Association of Tumor Necrosis Factor-α (-G308A) Polymorphism with risk of Upper Gastrointestinal Bleeding from Schistosomiasis in Pernambuco

ABSTRACT Background: We evaluated the association between polymorphisms in the tumor necrosis factor alpha (TNF-α) (-G308A) gene and upper gastrointestinal bleeding (UGIB) in schistosomiasis. Methods: This was a transverse study involving 294 Brazilian patients infected with Schistosoma mansoni. Results: The homozygous A/A genotype in TNF-α (-G308A) showed a risk association (prevalence ratio = 1.90, p = 0.008) with UGIB. There was no statistically significant difference in serum TNF-α levels between the clinical groups. Conclusions: The polymorphic TNF-α (-G308A) can be a risk factor for UGIB, in addition to being a potentially predictive factor for the severity of UGIB in schistosomiasis.

High schistosomiasis-related mortality in Northeast Brazil: trends and spatial patterns

ABSTRACT Background: We analyzed the trends and spatial patterns of schistosomiasis-related mortality in Northeast Brazil in 2000-2019. Methods: A mixed population-based ecological study was conducted, using information on the underlying or associated causes of death. We used Joinpoint regression analysis to calculate the trends. The spatial analysis included rates, spatial moving averages, and standardized mortality rates. The spatial dependence analysis was based on Getis-Ord's G and Gi* indices (Gi star) and local Moran's index to check for autocorrelation. Results: A total of 5,814,268 deaths were recorded, of which 9,276 (0.16%) were schistosomiasis-related; 51.0% (n=4,732, adjusted rate 0.90/100,000 inhabitants [95% confidence interval (CI) 0.88-0.93]) were males; 40.0% (n=3,715, adjusted rate 7.40/100.000 inhabitants [95%CI: 7.16-7.64]) were ≥70 years old; 54.8% (n=5,087, crude rate 0.80/100,000 inhabitants) were of mixed/Pardo-Brazilian ethnicity; and 77.9% (n=7,229, adjusted rate 0.86/100,000 inhabitants [95%CI: 0.84-0.88]) lived outside state capitals. The highest proportion of deaths was in the state of Pernambuco (53.9%, n=4,996, adjusted rate 2.72/100,000 inhabitants [95%CI: 2.64-2.79]). Increasing mortality rate was verified in the state of Sergipe. On the coast of the state of Rio Grande do Norte and Bahia, there was spatial dependence of spatio-temporal risk patterns with clusters. Throughout the study period, we found positive spatial autocorrelation and cluster formation. Conclusions: In Northeast Brazil, schistosomiasis persists with a high mortality rate, especially in the coastal region, with heterogeneous spatial and temporal patterns. To eliminate schistosomiasis by 2030, it is necessary to strengthen the financing and management of the unified health system (SUS).

Association of the polymorphism Exon 1 (A/O) region of the mannose-binding lectin gene and periportal fibrosis regression in schistosomiasis after specific treatment

Abstract INTRODUCTION: We evaluated the association between genetic polymorphisms in exon 1 (A/O alleles) and promoter regions at positions -550 (H/L variant, rs11003125) and -221 (X/Y variant, rs7096206) MBL2 and periportal fibrosis regression. METHODS: This was a retrospective cohort study involving 114 Brazilians infected with Schistosoma mansoni, who were subjected to follow-up for three years after specific treatment for schistosomiasis to estimate the probability of periportal fibrosis regression. RESULTS: A risk association was observed between polymorphism at the exon 1 MBL2 and periportal fibrosis regression. CONCLUSIONS: This study suggests that the polymorphism of exon 1 MBL2 may potentially be used to predict periportal fibrosis regression in this population.

The cost of a disease targeted for elimination in Brazil: the case of schistosomiasis mansoni

BACKGROUND Schistosomiasis mansoni is a poverty-related parasitic infection that has a variety of clinical manifestations. We consider the disability and deaths caused by schistosomiasis unacceptable for a tool-ready disease. Its condition in Brazil warrants an analysis that will enable better understanding of the local health losses and contribute to the complex decision-making process. OBJECTIVE This study estimates the cost of schistosomiasis in Brazil in 2015. METHODS We conducted a cost of illness study of schistosomiasis mansoni in Brazil in 2015 based on a prevalence approach and from a societal perspective. The study included 26,499 schistosomiasis carriers, 397 hepatosplenic cases, 48 cases with the neurological form, 284 hospitalisations, and 11,368.26 years of life lost (YLL) of which 5,187 years are attributable to economically active age groups. RESULTS The total cost of schistosomiasis mansoni in Brazil was estimated to be US$ 41,7million in 2015 with 94.61% of this being indirect costs. CONCLUSIONS The economic burden of schistosomiasis mansoni in Brazil is high and results in the loss of productivity. Its persistence in Brazil is a challenge to public health and requires inter-sectorial interventions in areas such as indoor water supply, basic sanitation, and education.

Schistosomiasis and hepatopulmonary syndrome: the role of concomitant liver cirrhosis

BACKGROUND Hepatopulmonary syndrome (HPS) is defined as an oxygenation defect induced by intrapulmonary vasodilation in patients with liver disease or portal hypertension. It is investigated in patients with liver cirrhosis and less frequently in those with portal hypertension without liver cirrhosis, as may occur in hepatosplenic schistosomiasis (HSS). OBJECTIVES To investigate the prevalence of HPS in patients with HSS, and to determine whether the occurrence of HPS is influenced by concomitant cirrhosis. METHODS We evaluated patients with HSS with or without concomitant liver cirrhosis. All patients underwent laboratory testing, ultrasound, endoscopy, contrast echocardiography, and arterial blood gas analysis. FINDINGS Of the 121 patients with HSS, 64 were also diagnosed with liver cirrhosis. HPS was diagnosed in 42 patients (35%) and was more frequent among patients with concomitant liver cirrhosis than in those without cirrhosis (42% vs. 26%), but the difference was not significant (p = 0.069). HPS was more common in those with spider naevi, Child-Pugh classes B or C and high model for end stage liver disease (MELD) scores (p < 0.05 each). MAIN CONCLUSIONS The prevalence of HPS was 35% in this study. The occurrence of liver cirrhosis concomitantly with HSS may have influenced the frequency of patients presenting with HPS.

