Plantar pressure distribution and altered postural control in multibacillary leprosy patients

BACKGROUND

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, predominantly affecting the peripheral nerves, resulting in sensory and motor deficits in the feet. Foot ulcers and imbalances are frequent manifestations in leprosy, often correlating with diminished sensitivity. While clinical scales and monofilament esthesiometers are conventionally utilized to evaluate foot sensitivity and balance in these patients, their discriminatory power is limited and their effectiveness is greatly dependent on the examiner's proficiency. In contrast, baropodometry and posturography offer a more comprehensive evaluation, aiming to preempt potential damage events. This study aimed was to assess the correlation between baropodometry and force plate measurements in leprosy patients and control participants, to improve the prevention and treatment of foot ulcers and complications associated with leprosy.

METHODOLOGY

This cross-sectional study was conducted during 2022 and enrolled 39 participants (22 patients with multibacillary leprosy and 17 non-leprosy controls). Demographic data were collected, and a monofilament esthesiometer was used to assess sensory deficits. In addition, physical examinations and balance and plantar pressure tests were conducted. The Student's t-test was used to compare mean and maximum plantar pressures between groups. For most COP variables, a Mann-Whitney Wilcoxon test was used, except for AP amplitude which was analyzed with the Student's t-test due to its normal distribution. The relationship between foot pressure and balance control was assessed using Spearman's correlation, focusing on areas with significant pressure differences between groups.

PRINCIPAL FINDINGS

Leprosy patients showed increased pressure in forefoot areas (T1, M1, T2-T5, and M2) and decreased pressure in hindfoot regions (MH and LH) compared to controls. These patients also displayed higher AP and ML amplitudes, suggesting poorer COP control. Correlation analyses between the two groups revealed that foot plantar pressures significantly impact balance control. Specifically, increased T1 region pressures correlated with greater sway in balance tasks, while decreased MH region pressures were linked to reduced COP control.

CONCLUSIONS/SIGNIFICANCE

The findings suggest a joint disturbance of plantar pressure distribution and static balance control in leprosy patients. These alterations may increase the risk of tissue injuries, including calluses and deformities, as well as falls.

Relationship of handgrip strength with health indicators of people living with HIV in west Pará, Brazil

BACKGROUND

Handgrip strength (HGS) is an important health indicator that can be influenced by body composition and biochemical markers of people living with HIV, contributing to better understanding of health-related outcomes.

OBJECTIVE

To analyze the relationship between HGS and health indicators in people living with HIV.

METHODS

Cross-sectional study, with 207 people living with HIV, attending a reference center, located in Santarém, Pará, Brazil. Data collection covered sociodemographic, clinical, laboratory, physical activity level, body composition, and HGS information. Data were analyzed using descriptive and inferential statistics, adopting p < .05.

RESULTS

There was a predominance of men (60%), aged 33-47 years (42%). A relationship was observed between adequate HGS and the male sex (p < .001), and adequate values for body mass index (p = .003), abdominal circumference (p < .001), and total cholesterol (p = .012). In addition, higher values of fat mass (p < .001), and lower lean mass (p = .006) were observed for people living with HIV with low HGS.

CONCLUSION

People living with HIV present an association between lean body mass and high HGS. On the other hand, low HGS favored obesity and hypercholesterolemia. Thus, monitoring HGS is an important indicator of body, laboratory, and functional capacity changes, with HGS being an additional element in the clinical evaluation.

The Correlation between Anthropometric Variables and Muscular Strength in Patients Coinfected with Leprosy and HIV

Background

Peripheral nerve disease may lead to physical disability because of decreased muscle strength and/or loss of sensitivity in the dermatomes of affected peripheral nerves. Both human immunodeficiency virus (HIV)- and leprosy-affected patients can develop neurological damage; therefore, the coinfection of these diseases presents new challenges to the health care of these patients.

Aims and Objective

This study aimed to investigate the motor alterations of patients coinfected with HIV and leprosy and their relationship with clinical and anthropometric characteristics, compared with individuals with isolated diseases.

Materials and Methods

In this cross-sectional study, 90 individuals were divided equally into three groups: HIV/acquired immunodeficiency syndrome (AIDS) group, leprosy group and HIV/leprosy group. All individuals underwent an evaluation of muscle strength and upper limb endurance adjusted for the Brazilian standards, a palm print pressure test using a digital dynamometer and anthropometric measurements (weight, height and skin folds).

Results

The HIV/leprosy group had the highest mean body mass index, followed by the leprosy group and the HIV/AIDS group. Skinfolds were similar between the groups. Multiple linear regression, adjusted for sex and age, revealed the coinfection of HIV and leprosy as possible contributor to a worse prognosis of muscle function, highlighting the bilateral reduction in the levels of palm print compression strengths compared with isolated diseases (HIV and leprosy). High CD4 count and shorter antiretroviral therapy duration were associated with worse indices of muscle strength, such as gripping and resistance, in coinfected patients.

Conclusion

Patients coinfected with HIV and leprosy exhibited greater motor damage than those with isolated diseases. Thus, motor damage may be related to the sum of the neurological manifestations of the two morbidities.

