Takayasu arteritis in Mexico: a 38-year clinical perspective through literature review

A literature search covering national reports since the first published in Mexico (1957), discloses 237 adults and 55 children with a definitive diagnosis of Takayasu's arteritis. This condition was first recognized by an ophtalmologist in 1946, and it was communicated 10 years after his observation. Since 1957, 11 clinical papers on Takayasu's arteritis had been published in Mexico and abroad; in contrast few papers were published in other Latinamerican countries and even in North America. Takayasu's arteritis in Mexico follows the clinical pattern described in Asian reports, it affects mainly non-caucasic young women, is a chronic disease which causes prominent cardiovascular complaints. Children developed a systemic disease with higher morbility and mortality. Uncommon diseases, such as Takayasu's arteritis represent an unique opportunity to compare clinical and biological profile among different populations to gain valuable knowledge and understanding of ethiopathogenesis.

American trypanosomosis: in situ and generalized features of parasitism and inflammation kinetics in a murine model

American trypanosomiasis: In situ and generalized features of parasitism and inflammation kinetics in a murine model. Experimental Parasitology 83, 267-274. Mimicking the natural conditions of mammalian infection, metacyclic trypomastigote forms of a Mexican isolate (Ninoa) of Trypanosoma cruzi were inoculated into mice in order to study inflammation kinetics and parasite clearance at the inoculation site, parasite tropism to different organs, and local inflammatory cell infiltrates. Polymorphonuclear cells were detected at the inoculation site as early as 1 hr after inoculation. Peak cell infiltrate was observed at 24 hr; at 96 hr polymorphonuclear cells had disappeared. Mononuclear cell infiltrates began at 24 hr, peaking at Day 15, and then stared disappearing by Day 30. Antigens and parasites were detected by conventional techniques up to 15 min and thereafter became undetectable. Amplification of the hypervariable region of kinetoplast minicircle DNA by polymerase chain reaction was positive from 24 hr to Day 15, and the reaction became negative on Day 30. Myositis was observed in skeletal muscle from Days 7 to 180, it progressed from slight to severe, with an inflammation process which included macrophages, plasmatic cells, and a few eosinophils, the phenotype of the infiltrating cells included LyT2+ and LyT1+ on Day 30, and both cell populations decreased in parallel on Day 180. Antigen and parasite nests were present from Day 15 to 180; in muscle the earliest time at which minicircle DNA was detected was Day 7 and it was present until Day 180. Myocarditis was also observed; it developed from slight to severe in between Days 7 and 30, then gradually decreased, and cleared up. Mononuclear cell infiltrates in the myocardium were present from Days 7 to 180. Antigen and parasite nests were detected at Days 15 and 30 and disappeared at Day 180, although minicircle DNA was detected until the last day of observation. Both skeletal and heart muscles showed inflammatory reaction foci containing T. cruzi antigen. There was twice the number of foci in heart as in skeletal muscle. This ratio was maintained by Day 30; later skeletal muscle showed persistent inflammation which was practically cleared up in the heart. Parasites or antigen were not detected by Day 180 in both skeletal and cardiac muscle; however, minicircle DNA was amplified, indicating that an small proportion of parasites evaded immune response. According to these data, Mexican Ninoa Strain has a classification as biodeme 3.

Primary antiphospholipid syndrome presenting as chronic thromboembolic pulmonary hypertension. Treatment with thromboendarterectomy

Pulmonary hypertension may occur in the antiphospholipid syndrome as a result of recurrent pulmonary embolism or microthrombosis of pulmonary vessels. We describe 3 cases of primary antiphospholipid syndrome (APS) and cor pulmonale that fulfilled the criteria for chronic major vessel thromboembolic pulmonary hypertension. Pulmonary thromboendarterectomy was performed in all 3 patients and it was successful in 2. One patient died in the immediate postoperative period from hemorrhagic pulmonary edema. Chronic thromboembolic pulmonary hypertension should be added to the list of pulmonary vascular complications of primary APS. Despite its risk, pulmonary thromboendarterectomy represents a treatment option for this otherwise lethal condition.

Valvular heart disease in primary antiphospholipid syndrome (PAPS): clinical and morphological findings

PURPOSE

To describe clinically and pathologically the valvular lesion of the primary antiphospholipid syndrome (PAPS).

PATIENTS AND METHODS

We studied six patients with PAPS and valvulopathy. Four of them died and had autopsy and two had valvular replacement. The study comprised 18 heart valves, 16 from autopsy and two, one mitral and one aortic, resected at surgery.

