Zika Virus Seroprevalence in Two Districts of Chincha, Ica, Peru: A Cross-Sectional Study

In 2017, a major outbreak of Zika virus (ZIKV) infection took place in Chincha Province, Peru, where arboviral circulation had never been reported before. We conducted a cross-sectional survey (March-May 2019) in two districts of Chincha Province: Pueblo Nuevo and Chincha Baja. We included residents who were 20 to 40 years old and who had lived in these districts for at least 1 year. Serological testing combined screening with a commercial NS1 protein-based Zika IgG ELISA, and confirmation by a cytopathic effect-based virus neutralization test (VNT). Prevalence ratios (PRs) were calculated using Poisson regression with robust error variance. Four hundred participants, divided equally among districts, were enrolled. Anti-ZIKV IgG ELISA was positive for 42 participants (10.5%) and borderline for 12 (3%). Fifty-two of these 54 samples were confirmed positive by ZIKV VNT (13% of the total population). The Pueblo Nuevo district exhibited a greater ZIKV seroprevalence based on VNT results than the Chincha Baja district (23.5% versus 2.5%), with participants from the Pueblo Nuevo district being 9.4 times more likely to have a positive ZIKV VNT result. Average monthly income greater than the minimum wage and adequate water storage were found to be protective factors (PR, 0.29 and 0.24, respectively). In multivariate analysis, living in the Pueblo Nuevo district and a personal history of fever and rash were strong predictors of ZIKV positivity by VNT. The low ZIKV seroprevalence should prompt health authorities to stimulate interventions to prevent potential future outbreaks. In the Pueblo Nuevo district, the seroprevalence was greater but presumably not sufficient to ensure protective herd immunity.

Carrion's disease: more than a neglected disease

Infections with Bartonella bacilliformis result in Carrion's disease in humans. In the first phase of infection, the pathogen causes a hemolytic fever ("Oroya fever") with case-fatality rates as high as ~90% in untreated patients, followed by a chronical phase resulting in angiogenic skin lesions ("verruga peruana"). Bartonella bacilliformis is endemic to South American Andean valleys and is transmitted via sand flies (Lutzomyia spp.). Humans are the only known reservoir for this old disease and therefore no animal infection model is available. In the present review, we provide the current knowledge on B. bacilliformis and its pathogenicity factors, vectors, possible unknown reservoirs, established and potential infection models and immunological aspects of the disease.

Rapid detection of salmonellosis due to Salmonella enterica serovar Typhimurium in Peruvian commercially bred cavies, using indigenous wild bacteriophages

Introduction

The salmonelloses are among the commonest, most widespread human zoonotic infections. They have generated international networks to attempt their control, since they cause a spectrum of ailments, ranging from inapparent carrier states to full-blown, severe, sometimes deadly diarrheal and systemic disease. Rapid diagnosis is needed for a number of reasons. The aim of this study was to standardize and validate a phage amplification test for the identification of salmonellosis to be applied to infections of Cavia porcellus.

Methods

Native bacteriophages were isolated from infected cavies and environmental residues from commercial cavy-breeding facilities. Salmonella enterica serovar Typhimurium ATCC 14028 was used to detect, isolate and propagate the bacteriophages, and to standardize a phage amplification assay to detect S. Typhimurium from rectal swabs of cavies. The phage amplification assay was tested using 2 antiviral agents, MgSO₄·7H₂O (MAS) and pomegranate rind extract (PRE) plus ferrous sulfate (PRE-FeSO₄).

Results

The final assay format chosen used PRE-FeSO₄ and allowed detection of S. Typhimurium in 90 min from culture, 5 h from clinical samples, with a limit of detection at 10³ pfu; sensitivity was 98.2%, specificity 98%, negative predictive value (NPV) 96.1%, and positive predictive value (PPV) 99.1%.

Conclusion

Bacteriophage amplification is therefore an appropriate, fast procedure for detection of this pathogen in clinical samples.

Interplay between MexAB-OprM and MexEF-OprN in clinical isolates of Pseudomonas aeruginosa

MexAB-OprM and MexEF-OprN are Pseudomonas aeruginosa efflux pumps involved in the development of antibiotic resistance. Several studies developed with laboratory strains or using a few clinical isolates have reported that the regulation system of MexEF-OprN is involved in the final levels of MexAB-OprM expression. Therefore, this study was aimed to determine the interplay between MexAB-OprM and MexEF-OprN in 90 out of 190 P. aeruginosa clinical isolates with an efflux pump overexpression phenotype. Regarding oprD, 33% (30/90) of isolates displayed relevant modifications (RM) defined as frameshift or premature stop, both related to carbapenem resistance. On the other hand, 33% of the isolates displayed RM in nalC, nalD or mexR, which were significantly associated with multidrug resistance (MDR), non-susceptibility to carbapenems, OprD alterations and strong biofilm production. Meanwhile, the RM in MexS were associated with presence of pigment (p = 0.004). Otherwise, when all the regulators were analysed together, the association between RM in MexAB-OprM regulators and MDR was only significant (p = 0.039) when mexS was the wild type. These data show the modulatory effect of MexEF-OprN on MexAB-OprM in a clinical population of P. aeruginosa. Further studies may contribute to design of novel molecules acting on this interplay to fight against antimicrobial resistance.

