Anastácio Q. Sousa

Melioidosis, Northeastern Brazil

Melioidosis was first recognized in northeastern Brazil in 2003. Confirmation of additional cases from the 2003 cluster in Ceará, more recent cases in other districts, environmental isolation of Burkholderia pseudomallei, molecular confirmation and typing results, and positive serosurveillance specimens indicate that melioidosis is more widespread in northeastern Brazil than previously thought.

Sexually transmitted infections, bacterial vaginosis, and candidiasis in women of reproductive age in rural Northeast Brazil: a population-based study

Population-based data on sexually transmitted infections (STI), bacterial vaginosis (BV), and candidiasis reflect the epidemiological situation more accurately than studies performed in specific populations, but such data are scarce. To determine the prevalence of STI, BV, and candidiasis among women of reproductive age from a resource-poor community in Northeast Brazil, a population-based cross sectional study was undertaken. All women from seven hamlets and the centre of Pacoti municipality in the state of Ceará, aged 12 to 49 years, were invited to participate. The women were asked about socio-demographic characteristics and genital symptoms, and thereafter examined gynaecologically. Laboratory testing included polymerase chain reaction (PCR) for human papillomavirus (HPV), ligase chain reaction (LCR) for Chlamydia trachomatis and Neisseria gonorrhoeae, ELISA for human immunodeficiency virus (HIV), venereal disease research laboratory (VDRL) and fluorescent treponema antibody absorption test (FTA-ABS) for syphilis, and analysis of wet mounts, gram stains and Pap smears for trichomoniasis, candidiasis, and BV. Only women who had initiated sexual life were included in the analysis (n = 592). The prevalences of STI were: HPV 11.7% (95% confidence interval: 9.3-14.7), chlamydia 4.5% (3.0-6.6), trichomoniasis 4.1% (2.7-6.1), gonorrhoea 1.2% (0.5-2.6), syphilis 0.2% (0.0-1.1), and HIV 0%. The prevalence of BV and candidiasis was 20% (16.9-23.6) and 12.5% (10.0-15.5), respectively. The most common gynaecological complaint was lower abdominal pain. STI are common in women in rural Brazil and represent an important health threat in view of the HIV pandemic.

Early Histopathology of Experimental Infection with Leishmania donovani in Hamsters

The extracellular promastigote stage of Leishmania donovani is inoculated by a phlebotomine sandfly into the skin of a susceptible host, after which visceral dissemination and clinical disease may ensue. Using a hamster model we examined the histopathology of early infection with L. donovani after intradermal inoculation of cultured promastigotes. The initial response was a mixed polymorphonuclear (PMN)-mononuclear phagocyte infiltrate, noted between 1 and 24 hr after inoculation, which became primarily mononuclear by 48 hr. Parasites were initially found intracellularly in both PMNs and mononuclear phagocytes, but by 48 hr they had assumed amastigote-like morphology and were found exclusively in macrophages. The number of parasites per infected macrophage increased during the first week after inoculation, suggesting that intracellular replication of the organism was taking place. This was followed by the formation of granulomas between 4 and 6 wk. By 8 wk intracellular parasites were largely gone. The histologic response was consistent with early destruction of parasites in PMNs, and survival and replication of L. donovani in macrophages. Cutaneous infection with the parasite was eventually controlled locally, coincident with granuloma formation. Despite these local responses, the organism was able to disseminate and eventually produce typical visceral leishmaniasis.

High-Dose Oral Fluconazole Therapy Effective for Cutaneous Leishmaniasis Due to Leishmania (Vianna) braziliensis

We report for the first time the successful use of fluconazole to treat cutaneous leishmaniasis due to Leishmania braziliensis. We used escalating doses from 5 to 8 mg/kg per day. At a dose of 5 mg/kg per day, 75% patients were cured, and at 8 mg/kg per day, the cure rate was 100%. Fluconazole was well tolerated.

