Caracterización clínico epidemiológica de la leishmaniosis visceral infantil / Clinical epidemiological characterization of children visceral leishmaniasis

Introducción: La leishmaniosis visceral es la más grave de las formas clínicas de la leishmaniosis, afecta principalmente a los niños y es potencialmente fatal. Objetivo: Exponer la caracterización clínico-epidemiológica de la leishmaniosis visceral en población pediátrica y su respuesta terapéutica. Métodos: Se realizó un estudio retrospectivo, longitudinal y descriptivo en el Hospital Italiano, Ciudad de Djibouti en el período septiembre 2016-agosto 2017. El universo lo conformaron 166 menores de 15 años que ingresaron con diagnóstico de fiebre prolongada sin foco de localización, la muestra fue de 22 niños con diagnóstico confirmado de leishmaniosis visceral. La información se obtuvo de las historias clínicas. Se operacionalizaron 20 variables: sociodemográficas, clínicas, analíticas, terapéuticas y evolutivas. Se utilizó el procesador Epidat 3.1. Los resultados se expresaron en valores absolutos y porcentajes. Resultados: Se diagnosticó leishmaniosis visceral en 13,2 por ciento de niños hospitalizados por fiebre prolongada, 90,9 por ciento de procedencia rural y 59,1 por ciento desnutridos. El 77,3 por ciento de los casos recibió antimoniales, 90,9 por ciento tuvo estadía hospitalaria mayor de 21 días y el 36,4 por ciento se complicó con neumonía. Conclusiones: La leishmaniosis visceral es una entidad relativamente frecuente en niños admitidos por fiebre prolongada en el Hospital Italiano, predominan los varones desnutridos, mayores de cinco años de edad, procedentes de zonas rurales. La fiebre y la esplenomegalia son manifestaciones clínicas constantes, la anemia y la leucopenia los principales hallazgos de laboratorio. La aplicación de antimoniales es el tratamiento electivo, con larga estadía hospitalaria y la neumonía es la complicación más frecuente(AU)

Introduction: Visceral leishmaniasis is the most severe clinical form of leishmaniasis that mainly affects children and is potentially fatal. Objective: To explain the clinical-epidemiological characterization of visceral leishmaniasis in the pediatric population and its therapeutic response. Methods: It was conducted a retrospective, longitudinal and descriptive study in the Italian Hospital, Djibouti City in the period from September 2016 to August 2017. The sample group was formed by 166 children under 15 years old that were admitted with a diagnosis of prolonged fever without localization focus and the sample was of 22 children with confirmed diagnosis of visceral leishmaniasis. The information was obtained from the clinical records. Twenty variables were operationalized: sociodemographic, clinical, analytical, therapeutic and evolutive ones. Epidat 3.1 proccessor was used. The results were expressed in absolute values and percentages. Results: Visceral leishmaniasis was diagnosed in 13.2 percent children that were admitted in hospital due to prolonged fever, 90.9 percent of them were from rural areas and 59.1 percent were undernourished. 77,3 percent of the cases had antimonial treatment, 90.9 percent had hospital stay for more than 21 days and the 36.4 percent had complications due to pneumonia. Conclusions: Visceral leishmaniasis is a relatively frequent entity in children admitted in the Italian Hospital due to prolonged fever with a predominance of undernourished males, older that five years and from rural areas. Fever and splenomegaly are constant clinical manifestations, and anemia and leucopenia are the main laboratory findings. The use of antimonials is the election treatment with long hospital stay, and pneumonia is the most frequent complication(AU)

Risk Factors associated with defaulting from visceral leishmaniasis treatment: analysis under routine programme conditions in Bihar, India.