The isolation of Balamuthia mandrillaris from environmental sources from Peru

Balamuthia mandrillaris is an opportunistic free-living amoeba that has been reported to cause skin lesions and the fatal Balamuthia amoebic encephalitis (BAE) in humans and other animals. Currently, around 200 human BAE cases have been reported worldwide, although this number is considered to be underestimated. The highest number of BAE cases has been reported in the American continent, mainly in the southwest of the USA. Peru seems to be another hotspot for BAE with around 55 human cases having been identified, usually involving cutaneous infection, especially lesions in the central face area. The isolation of Balamuthia from environmental sources has been reported on only three prior occasions, twice from Californian soils and once from dust in Iran and so it seems that this amoeba is relatively rarely encountered in samples from the environment. We investigated that possibility of finding the amoebae in soil samples from different regions where clinical cases have been reported in Peru. Twenty-one samples were cultured in non-nutrient agar plates and were checked for the presence of B. mandrillaris-like trophozoites and/or cysts. Those samples that were positive for these amoebae by microscopic criteria were then confirmed by PCR amplification and DNA sequencing of the mitochondrial 16S rDNA gene of B. mandrillaris. We have detected the presence of B. mandrillaris in four samples collected in the regions of Piura (3) and Lima (1) where infection cases have been previously reported. We hypothesize that B. mandrillaris is present in Peru in soil and dust which therefore constitutes a source of the infection for the BAE cases previously reported in this country. Further studies should be carried out in the area to confirm the generality of this finding.

Prevalence and risk factors associated with pediculosis capitis in an impoverished urban community in lima, peru

Background:

Pediculosis capitis is a ubiquitous parasitic skin disease associated with intense pruritus of the scalp. In developing countries it frequently affects children and adults, but epidemiological data at the community level are rare.

Objectives:

To assess prevalence and risk factors associated with pediculosis capitis in a resource-poor community in Lima, Peru.

Materials and Methods:

In total, 736 persons living in 199 households in a circumscribed neighbourhood were examined for head lice and nits by visual inspection. At the same time, socio-demographic data were collected using a structured questionnaire. Variables associated with pediculosis were identified by performing a bivariate analysis, followed by a multivariate logistic regression analysis.

Results:

Prevalence of pediculosis capitis was 9.1% (95% confidence interval (CI): 7.0-11.2 %) in the general population and 19.9% (CI: 15.4-24.4%) in children ≤15 years of age. Multivariate analysis showed that pediculosis capitis was significantly associated with age ≤ 15 years (OR: 16.85; CI:7.42-38.24), female sex (OR: 2.84; CI: 1.58-5.12), household size of >4 persons (OR: 1.98; CI: 1.11-3.55), low quality of house construction material (OR:2.22; CI: 1.20-4.12), and presence of animals in the household (OR: 1.94; CI: 1.11-3.39).

Conclusion:

Pediculosis capitis was a very common disease in the studied community in Lima, Peru. Our logistic regression analysis affirms that young age is the most important risk factor for pediculosis capitis. Moreover, female sex, large household size, living in wooden houses and the presence of animals were identified as being significantly associated with head lice infestation.

Genotyping of potentially pathogenic Acanthamoeba strains isolated from nasal swabs of healthy individuals in Peru

Free Living Amoebae (FLA) of Acanthamoeba genus are widely distributed in the environment and can be found in the air, soil and water; and have also been isolated from air-conditioning units. In humans, they are causative agents of a sight-threating infection of the cornea, Acanthamoeba keratitis (AK) and a fatal infection of the central nervous system known as Granulomatous Amoebic Encephalitis (GAE). In this study, a survey was conducted in order to determine the presence and pathogenic potential of free-living amoebae of Acanthamoeba genus in nasal swabs from individuals in two regions of Peru. Identification of isolates was based on cyst morphology and PCR-sequencing of the Diagnostic Fragment 3 to identify strains at the genotype level. The pathogenic potential of the isolates was also assayed using temperature and osmotolerance assays and extracellular proteases zymograms. The obtained results revealed that all isolated strains exhibited pathogenic potential. After sequencing the highly variable DF3 (Diagnostic Fragment 3) region in the 18S rRNA gene as previously described, genotype T4 was found to be the most common one in the samples included in this study but also genotype T15 was identified. To the best of our knowledge, this is the first study on the characterization of Acanthamoeba strains at the genotype level and the first report of genotype T4 and T15 in Peru.

[Phagotherapy faced with Staphylococcus aureus methicilin resistant infections in mice]

OBJECTIVES

To assess the bacteriophage activity in localized and systemic infections caused by Staphylococcus aureus resistant to methicilin (MRSA).

MATERIALS AND METHODS

An experimental study was performed in 45 mice of the Balb/c strain divided in nine groups of five individuals. Ten naive bacteriophages were isolated through clinical samples and hospital effluents. Lytic capacity and spectrum activity was evaluated on the basis of which six phages were selected for phagotherapy trials. Additionally, a commercial bacteriophage was used. The phagotherapy was evaluated through prophylaxis, and therapy of localized and systemic infections caused by MRSA by subcutaneous and intravenous inoculation, respectively. The effectiveness of three therapeutic schemes was tested: monotherapy, phage cocktail in multiple doses and phage cocktail in a single dose. The therapeutic activity of the phages was also compared with vancomycin and clindamycin.

RESULTS

The phage cocktail and the diverse dose therapy were effective in preventing and controlling MRSA localized infections; its activity was similar to the vancomycin and clindamycin activity. The single dose phage cocktail failed to control localized infection and phagotherapy was not effective in systemic infections.

CONCLUSIONS

Phagotherapy could be a viable alternative for infections caused by MRSA. Further studies that assess related aspects to phages and patient safety are required.

[Antibiotic resistance of streptococcus pneumoniae among healthy nasopharyngeal carriers in seven regions of Peru]

OBJECTIVES

To determine the pattern of antibiotic susceptibility of isolated Streptococcus pneumoniae strains of healthy nasopharyngeal carriers younger than 2 years in seven regions of Peru.

