Hantavirus in Panama: Twenty Years of Epidemiological Surveillance Experience.

Twenty years have passed since the emergence of hantavirus zoonosis in Panama at the beginning of this millennium. We provide an overview of epidemiological surveillance of hantavirus disease (hantavirus pulmonary syndrome and hantavirus fever) during the period 1999-2019 by including all reported and confirmed cases according to the case definition established by the health authority. Our findings reveal that hantavirus disease is a low-frequency disease, affecting primarily young people, with a relatively low case-fatality rate compared to other hantaviruses in the Americas (e.g., ANDV and SNV). It presents an annual variation with peaks every 4-5 years and an interannual variation influenced by agricultural activities. Hantavirus disease is endemic in about 27% of Panama, which corresponds to agroecological conditions that favor the population dynamics of the rodent host, Oligoryzomys costaricensis and the virus (Choclo orthohantavirus) responsible for hantavirus disease. However, this does not rule out the existence of other endemic areas to be characterized. Undoubtedly, decentralization of the laboratory test and dissemination of evidence-based surveillance guidelines and regulations have standardized and improved diagnosis, notification at the level of the primary care system, and management in intensive care units nationwide.

Case Report: First Confirmed Case of Coinfection of SARS-CoV-2 With Choclo orthohantavirus.

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a major international public health concern. The World Health Organization (WHO) declared the pandemic of coronavirus disease 2019 (COVID-19) on March 11, 2020. In Panama, the first SARS-CoV-2 infection was confirmed on March 9, 2020, and the first fatal case associated to COVID-19 was reported on March 10. This report presents the case of a 44-year-old female who arrived at the hospital with a respiratory failure, five days after the first fatal COVID-19 case, and who was living in a region where hantavirus pulmonary syndrome cases caused by Choclo orthohantavirus (CHOV), are prevalent. Thus, the clinical personnel set a differential diagnosis to determine a respiratory disease caused by the endemic CHOV or the new pandemic SARS-CoV-2. This case investigation describes the first coinfection by SARS-CoV-2 and CHOV worldwide. PCR detected both viruses during early stages of the disease and the genomic sequences were obtained. The presence of antibodies was determined during the patient's hospitalization. After 23 days at the intensive care unit, the patient survived with no sequelae, and antibodies against CHOV and SARS-CoV-2 were still detectable 12 months after the disease. The detection of the coinfection in this patient highlights the importance, during a pandemic, of complementing the testing and diagnosis of the emergent agent, SARS-CoV-2, with other common endemic respiratory pathogens and other zoonotic pathogens, like CHOV, in regions where they are of public health concern.

Elastografía esplénica como predictor de varices esofágicas / Spleen elastography as a predictor of esophageal varices

El propósito del estudio fue evaluar el rendimiento diagnóstico de la elastografía esplénica y otros métodos no invasivos para detectar varices esofágicas de alto riesgo en pacientes con cirrosis. La verificación de la existencia de varices se realizó con endoscopia digestiva alta que es el gold standard. Se incluyeron 40 pacientes con reciente diagnóstico de cirrosis los cuales fueron evaluados con ecografía Doppler portal, elastografía hepática, elastografía esplénica, endoscopia y que cumplieron con los siguientes criterios: no antecedentes de sangrado digestivo, no tratamiento con betabloqueantes, no trombosis de la porta. Se realizó un estudio transversal, unicéntrico desde abril del 2017 hasta agosto del 2018. Los datos se presentan organizados en tablas de frecuencia. La comparación con el standard incluyo el uso de chi cuadrado y obtuvimos curvas ROC para presentar los datos de sensibilidad y especificidad. La elastografía demostró ser un buen estudio predictivo de la presencia de várices esofágicas (AUC 0,84 ; IC 95%: 0,71 - 0,97), seguido del diámetro del bazo (AUC 0,81 ; IC 95%: 0,66 - 0,96), mientras que el índice de congestividad (AUC 0,46 ; IC 95%: 0,27 - 0,64) y la elastografía hepática (AUC 0,39 ; IC 95%: 0,21 - 0,58) fueron los parámetros con menor precisión, el punto de corte de 3,8 m/seg en la elastografía esplénica fue capaz de identificar las varices de alto riesgo con una sensibilidad del 90,9% . La elastografía esplénica y el diámetro del bazo alcanzaron mayor rendimiento diagnostico en comparación a la elastografía hepática para identificar varices esofágicas de alto riesgo

