Fatores prognósticos na meningite criptocócica em hospital de referência para doenças infecciosas / Prognostic factors of cryptococcal meningitis in a referrence hospital for infectious diseases / Factores pronósticos en la meningitis criptocócica en un hospital de referencia para enfermedades infecciosas

Nos últimos 20 anos, a doença criptocócica cresceu significativamente e aletalidade, bem como a taxa de recidiva da doença, ainda permanece elevada, a despeito dos avanços no seu entendimento e no desenvolvimento de novas abordagens terapêuticas. O objetivo deste artigo é analisar o perfil clínico-epidemiológico dos pacientes com encefalite. criptocócica no Hospital Couto Maia (HCMaia), propondo-se a avaliar quais condições interferem na evolução desses pacientes e elevam as taxas de letalidade da doença. Trata-se de um estudo retrospectivo com dois componentes: descritivo e analítico. Estudaram-se fatores prognósticos de 50 pacientes com diagnóstico de meningoencefalite criptocócica admitidos no Hospital Couto Maia, Salvador, Bahia, Brasil, entre 2002 e 2008. Os resultados indicamque 70por cento dos pacientes eram masculinos; 90por cento tinham sorologia conhecida para HIV, sendo positiva em 52por cento; 46por cento apresentavam sintomas entre 14 e 30 dias. Observou-se menor celularidade liquórica e maior percentagem de líquor com citoquímica normal nos pacientes HIV positivos. A letalidade foi de 22por cento. O comprometimento do nível de consciência foi associado a maior letalidade. Maior frequência de óbito foi encontrada entre os HIV positivos e naqueles que não realizaram punção lombar como método terapêutico da hipertensão intracraniana. Concluiu-se que pacientes HIV positivos podem apresentar característicasclínicas e liquóricas não encontradas habitualmente na meningoencefalite criptocócica. Rebaixamento do nível de consciência foi o único preditor independente de letalidade na população estudada.

During the last 20 years, the cryptococcal disease increased significantly but the mortality and the rate of disease recurrence still remains high despite advances in their understanding and the development of new therapeutic approaches. The objective of this document is to analyze the clinical and epidemiological profile of patients with encephalitis cryptococcal in the Couto Maia Hospital (HCMaia), in order to evaluate what are the circumstances that affect the evolution of these patients and increase the fatality rates of the disease. This is a retrospective study, with two components: descriptive and analytical. Prognostic factors were studied with 50 patients diagnosed with cryptococcal meningoencephalitis,admitted in the Couto Maia Hospital, in Salvador, Bahia, Brazil, between 2002 and 2008. The results indicate that 70percent of patients were male, 90percent have serology indicating HIV and positive in 52percent of the cases and 46percent presenting symptoms between 14 and 30 days. There was less cellularity CSF and CSF with largest percentage cytochemistry normal in HIV-positive patients. The mortality rate was 22percent. The commitment level of consciousness was associated with increased mortality. Major frequency of death was found among HIV positive and those who did not made lumbar puncture as a treatment of intracranial hypertension. It can be concluded that HIV-positive patients may present clinical and cerebrospinal fluid characteristics not usually found in cryptococcal meningoencephalitis. Decreased level of consciousness was the onlyindependent predictor of mortality in this population.

En los últimos 20 años, la enfermedad por Cryptococcus, y su letalidad, creció significativamente, y la tasa de recaida de la misma aún permanece elevada, a pesar de los logros en su comprensión y en el desarrollo de nuevos enfoques terapéuticas. El objetivo de este estudio es analizar el perfil clínico- epidemiológico de los pacientes con encefalitis criptocócica en el Hospital Couto Maia (HCMaia), proponiendo evaluar las condiciones que interfieren en la evolución de esos pacientes, así como la elevación de la tasa de letalidad de la enfermedad. Se trata de un estudio retrospectivo, con dos componentes: descriptivos y analítico. Se estudiaron los factores pronósticos de 50 pacientes con diagnóstico demeningoencefalitis criptocócica, ingresados, entre 2002 y 2008, en el Hospital Couto Maia, Salvador, Bahia, Brasil. Los resultados indican que 70por ciento de los pacientes eran masculinos; 90por ciento tenían serología conocida para el VIH, siendo, en el 52por cientoositiva; 46por ciento presentaban síntomas entre 14 y 30 días. Se observó menor celularidad licuórica y un mayor porcentaje de lícuor con citoquímica normal en los pacientes VIH positivos. La letalidad fue de 22por ciento. El comprometimiento del nivel de conciencia fue asociado a la mayor letalidad. Se detectó mayor frecuencia de óbito entre los VIH positivos y en aquellos que no han realizado la punción lumbar como método terapéutico de la hipertensión intracraneal. Se concluyeque los pacientes con VIH positivos pueden presentar características clínicas y licuóricas no encontradas habitualmente en la meningoencefalitis criptocócica. En la población estudiada, la disminución del nivel consciencia, fue el único predictor independiente de la letalidad.