MATERIALS AND METHODS

Between 2007 and 2009, nasopharyngeal swab samples were collected among 2123 healthy children aged 2-24 months in growth and development medical practices (CRED) and vaccination offices of hospitals and health centers in Lima, Piura, Cusco, Abancay, Arequipa, Huancayo, and Iquitos. The resistance to ten antibiotics through disk diffusion sensitivity testing of isolated pneumococcus strains was determined.

RESULTS

572 strains were isolated. High rates of resistance to co-trimoxazole (58%), penicillin (52.2% non-sensitive); tetracycline (29,1%); azithromycin (28,9%), and erythromycin (26,3%). Resistance to chloramphenicol was low (8.8%). Multiresistance was found at 29.5%. Resistance to azithromycin and penicillin was different in all seven regions (p<0,05), the highest percentage of non-sensitive strains being found in Arequipa (63,6%), whereas the lowest percentage was found in Cusco (23.4%).

CONCLUSIONS

High levels of resistance found to penicillin, co-trimoxasole and macrolides in isolated pneumococcus strains of healthy carriers in all studied regions, and their association to a previous use of antibiotics, represent a significant public health problem in our country. This emphasizes the need to implement nationwide strategies to reduce the irrational use of antibiotics, especially among children. It is necessary to complement data of resistance to penicillin with the determination of minimal inhibitory concentration to make proper therapeutic recommendations.

A foodborne outbreak of brucellosis at a police station cafeteria, Lima, Peru

Brucella melitensis is highly infectious for humans and can be transmitted to humans in a number of epidemiological contexts. Within the context of an ongoing brucellosis surveillance project, an outbreak at a Peruvian police officer cafeteria was discovered, which led to active surveillance (serology, blood culture) for additional cases among 49 police officers who had also eaten there. The cohort was followed up to 18 months regardless of treatment or symptoms. Active surveillance estimated the attack rate at 26.5% (13 of 49). Blood cultures from four cases were positive; these isolates were indistinguishable using multiple locus variable number tandem repeat analysis. This investigation indicates the importance of case tracking and active surveillance for brucellosis in the context of potential common source exposure. These results provide rationale for public health investigations of brucellosis index cases including the bioterrorism-related dissemination of Brucella.

[Return scholarship of the Universidad Peruana Cayetano Heredia]

Developing countries suffer from brain drain for many decades. Industrialized countries have raised their barriers against immigrants, but have created mechanisms to attract foreign professionals, with aggressive policies to capture talents, in an effort to increase their competitiveness. To mitigate the effects of the migration of scientists, the Universidad Peruana Cayetano Heredia has created its own "return scholarship" about 12 years ago, and has repatriated 12 scientists through it. The funds invested in attracting the scholars total U.S. $333,540.00 and they have secured U.S. $9,249,828.42 in research funds during the same period, a figure over 27 times higher. They have published 8 articles in national journals, 68 internationally, and trained 29 undergraduate and 20 graduate students as Thesis Tutors. Other universities and institutions of our countries can emulate this successful experience, which is still evolving.

Brucellar uveitis: intraocular fluids and biopsy studies

BACKGROUND

Ocular brucellosis is usually diagnosed by clinical criteria and serological tests. Little is known with regard to the ocular immunology of brucellosis and the use of intraocular diagnostic tests. We report retrospectively the laboratory findings of patients with ocular involvement associated with brucellosis.

MATERIALS AND METHODS

Patients with uveitis with no evident etiologic diagnosis were evaluated at the Instituto de Medicina Tropical "Alexander von Humboldt" of the Universidad Peruana Cayetano Heredia and the Hospital Nacional Cayetano Heredia. Patients were tested for brucellosis, tuberculosis, syphilis, toxoplasmosis, toxocariasis, and human T-cell lymphotropic virus-1. Blood and intraocular fluid samples were examined. Patients with a diagnosis of brucellar uveitis were selected as cases and patients with a diagnosis of uveitis of other etiology were included as controls. The Goldmann-Witmer coefficient was determined.

RESULTS

Twelve patients with clinical and laboratory findings suggestive of brucellar uveitis were considered as cases. Seven patients with uveitis of other etiology were selected as controls. Four (33.3%) patients with ocular brucellosis had negative ocular agglutinations and eight (66.7%) had positive agglutinations. No control cases had positive agglutinations for Brucella melitensis. The sensitivity of the test was 66.7% and the specificity 100%. Only one patient had a positive culture for B. melitensis in subretinal fluid. The Goldmann-Witmer coefficient was calculated in six cases of brucellosis uveitis and five uveitis controls. It was highly positive in three patients with ocular brucellosis. Tissue samples showed lymphoplasmacytic infiltrates.

CONCLUSIONS

Intraocular serological tests could be used to support the diagnosis of ocular brucellosis.

BALB/c Mice resist infection with Bartonella bacilliformis

BACKGROUND

Bartonellosis due to Bartonella bacilliformis is a highly lethal endemic and sometimes epidemic infectious disease in South America, and a serious public health concern in Perú. There is limited information on the immunologic response to B. bacilliformis infection. The objective of this research was to produce experimental infection of BALB/c mice to B. bacilliformis inoculation.

FINDINGS

BALB/c mice were inoculated with 1.5, 3.0 or 4.5 x 108 live B. bacilliformis using different routes: intraperitoneal, intradermal, intranasal, and subcutaneous. Cultures of spleen, liver, and lymph nodes from one to 145 days yielded no cultivable organisms. No organs showed lesions at any time. Previously inoculated mice showed no changes in the reinoculation site.

