Cardiothoracic surgery and peripheral endovascular intervention in cardiovascular damage from a cohort of orphan rheumatological diseases-epidemiological and survival analysis

Background

Aortic diseases in some orphan rheumatological diseases require medical, surgical or peripheral endovascular intervention because they can be catastrophic. Objectives: to analyze the main clinical and epidemiological characteristics of patients with Takayasu arteritis (TA), Marfan syndrome (MS) and similar conditions that were treated with cardiothoracic surgery and peripheral endovascular intervention.

Methods

Retrospective and descriptive cohort study that included patients of any age and gender with TA (as per the criteria of the American College of Rheumatology and EULAR/PRINTO), MS (according to Ghent criteria), and similar conditions who underwent cardiothoracic surgery or peripheral endovascular intervention. Data were collected from electronic charts.

Results

A total of 77 patients with TA and 135 patients with MS and similar conditions were included. The frequency of surgical or interventional requirements in patients with TA and MS/similar conditions was 77/364 (21.2%) and 135/300 (45%), respectively; such patients were followed for a median of 6 [2–12] and 3.29 (0.42–6.62) years, with (maximum follow-up range of 47 and 21.37 years, respectively). Aneurysms were present in 11 (14.3%) and 66 (48.9%) in patients with TA and MS/similar conditions, respectively. Aortic, mitral and tricuspid valve damage occurred in 8 (10.4%) patients, 4 (5.2%) patients and 1 (1.3%) patient with TA, respectively; corresponding frequencies in patients with MS/similar conditions were 98 (72.6%), 50 (37.0%) and 20 (14.8%). We identified that 20% of patients with TA died after 5.08 years (95% CI: 0.23–25.42 years) and 20 % of the patients with MS and other similar conditions died after 7.52 years (95% CI: 1.10–9.02 years).

Conclusions

The frequency of surgical intervention was low in this study. Long-term prognosis is good if surgery is performed in a timely manner. Epidemiological studies provide relevant information for public health decisions related to the management of orphan rheumatological diseases.

Serum cytokines and activation ex vivo of CD4+ and CD8+ T cells in chagasic chronic Mexican patients

The clinical manifestations of human Chagas disease are associated with several factors, including immunological alterations, in this regard, many studies propose that tissue damage might be more severe in the absence of immune regulatory mechanisms, other factors are the genetic background of host and parasite. Trypanosoma cruzi population is genetically, biochemistry and pathogenic diverse along the Latin-America continent and phylogenetic ally are divided into six intra-species lineages TcI-VI. The TcI lineage has a wide distribution with heterogeneous virulence and pathogenesis within strains. In Mexico, the main circulating lineage is TcI in human infections. We analyzed intracytoplasmic cytokines of unstimulated peripheral T lymphocytes, and the level of cytokines (IL-2, IL-4, IL-12, IL-10, IFN-γ and sIL-2R) in the serum of Mexican chagasic subjects. The population studied consisted of 15 asymptomatic individuals, 17 patients with chronic chagasic cardiopathy (CCC), 20 patients with cardiopathy but negative serology for T. cruzi, and 10 healthy subjects. The analysis of CD4+ cells revealed that CCC and asymptomatic patients have higher CD25+ and CD69 activation markers than controls. The Th1 subset (CD4+/IFN- γ +) was higher in CCC than in asymptomatic and control subjects, whereas Th2 subset was markedly high in asymptomatic subjects. Circulating cytokines were below level detection with the exception of IL-2 and sIL-2R. Infection with Mexican Trypanosoma cruzi strains in asymptomatic chagasic subjects have a tendency for a Th2 response with higher CD8+/IFN-γ T cells. In contrast, CCC patients have low levels of intracellular IFN- γ and IL-2 cytokines. In both groups circulating serum cytokines are below the detectable level.

Obesity, Thrombotic Risk, and Inflammation in Cancer

Neoplasms exhibits a high incidence and mortality rates due to their complex and commonly overlapping clinical, biochemical, and morphologic profiles influenced by acquired or inherited molecular abnormalities, cell of origin, and level of differentiation. Obesity appears related to ~20% of cancers including endometrial, esophageal, colorectal, postmenopausal breast, prostate, and renal. Several factors other than obesity, i.e., insulin, insulin-like growth factor, sexual hormones, and adipokines may play a potential role in neoplasia. Cancer-associated hypercoagulable and thrombotic states are influenced by abnormalities in the vascular wall and susceptibility to invasion, interference in blood flow and increase in circulating tissue factor and thrombin, activation of cell growth factors, the presence of a central catheter, chemotherapies, neoplasm type, and surgery. In cancer, thromboembolic complications are the second most frequent cause of death with pulmonary thromboembolism in ~50% of cases postmortem. Thrombosis worsens prognosis as demonstrated with a survival rate as low as 12% per year vs 36% in nonthrombic patients. Deep vein thrombosis is the most frequent thromboembolic complication in cancer. It is usually detected at diagnosis and within the first 3 months of chemotherapy. The underlining mechanisms of this association should be further studied to identify patients at higher risk and develop adequate prevention, diagnostic, and treatment measures. The D-dimer test can be successfully used to assess the fibrinolytic phase of coagulation and as such is routinely used in suspected cases of deep vein thrombosis and pulmonary thromboembolism. In addition, significant advances have been made in understanding the composition and functional capabilities of the gut microbiota in the inflammatory process, obesity, and its roles in cancer; however, the intricate balance that exists within the microbiota may not only affect the host directly, it can also disrupt the entire microbial community.

CONCLUSIONS

Cancer is a prothrombotic and inflammatory state in which the activation of coagulation is related to tumor growth, angiogenesis, and metastasis. It is important to identify the relationship between body mass index with these processes and clarify their importance in cancer prognosis. Future research should answer the question if manipulation of resident microbial communities could potentially improve prognosis and treatment outcome.

Trypanosoma cruzi connatal transmission in dogs with Chagas disease: experimental case report

Trypanosoma cruzi connatal transmission was studied in male and female mongrel dogs. Both dogs were experimentally infected, after which on the 20(th) day, lymphoadenomegaly and fever were found. Four months postinfection, they mated. At this time, Chagas disease was confirmed by two different diagnostic tests. The electrocardiogram and echocardiogram taken at the eight postinoculation month showed data consistent with ischemia, local conduction abnormalities and hypertrophy, as well as a diminished ejection fraction and left ventricular dilation, respectively. Four puppies were born and after weaning had weakness, progressive weight loss, and chronic diarrhea. Necropsy of all four showed digestive alterations and cardiac dilation. Serology in the offspring was positive for Chagas disease. The histopathological study demonstrated a cardiac chronic inflammatory process, although no parasites were found. Clinical data and serological determinations are consistent with death from advanced Chagas disease.