Ovarian Manson's Schistosomiasis: Rare Diagnosis or Underestimated Prevalence? / Esquistossomose mansônica no ovário: diagnóstico raro ou prevalência subestimada?

Abstract The occurrence of Manson's schistosomiasis in organs of the female reproductive tract is an uncommon event, given that the etiological agent for this disease is a blood parasite that inhabits the mesenteric veins. In this case report, a 45-year-old female patient reported that her first symptoms had been strong pain in the left iliac region around two years earlier. An endovaginal pelvic ultrasonography showed that the left ovary was enlarged, and the report suggested that this finding might be correlated with clinical data and tumor markers. After being examined at several healthcare services, the patient was referred to an oncology service due to suspected neoplasia, where she underwent a left ovariectomy. The result from the histopathological examination showed the presence of granulomatous inflammatory processes surrounding both viable and calcified eggs of Schistosoma mansoni. There was no evidence of any neoplastic tissue. The patient was medicated and followed-up as an outpatient.

Resumo A ocorrência da esquistossomose mansônica em órgãos do aparelho reprodutor feminino é um evento pouco comum, tendo em vista que o agente etiológico desta doença é um parasito sanguíneo que habita as veias mesentéricas. Neste relato decaso, uma paciente de 45 anos referiu como primeira sintomatologia fortes dores na região ilíaca esquerda há cerca de 2 anos. Uma ultrassonografia pélvica endovaginal identificou aumento do ovário esquerdo, e o laudo sugeriu correlacionar tal achado com dados clínicos e marcadores tumorais. Após passar por vários serviços de saúde, a paciente foi encaminhada para um serviço de oncologia por suspeita de neoplasia, sendo submetida a uma ovariectomia à esquerda. O resultado do exame histopatológico evidenciou a presença de processos inflamatórios granulomatosos em torno de ovos viáveis e calcificados de Schistosoma mansoni. Não houve qualquer evidência de tecido neoplásico. A paciente foi medicada, e seguiu em acompanhamento ambulatorial.

New index for the diagnosis of liver fibrosis in Schistosomiasis mansoni / Novo índice biológico para o diagnóstico da fibrose hepática na Esquistossomose mansoni

ABSTRACT BACKGROUND Periportal fibrosis is the major pathological consequence of the Schistosoma mansoni infection. OBJECTIVE To evaluate the accuracy of serum markers and to construct an index to assess fibrosis. METHODS Patients (n=116) with schistosomiasis were evaluated by ultrasound scan and measurements of serum levels of aminotransferases, γ-glutamyl transferase, alkaline phosphatase, hyaluronic acid, cytokines and platelets. Ultrasound images were used to evaluate the fibrosis using Niamey's classification and identified 19 patients without periportal fibrosis (patterns A and B), 48 with mild to moderate fibrosis (C and D) and 49 with advanced fibrosis (E and F). RESULTS Using multivariate analysis, a model was created, which involved alkaline phosphatase and platelets and could separate patients with different patterns of fibrosis. This index showed a better performance in separating patients without fibrosis from with advanced periportal fibrosis. The biological index showed an area under the ROC curve of 1.000. Using values below the lowest or above the highest cut-off point, the presence or absence of advanced fibrosis could be predicted in all patients. CONCLUSION The index constructed can be used to separate patients with different patterns of periportal fibrosis, specially to predict advanced fibrosis in schistosomiasis patients.

RESUMO CONTEXTO A fibrose periportal é a maior consequência patológica da infecção pelo Schistosoma mansoni. OBJETIVO Avaliar a acurácia de marcadores séricos e construir um índice para avaliar a fibrose. MÉTODOS Pacientes (n=116) com esquistossomose foram avaliados pela ultrassonografia e dosados os níveis de aminotransferases, γ-glutamil transferase, fosfatase alcalina, ácido hialurônico, citocinas e plaquetas. Imagens de ultrasom foram utilizadas para avaliar a fibrose através de classificação de Niamey e identificados 19 pacientes sem fibrose periportal (padrão A e B), 48 com fibrose média a moderada (C e D) e 49 com fibrose avançada (E e F). RESULTADOS Através de análise multivariada, um modelo foi criado, que envolveu a fosfatase alcalina e plaquetas e conseguiu separar pacientes com diferentes padrões de fibrose periportal. Este índice mostrou um melhor desempenho em separar pacientes sem fibrose dos pacientes com fibrose avançada. O índice biológico mostrou uma área sob a curva ROC de 1,000. Usando valores infereiores e acima do ponto de corte, a presença ou ausência de fibrose avançada pode ser prevista em todos os pacientes. CONCLUSÃO O índice construído pode ser usado para separar os pacientes com diferentes padrões de fibrose periportal, especialmente para prever fibrose avançada em pacientes com esquistossomose.

There is no evident correlation between interleukin-10 gene polymorphisms and periportal fibrosis regression after specific treatment

Abstract INTRODUCTION: We evaluated the associations between interleukin-10 (IL-10) gene polymorphisms -G1082A/-C819T/-C592A and periportal fibrosis regression after specific treatment for schistosomiasis. METHODS: This retrospective cohort study involved 125 Brazilian patients infected with Schistosomiasis mansoni, who were followed up for 2 years after specific treatment to estimate the probability of periportal fibrosis regression. RESULTS: There was no evidence of associations between IL-10 polymorphisms and periportal fibrosis regression after treatment. CONCLUSIONS: There was no evidence of associations between gene promoter polymorphisms of IL-10 and the regression of periportal fibrosis in this Brazilian population.