Relationship Between Handgrip Strength and Age in the Body Composition Variables Among People Living with HIV

BACKGROUND

The study of aging and handgrip strength (HGS) is important to gain knowledge regarding health care and quality of life in people living with HIV (PLHIV).

OBJECTIVE

The aim of the study is to analyze the relationship between HGS and age in the body composition variables of PLHIV.

METHODS

The sample consisted of 77 PLHIV, divided into three groups: G40 - PLHIV aged 40-49 years (n=39); G50 - PLHIV aged 50-59 years (n=26); and G60 - PLHIV aged 60-69 years (n=12). Data collection included anamnesis (sociodemographic, clinical, and laboratory information), physical assessment (body composition and HGS), and physical activity level. Data were analyzed by descriptive and inferential statistics.

RESULTS

It was noted that men, compared to women, are 5.85 times more likely to present adequate HGS (p<0.001). In addition, adequate HGS was associated with adequate values of body mass index (p<0.001), waist circumference (p<0.001), and fat percentage (p<0.001). The G40 and G50 groups, in relation to the G60, were associated with adequate abdominal circumference (p=0.04).

CONCLUSION

Monitoring the evolution of HGS in PLHIV, over time, makes it possible to infer about body fat and muscle mass, in order to propose prevention actions and guidelines to prevent early muscle loss, the development of overweight/obesity, and abdominal obesity.

The expression of FOXP3 in lesions of several forms of leprosy in patients co-infected with HIV

BACKGROUND

Brazil remains endemic for infection by the human immunodeficiency virus (HIV) and leprosy, having a major impact on public health and the life quality of affected patients. Although the relevance of this co-infection is recognized, several aspects, such as the immune response, are not yet fully understood. The objective of this study was to investigate the expression of FOXP3+ Treg cells in leprosy skin lesions and to correlate their clinical forms, laboratory characteristics (CD4, CD8, and CV), and the immune reconstitution syndrome in HIV-leprosy co-infection.

METHODOLOGY/PRINCIPAL FINDINGS

An observational, cross-sectional, and analytical study was carried out comparing four groups of patients: those with concomitant diagnosis of leprosy and HIV infection without a leprosy reaction, those with leprosy and HIV co-infection patients with a reverse reaction (RR), those with leprosy without HIV and without reaction, and those with leprosywithout HIV and with RR. The patients were diagnosed at a dermatology outpatient clinic located in Belém, Pará, Brazil, from 2003 to 2017. In the sample studied, there was a positive correlation between FOXP3+ cell density and viral load, negative correlation with blood CD4+ (not statistically significant), significant positive correlation in CD8 count in patients with leprosy reaction, and positive relationship in patients with IRIS. The density of cells expressing FOXP3 was higher in the BL/LL forms in patients without HIV, although the difference was not statistically significant. However, the cell mean was higher in the TT/BT forms in patients co-infected with leprosy and HIV, showing contradictory results.

CONCLUSIONS/SIGNIFICANCE

These findings support that higher activity of the HIV may stimulate or result in a higher expression of FOXP3-Tregs and that they may be involved in active immunosuppression observed at the infection site at the tissue level. This supports the need to expand studies on FOXP3+ Treg cells in co-infected patients.

Therapeutic outcomes of pemphigus in a referral service in Northern Brazil: a retrospective study of 32 patients

BACKGROUND

Pemphigus are rare chronic autoimmune blistering disorders with challenging therapeutic management.

OBJECTIVE

To investigate the therapeutic outcomes of pemphigus patients admitted to a dermatology referral service in northern Brazil.

MATERIALS AND METHODS

We conducted a retrospective analysis of 32 patients with histopathological diagnosis of pemphigus between 2010 and 2016. Clinical and epidemiological data were collected. Therapeutic outcome was evaluated according to the criteria proposed by the International Pemphigus Committee. Pemphigus Disease Area Index (PDAI) was used to quantify disease severity.

RESULTS

Of the 32 patients, 68.75% had pemphigus vulgaris (PV) and 31.25% had pemphigus foliaceus (PF). Female-to-male ratio was 1:1. The average age was 49.5 years. All patients received oral prednisone as the first-line therapy. Adjuvant immunosuppressive drugs were gradually added in refractory and/or severe cases. After 24 months of treatment, disease control and complete remission rates were 37.5% and 25%, respectively. The mortality rate was 9.37%. PDAI score was significantly lower at 24 months of therapeutic follow-up (p < .0001).

CONCLUSION

Therapeutic management with corticosteroids and/or immunosuppressive drugs was able to induce disease control/complete remission in most of patients. PDAI was a useful tool for objective assessment of disease severity during therapeutic follow-up.

Cutaneous leishmaniasis: Spatial distribution and environmental risk factors in the state of Pará, Brazilian Eastern Amazon

INTRODUCTION

Cutaneous leishmaniasis is an infectious disease transmitted by phlebotomine sandflies and is considered a great environmental and public health problem. Thus, this work presents initial results of the analyses about the relationship between the spatial distribution of this disease and its environmental risk factors in three municipalities, in the state of Pará, Brazil, from 2012 to 2016.