Specific humoral and cellular immunity induced by Trypanosoma cruzi DNA immunization in a canine model

Chagas disease has a high incidence in Mexico and other Latin American countries. Because one of the most important known methods of prevention is vector control, which has been effective only in certain areas of South America, the development of a vaccine to protect people at risk has been proposed. In this study, we assessed the cellular and humoral immune response generated following immunization with pBCSP and pBCSSP4 plasmids containing the genes encoding a trans-sialidase protein (present in all three forms of T. cruzi) and an amastigote specific glycoprotein, respectively, in a canine model. Thirty-five beagle dogs were divided randomly into 5 groups (n = 7) and were immunized twice intramuscularly with 500 μg of pBCSSP4, pBCSP, pBk-CMV (empty plasmid) or saline solution. Fifteen days after the last immunization the 4 groups were infected intraperitoneally with 500 000 metacyclic trypomastigotes. The fifth group was unimmunized/infected. The parasitaemia in the immunized/infected dogs was for a shorter period (14 vs. 29 days) and the parasite load was lower. The concentration of IgG1 (0.612 ± 0.019 O.D.) and IgG2 (1.167 ± 0.097 O.D.) subclasses was measured (absorbance) 15 days after the last immunization with both recombinant plasmids, the majority of which were IgG2. The treatment of parasites using the serum from dogs immunized with pBCSP and pBCSSP4 plasmids produced 54% (± 11.8) and 68% (± 21.4) complement-mediated lysis, respectively. At 12 h post immunization, an increase in cytokines was not observed; however, vaccination with pBCSSP4 significantly increased the levels of IFN-γ and IL-10 at 9 months post-infection. The recombinant plasmid immunization stimulated the spleen cell proliferation showing a positive stimulatory index above 2.0. In conclusion, immunization using both genes effectively induces a humoral and cellular immune response.

The interleukin-1 gene cluster polymorphisms are associated with Takayasu's arteritis in Mexican patients

Takayasu's arteritis (TA) is a chronic inflammatory arteritis of unknown etiology involving mainly the aorta and its major branches. The interleukin (IL) 1β and IL-1 receptor antagonist have been playing an important role as regulators of inflammation. We investigated whether the polymorphisms at the IL-1B and IL-1RN gene cluster were associated with the genetic susceptibility to develop TA. We analyzed the IL-1B, IL-1F10.3, and IL-1RN polymorphisms in a sample of 58 TA patients, and 248 clinically healthy unrelated Mexican individuals by 5' exonuclease TaqMan polymerase chain reaction. Polymorphic haplotypes were constructed after linkage disequilibrium analysis. We found increased frequencies of different polymorphisms (C allele and TC genotype of IL-1F10.3; TT genotype of IL-1RN.4; C allele and TC genotype of IL-1RN6.1; G allele of IL-1RN6.2 and haplotypes "1T" and "1C" of IL-RN VNTR and IL-1RN6.1) in the group of TA when compared to healthy controls. On the other hand, decreased frequency of IL-1-511 TC genotype was found in the TA group compared to controls. IL-1B and IL-1RN gene polymorphisms could be involved in the risk of developing TA in the Mexican population. These associations were independent of the affected vessels.

Plasmid DNA immunization with Trypanosoma cruzi genes induces cardiac and clinical protection against Chagas disease in the canine model

The only existing preventive measure against American trypanosomosis, or Chagas disease, is the control of the transmitting insect, which has only been effective in a few South American regions. Currently, there is no vaccine available to prevent this disease. Here, we present the clinical and cardiac levels of protection induced by expression to Trypanosoma cruzi genes encoding the TcSP and TcSSP4 proteins in the canine model. Physical examination, diagnostic chagasic serology, and serial electrocardiograms were performed before and after immunization, as well as after experimental infection. We found that immunization with recombinant plasmids prevented hyperthermia in the acute phase of experimental infection and produced lymphadenomegaly as an immunological response against the parasite and additionally prevented heart rate elevation (tachycardia) in the acute and/or chronic stages of infection. Immunization with T. cruzi genes encoding the TcSP and TcSSP4 antigens diminished the quality and quantity of the electrocardiographic abnormalities, thereby avoiding progression to more severe developments such as right bundle branch block or ventricular premature complexes in a greater number of dogs.

Detection of IS6110 and HupB gene sequences of Mycobacterium tuberculosis and bovis in the aortic tissue of patients with Takayasu's arteritis

BACKGROUND

Takayasu's arteritis (TA) is a chronic inflammatory disease affecting the large arteries and their branches; its etiology is still unknown. In individuals suffering from TA, arterial inflammation progresses to stenosis and/or occlusion, leading to organ damage and affecting survival. Relation of TA with Mycobacterium tuberculosis has been known, but there have been only a few systematic studies focusing on this association. The IS6110 sequence identifies the Mycobacterium tuberculosis complex and the HupB establishes the differences between M. tuberculosis and M. bovis. Our objective was to search the presence of IS6110 and HupB genes in aorta of patients with TA.

METHODS

We analyzed aorta tissues embedded in paraffin from 5760 autopsies obtained from our institution, we divided the selected samples as cases and controls;

CASES

aortic tissues of individuals with Takayasu's arteritis. Control positive: aortic tissues (with tuberculosis disease confirmed) and control negative with other disease aortic (atherosclerosis).

RESULTS

Of 181 selected aorta tissues, 119 fulfilled the corresponding criteria for TA, TB or atherosclerosis. Thus 33 corresponded to TA, 33 to tuberculosis (TB) and 53 to atherosclerosis. The mean age was 22 ± 13, 41 ± 19, and 57 ± 10, respectively. IS6110 and HupB sequences were detected in 70% of TA tissues, 82% in tuberculosis, and in 32% with atherosclerosis. Important statistical differences between groups with TA, tuberculosis versus atherosclerosis (p = 0.004 and 0.0001, respectively) were found.

CONCLUSION

We identified a higher frequency of IS6110 and HupB genes in aortic tissues of TA patients. This data suggests that arterial damage could occur due to previous infection with M. tuberculosis.

[Some ethical dilemmas in the medical praxis]

We reviewed from a bioethical perspective and attempting prevention of potential conflicts derived communication failure during medical practice, palliative treatments and dignified death in the institutional practice as well as general practice; most of conflicts related to patient-doctor relationship could de prevented. We propose an attitude and aptitude plus in deep knowledge of patient, family, friends and legal representatives in terms fully honest communication to prevent most of conflicts and avoid its consequences against doctors and other health workers. Prevention is better and it depends of knowledge of norms, laws, general beliefs and common sense in this country and maybe others.