CONCLUSION

Parenteral inoculation of live B. bacilliformis via different infection routes produced no macroscopic or microscopic organ lesions in BALB/c mice. It was not possible to isolate B. bacilliformis using Columbia blood agar from 1 to 15 days after inoculation.

Mycobacterium ulcerans disease, Peru

Eight adult patients with Buruli ulcer were seen in a recent 10-year period.

Eight adult patients (ages 18–58, 5 women) with Buruli ulcer (BU) confirmed by at least 2 diagnostic methods were seen in a 10-year period. Attempts to culture Mycobacterium ulcerans failed. Five patients came from jungle areas, and 3 from the swampy northern coast of Peru. The patients had 1–5 lesions, most of which were on the lower extremities. One patient had 5 clustered gluteal lesions; another patient had 2 lesions on a finger. Three patients were lost to follow-up. All 5 remaining patients had moderate disease. Diverse treatments (antituberculous drugs, World Health Organization [WHO] recommended antimicrobial drug treatment for BU, and for 3 patients, excision surgery) were successful. Only 1 patient (patient 7) received the specific drug treatment recommended by WHO. BU is endemic in Peru, although apparently infrequent. Education of populations and training of health workers are first needed to evaluate and understand the full extent of BU in Peru.

Novel hypertonic saline-sodium hydroxide (HS-SH) method for decontamination and concentration of sputum samples for Mycobacterium tuberculosis microscopy and culture

This study evaluated a new decontamination and concentration (DC) method for sputum microscopy and culture. Sputum samples from patients with suspected pulmonary tuberculosis (TB) (n=106) were tested using the proposed hypertonic saline-sodium hydroxide (HS-SH) DC method, the recommended N-acetyl-L-cysteine-sodium citrate-sodium hydroxide (NALC-NaOH) DC method and unconcentrated direct smear (Ziehl-Neelsen) techniques for the presence of mycobacteria using Löwenstein-Jensen culture and light microscopy. Of 94 valid specimens, 21 (22.3%) were positive in culture and were further characterized as Mycobacterium tuberculosis. The sensitivity for acid-fast bacilli (AFB) smears was increased from 28.6% using the direct method to 71.4% (HS-SH) and 66.7% (NALC-NaOH) using DC methods. Both concentration techniques were highly comparable for culture (kappa=0.794) and smear (kappa=0.631) for AFB. Thus the proposed HS-SH DC method improved the sensitivity of AFB microscopy compared with a routine unconcentrated direct smear; its performance was comparable to that of the NALC-NaOH DC method for AFB smears and culture, but it was methodologically simpler and less expensive, making it a promising candidate for evaluation by national TB control programmes in developing countries.

Cost-effectiveness analysis of introduction of rapid, alternative methods to identify multidrug-resistant tuberculosis in middle-income countries

BACKGROUND

Resistance to commonly used antituberculosis drugs is emerging worldwide. Conventional drug-susceptibility testing (DST) methods are slow and demanding. Alternative, rapid DST methods would permit the early detection of drug resistance and, in turn, arrest tuberculosis transmission.

METHODS

A cost-effectiveness analysis of 5 DST methods was performed in the context of a clinical trial that compared rapid with conventional DST methods. The methods under investigation were direct phage-replication assay (FASTPlaque-Response; Biotech), direct amplification and reverse hybridization of the rpoB gene (INNO-LiPA; Innogenetics), indirect colorimetric minimum inhibitory concentration assay (MTT; ICN Biomedicals), and direct proportion method on Löwenstein-Jensen medium. These were compared with the widely used indirect proportion method on Löwenstein-Jensen medium.

RESULTS

All alternative DST methods were found to be cost-effective, compared with other health care interventions. DST methods also generate substantial cost savings in settings of high prevalence of multidrug-resistant tuberculosis. Excluding the effects of transmission, the direct proportion method on Löwenstein-Jensen medium was the most cost-effective alternative DST method for patient groups with prevalences of multidrug-resistant tuberculosis of 2%, 5%, 20%, and 50% (cost in US$2004, $94, $36, $8, and $2 per disability-adjusted life year, respectively).

CONCLUSION

Alternative, rapid methods for DST are cost-effective and should be considered for use by national tuberculosis programs in middle-income countries.

A simple and improved method for diagnosis of tuberculosis using hypertonic saline and sodium hydroxide to concentrate and decontaminate sputum

We report the use of hypertonic saline and sodium hydroxide (HS-SH) for concentration-decontamination of sputum samples for the diagnosis of tuberculosis. This method increases detection of mycobacteria in smears compared to examination of direct smears, is comparable and reduces contamination in cultures compared to NALC-NaOH.

Evaluation of the accuracy of the microplate Alamar Blue assay for rapid detection of MDR-TB in Peru

Tuberculosis control is hampered by the widespread increase in multidrug resistance. Rapid drug susceptibility testing would greatly aid in the adequate treatment of the disease. This study evaluates the usefulness of the colorimetric method using Alamar Blue for the rapid detection of resistance to rifampicin and isoniazid in 63 clinical isolates of Mycobacterium tuberculosis in Peru. Results obtained by receiver operating characteristic curve analysis and measures of gain in certainty showed greater diagnostic accuracy than with the gold standard, the proportion method on Löwenstein-Jensen medium.