METHODOLOGY

It was used data from the Ministry of Health, the National Institute for Space Research and the Brazilian Institute of Geography and Statistics. The statistical and spacial analysis of the variables were done using G-test goodness-of-fit, kernel interpolation technique and the Bivariate Global Moran Index (I).

RESULTS

The analyses showed that the most affected individuals were males, adults, low schooling, residents in rural areas and small farmers. The disease spatial distribution was not homogeneous in the municipalities and it was associated to different relationships between the land use and occupation and the notificated cases density, with direct spatial autocorrelation.

CONCLUSIONS

The deforestation was the most significant risk factor linked to the cases occurrence in all the studied area. We emphasize the need of intensification of epidemiological and environmental surveillance actions in the studied areas.

[ID 33364] CARGA DE TRABALHO DA ENFERMAGEM E A MORTALIDADE DE PACIENTES NA UNIDADES DE TERAPIA INTENSIVA

Objetivo: Analisar a correlação entre a carga de trabalho da equipe de enfermagem, aferida pelo escore NAS (Nursing Activities Score) e a mortalidade predita pelo escore SAPS 3 dos pacientes internados em Unidade de Terapia Intensiva, verificando as correlações entre os profissionais de enfermagem atuantes na unidade segundo o preconizado pela RDC e o recomendado pelo escore NAS. Material e Métodos: Trata-se de um estudo de coorte realizado no período de setembro de 2014 a abril de 2015, com 270 pacientes. Utilizou-se o instrumento NAS e, posteriormente, foi submetido a análise estatística no BioEstat 5.3®. Resultados: A partir da análise dos resultados foi possível identificar que a sepse foi o principal diagnóstico. Houve correlação linear entre o NAS médio e o inicial dos pacientes internados com o índice prognóstico SAPS 3, com diferença estatisticamente significante entre o número de profissionais atuantes nas unidades e o número de profissionais de enfermagem dimensionados pelo NAS. Conclusão: Conclui-se que o NAS é uma ferramenta importante para dimensionar a carga de trabalho da equipe nas UTIs. Descritores: Administração Hospitalar. Unidade de Terapia Intensiva. Carga de trabalho.

Leprosy in elderly people and the profile of a retrospective cohort in an endemic region of the Brazilian Amazon

Background

Leprosy has a global presence; more than 180 thousand new cases were registered in 2013, 15% of which were found in the Americas. The elderly are a very susceptible demographic in terms of developing illnesses, mainly because of characteristics natural to the senescence of the human organism. This study’s goals were to analyze leprosy in an elderly population from a hyperendemic region of the Brazilian Amazon in a historical series from 2004 to 2013 and to determine the clinical and epidemiological profile of a series of leprosy cases of elderly people in the period spanning from 2009 to 2013.

Methods

To achieve these goals, an observational, longitudinal, retrospective and descriptive study was put together to analyze leprosy in elderly people from data acquired from the Notification Aggravations Information System. Furthermore, a profile of the disease from a retrospective cohort based on data collected from medical records was developed.

Results

The number of new cases and the leprosy detection rate decreased across the observed period but remained stable among the elderly. The trend for the next ten years indicates decreases in the number of cases and in the detection rate in the general population and an increase in only the elderly. The overall profile was characterized by a predominance of males (64.32%), the multibacillary clinical form (87.57%), Type 1 reaction episodes (37.50%) and some physical incapacity at diagnosis (49.19%). The risk of reaction was greater in the first six months of multidrug therapy, and the positive result from the skin smear was associated with the greater chance of reactional condition development.

Conclusions

The resulting data demonstrate that leprosy amongst the elderly deserves attention because of the increased susceptibility to disability in this age group, with their higher risk of reaction and their greater level of co-morbidity.

Leprosy, despite being an ancient disease, still represents a challenge to public health systems today. There are still just a few studies about it, particularly among the elderly. It is known that they constitute a very heterogeneous group in terms of immune response to infections, alterations to the peripheral nervous system and predisposition to situations of vulnerability and functional dependency. The Amazon region is a hyperendemic region for leprosy and has been trying to address, along with the rest of Brazil, a rapid increase in the population’s life expectancy. This article surveys medical records from elderly people diagnosed with leprosy in a five-year period at the metropolitan region of Belém, state of Pará (Brazil), identifying a predominance of the multibacillary forms of the disease, a high prevalence of leprosy reactions mainly during treatment with multidrug therapy, and the presence of some physical incapacity in most of the people evaluated. It is expected that this study will contribute to knowledge about the clinical and epidemiological characteristics of leprosy among the elderly and stimulate the making of new studies on the theme.

