Fever of undetermined origin in patients with the acquired immunodeficiency syndrome in Brazil: report on 55 cases

The medical records of patients with AIDS admitted to a general hospital in Brazil from 1989 to 1997 were reviewed retrospectively with the aim at defining the frequency and etiology of fever of undetermined origin (FUO) in HIV-infected patients of a tropical country and to evaluate the usefulness of the main diagnostic procedures. 188 (58.4 percent) out of 322 patients reported fever at admission to hospital and 55 (17.1 percent) had FUO. Those with FUO had a mean CD4+ cell count of 98/ml. A cause of fever was identified for 45 patients (81.8 percent). Tuberculosis (32.7 percent), Pneumocystis carinii pneumonia (10.9 percent), and Mycobacterium avium complex (9.1 percent) were the most frequent diagnoses. Other infectious diseases are also of note, such as cryptococcal meningitis (5.5 percent), sinusitis (3.6 percent), Salmonella-S. mansoni association (3.6 percent), disseminated histoplasmosis (3.6 percent), neurosyphilis (1.8 percent), and isosporiasis (1.8 percent). Four patients had non-Hodgkin's lymphoma (7.3 percent). We conclude that an initial aggressive diagnostic approach should be always considered because biopsies (lymph node, liver and bone marrow) produced the highest yield in the diagnosis of FUO and the majority of the diagnosed diseases are treatable. The association of diseases is common and have contributed to delay the final diagnosis of FUO in most cases. In our study area the routine request of hemocultures for Salmonella infection and the investigation of cryptococcal antigen in the serum should be considered.

Schistosomiasis and associated infections

In hospital-based series viral hepatitis B has been frequently described in association with schistosomiasis whilst in field-based studies the association has not been confirmed. The association between schistosomiasis and Salmonella bacteraemia has been well documented. More recently, acute schistosomiasis has been shown to be a facilitating factor in the genesis of pyogenic liver abscesses caused by Staphylococcus aureus. New evidences indicate an interaction between the acquired immunodeficiency syndrome (AIDS) and schistosomiasis. In this paper, data on the association of schistosomiasis with other infections are updated.

Splenic palpation for the evalution of morbidity due to schistosomiasis mansoni

This study was undertaken to determine the accuracy of splenic palpation for the diagnosis of splenomegaly, and to determine whether the frequency of individuals with a palpable spleen in an endemic area can be considered as an index of morbidity of schistosomiasis. For the clinical diagnosis of splenomegaly, two criteria have been tested: (A) presence of a palpable spleen and (B) presence of a palpable spleen whose border could be felt more than 4 cm below the costal margin. In an area of high prevalence of the disease (66.3 per cent) 285 individuals aged 18 years or more have been submitted to abdominal ultrasonography and physical examination. Splenomegaly was defined as a splenic lengh greater than 120 mm by ultrasound and the sensitivity, specificity, positive and negative predictive values of criterion A were 72.2 per cent, 90.5 per cent, 35.1 per cent and 97.8 per cent. The values for criterium B were 27.8 per cent, 98 per cent, 50 per cent and 95 per cent, respectively. In an non endemic area, 517 individuals were submitted to the same protocol and 22 individuals had a palpable spleen, but no patient fulfilled criterium B for splenomegaly, and only one met the ultrasonographic criterium for splenomegaly. The authors concluded that abdominal palpable is a poor method for the diagnosis of splenomegaly.

Chronic carriers of hepatitis B surface antigen in an endemic area for shistosomiasis mansoni in Brazil

Data on the association of schistosomiasis and hepatitis B in field-based studies are scarce. Two areas have been selected for this study: i) Queixadinha, endemic for shistosomiasis, with a population of 693 individuals, and ii) Capäo, a control non-endemic area, with 515 inhabitants. Sera of all individuals in both areas were tested for hepatitis B infection, yearly, from 1994 to 1997. In the first area hepatitis B was found in 32.1 per cent of children up to one year old and reached a peak of 68.7 per cent in the age range of 15 to 19 years. In the control area the prevalence of hepatitis B was under 5 per cent up to 19 years of age and the highest prevalence was observed in adults over 45. HBsAg was detected in 9.4 per cent of the individuals living in the endemic area for shistosomiasis and in 1.4 per cent of the controls (OR=4.98; 95 per centCI=3.7-6.7). The index of chronicity of HBsAg was not statistically different in the studied areas (8.1 per cent x 7.3 per cent; OR=1.09; 95 per cent CI=0.42-3.03) nor was it different for people with and without schistosomiasis in Queixadinha (8.7 per cent x 7.0 per cent). We conclude that the Schistosoma mansoni infection has not altered the course of hepatitis B in the studied area.

Salmonella-S. mansoni association in patients with acquired immunodeficiency syndrome

Apresentam-se os casos de dois jovens com bacteriemia por Salmonella associada a esquistossomose mansoni ativa em pacientes com a sindrome da imunodeficiencia adquirida. A apresentacao clinica incluiu sintomas e sinais inespecificos como fadiga, perda de peso, diarreia, febre prolongada e hepatoesplenomegalia. A biopsia hepatica em um paciente revelou granulomas mal formados em torno de ovos de S. mansoni e hepatite de intensidade moderada. O tratamento da esquistossomose com a oxamniquine induziu melhora clinica progressiva culminando com a cura da salmonelose e da esquistossomose. O reconhecimento da associacao Salmonella-S. mansoni em pacientes com AIDS mostra-se importante nesses casos pois o tratamento da esquistossomose melhora o prognostico da bacteriemia por Salmonella que pode tornar-se recorrente e fatal nos pacientes com AIDS

O Projeto Queixadinha: a morbidade e o controle da esquistossomose em área endêmica no nordeste de Minas Gerais, Brasil / Queixadinha project: morbidity and control of schistosomiasis in an endemic area in the northeast of State of Minas Gerais, Brazil

In an endemic area for schistosomiasis in the northeast of the state of Minas Gerais in Brazil 516 individuals have been submitted to clinical and laboratory examination, ultrasonography of the abdomen and dopplerecocardiography in order to define the morbidity of schistosomiasis before and after treatment. A high prevalence of schistosomiasis (66.3 per cent) and of severe disease (9.5per cent with palpable spleens) were recorded. Ultrasonography classified liver periportal fibrosis as light (19.4 per cent), moderate (27.6 per cent) and intense (6.8 per cent), and 46.0 per cent presented no periportal fibrosis. Twenty one out of the 53 individuals (39.6 per cent) with palpable spleens did not present liver fibrosis on ultrasound. Periportal lymph nodes were described in 33.8 per cent of the population and anti-KLH antibodies were found in the serum of 40.7 per cent. Urinary alterations compatible with the glomerulopathy of schistosomiasis were observed in 4.5 per cent of the population, and 11.7 per cent of the individuals examined by dopplerecocardiography had pulmonary hypertension. Twelve months after treatment for schistosomiasis the prevalence of the disease dropped from 66.3 per cent to 25.0 per cent. In Queixadinha, a profile of the morbidity of schistosomiasis has just been established.