Elza Ferreira Noronha

IL6 −174 G/C Promoter Polymorphism Influences Susceptibility to Mucosal but Not Localized Cutaneous Leishmaniasis in Brazil

BACKGROUND Mucosal leishmaniasis (ML) is associated with exaggerated tumor necrosis factor- alpha and interferon- gamma responses and tissue destruction. ML follows localized cutaneous leishmaniasis (CL) caused by Leishmania braziliensis infection. Interleukin (IL)-6 down-regulates T helper (Th) cell type 1 differentiation and drives Th2 cell differentiation. The IL6 -174 G/C polymorphism is associated with proinflammatory diseases and IL-6 regulation. METHODS The -174 G/C polymorphism was genotyped in population samples and families with CL and ML from Brazil. Genotype frequencies were compared among patients with ML, patients with CL, and 2 control groups by logistic regression and family-based association test (FBAT) analysis. IL-6 levels were measured in macrophages. RESULTS The C allele was more common in patients with ML than in patients with CL (odds ratio [OR], 2.55 [95% confidence interval {CI}, 1.32-4.91]; P=.005), than in patients who were leishmanin skin-test positive (OR, 2.23 [95% CI, 1.23-4.05]; P=.009), and than in neighborhood control subjects (OR, 2.47 [95% CI, 1.24-4.90]; P=.01). FBAT analysis confirmed an association between allele C and ML under both additive (z=4.295; P=.000017) and dominant (z=4.325; P=.000015) models. Significantly lower levels of IL-6 were measured in unstimulated macrophages from CC individuals than from GG individuals (P=.003) as well as after stimulation with soluble leishmania antigen (P=.009). CONCLUSIONS IL-6 may regulate type 1 proinflammatory responses, putting individuals with low macrophage IL-6 levels at increased risk for ML.

The epidemiology of malaria in Rondonia (Western Amazon region Brazil): study of a riverine population.

We report on a longitudinal study concerning the incidence of malaria in a riverine population (Portuchuelo) settled on the riverbanks of Rio Madeira, in the State of Rondonia, Brazil. We found the incidence of malaria to be seasonal, prevailing in the dry months of June and July. The Annual Parasite Index (API) was 292/1000 inhabitants, almost three times that of the state of Rondonia for the same period. In contrast with other studied Rondonian populations, malaria in Portuchuelo was more prevalent in youngsters < 16 years old, particularly in the 0-1 year age group. Adults were relatively spared, particularly those over 50 years. Besides being indicative of indoor transmission, these facts may suggest the existence of a certain degree of acquired resistance to infection and/or of lessened symptoms in older people. Riverine populations are spread over the entire Amazon region where most of its members were born. Due to the permanent presence of malaria among riverine populations, we are proposing that they may act as perennial reserves of malaria and, therefore, as sources of infection for migrants or eventual settlers at their vicinity. To date, the opposite view has been generally held. Anopheles darlingi, the main vector species in the area, is essentially sylvatic, which contributes to make the control of malaria highly problematic. The only hopes for control rest on permanent surveillance and the prompt treatment of patients, which are also problematic considering the vastness of the Amazon region and the remoteness of some of its riverine settlements.

Incidência de tuberculose e taxa de cura, Brasil, 2000 a 2004

OBJETIVO: Descrever a distribuicao geografica da incidencia de tuberculose, a partir de um conjunto de indicadores epidemiologicos e operacionais de dados de notificacao oficial. METODOS: Dados sobre incidencia de tuberculose foram coletados no Sistema de Informacao de Agravos de Notificacao, apos processo de pareamento e depuracao de registros repetidos. As taxas de incidencia de tuberculose foram calculadas segundo unidade geografica, grupo etario, sexo, forma clinica e regime de tratamento, e padronizadas para a distribuicao etaria da populacao com base no Censo de 2000. RESULTADOS: Em 2004, o Brasil apresentou taxa de incidencia de 41/100.000 habitantes, com 74.540 casos novos notificados. Desses, 52,8% eram casos pulmonares com baciloscopia positiva, 24,1% estavam em tratamento supervisionado, 63,5% eram provenientes de capitais ou das regioes metropolitanas e 54,9% eram casos curados. Excluindo-se os registros sem preenchimento da variavel de desfecho, a proporcao de cura alcancou 72,4% para casos novos, 47% para casos novos HIV positivos, 64,9% para recidivas, 64,5% transferencias e 40% para reingressos apos abandono. A taxa de cura para os casos novos em tratamento supervisionado foi de 77,1%. A proporcao de registros sem informacao sobre desfecho foi maior em anos mais recentes. CONCLUSOES: Houve extensas diferencas estaduais em relacao a incidencia e as categorias de desfecho. Para alcancar a meta de 85% de cura para casos novos e aumentar a cura dos casos HIV positivos e reingressos sao necessarios esforcos adicionais por parte do Programa Nacional de Controle da Tuberculose, incluindo a expansao da estrategia de tratamento diretamente supervisionado.

