Leonardo Campos de Queiroz

Imaging techniques in the evaluation of morbidity in schistosomiasis mansoni.

Over the last 20 years a great advance has been observed in many aspects of medicine, and the advent of novel imaging techniques is certainly amongst the most important. In schistosomiasis these new methods caused a revolution in the definition of the clinical forms of the disease and in the evaluation of its complications, such as, liver fibrosis, pulmonary hypertension and neuroschistosomiasis, as never before. Herein we present an overview of the image methods used to diagnose schistosomiasis mansoni nowadays.

Ultrasound in schistosomiasis mansoni

We reviewed ultrasound features in patients with schistosomiasis mansoni. The alterations that we observed in acute and hepatosplenic schistosomiasis are described. The advantages and disadvantages of using ultrasound patterns in the evaluation of liver fibrosis are discussed. Other diseases that are important in the differential diagnosis of schistosomal liver fibrosis are presented. Ultrasound is an effective and flexible diagnostic tool in the evaluation of a variety of diseases. It presents no harmful effects to patients, allowing non-invasive studies in hospitalized patients and in other facilities.

Ultrasonographic measurement of intra-abdominal fat thickness in HIV-infected patients treated or not with antiretroviral drugs and its correlation to lipid and glycemic profiles.

Aims: To compare the intra-abdominal fat thickness measured by ultrasound between HIV-infected patients treated or not with antiretroviral drugs and to correlate these visceral adiposity measurements to other parameters of cardiovascular risks. Methods: In a transversal observational study, 160 HIV-infected patients were recruited and divided in two groups, i.e., 123 antiretroviral (ARV)-treated and 37 ARV-naïve patients. These patients were submitted to anthropometric determinations, laboratorial analysis, ultrasonographic measurements of subcutaneous and intra- abdominal fat thickness and to tetrapolar bioelectrical impedance analysis in order to measure the body composition. Results: In the patients treated with highly active antiretroviral therapy (HAART) the intra-abdominal fat pad was significantly thicker than that of the untreated group (69 ± 21 mm, n = 123 vs. 60 ± 18 mm, n = 37; p = 0.03 Student’s t test). The intra-abdominal fat thickness correlated significantly with plasma triglyceride, total cholesterol, fasting glucose, glucose measurements 2 h after dextrose load, fasting insulin, HOMA-IR index, systolic and diastolic blood pressures, weight, BMI, WHR and caliper-measured total fat percentage. Conclusion: The results showed that antiretroviral therapy is associated with increased ultrasonographic measurements of visceral adiposity. Our data demonstrated a strong correlation between intra-abdominal fat thickness and independent risk factors of cardiovascular disease: atherogenic lipid profile and insulin resistance.

Serum hyaluronan and collagen IV as non-invasive markers of liver fibrosis in patients from an endemic area for schistosomiasis mansoni: a field-based study in Brazil

Non-invasive markers of fibrosis have been used to diagnose liver fibrosis in a variety of diseases. Hyaluronic acid (HA) and collagen IV (C-IV) levels were measured in the sera of patients from an endemic area for schistosomiasis in Brazil to diagnose and to rank the intensity of liver fibrosis. Seventy-nine adult patients with schistosomiasis, in the age range of 21-82 years (49 +/- 13.4) were submitted to clinical and ultrasonographic examinations. Ultrasound was employed to diagnose and categorise liver fibrosis according to World Health Organization patterns. Serum HA and C-IV levels were measured using commercial ELISA kits. Ultrasound revealed six patients with intense liver fibrosis, 21 with moderate, 23 with light and 29 without. Serum HA was able to separate individuals with fibrosis from those without (p < 0.001) and light from intense fibrosis (p = 0.029), but C-IV was not (p = 0.692). The HA diagnostic accuracy for fibrosis was 0.89. The 115.4 ng/mL cut-off level diagnosed patients with fibrosis (sensitivity 0.98, specificity 0.64). HA correlated positively with portal hypertension. Periportal fibrosis (subjective evaluation), age and collateral circulation predicted HA increase. In conclusion, we propose that serum HA can be used to identify patients with liver fibrosis in an endemic area for schistosomiasis mansoni in Brazil.

Comparison between clinical and ultrasonographic findings in cases of periportal fibrosis in an endemic area for schistosomiasis mansoni in Brazil.