Leprosy: demographic and clinical characteristics of patients of endemic area in Amazon Region

Introduction: The hyperendemicity of leprosy in the northern region permeates regional aspects, including its large territorial extension and waterways, which make it difficult to access health and, consequently, control the disease. So that, the objective of this project is to describe the demographic and clinical profile of patients with leprosy and to evaluate their intradomiciliary contacts. Methods and findings: Observational, descriptive study, type of case series, through interview and complementary analysis of the medical records of patients undergoing specific treatment and / or treatment of leprosy reactions followed at the Dermatology outpatient clinic of the University of the State of Pará, in the city of Belém-PA, from January 2015 to December 2017. With convenience sampling, we interviewed 83 patients that met the inclusion criteria and collected socioeconomic and demographic variables, as well as clinical aspects based on the Madrid classification. Descriptive and inferential statistical methods were applied as: tables, graphs and statistical measures of position and Test G, with alpha significance = 0,05 and reliability of 95%. The predominance of males was observed (60.24%), the most affected age group was between 30 and 44 years old and the majority with incomplete secondary education. The predominant family income was up to 1 minimum wage. The most frequent clinical type was Virchowian (38 patients). Most of the patients did not present leprosy reaction and those who presented, the type 1 reaction was the most frequent and the nerve most affected was ulnar. Conclusion: Prevalence of multibacillary cases is a reflex of late diagnosis. It is important that there be intensification of actions and monitoring and active search for new cases.

Botulinum toxin type A in chronic neuropathic pain in refractory leprosy

OBJECTIVE

Neuropathic pain is a chronic syndrome that is difficult to treat and often affects patients with leprosy. Recommended treatment includes the the use of analgesic drugs, codeine, tricyclic antidepressants, neuroleptics, anticonvulsants and thalidomide, but without consensus on uniform dose and fully satisfactory results. To analyze botulinum toxin type A (BoNT-A) effectiveness in treatment of chronic neuropathic pain in refractory leprous patients, as well as evaluate and compare the quality of life of patients before and after using the medication.

METHODS

We used a specific protocol including clinical, demographic, DN4 protocol, analogue scale (VAS), sensory evaluation and evaluation of the WHOQOL-BREF. Therapeutic intervention was performed with BOTOX® BTX-A 100U administered subcutaneously. Fifteen patients were evaluated on days 0, 10 and 60.

RESULTS

Patients on VAS showed pain between 5 and 10, in one case there was complete pain relief in 60 days, while others showed improvement in the first week with the return of symptoms with less intensity after this period. WHOQOL-BREF's domains Quality of Life and Physical to have a significant increase in QOL.

CONCLUSION

BoNT-A proved to be a good therapeutic option in relieving pain with improved quality of life for these patients.

Abstract P1-15-16: Pathological complete response rates with the addition of carboplatin to standard neoadjuvant chemotherapy in a cohort of real–world patients with triple negative breast cancer

Objectives: Addition of carboplatin to standard neoadjuvant chemotherapy (NACT) for triple negative breast cancer (TNBC) remains controversial. There are several randomized trials showing that carboplatin increases the likelihood of achieving pathological complete response (pCR) in TNBC. Patients with TNBC who achieve pCR has been shown to have better disease-free and overall survival. The aim of this study was to asses the impact of adding carboplatin to standard NACT in TNBC in terms of pCR rates and toxicity. Methods:In this cross-sectional study, 252 consecutive patients with primary TNBC who were submitted to neoadjuvant chemotherapy between 2013 and 2018, in a single center, were selected. Patients with biopsy-confirmed TNBC, previously untreated, with clinical stages I-III were included (n=179). Clinical pathological features, pathological response, treatment protocol, and toxicities were analyzed and considered for statistical analysis. Eighty patients treated from 2013 to 2015 received doxorubicin plus cyclophosphamide once every 3 weeks (AC) for four cycles, followed by 12 weeks (wP) or every 3 weeks (P) paclitaxel(AC-T group). Ninety-nine patients, treated from 2015 to 2018 had four cycles of AC followed by wP plus weekly carboplatin (Cb) area under curve (AUC) 1.5-2.0 (AC-TCb group). Pathologic response was determined locally, and pCR was defined as the absence of residual invasive disease with or without ductal carcinoma in situ in the breast and axilla. Results: Data from 179 patients were included in the analysis (AC-T: n=80; AC-TCb: n=99). Patients in AC-TCb group had a median age of 51.7 years vs. 47.4 years in AC-T group, p=0.01. In AC-TCb group 61.6% of patients were postmenopausal vs 43.7% in AC-T group, p=0.03. The distribution of clinical stage in groups AC-TCb and AC-T were as follows: stage I 6.0% vs 0%; stage II 42.4% vs 43.7%; stage III 51.6% vs 56.3%, respectively (p=0.02). In AC-TCbgroup, 34 patients (35.0%) had pCR in comparison to 20 patients (25.0%) on AC-T group (p=0.22). Pathological stage distribution in groups AC-TCb and AC-T were: stage I 24.7% vs 33.7%; stage II 23.7% vs 26.3%; stage III 16.4% vs 15%, respectively (p=0.42). More than 85.0% of patients in AC-TCb group received at least 9 weeks of carboplatin and less than 20.0% required dose reduction due to toxicity.Conclusions: An improved pathological complete response for TNBC patients submitted to standard NACT plus carboplatin was observed. The results are in accordance with previous studies demonstrating that the addition of carboplatin to NACT improves pCR rate in TNBC with a favorable risk to benefit profile. Therefore carboplatin might be a potential component of NACT and should be considered in this context.

