Maria Eugenia Noviski Gallo

REACTIONAL STATES IN MULTIBACILLARY HANSEN DISEASE PATIENTS DURING MULTIDRUG THERAPY

It is well known that reactions are commonplace occurrences during the course of leprosy disease. Stigmatization may even be attributable to reactions which are also responsible for the worsening of neural lesions. A cohort of 162 newly-diagnosed baciloscopically positive patients from the Leprosy Care Outpatient Clinic of the Oswaldo Cruz Foundation (FIOCRUZ) was selected for this study. While 46% of the multibacillary (MB) patients submitted to the 24 fixed-dose multidrug therapy (MDT) regimen suffered reactions during treatment, it was found that all MBs were susceptible and that constant attention and care were required at all times. Fourteen per cent were classified as BB, 52% as BL, and 33% as LL. None of the variables under study, such as, sex, age, clinical form, length of illness, length of dermatological lesions, baciloscopic index (BI), or degree of disability proved to be associate with reaction among the patients studied. Reversal Reaction (RR) occurred in 45%, and Erythema Nodosum Leprosum (ENL) occurred in 55%. Among BB patients who developed reactions (15 patients), 93% presented RR; while among the LL patients who developed reactions (34 patients), 91% presented ENL. Likewise, ENL was very frequent among those with disseminate lesions, while RR was most often observed in patients with segmentary lesions. RR was also most likely to occur during the initial months of treatment. It was demonstrated that the recurrence rate of ENL was significantly higher than that of RR. Neither grade of disability nor BI was shown to be associated with RR and ENL reaction. However, the RR rate was significantly higher among patients showing BI < 3, while ENL predominated among those patients with BI > 3.

Associação entre reação hansênica após alta e a carga bacilar avaliada utilizando sorologia anti PGL-I e baciloscopia

Leprosy (Hansens disease, HD) reactions are immune-inflammatory phenomena that occur during the evolution of the disease. Given the current criteria for treatment of the disease, this event is often observed after the patient has been released from treatment (RFT) from multi-drug therapy (MDT). A case-control study was conducted comparing laboratory results of cases of leprosy reactions after RFT from multibacillary MDT (MDT/MB) with a control group to analyze the possible association between posttreatment reactions and bacterial load using the ML Flow serological test for detection of antibodies to Mycobacterium leprae and the results of bacilloscopic skin smears. The study was conducted in two reference centers in Recife, Pernambuco State, Brazil, involving 208 patients. The results obtained indicate that posttreatment reaction is statistically associated with bacterial load through positive serology post-RFT. In conclusion, common risk factors exist between relapses and post-RFT reactions.

O retratamento por recidiva em hanseníase

FUNDAMENTOS: Estudos sobre os pacientes hansenianos retratados justificam-se pela dificuldade do diagnostico diferencial entre quadro reacional apos alta do tratamento especifico de hanseniase e recidiva, devido as limitacoes de criterios clinicos e laboratoriais para diferencia-los. OBJETIVOS: Verificar os procedimentos diagnosticos clinicos e laboratoriais que subsidiaram o retratamento por recidiva e a ocorrencia de episodios reacionais, em especial os que ocorreram apos o termino do tratamento. METODOS: Mediante o estudo retrospectivo de serie de casos foram estudados 155 pacientes hansenianos retratados por recidiva em duas unidades de referencia em hanseniase, no municipio de Recife/PE, Brasil. RESULTADOS: O criterio clinico foi o mais utilizado para a decisao de retratamento por recidiva, e as lesoes novas descritas foram principalmente do tipo macula e infiltracao. Os episodios reacionais apos alta ocorreram em 34% desses pacientes, e 33,9% relatavam a presenca de comunicantes com hanseniase. Dos 155 pacientes estudados apenas 14,9% realizaram exame histologico e 18,1% nao realizaram a baciloscopia antes de reiniciar a terapia especifica. CONCLUSAO: Este estudo evidenciou que os episodios reacionais apos o tratamento e a presenca de comunicantes com hanseniase ocorreram em torno de 30% nos pacientes retratados por recidiva e que se fazem necessarios outros estudos controlados para o melhor entendimento desses fatores.

Alocação do paciente hanseniano na poliquimioterapia: correlação da classificação baseada no número de lesões cutâneas com os exames baciloscópicos

FUNDAMENTOS: A integracao das acoes de controle da hanseniase as estrategias dos Programas de Saude da Familia e Agentes Comunitarios de Saude, na conformidade do processo de reorganizacao da atencao basica, fundamentou a atualizacao das normas da legislacao sobre o controle da doenca no Brasil. A classificacao operacional adotada, para alocacao do paciente na poliquimioterapia, foi adaptada da sugerida pela Organizacao Mundial de Saude, essencialmente clinica, baseada no numero de lesoes cutâneas. De acordo com essa recomendacao, sao considerados paucibacilares (PB) os casos com ate cinco lesoes e multibacilares (MB) os com mais de cinco lesoes cutâneas.O que se discute e a validade desse metodo de classificacao, que toma como referencia apenas aspectos clinicos. OBJETIVOS: Avaliar o metodo clinico de classificacao baseado no numero de lesoes cutâneas correlacionando-o com os resultados dos exames baciloscopicos de esfregacos da pele. METODOS: A fonte de informacoes foi o banco de dados no qual sao registradas informacoes clinicas, epidemiologicas e laboratoriais dos pacientes. Foram selecionados 837 registros do periodo de 1986 a 1999, e os criterios avaliados foram o numero de lesoes cutâneas e o resultado do exame baciloscopico, ambos no momento do diagnostico. Estabeleceu-se a comparacao e calcularam-se a sensibilidade e especificidade relativa e os valores preditivo positivo e negativo do criterio lesao cutânea e determinou-se a concordância entre o numero de lesoes e a baciloscopia por meio do calculo do indice Kappa (k). RESULTADOS: Dos 837 casos avaliados, 652 apresentavam baciloscopias positivas, e 185, negativas. Dos positivos, 68 (11.4%) apresentavam menos de cinco lesoes, e dos negativos 30 (16.0%) apresentavam mais de cinco lesoes cutâneas. A sensibilidade e a especificidade do criterio clinico foram de 89.6% e de 83.8% respectivamente, e o valor preditivo positivo de 95.1%, e o negativo de 69.5%. CONCLUSAO: o metodo clinico baseado no numero de lesoes cutâneas para classificacao dos pacientes hansenianos apresenta limitacoes que nao invalidam sua operacionalidade, porem novos criterios devem ser desenvolvidos possibilitando uma melhor acuracia na alocacao dos pacientes nos esquemas poliquimioterapicos.