Comparative study of the in-hospital case-fatality rate of leptospirosis between pediatric and adult patients of different age groups

O objetivo principal foi comparar a letalidade hospitalar da leptospirose entre pacientes pediátricos (< 19 anos) e adultos (> 19 anos), levando em consideração gênero, função renal, duração dos sintomas e icterícia. Prontuários de 1016 pacientes foram revistos. Análise comparativa foi restrita a 840 pacientes (100 pediátricos, 740 adultos) com informações sobre as variáveis incluídas na análise. Entre estes pacientes 81,4 por cento eram do sexo masculino e 91,5 por cento apresentavam icterícia à admissão. A letalidade da leptospirose foi 14,4 por cento. A razão entre número de pacientes que morreram e número de pacientes que sobreviveram, ajustada para gênero, icterícia, duração de sintomas, uréia sérica e creatinina sérica foi quase quatro vezes maior no grupo adulto do que no pediátrico (odds ratio (OR) = 3,94; intervalo de confiança de 95 por cento = 1,19-13,03, p = 0,029). Em adultos, idade mais avançada foi também significantemente e independentemente associada com maior risco de morte (p < 0,01). Pacientes mais velhos foram também mais freqüentemente dialisados. Em conclusão, os dados mostram que a letalidade da leptospirose é mais alta em adultos do que em crianças e adolescentes, mesmo após o ajuste para os efeitos de potenciais fatores de risco de morte. Entre adultos, idade avançada mostrou-se também associada fortemente e independentemente com risco mais alto de morte.

Penicillin at the late stage of leptospirosis: a randomized controlled trial

There is evidence that an early start of penicillin reduces the case-fatality rate of leptospirosis and that chemoprophylaxis is efficacious in persons exposed to the sources of leptospira. The existent data, however, are inconsistent regarding the benefit of introducing penicillin at a late stage of leptospirosis. The present study was developed to assess whether the introduction of penicillin after more than four days of symptoms reduces the in-hospital case-fatality rate of leptospirosis. A total of 253 patients aged 15 to 76 years with advanced leptospirosis, i.e., more than four days of symptoms, admitted to an infectious disease hospital located in Salvador, Brazil, were selected for the study. The patients were randomized to one of two treatment groups: with intravenous penicillin, 6 million units day (one million unit every four hours) for seven days (n = 125) and without (n = 128) penicillin. The main outcome was death during hospitalization. The case-fatality rate was approximately twice as high in the group treated with penicillin (12 percent; 15/125) than in the comparison group (6.3 percent; 8/128). This difference pointed in the opposite direction of the study hypothesis, but was not statistically significant (p = 0.112). Length of hospital stay was similar between the treatment groups. According to the results of the present randomized clinical trial initiation of penicillin in patients with severe forms of leptospirosis after at least four days of symptomatic leptospirosis is not beneficial. Therefore, more attention should be directed to prevention and earlier initiation of the treatment of leptospirosis

Electrocardiographic alterations in patients hospitalized with leptospirosis in the Brazilian City of Salvador

OBJECTIVE: To report the frequency and types of electrocardiographic alterations in patients with leptospirosis in the first 24 hours of hospitalization. METHODS: We analyzed the electrocardiograms of 157 patients admitted to the Hospital Couto Maia in the city of Salvador, in the State of Bahia, Brazil, from March 1998 to June 1999. The electrocardiograms were performed in the first 24 hours after hospital admission, independent of the clinical manifestations of the patients. RESULTS: The mean ± SD for patients' age was 35.5± 13.7 (median = 32) years, and jaundice was present in 95.5 percent of them. Alterations in the electrocardiogram were detected in 68.2 percent (107/157) of the patients (95 percent confidence interval = 60.6 percent - 75.1 percent). Atrial fibrillation was the most frequent arrhythmia, occurring in 10.8 percent (17/157) of the patients. Other frequent findings were alterations in ventricular repolarization detected in 38.9 percent (61/157) of patients and first-degree atrioventricular block in 10.2 percent (16/157). The patients with atrial fibrillation were older and had higher levels of creatinine and aminotransferases. CONCLUSION: In this sample, approximately 2/3 of the patients had electrocardiographic alterations after hospital admission. Of the major arrhythmias, atrial fibrillation was the most frequent, and the patients with this arrhythmia had evidence of more severe disease. The relation between the presence and type of electrocardiographic alteration and the prognosis of leptospirosis is yet to be assessed