Dendritic cells and B cells cooperate in the generation of CD4(+)CD25(+)FOXP3(+) allogeneic T cells

BACKGROUND

CD4(+)CD25(+)Foxp3(+) regulatory T cells (Treg) play an essential role in immune tolerance, suppressing responses against self-antigens. Additionally, Treg play an important role in maintaining immunosuppression to alloantigens as well as to other antigens. It is well known that in the gut, a subset of dendritic cells produces retinoic acid (RA), which together with transforming growth factor (TGF-beta) is able to differentiate naïve T cells into Treg. The aim of this study was to establish the role of antigen-presenting cells (APC) in the differentiation of allogeneic Tregs under the effect of RA and TGF-beta.

METHODS

Splenic CD4(+)CD25(-) naïve T cells from C57BL/6 mice were co-cultured with splenic CD11c-enriched APC from Balb/c mice in the presence of TGF-beta, RA, and interleukin (IL-2). After 6 days of culture, cells were analyzed for the expression of Foxp3 by flow cytometry. Additionally, we investigated the role of B cells and dendritic cells (DCs) and their stimulatory capacity in the generation of Tregs.

RESULTS

Our results showed that co-culture of naive T cells with the appropriate level of stimulation by APC in the presence of TGF-beta, RA, and IL-2 provided a new powerful approach to generate allogeneic Treg cells. We demonstrated that although B cells and DCs can generate Tregs by themselves, a mixure of both APC improved their capacity to efficiently generate Tregs. Also, we observed that although the addition of IL-2 to the cultures was not crucial to generate Tregs, it was required to optimize their expansion and cell survival.

Association between IL-1B and IL-1RN gene polymorphisms and Chagas' disease development susceptibility

Though it is known that the immune system exerts some influence on the resistance against T. cruzi infection its precise role in this process is not well-understood. Some IL-1B alleles and haplotypes have been associated with susceptibility to inflammatory, autoimmune and infectious diseases. The objective of this study was to determine and compare the distribution of IL-1B and IL-1 receptor antagonist (IL-1RN) polymorphisms among T. cruzi seropositive patients, patients with idiopathic dilated cardiomyopathy (IDC) and healthy individuals. We studied 86 individuals seropositive for T. cruzi (58 patients with chronic chagasic cardiomyopathy (CCC) and 28 asymptomatics), 50 seronegative individuals with IDC and 109 healthy individuals. IL-1B-511, IL-1F10.3 IL-1RN.4, IL-1RN 6/1, and IL-1RN 6/2 polymorphisms were analyzed using real-time PCR allelic discrimination technology. Infected patients presented an increased frequency of the CC genotype of the IL-1RN.4 polymorphism when compared to IDC (pC = 0.028; OR = 11.46). The C allele of this polymorphism was found increased in CCC when compared with IDC (pC = 0.036; OR = 0.5) and with controls (pC = 0.035; OR = 1.87). CC genotype of IL-1RN.4 polymorphism was increased in patients with CCC when compared to IDC (pC = 0.0018; OR = 16.74) and healthy individuals (pC = 0.011; OR = 3.6). There is an evident association between the IL1RN.4 polymorphism, T. cruzi infection and CCC development.

[Serum levels of antistreptolysin O in teenagers from Mexican urban and rural areas]

BACKGROUND

Antistreptolysin O (ASLO) may be an isolated evidence of recent infection by group A Streptococcus, especially in patients suspected of having a nonsuppurative sequel to this infection. We evaluated ASLO titers in students from urban and rural areas, age and geographic characteristics of study population among several other variables, could be factors that may influence in the ASLO levels in children.

OBJECTIVE

To determine sera titers ofASLO in healthy adolescents from rural and urban areas in Mexico.

MATERIAL AND METHODS

ASLO were detected by nephelometry, including 218 sera from asymptomatic high school students, two schools belong to government, one was at urban area (group 1; n = 68) and other was located at country side (rural) area (group 2; n = 75). The remaining school belong to private system and was located at urban area (group 3; n = 75).

RESULTS

We included 218 sera, 58% were from females. Age (years) was expressed as median (maximum-minimum values) for groups 1, 2, and 3; 13 (12-18), 14 (12-18) and 14 (12-16) respectively. Weight (kg), height (cm) and body mass index (BMI) was expressed by mean +/- SD values for groups 1, 2, and 3; weight 48.8 +/- 8.8, 50.8 +/- 7.8, 57.2 +/- 11 respectively; height 154 +/- 6.9, 156 +/- 6.8, 161 +/- 8.2 and BMI 20.2 +/- 3.0, 20.9 +/- 2.9, and 21.9 +/- 3.6 respectively; when comparison among groups was performed, we found statistical differences in all variables. Titers for ASLO (UI/mL) expressed as median (maximum-minimum values) for groups 1, 2, and 3 were: 147 (20-828), 129 (25-1390) and 84 (25-848). Statistical differences between groups 1 vs 3, and 2 vs 3 were found.

DISCUSSION

We confirm the variability of serum ASLO values among high school students. Thus, group 1 exhibited the highest levels of ASLO, and lowest values of weight, height, and BMI. When comparing against group 2 differences were non-significant. When comparing ASLO titers, Group 3 displayed lowest levels, which significantly differed from those of both groups 1 and 2. These findings discard influence of geographic location in ASLO titers, and indicate that better socioeconomic conditions may play a role.

Takayasu arteritis: clinical features in 110 Mexican Mestizo patients and cardiovascular impact on survival and prognosis

OBJECTIVE

Takayasu Arteritis (TA) is a rare disease that mainly affects large elastic arteries. It is more frequently seen in Asia, the Mediterranean basin, South Africa and Latin America. We have characterized its clinical manifestations and identified the cardiovascular mortality predictors in a cohort of 110 Mexican Mestizo patients.

MATERIAL AND METHOD

Retrospective review of 110 charts of TA patients complying with the American College of Rheumatology (ACR) criteria, seen in a single hospital between 1976 and 2003. Demographic, clinical, and radiological characteristics were described. With the use of actuarial table analysis at 2, 5, and 10 years, and Kaplan Meier methods applying t function for probability, plus Cox regression analysis, the following factors were identified as mortality predictors: systemic arterial hypertension, coronary heart disease and aortic valve regurgitation. Informed consent and approval from the institutional Internal Review Board (IRB) were obtained.

RESULTS

We observed a slowly progressive widespread obstructive arterial disease with cardiovascular (48%), neuro-ophthalmic (36%), and skin morbidity (13%). Systemic hypertension and heart disease were significant mortality predictors. Twenty-six percent of cases died due to myocardial infarction, chronic renal failure, stroke, or surgical complications.

CONCLUSION

TA in Mexican Mestizos shows a clinical pattern similar to the one recognized in the Far East. Management strategies must be directed at reducing the identified mortality risk factors.

Evaluation and treatment of chagas disease in the United States: a systematic review

CONTEXT

Because of population migration from endemic areas and newly instituted blood bank screening, US clinicians are likely to see an increasing number of patients with suspected or confirmed chronic Trypanosoma cruzi infection (Chagas disease).

