Análisis de serie de tiempo de patrones estacionales en defunciones por neumonía en el Perú, periodo 2003-2017

Introducción. Es un concepto generalizado que las infecciones respiratorias son estacionales, pero pocas veces se precisan localmente estos períodos de alta frecuencia en un país con diversidad de climas. Anticipar la temporada de neumonía a nivel local puede proveer de un mejor uso de recursos críticos. Objetivo. Examinar la variabilidad estacional en defunciones mensuales por neumonía en el Perú. Métodos. Estudio observacional retrospectivo de análisis de serie de tiempo para identificar períodos de alta mortalidad por neumonía en siete ciudades del Perú. Se revisaron registros administrativos del Ministerio de Salud sobre defunciones por neumonía durante los años 2003-2017. Se calcularon estadísticas descriptivas y se analizó mediante una serie de tiempo a escala mensual la frecuencia de defunciones por neumonía, precipitación acumulada, y la temperatura ambiental máxima y mínima. Resultados. El 94,4% de las defunciones por neumonía (N = 166 844) reportaron como causa «organismo no especificado», y el 75,6% eran adultos mayores de 65 años. En Tarma, Arequipa y Cusco la temperatura mínima tiene una correlación negativa con las defunciones por neumonía en todas las edades y al menos uno de los grupos de riesgo. En Iquitos la temperatura mínima tiene una correlación positiva con las defunciones en menores de 5 años. Pucallpa y Cajamarca no tuvieron correlaciones significativas. El clima de Lima es un caso particular. La distribución durante el año de las muertes por neumonía sugiere una secuencia norte-sur, mientras que el análisis espaciotemporal del clima sugiere un patrón que va de sur-norte. Conclusión. Existen diferentes patrones estacionales en diferentes ciudades y grupos de riesgo.

An Outbreak of Bartonella bacilliformis in an Endemic Andean Community

Background

Bartonellosis affects small Andean communities in Peru, Colombia and Ecuador. Research in this area has been limited.

Methods

Retrospective review of 191 cases of bartonellosis managed in Caraz District Hospital, Peru, during the last outbreak (2003).

Results

The majority of cases (65%) were 14 years old and younger. There was a peak in acute cases after the rainy season; chronic cases presented more constantly throughout the year. The sensitivity of blood smear against blood culture in acute disease was 25%. The most commonly used treatment for chronic disease was rifampicin; chloramphenicol was used to treat most acute cases. Complications arose in 6.8% and there were no deaths.

Conclusions

Diagnostic and treatment algorithms for acute and chronic bartonellosis have been developed without a strong evidence base. Preparation of ready-to-go operational research protocols for future outbreaks would strengthen the evidence base for diagnostic and treatment strategies and enhance opportunities for control.

Description of Bartonella ancashensis sp. nov., isolated from the blood of two patients with verruga peruana

Three novel isolates of the genus Bartonella were recovered from the blood of two patients enrolled in a clinical trial for the treatment of chronic stage Bartonella bacilliformis infection (verruga peruana) in Caraz, Ancash, Peru. The isolates were initially characterized by sequencing a fragment of the gltA gene, and found to be disparate from B. bacilliformis. The isolates were further characterized using phenotypic and genotypic methods, and found to be genetically identical to each other for the genes assessed, but distinct from any known species of the genus Bartonella, including the closest relative B. bacilliformis. Other characteristics of the isolates, including their morphology, microscopic and biochemical properties, and growth patterns, were consistent with members of the genus Bartonella. Based on these results, we conclude that these three isolates are members of a novel species of the genus Bartonella for which we propose the name Bartonella ancashensis sp. nov. (type strain 20.00T = ATCC BAA-2694T = DSM 29364T).

[Carrión's disease complicated with severe acute leptospirosis: a case report]

The case of an adult, 56 year old male is reported, from Sihuas (Ancash) who presented at Hospital Nacional Dos de Mayo with fever, jaundice and anemia. In three days of hospitalization, he developed severe anemia (Hb: 11.8 to 6.7 g / dL) and generalized myalgias associated with a sudden worsening jaundice correlated with elevated bilirubin (TB 3.2 to 19.6 mg / dL direct dominance) and general deterioration. Microbiological smear and culture were positive for Bartonella bacilliformis. Subsequent serology (microagglutination) was positive for Lesptospira serovar Pomona. The patient was given specific antibiotic therapy (ceftriaxone and ciprofloxacin), transfused two units of packed red blood cells, improved clinically and was discharged.