OBJECTIVE: To assess the rate of default from treatment in the visceral leishmaniasis (VL) elimination programme and to identify risk factors and its underlying causes. METHODS: Case-control study conducted between December 2009 and June 2012 in three primary health centres (PHCs) of Muzaffarpur district, India. Patients who defaulted from treatment from the PHCs were considered as 'cases' and those who completed their treatment as 'controls'. Two controls were included in the study for each case. Respondents' opinion and satisfaction with the services provided at the PHCs were also elicited. Logistic regression was performed to assess the contribution of sociodemographic variables on patient status, and a discriminant analysis was used (after decomposing the original data) to identify factors that can predict the patient status as defaulter or not, based on factor scores of the components as predictor variables. RESULTS: During the study period, 16.3% (89/544) of patients defaulted; 87 cases and 188 controls were interviewed through a semistructured questionnaire. Women tended to be more at risk for default (OR, 1.6, 95% CI (0.9 -2.9). Treatment received was miltefosine in 55.6% and sodium stibogluconate (SSG) in 44.4%. Most (86%) defaulters completed their treatment at other healthcare facilities; 70% of them preferred non-governmental institutions. Most cited reasons for default were seeking a second opinion for VL treatment and preferring to be treated in specialised VL centres. Discriminant analysis showed only one significant predictor: dissatisfaction with the medical care received in PHCs. CONCLUSION: Efforts are needed to enhance the quality of VL care at PHC level, which will be beneficial in increasing treatment completion rates.

Causes and consequences of higher Leishmania infantum burden in patients with kala-azar: a study of 625 patients.

BACKGROUND: An infected host's Leishmania infantum load in blood is considered to be an estimate of his or her total parasite burden. Therefore, the measurement of blood parasite burden is important in the identification of factors involved in parasite control. METHODS: Quantitative polymerase chain reaction was performed on blood samples from 625 patients with kala-azar consecutively admitted to a reference hospital in Teresina, Brazil. Primers were used to amplify a segment of kDNA using the TaqMan system. Non-parametric statistical tests were applied. RESULTS: The median blood parasite burden was 499.2 amastigote equivalents (AE)/ml. Children <1 year old (yo) had a high parasite burden, which dropped sharply after the first year of life (192.8, AE/ml at 1 < 2 yo) and remained lower until adolescence. Following adolescence, the parasite burden increased with age, peaking among elderly individuals. Men had a higher parasite burden than women. HIV-infected patients had a much higher parasite burden than non-infected patients. The parasite burden of children under 5 years with acute moderate to severe malnourishment (weight-for-age and body mass index z-scores <-2) was almost three times greater than that of better-nourished children. The parasite burden identified in deceased patients was more than twice that of surviving patients; those with a higher risk of death, sepsis, pneumonia and jaundice also had increased parasite burdens. All of these differences were statistically significant at P-values <0.05. CONCLUSIONS: These data indicate that the parasite burden in patients with kala-azar was associated with age- and gender-associated factors and with HIV infection status. Acute malnutrition could be either a cause or a consequence of a higher parasite burden. An individual's parasite burden influences his or her clinical profile, disease severity and mortality risk. The best explanation for the presence of a higher parasite burden in individuals with these immunoregulatory conditions and severe disease is the occurrence of acquired immunosuppression followed by heightened innate immunity.

Systemic insecticides used in dogs: potential candidates for phlebotomine vector control?

Zoonotic visceral leishmaniasis (ZVL) is a public health problem endemic in some countries. Current control measures, in particular culling infected dogs, have not reduced ZVL incidence in humans. We evaluated the use of five systemic insecticides (spinosad, fluralaner, afoxolaner, sarolaner and moxidectin) currently used in dogs for other purposes (e.g. tick, flea control) in controlling ZVL transmission. The anti-phlebotomine capacity of these compounds confirmed in experimental studies makes their use in ZVL control programmes very promising. Limitations and benefits of using this new control tool are compared to current practices.