Hepatitis E virus seroprevalence among schistosomiasis patients in Northeastern Brazil

Abstract Background Hepatitis E virus (HEV) can cause chronic infection with rapid progression to liver cirrhosis in immunocompromised patients. HEV seroprevalence in patients with Schistosoma mansoni in Brazil is unknown. We evaluated the prevalence of past or present HEV infection in schistosomiasis patients in Recife, Pernambuco, Brazil. A total of 80 patients with Schistosoma mansoni were consecutively enrolled in a cross-sectional study. Serum samples were tested for the presence of anti-HEV IgG antibodies by enzyme immunoassay (Wantai anti-HEV IgG, Beijing, China) and for the presence of HEV RNA using real time reverse transcriptase-polymerase chain reaction with primers targeting the HEV ORF2 and ORF3. Clinical and laboratory tests as well as abdominal ultrasound were performed at the same day of blood collection. Results Anti-HEV IgG was positive in 18.8% (15/80) of patients with SM. None of the samples tested positive for anti-HEV IgM or HEV-RNA. Patients with anti-HEV IgG positive presented higher levels of alanine aminotranferase (p = 0.048) and gama-glutamil transferase (p = 0.022) when compared to patients without anti-HEV IgG antibodies. Conclusion This study demonstrates that the seroprevalence of HEV is high in patients with Schistosoma mansoni in Northeastern of Brazil. Past HEV infection is associated with higher frequency of liver enzymes abnormalities. HEV infection and its role on the severity of liver disease should be further investigated among patients with Schistosoma mansoni.

First record of prostatic schistosomiasis in Pernambuco, Brazil: signs of chronicity in an endemic disease

Schistosomiasis has affected the rural population of Pernambuco, Brazil, for centuries. The hepatosplenic and neurological manifestations of this parasitosis have often been described. However, prostatic schistosomiasis caused by Schistosoma mansoni had never been registered in Pernambuco, thus the importance of this particular case being reported. Case presentation: This report records the first case of prostatic schistosomiasis in Pernambuco. A 51-year-old patient underwent partial prostatectomy due to possible cancer and was diagnosed with this ectopic form of schistosomiasis. After the surgical procedure, stool samples were collected to run Kato-Katz parasitological tests, which were positive for S. mansoni, thus confirming that the patient was still infected. Laboratory blood tests and clinical examination showed alterations in liver function and confirmed the presence of hepatointestinal damage. Patient monitoring evidenced that the prostate-specific antigen levels remained high and, one year after the first surgical intervention, a new prostatic puncture showed that schistosomiasis and fibromatosis lesions remained present. It is noteworthy that after triple praziquantel treatment (April 2014, July 2014, February 2015) parasitological stool examinations were all negative for S. mansoni. In conclusion this accidental diagnosis of prostatic schistosomiasis raises doubts regarding the ability of healthcare services to identify and treat ectopic schistosomiasis. The persistently high levels of PSA even after surgical and pharmacological treatment, indicate irreversible damage to tissue caused by S. mansoni. Therefore, healthcare services need to be prepared to investigate and diagnose these cases, with a view to preventing chronic sequelae through early treatment

Alterações duodenais na hipertensão portal da esquistossomose mansônica / Duodenal changes in portal hypertension schistosomiasis

A Hipertensão Portal (HP) na Esquistossomose Mansônica (EM) tem, como repercussão, varizes esofagogástricas, gastropatia, colopatia, sendo pouco estudadas as repercussões duodenais já evidenciadas em cirróticos. As lesões duodenais observadas na esquistossomose podem ser secundárias à HP (Duodenopatia da Hipertensão Portal - DHP) ou à agressão parasitária, duodenite, sendo importante saber a causa das lesões duodenais em pacientes esquistossomóticos a fim de realizar uma abordagem terapêutica com maior segurança e especificidade nos pacientes. Objetivos: avaliar a ocorrência e as características de alterações duodenais em pacientes com esquistossomose mansônica na forma hepatoesplênica; a frequência da DHP endoscópica e histológica; verificar a associação da DHP endoscópica com DHP histológica; presença de GHP; presença e grau das VE; presença de HDA; presença de circulação colateral; diâmetro longitudinal do baço e padrão ultrassonográfico da Fibrose Periportal (FPP). Métodos: avaliados 65 pacientes portadores de EM, estudo tipo série de casos. Preencheram critérios de inclusão 50 pacientes, com a forma hepatoesplênica, com ou sem história de HDA, exames realizados (parasitológico de fezes, marcadores virais para VHB e VHC, bioquímica, função e testes hepáticos, hemograma, ultrassonografia e endoscopia digestiva alta - EDA com biopsia de estômago e duodeno). Resultados: a média de idade de 50, 58 anos, sendo 29 (58%) do sexo feminino: apenas 8/50 (16%) tinham história de HDA. Lesões duodenais foram observadas à EDA em 47/50 (94%) dos pacientes, sendo, as mais frequentes, o eritema em 16/50 (32%), a congestão em 9/50 (18%) e associados (eritema e congestão) em 16/50 (32%). DHP à EDA foi observada em 56% (28/50) dos pacientes, 53,6% (15/28) com intensidade acentuada. DHP à histologia foi evidenciada em 62% (31) dos pacientes. Houve associação do diagnóstico endoscópico e histológico da DHP em 23/28 (82,1%) pacientes (p=0,001). Houve associação entre DHP endoscópica com diâmetro longitudinal do baço (P=0,045) e com padrão da FPP (p=0,038). Não houve associação entre DHP endoscópica com a GHP (p=0,569), com presença e grau das VE (p=0,444; p=0,350), nem com história de HDA (p=0,116). Conclusão: na EM forma hepatoesplênica, as lesões duodenais são bastante frequentes, sendo as mais encontradas o eritema, eritema e congestão, a erosão e a congestão. A DHP foi evidenciada à EDA em 56%, histologia em 62% dos casos. Houve concordância do diagnóstico endoscópico com histológico em 82,1%. Não houve significância estatística entre DHP endoscópica com GHP, VE e HDA. Houve significância entre o padrão da FPP com a presença de DHP à endoscopia e relação inversa entre o diâmetro longitudinal do baço e a presença de DHP à endoscopia.