Disseminated intra-abdominal hydatidosis

We present the case of a 26-year-old male Peruvian patient who presented with disseminated intra-abdominal hydatidosis. The patient was treated with surgical removal of the cysts and prolonged medical treatment with albendazole.

Compromiso del sistema nervioso central en la enfermedad de Carrión

.

Bartonella bacilliformis: a systematic review of the literature to guide the research agenda for elimination

Background

Carrion's disease affects small Andean communities in Peru, Colombia and Ecuador and is characterized by two distinct disease manifestations: an abrupt acute bacteraemic illness (Oroya fever) and an indolent cutaneous eruptive condition (verruga Peruana). Case fatality rates of untreated acute disease can exceed 80% during outbreaks. Despite being an ancient disease that has affected populations since pre-Inca times, research in this area has been limited and diagnostic and treatment guidelines are based on very low evidence reports. The apparently limited geographical distribution and ecology of Bartonella bacilliformis may present an opportunity for disease elimination if a clear understanding of the epidemiology and optimal case and outbreak management can be gained.

Methods

All available databases were searched for English and Spanish language articles on Carrion's disease. In addition, experts in the field were consulted for recent un-published work and conference papers. The highest level evidence studies in the fields of diagnostics, treatment, vector control and epidemiology were critically reviewed and allocated a level of evidence, using the Oxford Centre for Evidence-Based Medicine (CEBM) guidelines.

Results

A total of 44 studies were considered to be of sufficient quality to be included in the analysis. The majority of these were level 4 or 5 (low quality) evidence and based on small sample sizes. Few studies had been carried out in endemic areas.

Conclusions

Current approaches to the diagnosis and management of Carrion's disease are based on small retrospective or observational studies and expert opinion. Few studies take a public health perspective or examine vector control and prevention. High quality studies performed in endemic areas are required to define optimal diagnostic and treatment strategies.

Carrion's disease is one of the truly neglected tropical diseases. It affects children predominantly in small Andean communities in Peru, Colombia and Ecuador. Case fatality rates of untreated acute disease can exceed 80% during outbreaks. Diagnostic and treatment guidelines are based on very low evidence reports and public health and prevention programs have been limited. This paper presents the first systematic review of Carrion's disease in Peru and encompasses a detailed analysis of all the highest level evidence regarding not only diagnosis and management but also vector control and prevention. In the review, the authors highlight the considerable knowledge gaps in this field and suggest a strategy for a renewed effort in its investigation. The authors hope that through this work we will be able to develop a better understanding of the epidemiology, natural history and optimal approaches to case and outbreak

Cytokines and T-Lymphocute count in patients in the acute and chronic phases of Bartonella bacilliformis infection in an endemic area in peru: a pilot study

Human Bartonellosis has an acute phase characterized by fever and hemolytic anemia, and a chronic phase with bacillary angiomatosis-like lesions. This cross-sectional pilot study evaluated the immunology patterns using pre- and post-treatment samples in patients with Human Bartonellosis. Patients between five and 60 years of age, from endemic areas in Peru, in the acute or chronic phases were included. In patients in the acute phase of Bartonellosis a state of immune peripheral tolerance should be established for persistence of the infection. Our findings were that elevation of the anti-inflammatory cytokine IL-10 and numeric abnormalities of CD4(+) and CD8(+) T-Lymphocyte counts correlated significantly with an unfavorable immune state. During the chronic phase, the elevated levels of IFN-γ and IL-4 observed in our series correlated with previous findings of endothelial invasion of B. henselae in animal models.

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.

Clinical Evaluation of a 16S Ribosomal RNA Polymerase Chain Reaction Test for the Diagnosis of Lymph Node Tuberculosis

Reports on the sensitivity of polymerase chain reaction (PCR) for the diagnosis of lymph node tuberculosis (TB) show divergent results. We evaluated the accuracy of the Roche Amplicor Mycobacterium tuberculosis PCR test with lymph node aspirate and biopsy samples.

METHODS

The study was conducted at a public reference hospital in Lima, Peru. From the period of January 2003 to January 2004, we included patients who had lymphadenopathy and in whom the attending physician suspected TB. Aspirate and biopsy samples were submitted for culturing in Lowenstein-Jensen medium, for histopathologic testing, and for PCR. The sensitivity and specificity of PCR were calculated against a reference standard based on histopathologic findings and culture.