Distribution of patients with TNBC submitted to NACT with AC-T and AC-TCb according clinical–pathological characteristicsClinical pathological characteristicsAC-T n= 80AC-TCb n=99pMenopausal  0.03yes3561 no4538 Clinical stage  0.02I06 II3542 III4551 Histologic type  0.25IDC8096 others03 Histologic grade  0.86101 22932 35164 Pathological stage  0.42O2034 I2724 II2123 III1216 pCR  0.22yes2034 no6063 

Citation Format: Ramalho S, Natal RdA, Cardoso Filho C, Xavier MB, da Silva AER, Silva LR, Vasconcelos V, Reinert T, Coelho GP, Silva GRdP, dos Santos CC. Pathological complete response rates with the addition of carboplatin to standard neoadjuvant chemotherapy in a cohort of real–world patients with triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-16.

Quality of life and handgrip strength of HIV patients diagnosed with neurotoxoplasmosis

Abstract HIV / AIDS epidemic continues to be a major public health problem, and when there is poor adherence to treatment, patients become susceptible to other infections such as toxoplasmosis. The aim of this study was to evaluate the handgrip strength and quality of life of HIV infected patients diagnosed with neurotoxoplasmosis. A cross-sectional study was conducted with 40 HIV-infected patients, with and without diagnosis of neuroxoplasmosis.Sociodemographic and clinical profile information was collected, and handgrip strength and quality of life were evaluated. Almost all patients of both groups used antiretroviral therapy. In the handgrip strength evaluation, no statistical difference was observed for the right and left hand between groups with and without neurotoxoplasmosis (p> 0.05). However, the classifica-1 Federal University of Pará. Gradution of inadequate handgrip strength in the neurotoxoplasmosis group was significantly higher.ate Program in Tropical Diseases. In the quality of life domain, it was observed that financial concern had lower scores in the Belém, PA. Brazil. group with neurotoxoplasmosis (p = 0.0379). It was observed that neurotoxoplasmosis showedno association with epidemiological, clinical, handgrip strength and quality of life variables.2 State University of Pará. Center However, patients with neurotoxoplasmosis showed a trend towards lower muscle strength.

Expression of interleukin-1β and interleukin-6 in leprosy reactions in patients with human immunodeficiency virus coinfection

Previous studies suggest that coinfection of leprosy and human immunodeficiency virus (HIV) does not decrease the frequency and intensity of leprosy reactions. However, the immunological aspects of leprosy reactions in coinfected patients remain obscure, with a limited number of studies showing contradictory results. Observational study using tissue samples collected during leprosy reactions from 15 patients coinfected with leprosy and HIV and from 15 patients with leprosy alone. Patients were part of a prior larger cohort study of leprosy patients with and without HIV coinfection. Specific antibodies were used to detect IL-1β and IL-6 expression in skin biopsy tissue cells. IL-1β and IL-6 expression was similar between leprosy patients with and without HIV coinfection (p>0.05). Coinfected and non-coinfected tissues showed similar levels of IL-1β and IL-6 expression for type 1 reactions. A trend towards increased levels of IL-1β and IL-6 expression was observed in tissue from coinfected patients (p=0.0024). The expression of IL-1β and IL-6 during leprosy reactions did not differ significantly between tissues obtained from leprosy patients with and without HIV coinfection. Therefore, we conclude that HIV coinfection does not affect the immunological pattern of leprosy reactions.

Prevalence of autoantibodies against cellular antigens in patients with HIV and leprosy coinfection in the Amazon region

BACKGROUND

Infectious agents can activate self-reactive T cells. In general, infections trigger various mechanisms, including a lack of auto-tolerance, induction of costimulatory molecules on antigen presenting cells, and molecular simulation, in addition to cross-reactions between microbial antigens and self-antigens. HIV and leprosy coinfections lead to self-immunity with the production of autoantibodies. However, not enough data on the immune behaviour associated with this coinfection are available. Therefore, this study focused on the detection of autoantibodies against cellular antigens (AACA) in individuals with HIV and leprosy coinfection in the Amazon region.

METHODS

Patients were distributed into four groups according to their infections: (i) coinfection with HIV and leprosy (n = 23), (ii) infection with leprosy (n = 33), (iii) infection with HIV/AIDS (n = 25), and (iv) healthy blood donor controls (n = 100). AACA were identified by indirect immunofluorescence and the samples were tested using a commercial diagnosis kit containing the antinuclear antibody HEp-2.

RESULTS

Morphologically, all stages of cell division were assessed in addition to the morphological features associated with the nuclear matrix, nucleolus, mitotic spindle, and cytoplasm. There was a high prevalence of AACA in the coinfection group (47.8%, n = 11) when compared with the control group of healthy blood donors (2.0%). The results showed predominantly cytoplasmic staining in all groups analysed, and no difference was observed between the presence or absence of AACA and the leprosy forms (paucibacillary and multibacillary) in the coinfection group.

CONCLUSIONS

The results of this study show that despite the tendency of coinfected patients to have higher levels of autoantibodies, no correlation was observed between clinical and laboratorial variables and morbidity associated with HIV and leprosy coinfections or the levels of AACA in the serum of coinfected patients. These data are important to elucidate this complex relationship between HIV and leprosy and thus improve the follow-up of these patients.