Avaliação de estratégia de organização de serviços de saúde para prevenção e controle da leishmaniose visceral / Evaluation of the organization of health services as a strategy for the prevention and control of visceral leishmaniasis / Evaluación de la organización de los servicios de salud como estrategia para la prevención y control de la leishmaniosis visceral en Brasil

OBJETIVO: avaliar a estratégia de organização de serviços de saúde para prevenção e controle da leishmaniose visceral (LV) em Ribeirão das Neves, Minas Gerais, Brasil, de 2010 a 2012. MÉTODOS: pesquisa avaliativa de tipo estudo de caso, sobre o grau de implantação de uma estratégia voltada à integração dos serviços de assistência, controle de zoonoses e vigilância epidemiológica; consistiu de observação do processo de trabalho, entrevistas com profissionais e análise de dados secundários dos sistemas de informações. RESULTADOS: a implantação mostrou-se parcialmente adequada (84%); na estrutura, o fator de recursos humanos obteve a pior avaliação (64%), e no processo, a reorganização da assistência (80%) e da vigilância (77%); no período 2010-2012, houve aumento de 20% nas notificações de casos de LV e redução de 20% no intervalo entre notificação e início do tratamento. CONCLUSÃO: a estratégia contribuiu para a melhoria da organização das ações de prevenção e controle da LV.

OBJECTIVE: to evaluate the organization of health services as a strategy for the prevention and control of visceral leishmaniasis (VL) in Ribeirão das Neves, Minas Gerais, Brazil, from 2010 to 2012. METHODS: this was a case study evaluation of the degree of implementation of a strategy for the integration of health care services, control of zoonosis and epidemiological surveillance; it consisted of observing the work process, interviewing health professionals and analysing secondary data from information systems. RESULTS: implementation was partially adequate (84%); in terms of structure, the human resources component had the worst evaluation (64%) whilst in terms of work process, evaluation was 80% for reorganization of care and 77% for surveillance; in the period 2010-2012 there was a 20% increase in reported cases of VL and a 20% reduction in the time interval between reporting a case and starting treatment. CONCLUSION: the strategy contributed to the improvement of the organization of VL prevention and control actions.

OBJETIVO: evaluar la estrategia de organización de servicios de salud para la prevención y control de leishmaniosis visceral (LV) en Ribeirão das Neves, Minas Gerais, Brasil, 2010-2012. MÉTODOS: estudio de caso sobre el grado de implantación de la estructura y el proceso de estrategia centrada en la integración de los servicios de atención en salud, el control de zoonosis y vigilancia epidemiológica; se realizó la observación del proceso de trabajo, entrevistas con profesionales y análisis de datos secundarios de sistemas de información. RESULTADOS: la implementación se mostró parcialmente adecuado (84%); en la estructura, el componente recursos humanos obtuvo la peor puntuación (64%) y en el proceso, la reorganización de la atención (80%) y vigilancia (77%); en el periodo 2010-2012 hubo un aumento (20%) de casos reportados de LV y una reducción (20%) del intervalo de tiempo entre notificaciones e inicio de tratamiento. CONCLUSIÓN: la estrategia contribuyo con la mejora en la organización de las accionesde prevencio y control de la LV.

Abordaje clínico de adultos con fiebre prolongada / Clinical management of adults with prolonged fever

INTRODUCCIÓN: el síndrome febril prolongado (SFP) es todo cuadro de hipertermia que persiste al menos 10 días, sin diagnóstico, a pesar de un estudio etiológico inicial. OBJETIVO: determinar las causas más frecuentes de SFP en adultos del Hospital Nacional (Itauguá, Paraguay). METODOLOGÍA: estudio observacional, descriptivo, retrospectivo, de corte transversal, que incluyó 57 pacientes internados en el Servicio de Clínica Médica y salas de urgencias del Hospital Nacional a partir de enero 2010 hasta noviembre 2015. Se consideró SFP a todo cuadro de hipertermia que persiste al menos 10 días, sin diagnóstico, a pesar de estudios básicos. RESULTADOS: el SFP se caracterizó por afectar preferentemente a varones, provenientes del Departamento Central, con una edad media 41±17 años. La duración media de la fiebre fue 47±38 días. El indicio diagnóstico más frecuente fue la visceromegalia. Las etiologías más frecuentes fueron la leishmaniasis visceral, la leucemia linfoblástica aguda y la endocarditis bacteriana. En 17,5% no se llegó al diagnóstico final. El tiempo medio requerido para llegar al diagnóstico fue 4 días. La mayoría, 90%, fueron dados de alta vivos, con o sin diagnóstico. Hubo 5 fallecidos, de los cuales en 2 sujetos se consideró a la fiebre como la causa del óbito. CONCLUSIONES: las causas más frecuentes de SFP fueron las infecciones, sobre todo leishmaniosis visceral, y leucemias.