Evaluation of rifampicin and isoniazid susceptibility testing of Mycobacterium tuberculosis by a mycobacteriophage D29-based assay

Conventional methods for determining drug susceptibility of Mycobacterium tuberculosis require several weeks to obtain results, limiting their usefulness; automated methods and those based on molecular biology techniques have been able to reduce the turnaround time, but their high cost and need for sophisticated equipment restrict their use in developing countries. The goal of the present study was to evaluate the diagnostic accuracy of a rapid (3-4 days) low-cost test based on the use of mycobacteriophage D29 to determine the susceptibility of strains of M. tuberculosis to rifampicin (RIF) and isoniazid (INH). Results obtained show that susceptibility testing for RIF has a high diagnostic accuracy as compared to the standard indirect proportion method on Löwenstein-Jensen medium (sensitivity 100% and specificity 98%). Given the association between the resistance to RIF and INH, which define multidrug resistance (MDR), this test seems suitable for rapid detection of MDR tuberculosis strains (kappa=0.978). Susceptibility testing for INH using mycobacteriophage D29 had a good but lower diagnostic accuracy as compared to the standard method (sensitivity 80.4% and specificity 80.8%); the test would then be of limited usefulness in the management of tuberculosis patients. Further studies to determine the relationship of mycobacteriophage D29 tests to in vivo correlates of sensitivity to specific antituberculosis drugs are warranted.

Rhinoscleroma: eight Peruvian cases

Rhinoscleroma is a rare infection in developed countries; although, it is reported with some frequency in poorer regions such as Central Africa, Central and South America, Eastern and Central Europe, Middle East, India and Indonesia. Nowadays, rhinoscleroma may be erroneously diagnosed as mucocutaneos leishmaniasis, leprosy, paracoccidioidomycosis, rhinosporidiasis, late syphilis, neoplasic diseases or other upper airway diseases. From 1996 to 2003, we diagnosed rhinoscleroma in eight patients attended in the Dermatologic and Transmitted Diseases service of "Cayetano Heredia" National Hospital, in Lima, Peru. The patients presented airway structural alterations producing nasopharyngeal, oropharyngeal and, in one patient, laryngeal stenosis. Biopsy samples revealed large vacuolated macrophages (Mikulicz cells) in all patients. Ciprofloxacin 500 mg bid for four to 12 weeks was used in seven patients and oxytetracycline 500 mg qid for six weeks in one patient. After follow-up for six to 12 months the patients did not show active infection or relapse, however, all of them presented some degree of upper airway stenosis. These cases are reported because of the difficulty diagnosing the disease and the success of antibiotic treatment.

Evaluation of a rapid screening method for detection of antimicrobial resistance in the commensal microbiota of the gut

The assessment of antimicrobial resistance among commensal bacteria is an indicator of the spread of antimicrobial resistance. Rapid screening methods for detection of antimicrobial-resistant faecal Escherichia coli directly on MacConkey plates have been successfully adopted but suffer from lack of standardisation. The purpose of this study was to evaluate a direct plating method (DPM) for detection of antimicrobial-resistant faecal E. coli and to compare it with a conventional method. Faecal samples were collected from 71 healthy children from Peru and Bolivia. In the DPM, a faecal swab was directly plated onto a MacConkey agar plate and antimicrobial disks were applied onto the seeded plate. Raw data were obtained by direct reading of the plate and were subjected to confirmatory analysis. Good concordance between the DPM and a conventional method was observed in detecting carriage of resistant E. coli, with a higher sensitivity for the DPM. Analysis of the results allowed interpretive criteria to be defined for DPM raw data. The DPM showed good sensitivity and specificity at very low cost (ten times cheaper than the conventional method) to investigate the faecal carriage of drug-resistant E. coli. It may represent a useful tool to conduct large-scale resistance surveillance studies and to monitor resistance control programmes cost effectively, particularly in low-resource countries.

Penicillin resistance and serotypes/serogroups of Streptococcus pneumoniae in nasopharyngeal carrier children younger than 2 years in Lima, Peru

The purpose of this study was to determine the carriage rate, susceptibility pattern, and serotype distribution of Streptococcus pneumoniae in the nasopharynx of children younger than 2 years old in Lima, Peru. A total of 666 children were evaluated during 3 periods, 1997, 2001, and 2003. The overall pneumococcal carrier rate was 41%. Reduced susceptibility to penicillin was found in 5% (4/75) of isolates in 1997, 20% (15/75) in 2001, and 37% (40/109) in 2003. Reduced susceptibility to ceftriaxone was found in 12% of isolates in 2003. Serogroups 6, 19, 23, 15, and 14 accounted for 68% of all the isolates and for 81% of the penicillin-nonsusceptible strains. Only 65% of the isolated strains had serogroups found in the 7-valent conjugate pneumococcal vaccine. This highlights the importance of regional surveillance studies for effective vaccine strategies and treatment protocols.

Cutaneous anthrax in Lima, Peru: retrospective analysis of 71 cases, including four with a meningoencephalic complication

Anthrax is a zoonosis produced by Bacillus anthracis, and as an human infection is endemic in several areas in the world, including Peru. More than 95% of the reported naturally acquired infections are cutaneous, and approximately 5% of them can progress to meningoencephalitis. In this study we review the clinical and epidemiological characteristics of the patients with diagnosis of cutaneous anthrax evaluated between 1969 and 2002 at the Hospital Nacional Cayetano Heredia (HNCH) and the Instituto de Medicina Tropical Alexander von Humboldt in Lima, Peru. Seventy one patients were included [49/71 (69%) of them men], with a mean age of 37 years. The diagnoses were classified as definitive (44%) or probable (56%). The most common occupation of the patients was agriculture (39%). The source of infection was found in 63 (88.7%) patients. All the patients had ulcerative lesions, with a central necrosis. Most of the patients (65%) had several lesions, mainly located in the upper limbs (80%). Four patients (5.6%) developed meningoencephalitis, and three of them eventually died. In conclusion, considering its clinical and epidemiological characteristics, cutaneous anthrax must be included in the differential diagnosis of skin ulcers. A patient with clinical suspicion of the disease should receive effective treatment soon, in order to avoid neurological complications which carry a high fatality rate.