The -2518 bp promoter polymorphism at CCL2/MCP1 influences susceptibility to mucosal but not localized cutaneous leishmaniasis in Brazil

Mucosal leishmaniasis (ML) follows localized cutaneous leishmaniasis (CL) caused by Leishmania braziliensis. Proinflammatory responses mediate CL self-healing but are exaggerated in ML. Proinflammatory monocyte chemoattractant protein 1 (MCP-1; encoded by CCL2) is associated with CL. We explore its role in CL/ML through analysis of the regulatory CCL2 -2518bp promoter polymorphism in CL/ML population samples and families from Brazil. Genotype frequencies were compared among ML/CL cases and control groups using logistic regression and the family-based association test (FBAT). MCP-1 was measured in plasma and macrophages. The GG recessive genotype at CCL2 -2518bp was more common in patients with ML (N=67) than in neighborhood control (NC; N=60) subjects (OR 1.78; 95% CI 1.01-3.14; P=0.045), than in NC combined with leishmanin skin-test positive (N=60) controls (OR 4.40; 95% CI 1.42-13.65; P=0.010), and than in controls combined with CL (N=60) patients (OR 2.78; 95% CI 1.13-6.85; P=0.045). No associations were observed for CL compared to any groups. FBAT (91 ML and 223 CL cases in families) confirmed recessive association of ML with allele G (Z=2.679; P=0.007). Higher levels of MCP-1 occurred in plasma (P=0.03) and macrophages (P<0.0001) from GG compared to AA individuals. These results suggest that high MCP-1 increases risk of ML.

Efeito da remoção de notificações repetidas sobre a incidência da tuberculose no Brasil

OBJETIVO: Avaliar o impacto nas taxas de incidencia de tuberculose com a exclusao de registros indevidamente repetidos no sistema de notificacao. METODOS: Foram analisados dados do Sistema de Informacao de Agravos de Notificacao do Ministerio da Saude, referentes ao periodo de 2000 a 2004. Os registros repetidos foram identificados por pareamento probabilistico e classificados em seis categorias excludentes que determinaram suas remocoes, vinculacoes ou permanencias na base. RESULTADOS: Verificou-se que 73,7% das notificacoes eram unicas, 18,9% formavam duplas, 4,7% triplas e 2,7% grupos de quatro ou mais registros. Dentre os registros repetidos, 47,3% foram classificados como transferencia entre unidades de saude, 23,6% reingresso, 16,4% duplicidade verdadeira, 10% recidiva, 2,5% foram inconclusivos e 0,2% tinham dados incompletos. Essas percentagens variaram entre estados. A exclusao de registros indevidamente repetidos resultou em reducao na taxa de incidencia por 100.000 habitantes de 6,1% em 2000 (de 44 para 41,3), 8,3% em 2001 (de 44,5 para 40,8), 9,4% em 2002 (de 45,8 para 41,5), 9,2% em 2003 (de 46,9 para 42,6) e 8,4% em 2004 (de 45,4 para 41,6). CONCLUSOES: Os resultados sugerem que as taxas observadas de incidencia de tuberculose representem estimativas mais proximas do que seriam os valores reais do que as obtidas com a base em seu estado bruto, tanto em nivel nacional como estadual. A pratica de pareamento de registros de notificacao de tuberculose deve ser estimulada e mantida para melhoria da qualidade dos dados de notificacao.

High frequency of skin reactions in patients with leishmaniasis treated with meglumine antimoniate contaminated with heavy metals: a comparative approach using historical controls

We analyzed data from historical controls treated with meglumine antimoniate to compare the frequency of adverse events observed in patients with cutaneous leishmaniasis treated with the same dose of meglumine antimoniate contaminated with heavy metals in an endemic area of the State of Bahia, Brazil. Group A patients were treated in 2000 with the drug produced by Eurofarma Laborat rios Ltda., S o Paulo, Brazil (lot A) and group B patients were treated in 1996 with the reference drug produced by Rhodia Farma Ltda., S o Paulo, Brazil (lot B). We observed an unusual higher frequency of skin reactions in group A patients. However, all type of adverse events observed in group A were also observed in group B. The physico-chemical analysis of these lots revealed that lot A had lower pH and higher concentration of total and trivalent antimony, lead, cadmium, and arsenic. Our findings suggest that the skin reactions could be attributed to heavy metal contamination of lot A.

Sensitivity and reproducibility of a PCR assay for Leishmania detection using skin biopsy imprints on filter paper.