Despite of the fact that Portal Hypertension (PH) in Mansoni Schistosomiasis can cause esophagogastric varices, gastropathy and colopathy, its duodenal repercussions, already evidenced in cirrhotic patients, have been little studied. The duodenal lesions seen in schistomiasis may be secondary to PH (Portal Hypertensive Duodenopathy -PHD) or parasitic aggression, duodenitis. It is particularly important to understand the cause of duodenal lesions in schistosomotic patients in order to approach their treatment with greater security and specificity. Aims: The present study has the following aims: to evaluate the occurrence of alterations and the type of duodenal lesions in patients suffering from the hepatosplenic form of mansoni schistosomiasis; to determine the frequency of PHD by histological and endoscopic means; and to associate the presence of PHD on endoscopy with the following: PHD on histology; the presence of portal hypertensive gastropathy (PHG); the presence and degree of esophageal varices, the presence of upper gastrointestinal bleeding; the longitudinal diameter of the spleen, and the pattern of periportal fibrosis. Patients and methods: Sixty- -five patients with mansoni schistomiasis were studied in a case series study. Fifty patients met the inclusion criteria; all of them had the hepatosplenic form, with or without a history of upper gastrointestinal bleeding, and underwent a series of investigations, namely parasitological feces examination, viral markers for HVB and HCV, ultrasound and endoscopy of the upper gastrointestinal tract with biopsy of the stomach and duodenum. Results: The mean age was 50.58 yr (range, 26-70 yr), 29 (58%) being females, and only eight of the 50 (16%) had a history of bleeding of the digestive tract. Duodenal lesions were observed on endoscopy of the upper gastrointestinal tract in 47 (94%) patients, the most frequent ones being erythema in 16 (32%), congestion in 9 (18%) and both erythema and congestion in 16 (32%). Portal hypertensive duodenopathy on endoscopy was observed in 28 (56%), and in 15 of these (53.6%) it was particularly intense. Portal hypertensive duodenopathy was evidenced on histology in 31 (62%) patients. In 23 of 28 (82.1%) patients the histological diagnosis of PHD was associated with the endoscopic diagnosis (p=0.001). Portal hypertensive duodenopathy was associated with the longitudinal diameter of the spleen (p=0.045) and with the pattern of the periportal fibrosis (p=0.038). There was no association between PHD on endoscopy with PHG (p=0.569), the presence and degree of esophageal varices (p=0.444; p=0.350) or a history of upper gastrointestinal bleeding (p=0.116). Conclusion: on the basis of the results of the present study, it is concluded that in the hepatosplenic form of mansoni schistosomiasis duodenal lesions are extremely frequent, the most common ones being erythema, erythema and congestion, erosion and congestion. Portal hypertensive duodenopathy was evidenced endoscopically in 56% and histologically in 62% of the cases, with an 82.1% agreement between the endoscopic and histological diagnoses. There was no statistically significant association between PHD on endoscopy and PHG, esophageal varices or upper gastrointestinal bleeding. There was a significant association between the pattern of periportal fibrosis in the presence of PHD on endoscopy and the inverse relationship between the longitudinal diameter of the spleen and the presence of PHD on endoscopy.

Comparison of Doppler Echocardiographic Findings in Patients with Chronic Liver Disease with and without Intrapulmonary Shunt.

Aims: Doppler echocardiography is the gold standard for the diagnosis of intrapulmonary shunt (IPS) and screening for portopulmonary hypertension in chronic liver disease (CLD). Echocardiography has become fundamental to the diagnosis of cirrhotic cardiomyopathy in the last decade. The purpose of this article was to compare echocardiographic changes in patients with CLD, with and without IPS. Methodology: A total of 168 patients with CLD and portal hypertension underwent transthoracic contrast echocardiography and were allocated to two groups: Group 1 – 72 (42.9%) patients with IPS; and Group 2 – 96 (57.1 %) patients without IPS (control group). Echocardiographic variables and the presence/absence of IPS were evaluated in bilateral tests, with the level of statistical significance established at 5% (p < 0.05). Results: A higher prevalence of moderate diastolic dysfunction was found in patients with IPS (24 vs. 16 patients; p = 0.034). Patients with grade II IPS had a greater frequency of moderate diastolic dysfunction than those with grade I (16 vs. 8 patients; p = 0.028). No statistically significant differences between groups were found in left atrial volume (58 vs. 55 ml; p = 0.181) or the occurrence of pulmonary arterial hypertension (25 vs. 33 patients; p = 0.963). Conclusion: In the present study, IPS and grade II IPS were associated with moderate diastolic dysfunction determined by contrast-enhanced transthoracic Doppler echocardiography. Moderate diastolic dysfunction appeared to be a predictive factor for the onset of intrapulmonary shunt.

Correlation beteeen platelet count and both livr fibrosis and spleen diameter in patients with schistosomiasis mansnni / Correlação entre o número de plaquetas e o grau de fibrose hepática e o tamanho do baço em pacientes com Esquistossomose mansoni

Context Studies have described the correlation between platelet count and the stages of fibrosis in chronic viral hepatitis, but few publications have studied this correlation in Schistosomiasis mansoni. Objectives Therefore, this study aimed to correlate platelet count with both the periportal fibrosis pattern and spleen diameter evaluated by ultrasound exam in patients with Schistosomiasis mansoni. Methods Patients with Schistosomiasis mansoni were evaluated by abdominal ultrasound by a single examiner for the determination of periportal fibrosis pattern (Niamey classification) and spleen diameter. Platelet counts were performed in an automated cell counter. Results One hundred eighty-seven patients with Schistosomiasis mansoni (mean age: 50.2 years) were included in the study, 114 of whom (61%) were women. Based on the Niamey classification, the ultrasound analysis revealed that 37, 64, 64 and 22 patients exhibited patterns C, D, E and F, respectively. In these four groups, the mean number of platelets was 264, 196, 127 and 103 x 109/L and mean spleen diameter was 9.2, 11.9, 14.9 and 16.2 centimeters, respectively. A reduction in platelet count was significantly associated with both the progression of the periportal fibrosis and the increase in spleen size. Conclusions Platelet count in patients with Schistosomiasis mansoni was inversely correlated with the severity of periportal fibrosis and spleen diameter. .

