Bernardino Cláudio de Albuquerque

Outbreak of acute Chagas disease associated with oral transmission in the Rio Negro region, Brazilian Amazon

INTRODUCTION Chagas disease is considered as emerging in the Brazilian Amazon, usually occurring in acute outbreaks. METHODS We describe 17 cases of acute Chagas disease in Rio Negro, Amazonas. RESULTS There were 15 males (average age, 31.3 years), all positive for Trypanosoma cruzi in fresh blood smear examination, and 14 positive by xenodiagnosis and PCR. The top clinical manifestations were fever, asthenia, abdominal pain, and palpitations. Electrocardiograms featured low-voltage QRS, anterosuperior divisional block, and right bundle branch block associated with anterosuperior divisional block. CONCLUSIONS All patients had consumed açaí products from Monte Alegre in the rural area around Santa Izabel do Rio Negro, Brazil.

Outbreak of Half disease in the Brazilian Amazon

Haff disease, first reported along the Baltic coast in 1924, is unexplained rhabdomyolysis in a person who ate fish in the 24 hours before onset of illness (1). Outbreaks resembling Haff disease were described in Sweden and the Soviet Union between 1934 and 1984 (2, 3). In the United States, only three reports have been published to date (4). Haff disease remains a rare clinical syndrome for which there is no physiologic explanation. Outbreaks of Haff disease have never been reported in Brazil. But in June 2008, a 39-year-old female medical doctor was admitted by the emergency service of a public hospital in Manaus, Amazonas State, Brazil, with diffuse myalgia and chest pain. The plasma creatine kinase (CK) activity levels were 6 252 units per liter (U/L) and no history of classic risk factors for rhabdomyolysis was detected. Her mother had been admitted 1 week before, presenting the same symptoms. Both women reported eating fish 24 hours before the onset of symptoms; further inquiry revealed that two residents from the same household who had not eaten fish did not become sick. The attending physician at the hospital was intrigued by the diagnosis of the two familial cases of Haff disease and began an epidemiologic investigation, looking for similar cases and potential risk factors. A case report form was designed and distributed along with a technical note to all hospitals in Manaus, instructions on how to report suspected cases, and suggestions for their management. The cases were defined as those who were hospitalized on or after 1 June 2008 with a diffuse myalgia of sudden onset who ate fish in the 24 hours before onset of illness and CK serum activity that exceeded five times the upper limit of normal. Patients with a classic risk factor for rhabdomyolysis were not included. The results of the investigation are reported here. Twenty-five cases of Haff disease were identified in Manaus between June and September 2008. All reported consumption of fried or roasted pacu—silver dollars (Mylossoma spp.), tambaqui—black-finned colossoma (Colossoma macropomum), or pirapitinga—freshwater pompano (Piaractus brachypomus), three river fishes of the region, within 24 hours before the onset of symptoms. All patients were older than 13 years of age (range 13–80 years); there were a similar number of males and females (59% and 41%, respectively). Three patients came from rural areas surrounding Manaus and nine patients were clustered in four families: the initial mother–daughter pair, a brother–sister pair, a husband–wife pair, and a family of three (husband, wife, and daughter). Five other members of these four families, who did not eat fish, did not fall ill. All patients were hospitalized (range 3–6 days) with myalgia of sudden onset, mostly localized at the beginning of symptoms and followed by generalized spreading within a few hours. Nineteen patients reported chest pain, among other symptoms (see Table 1). No fever or kidney damage was observed. TABLE 1 Symptoms of Haff disease cases, Amazon, Brazil, 2008 Predominant laboratory abnormalities were elevated CK serum activity (mean = 12 795 U/L, range 1 444–36 896 U/L). Serum activities of transaminases and lactate dehydrogenase were also elevated. In two patients, myoglobin was measured and found to be higher than 700 U/L. Serology for leptospirosis and hepatitis A and B was negative. Patients were treated with intravenous fluid hydration and bicarbonate infusion. No deaths were observed. In only 4 months, 27 cases of Haff disease were reported in Manaus and surrounding municipalities of the Brazilian Amazon. The diagnosis of Haff disease was made based on the fact that none of the cases could be explained by classic causes of rhabdomyolysis; all patients reported consumption of fish within 24 hours before the onset of symptoms; some cases occurred in family clusters and no cases were observed after the beginning of the period of prohibition of fishing in the region that occurs every year from October to March. This possible association between fish eating and rhabdomyolysis in the Amazon region may have an important impact, as fish is a major source of protein in the Brazilian Amazon (5). Active surveillance of this supposedly uncommon condition is necessary to corroborate its frequency in the region and enhance our understanding of this elusive disease. This paper is part of the doctoral thesis of Marcelo Cordeiro dos Santos of Amazonas State University, Amazonas State Tropical Medicine Foundation. The views expressed here are those of the authors and do not necessarily reflect the official policy or position of the Brazilian Government, the U.S. Government, Department of the Navy, or Department of Defense.