Clinical spectrum of pulmonary involvement in leptospirosis in a region of endemicity, with quantification of leptospiral burden

BACKGROUND

Pulmonary involvement in leptospirosis remains poorly recognized in regions where it is endemic, despite reports of recent outbreaks and epidemic disease.

METHODS

A prospective, population-based study was carried out to identify febrile patients exposed to Leptospira in urban and rural contexts in Iquitos, Peru. Evidence of exposure to Leptospira was obtained by serologic testing, and diagnosis of leptospirosis was confirmed in pulmonary cases by culture or quantitative real-time PCR assay.

RESULTS

Of 633 consecutively enrolled febrile patients, 321 (50.7%) had antileptospiral IgM antibodies or high titers of antileptospiral antibodies. Seven patients with histories of only urban exposure to leptospires had severe pulmonary manifestations; of these, 5 patients died; 4 of the deaths were caused by pulmonary hemorrhage, and 1 was caused by acute respiratory distress syndrome and multiorgan failure. Real-time, quantitative PCR assay showed high levels of leptospiremia (>or=10(4) leptospires/mL) in most fatal cases; 1 patient, from whom tissue specimens were obtained at autopsy, had >or=10(5) leptospires/g of lung, kidney, and muscle tissue. DISCUSSION. This study demonstrates the underdiagnosis of leptospirosis in a region of high endemicity and the underrecognition of grave pulmonary complications. Pulmonary involvement in leptospirosis was present in urban but not rural areas. Presumptive treatment for leptospirosis should be initiated immediately in the appropriate epidemiological and clinical context.

Gelatin particle indirect agglutination and enzyme-linked immunosorbent assay for diagnosis of strongyloidiasis using Strongyloides venezuelensis antigen

Routine microscopical examination of stool specimens for diagnosis of strongyloidiasis is insensitive and serological methods using Strongyloides stercoralis antigen are at present not available for field studies. We evaluated 2 techniques, enzyme-linked immunosorbent assay (ELISA) and gelatin particle indirect agglutination (GPIA), using an antigen obtained from the rodent parasite, S. venezuelensis. Fifty-four Peruvian patients with different clinical forms of strongyloidiasis were studied: 12 asymptomatic, 31 symptomatic, and 11 hyperinfection cases. Our results demonstrate that both ELISA and GPIA using S. venezuelensis antigen are useful for diagnosis of strongyloidiasis, with sensitivities of 74.1% and 98.2%, respectively and a specificity of 100% for both techniques. We found that GPIA is a highly sensitive test for patients with suspected chronic infection and/or hyperinfection. In the hyperinfection cases, significantly lower concentrations of specific immunoglobulin antibodies and eosinophils (P < 0.001) were found compared with the asymptomatic and symptomatic cases.

Cryptosporidium muris, a rodent pathogen, recovered from a human in Perú

Cryptosporidium muris, predominantly a rodent species of Cryptosporidium, is not normally considered a human pathogen. Recently, isolated human infections have been reported from Indonesia, Thailand, France, and Kenya. We report the first case of C. muris in a human in the Western Hemisphere. This species may be an emerging zoonotic pathogen capable of infecting humans.

First molecular evidence of new Bartonella spp. in fleas and a tick from Peru

Fleas, lice, and ticks collected in Peru in a suburban area of Cusco in November 1998 were tested by polymerase chain reaction for the presence of Bartonella DNA using primers amplifying a fragment of the intergenic spacer region (ITS) gene. Three new Bartonella genotypes were detected in Pulex fleas self-collected from the beds and clothes of schoolchildren and adults. A fourth new genotype was also detected from a tick found on a sheep in the same area. One of the genotypes is closely related to B. vinsoni subsp. berkhoffii, and the others seem to originate from unknown Bartonella species, whose medical importance has yet to be clarified.

Resazurin microtiter assay plate: simple and inexpensive method for detection of drug resistance in Mycobacterium tuberculosis

A method for detecting multidrug-resistant Mycobacterium tuberculosis by using a reduction of resazurin is described. Eighty clinical isolates were evaluated against isoniazid and rifampin; results at 7 days were compared with those of the proportion method. Specificity and sensitivity were excellent. The method is simple, inexpensive, and rapid and might be used with other antituberculosis drugs.

The acrosomic reaction in stallion spermatozoa: inductive effect of the mare preovulatory follicular fluid

In the female genital tract, spermatozoa must undergo capacitation and acrosome reaction prior to fertilization. A number of factors may induce physiological acrosome reaction assayed in vitro. The aims of this study are to determine the inductive effect of the preovulatory follicular fluid on the sperm acrosomal status in the equine, once some characteristics of the follicular fluid during folliculogenesis had been evaluated. The spermatozoa were obtained from cauda epididymes of adult stallion. Follicular fluid was taken from mare ovarian follicles classified according to their diameter. In these fluids, total protein, progesterone, estradiol and osmolarity were determined. Afterwards, the effect of preovulatory follicular fluid (50%) upon induction of the acrosomic reaction in stallion capacitated spermatozoa was assayed. Results show that during folliculogenesis the ratio progesterone/estrogen is below 1. In large preovulatory follicles, there is a sharp increase of progesterone, reaching a ratio progesterone/estrogen close to 4. Protein concentration and osmolarity increase together with follicular development, being osmolarity very high at the preovulatory stage. Follicular fluid--in vitro--increases the percentage of spermatozoa with acrosome reaction, maintaining high rates of vitality and motility. The characteristics of follicular fluid undergo dynamic changes during the folliculogenesis, such as steroid level, protein concentration and osmolarity. These events may play a role in the reproductive process in vivo, considering that in vitro the follicular fluid is a very effective inductor of the acrosome reaction, with optimum levels of vitality and motility.