OBJECTIVE

To examine the evidence base and provide practical recommendations for evaluation, counseling, and etiologic treatment of patients with chronic T cruzi infection. Evidence Acquisition Literature review conducted based on a systematic MEDLINE search for all available years through 2007; review of additional articles, reports, and book chapters; and input from experts in the field.

EVIDENCE SYNTHESIS

The patient newly diagnosed with Chagas disease should undergo a medical history, physical examination, and resting 12-lead electrocardiogram (ECG) with a 30-second lead II rhythm strip. If this evaluation is normal, no further testing is indicated; history, physical examination, and ECG should be repeated annually. If findings suggest Chagas heart disease, a comprehensive cardiac evaluation, including 24-hour ambulatory ECG monitoring, echocardiography, and exercise testing, is recommended. If gastrointestinal tract symptoms are present, barium contrast studies should be performed. Antitrypanosomal treatment is recommended for all cases of acute and congenital Chagas disease, reactivated infection, and chronic T cruzi infection in individuals 18 years or younger. In adults aged 19 to 50 years without advanced heart disease, etiologic treatment may slow development and progression of cardiomyopathy and should generally be offered; treatment is considered optional for those older than 50 years. Individualized treatment decisions for adults should balance the potential benefit, prolonged course, and frequent adverse effects of the drugs. Strong consideration should be given to treatment of previously untreated patients with human immunodeficiency virus infection or those expecting to undergo organ transplantation.

CONCLUSIONS

Chagas disease presents an increasing challenge for clinicians in the United States. Despite gaps in the evidence base, current knowledge is sufficient to make practical recommendations to guide appropriate evaluation, management, and etiologic treatment of Chagas disease.

[Correlation between serum levels of antistreptolysin O and C reactive protein]

INTRODUCTION

Measurement of antibodies to extracellular products of group A streptococcus, specifically streptolysin O (ASO), is useful to detect previous streptococcal infection, besides its ability to identify those asymptomatic carriers or to support diagnosis of poststreptococcal disease. An inflammatory process has been considered as a one variable that could be modifying the interpretation of ASO test.

OBJECTIVE

identify in serum from clinically healthy subjects the covariability of antibodies to streptolysin O (ASO) serum concentration, high sensitivity C reactive protein (hsCRP).

METHODS

87 serum samples from 87 clinically healthy subjects were tested. ASO, hsCRP, and total IgG were measured by nephelometry. Statistical analysis was performed using mean, median, and standard deviation with descriptive purpose; in addition, normality of the distribution of variables was determined. Spearman correlation test was performed in all cases. Significance was considered for p < or = 0.05.

RESULTS

A non-parametric distribution was exhibited by both ASO and hsCRP values. Gaussian distribution was finding only for IgG values. Spearman correlation values for ASO against both hsCRP and IgG were 0.19 (p = NS).

CONCLUSIONS

ASO values distribution did not correlate with dispersion of levels of hsCRP, neither IgG. This suggests that values obtained from clinically healthy subjects in this study where not modified influenced by a potential subjacent inflammatory process, neither IgG serum levels.

Comparison Distribution of HLA-B Alleles in Mexican Patients with Takayasu Arteritis and Tuberculosis

A possible relationship between Takayasu arteritis (TA) and Tuberculosis (Tb) has been suggested. Both diseases present similar chronic inflammatory lesions and occasionally granulomas on the arterial walls. The genetic relationship between these two diseases has not been explored before, however, both diseases have been associated with human leukocyte antigen (HLA) alleles. Therefore, the aim of the present study was to analyze the distribution of HLA-B alleles in TA (n = 40) and Tb (n = 34) patients and healthy controls (72 exposed and 99 nonexposed). HLA-B alleles were determined by reverse dot blot. The statistical methods used included the Chi(2), and odds ratio (OR) with 95% confidence intervals. In spite of the loose clinical relationship between TA and Tb, we did not detected any genetic relationship between them when the HLA-B alleles were analyzed in these groups of patients. On the contrary, we detected distinct specific HLA-B alleles for each disease. TA was characterized by HLA-B39, -B44, and -B52, pulmonary Tb by HL-B35 and extrapulmonary Tb by HLA-B39 and -B40. This preliminary study suggests a difference in the distribution of HLA-B alleles in patients with TA and Tb.

Pre-pulseless Takayasu's arteritis evaluated with 18F-FDG positron emission tomography and gadolinium-enhanced magnetic resonance angiography

Takayasu's arteritis is a primary vasculitis that affects large vessels and is characterized by chronic granulomatous inflammation. Diagnosis has been primarily clinical, with verification by angiography as the gold standard. More recently, however, it has become apparent that positron emission tomography enables better evaluation of vascular inflammation. This study presents 2 cases of Takayasu's arteritis. Magnetic resonance angiography was used to evaluate aortic anatomy by analyzing vascular wall thickness and also to quantify disease activity by measuring gadolinium enhancement. Positron emission tomography was used to evaluate active vascular inflammation by quantifying fluorodeoxyglucose F18 uptake. We conclude that both techniques support clinical diagnosis and aid in the evaluation of disease activity during and after treatment.

MHC class II genes in Mexican patients with idiopathic dilated cardiomyopathy

The purpose of the present study was to evaluate the relationship between class II major histocompatibility complex (MHC) genes (HLA-DR and HLA-DQB) and the genetic susceptibility to idiopathic dilated cardiomyopathy (IDC) in Mexican patients. The HLA-DR and DQB alleles were analyzed in 53 patients with IDC and 99 ethnically matched healthy controls using the polymerase chain reaction-sequence specific oligonucleotides (PCR-SSO) technique. IDC patients showed increased frequencies of HLA-DR4 (pC=0.02, OR=1.87), HLA-DQB1*0301 (pC=0.02, OR=1.92) and HLA-DQB1*0302 (pC=0.02, OR=1.87) when compared to healthy controls. On the other hand, IDC patients also showed decreased frequencies of HLA-DR11 allele (pC=0.03, OR=0.26) and HLA-DQB1*0201 (pC=0.04, OR=0.41). These data suggest that variation in class II HLA alleles could be a genetic factor involved in the susceptibility to IDC of the Mexican Mestizo population.