The purpose of the study was to evaluate the diagnostic performance of splenic elastography and other non-invasive methods to detect high-risk esophageal varices in patients with cirrhosis. Verification of the existence of varicose veins was performed with upper digestive endoscopy, which is the gold standard. Forty patients with a recent diagnosis of cirrhosis were included, who were evaluated with portal Doppler ultrasound, hepatic elastography, splenic elastography, endoscopy and who fulfilled the following criteria: no history of digestive bleeding, no treatment with beta-blockers, no thrombosis of the portal. A cross-sectional, unicentric study was conducted from August 2018 to April 2017. The data are presented organized in frequency tables. The comparison with the standard included the use of chi square and we obtained ROC curves to present the sensitivity and specificity data. Elastography proved to be a good predictive study of the presence of esophageal varices (AUC 0.84, 95% CI: 0.71-0.97), followed by spleen diameter (AUC 0.81, 95% CI: 0.66 - 0.96), while the congestivity index (AUC 0.46, 95% CI: 0.27 - 0.64) and hepatic elastography (AUC 0.39, 95% CI: 0.21) - 0.58) were the parameters with less precision, the cutoff point of 3.8 m / sec in splenic elastography was able to identify high risk varicose veins with a sensitivity of 90.9%. Splenic elastography and spleen diameter achieved a higher diagnostic yield compared to hepatic elastography to identify high risk esophageal varices.

Apoyo de los métodos de imagen para el Diagnóstico de Áscaris complicado en la vía biliar. Reporte de un caso / Advocacy for imaging methods for the diagnosis of complex Ascaris in the billiary tract: case report

Introducción: El presente caso nos permite revisar la utilidad de los diferentes métodos de imagen en la ascaridiasis en vía biliar a través del ultrasonido abdominal (US), la colangioresonancia (MRCP), la colangiopancreatografía retrógrada endoscópica (CPRE/ERCP) para el diagnóstico y/o tratamiento, para conocer el escenario de esta patología y definir los protocolos de diagnóstico por imagen y abordaje de la misma. La sensibilidad y especificidad de cada uno de los mismos en las diferentes series mundiales. Reporte de Caso: Nos apoyamos en la presentación de un caso clínico de una paciente proveniente del Oriente, que acude con cuadro de dolor abdominal tipo cólico en hipocondrio derecho, ictericia de 15 días de evolución, es transferida al Hospital Carlos Andrade Marín donde se realizaron estudios complementarios dentro de los cuales varios métodos de imagen, se describen los hallazgos en esta patología, así como protocolizar los métodos de imagen. Discusión: El ultrasonido es un método eficaz, accesible, no costoso, en manos expertas tiene elevada sensibilidad, al encontrar hallazgos concluyentes no se requiere el apoyo de otros métodos de imagen adicionales y en caso de ascaridiasis complicada como en nuestra paciente se debe proceder directamente a CPRE con extracción del parásito, en caso de no tener hallazgos concluyentes nos podemos apoyar de métodos como una colangioresonancia.

Introduction: This report let us review the usefulness of different imaging methods in common bile duct ascariasis like abdominal ultrasound, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis and / or treatment, to know the stage of this disease and to define the imaging protocols and addressing it. The sensitivity and specificity of each of them in different world series. Case Report: This is a clinical case of a patient from the Eastern región of Ecuador who was admitted to our hospital with a crampy abdominal pain focused in the right upper quadrant and jaundice that started 15 days before he was transferred to us. Imaging tests performed helped us to find out the problem and prescribe a propper treatment. Discusion: Ultrasound is an effective, accesible and inexpensive tool in expert hands. When the initial findings are not conclusive, other imaging methods can be applied, like Nuclear Magnetic Resonance cholangiopancreatography. Endoscopic retrograde cholangiopancreatography (ERCP) can be used in case of complicated ascariasis, as in our patient, to remove the parasite.