzyme-linked immunosorbent assay for diagnosis of leishmaniasis in human immunodeficiency virus-infected patients

A PCR enzyme-linked immunosorbent assay (ELISA) involving the use of bone marrow aspirates (BMA) and blood samples (BS) for the diagnosis of visceral leishmaniasis (VL) in human immunodeficiency virus-infected patients was developed with primers selected from the sequence of the small-subunit rRNA gene and compared with direct examination and in vitro cultivation. The PCR was optimized for routine diagnosis: processing of samples with lysis of erythrocytes without isolation of leukocytes, enzymatic prevention of contamination, internal control of the reaction, and ELISA testing in a microtitration plate hybridization. Of 79 samples (33 BMA and 46 BS) from 77 patients without VL, all the results were negative. Fifty-three samples (9 BMA and 44 BS) were obtained from 13 patients with VL: 6 samples drawn during anti-Leishmania treatment were negative whatever the technique used, and 47 samples (9 BMA and 38 BS) were positive with at least one technique. The sensitivities were 51% (24 of 47), 81% (38 of 47), and 98% (46 of 47) for direct examination, culture, and PCR, respectively. Thus, PCR ELISA is reliable for diagnosing VL in human immunodeficiency virus-infected patients, and blood sampling should be sufficient for the follow-up.

[The epidemiological determinant aspects in the maintenance of visceral leishmaniasis in the state of Maranhão, Brazil]

The authors analysed the visceral leishmaniasis (VL) aspects in the state of Maranhão, Brazil, from 1982 to 1993. The disease happens to occur predominantly in São Luís Island (MA) and during the epidemic period, town of São Luís was pointed out as the main endemic area. The greatest frequency of cases occurred in 1993, despite the use of insecticide and dogs control. There was predominance of age between 0- to 4-year-old population with 58.04% of cases. Neither the human disease nor the rainfall index had significant seasonal variation. However they were correlated moderately, with high number of cases after the period of great precipitation of rain. After this study, the data obtained will allow a better control of the disease, despite some factors such as: the urbanization, localization and dynamic of transmission in endemic areas in the Maranhão state.

Diabetes mellitus associated with pentamidine isethionate in diffuse cutaneous leishmaniasis

The authors report a case of a male patient from Bacabal, MA with diffuse cutaneous leishmaniasis (DCL), for at least nine years, with 168 lesions on his body. These were tumour-like nodules with some ulceration. He used pentavalent antimonial (glucantime) and an association of gamma interferon plus glucantime with improvement of the lesions but relapsed later. Recently, pentamidine isethionate (pentacarinat) was given a dosage of 4mg/kg/weight/day on alternate days for 20 applications. After 3 months a similar course of 10 application was given 2 times. Later he developed diabetic signs with weight loss of 10kg, polydypsia, polyuria and xerostomia. The lower limbs lesions showed signs of activity. Blood glucose levels normalised and remain like this at moment. Attention is drawn to the fact that pentamidine isethionate should be used as a therapy option with care, obeying rigorous laboratory controls including a glucose tolerance test.

Factor VIII gene inversions in severe hemophilia A: results of an international consortium study

Twenty-two molecular diagnostic laboratories from 14 countries participated in a consortium study to estimate the impact of Factor VIII gene inversions in severe hemophilia A. A total of 2,093 patients with severe hemophilia A were studied; of those, 740 (35%) had a type 1 (distal) factor VIII inversion, and 140 (7%) showed a type 2 (proximal) inversion. In 25 cases, the molecular analysis showed additional abnormal or polymorphic patterns. Ninety-eight percent of 532 mothers of patients with inversions were carriers of the abnormal factor VIII gene; when only mothers of nonfamilial cases were studied, 9 de novo inversions in maternal germ cells were observed among 225 cases (approximately 1 de novo maternal origin of the inversion in 25 mothers of sporadic cases). When the maternal grandparental origin was examined, the inversions occurred de novo in male germ cells in 69 cases and female germ cells in 1 case. The presence of factor VIII inversions is not a major predisposing factor for the development of factor VIII inhibitors; however, slightly more patients with severe hemophilia A and factor VIII inversions develop inhibitors (130 of 642 [20%]) than patients with severe hemophilia A without inversions (131 of 821 [16%]).