Malaria in the State of Amazonas: a typical Brazilian tropical disease influenced by waves of economic development

In Brazil, more than 99% of malaria cases are reported in the Amazon, and the State of Amazonas accounts for 40% of this total. However, the accumulated experience and challenges in controlling malaria in this region in recent decades have not been reported. Throughout the first economic cycle during the rubber boom (1879 to 1912), malaria was recorded in the entire state, with the highest incidence in the villages near the Madeira River in the Southern part of the State of Amazonas. In the 1970s, during the second economic development cycle, the economy turned to the industrial sector and demanded a large labor force, resulting in a large migratory influx to the capital Manaus. Over time, a gradual increase in malaria transmission was observed in peri-urban areas. In the 1990s, the stimulation of agroforestry, particularly fish farming, led to the formation of permanent Anopheline breeding sites and increased malaria in settlements. The estimation of environmental impacts and the planning of measures to mitigate them, as seen in the construction of the Coari-Manaus gas pipeline, proved effective. Considering the changes occurred since the Amsterdam Conference in 1992, disease control has been based on early diagnosis and treatment, but the development of parasites that are resistant to major antimalarial drugs in Brazilian Amazon has posed a new challenge. Despite the decreased lethality and the gradual decrease in the number of malaria cases, disease elimination, which should be associated with government programs for economic development in the region, continues to be a challenge.

Outbreak of chemical meningitis following spinal anesthesia caused by chemically related bupivacaine.

Bupivacaine • Author(s): Marcelo Cordeiro dos Santos, MD, MSc; Bernardino Claudio de Albuquerque, MD, MSc; Rossicléia Lins Monte, MSc; Gilberto Gama Filho, MD; Maria das Graças Costa Alecrim, MD, PhD Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 9 (September 2009), pp. 922924 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/599358 . Accessed: 16/05/2014 14:25

Dengue hemorrhagic fever and acute hepatitis: a case report

Dengue fever is the worlds most important viral hemorrhagic fever disease, the most geographically wide-spread of the arthropod-born viruses, and it causes a wide clinical spectrum of disease. We report a case of dengue hemorrhagic fever complicated by acute hepatitis. The initial picture of classical dengue fever was followed by painful liver enlargement, vomiting, hematemesis, epistaxis and diarrhea. Severe liver injury was detected by laboratory investigation, according to a syndromic surveillance protocol, expressed in a self-limiting pattern and the patient had a complete recovery. The serological tests for hepatitis and yellow fever viruses were negative. MAC-ELISA for dengue was positive.

Rio Mamore Virus and Hantavirus Pulmonary Syndrome, Brazil

Hantavirus pulmonary syndrome (HPS) is an acute, severe, frequently fatal disease associated with cardiopulmonary failure; it is caused by hantaviruses naturally hosted by wild rodents. Rio Mamore virus (RIOMV) was first described in 1996 in Bolivia; it was associated with the small-eared pygmy rice rat, Oligoryzomys microtis (1). Subsequently, 1 strain of RIOMV was isolated from O. microtis rats in Peru, designated HTN-007 (2); and 2 strains were recovered in the Brazilian Amazon from O. microtis rats (RIOMV-3) and uncharacterized species of rodents of the genus Oligoryzomys (RIOMV-4) (3). Recently, HPS cases associated with RIOMV have been reported: 2 cases in Peru (4) and 1 case in French Guiana (caused by a variant named Maripa virus) (5). We report isolation of a strain of RIOMV from a patient with fatal HPS in Brazil....

Human hantavirus infection, Brazilian Amazon.