The sensitivity and reproducibility of a PCR targeted to amplify the conserved 120 base-pair region of minicircles from Leishmania kDNA was defined using DNA extracted from skin biopsy imprints on filter paper. Seventy-seven patients with cutaneous leishmaniasis from an endemic region of Leishmania (Viannia) braziliensis in Brazil underwent skin biopsy of the ulcer border. Tissue samples were imprinted on filter paper and then, they were stored at -20 degrees C. Imprints on filter paper were stored at 4 degrees C. Samples were processed at three laboratories; Lab1 and Lab2 performed the PCR-kDNA assay using DNA extracted from the filter paper, and Lab3 processed PCR-kDNA using DNA from fresh-frozen tissue used as a gold standard. All samples were codified to maintain blinding during lab processing. Fifty-three (68.8%) patients had parasites isolated and identified by isoenzymes as L. (V.) braziliensis. The positivity of PCR-kDNA was similar between the three laboratories: 87.0, 85.7 and 88.3% (Lab1, Lab2 and Lab3, respectively). The sensitivity of PCR-kDNA in culture-proven cases was better, and showed similar results in all laboratories: 95.8, 95.8 and 97.9% (Lab1, Lab2 and Lab3, respectively). Data from the 77 enrolled patients showed an overall percent agreement of 80.5% (Kappa=0.173) for the filter-paper approach between Lab1 and Lab2. Percent agreement between Lab1 and Lab3 was 83.1% (Kappa=0.22), and it was 94.8% between Lab2 and Lab3 (Kappa=0.77). Fifteen patients were diagnosed in just one of the two laboratories that used DNA extracted from filter paper. We conclude that the sensitivity of the filter paper approach is satisfactory and could be used in clinical trials and field work. Reproducibility could be improved using two separate imprints from the same biopsy sample.

Validity and Reliability of Enzyme Immunoassays Using Leishmania major or L. infantum Antigens for the Diagnosis of Canine Visceral Leishmaniasis in Brazil

Background American visceral leishmaniasis is caused by the protozoan Leishmania infantum. Dogs are the main reservoirs in the domestic transmission cycle. The limited accuracy of diagnostic tests for canine leishmaniasis may contribute to the lack of impact of control measures recommended by the Brazilian Ministry of Health. The objective of this study was to estimate the accuracy of two enzyme-linked immunosorbent assays employing L. major or L. infantum antigens and their reliability between three laboratories of different levels of complexity. Methods A validation study of ELISA techniques using L. major or L. infantum antigens was conducted. Direct visualization of the parasite in hematoxylin/eosin-stained histopathological sections, immunohistochemistry, and isolation of the parasite in culture.were used as gold standard. An animal that was positive in at least one of the tests was defined as infected with L. infantum. Serum samples collected from 1,425 dogs were analyzed. Samples were separated in three aliquots and tested in three different laboratories. Sensitivity, specificity and the area under de ROC curve were calculated and the reliability was evaluated between the participant laboratories. Results The sensitivity was 91.8% and 89.8% for the L. major and L. infantum assays, respectively. The specificity was 83.75% and 82.7% for the L. major and L. infantum assays, respectively. The area under de ROC curve was 0.920 and 0.898 for L. major and L. infantum, respectively. The mean intraclass correlation coefficients between laboratories ranged from 0.890 to 0.948 when L. major was used as antigen, and from 0.818 to 0.879 when L. infantum was used. Interpretation ELISA tests using L. major or L. infantum antigens have similar accuracy and reliability. Our results do not support the substitution of the L. major antigen of the ELISA test currently used for the diagnosis of canine visceral leishmaniasis in Brazil.

RIII mefloquine resistance in children with falciparum malaria in Manaus, AM, Brazil

We report the occurrence of resistance to mefloquine 20mg/day in 51 children with falciparum malaria treated, at reference center of Manaus, Brazil, from October to December 1997. All children were evaluated at day 3, 5, 7, 14, 21, 28 and 35 of treatment. Clinical and parasitological cure criteria were adopted. The incidence of RIII mefloquine resistance was 5.9% (IC 95% 1.5-17.2). The cure/resistance proportion was 20:1 and cure/severity was 62:1. These findings suggest the importance of mefloquine resistance within this group of children.

Clinical study of falciparum malaria in children in Manaus, AM, Brazil

The clinical characteristics of falciparum malaria were studied among 61 children, aged 0 to 14 treated at a reference center in Manaus, from October to December 1997. The symptoms observed were fever (98.4%), headache (80.3%), chills (68.9%), perspiration (65. 6%), myalgia (59.0%), nausea (54.1%), lumbar pain (49.2%), vomiting (49.2%), cough (45.9%), arthralgia (31.1%), diarrhea (34.4%), dyspnea (8.2%), convulsions (8.2%) and dizziness (4.9%). Pallor and anaemia were found more frequently in children under five years old. Anaemia was associated with high levels of parasitaemia. Fifty-eight (91.5%) patients had uncomplicated malaria, 3 (4.9%) had severe malaria and the lethality was 1.6%.