Echocardiographic follow-up of patients with Takayasu's arteritis: five-year survival

Takayasu's arteritis (TA) is a primary vasculitis that causes stenosis or occlusion, rarely aneurysm and distal ischemia. This study was undertaken to examine cardiovascular damage using echocardiography and determine the causes of morbid-mortality in Mexican Mestizo patients with TA. Seventy-six patients were studied by transthoracic echocardiography. Left ventricular diameters, parietal thickness, systolic function, and wall motion were analyzed, also, valvular lesions and aorta features were assessed. Thickness of the interventricular septum was 12 mm +/- 3 (8-19), and that of posterior wall was 12 mm +/- 2 (9-18). The average left ventricular diastolic diameter was 47 mm +/- 7 (33-68) and the left ventricular systolic diameter 32 mm +/- 8 (16-64). The left ventricular ejection fraction was of 57 +/- 11%. Left ventricular concentric hypertrophy was found in 28 (50%) of the 56 hypertensive patients. The five-year survival of patients with left ventricular concentric hypertrophy was 80%, compared to 95% in patients without hypertrophy (P = 0.00). Abnormal wall motion was found in 15 patients. Thirty-one patients had aortic regurgitation, 19 had mitral regurgitation, 13 had tricuspid regurgitation, and 10 and pulmonary hypertension. Six patients had aneurysms of ascending aorta and 7 stenosis of descending aorta. Thirteen of 76 patients died (17%), 85% were hypertensive, and 9% also had acute myocardial infarction (AMI). Echocardiography, a noninvasive technique, shows a great utility in detection and follow-up of cardiovascular manifestations in patients with TA. New techniques, more sensitive toward detecting the early stages of left ventricular dysfunction, are promising to limit left ventricular hypertrophy development.

Serological and Parasitological Screening of Trypanosoma cruzi Infection in Mothers and Newborns Living in Two Chagasic Areas of Mexico

BACKGROUND

Maternal-fetal transmission of Trypanosoma cruzi generally occurs in 2-12% of pregnant infected mothers. This transmission form has been poorly studied in Mexico where only one case of congenital infection published in 1998 has been reported.

METHODS

We screened 145 mothers and their delivered babies in two hospitals of endemic regions in Mexico (states of Chiapas and Veracruz) searching for anti-T. cruzi antibodies and circulating parasites by hemoculture and PCR.

RESULTS

In Poza Rica, Veracruz, 3/85 (3.5%) mothers were seropositive for T. cruzi infection and in Palenque, Chiapas, 3/60 (5%) cases. In total 6/145 (4.1%) were seropositive subjects. Although cord blood samples of delivered babies from seropositive mothers have IgG anti-T. cruzi antibodies, none presented PCR and positive hemoculture.

CONCLUSIONS

Although a high relative seroprevalence of T. cruzi infection in pregnant women was detected, no case of vertical transmission was recognized. Undoubtedly, further studies of large samples are necessary to evaluate maternal transmission risk in Mexico.

[Chronic Chagasic Cardiomyopathy at the Hospital General de Zona no. 24 IMSS. Poza Rica, Veracruz]

Northern Veracruz has conditions, biotic and abiotic, to support Triatomine bugs and vectorial transmission of Trypanosoma cruzi to human beings. Therefore we explore seroprevalence of antibodies to this parasite and the presence of Chronic Chagasic Cardiopathy (CCC) at Cardiology ward in a General Hospital serving North of Veracruz State, and neighbord states Hidalgo, Puebla San Luis Potosi and Tamaulipas.

MATERIAL AND METHODS

We search for consecutive adult patients attending outpatient and beds assigned to Cardiology between March through September, 2003. An epidemiology questionnaire, clinical work up, chest roentgenogram, 12 lead peripheral EKG and transthoracic echocardiogram were performed in 240 female/males patients. All of them were bled to blindly search for T. cruzi antibodies.

RESULTS

Seroprevalence was 8%, 49 cases of dilated cardiomyopathy were diagnosed 23 attributed to chronic diseases such as systemic hypertension diabetes mellitus or ischemic heart disease 12 with idiopathic disease and 14 (29%) had CCC. The latter accumulated epidemiologic features suggestive of vectorial infection. Four additional individuals without CCC but having specific antibodies were considered indeterminate Chagasic cases.

DISCUSSION AND CONCLUSIONS

This case series identify American Trypanosomiasis among 19 people attending a Cardiology Service, and 14 of them had a severe heart disease linked to progressive and fatal course. This observation points out that Chagas disease could be a regional public health problem in Northern Veracruz.

Beta1-adrenergic receptor gene polymorphisms in Mexican patients with idiopathic dilated cardiomyopathy

The objective of the study was to evaluate the role of beta1-adrenergic receptor gene polymorphisms (Ser49Gly and Arg389Gly) as susceptibility markers for idiopathic dilated cardiomyopathy (IDC) in Mexican patients. The polymorphisms were analyzed in 47 patients with IDC and 93 ethnically matched healthy controls by polymerase chain reaction-restriction fragment length polymorphism. The Ser49Gly allele and genotype frequencies were similar in patients and healthy controls. On the other hand, the analysis of the Arg389Gly polymorphism showed an increased frequencies of the *Gly allele (pC = 0.022, OR = 2.16) and *Arg/*Gly genotype (pC = 0.027, OR = 2.70) in the group of IDC patients when compared to healthy controls. The data suggest that Arg389Gly polymorphism could be involved in the genetic susceptibility to develop IDC in Mexicans.

[Epidemiological and clinical outlook of chronic Chagas' heart disease in Mexico]

OBJECTIVE

To compare the epidemiological and clinical characteristics of chronic Chagas' heart disease to other dilated cardiomyopathies.

METHODS

A study comprising 128 patients from a heart disease center was carried out from 1993 to 2003. Of them, 51 (40%) were Trypasonoma cruzi positive. Epidemiological data was obtained through interviews and clinical and serological data from health services. Statistic analysis was conducted using the Chi-square, Fischer, Mann-Whitney or Students' t-test as well as multivariate analysis.

RESULTS

Chronic Chagas' disease patients were older (55+/-10 years old) than those patients with cardiopathy (42+/-17 years old). Most of them were born in rural areas (90% vs 68%), lived in poor (75% vs 16%), crowded households (45% vs 20%), together with domestic animals (71% vs 61%) and were aware of the Chagas' vector (73% vs 25%). Rhythm and conduction ECG abnormalities as well as permanent pacemaker were common among Chagas' patients (84% vs 55%, 78% vs 64% and 24% vs 10%, respectively). Congestive heart failure was more frequent among cardiomiopathy patients (88% vs 71%). Both groups had abnormal myocardial perfusion with normal epicardial arteries. Comorbidities were more frequent in cardiomiopathy patients than in chronic Chagas' disease patient (two cases only).

CONCLUSIONS

Chagas' disease is the most common cause of dilated cardiomiopathy in the study hospital. Due to its regional distribution in Mexico, it deserves special attention and control programs proven to be effective in other countries.

Trypanocidal drugs for late stage, symptomatic Chagas disease (Trypanosoma cruzi infection)

BACKGROUND

People with Chagas disease (American Trypanosomiasis) may develop progressive and potentially lethal heart conditions. Drugs to eliminate the causative parasite, Trypanosoma cruzi, currently in use have limited therapeutic value and are used in early stages of the disease. Extending the use of these drugs to treat symptomatic chronic parasitism with chronic Chagasic cardiopathy (CCC) and progressive dilated cardiomyopathy has been proposed.