To the Editor: Since hantavirus pulmonary syndrome (HPS) caused by Sin Nombre virus (SNV) was identified in the southwestern United States in 1993, cases have been diagnosed in many Latin American countries, and an increasing number of hantaviruses and their rodent reservoirs have been reported (1). The first evidence of hantavirus circulation in the western Brazilian Amazon region was documented in 1991 (2). Vasconcelos et al., by using antigens from the Old World hantavirus, found evidence of hantavirus antibodies in 45.2% of serum samples acquired from contacts of patients who died with undiagnosed hemorrhagic fever in Manaus. The first human cases of symptomatic infection by hantaviruses were reported from Brazil in 1993, in Juquitiba (Sao Paulo State). HPS developed in 3 young brothers, who lived in a forested region along the Atlantic Coast, after they had cleared trees on their land, and 2 of them died. These patients were living in poor conditions, without appropriate storage spaces for human food or for animal feed, and their dwelling was constantly invaded by wild rodents who were looking for food (3). Since then, many other HPS cases have been reported, especially from the southern and southeastern regions of Brazil where agricultural activities are prominent; the mean case-fatality ratio is 48% (3). In the Brazilian Amazon, HPS has been frequently reported in Mato Grosso and sporadically in Maranhao and Para states, which indicates an endemic circulation of hantaviruses (4,5) We report here the first human cases of HPS in the state of Amazonas in the western part of the Brazilian Amazon. All 4 patients belonged to the same family cluster and came from a rural area near the town of Itacoatiara, on the edge of an important industrial waterway for soybean transport (the Itacoatiara soybean terminal). This family (patients 1, 2, and 3) had cleared a forested area on their farm and killed many rodents found in the bases of trees and near the house from May 25 to June 5, 2004. They also reported that wild rodents were inside their house. All serologic tests were performed in the Arbovirology and Hemorrhagic Fever Department, at the Evandro Chagas Institute (Para, Brazil), with antigens provided by the Centers for Disease Control and Prevention (Atlanta, GA, USA). An enzyme-linked immunosorbent assay (ELISA) was performed by using cellular fluid and Laguna Negra virus antigens for immunoglobulin M (IgM) detection (MAC-ELISA), and recombinant SNV antigens for IgG detection. Samples were considered positive with an optical density >0.2 in 1:100 (IgM) and 1:400 (IgG) dilutions (6,7). Viral isolation or polymerase chain reaction (PCR) for hantavirus were not attempted in human or rodent samples. In the index patient, symptoms developed 15 days after she had killed 20 rodents with hot water during the tree-clearing process on the farm. She was a 25-year-old woman who sought treatment with an acute syndrome of high fever, dry cough, and dyspnea. She was admitted to the Itacoatiara general hospital; her condition was diagnosed as bacterial pneumonia and treated with intravenous penicillin. She died within 5 days because of respiratory failure; since no laboratory tests were conducted, she does not fulfill the case definition criteria for HPS. This was the only case in this series not confirmed with laboratory tests. The second case was in the first patients 31-year-old husband. Symptoms developed 2 weeks after the wifes death, starting with a 5-day febrile syndrome, which progressed to a dry cough and then respiratory distress, with a petechial rash, hemoconcentration, and thrombocytopenia (53,000 platelets/μL) over the next 2 days. He exhibited a diffuse, alveolar infiltrate on chest radiograph and a mild cardiomyopathy on echocardiogram. He was admitted to an intensive care unit and required mechanical ventilation for 10 days; he made a gradual recovery. Results of his laboratory tests ruled out malaria, dengue fever, and leptospirosis. Three consecutive blood culture samples were negative for bacterial growth. The IgG and IgM ELISA results for hantavirus were positive in both acute- and convalescent-phase serum samples. The third case was in the second patients brother, a 43-year-old man, who exhibited a self-limited, acute febrile syndrome 1 month after the index patient. He did not live on the same farm but visited there often and had actively participated in removing the trees on his brothers farm. He had no respiratory complaints, and results of his chest radiographs were normal, but the complete blood count showed hemoconcentration and mild thrombocytopenia (130,000 platelets/μL). He was hospitalized for 3 days and recovered completely. An IgM ELISA result was positive for hantavirus in 2 consecutive blood samples, and an IgG ELISA result was positive in convalescent-phase serum. The fourth patient was a 67-year-old farmer, the uncle of the last 2 patients. He visited his nephews farm regularly and was present during the deforestation process. He presented for medical assistance after a 15-day febrile syndrome, with a dry cough and mild dyspnea, 5 weeks after the index patient. He was hospitalized for 3 days and also had an uneventful recovery. The IgM ELISA result in this patient was also positive for hantavirus in 2 consecutive blood samples as was the IgG ELISA result for convalescent-phase serum. Shortly after the report of the first 3 cases, the Brazilian Health Surveillance Secretary (Ministry of Health) performed an epidemiologic field study to seek the probable site of infection, collect sylvatic rodents, and conduct a serologic survey of human contacts. No areas for soybean cultivation or seed storage were found, but local farmers commonly store dry corn for feeding their domestic fowl. Eighty-two blood samples were collected from asymptomatic persons and were all negative for hantavirus IgG antibodies by ELISA. Eleven sylvatic rodents were captured in 3 days of trapping (270 traps/night) on the farm, on neighboring farms, and in the nearby forest. Two species were identified, Proechimys sp. (2 animals) and Oligoryzomys microtis (9 animals). This finding is very similar to reports of rodents in other regions of Brazil (8). Four Oligoryzomys microtis had positive IgG results for hantavirus (9). Identification of human and rodent hantavirus infection in the Amazonas State adds this emergent disease to our differential diagnoses of febrile tropical diseases and to our syndromic surveillance approach for febrile respiratory diseases. Further research is needed to identify the viral genotype that circulates in this area and to determine the real prevalence of human infection and the epidemiologic scenario of HPS in the western Brazilian Amazon region.