Polar and subpolar diffuse cutaneous leishmaniasis in Brazil: clinical and immunopathologic aspects

BACKGROUND

Diffuse cutaneous leishmaniasis (DCL) is a rare manifestation of human leishmaniasis, characterized by multiple, slowly progressive nodules or plaques without ulceration, involving almost the entire body. It has been suggested, that DCL results from a lack of cell-mediated immunity to leishmanial antigen, leading to uncontrolled parasite growth.

METHODS

We have performed detailed clinical, histopathologic, and immunologic investigations in six patients with DCL. Biopsies were taken from the nodules, processed, and examined for determination of the macrophagic pattern present, based on the intensity of vacuolation and the frequency of vacuolated cells, the parasite index, and the presence of eosinophils. Immunologically, patients were evaluated by their response to intradermal skin test to PPD or leishmania antigen, determination of antileishmania antibodies by immunofluorescent assay, and lymphocyte proliferation assay.

RESULTS

There seemed to be a negative relation between nodules and skin ulcerations, whereas the highest number of parasites were observed in patients with the greatest number of vacuolated macrophages. The delayed hypersensitivity skin test to leishmanial antigen was negative, and antileishmania IgG antibodies were positive in all patients.

CONCLUSIONS

Although all cases fulfill the criteria for being classified as DCL, they present a wide spectrum. Three cases were clearly at the unresponsive pole, and three other cases belonged to the subpolar form of DCL, exhibiting varying weak signs of antiparasite responsiveness.

Leishmaniose visceral no estado do Maranhão, Brasil: a evolução de uma epidemia

Os autores fazem um breve relato da evolução histórica da leishmaniose visceral no Estado do Maranhão, Brasil, avaliando as possíveis causas da expansão da referida doença no Estado, assim como as medidas de controle adotadas pelo Ministério da Saúde objetivando a diminuição da incidência da mesma.

Quantitative competitive PCR with bronchoalveolar lavage fluid for diagnosis of toxoplasmosis in AIDS patients

Of 121 AIDS patients, 12 (10%) had Toxoplasma gondii DNA detected by competitive PCR in their bronchoalveolar lavage samples. Quantitation of the PCR results showed a correlation between the parasite burden and the serum lactic dehydrogenase titer. Quantitative competitive PCR could be useful to assess the diagnosis and the severity of pulmonary toxoplasmosis.

A comparison of three interferon alfa-2b regimens for the long-term treatment of chronic non-A, non-B hepatitis. Multicenter Study Group

BACKGROUND

We studied the effects of long-term treatment with interferon on histologic features of the liver and serum alanine aminotransferase concentrations in patients with chronic non-A, non-B hepatitis.

METHODS

Consecutive patients who met the inclusion criteria were enrolled in the study. The diagnosis of chronic non-A, non-B hepatitis was established on the basis of the liver-biopsy findings and an abnormal serum alanine aminotransferase value (greater than 1.5 times the normal value) for at least one year. All patients were treated for six months with 3 million units of interferon alfa-2b given subcutaneously three times a week and were then randomly assigned to the same treatment for an additional 12 months (group 1), a regimen of 1 million units three times a week for 12 months (group 2), or no further treatment (group 3). Patients in group 3 who had elevated serum alanine aminotransferase concentrations for three consecutive months underwent the initial regimen once again. Follow-up continued for two years after the discontinuation of treatment. Histologic improvement was defined as a decrease of at least one grade in the score for necroinflammatory activity (0, no activity; 1, mild; 2, moderate; or 3, severe) between the first liver biopsy and a biopsy performed at 18 months.

RESULTS

Of the 329 patients initially treated, 303 were randomized: 103 to group 1, 101 to group 2, and 99 to group 3. Of the 286 patients tested, 252 (88.1 percent) had antibodies to hepatitis C virus. In an intention-to-treat analysis, 46 of the patients in group 1 (44.7 percent) had normal serum alanine aminotransferase values at 18 months, as compared with 27 of the patients in group 2 (26.7 percent, P = 0.008) and 30 of those in group 3 (30.3 percent, P = 0.04). Between 19 and 42 months, 23 of the patients in group 1 (22.3 percent) continued to have normal serum alanine aminotransferase values (measured every six months), as compared with 10 of the patients in group 2 (9.9 percent, P = 0.02) and 8 of those in group 3 (8.1 percent, P = 0.005). Among the 176 patients with repeated liver biopsies at 18 months, more patients in group 1 had improved histologic-activity scores (69.6 percent) than in group 2 (47.6 percent, P = 0.02) or group 3 (38.6 percent, P < 0.001).