OBJECTIVES

To assess the effects (harms and benefits) of nitrofurans and imidazolic trypanocidal drugs for treating late stage chronic Chagas disease and CCC.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2004), MEDLINE (1985-2004), EMBASE (1985-2004), BIREME (1985-2004), LILACS (1985-2004), ARTEMISA (1985-2004), SCIELO (1985-2004). Indexing terms in English and Spanish were used. References obtained were assessed for relevance by two reviewers independently.

SELECTION CRITERIA

We included randomized controlled clinical trials (RCTs), single or double blind using trypanocidal drugs versus placebo or no treatment in CCC.

DATA COLLECTION AND ANALYSIS

All articles retrieved were assessed using a predefined check list to determine if they met the inclusion criteria. Two independent reviewers collected data using a pre-designed form piloted on three articles before the review process started. Disagreements were resolved by a third reviewer. If the information was unavailable the articles were excluded. We planned a quantitative analysis of reduction of parasite load whether recorded as a categorical variable or the reduction of specific antibody titers. However insufficient data were available for quantitative analysis. We prepared a qualitative description of data identified.

MAIN RESULTS

We found only one randomized double blind placebo controlled trial. We also found six uncontrolled or non-randomized studies which were of some relevance and were therefore described. We found insufficient evidence to define the effects of drug treatment for people with CCC.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the efficacy of nitrofurans or imidazolic drugs as recommended treatment in CCC and chronic T.cruzi infections, specifically if overt heart disease is present. A well designed randomized controlled trial is necessary to establish if new drugs are suitable for treatment of cardiac patients with CCC.

Autoantibodies to Human Heart Conduction System in Chagas' Disease

Destruction of heart tissue in chronic chagasic cardiopathy may be caused by autoimmune recognition of heart tissue. Indirect evidence suggests that there is antigenic cross-reactivity between Trypanosoma cruzi and heart tissue. The objective of this study was to determine whether seric autoantibodies against atrio-ventricular (AV) node and sinus auricular node tissues are markers of chronic cardiopathy condition. We searched for the presence of seric autoantibodies against AV node and sinus auricular node tissues in 25 sera from chronic chagasic cardiopathy patients, 20 sera from non-chagasic cardiopathy patients, 20 sera from indeterminate chagasic subjects, and 20 sera from healthy blood donors as controls. Diagnosis of dilated cardiopathy was established based on the left-ventricular end systolic dimension and cardiothoracic ratio on chest x-radiography and impaired contracting ventricle, and chagasic etiology by demonstration of circulating antibodies using ELISA and IIF. Autoantibody detection against conduction heart tissue was carried out by immunohistochemical test. The tissues were obtained from non-cardiopathy necropsy case. Human sera were diluted at 1:10 in PBS-FSB. Goat antihuman laminin was used as positive control. Autoantibodies were more frequently found in chronic chagasic cardiopathy (20%) compared to non-chagasic cardiopathy (5%) and indeterminate chagasic subjects (5%), pattern staining define interstitial and membrane targets on rich conduction system tissue. In conclusion seric autoantibodies against heart conduction system are not a good markers for chagasic cardiopathy group. Their presence showed no clear association with complex rhythm/conduction aberrations.

[Antibodies against T. cruzi in patients with dilated cardiomyopathy in Tuxtla Gutierrez, Chiapas]

Chagas disease is caused by the flagellate protozoan T: cruzi. Seroepidemiological surveys in Chiapas, Mexico have shown seropositive individuals, therefore, we searched for people affected by the chronic form of Chagas disease which involves the heart, causing a chronic, progressive and fatal disease called Chronic Chagasic Cardiopathy (CCC).

MATERIAL AND METHODS

To establish the frequency of CCC we studied 28 patients seen at the Hospital General Regional "Dr. Rafael Pascacio Gamboa" during October 2002 through October 2003 in Tuxtla Gutierrez, Chiapas, the State capital city, with diagnosis of dilated cardiomyopathy (DC), a serological survey for antibodies against T. cruzi was done. This hospital cares for people from all parts of Chiapas, Mexico. Clinical diagnosis of DC was established there and blind serological studies were performed in Mexico City.

RESULTS

Fifteen out of 28 DC patients (54%) had anti T. cruzi antibodies. All of them came from poor rural villages and they had heart failure and/or arrhythmia or heart blockade on EKG.

CONCLUSIONS

This observation suggest that in Chiapas were Chagas disease is endemic, there are CCC patients. Any case with a clinical diagnosis of DC should be tested for antibodies against T. cruzi. The low socioeconomic status, culture and environment in this Mexican State favour the presence and transmission of this parasitic disease.

[Primary acute myocarditis. A 10- years institutional experience]

Acute myocarditis (AM) is associated with viral infections: Coxsackie and ECHOviruses among others. Autoimmunity has been proposed as a pathogenic mechanism. Benefit of classic immunosuppression (prednisone-azathioprine) or immunomodulation (monomeric-human IgG) is still uncertain.

OBJECTIVE

To review incidence and clinical approach to AM at a Cardiology referral center.

MATERIAL AND METHODS

A 10-yeard period (1992-2003) is reviewed. A standard questionary was applied to 49 consecutive patients referred by clinicians with a diagnosis of AM.

RESULTS

AM was found in 17 women and 32 men, median age 24 and 28 years, respectively. They presented heart failure with dyspnea/ortopnea (70-47%), peripheral edema/jugular vein plethora (41-37%), chest pain, and tachycardia (50%), NYHA functional class was Ill-IV in 22. The EKG showed sinus tachycardia or conduction defects. Transthoracic echocardiograms in 47 cases showed EF (mean) of 41% with enlarged left ventricle diameter. Antivirus antibodies were present in 54% of those cases studied, Coxsackie or ECHOvirus were identified through a serologic assay. Twenty-nine (61%) of our cases developed dilated cardiomyopathy, three patients died. It is not possible to reach a conclusion regard to immunomodulation therapy, because it was applied to only 12 patients.

CONCLUSIONS

At the Instituto Nacional de Cardiología "I. Chávez", AM depicts an incidence of 1/1,000 patients a year. It is necessary to standardize the clinical approach for diagnosis and treatment, progression to dilated cardiomyopathy and death during acute stage occurs in two-thirds of our patients.

Trypanosoma cruzi isolates from Mexican and Guatemalan acute and chronic chagasic cardiopathy patients belong to Trypanosoma cruzi I

Trypanosoma cruzi is classified into two major groups named T. cruzi I and T. cruzi II. In the present work we analyzed 16 stocks isolated from human cases and four isolated from triatomines from diverse geographical origins (Mexico and Guatemala). From human cases four were acute cases, six indeterminates, and six from chronic chagasic cardiophatic patients with diagnosis of dilated cardiomyopathy established based on the left-ventricular end systolic dimension and cardiothoracic ratio on chest X-radiography and impaired contracting ventricle and different degree conduction/rhythm aberrations. DNA samples were analyzed based on mini-exon (ME) polymorphism, using a pool of three oligonucleotide for the amplification of specific intergenic region of T. cruzi ME gene. All the Mexican and Guatemalan isolates regardless their host or vector origin generated a 350 bp amplification product. In conclusion T. cruzi I is dominant in Mexico and Guatemala even in acute and chronic chagasic cardiopathy patients. To our knowledge, this is the first study describing predominance of T. cruzi I in human infection for North and Central America.