Epidemiology of infectious meningitis in the State of Amazonas, Brazil

INTRODUCTION In the State of Amazonas, particularly in the capital Manaus, meningitis has affected populations of different cultures and social strata over the years. Bacterial meningitis is caused by several different species and represents a major issue of public health importance. The present study reports the meningitis case numbers with different etiologies in Amazonas from January 1976 to December 2012. METHODS Since the 1970s, the (currently named) Tropical Medicine Foundation of Doutor Heitor Vieira Dourado [Fundação de Medicina Tropical Doutor Heitor Vieira Dourado (FMT-HVD)] has remained a reference center in Amazonas for the treatment of meningitis through the diagnosis and notification of cases and the confirmation of such cases using specific laboratory tests. RESULTS The foundation has achieved coverage of over 90% of the state medical records for many years. Between 1990 and 2012, meningitis cases caused by Haemophilus influenzae decreased with the introduction of the H. influenzae vaccine. Meningococcal disease previously had a higher frequency of serogroup B disease, but starting in 2008, the detection of serogroup C increased gradually and has outpaced the detection of serogroup B. Recently, surveillance has improved the etiological definition of viral meningitis at FMT-HVD, with enteroviruses, Epstein-Barr virus (EBV) and varicella zoster virus (VZV) prevailing in this group of pathogens. With the advent of acquired immunodeficiency syndrome (AIDS), cryptococcal meningitis has become an important disease in Amazonas. Additionally, infectious meningitis is an important burden in the State of Amazonas. CONCLUSIONS Changes in the epidemiological profile for the different etiology-defined cases are the result of continuous epidemiological surveillance and laboratory capacity improvements and control measures, such as Haemophilus influenzae vaccination.

From Haiti to the Amazon: public health issues related to the recent immigration of Haitians to Brazil.

1 Western General Hospital, Edinburgh, United Kingdom, 2Fundac¸a˜o de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brazil, 3Universidade do Estadodo Amazonas, Programa de Po´s-Graduac¸a˜o em Medicina Tropical, Manaus, Amazonas, Brazil, 4 Universidade Federal de Sa˜oJoa˜o Del Rei, Campus Centro Oeste,Divino´polis, Minas Gerais, Brazil, 5 Fundac¸a˜o de Vigilaˆncia em Sau´de, Manaus, Amazonas, Brazil

Mortality Predictors in Patients with Severe Dengue in the State of Amazonas, Brazil.

Dengue is a major public health problem in tropical and subtropical areas worldwide. There is a lack of information on the risk factors for death due to severe dengue fever in developing countries, including Brazil where the state of Amazonas is located. This knowledge is important for decision making and the implementation of effective measures for patient care. This study aimed to identify factors associated with death among patients with severe dengue, in Amazonas from 2001 to 2013. We conducted a retrospective cohort study based on secondary data from the epidemiological surveillance of dengue provided by the Fundação de Vigilância em Saúde do Amazonas, FVS (Health Surveillance Foundation) of the Secretaria de Saúde do Amazonas, SUSAM (Health Secretariat of the State of Amazonas). Data on dengue cases were obtained from the SINAN (Notifiable Diseases Information System) and SIM (Mortality Information System) databases. We selected cases of severe dengue with laboratory confirmation, including dengue-related deaths of residents in the state of Amazonas from January 1, 2001, to December 31, 2013. The explanatory variables analyzed were sex, age, level of education, spontaneous hemorrhagic manifestations, plasma extravasation and platelet count. Patients who died due to severe dengue had more hematuria, gastrointestinal bleeding, and thrombocytopenia than the survivors. Considering the simultaneous effects of demographic and clinical characteristics with a multiple logistic regression model, it was observed that the factors associated with death were age >55 years (odds ratio [OR] 4.98), gastrointestinal bleeding (OR 10.26), hematuria (OR 5.07), and thrombocytopenia (OR 2.55). Gastrointestinal bleeding was the clinical sign most strongly associated with death, followed by hematuria and age >55 years. The study results showed that the best predictor of death from severe dengue is based on the characteristic of age >55 years, together with the clinical signs of gastrointestinal bleeding, hematuria, and low platelet count.