Hanseníase e Atenção Primária à Saúde: uma avaliação de estrutura do programa

RESUMO O presente trabalho objetivou avaliar a estrutura do programa municipal de controle da hanseníase, em Canaã dos Carajás (Pará), no contexto da Atenção Primária à Saúde. Trata-se de um estudo de avaliação de programas de saúde, com foco na hanseníase, tendo como público-alvo os gestores do programa de hanseníase e os gerentes das unidades de saúde da atenção primária. Foram utilizados dois questionários diferentes, elaborados especificamente para esse fim. Concluiu-se que o município em questão possui uma estrutura classificada entre insatisfatória e regular, demonstrando várias fragilidades no programa avaliado, para o atendimento em hanseníase.

The cytotoxic T cells may contribute to the in situ immune response in Jorge Lobo's Disease human lesions

Jorge Lobo's Disease (JLD) is a cutaneous chronic granulomatous disease caused by the pathogenic fungus Lacazia loboi. It is characterized by a granulomatous reaction with multinucleated giant cells and high number of fungal cells. In order to contribute to the comprehension of immune mechanisms in JLD human lesions, we studied the cytotoxic immune response, focusing on TCD8+ and NK cells, and granzyme B. Forty skin biopsies of lower limbs were selected and an immunohistochemistry protocol was developed to detect CD8+ T cells, NK cells and Granzyme B. In order to compare the cellular populations, we also performed a protocol to visualize TCD4+ cells. Immunolabeled cells were quantified in nine randomized fields in the dermis. Lesions were characterized by inflammatory infiltrate of macrophages, lymphocytes, epithelioid and multinucleated giant cells with intense number of fungal forms. There was a prevalence of CD8 over CD4 cells, followed by NK cells. Our results suggest that in JLD the cytotoxic immune response could represent another important mechanism to control Lacazia loboi infection. We may suggest that, although CD4+ T cells are essential for host defense in JLD, CD8+ T cells could play a role in the elimination of the fungus.

NÍVEL DE ATIVIDADE FÍSICA E SÍNDROME LIPODISTRÓFICA EM PACIENTES COM HIV/AIDS

Introdução: A atividade física pode ser uma aliada para minimizar o surgimento da lipodistrofia e seus efeitos deletérios. Objetivo: Analisar a relação do nível de atividade física (NAF) e a síndrome lipodistrófica com a composição corporal e a qualidade de vida (QV) de portadores do HIV/Aids. Métodos: Participaram do estudo 120 pacientes com HIV/Aids (38,55 ± 11,47 anos). Foram avaliados quanto ao índice de massa corporal, composição corporal, taxa metabólica basal, índice cintura-quadril, QV, presença, tipo e local de lipodistrofia, força de preensão manual e NAF. Resultados: Constatou-se que 70% eram sedentários; além disso, a massa magra foi 9,5% maior nos pacientes ativos, bem como a força muscular de preensão com a mão direita (11%) e esquerda (12%) e a taxa metabólica basal (6,9%). Quanto à associação da QV ao NAF, foi notada correlação fraca apenas para a preocupação com o sigilo (r = 0,2160; p = 0,0210), bem como, os pacientes ativos demonstraram melhor resultado que os sedentários (p < 0,05). Dos pacientes que apresentaram lipodistrofia, 66% eram sedentários; o tipo predominante foi a lipodistrofia mista (46%) e as regiões mais comuns foram a face e abdome. Ressalta-se que nos pacientes sem a síndrome a taxa metabólica basal foi maior (p = 0,0175) e o tempo de infecção (p = 0,0020) e de TARV (p = 0,0002) foram menores. Conclusão: Conclui-se, conforme metodologia adotada, que o sedentarismo predominou, o NAF apresentou associação positiva somente com a preocupação com o sigilo e os sedentários apresentaram dois domínios abaixo do escore de 50 (preocupação financeira e com o sigilo), com relação a um domínio dos pacientes ativos. A lipodistrofia esteve presente em 37% da amostra, sendo o tipo mais presente a lipodistrofia mista, e os locais de maior ocorrência foram a face e o abdome. Para esse grupo o NAF não se apresentou positivo para a composição corporal e a presença da lipodistrofia não influenciou na QV.

New Players in the Same Old Game: Disturbance of Group 2 Innate Lymphoid Cells in HIV-1 and Mycobacterium leprae Co-infected Patients

Leprosy control is achieved through a fine-tuning of TH1 and TH2 immune response pattern balance. Given the increasing epidemiological overlay of HIV and M. leprae infections, immune response in co-infected patients consists in an important contemporary issue. Here we describe for the first time the innate lymphoid cells compartment in peripheral blood of leprosy and HIV/M. leprae co-infected patients, and show that co-infection increases group 2 innate lymphoid whilst decreasing group 1 innate lymphoid cells frequencies and function.

Comparison between histopathologic features of leprosy in reaction lesions in HIV coinfected and non-coinfected patients

BACKGROUND

Leprosy and HIV are diseases that have a major impact on public health in Brazil. Patients coinfected with both diseases, appear to be at higher risk to develop leprosy reactions.

OBJECTIVE

The aim of this study is to describe the histopathological aspects of cutaneous lesions during reactional states in a group of patients with HIV-leprosy coinfection, compared to patients with leprosy, without coinfection.