INTRODUCTION: prolonged febrile syndrome (PFS) is all hyperthermia that persists for at least 10 days without diagnosis, despite an initial etiologic study. OBJETIVE: to determine the most frequent causes of adult with PFS. METHODOLOGY: observational, descriptive, retrospective, cross-sectional study that included 57 patients admitted to the Medical Clinic Service and emergency rooms from the National Hospital (Itauguá, Paraguay) from January 2010 to November 2015. It was considered PFS to all patients with hyperthermia that persists at least 10 days without diagnosis, despite basic studies. RESULTS: The PFS affect preferentially men, from the Central Department, with an average age 41 ± 17 years. The average duration off ever was 47 ± 38 days. The most frequent diagnosis clue was visceromegaly. The most frequent etiology were visceral leishmaniasis, acute lymphoblastic leukemia and bacterial endocarditis. En 17.5% we didn't reach the final diagnosis. The average time required for diagnosis was 4 days. The majority, 90%, were discharged alive, with or without diagnosis. There were 5 deaths, of which in 2 subjects the fever was considered as the cause of death. CONCLUSIONS: the most frequent causes of PFS were infections, especially visceral leishmaniasis, and leukemias.

Serological diagnosis of canine visceral leishmaniasis in Brazil: systematic review and meta-analysis.

OBJECTIVE: To evaluate the quality and accuracy of serological diagnosis of canine visceral leishmaniasis in the Americas. METHODS: A systematic review found original studies in the databases MEDLINE, EMBASE and LILACS up to November 2012 and in complementary sources up to February 2013. Studies were evaluated in accordance with QUADAS 2 and STARD parameters and recommended in accordance with GRADE parameters. Meta-analysis was carried out with Meta-DiSc software, using the random-effect model. RESULTS: Two hundred and eighty-four studies were identified, of which 25 met the inclusion criteria, comprising the final synthesis. All but one was conducted in Brazil, and only two were judged to be of good quality. 15 studies involving immuno-enzymatic tests with crude antigens (cELISA), 11 studies on indirect immunofluorescence tests (IFAT) and three on the immunochromatographic dual-path platform (DPP) test were meta-analysed. The combined results for sensitivity and specificity were cELISA: 0.89 (CI 95% 0.87-0.91) and 0.87 (CI 95% 0.86-0.88); IFAT: 0.88 (CI 95% 0.85-0.91) and 0.63 (CI 95% 0.61-0.65); and DPP: 0.83 (CI 95% 0.78-0.88) and 0.73 (CI 95% 0.70-0.75). CONCLUSION: Enzyme-linked immunosorbent assay with crude antigens and DPP tests have moderate accuracy for the diagnosis of canine visceral leishmaniasis, and the quality of the design, implementation and analysis of validation studies on diagnostic tests for this disease urgently require improvement. The recommendation for use of the evaluated tests is based on evidence that is scarce and restricted to Brazil.

Clinical aspects of paediatric visceral leishmaniasis in North-west Ethiopia.

OBJECTIVE: Visceral leishmaniasis (VL) in north-west Ethiopia is causing an overwhelming case load among adult migrant workers that masked the disease burden in children. This study describes the clinical profile and explores comorbidities in paediatric VL patients. METHODS: A prospective study at two hospitals in this region (Gondar and Humera) was conducted in a year period, 2011-2012. The clinical manifestations and comorbidities such as malnutrition, intestinal parasitosis and vitamin D deficiency and HIV infection were assessed, and treatment outcomes noted. RESULTS: A total of 122 children with VL were detected during the study period with median age of 8.5 years (IQR 5-12 years); 23% were under 5 years. Eighty-five (69.7%) cases were male. The clinical manifestations were similar to the adult patients. High rates of malnutrition, intestinal parasitosis (47.5%) and hypovitaminosis D (56.4%) were detected. The proportion of stunting and wasting was 63% and 22.2% in children aged under five years, and 50.5% and 75.9% in 5-year and older children, respectively, using WHO standard growth curves. Only one child had HIV infection. In 95% of the cases, sodium stibogluconate (20 mg/kg/day for 30 days) was used for treatment. The treatment success rate at end of therapy was 98.3%, but the definitive outcome at 6 months could not be determined because of a high loss to follow-up (80.2%). CONCLUSION: While HIV co-infection was rare, malnutrition, intestinal parasitosis and vitamin D deficiency were frequent indicating the need for further research on their role in the pathophysiology. Meanwhile, systematic assessment and management of malnutrition and intestinal parasitosis in VL programmes is recommended.