RESULTS

Murmurs and echocardiographic findings kept correlation with gross pathology. Abnormalities were found in one or more valves in all patients including two of five aortic, two of five mitral, one of four pulmonary and two of four tricuspid. Co-existence of new and old lesions was observed. Pathologic findings included intravalvular thrombosis with focal necrosis, and hemorrhage, vascular proliferation, mild histiocytic/fibroblastic infiltration, laminated and verrucous fibrin deposits, laminated and/or nodular fibrosis, and focal calcification.

CONCLUSION

The PAPS valvular lesion consists mainly of superficial or intravalvular fibrin deposits and its subsequent organization: vascular proliferation, fibroblast influx, fibrosis and calcification. This results in valve thickening, fusion and rigidity leading to functional abnormalities. Inflammation is not a prominent feature of this lesion.

Organ-specific circulating heart autoantibodies in Chagas' cardiomyopathy: exploratory study

Chagas' disease can evolve to a chronic phase with cardiomyopathy that may include autoimmune mechanisms, among others. Recently an organ-specific anti-heart muscle antibody was detected in idiopathic cardiomyopathy, using human heart muscle as antigen. We decide to standardize an indirect immunofluorescence assay using rat organs in order to evaluate frequency of organ-specific anti-heart antibodies in chagasic cardiomyopathy. We tested 18 patients with chagasic cardiomyopathy for serum organ-specific anti-heart muscle antibodies. Nine patients were positive for organ-specific anti-heart antibodies (positive in heart muscle but negative in tongue muscle) and one was positive for non-organ-specific anti-heart muscle antibodies (positive in both heart and tongue muscle). We conclude that organ-specific anti-heart muscle antibodies can be detected using rat organs as antigens. Organ-specific anti-heart muscle antibodies are present in patients with chagasic cardiomyopathy.

Antiphospholipid syndrome in patients with cyanotic congenital heart disease

Patients with cyanotic congenital heart disease exhibit an increased incidence of thrombotic episodes and are frequently thrombocytopenic. We studied the sera of 15 patients with this type of heart malformation, searching for anticardiolipin antibodies. 3/15 had positive results. The three of them were adult females; two had thrombotic episodes and a false positive VDRL. Thus, cyanotic congenital heart disease may be another disease entity associated with the antiphospholipid syndrome.

[Serological diagnosis of Chagas disease: self-sufficiency and interlaboratory concordance]

American trypanosomiasis (Chagas' disease) is becoming a relatively common condition in North America. Diagnosis at the chronic stage depends on demonstration of specific antibodies in body fluids, since parasitologic or pathologic diagnosis is uncertain at this stage. Therefore, standardization of immunodiagnostic techniques is mandatory, and it depends on antigen quality. Locally prepared antigens and crude extracts obtained from Mexican isolates, -both from infected vector and human cases-were compared using three different immunodiagnostic assays-indirect immunofluorescence, hemagglutination and enzyme linked immunosorbent assay (ELISA)-at two different laboratories from the Instituto Nacional de Cardiología and the Instituto Nacional de Diagnóstico y Referencia Epidemiológicos. Concordance between laboratories reached a significant Kappa value (0.8) and sensitivity, specificity and predictive values of individual diagnostic assays were adequate to use these tests in clinical diagnoses. This is the first attempt to standardize immunodiagnostic techniques in Mexico.

[Antibodies against extracellular products of group A Streptococcus. Diagnostic importance in acute rheumatic fever]

Streptococcal throat infection is a sine qua non for the development of rheumatic fever (RF) in genetically susceptible people. Demonstration of such infection is not easy. In overt RF less than 10% of patients still carry streptococci in their throat and immunologic methods are required to identify antibodies against streptococcal products (SP). Humoral response against SP was studied in children and adults with and without RF. Antistreptolysin O (ASO) showed a non-gaussian distribution, and reference value was established as percentile. Adults have a 97 percentile of 227, in children 90 percentile was 451. When RF was present all cases, except one, showed higher values. When antibodies against SP besides ASO were sought by an agglutination test (Streptozyme tm), people below 15 years of age showed low titers in 15 out of 28 cases. In contrast, high titers were the rule in children suffering RF. High ASO titer correlated with high Streptozyme value. These methods are capable to recognize an specific immune response against Group A Beta hemolytic streptococci, and are valuable tools in the diagnosis of RF.

Ocular vaso-occlusive disease in primary antiphospholipid syndrome

PURPOSE

To evaluate the ocular involvement in patients with the primary antiphospholipid syndrome.