METHODS

Two groups were established: group 1 comprised of 40 patients coinfected with HIV-leprosy; group 2, comprised of 107 patients with leprosy only. Patients presenting reactional states of leprosy had their lesions biopsied and comparatively evaluated.

RESULTS

Reversal reaction was the most frequent feature in both groups, with dermis edema as the most common histopathological finding. Giant cells were seen in all group 1 histopathological examinations. Dermis edema was the most common finding in patients with erythema nodosum leprosum.

CONCLUSION

Few histopathological differences were found in both groups, with reversal reaction as the most significant one, although this fact should be analyzed considering the predominant BT clinical form in the coinfected group and BB form in the group without HIV. Larger prospective studies in patients with HIV-leprosy coinfection are needed to confirm and broaden these results.

Leprosy Reactions in Patients Coinfected with HIV: Clinical Aspects and Outcomes in Two Comparative Cohorts in the Amazon Region, Brazil

Background

Leprosy, caused by Mycobacterium leprae, can lead to scarring and deformities. Human immunodeficiency virus (HIV), a lymphotropic virus with high rates of replication, leads to cell death in various stages of infection. These diseases have major social and quality of life costs, and although the relevance of their comorbidity is recognized, several aspects are still not fully understood.

Methodology/Principal Findings

Two cohorts of patients with leprosy in an endemic region of the Amazon were observed. We compared 40 patients with leprosy and HIV (Group 1) and 107 leprosy patients with no comorbidity (Group 2) for a minimum of 2 years. Group 1 predominantly experienced the paucibacillary classification, accounting for 70% of cases, whereas Group 2 primarily experienced the multibacillary classification (80.4% of cases). There was no significant difference in the prevalence of leprosy reactions among the two groups (37.5% for Group 1 vs. 56.1% for Group 2), and the most frequent reaction was Type 1. The appearance of Group 1 patients’ reversal reaction skin lesions was consistent with each clinical form: typically erythematous and infiltrated, with similar progression as those patients without HIV, which responded to prednisone. Patients in both groups primarily experienced a single episode (73.3% in Group 1 and 75% in Group 2), and Group 1 had shorter reaction periods (≤3 months; 93.3%), moderate severity (80%), with 93.3% of the patients in the state of acquired immune deficiency syndrome, and 46.7% presenting the reaction at the time of the immune reconstitution inflammatory syndrome.

Conclusions/Significance

This study used a large sample and makes a significant contribution to the clinical outcomes of patients in the reactive state with comorbid HIV and leprosy. The data indicate that these diseases, although concurrent, have independent courses.

Leprosy and HIV infections, separately, are serious modern public health problems. Many studies have been conducted on these diseases, but knowledge gaps remain. This article provides the first account of important clinical information on a significant sample of patients with leprosy, as well as patients with both leprosy and HIV, who were followed over a period of 24 months. We compared the clinical outcome of both groups, observed the occurrence of reactional episodes, and examined the characteristics of these episodes. The sample consisted of 40 co-infected patients (Group 1) and 107 patients with leprosy only (Group 2). Group 1 was characterized by high levels of paucibacillary leprosy cases (70%) and the borderline tuberculoid clinical form (45%), while Group 2 predominantly exhibited multibacillary leprosy (86%) and the borderline clinical form (40.2%). The Type I reaction was present in 13 and 34 patients of Groups 1 and 2, respectively. The Amazon region, where the study was conducted, is an endemic region for both diseases, which can be useful for conducting studies such as these owing to the generalizability of the results. This study seeks to contribute to the knowledge of the natural history of HIV and leprosy comorbidity.

Plasmacytoid dendritic cells in cutaneous lesions of patients with chromoblastomycosis, lacaziosis, and paracoccidioidomycosis: a comparative analysis

Plasmacytoid dendritic cells (pDCs) are characterized by expression of CD123 and BDCA-2 (Blood Dendritic Cell Antigen 2) (CD303) molecules, which are important in innate and adaptive immunity. Chromoblastomycosis (CBM), lacaziosis or Jorge Lobo's disease (JLD), and paracoccidioidomycosis (PCM), are noteworthy in Latin America due to the large number of reported cases. The severity of lesions is mainly determined by the host's immune status and in situ responses. The dendritic cells studied in these fungal diseases are of myeloid origin, such as Langerhans cells and dermal dendrocytes; to our knowledge, there are no data for pDCs. Forty-three biopsies from patients with CBM, 42 from those with JLD and 46 diagnosed with PCM, were evaluated by immunohistochemistry. Plasmacytoid cells immunostained with anti-CD123 and anti-CD303 were detected in 16 cases of CBM; in those stained with anti-CD123, 24 specimens were obtained from PCM. We did not detect the presence of pDCs in any specimen using either antibody in JLD. We believe that, albeit a secondary immune response in PCM and CBM, pDCs could act as a secondary source of important cytokines. The BDCA-2 (CD303) is a c-type lectin receptor involved in cell adhesion, capture, and processing of antigens. Through the expression of the c-lectin receptor, there could be an interaction with fungi, similar to other receptors of this type, namely, CD207 in PCM and CD205 and CD209 in other fungal infections. In JLD, the absence of expression of CD123 and CD303 seems to indicate that pDCs are not involved in the immune response.

