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% in the hypoK, 14.7% in the normoK and 47.1% 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.

[Severe forms of leptospirosis: clinical, demographic and environmental aspects]. / Formas graves de leptospirose: aspectos clínicos, demográficos e ambientais.

Characteristics of 1,016 patients hospitalized with leptospirosis in the Hospital Couto Maia, Salvador, BA, Brazil, between 1993 and 1997 are described. Higher pluviometric precipitation was related to an increase in the number of hospitalizations during the following month. Males corresponded to 81.1% (824/1,016) of these; mean age was 35.7+/-15.4 years. Almost 94% (778/829) of the 829 patients with information about race were black or mulatto (mixed race). For ages 18 years or above, almost 93% had not completed high school level. The mean incubation period was estimated as 6.3+/-3.9 days. Average duration of symptoms was 6.1+/-2.4 days. Hemorrhagic events corresponded to 14.3% (145/1,016). The case-fatality rate among 1,009 patients that were not transferred was 14.2% (143/1,009). Renal failure was the attributable cause of death in 76.2% (109/143). The data indicate that leptospirosis is closely related to lower socioeconomic levels, and that higher pluviometric precipitation antecedes the outbreaks.

Facial nerve palsy associated with leptospirosis.

This case report describes the findings of a 27-year-old black male from Bahia, Brazil, who developed facial palsy during the convalescence phase of leptospirosis. The patient recovered without neurological sequel. This work calls attention to a possible association between leptospirosis and facial palsy.

Formas graves de leptospirose: aspectos clínicos, demográficos e ambientais / Severe forms of leptospirosis: clinical, demographic and environmental aspects

Characteristics of 1,016 patients hospitalized with leptospirosis in the Hospital Couto Maia, Salvador, BA, Brazil, between 1993 and 1997 are described. Higher pluviometric precipitation was related to an increase in the number of hospitalizations during the following month. Males corresponded to 81.1% (824/1,016) of these; mean age was 35.7+/-15.4 years. Almost 94% (778/829) of the 829 patients with information about race were black or mulatto (mixed race). For ages 18 years or above, almost 93% had not completed high school level. The mean incubation period was estimated as 6.3+/-3.9 days. Average duration of symptoms was 6.1+/-2.4 days. Hemorrhagic events corresponded to 14.3% (145/1,016). The case-fatality rate among 1,009 patients that were not transferred was 14.2% (143/1,009). Renal failure was the attributable cause of death in 76.2% (109/143). The data indicate that leptospirosis is closely related to lower socioeconomic levels, and that higher pluviometric precipitation antecedes the outbreaks.

São descritas as características de 1.016 pacientes internados com leptospirose no Hospital Couto Maia, Salvador, BA, entre 1993 e 1997. Aumento na precipitação pluviométrica mostrou relação com aumento do número de internamentos no mês subsequente. Sexo masculino correspondeu a 81,1% (824/1.016); a média da idade foi 35,7±15,4 anos. Quase 94% (778/829) dos 829 com informação sobre raça eram negros ou mulatos. Para idade igual ou superior a 18 anos, quase 93% não cursaram o segundo grau. A média do período de incubação foi estimado em 6,3±3,9 dias. A duração dos sintomas foi em média 6,1±2,4 dias. Episódios hemorrágicos corresponderam a 14,3% (145/1.016). A letalidade entre 1.009 pacientes não transferidos foi de 14,2% (143/1.009). Insuficiência renal foi a causa atribuída de morte em 76,2% (109/143). Os dados indicam que leptospirose é estreitamente relacionada com baixos níveis socioeconômicos e que aumento da precipitação pluviométrica precede surtos epidêmicos.

Facial nerve palsy associated with leptospirosis

This case report describes the findings of a 27-year-old black male from Bahia, Brazil, who developed facial palsy during the convalescence phase of leptospirosis. The patient recovered without neurological sequel. This work calls attention to a possible association between leptospirosis and facial palsy.

Este relato de caso descreve os achados de um homem de 27 anos, residente na Bahia, Brasil, que desenvolveu paralisia facial durante a fase de convalescença da leptospirose. O paciente se recuperou sem sequela neurológica. Este trabalho chama atenção para uma possível associação entre leptospirose e paralisia facial.

[High intensity signal in basal ganglia on T1 weighted images: case report in Manson's Schistosomiasis with portal systemic encephalopathy]. / Hiperintensidade de sinal em T1 dos núcleos da base. Relato de caso na encefalopatia portal sistêmica esquistossomótica.