CONCLUSIONS

Among patients with chronic non-A, non-B hepatitis, a regimen of 3 million units of interferon alfa-2b given three times a week for 18 months produced better histologic findings and serum alanine aminotransferase values than regimens involving a lower dose or a shorter duration of treatment.

Detection of Aspergillus species DNA in bronchoalveolar lavage samples by competitive PCR

A competitive PCR assay involving the use of bronchoalveolar lavage (BAL) samples for the diagnosis of invasive pulmonary aspergillosis (IPA) was developed. For this purpose, a 1-kb mitochondrial DNA fragment of Aspergillus fumigatus was sequenced. The primers used allowed amplification of A. fumigatus, A. flavus, A. terreus, and A. niger DNAs but not DNAs of other fungi and yeasts. BAL samples from 55 consecutively enrolled patients were tested. Three samples were excluded because of failure of correct amplification of the internal competitive control. Of 28 immunocompromised patients, 6 were PCR positive; 3 died of IPA and their BAL cultures yielded A. fumigatus; and 3 were culture negative and did not develop IPA. Of 15 human immunodeficiency virus-positive patients and 9 immunocompetent patients, 5 and 4, respectively, were both PCR positive and culture negative, and none developed aspergillosis. Thus, PCR confirmed IPA in three patients but gave positive results for 25% (12 of 49) of the patients who did not develop aspergillosis. The predictive value of PCR-positive results seems low for patients at risk for aspergillosis. Moreover, the risk of contamination of reaction buffers or biological samples with Aspergillus conidia seems high and has to be weighed in regard to the potential diagnostic benefit of PCR testing as a routine procedure.

Late toxoplasmosis evidenced by PCR in a marrow transplant recipient

We report a case of disseminated toxoplasmosis occurring 12 months after allogeneic BMT. The patient was seropositive for Toxoplasma gondii, and the donor was seronegative, so the patient was given anti-Toxoplasma prophylaxis. One year after BMT, he developed fever and muscle pain without other clinical symptoms. PCR amplification for T. gondii performed on blood was positive. Toxoplasma were found in bronchoalveolar lavage by PCR and in the marrow by special stains. With treatment, the PCR signal disappeared in 3 days while clinical symptoms resolved over 15 days. This case emphasizes the possibility of late toxoplasmosis after BMT despite prophylatic treatment, and the value of PCR in making the diagnosis.

Spontaneous regional healing of extensive skin lesions in diffuse cutaneous Leishmaniasis (DCL)

The authors report a case of diffuse cutaneous leishmaniasis, with longstanding evolution and presenting with diffuse infiltrated lesions rich in amastigotes in the absence of mucosal involvement. In situ characterization with monoclonal antibodies revealed Leishmania amazonensis. Large regional lesions have presented spontaneous healing without specific therapy. Considering that DCL presents with a defect in the cellular immune response, this fact demonstrate that this patient may develop a regional cellular immune response enough to destroy the parasites and to produce clearing of some lesions.

[The coconut babaçu (Orbignya phalerata martins) as a probable risk of human infection by the agent of chromoblastomycosis in the State of Maranhão, Brazil]

During a survey of 30 patients with chromoblastomycosis followed at the Hospital dos Servidores do Estado do Maranhão, the authors observed in 2 (6.6%) patients with lesions on the buttock. This is an uncommon site for the initial lesions of chromoblastomycosis. There is often a history of microtraumatism during the farming job hence the more frequent development of lesions in the lower limbs. Both patients had 10 years disease, with the presence of nodules and vegetant warty lesions in coalescent plaques on the right buttock. Etiologic diagnosis made through histopatologic and culture exams, with Fonsecaea pedrosoi isolated. The epidemiological exposure of the patients, was suggested by the fact that both worked as babaçu coconut cutters a common activity in Maranhão State. The relation between this kind of professional activity and the development of infection merits for the investigation.