Aspectos clínicos da leishmaniose visceral canina no distrito de Monte Gordo, Camaçari (BA) / Clinical aspects of canine visceral leishmaniasis in the district of monte gordo, camaçari (BA) / Aspectos clínicos de la leishmaniosis visceral canina en el distrito de monte gordo, camaçari (BA)

No Brasil, a Leishmaniose Visceral Americana ocorre de forma zoonótica, acometendo humanos e tendo como reservatório principal o cão. O diagnóstico e a eliminação precoce dos animais soropositivos são elementares nos processos de formulação dos Programas de Controle da doença. Dada a importância do sorodiagnóstico, o presente estudo objetivouidentificar caninos positivos para a Leishmaniose Visceral Americana pela técnica sorológica Enzime-Linked Immunosorbent Assay (ELISA) no distrito de Monte Gordo, zona litorânea de intenso turismo do município de Camaçari (BA), e classificá-los de acordo com a sintomatologia clínica. O inquérito sorológico foi realizado em 358 cães e a soroprevalência encontrada foi de 14,8 porcento. A significância estatística ocorreu entre sorologia positiva e as variáveis: comportamento apático, estado nutricional caquético, onicogrifose, pelagem ruim, linfadenopatia presente e coloração pálida das mucosas.

In Brazil, American Visceral Leishmaniasis is characterized by a zoonotic cycle that affects humans with canines as the main reservoir. Early diagnosis and elimination of seropositive animals are fundamental for devising control programs for this disease. Given the importance of serodiagnosis, the purpose of this study was to identify positive canines for AmericanVisceral Leishmaniasis through the Enzyme-Linked Immunosorbent Assay (ELISA) technique in the district of Monte Gordo, a coastal zone with intense tourist activity in the municipality of Camaçari (BA). This study also aimed to classify the canine cases based on their clinical symptoms. Serological surveillance was performed in 358 dogs and the seroprevalence reached 14.8%. Statistical significance was found between positive serology and the following variables: apathetic behavior, cachexia, onynchogryphosis, bad hair, lymphoadenopathy, and pale mucous membrane.

En Brasil, la Leishmaniosis Visceral Americana ocurre de forma zoonótica, afectando a los humanos y teniendo, como reserva principal, al perro. El diagnóstico y la eliminación rápida de los animales seropositivos son elementales en los procesos de formulación de los programas de control de la enfermedad. Dada la importancia del serodiagnóstico, el presente estudio objetivó identificar a los perros positivos para la Leishmaniosis Visceral Americana usando la técnica serológica Enzime-Linked Immunosorbent Assay (ELISA) en el distrito de Monte Gordo, zona costera de intenso turismo en el municipio de Camaçari (BA), y clasificarlos de acuerdo con la sintomatología clínica. La investigación serológica fue realizada con 358 perros encontrándose una seroprevalencia de 14.8%. Estadísticamente hubo una diferencia significativa entre los resultados de serología positiva y las siguientes variables: comportamiento apático, estado nutricional caquéctico,onicogrifosis, pelaje pobre, linfadenopatía presente y palidez en las superficies mucosas.