We report a case of mansonic schistosomiasis with portal systemic encephalopathy associated with a high intensity signal in basal ganglia on TI weighted images due to deposition of manganese in tissues related with portal-systemic collateral vessels. A bibliographic review was done focusing the magnetic resonance findings. To the best of our knowledge, these signal changes have not yet been associated with Manson's schistosomiasis.

Characteristics of the acquired immunodeficiency syndrome in Brazil.

The clinical and epidemiologic characteristics of the acquired immunodeficiency syndrome (AIDS) were studied in a tropical area of Brazil. During an 18-month period (July 1989-January 1991), 111 consecutive AIDS patients (102 men and nine women) were evaluated. Patients reported homosexual/bisexual activities (60%), intravenous drug use (19%), or both (6%), heterosexual activities (11%), blood transfusions (2%), and 2% belonged to an undetermined category. Weight loss, fever, oral thrush, and diarrhea were present in > or = 70% of the patients at presentation. An unexpected high frequency of hepatomegaly (49%) was detected, and found to be significantly associated with tuberculosis (P < 0.0001). Although the epidemiologic features of human immunodeficiency virus transmission were comparable to the United States/European pattern, the clinical spectrum of opportunistic infections more closely resembled that reported in Africa and Haiti, with a greater frequency of fungal and mycobacterial infections than Pneumocystis carinii pneumonia and viral infections.

Correlation between cell-mediated immunity and degree of infection in subjects living in an endemic area of schistosomiasis.

Cell-mediated immunity to Schistosoma mansoni antigens, unrelated antigens and mitogens was evaluated in 50 subjects with the same degree of exposure to infection living in an endemic area of schistosomiasis. The degree of infection, assessed by the number of eggs/g of stool, was variable in this population (0-5604), suggesting differences in susceptibility to infection. Absence of lymphoproliferative response was observed in 56% of this group, despite having a response to purified protein derivative of tuberculin (PPD) and tetanus toxoid (TT) antigens and to pokeweed mitogen. The 50 subjects were divided into two groups, according to their degree of infection. The lymphoproliferative responses to schistosomula and adult worm antigens in the group with a low degree of infection (< 400 eggs/g of stool) were higher than the ones documented in patients with a high degree of infection (> 400 eggs/g of stool), and these differences were statistically significant (p < 0.001). An inverse correlation between the lymphocyte proliferation in response to S. mansoni antigens and the degree of infection was also observed (p = 0.02), indicating that subjects with a lower degree of infection have a higher lymphoproliferative response to schistosomula and adult worm antigens. No differences in the lymphocyte reactivity to other antigens (PPD and TT) were detected in these groups. An impairment of interferon-gamma in vitro production was observed when the lymphocytes from these subjects were stimulated with S. mansoni adult worm antigen, although they produced gamma interferon in response to phytohemagglutinin.

[Specific treatment as a weapon for controlling schistosomiasis]. / O tratamento específico como arma no controle da esquistossomose.

The specific treatment of schistosomiasis has been thought to prevent or revert severe forms of the disease, since 1957. Starting in 1977, prospective and controlled studies performed in different endemic areas of Brazil were able to confirm such facts. The new drugs, of high efficacy and well tolerated--Oxamniquine and Praziquantel--can actually prevent and cure the severe forms of some patients, contributing to change the morbidity pattern of the disease, thus being considered as important weapons in its control. Analysis of the principal Brazilian articles on the subject is presented.

Human resistance to Schistosoma mansoni is associated with IgG reactivity to a 37-kDa larval surface antigen.

The aim of this work was to determine whether human resistance to Schistosoma mansoni was associated with increased antibody reactivity to certain larval surface Ag. To this end, young residents of a hyperendemic area were selected for their low or high susceptibility to reinfection after parasitologic cure, and the reactivity of their sera to individual larval surface Ag was determined at different times before and after treatment. The data showed that six Ag: 202, 165, 90 to 92, 85, 72, and 37 kDa are the principal targets on the larva of IgG in the sera of resistant subjects. The comparative study, by immunoblotting and ELISA on purified Ag, of the sera from high and low susceptibility subjects indicates that IgG reactivity toward the 37-kDa Ag may be associated with resistance. This work and ongoing vaccination trials carried out in mice suggest that the 37-kDa Ag may have vaccinating potentials.

Enhancement of human eosinophil cytotoxicity and leukotriene synthesis by biosynthetic (recombinant) granulocyte-macrophage colony-stimulating factor.