METHODS

The authors performed a cross-sectional ophthalmologic study of 17 patients with the primary antiphospholipid syndrome. Retinal fluorangiography was performed in 13 patients.

RESULTS

Visual symptoms were described by ten patients. Visual acuity was markedly decreased in five eyes. Conjunctival telangiectases and microaneurysms, in addition to single instances of bilateral episcleritis and limbal keratitis, were the anterior segment findings. Fundus abnormalities were present in 15 patients. Venous tortuosity was the most common finding but there were instances of optic disc edema, vitreous hemorrhages, cotton-wool spots, vitreous bands, serous detachment of the macula, and retinal capillary abnormalities. Fluorangiography showed vaso-occlusive retinopathy in six eyes (5 patients, 29%). Choriocapillary vessel occlusion was observed in two eyes (1 patient) and binocular reticular degeneration of pigmentary epithelium was present in another case.

CONCLUSION

The eye is frequently involved in the primary antiphospholipid syndrome, and serious ocular damage may occur. Detailed ophthalmologic evaluation is warranted in these patients.

[Ventricular aneurysm in chronic Chagas' disease. The experience of the Instituto Nacional de Cardiología Ignacio Chávez]

This work describes the incidence of ventricular aneurysms in patients with angiographically normal epicardial coronary arteries, who have epidemiological, clinical and serologic features suggesting chronic Chagasic cardiomyopathy (C.C.C). Eight out of 22 patients (36%) with such features had ventricular aneurysm. Three were located on the apex, 3 anteroapical and 2 basal. All patients had arrhythmia. In a case it was necessary a surgical approach to control a medically intractable life threatening ventricular tachyarrhythmia. In regard of the incidence of ventricular aneurysms in C.C.C., our results are in agreement with published experiences in South America. Surgical treatment of chagasic aneurysm should be considered when medical treatment is unable to control dangerous arrhythmia and an electrophysiological study supports this approach.

Takayasu's arteritis in Mexico: a clinical review of 44 consecutive cases

OBJECTIVES

To review our experience in clinical diagnosis of the non-specific arteritis called Takayasu's arteritis (TA), and to assess its possible relationship with previous mycobacterial infections as judged by delayed hypersensitivity skin test.

METHODS

We examined 44 consecutive patients in Mexico City. All of them fulfilled the ACR criteria for the classification of TA and had a characteristic panaortogram in the absence of any other arterial or systemic disease.

RESULTS

Forty-three of our patients were Mexican mestizos; only one had a Caucasian appearance. 38 were women, and the age at diagnosis ranged from 15 to 64 years with a mean of 32 and a median of 35. Age at onset of the symptoms was under 30 years in most cases. Five patients had type I disease, and 4 had type II. Most had a diffuse arteritis (type III), and in seven cases involvement of the pulmonary artery (type IV) was recognized. All patients showed abnormal peripheral pulses and blood pressure differences, 35 had systemic arterial hypertension and 7 pulmonary hypertension. A noisy vascular auscultation was very common and cardiac ailments were also found in many cases. Systemic complaints such as fever, weight loss and malaise were present in the active stages of the disease. Arthritis did occur in a single case, arthralgia was frequent and inflammatory nodules involving the shin, perimalleolar area, and the antero-external surface of the distal leg were also common. Polyclonal hypergammaglobulinemia was a frequent finding in active and inactive cases; leukocytosis with neutrophilia, accelerated ESR and high fibrinogen, however, did occur when the disease was active. Eight of our patients had a previous diagnosis of tuberculosis, and 81% developed a delayed skin reactivity to PPD (2U old tuberculin). None had a bacteriologic diagnosis of tuberculosis or mycobacterial disease.

CONCLUSION

Non-specific arteritis, or Takayasu's disease, frequently affects young women of colored race in Mexico. Late diagnosis is common and cardiovascular features dominate the clinical picture. Arterial compromise is widespread and may involve the pulmonary artery and its branches. Most cases are inactive and morbidity results from systemic arterial hypertension and heart disease; active cases have systemic complaints and laboratory abnormalities suggestive of ongoing inflammation. The close relationship between Takayasu's arteritis and previous contact with Mycobacterium tuberculosis was again confirmed in our series, although further studies are necessary to clarify this probable relationship.

