Conceição de Maria P. e Silva

Cura espontânea da leishmaniose causada por Leishmania Viannia Braziliensis em lesões cutâneas

In field clinics in the communities of Três Braços and Corte de Pedra, Bahia, we have attended 1.416 patients with tegumentary leishmaniasis in fourteen years, the predominant species in transmission is Leishmania Viannia brasi liensis (LVB). Because of the danger of metastasis with this infection treatment was routinely recommended with Glucan-time. However sixteen patients refused injection therapy and six women were pregnant when seen and not treated. All patients were followed up in our clinic. All these patients closed their skin ulcers although one subsequently relapsed. Patients were followed up for variable periods (four to twelve years), after the diagnosis. In nine patients (40.9%) of the cohort, the time to healing after initiation of the lesion was calculated as six months of evolution. At twelve months, nineteen patients (86.3%) had complete healing of their lesions. In three patients an active lesion was present for longer than one year. The determinants of this variable natural evolution of human LVB lesion remains completely unknown. It is difficult for us to understand and compare the effects of therapeutic agents in mucocutaneous leishmaniasis.Os autores relatam que durante 14 anos de trabalho clinico em campo, realizado nas comunidades de Tres Bracos e Corte de Pedra, Bahia, acompanharam 1.416 pacientes portadores de Leishmaniose Tegumentar Americana, cuja especie envolvida na transmissao, e predominantemente a Leishmania Viannia brasilienses. A terapeutica utilizada rotineiramente nos casos e o antimoniato-N-metilglucamina (Glucantime). Contudo, 16 pacientes do sexo masculino recusaram-se a utilizar a medicacao e 6 do sexo feminino encontravam-se em periodo gestacional, portanto nao utilizaram o medicamento. Estes pacientes foram acompanhados por um periodo entre 4 a 12 anos, a partir do diagnostico. Observou-se que em 9 pacientes (40,9%) desta casuistica, o tempo de cicatrizacâo apos o aparecimento da lesao, pode ser calculado em 6 meses de evolucao. Quando se eleva a observacao para 12 meses, temos que 19 pacientes (86,3%) cicatrizaram suas lesoes neste periodo. Em 3 casos (13,6%) as lesoes permaneceram ativas por mais de 12 meses. Conclui-se que os determinantes da cicatrizacâo natural das lesoes produzidas por Leishmania Viannia Braziliensis permanecem desconhecidos, dificultando para nos entendermos e compararmos aos efeitos das drogas utilizadas no tratamento da leishmaniose tegumentar.

Estado atual da leishmaniose cutânea difusa (LCD) no Estado do Maranhão: II. aspectos epidemiológicos, clínico-evolutivos

Os Autores fazem um estudo retrospectivo e prospectivo de 6 pacientes portadores de leishmaniose cutânea difusa, observados no Estado do Maranhao a partir de 1974. Os casos abordados sao oriundos de diversas regioes do estado, observando-se em todos eles o envolvimento da leishmania (Leishmania) amazonensis, sendo que 5 (84%) dos pacientes apresentaram inicio de doenca na 1a decada de vida. Em todos os pacientes envolvidos no estudo, houve relato de lesao inicial nodular unica, que, posteriormente, em periodo variavel de tempo, disseminou-se adquirindo outros aspectos. Evolutivamente apresentaram multiplas lesoes nodulares e ulceradas, intradermorreacao de Montenegro(-) e refratariedade aos esquemas terapeuticos utilizados ate ao presente momento.

Cromoblastomicose produzida por Fonsecaea pedrosoi no Estado do Maranhão. I - aspectos clínicos, epidemiológicos e evolutivos

The aim of this study was to observe the clinical and of epidemiological behavior of chromoblastomycosis in the State of Maranhao. A retrospective and prospective study ofl 3 cases was performed at the infectious diseases section of the Hospital dos Servidores do Estado do Maranhao, from November, 1988 to July, 1991. In the investigation a protocol record was used with a view to further analysis. A higher prevalence betweem 50 and 60 years of age (46.1%) and in male patients (92.3%) was noted. Twelve patients (92.3%) were from Maranhao State, and 10 of them (76.9%) came from the Western Microregion of the State of Maranhao. Regarding occupation, 92.3 % were landworkers, and most of them presented the lesions on the lower limbs (84.6%) of a vegetant warty aspect, brown in color with itching. Histopathological exammination diagnosed chromomycosis in 100% of the cases. Culture was performed in 11 cases, and Fonsecaea pedrosoi isolated in 9 of them. Treatment with 5-fluorocytosine resulted in a good evolutive response. This study indicates the existence of a probable endemic area of chromomycosis in hinterland of Maranhao (Western Microregion) that hither to unknown.