Contexto Estudos vem descrevendo correlação entre o número de plaquetas e o grau de fibrose hepática na hepatite viral crônica, mas poucas publicações estudaram esta correlação em pacientes com Esquistossomose mansoni. Objetivos Correlacionar a contagem de plaquetas com o padrão de fibrose periportal e com o diâmetro do baço, avaliados pela ultrassonografia em pacientes com Esquistossomose mansoni. Métodos Os pacientes com Esquistossomose mansoni foram avaliados pela ultrassonografia abdominal, por um único examinador, para determinação do padrão de fibrose periportal (classificação de Niamey) e do diâmetro do baço. A contagem de plaquetas foi realizada em contador automatizado. Resultados Cento e oitenta e sete pacientes com Esquistossomose mansoni com média de idade de 50,2 anos foram incluídos no estudo, 114 (61%) dos quais eram mulheres. De acordo com a classificação de Niamey, a ultrassonografia revelou que 37, 64, 64 e 22 pacientes exibiam padrões C, D, E e F, respectivamente. Nestes quatro grupos, o número médio de plaquetas foi 264, 196, 127 e 103 x 109/L, respectivamente, e o diâmetro médio do baço foi 9,2, 11,9, 14,9 e 16,2 centímetros, respectivamente. Observou-se, portanto, redução significativa na contagem de plaquetas associada à progressão da fibrose periportal e ao aumento do tamanho do baço. Conclusões Neste estudo verificou-se que a contagem de plaquetas foi inversamente correlacionada com o padrão de fibrose periportal, como também com o diâmetro do baço nos pacientes com Esquistossomose mansoni. .

Hemorragia digestiva alta varicosa em hospital de emergência e, Recife - PE / Varicel upper gastrointestinal bleeding in emergency hospital in Recife - PE

A hemorragia digestiva alta varicosa (HDAV) é a mais grave complicação da hipertensão portal, com alta taxa de ressangramento e mortalidade. Em Pernambuco, devido à endemicidade da esquistossomose mansônica, há uma elevada frequência deste tipo de sangramento. Objetivos: avaliar a doença hepática de base de pacientes portadores de varizes esofagogástricas (VVEEGG) com HDA, além do seguimento quanto à orientação após alta hospitalar da emergência, taxa de ressangramento e óbito em hospital de emergência. Pacientes e métodos: trata-se de um estudo descritivo, tipo série de casos, em pacientes com VVEEGG atendidos no setor de endoscopia digestiva do Hospital da Restauração em Recife, referência no estado em hemorragia digestiva, de outubro de 2008 a outubro de 2009. Foram coletados dados sobre antecedentes pessoais, aspectos demográficos e clínicos e realizado exame endoscópico para avaliação do sítio de sangramento e propedêutica para controle da hemorragia se necessário. Resultados: foram analisados 178 pacientes portadores de VVEEGG com HDA. A média de idade foi 53,9 anos, sendo 115 (64,6%) do sexo masculino. A faixa etária mais frequente foi de 50 a 59 anos (31,5%) e 67 (37,7%) eram naturais de Zona da Mata. Ao exame físico, 58 (32,6%) pacientes apresentavam ascite. Foi evidenciado que 177 pacientes tinham varizes esofágicas (VVEE) e 78 tinham varizes gástricas. Quanto aos exames solicitados para caracterizar a doença de base, evidenciou-se um valor médio de albumina de 2,8 g/dl, de bilirrubina total 2,2 mg/dl e de INR 1,4. A doença hepática crônica (DHC) foi definida pelo ultrassom (USG) em cirrose (38), esquistossomose (60) e doença mista (22). Após a alta hospitalar, 45/174 pacientes (25,9%) ficaram em uso de propranolol e 57/174 (32,8%) conseguiram acompanhamento em ambulatório especializado. Após 3 meses do episódio de HDA, foi constatado relato de ressangramento em 92/161 (57,1%) pacientes e óbito em 44/161 (27,3%). Houve relação de ressangramento com óbito (p<0,001), com presença de manchas vermelhas nas VVEE (p<0,001), diagnóstico de cirrose hepática e DHC mista pelo USG (p=0,023), presença de ascite (p=0,004) e a não utilização de propranolol (p=0,002). Observou-se a associação de óbito e faixa etária de 50 a 59 anos (p=0,016) e com aspecto hepático pelo USG (p=0,001), assim como da presença de fibrose periportal no USG com a naturalidade (p=0,031). Conclusão: neste estudo, observou-se predomínio de pacientes do sexo masculino e naturais da Zona da Mata. A maioria dos pacientes apresentava fibrose periportal ao USG, mostrando a endemicidade da esquistossomose no estado e houve uma elevada frequência de ressangramento e óbito.

Background: variceal upper gastrointestinal bleeding (VUGB) is the most serious complication of portal hypertension, with high rebleeding and mortality rates. In Pernambuco, where schistosomiasis mansoni is endemic, this type of bleeding occurs frequently. Aim: to evaluate the etiology of esophageal variceal bleeding, as well as the rebleeding and death rates. The study also followed up the patients after hospital discharge, rebleeding and death rates of the patients admitted in an Emergency Hospital. Patients and methods: this is a descriptive study about patients with gastric-esophageal varices and UGB assisted at the digestive endoscopy unit of Restauração hospital in Recife from October 2008 to October 2009. An application form was filled out with demographic data, personal history, clinical aspects and an endoscopy was performed to identify the area of the bleeding, as well as a propaedeutical endoscopy to control the bleeding, when necessary. Results: 178 patients with gastric esophageal varices and UGB were observed. The specific-age rate was 53.9 years old, with 115 (64.6%) males. The most frequent age group was from 50 to 59 years old (31.5%) and 67 (37.7%) were born from the Zona da Mata region. Physical examination revealed ascites in 58 (32.6%) patients. It was seen that 177 patients had esophageal and 78 gastric varices. The blood tests done after the endoscopy to identify the underlying disease showed approximately 2,8g/dl of albumin, total bilirrubin of 2.2mg/dl and INR 1.4. Hepatic chronic disease (HCD) was defined with an ultrasound in cirrhosis (38), schistosomiasis (60) and mixed disease (22). After hospital discharge, 45/174 patients (25.9%) were prescribed propranolol and 57/174 (32.8%) were granted ambulatory care. Three months after the UGB episode, 92/161 (57.1%) patients had rebleeding and 44/161 (27.3%) died. There was a connection between the rebleeding and the deaths (p<0.001), there was presence of red spots on the esophageal varices (p<0.001), diagnose of cirrhosis and mixed hepatic chronic disease by ultrasound (p=0.023), ascitis (p=0.004) and the absence of propranolol use (p=0.002). There was also a relation between death and age 50 to 59 years (p=0.016) and the hepatic aspect detected by ultrasound (p=0.001), as well the presence of periportal fibrosis in the USG with the birthplace (p=0.031). Conclusion: in this study, it was possible to observe that there were predominance of male and patients from the Zona da Mata region. Most of the patients presented periportal fibrosis in the ultrasound, reflecting the high endemicity of schistosomiasis in the state and elevated rebleeding and death rates were observed.