Urbanization of visceral leishmaniasis (kala-azar) in Fortaleza, Ceará, Brazil

OBJECTIVES Visceral leishmaniasis (VL) is endemic in Brazil and appears to occur in epidemic form in the state of Ceará. Few epidemiologic studies have been done on VL in this state. The aim of this study is to establish the epidemiologic pattern of VL in Fortaleza City and to show how urbanization has occurred in recent years. METHODS Data were obtained from the State Health Department of Fortaleza, Ceará, and included all cases of VL registered in Fortaleza from January 2001 to December 2006. RESULTS There were a marked increase and an elevated incidence of cases of VL in urban areas. Children and young people were the most affected group. CONCLUSION The epidemic occurrence of VL in the region must convince authorities to adopt more adequate policies of disease control.

The public health implications of melioidosis

Melioidosis, which is caused by the bacterium Burkholderia pseudomallei, is a potentially fatal tropical infection, little known outside its main endemic zone of Southeast Asia and northern Australia. Though it has received more attention in recent years on account of its claimed suitability as a biological weapon agent, the principal threat from melioidosis is a result of naturally occurring events. Occasional case clusters, sporadic cases outside the known endemic zone and infections in unusual demographic groups highlight a changing epidemiology. As melioidosis is the result of an environmental encounter and not person-to-person transmission, subtle changes in its epidemiology indicate a role environmental factors, such as man-made disturbances of soil and surface water. These have implications for travel, occupational and tropical medicine and in particular for risk assessment and prevention. Practical problems with definitive laboratory diagnosis, antibiotic treatment and the current lack of a vaccine underline the need for prevention through exposure avoidance and other environmental health measures. It is likely that the increasing population burden of the tropical zone and extraction of resources from the humid tropics will increase the prevalence of melioidosis. Climate change-driven extreme weather events will both increase the prevalence of infection and gradually extend its main endemic zone.

Postmortem Findings for 7 Neonates with Congenital Zika Virus Infection

Postmortem examination of 7 neonates with congenital Zika virus infection in Brazil revealed microcephaly, ventriculomegaly, dystrophic calcifications, and severe cortical neuronal depletion in all and arthrogryposis in 6. Other findings were leptomeningeal and brain parenchymal inflammation and pulmonary hypoplasia and lymphocytic infiltration in liver and lungs. Findings confirmed virus neurotropism and multiple organ infection.