INTRODUCTION Abdominal palpation and ultrasound findings among patients from an endemic area for schistosomiasis in Brazil who had been followed up for 27 years were compared. METHODS In 2004, 411 patients from Brejo do Espírito Santo, in the State of Bahia, were selected for the present investigation after giving their written informed consent. Based on clinical data, they were divided into three groups: 41 patients with evidence of liver fibrosis in 2004 (Group 1); 102 patients with evidence of liver fibrosis in the past (1976-1989) but not in 2004 (Group 2); and 268 patients without evidence of liver fibrosis at any time during the 27-year follow-up (Group 3). All of the patients underwent abdominal ultrasound in which the examiner did not know the result from the clinical examination. The data were stored in a database. RESULTS The prevalence of periportal fibrosis on ultrasound was 82.9%, 56.9% and 13.4% in Groups 1, 2 and 3, respectively. In the presence of hard, nodular liver or prominent left lobe and a hard palpable spleen, ultrasound revealed periportal fibrosis in 70.9%. However, periportal fibrosis was diagnosed using ultrasound in 25.4% of the patients in the absence of clinical evidence of liver involvement. Thus, ultrasound diagnosed periportal fibrosis 3.1 times more frequently than clinical examination did. CONCLUSIONS Although clinical examination is important in evaluating morbidity due to Mansons schistosomiasis in endemic areas, ultrasound is more accurate in diagnosing liver involvement and periportal fibrosis.

Ultrasound and magnetic resonance imaging findings in Schistosomiasis mansoni: expanded gallbladder fossa and fatty hilum signs.

INTRODUCTION There is no study relating magnetic resonance imaging (MRI) to ultrasound (US) findings in patients with Schistosomiasis mansoni. Our aim was to describe MRI findings inpatients with schistosomal liver disease identified by US. METHODS Fifty-four patients (mean age 41.6±13.5years) from an area endemic for Schistosomiasis mansoni were selected for this study.All had US indicating liver schistosomal fibrosis and were evaluated with MRI performed witha 1.5-T superconducting magnet unit (Sigma). RESULTS Forty-seven (87%) of the 54 patientsshowing signs of periportal fibrosis identified through US investigation had confirmed diagnosesby MRI. In the seven discordant cases (13%), MRI revealed fat tissue filling in the hilar periportalspace where US indicated isolated thickening around the main portal vein at its point of entryto the liver. We named this the fatty hilum sign. One of the 47 patients with MRI evidence ofperiportal fibrosis had had his gallbladder removed previously. Thirty-five (76.1%) of the other46 patients had an expanded gallbladder fossa filled with fat tissue, whereas MRI of the remainingeleven showed pericholecystic signs of fibrosis. CONCLUSIONS Echogenic thickening of thegallbladder wall and of the main portal vein wall heretofore attributed to fibrosis were frequentlyidentified as fat tissue in MRI. However, the gallbladder wall thickening shown in US (expandedgallbladder fossa in MRI) is probably secondary to combined hepatic morphologic changes inschistosomiasis, representing severe liver involvement.

Aspectos ultrassonográficos e hemodinâmicos da esquistossomose mansônica : avaliação pela ultrassonografia Doppler em áreas endêmicas.

OBJECTIVE: The present field research was aimed at identifying sonographic and hemodynamic findings indicative of the presence of schistosomiasis mansoni in endemic areas. MATERIALS AND METHODS: Doppler sonography was performed in 554 patients with schistosomiasis in three areas with different endemicity levels: low (n = 109), medium (n = 255) and high endemicity (n = 190). The World Health Organization (Niamey Working Group, 2000) protocol was adopted for sonographic evaluation. Doppler study included portal vessels, hepatic and splenic arteries, hepatic veins and collateral vessels. RESULTS: A significant correlation was observed between the frequency of sonographic findings, except for left lobe hypertrophy, and the areas endemicity levels. Altered hepatic veins flow pattern was observed in 23.7% of cases, such abnormality being related to the presence and intensity of periportal thickening. Hepatic arteries did not present any alteration as related to the evaluated parameters. Collateral vessels were identified only in the patients from the high-endemicity area. The splenic artery presented alterations (increase in caliber, flow velocity and resistive index), most frequently in the high-endemicity area, with significant difference between groups. CONCLUSION: Doppler sonography has shown to be a relevant auxiliary tool in the study of the morbidity related to schistosomiasis mansoni, contributing for a more accurate description of the disease profile in endemic areas.