Differences in the contents of total sugars, reducing sugars, starch and sucrose in embryogenic and non-embryogenic calli from Medicago arborea L

The total sugars, reducing sugars, starch and sucrose in embryogenic and non-embryogenic calli from explants (cotyledons, petioles, hypocotyls and leaves) obtained from Medicago arborea L. seedlings were evaluated. Total sugars were the major components in the calli and no significant differences between embryogenic and non-embryogenic calli were observed. In contrast, important differences between the embryogenic and non-embryogenic calli were observed for reducing sugars, the highest levels being observed in embryogenic calli. The highest starch levels were found in non-embryogenic calli developed in MS medium. During the development of somatic embryogenesis very low starch levels in the callus were found. During the first months of culture, no significant differences in the sucrose content were found between calli that produced embryos and those that did not. The most important differences in sucrose were seen between calli transferred to medium F0, which had the greatest embryogenic capacity, and those transferred to medium F6, which inhibited embryogenesis. In the latter case, an increase in sucrose was observed.

Surveillance of bacterial pathogens associated with acute diarrhea in Lima, Peru

OBJECTIVES

A study was conducted in Lima, Peru, from January to April 1995, to determine the bacterial pathogens associated with acute diarrhea in adults, their susceptibility to common antimicrobials, the risk factors involved in cholera transmission, and the best clinical predictors of cholera.

METHODS

A random sample of adult patients with acute diarrhea was studied. Epidemiologic and clinical data and risk factors to acquire diarrheal diseases were evaluated. Identification of bacteria and susceptibility to antimicrobials were determined.

RESULTS

The study included 336 patients. Vibrio cholerae O1 (52.7%), Shigella spp. (4. 8%), and Salmonella spp (2.7%) were the pathogens most commonly isolated. No resistance to antimicrobials was observed. Patients with cholera had less access to municipal water (P = 0.0018) and were less likely to have homes connected to a sewage system (P = 0. 0003) or to have indoor toilet facilities (P = 0.0001) than those without cholera. Liquid stools (odds ratio [OR] = 16.51; confidence interval [CI] = 13.71-19.02; P = 0.003), severe dehydration (OR = 2. 48; CI = 1.57-3.38; P = 0.0083), generalized cramps (OR = 4.63; CI = 3.10-6.17, P < 0.0001), and washerwoman's hands (OR = 2.45; CI = 1. 55-3.34; P = 0.017) were the best clinical predictors of cholera in this setting.

CONCLUSIONS

Cholera is still prevalent in Lima, and people living in environments with low sanitary conditions are especially at risk. Clinical signs of severe dehydration and liquid stools were the best predictors of cholera.

Clinical application of a dot blot test for diagnosis of enteric fever due to Salmonella enterica serovar typhi in patients with typhoid fever from Colombia and Peru

Clinical application of a dot blot test to detect immunoglobulin G (IgG) (88% sensitivity and specificity) and IgM (12.1% sensitivity and 97% specificity) against flagellar antigen from Salmonella enterica serovar Typhi was performed in Peruvian and Colombian patients with typhoid fever. This test can be used as a good predictor of serovar Typhi infection in regions lacking laboratory facilities and in field studies.

Survey of three bacterial louse-associated diseases among rural Andean communities in Peru: prevalence of epidemic typhus, trench fever, and relapsing fever

Typhus and other louse-transmitted bacterial infections in Peruvian sierra communities are known to occur but have not recently been assessed. In this study, 194 of 1,280 inhabitants of four villages in Calca Province in the Urubamba Valley were included. Thirty-nine (20%) of the 194 volunteers had antibodies to Rickettsia prowazekii, whereas 24 (12%) had antibodies to Bartonella quintana and 2 against Borrelia recurrentis. There was a significant correlation between the presence of infesting ectoparasites and antibodies to R. prowazekii, as well as between antibodies to R. prowazekii and ectoparasite infestation and fever in the previous 6 months. The proportion of inhabitants infested with ectoparasites was significantly higher in the highest-altitude village than in the other three villages. Two volunteers' antibody levels suggested a recent typhus infection, but only B. quintana DNA was amplified from lice. Epidemic typhus remains extant in the area, and B. quintana infections were encountered and documented for the first time in South America.

Survey of Bartonella species infecting intradomicillary animals in the Huayllacallán Valley, Ancash, Peru, a region endemic for human bartonellosis

The natural cycle of Bartonella bacilliformis remains uncertain, and the suspected existence of animal reservoirs for the bacterium has never been convincingly demonstrated. We conducted a survey of Bartonella species infecting intradomicillary animals in a bartonellosis-endemic region of Peru, obtaining blood from 50 animals living in the homes of 11 families whose children had recently had bartonellosis. Bartonella-like bacteria were recovered from four of nine small rodents included in the study, but from none of the 41 domesticated animals. Identification and comparison of these isolates, and two Bartonella-like isolates obtained from Phyllotis mice in a different endemic region of Peru using serologic and genotypic methods indicated that although none were strains of B. bacilliformis, five were probably representatives of three previously unrecognized Bartonella species and one was a likely strain of the pathogenic species B. elizabethae.