Measles Reemergence in Ceará, Northeast Brazil, 15 Years after Elimination

To the Editor: Measles was endemic in Brazil before 2000 and caused large outbreaks every 2 or 3 years (1). Although measles was eliminated in Brazil in 2000, cases have continued to be imported (2,3). During 2001–2014, the median annual number of measles cases reported in Brazil was 50 (range 2–712). The median annual number of Brazilian states with reported cases was 2.5 (range 1–7). Since elimination, the highest numbers of cases reported in Brazil occurred in 2013 (220) and in 2014 (712) (3–5). According to the Pan American Health Organization, endemic transmission is reestablished when epidemiologic and laboratory evidence indicate that a chain of transmission of a virus strain has continued uninterrupted for >12 months in a defined geographic area (6). From December 2, 2013, through December 31, 2014, in the state of Ceara, Brazil, 681 measles cases were reported. A measles case was considered confirmed when a patient exhibited fever, rash, and >1 of 3 symptoms and signs (i.e., cough, runny nose, conjunctivitis); was positive for IgM and negative for IgG against measles virus; and had not been vaccinated in the previous 21 days. D8 genotype, the same virus genotype that was circulating in Europe, was the only genotype identified, and how the virus was introduced into the region was not clear (4,5). From 2000 to 2013, vaccine coverage among children 12 months of age remained >95% in Ceara, although that coverage was not homogeneous for the whole state. In 14.7% (27/184) of municipalities, the vaccination coverage was much lower (4). Pernambuco, the state that borders southern Ceara, reported a measles outbreak with 222 confirmed cases from March 2013 through March 2014 (4,5,7). Thus, the timing of the 2 outbreaks overlapped. During December 2013–December 2014, Ceara’s outbreak seemed to evolve in 2 waves: the first from epidemiologic weeks 3 through 6 (mainly in Fortaleza, the capital of Ceara) and the second from epidemiologic weeks 27 through 53 (mainly on the northwest side of Ceara, an economically disadvantaged region, which also included the capital). Cases were confirmed in 15.8% (29/184) of all municipalities. Most patients (47.3%; 322) were from Fortaleza, followed by Massape (18.6%; 127) and Sobral (12.2%; 83) (Figure). Figure Measles cases reported in Brazil after elimination, 2001–2014. A) Cases and genotypes identified, by year. B) Spatial distribution of measles outbreaks in the states of Pernambuco and Ceara during 2013–2014, in which only genotype ... Children 1 year of age; unknown vaccination status, 27.4% (69/252); and received only 1 dose of vaccine, 18.7% (47/252) (8). No deaths were reported (4). The main reported symptoms were rash (100%), fever (100%), cough (84.5%), runny nose (68.2%), and conjunctivitis (60.3%) (8). Response vaccination activities have taken 10–20 weeks to be initiated in some municipalities after the first cases were recognized. Vaccination campaigns involving children 6–60 months of age are being intensified and surveillance for suspected cases has increased, but as of January 1, 2015, the chain of transmission appeared ongoing (4,5). In addition, one cannot underestimate the fact that health professionals in Ceara had not seen cases of measles for 15 years. Younger health professionals had never seen even 1 case, and this lack of familiarity may have had some effect on surveillance, rapid recognition of new cases, and adoption of control measures. This difficulty of recognition should be taken into account in regions that have been free of endemic measles transmission for many years. In conclusion, the measles outbreak in Ceara was probably imported directly from Europe or from there through the bordering state of Pernambuco (4,5,9). Cases were concentrated in Fortaleza and the northwest region of the state. Patient age distribution was significantly different between the capital, where the infection most affected children 95%. In addition, vaccination campaigns directed at children 12 months, Ceara’s current outbreak may represent the reestablishment of endemic transmission of measles in the Americas.

Drought, Smallpox, and Emergence of Leishmania braziliensis in Northeastern Brazil

The Great Drought and smallpox epidemic (1877–1879) led to emergence of L. braziliensis in Ceará State, northeastern Brazil

Disseminated cutaneous leishmaniasis: a patient with 749 lesions

A 46 year-old man, agriculturist, presented with an eight-month history of skin lesions all over his body. Patient did not refer systemic symptoms; however he was a heavy alcoholic drinker until three months after the beginning of disease, when he stopped drinking. Physical exam was inconspicuous except for multiples skin lesions (papular, crusted or ulcerated) on face, trunk (Panels A and B), scalp, arms, legs, genitalia and nasal mucosa. Complete blood count, liver and renal tests, glucose as well as chest x-ray were normal. Tuberculin (PPD) test was 5mm, Montenegro test (leishmanin) was non reactive, VDRL and anti-HIV test were negative. Three 2mm punch skin biopsies were done: for imprint, leishmania culture (NNN) and histopathology. Imprint showed amastigotes in many fields (100X) (Panels C, D and E Arrows). Culture grew Leishmania. Histopathology showed moderate infiltrate of vacuolated macrophages with few lymphocytes, no granulomas were seen. Amastigotes were present in some macrophages. Patient was treated with intravenous pentavalent antimony (Glucantime®) 850mg per day for 30 days and all lesions healed. Leishmanin skin test at end of treatment was 8mm. Disseminated Cutaneous Leishmaniasis is seen in a small percentage of patients with cutaneous leishmaniasis in all endemic areas of Ceará State, northeastern Brazil. This patient was from one of these areas. Even though the Leishmania species was not characterized, the parasite in this case was probably Leishmania (Viannia) braziliensis, because this is the only species identified so far causing cutaneous leishmaniasis in Ceará.