Eloísa Silva

Behavioral Aspects of Lutzomyia longipalpis (Diptera: Psychodidae) in Urban Area Endemic for Visceral Leishmaniasis

ABSTRACT The study of some of the behavioral aspects of the main vector of Leishmania infantum chagasi Cunha & Chagas in the Americas, Lutzomyia longipalpis (Lutz & Neiva), such as dispersion, population size, and vector survival rates, is important for the elucidation of the mechanisms of visceral leishmaniasis transmission. These parameters were studied by means of capture-mark-release-recapture experiments in an urban area of Campo Grande municipality, an endemic area of visceral leishmaniasis, situated in Mato Grosso do Sul state, Brazil. Six capture-mark-release-recapture experiments were undertaken between November 2009 and November 2010 and once in January 2012 with a view to assessing the population size and survival rate of Lu. longipalpis. The insects were released in a peridomicile surrounded by 13 residences. The recaptures were undertaken with automatic light traps for four consecutive weeks after release in the surrounding area. In total, 3,354 sand flies were captured, marked, and released. The overall recapture rate during the capture-markrelease-recapture experiments was 4.23%, of which 92.45% were recaptured at the release site, indicating limited dispersal. The greatest distance recorded from the release site was 165 m for males and 241 m for females. The male daily survival rate, calculated on the basis of regressions from the numbers of marked recaptured insects during the 15 successive days after release was 0.897. The estimated male population size measured by the Lincoln Index was 10,947.127. Though Lu. longipalpis presented a limited dispersion the physical barriers typical of urban environments did not prevent the sand flies from flying long distances.

Obstructive sleep apnea and diabetes mellitus

BACKGROUND There is convincing evidence that obstructive sleep apnea (OSA) is highly associated with impaired glucose metabolism. OBJECTIVES Analyze the prevalence of OSA in type 1 and type 2 diabetes mellitus (DM) patients. Evaluate the influence of OSA on glycemic control. METHODS The adult patients with diabetes mellitus (DM) followed in the department of internal medicine were referred to our Sleep Unit. A home respiratory polygraphy was then performed on all patients with body mass index (BMI) <40 kg/m(2). The glycemic control was assessed by the value of glycated hemoglobin (Hba1c) in the previous 3 months. RESULTS A total of 46 patients were studied (20 men and 26 women), the mean age was 50±15 years and mean BMI was 28.6±4.9 kg/m(2). The mean Hba1c was 8.3±1.2. Twenty three patients had type 2 DM and 23 patients had type 1 DM. Twenty nine patients (63.0%) had OSA and 8.7% had severe OSA (AHI>30/h). The mean CT90 was 5.3±12.5 and the mean AHI was 13.6±18.3. The mean AHI was similar between type 1 and type 2 DM (15.7±24.5 Vs 11.6±8.9; p=0.46). The AHI was not correlated with the BMI. Type 2 DM patients with poor glycemic control (HbA1c>7.5%) had a significantly higher mean AHI (14.3±9.0 vs 6.4±6.2; p=0.038). This difference did not remain significant after adjustment for BMI (p=0.151). CONCLUSIONS The prevalence of OSA in type 1 DM is similar to that found in type 2 DM. We note the high prevalence of OSA in younger patients with type 1 DM.