RESULTS

Our study included 154 patients. Median age was 29 years (interquartile range, 21-40 years); 97 patients (62.9%) were men. Twenty-nine patients (18.8%) had acid fast bacilli-positive histopathologic findings, and 44 (28.6%) had a positive culture result. Using the combination of histopathologic findings and culture as reference standard, 55 patients (35.7%) had a diagnosis of tuberculous lymphadenitis. The sensitivity of the PCR test was 58.2%, and the specificity was 93.9%. For biopsy tissue only, the sensitivity of PCR was 52.7%, and the specificity was 97.0%. For aspirate samples only, the sensitivity of PCR was 47.3%, and the specificity was 96.0%.

CONCLUSION

The Amplicor PCR test revealed low sensitivity and high specificity for the diagnosis of lymph node TB. The sensitivity was higher in cases in which the bacillary load was high--in acid fast bacilli-positive samples and among HIV-infected patients. Considering the results of microbiological and PCR tests together, there was still a patient group in whom no final diagnosis could be established.

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.

Bartonelosis (Carrion's Disease) in the pediatric population of Peru: an overview and update

Bartonellosis, or Carrion's Disease, is an endemic and reemerging disease in Peru and Ecuador. Carrion's Disease constitutes a health problem in Peru because its epidemiology has been changing, and it is affecting new areas between the highland and the jungle. During the latest outbreaks, and previously in endemic areas, the pediatric population has been the most commonly affected. In the pediatric population, the acute phase symptoms are fever, anorexia, malaise, nausea and/or vomiting. The main signs are pallor, hepatomegaly, lymphadenopathies, cardiac murmur, and jaundice. Arthralgias and weight loss have also commonly been described. The morbidity and mortality of the acute phase is variable, and it is due mainly to superimposed infections or associated respiratory, cardiovascular, neurological or gastrointestinal complications. The eruptive phase, also known as Peruvian Wart, is characterized by eruptive nodes (which commonly bleed) and arthralgias. The mortality of the eruptive phase is currently extremely low. The diagnosis is still based on blood culture and direct observation of the bacilli in a blood smear. In the chronic phase, the diagnosis is based on biopsy or serologic assays. There are nationally standardized treatments for the acute phase, which consist of ciprofloxacin, and alternatively chloramphenicol plus penicillin G. However, most of the treatments are based on evidence from reported cases. During the eruptive phase the recommended treatment is rifampin, and alternatively, azithromycin or erythromycin.

Report of an unusual case of persistent bacteremia by Bartonella bacilliformis in a splenectomized patient

We report a case of a 56-year-old man with a history of splenectomy for idiopathic thrombocytopenic purpura who developed persistent bacteremia in the acute phase of human bartonellosis. This patient did not develop hemolytic anemia. Only after several courses of antibiotic treatment was the infection eradicated. This is an unusual case of overwhelming post-splenectomy infection by Bartonella bacilliformis, which provides clinical evidence that the spleen is a critical effector organ of clearance of this infection as well as the effector organ of bartonellosis-associated hemolytic anemia.

Carrion's disease (Bartonellosis bacilliformis) confirmed by histopathology in the High Forest of Peru

Bartonellosis or Carrion's disease is endemic in some regions of Peru, classically found in the inter-Andean valleys located between 500 and 3200 meters above sea level. We report the case of a 43 year-old male patient, farmer, who was born in the Pichanaki district (Chanchamayo, Junin), located in the High Forest of Peru. He presented with disseminated, raised, erythematous cutaneous lesions, some of which bled. The distribution of these lesions included the nasal mucosa and penile region. Additionally subcutaneous nodules were distributed over the trunk and extremities. Hematologic exams showed a moderate anemia. Serologic studies for HIV and Treponema pallidum were negative. The histopathologic results of two biopsies were compatible with Peruvian wart. Oral treatment with ciprofloxacin (500 mg BID) was begun. Over 10 days, the patient showed clinical improvement. This is the first report of a confirmed case of bartonellosis in the eruptive phase originating from the Peruvian High Forest, showing the geographical expansion of the Carrion's disease.