Culture medium conditioned by activated human T lymphocytes enhances the in vitro cytotoxicity of purified human eosinophils toward Schistosoma mansoni larvae, suggesting the existence of a mechanism for T lymphocyte regulation of eosinophil function. Here we show that purified biosynthetic (recombinant) human T lymphocyte granulocyte-macrophage colony-stimulating factor (GM-CSF) enhanced markedly two eosinophil functions: cytotoxicity toward schistosomula by a mean of 676%, and calcium ionophore A23187-induced generation of leukotriene C4 (LTC4) by a mean of 135%. Augmentation of each eosinophil function by GM-CSF was time- and dose-dependent, with a dose-response relationship at concentrations between 1 and 20 pM. Tumor necrosis factor (TNF) enhanced eosinophil cytotoxicity with slower kinetics, a different dose-dependence relationship, and to a lower maximum, as compared with GM-CSF. There was no detectable effect of TNF on calcium ionophore A23187-induced generation of LTC4. The effect of GM-CSF on arachidonic acid metabolism to LTC4 reached a plateau with 60 min of incubation before stimulation with ionophore, and was characterized by an initial augmentation of the intracellular level of LTC4 and a subsequent increment in extracellular LTC4. Thus, GM-CSF can serve as a mediator for T lymphocyte regulation of functions of mature eosinophils. It is also the first defined macromolecule known to enhance metabolism of membrane-derived arachidonic acid via the 5-lipoxygenase pathway.

The changing pattern of pathology due to Schistosoma mansoni infection.

A survey of the autopsy data on hepatosplenic schistosomiasis during periods, before and after the advent of new chemotherapeutic drugs, revealed that: a) the pathological presentation was the same for the two periods; b) the number of cases in the last five years is progressively decreasing; c) hepatosplenic disease due to schistosomiasis is becoming rare in young people. These data represent a change in the pattern of pathology in schistosomiasis, probably related to new chemotherapy.

Modulation of eosinophil cytotoxicity by blood mononuclear cells from healthy subjects and patients with chronic schistosomiasis mansoni.

Human blood mononuclear cells in culture release a factor(s) that markedly enhances eosinophil cytotoxicity. This factor(s) stimulates eosinophils to kill Schistosoma mansoni larvae at low antibody concentrations and cell/target ratios. A study of the mononuclear cells of 78 subjects with chronic schistosomiasis mansoni and 33 controls suggests that the production of eosinophil cytotoxicity enhancing activity (ECEA) is suppressed in most patients with S. mansoni infections. Suppression of ECEA production was not observed, however, with cells from many patients with heavy infections, including patients with hepatosplenomegaly. The possible role of ECEA in the development of pathology is discussed.

Regressão da hepatosplenomegalia pelo tratamento específico da esquistossomose

Foram tratados com oxamniquine 23 esquistossomóticos com forma hepatosplênica instalada há menos de seis anos. Eles permaneceram na área endêmica, se reinfectaram e foram revistos após 2-4 anos. Houve melhora na evolução da doença em 78,3%. A melhora variou da completa reversão da hepatosplenomegalia (26%) à simples diminuição da esplenomegalia com persistência ou não das lesões nodulares hepáticas. A resposta ao tratamento não foi influenciada pelo número de ovos de S. mansoni ms fezes e nem pela repetição do tratamento. Contudo, os pacientes com idade acima de nove anos responderam melhor ao tratamento. Na hipertensão porta esquistossomótica, pelo menos na ausência de hemorragias digestivas, o tratamento especifico deve preceder qualquer indicação cirúrgica.

Twenty three patients with a less than six year history of the hepatosplenic form of schistosomiasis were treated with oxamniquine. They remained in the endemic area, were reinfected and re-examined after 2-4 years. Improvement was noted in 78,3% of the patients. The recovery varied from complete reversion of the hepatosplenomegaly (26%) to a reduction of the splenomegaly with or without persistent hepatic nodular lesions. Response to the treatment was not influenced by the number of S. mansoni eggs in the feces nor by repetitions of the treatment. In schistosomiasis with portal hypertension, at least in theabsenceofdigestive hemorrhages, specific treatment must preceed any recommended surgery.

Titres of antibodies to gut-derived antigens in patients with chronic schistosomiasis mansoni.

Serum titres of antibodies against six intestinal, one ubiquitous and one non-intestinal bacteria were determined in patients with severe hepatosplenic schistosomiasis mansoni, with light intestinal schistosomiasis and in normal subjects. No significant difference was observed among the three groups of subjects for levels of antibodies against two non-intestinal bacteria and four of the intestinal bacteria. Patients with hepatosplenic schistosomiasis had titres of antibodies against one strain of Pseudomonas aeruginosa and one strain of Escherichia coli lower than those observed in other groups of subjects. Despite the partial obliteration of the hepatic blood outflow and the elevated portal pressure, hepatic clearance of the portal blood is efficient in chronic human schistosomiasis, and unlike alcoholic liver cirrhosis, avoids excessive stimulation of the immune system by a gut-derived antigens.