Comparative study of the residues 63 and 67 on the HLA-B molecule in patients with Takayasu's Arteritis

Takayasu's Arteritis (TA) has been associated with the Major Histocompatibility Complex (MHC) genes; nevertheless, results in several populations have been heterogeneous. Studies both in Mexican and Asian populations suggest that residues at positions 63 (glutamic acid) and 67 (serine) of the HLA-B molecule could be the genetic markers for TA. In the present work, we analyzed the sequence of HLA-B alleles in 26 TA patients and 62 healthy controls. HLA-B subtyping analysis showed that all B52 alleles were B*5201, whereas only one HLA-B39 allele was B*3902. Sequencing of HLA-B alleles showed that 19 out of 26 patients studied (73.0%) presented at least an allele with glutamic acid at position 63 and serine at position 67. This condition was observed in only 21.0% of the healthy controls (pC = 0.00001, OR = 10.23). Out of the seven remaining patients, one presented glutamic acid at position 63 and four showed serine at position 67. Two patients (2/26 = 7.7%) and 24 healthy controls (24/62 = 38.7%) did not show similarity at the mentioned positions (pC = 0.016, OR = 0.13). These data corroborate the participation of positions 63 and 67 in the genetic susceptibility to TA and explain the high heterogeneity of alleles associated with the disease in several populations.

Gender impact in systemic lupus erythematosus

OBJECTIVE

Systemic Lupus Erythematousus (SLE), an autoimmune disease of unknown etiology manifesting as a pleomorphic systemic disease, affects mostly females, (female:male ratio 9:1). Clinical differences between genders, including a higher death rate in males, has been reported. Here we compared clinical manifestations and the 5-year survival probability in Mexican male and female crossbred cases living under similar socioeconomic conditions. A systematic review of published literature was also carried out.

MATERIAL AND METHODS

SLE patients treated at the Instituto Nacional de Cardiología "Ignacio Chávez" México City who fulfilled at least four classification criteria (ACR) were included. The frequency of clinical variables with emphasis on cardiovascular findings before and after the diagnosis were described, disease activity based on a validated scale (SLEDAI) was determined, and the 5-year survival rate was estimated.

RESULTS

There were 33 men and 158 women, average age of 31 in both groups ranging from 7 to 65 and from 10 to 75 year in male and female patients respectively; both groups were followed for 3.8 years (median), average activity was of 12 points with a range of 5 to 23 in men, and 11 with a range of 2 to 24 in women. Main clinical characteristics in men were: discoid lupus, psychosis, pericarditis, lymphopenia, thrombocytopenia and SLE kidney disease. Immunological tests showed gender-linked differences in regard auto-antibodies (U1-nRNP, Sm, anticardiolipine and false VDRL) and hypocomplementemia. Cardiovascular features and survival rate were not different between gender.

CONCLUSION

Male Mexican SLE patients share clinical findings with other male SLE cases reported everywhere as can be deducted from systematic literature review covering 25-year.

Methods to detect antifibrillarin antibodies in patients with systemic sclerosis (SSc): a comparison

Autoantibodies against nucleolar antigens are common in systemic sclerosis (SSc). They include autoantibodies against fibrillarin (Fb), which are serological markers for SSc. Fb is associated with the evolutionally-conserved box C/D of small nucleolar RNAs (snoRNAs). We compared indirect immunofluorescence (IIF), Western blot (WB), and immunoprecipitation (IPP) of total small RNAs assays to determine which of these techniques is most specific for the detection of snoRNPs. We also examined the frequency and specificity of autoantibodies from SSc patients to snoRNAs, snRNAs, and scRNAs, and concluded that 1) IIF can not determine autoantibody specificity against Fb, 2) 36% of SSc sera were false-negative by WB, and 3) by IPP, anti-Fb autoantibodies from SSc patients can bind U3, U8, U13, U15, and U22 snoRNAs.

[Biotic and abiotic determinants of seroprevalence of antibodies against Trypanosoma cruzi in Palmar de Bravo, Puebla, Mexico]

OBJECTIVE

To establish the relationship between seroprevalence for antibodies against Trypanosoma cruzi and its relationship with biotic and abiotic factors.

MATERIAL AND METHODS

A cross-sectional study was conducted between August 2000 and September 2001. The study population consisted of a simple random sample of 390 volunteers residing in Palmar de Bravo, Puebla, Mexico. Sample and data collection procedures included assaying antibodies against T. cruzi with validated assays, and searching for domestic reservoirs and triatomine bugs. The relationship between biotic and abiotic factors with seropositivity was assessed. Statistical analysis was conducted using Kappa values for diagnostic tests; statistical significance was assessed with 2 x 2 tables, chi-squared test with Yates' correction, Fisher exact test, and odds ratios.

RESULTS

The seroprevalence of T. cruzi infection in humans was 4%; in domestic reservoirs (horses, pigs, and dogs) only 10% of canine reservoirs were positive. Vector species recognized were T. borberi and T. pallidipennis, with a Dispersion Area Index and a Colonization Index of 55% and 40%, respectively. The most important risk factors associated with positive serology were altitude (>2,150 and <2,180 meters above sea level), presence of triatomines, age, time of residence, and participation in a social assistance program.

CONCLUSIONS

T. cruzi infection was identified in human beings, vectors, and possibly in domestic reservoirs, in communities located over 2,000 meters above sea level.

MHC class II alleles in Mexican patients with rheumatic heart disease

BACKGROUND

Rheumatic heart disease (RHD) is an autoimmune sequel of group A streptococcal infection that has been associated with the presence of some major histocompatibility complex (MHC) genes. Thus, the aim of the present study was to investigate the role of class II alleles in the genetic susceptibility to RHD in Mexican patients and establish the relationship of these alleles with the pattern of valve damage.

METHODS

HLA-DR, -DQA1 and -DQB1 allele frequencies were determined by PCR-SSO reverse dot blot and PCR-SSP in 98 Mexican Mestizo patients with RHD and 99 healthy controls. Patients were divided into mitral valve damage (n=46), multivalvular lesion (n=49) and aortic damage (n=3).

RESULTS

RHD patients presented an HLA-DR16 increased frequency (pC=0.009, OR=3.9) and a decreased HLA-DR11 frequency (pC=0.018) when compared to healthy controls. HLA-DR16 subtyping showed that DRB1*1602 was the DR16 allele increased in patients (pC=0.007, OR=5.3). Haplotype analysis showed increased frequency of DR16-DQA1*0501-DQB1*0301 in RHD patients when compared to healthy controls (pC=0.011). HLA-DR16 frequency remained significantly increased on patients with multivalvular lesion (pC=0.004, OR=4.8).