Leishmaniosis visceral (1942-2006) y seroprevalencia en dos comunidades del estado Bolívar, Venezuela / Visceral leishmaniasis (1942-2006) and seroprevalence in two communities from Bolivar State, Venezuela

La leishmaniosis visceral (LV) es una enfermedad infecciosa sistémica causada por protozoos del complejo Leishmania donovani, que puede ser fatal si no es tratada. Afecta fundamentalmente al hombre y los caninos. El perro es un reservorio importante y es responsable de la naturaleza endémica/epidémica de la enfermedad. El objetivo de este estudio fue conocer la casuística de Leishmaniosis Visceral (LV) humana en el estado Bolívar, Venezuela, desde la ocurrencia del primer caso hasta el año 2006, y determinar la seroprevalencia de LV humana y canina en dos poblaciones del mismo. Se revisaron los casos con diagnóstico confirmado de LV y la bibliografía publicada al respecto; se aplicó una encuesta y se determinaron anticuerpos específicos contra la proteína K39 recombinante de LV, a humanos y caninos en comunidades de Las Bombitas y Los Tanques. Se registraron 54 casos de LV humana. El estudio seroepidemiológico mostró anticuerpos específicos en 3 casos humanos y en 8 caninos. La LV en el estado Bolívar es endémica en la mayoría de los municipios y afecta principalmente a jóvenes y niños. La aparición de casos nuevos y la presencia de caninos seropositivos para LV en Las Bombitas y Los Tanques muestran el carácter esporádico y endémico de esta enfermedad en estas localidades del estado Bolívar.

Visceral leishmaniasis (VL) is a systemic infectious disease produced by protozoa of the Leishmania donovani complex, which can be fatal if not treated. It basically affects man and canine species. The dog is an important reservoir and is responsible for the endemic/ epidemic nature of the disease. The purpose of this study was to determine the human Visceral Leishmaniasis casuistic in Bolivar State, Venezuela, since the occurrence of the first case until 2006, and determine human and canine VL seroprevalence in two populations from this state. We revised cases with a confirmed VL diagnosis and bibliography published in this respect; we carried out a survey and determined specific anti VL recombinant protein K39 antibodies in humans and canines from Las Bombitas and Los Tanques villages. We registered 54 human and 8 canine VL cases. VL is endemic in Bolivar State at most municipalities and affects mainly young persons and children. The occurrence of new cases and the presence of VL seropositive canines at Las Bombitas and Los Tanques shows the sporadic and endemic nature of this disease at these Bolivar State localities.

Presencia de vectores de leishmaniosis cutánea y visceral en la Isla de Santa Cruz de Mompóx, Departamento de Bolívar, Colombia / Vectors of cutaneous and visceral leishmaniosis in Snata Cruz de Mompox island, Bolivar, Colombia

Se realizó una prospección entomológica en la Isla de Santa Cruz de Mompóx entre los días 23 y 29 de diciembre de 1993, con el fin de determinar si se trata de una zona de riesgo potencial de infección por Leishmania; para ello se practicaron capturas de flebotomíneos en sitios de reposo diurno y con trampas de luz tipo CDC y Shannon, colocadas simultáneamente en el peri y el extradomicilio. Se colectaron 367 ejemplares de flebotomíneos cuya Identificación demostró por primera vez la presencia en la Isla de siete especies de Lutzomyia entre las cuales se encuentran Lu. panamensis y Lu. gomezi, vectoras de leishmaniosis cutánea y Lu. evansi vectora principal de la forma visceral en la Costa Caribe Colombiana; el hallazgo demuestra que la Isla es una zona de riesgo potencial para leishmanlosis cutánea y visceral

Se realizó una prospección entomológica en la Isla de Santa Cruz de Mompox entre los días 23 y 29 de diciembre de 1993, con el fin de determinar si se trata de una zona de riesgo potencial de Infección por Leishmania; para ello se practicaron capturas de flebotomíneos en sitios de reposo diurno y con trampas de luz tipo CDC y Shannon, colocadas simultáneamente en el peri y el extradomicilio. Se colectaron 367 ejemplares de flebotomíneos cuya Identificación demostró por primera vez la presencia en la Isla de siete especies de Lutzomyia entre las cuales se encuentran Lu. panamensis y Lu. gomezi, vectoras de leishmaniosis cutánea y Lu. evansi vectora principal de la forma visceral en la Costa Caribe Colombiana; el hallazgo demuestra que la isla es una zona de riesgo potencial para leishmaniosis cutánea y visceral