[Takayasu's arteritis. A seroimmunological test of its relationship to mycobacterial infection]

Takayasu's arteritis is an inflammatory arteritis of unknown origin. It affects the aorta, its main branches and at times the pulmonary artery. Takayasu's arteritis is a worldwide disease, however, there is predilection to affect young women of mongoloid ancestry, therefore most cases do occur in the Far East and Latin America. For more than 50 years a relationship with mycobacterial infection has been sought without definite proof. In this investigation we found a circulating IgG antibody in the sera of Takayasu's arteritis patients, which recognizes a 38 kD glycoprotein of M. tuberculosis. This glycoprotein is an specific antigen in the human immune response against mycobacterial infection.

[Reactivity of sera from Chagas patients to extracts of mexican Trypanosoma cruzi isolates]

An antigenic extract prepared from four different Mexican isolates of Trypanosoma cruzi cultured on BHI (three came from human cases-Agripina, Fidelfa and Ninoa, and other from triatoma-Cocula) were assayed with human sera. ELISA results always were consistent with clinical diagnosis. Sera from patients with a diagnosis of Chagas disease were reactive and non-chagasic sera were negative. Western blot of chagasic sera recognized antigens of molecular weight > 81 kd, 81 kd, 54 kd, 42 kd, and 26 kd. Sera with high OD in ELISA reacted with more peptide bands. The soluble extract antigens prepared from Mexican isolates of T. cruzi and from the Brazilian Y strain have an homogenous and similar reactivity.

Acute rheumatic fever

The diagnosis of acute rheumatic fever has become difficult. A growing number of diseases that were not recognized in the past could fulfill its diagnostic criteria. We emphasize its changing incidence, current knowledge of its pathogenesis, and lesser known clinical features such as pneumonitis, encephalitis and glomerulonephritis.

[Takayasu arteritis; IV. Absence of autoantibodies and coagulation/fibrinolysis abnormalities]

The etiopathogenesis of the non-specific arteritis known as Takayasu's arteritis, an inflammatory occlusive disease of the aorta and its main branches, is unknown. We searched for abnormalities in clotting and fibrinolytic systems, as well as the presence of non-organ specific autoantibodies, including those potentially reactive with vascular endothelium, in 21 untreated patients. There were only minor abnormalities in coagulation and fibrinolysis in a few patients, and the occasional presence of non-organ specific antibodies, including antiphospholipid antibodies. The findings had no clinical relevance. This study suggests that there is no support for a significative role of humoral immunity, coagulation and fibrinolysis in the pathogenesis of Takayasu's arteritis.

[American trypanosomiasis (Chagas' disease). A clinico-serological survey in a rural community of Oaxaca]

A survey at a rural community in Oaxaca, Mexico revealed 30 (29%) out of 104 people tested are carriers of anti-Trypanosoma cruzi antibodies. This high prevalence of seropositivity signals an important parasite circulation. We did not studied people under 15 years of age, therefore we can not identify transmission in this area. A concomitant study of 12 lead showed that those who are seropositive had more EKG abnormalities as a group. Such findings could indicate the parasitic disease impact on community health.

[The treatment of infectious endocarditis. Cefotaxime versus "traditional" medical management]

We performed an open study to compare efficacy and renal toxicity of cephotaxime versus the usual beta lactam plus aminoglucoside treatment of infectious endocarditis. Twenty cases were studied, 10 treated with cephotaxime 4 g/day per 21 days and aminoglucoside for only 10 days. Comparison group received a combination of different beta lactam antibiotic plus aminoglucoside for 21 to 50 days, these patients were under care of nonparticipant physicians. Although cephotaxime treatment was as good as conventional antimicrobial scheme for control of infectious endocarditis, the treatment cost increases, and there is only marginal benefit in regard renal toxicity.

Heat inactivation of bovine serum used for blockade in immunoenzymatic assay is associated with spurious fall on the titers of anticardiolipin antibodies in primary antiphospholipid syndrome sera

Anticardiolipin antibodies (ACA) were evaluated using enzyme-linked immunosorbent assay (ELISA) with and without heat inactivation of bovine serum used for plastic surface blockade. Untreated sera samples from primary antiphospholipid syndrome patients (PAS) and healthy blood donors (HBD) were tested. A significant decrease of ACA titers of PAS sera occurred with inactivated bovine serum blockade ELISA when compared with basal ELISA. In HBD sera there was no significant change. Probably, as happens with normal human serum, heating for normal bovine serum produces an increase in ACA titers. This bovine ACA may react with cardiolipin, and when human samples are added, they find antigen sites occupied, resulting in a spurious decrease of ACA titers.