[Chromoblastomycosis associated with leprosy: report of 2 cases]

Thirty cases of chromoblastomycosis were diagnosed at Hospital dos Servidores do Estado do Maranhão, from November, 1988 to March, 1993. The authors report 2 (6.6%) cases, that presented an association with leprosy. The first patient developed both diseases together, showing palpable bilateral cubital nerves, perforanting ulcer of the right foot, infiltration and lesions in verrucoid plaques in left leg, with positive biopsy for dimorphic leprosy. The second case, a patient with history of lepromatous leprosy for 30 years without treatment, with vegetant lesions with a warty aspect in right elbow for 12 months, histopathologic and positive culture for chromoblastomycosis. The possible factors for development of this disease in these patients are discussed.

[Chronic phase of Chagas disease. Clinical aspects and course of the disease]

PURPOSE

To evaluate the clinical and evolutive aspects of chronic chagasic patients.

METHODS

Three hundred chronic chagasic patients, 180 females, with age ranging from 19 to 81 years (55.6 +/- 13.1) were retrospectively studied. Patients were divided according to the following clinical types: indeterminated, cardiac (with the subtypes: arrhythmogenic, dilated and mixed), digestive isolated and digestive plus cardiac involvement. The following variables were analysed: prevalence of each clinical forms, symptoms, electrocardiographic pattern and clinical outcome.

RESULTS

At the start of the study, 73 (24.3%) patients were in indetermined type, 106 (35.3%) in cardiac arrhythmogenic, 95 (31.6%) in mixed, 7 (2.3%) in dilated, 16 (5.3%) in digestive plus cardiac type and 3 (1%) in the pure digestive type. The most prevalent symptoms were dyspnea on efforts (57%), palpitations (41.33%) and chest pain (33%). The most frequent electrocardiographic pattern was right bundle branch block plus antero-superior fascicular block, in 30% of the patients. The average follow-up time was 7.8 +/- 6.1 years and the outcome was considered good in 20 patients (6.6%), stable in 214 (71.3%) and bad in 66 (23%). At the end of the follow-up, 9 patients have evaluated from the indeterminated to the cardiac and digestive types, and 19 (17.92%), from the arrhythmogenic to mixed cardiac subtype. The follow-up was lost in 79 patients (26.3%), most of them, probably dead.

CONCLUSION

With a mean time of 7.8 years, 12.3% of the patients in the indeterminated type evolved to the cardiac and/or digestive type; right brundle branch block with antero-superior fascicular block was the most prevalent electrocardiographic pattern; the outcome was stable or good in the majority of these patients.

Prenatal diagnosis of congenital toxoplasmosis with a polymerase-chain-reaction test on amniotic fluid

BACKGROUND

Congenital infection with Toxoplasma gondii can produce serious sequelae. However, there is little consensus about screening during pregnancy, and the tests used to establish a prenatal diagnosis of toxoplasmosis are complex and slow. We evaluated a simpler approach that is based on a polymerase-chain-reaction (PCR) test.

METHODS

Prenatal diagnostic tests, including ultrasonography, amniocentesis, and fetal-blood sampling, were performed in 2632 women with T. gondii infection acquired during pregnancy. In 339 consecutive women, a competitive PCR test for T. gondii was performed on amniotic fluid, and its results were compared with those of conventional diagnostic tests. The PCR test targets the B1 gene of T. gondii, uses an internal control, and can be completed in a day. Positive tests were confirmed by serologic testing of newborns or by autopsy in terminated pregnancies.

RESULTS

Overall, the risk of fetal infection was 7.4 percent, but it increased sharply with gestational age. Congenital infection was demonstrated in 34 of 339 fetuses by conventional methods, and the PCR test was positive in all 34. In three other fetuses, only the PCR test gave positive results, and follow-up testing confirmed the presence of congenital toxoplasmosis. The PCR test gave one false negative result but no false positive results. The PCR test performed better than conventional parasitologic methods (sensitivity, 97.4 vs. 89.5 percent; negative predictive value, 99.7 vs. 98.7 percent).

CONCLUSIONS

For the prenatal diagnosis of congenital T. gondii infection, an approach based on a PCR test performed on amniotic fluid is rapid, safe, and accurate.