Etiologia da hemorragia digestiva alta em hospital de emergência em Recife - Pernambuco / Etiology of upper gastrointestional hemorrhage in an emergency hospital in Recife, Pernambuco

A hemorragia digestiva alta (HDA) é uma importante emergência médica, com grande índice de morbidade e letalidade. A literatura sobre o tema evidencia as úlceras pépticas como as principais causas de sangramento, porém, em Pernambuco, devido à endemicidade da esquistossomose mansônica, há uma elevada frequência de hemorragia por ruptura de varizes esofágicas (VVEE). Há poucos relatos no estado sobre as características dos pacientes com HDA. Objetivos: descrever e analisar aspectos demográficos, antecedentes pessoais, dados clínicos e endoscópicos de pacientes com HDA para caracterizar as etiologias mais frequentes do sangramento digestivo. Pacientes e métodos: foi realizado estudo descritivo, tipo série de casos, de pacientes com HDA atendidos no Setor de Endoscopia Digestiva do Hospital da Restauração em Recife, referência no estado em hemorragia digestiva, no período de outubro de 2008 a outubro de 2009. Foram coletados dados sobre antecedentes pessoais, aspectos demográficos e clínicos, e realizado exame endoscópico para avaliação do sítio de sangramento e propedêutica para controle da hemorragia, se necessário. Resultados: foram analisados 385 pacientes com média de idade de 55,9 anos (11-96 anos), sendo 60,8% do sexo masculino. A maioria dos pacientes era natural (43,1%) e procedente (59,7%) da Região Metropolitana do Recife (RMR). O uso abusivo de álcool foi relatado por 38,7% dos pacientes, consumo de anti-inflamatórios (AINES) por 43,4%, história prévia de hemotransfusão por 47,3%, doença hepática crônica por 29,1%. A principal queixa clínica foi hematêmese em 50,4% dos casos, seguida pela associação de hematêmese e melena em 35,8%. A HDA foi classificada em não varicosa (41,3%) e varicosa (39,7%) e quanto à etiologia, secundária à VVEE em 38,1% dos casos, a úlcera péptica em 19,5% e não determinada em 19%. Observou-se relação entre o uso de AINES e o sangramento não varicoso (p<0,001). Conclusão: no presente estudo, observa-se que a maioria dos pacientes era do sexo masculino e procedente da RMR. Houve elevado consumo de AINES, principalmente nos pacientes com sangramento do tipo não varicoso. As causas de HDA não varicosa e varicosa apresentam uma frequência semelhante, mas quando se considera a etiologia isolada, nota-se o predomínio de sangramento por VVEE devido à endemicidade de esquistossomose mansônica em Pernambuco.

Background: upper gastrointestinal bleeding (UGB) is an important medical emergency, with a high rate of morbidity and mortality. In other localities, peptic ulcers are the main causes of UGB, but in Pernambuco, where schistosomiasis mansoni is endemic, bleedings due to the rupture of esophageal varices are very frequent. However, there is little data on the characteristics of the patients with this disease in the state. Aim: to describe and analyze demographical aspects, personal history, endoscopic and clinical data of patients with UGB to characterize the most common etiologies of digestive bleeding. Patients and methods: it is a descritive study about patients with UGB assisted at the endoscopic unit of Restauração Hospital in Recife, which is reference in gastrointestinal bleeding in the state. The patients involved in the study filled out an application form regarding demographic features, personal history, clinical aspects and an endoscopy was performed to identify the area of the bleeding, as well as a propaedeutical endoscopy to control the bleeding, when necessary. Results: 385 patients were analyzed with specific-age rate of 55.9 years old (from 11 to 96 years old) and 60.8% of them were male. Most patients were born (43.1%) and lived (59.7%) in the metropolitan region of Recife. Alcohol abuse was detected in 38.7% of the patients, intake of NSAIDs (Non-steroidal anti-inflammatory drugs) in 43.4%, previous history of blood transfusion by 47.3% and hepatic chronic disease by 29.1%. The main clinical complaint was hematemesis in 50.4% of the cases followed by the association of hematemesis and melena in 35.8%. UGB was classified in nonvariceal (41.3%) and variceal (39.7%) bleeding, considering etiology causes, 38.1% of patients had esophageal varices, 19.5% peptic ulcer and 19% undetermined causes. A relation between use of NSAIDs and non-variceal bleeding was observed (p<0.001). Conclusion: at the current study, most of the patients were male and from the metropolitan region of Recife. There were high intake of anti-inflammatory drugs, specially in patients with nonvariceal bleeding. The causes of variceal and non-variceal UGB comprise a similar frequency, but when the single etiology is considered, there is a superiority bleedings due to esophageal varices, due triggered by the presence of schistosomiasis mansonin in an endemic level in Pernambuco.

Casos autoctones de esquistossomose mansonica em criancas de Recife, PE / Casos autoctonos de esquistosomiasis mansonica en ninos de Recife, PE, Brasil / Autochthonous cases of schistosomiasis in children in Recife, Northeastern Brazil

OBJETIVO : Investigar criadouros com moluscos hospedeiros e casos humanos autóctones para esquistossomose. MÉTODOS : Entre julho de 2010 e setembro de 2012 foram realizados: (1) levantamento malacológico para busca ativa de criadouros, coleta e identificação de caramujos Biomphalaria positivos para Schistosoma mansoni em Recife, PE; (2) inquérito de prevalência com 2.718 escolares, de sete a 14 anos, para diagnóstico de casos de esquistossomose; (3) exame clínico e ultrassonografia nos casos positivos para S. mansoni. Os casos foram investigados quanto à sua autoctonia e avaliados clinicamente. Os casos e criadouros foram georreferenciados e espacializados. RESULTADOS : Foram identificados 30 criadouros de B. straminea , quatro deles potenciais focos de transmissão, uma vez que os testes moleculares identificaram DNA de S. mansoni nos caramujos coletados. Foram diagnosticadas 14 crianças com esquistossomose; entre elas, cinco foram consideradas casos autóctones da doença. CONCLUSÕES : Ações emergenciais pela vigilância em saúde são necessárias para evitar que a esquistossomose se endemize em Recife, como acontece em localidades litorâneas do estado de Pernambuco. .