Cutaneous tuberculosis as metastatic tuberculous abscess

Cutaneous tuberculosis (CTB) continues to be one of the most difficult diagnoses to make because of the wide variations in its clinical appearance, histopathology, immunology and treatment response.(1,2) The incidence of this disease has increased in the 21st century, due to a high incidence of HIV infection and multidrugresistant pulmonary tuberculosis.(3,4) Although CTB accounts for only 1.5% of all cases of extrapulmonary tuberculosis and 0.15% of all cases of skin disease, given the high prevalence of tuberculosis in many countries, these numbers are significant.(1,2) Mycobacterium tuberculosis, M. bovis, and the BCG vaccine can all cause CTB.(5) In most cases, tuberculosis is transmitted via the airborne route, and skin manifestations are a result of hematogenous spread or direct extension from a focus of infection. However, primary inoculation can occur through direct introduction of the mycobacteria into the skin or mucosa of a susceptible individual by trauma or injury. The risk increases in the presence of HIV infection, intravenous drug abuse, diabetes mellitus, immunosuppressive therapy, malignancy, end-stage renal disease, or infancy.(5,6) Albeit a rare sign, CTB should be considered in the differential diagnosis of skin lesions, especially in individuals with a history of tuberculosis. A 68-year-old male presented with a six-month history of weight loss and asthenia. He was a retired factory worker and former smoker, with a history of pulmonary tuberculosis in his youth (two distinct episodes, 20 years apart, the treatment regimens employed in those episodes being unknown), schizophrenia, osteoarticular pathology, and reflux esophagitis. The patient also presented with two anterior thoracic skin swellings (22 × 60 cm and 80 × 30 cm, respectively) that were painful on palpation, with an elastic consistency and without local warmth on the overlying skin (Figure 1). He reported that the swellings had first appeared one month earlier. He reported no fever or respiratory complaints. No lymph nodes were detected. A CT scan of the chest showed two liquid collections in the anterior chest wall, with a dystrophic aspect, together with thickening of the costal arch and the adjacent costal cartilage. Diagnoses such as staphylococcal abscess, mixed bacterial infection, nocardiosis, atypical mycobacterial infections, and deep fungal infections were considered. A biopsy of one of the swellings showed granulation tissue with lymphocytes, plasma cells, and histiocytes, with suppurative areas and a fistulous tract. In sputum smears, staining for AFB was negative, although a PCR of a sputum sample was positive for M. tuberculosis. Serology for HIV was negative. The patient was referred to a center for the treatment of thoracic diseases, for evaluation and treatment. Another CT scan of the pulmonary parenchyma revealed some fibrotic changes in both lung apices. Sputum smear staining for AFB was again negative, although a culture of the biopsy sample was positive for M. tuberculosis. Drug susceptibility testing showed that the strain was susceptible to isoniazid and rifampin, as well as to all of the first-line antituberculosis drugs tested. The patient was started on four antituberculosis drugs, at doses adjusted for body weight—isoniazid (300 mg/day); rifampin (600 mg/day); pyrazinamide (1,500 mg/day); and ethambutol (1,000 mg/day).

Chiari malformation and central sleep apnea syndrome: efficacy of treatment with adaptive servo-ventilation

The Chiari malformation type I (CM-I) has been associated with sleep-disordered breathing, especially central sleep apnea syndrome. We report the case of a 44-year-old female with CM-I who was referred to our sleep laboratory for suspected sleep apnea. The patient had undergone decompressive surgery 3 years prior. An arterial blood gas analysis showed hypercapnia. Polysomnography showed a respiratory disturbance index of 108 events/h, and all were central apnea events. Treatment with adaptive servo-ventilation was initiated, and central apnea was resolved. This report demonstrates the efficacy of servo-ventilation in the treatment of central sleep apnea syndrome associated with alveolar hypoventilation in a CM-I patient with a history of decompressive surgery.

Tuberculosis retreatment in Northern Portugal

taken for other pathologies. It designates inflammation and fibrosis occurring predominantly in membranous and respiratory bronchioles walls and contiguous tissues, sparing distal respiratory bronchioles, with resultant lumen narrowing. Histology is characterized by focal changes, which are difficult to read, making diagnosis sometimes problematical. Clinically, patients usually report dyspnea and cough and, like both our patients, have functional airflow limitation. This reflects the effect of bronchiolar lumens concentric narrowing and eventually luminal obliteration. It is a chronic, slowly progressive disease. Chest X-ray is often normal or shows signs of hyperinflation or decreased vascular reticulum. Chest CT scan may help diagnosis, sometimes demonstrating the existence of a mosaic pattern, with areas of air-trapping caused by constricted and partially obstructed bronchioles. There are also frequently parenchymal densifications and bilateral ground glass opacities. There are several causes attributed to this entity. Even though it may be idiopathic, most commonly it is secondary to sequelae from childhood infections or inhalation of toxic gases. It can also occur in patients with connective tissue diseases and is a well-known complication of bone and lung transplantation. More recently, it has been associated with ulcerative colitis, proliferation of neuroendocrine cells in the lung or with cystic fibrosis. Treatment is based on oral systemic corticosteroid therapy. However, it appears that most cases are steroid-resistant, with development of irreversible airway obstruction. Association with other immunosuppressants is also controversial, due to the absence of directed studies. Recent trials have also shown that macrolide in the form of azithromycin (250 mg three times a week) may be important in reducing the inflammatory component. Prognosis is difficult to establish since most of the available studies only enrolled patients with constrictive bronchiolitis associated to organ transplantation. In such patients, the overall mortality rate is 25%. However, for 87% of patients who were asymptomatic there was resolution or stabilization of the disease, compared with 38% of those with moderate symptoms and 40% of those with severe symptoms. The authors describe two patients with histological diagnosis of constrictive bronchiolitis in order to highlight an uncommon entity that in clinical practice is often misread. Further studies targeting treatment regimens are needed in the near future.