A prospective study of Cat-Scratch Disease in Lima-Peru

Cat-Scratch Disease (CSD) is a benign lymphadenitis that may progress to severe or recurrent forms, and it is occasionally associated with morbidity. Between January of 1998 and March of 1999, forty-three suspected CSD patients were assessed in the Hospital Cayetano Heredia and the Instituto de Salud del Niño, in Lima, Peru. Twelve patients had a confirmed diagnosis, 8 of whom were women, and the mean age was 10 years old. The majority (53%) of the cases were encountered in the summer. All patients reported having had contact with cats. Fever, malaise, lymphadenopathy and skin lesions were the most frequent clinical features. Twelve patients had indirect immunofluorescence antibody test titers of between 1/50 and 1/800 for Bartonella henselae and Bartonella clarridgeiae. Two lymph node biopsies were histologically compatible with CSD. No positive blood cultures could be obtained. This is the first Peruvian prospective study able to identify B. henselae and B. clarridgeiae in pediatric patients.

Natural history of infection with Bartonella bacilliformis in a nonendemic population

An investigation was performed after an outbreak of bartonellosis in a region of Peru nonendemic for this disorder. Symptoms of acute and chronic bartonellosis were recorded. Serological analysis was performed on 55% of the affected population (554 individuals), 77.5% of whom demonstrated previous infection with Bartonella bacilliformis. The attack rate of Oroya fever was 13.8% (123 cases); the case-fatality rate was 0.7%. The attack rate of verruga peruana was 17.6%. A new specific immunostain was developed and used to confirm the presence of B. bacilliformis in the biopsied skin lesions. Most seropositive individuals (56%) were asymptomatic. The symptoms that were associated with prior infection, as determined by Western blot, included fever (37.2% of the seropositive vs. 17.2% of the seronegative population; P<.001), bone and joint pain (27% vs. 9%; P<.001), headache (27% vs. 12.3%; P <.001), and skin lesions described as verruga peruana (26.8% vs. 4.9%; P<.001). Our findings suggest that infection with B. bacilliformis causes a broad spectrum of disease that is significantly milder in severity than that frequently reported.

Bartonellosis. New and old

The number of species that comprise the family of Bartonellaceae, genus Bartonella, has recently increased from one to 11 species, five of which have been associated with different diseases and syndromes in humans. The rapidly growing number of human pathogens has led several investigators to regard bartonellosis and other associated syndromes as important emerging infectious diseases. This article presents the history and epidemiology, clinical features, diagnosis, and treatment of bartonellosis and associated diseases, including Carrión's disease, trench fever, endocarditis and bacteremia, bacillary angiomatosis, and cat-scratch disease.

[GASTROINTESTINAL INVOLVEMENT IN HUMAN BARTONELLOSIS]

We present a prospective study of 68 patients with the acute phase of human bartonellosis, admitted to Cayetano Heredia National Hospital.Gastrointestinal symptoms were reported as follows: abdominal pain 46,3%, coluria 44,4%, vomiting 40,3%, jaundice 38,5%, diarrhea 29,9%, constipation 8,9%. The more common signs were pallor 97%, hepatomegaly 82%, fever 79,1%, malnutrition 75,2%, systolic heart murmur 77,9%, jaundice 71,6%, lymph node enlargement 70,1%.Signs observed during the hospital course were 29,4% lower extremities edema, 22,6% myalgia, 16,4% pericardial effusion, 16,4% generalized edema. The more common gastrointestinal signs were hepatomegaly 82%(52/68), jaundice 71,6% (48/68) and splenomegaly 29,4%(20/68).The -lower liver border was found between 1 to 4 below the lower rib border in 71,6%(48/67) and below 5 cm b. l. r. b. in 11,9%(8/67).60% had abnormal liver function tests, 54,6% had mainly direct bilirrubin elevationand 45,4% mainly indirect.SGOT was elevated in 28,5% and SGPT in 25%, 28,3% had elevated alkaline phosphatase. The bilirrubin media was 3,5 mg/dI (range 0,6-21), the indirect bilirrubin media was 1,6 mg/dI (range 0,5-11,5), the direct bilirrubin media was 1,9 mg/dI (range 0,3-18), The SGOT media 73,9 U/L (range 9-1250), SGPT media 65,5U/L (range 6-1596). Alkaline phosphatase 5,9 mui/ml (range 3-497). Albumin media 3,09 (range 2-4,2).Patients with bacterial coinfection (salmonella, staphilococcus, enterobacter, shigella) had a higher increase in bilirrubin and transaminases.Three patients had liver biopsies, two revealed Küpffer cells hyperplasia (moderate to severe), one revealed intracellular hyperplasia, one patient coinfected with diseminated hystoplasmosis had granulomas in the liver.Mortality(8,8%) was associated to hepatocellular involvement (SGOT media 330U/L, SGPT media 207 U/L, alkaline phosphatase media 183 mui/ml), hypoalbuminemia media = 2,4 gr/1) and generalized edema.