OBJETIVO Investigar criaderos con moluscos hospedadores y casos humanos autóctonos para esquistosomiasis. MÉTODOS Se ejecutaron: estudio malacológico para búsqueda activa de criaderos, colecta e identificación de caracoles Biomphalaria positivos para S. mansoni en Recife, PE, entre julio de 2010 y septiembre de 2012, pesquisa de prevalencia con 2.718 escolares, de siete a 14 años, para diagnóstico de casos de esquistosomiasis, examen clínico y de ultrason en los casos positivos para S. mansoni. Los casos fueron investigados con respecto a su autoctonía y evaluados clínicamente. Los casos y criaderos fueron geo-referenciados y espacializados. RESULTADOS Se identificaron 30 criaderos de B. straminea, cuatro de ellos potenciales focos de transmisión, luego que las pruebas moleculares identificaron DNA de S. mansoni en los caracoles colectados. Se diagnosticaron 14 niños con esquistosomiasis, entre ellas cinco fueron considerados casos autóctonos de la enfermedad. CONCLUSIONES Acciones de emergencia para vigilancia de salud son necesarias para evitar que la esquistosomiasis se vuelva endémica en Recife como sucede en localidades del litoral de Pernambuco. .

OBJECTIVE : Investigate breeding sites with host snails and autochthonous human cases of schistosomiasis. METHODS : Between July 2010 and September 2012 were performed: (1) malacological survey searching for breeding sites, collection and identification of Biomphalaria snails positive for Schistosoma mansoni in Recife, PE, Northeastern Brazil; (2) prevalence survey in 2,718 schoolchildren aged from seven to 14 years old to identify cases of schistosomiasis, clinical examination and ultrasound in positive cases of S. mansoni. The autochthony of the cases was investigated and the case were clinically evaluated. The cases and breeding sites were georeferenced and spatially described. RESULTS : The results identified 30 breeding with B. straminea, four of which were potential foci of transmission, as molecular testing identified snails with S. mansoni DNA. There were 14 children diagnosed with schistosomiasis, of which five were considered to be autochthonous cases of the disease. CONCLUSIONS : Urgent measures are required in order to avoid schistosomiasis becoming endemic to Recife, as has happened in other coastal areas of the state of Pernambuco. .

Treatment and education reduce the severity of schistosomiasis periportal fibrosis

Introduction This study evaluates the factors associated with the development of severe periportal fibrosis in patients with Schistosoma mansoni. Methods A cross-sectional study was conducted from April to December 2012 involving 178 patients infected with S. mansoni who were treated in the Hospital das Clínicas of Pernambuco, Brazil. Information regarding risk factors was obtained using a questionnaire. Based on the patients' epidemiological history, clinical examination, and upper abdomen ultrasound evaluation, patients were divided into 2 groups: 137 with evidence of severe periportal fibrosis and 41 patients without fibrosis or with mild or moderate periportal fibrosis. Univariate and multivariate analyses were conducted using EpiInfo software version 3.5.5. Results Illiterate individuals (30.1%) and patients who had more frequent contact with contaminated water in towns in the Zona da Mata of Pernambuco (33.2%) were at greater risk for severe periportal fibrosis. Based on multivariate analysis, it was determined that an education level of up to 11 years of study and specific prior treatment for schistosomiasis were preventive factors for severe periportal fibrosis. Conclusions The prevailing sites of the severe forms of periportal fibrosis are still within the Zona da Mata of Pernambuco, although there has been an expansion to urban areas and the state coast. Specific treatment and an increased level of education were identified as protective factors, indicating the need for implementing social, sanitary, and health education interventions aimed at schistosomiasis to combat the risk factors for this major public health problem. .

Association between Schistosomiasis mansoni and hepatitis C: systematic review / Associacao entre esquistossomose mansonica e hepatite C: revisao sistematica / Asociacion entre esquistosomiasis mansoni y hepatitis C: revision sistematica

OBJECTIVE: To perform a systematic review of the prevalence of the HCV/ S. mansoni co-infection and associated factors in Schistosoma mansoni -infected populations. METHODS: The bibliographic search was carried out using the Medline, Lilacs, SciELO, Cochrane Library and Ibecs databases. The criteria for the studies' selection and the extraction data were based on systematic review methods. Forty five studies were found, with nine being excluded in a first screening. Thirteen articles were used for data extraction. RESULTS: The HCV infection rates in schistosomiasis populations range from 1% in Ethiopia to 50% in Egypt. Several studies had poorly defined methodologies, even in areas characterized by an association between hepatitis C and schistosomiasis, such as Brazil and Egypt, which meant conclusions were inconsistent. HCV infection rates in schistosomotic populations were heterogeneous and risk factors for acquiring the virus varied widely. CONCLUSIONS: Despite the limitations, this review may help to identify regions with higher rates of hepatitis C and schistosomiasis association. However, more studies are necessary for the development of public health policies on prevention and control of both diseases. .

OBJETIVO: Realizar revisão sistemática sobre a prevalência da confecção do vírus da hepatite C e Schistosoma mansoni e os fatores de risco associados a indivíduos com esquistossomose. MÉTODOS: Revisão realizada nas bases de dados Medline, Lilacs, SciELO, Biblioteca Cochrane e Ibecs. Os critérios de seleção e a obtenção dos dados foram baseados em métodos de revisão sistemática. Foram encontradas 45 referências relevantes, das quais nove foram excluídas na primeira triagem, 14 na leitura dos resumos e nove na leitura completa. Treze artigos foram selecionados para análise. RESULTADOS: A prevalência da associação entre vírus da hepatite C e Schistosoma mansoni variou de 1% na Etiópia a 50% no Egito. Alguns estudos apresentam metodologias pouco definidas, mesmo em áreas caracterizadas pela associação entre vírus da hepatite C e S. mansoni , como Brasil e Egito, o que não permitiu conclusões consistentes. As taxas de infecção pelo VHC em populações esquistossomáticas foram heterogêneas e os fatores de risco para adquirir o vírus foram variáveis. CONCLUSÕES: Apesar das limitações, esta análise pode ajudar a identificar regiões com maiores taxas dessa associação. Outros estudos serão necessários para o desenvolvimento de políticas públicas de prevenção e controle dessas doenças. .