Comparative randomised trial of high and conventional doses of praziquantel in the treatment of schistosomiasis mansoni

The efficacy of oral praziquantel in the treatment of schistosomiasis has been considered low by most public health institutions. In this paper, we compared the efficacy of two dosages of praziquantel (80 mg/kg vs. 50 mg/kg) in patients with chronic schistosomiasis mansoni. Two hundred eighty-eight patients with schistosomiasis from a community in Brazil were randomly divided into two groups: 145 patients (Group 1) received 80 mg/kg body weight of oral praziquantel divided in two equal doses with 1 h interval and 143 patients (Group 2) received 50 mg/kg body weight of oral praziquantel. To keep the study masked, patients in Group 2 received placebo 1 h after the first dose. All patients were subjected to clinical and ultrasonographic examination. Cure assessment was performed by repeating two stool examinations, by a quantitative method, at 30, 90 and 180 days after treatment. The morbidity of schistosomiasis was low, with a few cases of light periportal thickening and 16 cases of mild splenomegaly. The cure rates were 89.7% for Group 1 and 83.9% for Group 2. There was no difference in the efficacy of both therapeutic dosages of praziquantel assayed. The adverse reactions were more frequent with higher dosage.

Cryptococcal meningoencephalitis and pulmonary nodule in a non-HIV-infected immunocompetent patient

.ELISA, western blot and PCR for HIV infection resulted negative.Clinical history and a series of tests excluded subjacentimmunodeficiency and other associated diseases. Computedtomography (CT) of the brain depicted the presence of multiplenodules in the basal ganglia with contrast enhancement (FigureA – arrows). He was treated with conventional amphotericin B(50mg/day) and improved quickly. CT of the lungs revealedbilateral pleural effusion and a slightly irregular solitary nodulein the periphery of the right lower lobe (Figure B – arrow). Tendays after starting amphotericin B, renal insufficiency, phlebitis,sepsis and disturbances in fluid and electrolytes balance wereobserved and fluconazole was substituted for amphotericin B.The patient was discharged from hospital 25 days later in goodclinical condition. After a stay at home for twenty days he returnedto hospital with symptoms resembling those of the first admission.A lumbar tap confirmed the diagnosis of meningitis: cryptococcalantigen was found in the cerebral spinal fluid (1:32). Intravenousliposomal amphotericin B (5mg/kg/day for 18 days) was givenand he improved again. The CT of the chest still showed a nodule inthe right lower lobe, but with no pleural effusion (Figure C – arrow).He is now receiving conventional amphotericin B (50 mg/day), twicea week, at the outpatient clinic and remains asymptomatic.O paciente, de 39 anos, foi admitido ao hospital com historiade febre, cefaleia, nauseas, fotofobia e vomitos de inicio havia seisdias. A puncao lombar revelou a presenca do fungo

Sensitivity and specificity of the circulating cathodic antigen rapid urine test in the diagnosis of Schistosomiasis mansoni infection and evaluation of morbidity in a low- endemic area in Brazil.

INTRODUCTION: The Kato-Katz technique is the standard diagnostic test for Schistosoma mansoni infection in rural areas. However, the utility of this method is severely limited by the day-to-day variability in host egg excretion in the stool. In high-transmission areas, the point-of-care circulating cathodic antigen (POC-CCA) urine assay has proven to be a reliable test. However, investigations of the reliability of the POC-CCA assay in low-transmission regions are under way. This study aimed to evaluate the sensitivity and specificity of the POC-CCA assay and the morbidity of schistosomiasis in a low-endemic area in Brazil. METHODS: Pains City is a low-transmission zone for schistosomiasis. A total of 300 subjects aged 7-76 years were randomly selected for the POC-CCA cassette test. For S. mansoni diagnosis, three stool samples on six slides were compared with one urine sample for each subject. The sensitivity and specificity in the absence of a gold standard were calculated using latent class analysis. Clinical examinations and abdominal ultrasounds were performed in 181 volunteers to evaluate morbidity associated with schistosomiasis. RESULTS: The sensitivity and specificity of the Kato-Katz technique were 25.6% and 94.6%, respectively. By contrast, the sensitivity and specificity of the POC-CCA assay were 68.1% and 72.8%, respectively. Hepatosplenic schistosomiasis was diagnosed in two patients (1.1%). CONCLUSIONS: Overall, the POC-CCA urine assay proved to be a useful test for diagnosing S. mansoni in a low-endemic area in Brazil. Severe clinical forms of schistosomiasis can be present even in such low-endemic areas.