CONCLUSIONS

Our data suggest an important participation of Amerindian autochthonous HLA-DR16 (DRB1*1602) allele and DR16-DQA1*0501-DQB1*0301 haplotype as markers for RHD genetic susceptibility in the Mexican Mestizo population. HLA-DR16 allele could also play an important role in determining the pattern of valve damage on these patients.

Tumor necrosis factor-alpha promoter polymorphisms in Mexican patients with rheumatic heart disease

The major histocompatibility genes (MHC) have been associated with the genetic susceptibility to rheumatic heart disease (RHD). Results have been inconsistent and new genes located on the MHC region such as tumor necrosis factor (TNF-alpha) need to be analyzed. TNF-alpha polymorphisms (positions -238 and -308) were determined in 87 RHD Mexican Mestizo patients and 101 healthy controls. Patients were classified into mitral valve damage (MVD) and multivalvular lesion (MVL) categories. TNF-238 G allele and GG genotype were increased in patients when compared to healthy controls (pC=0.001, OR=14.1 and pC=0.003, OR=14.1, respectively). Also, decreased frequencies of TNF-238 A allele (pC=0.001) and AG genotype (pC=0.003) were found. TNF-308 polymorphism analysis showed increased frequencies of T2 (A) allele (pC<10(-3), OR=10.8) and T1T2 (AG) genotype (pC<10(-3), OR=9.85) and decreased frequencies of T1 (G) allele and T1T1 (GG) genotype (pC<10(-3)). When comparing valvular damage to healthy controls, patients with MVD showed increased frequencies of -238 GG (pC=0.03, OR=ND), -308 T1T2 (AG) (pC<10(-3), OR=14) and -308 T2 (A) (pC<10(-3), OR=11.7). Also, this group showed decreased frequencies of T1 (G) allele and T1T1 (GG) genotype (pC<10(-3)). Patients with MVL presented increased frequency of -308 T2 (A) allele (pC=0.0003, OR=8.65) and decreased frequencies of -308 T1 (G) allele and -308 T1T1 (GG) genotype (pC=0.0003 and pC=0.006, respectively). Distribution of -238 and -308 polymorphisms were similar between MVD and MVL. The data demonstrate that RHD is associated with TNF-alpha polymorphisms in the Mexican population; however, these polymorphisms do not have relation with the valve damage.

Electrocardiographic findings in Mexican chagasic subjects living in high and low endemic regions of Trypanosoma cruzi infection

In México the first human chronic chagasic case was recognized in 1940. In spite of an increasing number of cases detected since that time, Chagas disease in México has been poorly documented. In the present work we studied 617 volunteers subjects living in high and low endemic regions of Trypanosoma cruzi infection with seroprevalence of 22% and 4% respectively. Hemoculture performed in those seropositive subjects failed to demonstrate circulating parasites, however polymerase chain reaction identified up to 60% of them as positives. A higher level of anti-T. cruzi antibodies was observed in seropositive residents in high endemic region, in spite of similar parasite persistence (p < 0.05). On standard 12 leads electrocardiogram (ECG) 20% to 22% seropositive individuals from either region showed right bundle branch block or ventricular extrasystoles which were more prevalent in seropositive than in seronegative individuals (p < 0.05). In conclusion, the frequency or type of ECG abnormality was influenced by serologic status but not by endemicity or parasite persistence. Furthermore, Mexican indeterminate patients have a similar ECG pattern to those reported in South America.

Familial collapsing glomerulopathy: clinical, pathological and immunogenetic features

BACKGROUND

Collapsing glomerulopathy (CG) is an aggressive form of glomerular injury frequently seen in association with HIV infection, although it is also recognized in non-HIV patients as a primary disease. Until now, the occurrence of CG in a familial pattern has not been reported.

METHODS

We studied five members of a family (siblings), admitted for evaluation of proteinuria and nephrotic syndrome. They had no other family history of renal disease. Blood samples for major histocompatibility complex (MHC) analysis were obtained from the five siblings, both parents and four relatives.

RESULTS

Renal biopsy performed in four out of the five siblings revealed capillary collapse and retraction with visceral epithelial cell swelling and reabsorption droplets, consistent with CG. Two of the patients had suggestive symptoms of systemic lupus erythematosus, such as arthritis, rash, hair loss, moderate leukopenia and lymphopenia, low titers of antinuclear antibodies (ANA) and anti-SSA/Ro antibodies, but no immune complex deposition on renal biopsy. IgG serology for parvovirus B19 (PVB-19) was positive only in two siblings but polymerase chain reaction (PCR) was negative. Immunogenetic analysis showed that all patients shared the same MHC haplotype inherited from the mother.

CONCLUSIONS

CG can present in a familial pattern. Since a similar MHC haplotype was observed in affected and non-affected members of the family, we conclude that the environment plays an important role in the development of the disease.

Anticardiolipin antibodies are not associated with rheumatic heart disease

The aim of this study was to examine the prevalence of anticardiolipin antibodies in rheumatic valve heart disease. Serum samples of 31 consecutive patients with rheumatic heart disease and documented valve involvement, as well as six patients with acute rheumatic fever were tested for IgG anticardiolipin antibodies by a validated ELISA. No anticardiolipin antibodies were found when a cut-off point set at mean +/- 5 s.d. was applied. We can conclude that anticardiolipin antibodies are not present in rheumatic heart disease patients and, as suggested by several observations, these antibodies do not appear to have a pathogenic role in this particular disease.

[How much does the medical treatment of chronic Chagas cardiopathy cost? Direct costs in a cardiology hospital]

OBJECTIVE

To estimate health care costs of patients with chronic Chagasic cardiomyopathy (CCC) in a cardiovascular referral center (Instituto Nacional de Cardiología I. Chávez).

MATERIAL AND METHODS

In a retrospective study, 13 clinical charts of CCC patients treated in the hospital during 1998 were reviewed. Diagnostic and therapeutic procedures and patients admission were identify as well as health care costs, which were drawn from the hospital costs system.

RESULTS

62% of the cases were admitted to the hospital through the out-patient facilities. All the patients had a health care subsidy of 15 to 55% allocated to the institutional budget. Health care costs were calculated for minimal, average, and maximum scenarios, according to the patient's clinical stage and the price of medical equipment used (low, medium, and high). Most of the health care costs are due to the use of high cost diagnostic equipment (33 a 58%) and hospital stay (including the emergency room) (19 a 28%).

CONCLUSION

This is the first approximation to the economic study of Chagas disease in Mexico, providing foundations for further studies on health economics and quality care of CCC, and suggests that prevention should be enhanced.