A major gene effect controls resistance to caries

Despite recent advances revealing genetic factors influencing caries susceptibility, questions regarding the model of inheritance involved are yet to be addressed. We conducted a Complex Segregation Analysis on decayed teeth in a sample of homogenous, isolated families recruited from the Brazilian Amazon. A dominant, major gene effect controlling resistance to phenotype was detected. The frequency of the resistance allele "A" was 0.63; mean numbers of decayed teeth were 1.53 and 9.53 for genotypes AA/AB and BB, respectively. These results represent a step toward a description of the exact nature of the genetic risk factors controlling human susceptibility to caries.

[Detection of Mycobacterium leprae DNA in nasal swab]

Studies have demonstrated high sensibility of the polimerase chain reaction (PCR) technique in the identification of the Mycobacterium leprae DNA . This study aimed to evalue the PCR sensibility at the detection of the M. leprae DNA in nasal swab of leprosy patients and to compare the results with the bacilloscopy and multibacillary (MBs) and paucibacilares (PBs) forms. Nasal secretion samples of 24 leprosy patients were collected, and were preserved in one and two lise's solution. The PCR results were highly significant (p <0.0000) and they revealed grater sensibility than bacilloscopy, in several clinical forms. Nevertheless, still different studies are necessary, testing new markers and preservatives, with the purpose of lifting up the sensibility of this technique, in nasal secretion samples.

Cyclosporine A treatment of leprosy patients with chronic neuritis is associated with pain control and reduction in antibodies against nerve growth factor

OBJECTIVES

Chronic neuritis (CN) is still a major problem in leprosy and is difficult to manage in patients who do not respond well to prednisone. In this study we (i) evaluate the efficacy of cyclosporine A (CyA) in controlling CN patients, and (ii) analyse the presence of anti-NGF antibodies in the sera of leprosy patients, and their behaviour during CyA treatment.

DESIGN

This was an open, prospective, non-comparative study. Sixty-seven leprosy patients in three different institutions in Pará, Brazil were studied from January, 2001 to January, 2004. Of these, 47 had no CN and 20 were leprosy patients suffering from CN and taking at least 40 mg/day prednisone to control nerve impairment and pain. Patients received 12 months reducing course CyA starting at 5 mg/kg per day. The outcome measure was sensory impairment, assessed using Semmes-Weinstein monofilament examination (SWME), muscular force and spontaneous or palpation-related pain.

RESULTS

Antibodies against NGF were detected in the sera of leprosy patients, which may explain the depletion of NGF in leprosy contributing to neuritis, inflammation and loss of cutaneous nociception. The levels of these antibodies in CN patients were slightly lower than in patients with no CN. However, anti-NGF titres in CN patients treated with CyA were lowered to levels similar to those in the normal subjects. There was also improvement in sensory impairment, muscular force and pain.

CONCLUSIONS

These data suggest that anti-NGF antibodies are present in the sera of leprosy patients and may influence the outcome of neuritis, and that CyA might be a useful drug in controlling nerve impairment and pain in leprosy patients.

American tegumentary leishmaniasis: a quantitative analysis of Langerhans cells presents important differences between L. (L.) amazonensis and Viannia subgenus

A quantitative study was conducted on the density of Langerhans cells (LCs) CD1a+ in specimens obtained from patients with American tegumentary leishmaniasis (ATL) lesions without previous treatment, as well as from control healthy individuals. LC density was significantly higher among infected patients when compared to controls and also higher in longer term ones. Regarding parasite quantities, these were proportionally inverse and diminished in chronic patients. Localized cutaneous leishmaniasis (LCL) showed an increase in cell population when compared to diffuse cutaneous leishmaniasis (DCL). A tendency towards density increase was observed in LC Leishmania (Leishmania) amazonensis patients when compared to Leishmania (Viannia) sp. Regarding the delayed hypersensitivity test (DTH, Montenegro skin test), L. (L.) amazonensis demonstrated a peculiar behavior because it is a poor cell immune inducer, presenting--among LCL patients--higher density in negative Montenegro patients than in positive ones. Negative DTH responses are usually poor in LC, although this was not evidenced in this study, possibly due to cell reposition, in order to stimulate immune response. Such results confirm the important role of LC in ATL, while suggesting that L. (L.) amazonensis may be a good model for LC studies as APC in ATL, due to its spectral immunological and clinical behavior.

[Methylmercury human exposure in riverside villages of Tapajos basin, Pará State, Brazil]

Evaluation of total human exposure to mercury and methylmercury was effected in riverine villages along the Tapajos river and in the metropolitan area of Belem city, state of Para, Brazil, by using total mercury and methylmercury concentrations in hair samples in 1994 and 1995. It was observed that average concentrations of total mercury are in a range from 2 +/- 1 microg/g-1 to 20.5 +/- 12. 1 microg/g-1. While methylmercury average concentration varies from 1. 4 +/- 0.7 microg/g-1 to 18.5 +/- 11 microg/g-1. These results confirm mercury contamination in the Tapajos river and possible appearance of mercury intoxication symptoms, and recommends the monitoring of compounds in hair samples as well as the need for epidemiological and clinical studies for human health prevention and control of mercury intoxication.