Cholera in Lima, Peru, correlates with prior isolation of Vibrio cholerae from the environment

The authors utilized a recently developed DNA probe technique to obtain quantitative data on occurrence of Vibrio cholerae in samples collected monthly from 12 environmental sites in Lima, Peru, from November 1993 through March 1995. Peak V. cholerae counts ranged from 10(2)/ml to 10(5)/ml, with the highest counts in sewage-contaminated areas and irrigation water. With our methodology, no V. cholerae cases were detected at any site during the winter months of July through October. Counts were detectable in the environment before onset of cholera in the community, with counts at "cleaner" sites upriver correlating significantly with occurrence of community disease 2 and 3 months later. In sites with heavy sewage contamination, V. cholerae could still be detected before the onset of cases in the community; however, in contrast to upriver sites, counts at these latter sites correlated most closely with the number of concurrently occurring cholera cases. These data support a model of cholera seasonality in which initial increases in number of V. cholerae in the environment (possibly triggered by temperature) are followed by onset of illness in the community, with these human cases further amplifying the organism as the epidemic cycle proceeds.

Fasciola hepatica cysteine proteinases: immunodominant antigens in human fascioliasis

Fasciola hepatica adult worm cysteine proteinases were active-site, affinity radio-labeled with benzyloxicarbonyl-L-tyrosine-L-alanine diazomethylketone (Z-Tyr125I-Ala-CHN2). Sera from patients with fascioliasis and from rabbits experimentally infected with F. hepatica immunoprecipitated the radiolabeled parasite cysteine proteinases in immunoelectrophoresis assays. Two purified antigens were identified as part of the complex mosaic of antigens immunoprecipitated by the sera of infected patients. These antigens (Fas1 and Fas2) have been shown to be an important part of the Fharc2 precipitin band used for serologic diagnosis in humans and cattle. They showed cysteine proteinase activity with different proteolytic specificities and partial identity in double immunodiffusion assays. The results obtained in this work show that the Fas1 and Fas2 antigens are sensitive and specific antigens for diagnosis of this serious helminthic disease in humans and other susceptible hosts.

Cloning and characterization of dnaE, encoding the catalytic subunit of replicative DNA polymerase III, from Vibrio cholerae strain C6706

We report that Vibrio cholerae (Vc) contains a gene homologous to Escherichia coli dnaE, the structural gene for the alpha (catalytic) subunit of replicative DNA polymerase III (PolIII). Despite 24% amino acid (aa) differences in the encoded proteins, the Vc gene strongly complements an E. coli dnaE temperature sensitive (ts) mutant, indicating that all functional features essential for replication are conserved.

Karyotype plasticity in neotropical Leishmania: an index for measuring genomic distance among L. (V.) peruviana and L. (V.) braziliensis populations

A method for phenetic analysis of karyotype data has been developed for Leishmania populations. Measurement of size difference between chromosomes recognized by a given DNA probe in different isolates led to the formulation of a Chromosome Size Difference Index (CSDI). The method was applied to phenetic analysis of 4 sets of chromosomes--each set being recognized by a different probe--in 37 L. (Viannia) peruviana isolates sampled along a North-South transect through the Peruvian Andes and, in 11 L. (V.) braziliensis isolates from the Amazonian forest (Peru, Bolivia and Brazil). Karyotype variability was better accounted for by CSDI than by a method based on disjunctive encoding of karyotype data. CSDI evidenced the nature of relationships between L. braziliensis and L. peruviana and it provided a coherent picture of geographical and genomic differentiation among parasite populations. The latter did cluster according to their geographical origin. L. braziliensis was found karyotypically more homogeneous than L. peruviana. Within L. peruviana, Northern populations were closer to L. braziliensis than to Southern L. peruviana populations. The validity of karyotypic populations, or karyodemes, was sustained.

Identification of bloodmeal sources of Lutzomyia spp. in Peru

Bloodmeal sources of Lutzomyia spp. were determined, using the bloodmeal analysis precipitin test, in Chaute, Lima, Peru, an area endemic for cutaneous leishmaniasis (uta). From April 1990 to May 1991, sandflies were sampled in and around the village houses, with CDC light traps and a Shannon trap with protected human bait, respectively. Overall, 1424 sandflies were collected engorged. In indoor collections, human blood (N = 275) was the most frequent bloodmeal found, followed by cow (171) and cat (152). The most frequent bloodmeals of the flies caught in the Shannon trap collections were from cow (31), man (23) and cat (23). Of the two predominant sandfly species in the area, Lutzomyia peruensis was more anthropophilic than Lu. verrucarum (chi 2 = 14.13, P < 0.001). The sandflies from Chaute appear to be opportunistic feeders; 16 different hosts were identified. There was evidence of bloodmeals from more than one host in each of 151 sandflies, including bloodmeals containing blood from an animal only present within the houses mixed with blood from animals only present in the corrals near the house. Some sandflies must therefore have flown from the corrals to the houses (or vice versa) to take the last bloodmeals before their capture.

Natural Leishmania infection of Lutzomyia spp. in Peru

Natural infection of Lutzomyia spp. with Leishmania was studied with the aid of the polymerase chain reaction (PCR) in Chaute, Lima, Perú, a locality endemic for Andean cutaneous leishmaniasis (uta). The PCR, with primers specific for the L. braziliensis complex, was applied to sandfly pools. Sandflies were sampled from April 1990 to May 1991 with CDC light traps in homes, and from near homes with a Shannon trap using protected human bait. Lu. verrucarum (4 pools) and Lu. peruenis (2 pools) from the anthropophilic collections, and Lu. verrucarum (2 pools) from indoors were found to be infected with Leishmania. The majority of infected sandflies were recorded mainly in April 1991 (4 pools), coinciding with the highest sandfly densities and the maximum number of new cases of uta (7). Non-infected sandflies were found from May to October 1990 and January to March 1991. Thus, these 2 sandfly species play a role in the spread of leishmaniasis among humans and other animals in Chaute.