Randomized comparison of aztreonam and chloramphenicol in treatment of typhoid fever

Patients with clinical typhoid fever plus a blood, bone marrow, or bile positive for Salmonella typhi or Salmonella paratyphi were included in an open clinical trial to compare the efficacy of aztreonam (6 g/day [2 g intravenously every 8 h]) given for 10 days with that of chloramphenicol (50 mg/kg of body weight per day [intravenously or orally]) administered for 14 days. A total of 44 patients, 22 in each group, were included in the study, and both groups were comparable in terms of baseline parameters. All patients randomized to receive chloramphenicol completed the 14 days of treatment, while two patients randomized to receive aztreonam developed an intestinal hemorrhage, and a third patient elected to withdraw from the trial. Defervescence occurred more quickly in the subjects receiving chloramphenicol than in those receiving aztreonam (P < 0.05). All patients in the chloramphenicol group were clinically cured during therapy, while four patients (21%) in the group receiving aztreonam were declared clinical treatment failures. None of the 19 patients receiving aztreonam, compared with 7 of 22 (32%) patients receiving chloramphenicol, had a positive blood culture after 24 h of therapy (P < 0.05). Adverse experiences were unusual and mild. In the study, aztreonam was less effective than chloramphenicol with regard to clinical effectiveness and time of defervescence but was more effective in the elimination of the infecting Salmonella organisms from the bloodstream.

[Epidemiological and clinical features of brucellosis in 39 family groups]

Clinical epidemiological evaluations on brucellosis, done during the last five years in endemic areas in Lima (Peru), in 39 families with 232 members, have let us observe a high rate of symptomatic infection 118/232 (50.9%) and has also let us identify, as risk factors to contract the disease; age older than 10 years 97/190 (56.3%) versus 11/42 (26.1%); in younger than 10 years of age (p less than 0.05) and families with 5 or less members 40/54 (74.0%) versus 78/175 (44.5%) of more numerous families (p less than 0.001), and also to be exposed to a common source as a form to contract the disease. We observed the importance of an adequate treatment in early stages of the disease. We detected major clinical gravity in women 23/55 than in men 5/38 (p less than 0.01), specially in brucellar arthritis (p less than 0.05). Period of time between the appearance of index case and secondary cases was of 33.8 days, but range was of 1-115 days. The heterogeneous aspects of the disease between members of the same family, suggest that response of host, more than bacterial virulence, is so important in the clinical course of the disease.

Comparison of single-dose treatment with norfloxacin and standard 5-day treatment with trimethoprim-sulfamethoxazole for acute shigellosis in adults

Shigellae have been shown to be highly susceptible to new quinolone agents, with average MICs for 90% of isolates of less than 0.1 microgram/ml. Because these agents also reach high concentrations in the stool after a single dose, the effectiveness of a single 800-mg dose of norfloxacin and of 5-day treatment with trimethoprim-sulfamethoxazole (TMP-SMX) were compared in a randomized trial. Patients with clinical dysentery received one of these treatment regimens, and clinical data and follow-up culture results were analyzed for patients whose stool culture on presentation grew shigellae. When 55 patients with shigellosis (26 treated with TMP-SMX, 29 treated with norfloxacin) whose bacterial isolates were susceptible to the antibiotic given were compared by treatment group, no significant differences were seen in days of illness (mean, 2.5 +/- 0.65 days with TMP-SMX and 2.0 +/- 0.47 days with norfloxacin; P = 0.200) or number of unformed stools after starting treatment (mean, 9.7 +/- 2.37 stools with TMP-SMX and 7.6 +/- 3.19 stools with norfloxacin; P = 0.312). Resistance in vitro to TMP-SMX was seen in 15% of Shigella isolates, whereas none was resistant to norfloxacin. Bacteriologic failure was found in 1 patient among 24 receiving TMP-SMX and in none of 25 patients receiving norfloxacin. One single dose of norfloxacin was as effective as 5 days of treatment with TMP-SMX in these adults with shigellosis.