Derivation of Mutants of Erwinia carotovora subsp. betavasculorum Deficient in Export of Pectolytic Enzymes with Potential for Biological Control of Potato Soft Rot

Erwinia carotovora subsp. betavasculorum Ecb168 produces an antibiotic(s) that suppresses growth of the related bacterium Erwinia carotovora subsp. carotovora in culture and in wounds of potato tubers. Strain Ecb168 also produces and secretes pectolytic enzymes and causes a vascular necrosis and root rot of sugar beet. Genes ( out ) involved in secretion of pectolytic enzymes by Ecb168 were localized to two Hin dIII fragments (8.5 and 10.5 kb) of Ecb168 genomic DNA by hybridization to the cloned out region of E. carotovora subsp. carotovora and by complementation of Out - mutants of E. carotovora subsp. carotovora. Out - mutants of Ecb168, which did not secrete pectate lyase into the culture medium, were obtained when deletions internal to either Hin dIII fragment were introduced into the genome of Ecb168 through marker exchange mutagenesis. Out - mutants of Ecb168 were complemented to the Out + phenotype by introduction of the corresponding cloned Hin dIII fragment. Out - mutants of Ecb168 were less virulent than the Out + parental strain on potato tubers. Strain Ecb168 and Out - derivatives inhibited the growth of E. carotovora subsp. carotovora in culture, indicating that the uncharacterized antibiotic(s) responsible for antagonism was exported through an out -independent mechanism. Strain Ecb168 and Out - derivatives reduced the establishment of large populations of E. carotovora subsp. carotovora in wounds of potato tubers and suppressed tuber soft rot caused by E. carotovora subsp. carotovora.

Clinical and immunopathological aspects of disseminated cutaneous leishmaniasis

The clinico-pathological and immunological findings in eight patients from Bahia, Brazil with disseminated cutaneous leishmaniasis are described. This condition differs from anergic diffuse cutaneous leishmaniasis (DCL) and from classical American cutaneous leishmaniasis (ACL). The number of lesions in these patients ranged from 75 to 800 and were characterized by papules and an acneiform type of lesion with a few ulcers rather than nodules that are the main characteristic of DCL. On the other hand the high incidence of mucosal disease (38%) in patients with disseminated cutaneous leishmaniasis make the prevalence of mucosal involvement in this condition higher than that observed in ACL. L. amazonensis (five cases) and L. braziliensis (two cases) were the causal agents in the patients where the infecting agent was characterized. Antibody titers in disseminated cutaneous leishmaniasis were higher than those observed in ACL and patients with the highest antibody titers had mucosal involvement. Abnormalities in cellular immunity that are not observed in ACL such as decrease in CD4+ cells and absence of T cell response to leishmania antigen were observed in several patients with disseminated cutaneous leishmaniasis but restoration of these abnormalities occurred after treatment. In spite of the great number of lesions, the therapeutic response was good in six patients with disappearance of the lesions in a period shorter than that observed in ACL. In the two patients that presented therapeutic failure the causal agent was L. amazonensis. In such patients there was a predominance of ulcerated lesions, and a high titer of antibody was detected.

Detection of Toxoplasma gondii by competitive DNA amplification of bronchoalveolar lavage samples

The prevalence of pulmonary toxoplasmosis was assessed by a prospective analysis of 144 bronchoalveolar lavage (BAL) samples using competitive polymerase chain reaction (PCR) to avoid false-negative results due to PCR techniques. Six samples were excluded because they contained amplification reaction inhibitors. None of the samples from the 37 immunocompetent patients and only 1 sample (1.7%) from the 59 immunocompromised patients without human immunodeficiency virus infection were PCR-positive. In contrast, Toxoplasma gondii DNA was found in 6 (14%) of 42 samples from patients with AIDS. All 6 patients had < or = 40 CD4 cells/microL and anti-Toxoplasma antibodies, and 5 had other sites of Toxoplasma infection. Six other AIDS patients who had received treatment for cerebral toxoplasmosis were PCR-negative. Thus, pulmonary toxoplasmosis is frequent in AIDS patients who have other sites of Toxoplasma infection and low CD4 lymphocyte counts and who are not receiving prophylaxis.