OBJETIVO: Realizar revisión sistemática sobre la prevalencia de la co-infección del virus de la hepatitis C y Schistosoma mansoni y los factores de riesgo asociados a individuos con esquistosomosis. MÉTODOS: Revisión realizada en las bases de datos MEDLINE, LILACS, SciELO, Biblioteca Cochrane e IBECS. Los criterios de selección y la obtención de los datos fueron basados en métodos de revisión sistemática. RESULTADOS: Fueron encontradas 45 referencias relevantes, de las cuales, nueve fueron excluidas en la primera selección, 14 en la lectura de los resúmenes y nueve en la lectura completa. Trece artículos fueron seleccionados para análisis. La prevalencia de la asociación entre virus de la hepatitis C y Schistosoma mansoni varió de 1% en Etiopia, a 50% en Egipto. Algunos estudios presentan metodologías poco definidas, inclusive en áreas caracterizadas por la asociación entre el virus de la hepatitis C y S. mansoni, como Brasil y Egipto, lo que no permitió conclusiones consistentes. Los cocientes de infección por el VHC en poblaciones esquistosómicas fueron heterogéneos y los factores de riesgo para adquirir el virus fueron variables. CONCLUSIONES: A pesar de las limitaciones, este análisis pudo ayudar a identificar regiones con mayores cocientes de esa asociación. Otros estudios serán necesarios para el desarrollo de políticas públicas de prevención y control de estas enfermedades. .

Improvement of cchistosomal portal hypertensive colopathy after surgical treatment

Context Data on vascular alterations in patients with hepatosplenic schistosomiasis and portal hypertensive colopathy and changes in these after surgery to decrease portal hypertension are limited. Objective The purpose of this study was to analyse the alterations of portal hypertensive colopathy previously and 6-12 months after splenectomy and gastric devascularization. Methods Twelve patients with hepatosplenic schistosomiasis who also had upper gastrointestinal bleeding were studied prospectively. Their endoscopic findings before and 6-12 months after the surgery were analysed. In addition, mucosal biopsies from ascending colon, sigmoid colon and rectum at these time points were subjected to histological and histomorphometric assessment. It was used a control group due to lack of normal pattern of the histomorphometric measures of vessels in individuals without portal hypertension. The critical level of significance adopted in all tests was of a maximum probability error of 5%. Results Surgery did not lead to significant improvement in histological and endoscopic findings. However, on histomorphometry, there was a significant decrease in the area, diameter and thickness of the vessels in mucosa at all colonic sites. Conclusion Surgery for decompression of schistosomal portal hypertension has a beneficial effect on the associated colopathy, being best indicated in patients with gastrointestinal bleeding and esophageal varices. .

Contexto Dados em relação às alterações vasculares em pacientes com esquistossomose hepatoesplênica e colopatia hipertensiva portal e suas modificações após cirurgia para atenuação da hipertensão portal são restritos. Objetivo Analisar as alterações da colopatia hipertensiva portal antes e seis a 12 meses após a esplenectomia e desvascularização gástrica. Métodos Foram estudados prospectivamente 12 pacientes com esquistossomose hepatoesplênica e antecedente de hemorragia digestiva alta. Os achados colonoscópicos antes e após 6 a 12 meses após a cirurgia foram analisados. Nesses períodos, biopsias da mucosa do cólon ascendente, sigmóide e reto foram encaminhadas para análise histológica e histomorfométrica. Foi utilizado um grupo controle pela falta de padrão de normalidade das medidas histomorfométricas das vênulas do cólon e reto em indivíduos sem hipertensão portal. O nível de significância crítica adotado em todos os testes foi de probabilidade máxima de erro de 5%. Resultados Não foram encontradas diferenças significantes na intensidade das alterações endoscópicas e histológicas nos vasos da mucosa do cólon e reto após a cirurgia. Entretanto, houve decréscimo estatisticamente significante nas áreas, diâmetros e espessuras dos vasos estudados através da histomorfometria. Conclusão Cirurgia para descompressão da hipertensão portal esquistossomótica tem efeito benéfico na colopatia associada, sendo bem indicada nos pacientes com hemorragia digestive alta e varizes esofágicas. .

Relationship between splenomegaly and hematologic findings in patients with hepatosplenic schistosomiasis

BACKGROUND Schistosomiasis is a tropical disease. Patients who develop hepatosplenic schistosomiasis have clinical findings including periportal fibrosis, portal hypertension, cytopenia, splenomegaly and gastrointestinal hemorrhage. OBJECTIVE The aim of this study was to analyze the hemostatic and hematologic findings of patients with schistosomiasis and correlate these to the size of the spleen. METHODS Fifty-five adults with hepatosplenic schistosomiasis and 30 healthy subjects were selected through a history of contact with contaminated water, physical examination and ultrasound characteristics such as periportal fibrosis and splenomegaly in the Gastroenterology Service of the Universidade Federal de Pernambuco. Blood samples were collected to determine liver function, blood counts, prothrombin (international normalized ratio), partial thromboplastin time and fibrinogen and D-Dimer levels using the Pentra 120 hematological analyzer (HORIBA/ABX), Density Plus (test photo-optical Trinity Biotech, Ireland) and COBAS analyzer 6000 (Roche). Furthermore, the longitudinal size of the spleen was measured by ultrasound (Acuson X analyzer 150, Siemens). The Student t-test, the Fisher test and Pearson's correlation were used to analyze the results with statistical significance being set for a p-value < 0.05. RESULTS The mean age was higher for the Study Group than for the Control Group (54 ± 13.9 vs. 38 ± 12.7 years). The average longitudinal diameter of the spleen was 16.9 cm (Range: 12.3-26.3 cm). Anemia is a common finding in patients with schistosomiasis (36.3%). The mean platelet and leukocyte counts of patients were lower than for the Control Group (p-value < 0.001). Moreover, the international normalized ratio (1.42 vs. 1.04), partial thromboplastin time (37.9 vs. 30.5 seconds) and D-Dimer concentration (393 vs. 86.5 ng/mL) were higher for the Study Group compared to the Control Group...