Chronic ulcers and myasis as ports of entry for Clostridium tetani

Evaluating tetanus immune status is not yet the usual clinical practice regarding patients with chronic ulcers or myasis. However, of 858 tetanus patients at Hospital Couto Maia (Salvador, Bahia, Brazil) aged 1 year or above, 2 had pressure ulcers and 17 had chronic ulceration of the lower limbs where these skin lesions were the ports of entry for Clostridium tetani. In these 19 cases, the following predisposing factors were described: venous insufficiency (n=6), sickle cell anemia (n=2), Hansen s disease (n=1), malnutrition (n=1), diabetes mellitus (n=1), trauma (n=1) and unknown factors (n=7). In 6 other cases, in addition to the Hansen s disease patient, the port of entry for tetanus was the site of extraction of Tunga penetrans larvae. In these 25 cases, the majority of patients (68) were over 40 years old (17/25) and all of these patients stated that they had either not followed a tetanus toxoid vaccination regimen (19/25), or had partially completed such a regimen, or did not give precise information (6/25). Among the same series studied, over half (52) of the patients died (13/25). We conclude that tetanus prevention must be included in the treatment of chronic skin ulcer patients, vaccination coverage should be increased among older people, and strategies aimed at improving coverage for all age groups must be reviewed.

The association between serum potassium at hospital admission and the case-fatality rate of leptospirosis in men

Severe leptospirosis affects predominantly males and presents a high susceptibility to hypokalemic acute renal failure. As hypokalemia and hyperkalemia induce severe complications, it is important to evaluate if the initial serum potassium is an independent risk factor for death in leptospirosis. The medical records of 1016 patients hospitalized with the diagnosis of leptospirosis were reviewed. The analysis was restricted to 442, according to the following criteria: male, 18 years or older, information about death or hospital discharge and recorded values of serum potassium, serum creatinine and duration of symptoms at admission. Potassium values lower than 3.5 mEq/L (hypoK), 3.5-5 mEq/L (normoK) and above 5 mEq/L (hyperK) were detected in 180, 245 and 17 patients, respectively. The death rate increased with serum potassium: 11.1 percent in the hypoK, 14.7 percent in the normoK and 47.1 percent in the hyperK group (p = 0.002). In a logistic regression model (normoK as referent), including age, creatinine and duration of symptoms, hypoK was not associated with increased death rate (odds ratio (OR) = 0.80; p > 0.1). On the other hand, hyperK showed a significant association with increased risk of death (OR = 3.95, p = 0.021). In conclusion, in this sample of men with leptospirosis initial serum potassium was positively and independently correlated with the risk of in-hospital death

Chest radiograph abnormalities in patients hospitalized with leptospirosis in the city of Salvador, Bahia, Brazil

This study was designed to estimate the prevalence of pulmonary radiograph abnormalities and describe the distribution of the patterns of radiographic alterations among patients hospitalized with leptspirosis. Chest radiographs of 139 patients hospitalized with leptospirosis in Couto Maia Hospital, in Salvador, Bahia, Brazil, between July, 1997, and July, 1999, were analyzed. The radiographs were requested soon after hospital admission, independent of the clinical manifestations of the patients. Only the first radiograph was considered. Pulmonary radiograph alterations were recorded in 35/139 patients (25.2 percent); 95 percent mid-point confidence interval = 18.5 percent to 32.9 percent. Among the patients with radiograph alterations, alveolar infiltrate was seen in 26/35 (74.3 percent). The lesions were bilateral in 54.3 percent and located in the inferior lobes in 45.5 percent. Pleural effusion, represented by blunting of the costo-phrenic angle, was detected in 8.6 percent of the patients. The pattern of the pulmonary alterations, predominantly bilateral alveolar infiltrates, is consistent with the evidence that the basic pulmonay alteration in leptospirosis is a generalized capillaritis.

Massive ocular hemorrhage resulting in blindness in a patient with the sickle cell trait who developed leptospirosis. Case report

This case report describes the findings of a 18 year-old black male from Bahia, a Northeastern state in Brazil, with the sickle cell trait, who developed bilateral hyphema and vitreous hemorrhage with blindness in the course of leptospirosis. The patient started to complain of blurred vision four days after the start of fever and muscular pain and approximately twelve hours after the introduction of penicillin. The severity of the leptospirosis in conjunction with sickle cell trait was considered to be the most likely explanation for this ocular complication