O babaçu (Orbignya phalerata martins) como provável fator de risco de infecção humana pelo agente da cromoblastomicose no Estado do Maranhão, Brasil

During a survey of 30 patients with chromoblastomycosis followed at the Hospital dos Servidores do Estado do Maranhão, the authors observed in 2 (6.6%) patients with lesions on the buttock. This is an uncommon site for the initial lesions of chromoblastomycosis. There is often a history of microtraumatism during the farming job hence the more frequent development of lesions in the lower limbs. Both patients had 10 years disease, with the presence of nodules and vegetant warty lesions in coalescent plaques on the right buttock. Etiologic diagnosis made through histopatologic and culture exams, with Fonsecaea pedrosoi isolated. The epidemiological exposure of the patients, was suggested by the fact that both worked as babaçu coconut cutters a common activity in Maranhão State. The relation between this kind of professional activity and the development of infection merits for the investigation.

Leishmaniose cutânea disseminada produzida por Leishmania viannia braziliensis no Estado do Maranhão - Brasil

Os autores relatam o caso de um paciente procedente do Municipio de Barreirinhas, MA, portador de leishmaniose cutânea disseminada, que apresentava 58 lesoes distribuidas pelo corpo, sob os mais variados aspectos com predominância da lesao ulcerada. Discutem a dificuldade do diagnostico laboratorial na fase inicial da investigacao e suas implicacoes com a terapeutica. O parasita isolado e caracterizado pela tecnica de anticorpos monoclonais foi a Leishmania viannia braziliensis. Esta forma da doenca e diferente da leishmaniose cutânea difusa, encontrada no Maranhao, cujo agente etiologico e a Leishmania (Leishmania) amazonensis, responsavel pela grande maioria dos casos de leishmaniose tegumentar naquele Estado. Os possiveis mecanismos de disseminacao das lesoes sao tambem discutidos neste trabalho.

Spontaneous regional healing of extensive skin lesions in diffuse cutaneous Leishmaniasis (DCL).

The authors report a case of diffuse cutaneous leishmaniasis, with longstanding evolution and presenting with diffuse infiltrated lesions rich in amastigotes in the absence of mucosal involvement. In situ characterization with monoclonal antibodies revealed Leishmania amazonensis. Large regional lesions have presented spontaneous healing without specific therapy. Considering that DCL presents with a defect in the cellular immune response, this fact demonstrate that this patient may develop a regional cellular immune response enough to destroy the parasites and to produce clearing of some lesions.

Detection of delayed hypersensitivity to Fonsecaea pedrosoi metabolic antigen (chromomycin).

An experimental study was conducted between January 2002 and April 2003 for the detection of delayed hypersensitivity to Fonsecaea pedrosoi metabolic antigen (chromomycin) in skin tests. A total of 194 subjects were attended by spontaneous demand at the Infectious and Parasitic Diseases outpatient clinic of the Federal University of Maranhão-UFMA and at the Department of Microbiology, Federal University of Minas Gerais-UFMG and classified into three groups: patients with chromoblastomycosis caused by F. pedrosoi (n=20), healthy subjects (n=86) and patients with other diseases (n=88). For the skin test, 0.1 ml of the antigen was applied to the anterior side of the right forearm and 0.1 ml Smith medium was applied to the anterior side of the left forearm as control. The results were analyzed 48 h after inoculation of the antigen and an induration >/= 5 mm was considered to indicate a positive test. A cellular immune response to chromomycin was detected in 18 (90.0%) of the 20 patients with chromoblastomycosis caused by F. pedrosoi, and one of the patients with a negative test had reactional leprosy. Eighty-five (98.8%) of the 86 healthy subjects presented a negative reaction and only one reacted positively to the antigen. The skin test was negative in all 88 (100%) patients with other diseases, such as dermatophytosis, paracoccidioidomycosis, pulmonary aspergilloma, candidiasis, pityriasis versicolor, tuberculosis, leprosy, tegumentary leishmaniasis and syphilis, and one case of chromoblastomycosis caused by Rhinocladiella aquaspersa. Chromomycin was effective in detecting delayed hypersensitivity in patients with chromoblastomycosis caused by F. pedrosoi, with a sensitivity and specificity of 90.0% and 98.8%, respectively. These results suggest that this antigen can be used in the auxiliary diagnosis of the disease and also in epidemiological studies for determination of the prevalence of chromoblastomycosis infection in endemic areas.

ASSOCIAÇÃO DE CROMOBLASTOMICOSE E HANSENÍASE: RELATO DE DOIS CASOS

Thirty cases of chromoblastomycosis were diagnosed at Hospital dos Servidores do Estado do Maranhao, from November, 1988 to March, 1993. The authors report 2 (6.6%) cases, that presented an association with leprosy. The first patient developed both diseases together, showing palpable bilateral cubital nerves, perforanting ulcer of the right foot, infiltration and lesions in verrucoid plaques in left leg, with positive biopsyfor dimorphic leprosy. The second case, a patient with history of lepromatous leprosy for 30 years without treatment, with vegetant lesions with a warty aspect in right elbow for 12 months, histopatologic and positive culture for chromoblastomycosis. The possible factors for development of this disease in these patients are discussed.