Effect of treatment on immune responsiveness in lepromatous leprosy patients.

This study was performed in order to analyse whether the immune unresponsiveness to Mycobacterium leprae, largely seen in lepromatous patients, persisted after discharge from treatment. Lymphoproliferation and skin tests were performed using two mycobacterial antigens (M. leprae and BCG) in three groups of lepromatous patients grouped by treatment status. Forty-seven per cent of the lepromatous patients tested acquired reactivity to M. leprae after long-term treatment.

Use of the polymerase chain reaction in the diagnosis of leprosy

One of the main limitations for successful epidemiological control of leprosy is the lack of a method for its diagnosis in subclinical cases. Because of the long incubation period of the disease, liberation and spread of Mycobacterium leprae during subclinical stages-principally in cases of untreated multibacillary forms of leprosy-constitute the main source of infection. This report describes the use of the polymerase chain reaction (PCR) for the detection of M. leprae in different types of tissue samples (blood, lymph, nasal secretion and hair) from an individual who was suspected of having leprosy. Although no conclusive diagnosis could be made by traditional diagnostic methods, the individual was found to be infected with M. leprae after amplification of the bacterial DNA.

Avaliação oftalmológica em hanseníase multibacilar

Objetivo: Determinar a frequencia e o tipo de comprometimento ocular em pacientes portadores de hanseniase no momento do diagnostico. Metodologia: O estudo foi realizado na Fundacao Oswaldo Cruz (Rio de Janeiro) e avalia 77 casos classificados como multibacilares. O exame oftalmologico foi realizado de acordo com o sistema de classificacao de discapacidades recomendado pela Organizacao Mundial de Saude. Resultados: Referiam queixas especificas 36,3%: dor e ardencia ocular, lacrimejamento e dificuldade para enxergar. Em 55,8% dos pacientes foram detectadas alteracoes oculares no exame oftalmologico. A diminuicao da sensibilidade da cornea, que predispoe a ulceracao e opacificacao, foi a alteracao mais frequente (29,3%). Conclusao: Os achados desta pesquisa demonstram a gravidade e a alta frequencia das lesoes oculares nos casos avaliados e alertam para a importância do exame oftalmologico como rotina em portadores de hanseniase multibacilar.

Borderline--tuberculoid leprosy: clinical and immunological heterogeneity.

The authors analysed some immunological criteria in leprosy patients diagnosed as borderline tuberculoid by the presentation of different grades of skin lesions as well as different grades of nerve involvement. Only 50% of the patients presented a single skin lesion and 58% had none or only one affected nerve. Nineteen patients (39.6%) showed a positive lepromin reaction (induration > or = 5 mm). Patients with a positive skin test had a greater number of skin lesions when compared with patients with a negative lepromin test. Fifty-seven percent of the patients were found to be positive using a lymphoproliferation test (LTT) in response to Mycobacterium leprae antigens. Positive LTT results did not correlate with the number of skin lesions, but patients unresponsive to LTT had a lesser extent of nerve involvement. Four out of 18 patients (22%) released high IFN gamma levels in PBMC culture stimulated by M. leprae. (mean U/ml +/- SD = 142 +/- 72). All of these 4 patients presented only one skin lesion, although three of them had more than one affected nerve. Nineteen out of 21 patients (90.5%) showed no anti-PGL-1 antibodies in their serum. The low levels of anti-PGL-1 antibodies among these patients confirmed their tuberculoid background even in those with multiple skin lesions. These findings seem to attribute an important role to IFN gamma in restraining the spreading of the infection in the skin, but IFN gamma may have an opposite effect on the nerves. The potential pathological effects of IFN gamma during the delayed type of hypersensitivity can be related to its ability to synergise with other inflammatory cytokines such as TNF alpha, IL-1 beta, and others.

Determinação do grau de incapacidade em hansenianos não tratados

Foi determinado o grau de incapacidades em 189 pacientes hansenianos virgens de tratamento, sendo 39 Tuberculoides, 16 Indeterminados, 91 Dimorfos e 43 Virchowianos. Apenas 62 (32,8%) dos pacientes apresentaram grau 0, nos 127 (67,2%) restantes, os graus I, II e III determinados indicam a necessidade de educacao sanitaria e tecnicas simples de fisioterapia, para evitar a instalacao de sequelas irreversiveis.

Serology with ML Flow test in health professionals from three different states of Brazil

BACKGROUND In highly endemic countries, transmission and sub-clinical infection of leprosy are likely and the disease manifests itself in individuals without any known close contact with a leprosy patient. Health workers are social contacts belonging to the same network (the Health System) and some of them share the same social environment (nursing assistants) as patients with known patients and / or carriers. OBJECTIVE To identify ML Flow seropositivity among health professionals. METHODS We conducted a cross-sectional study using a serological survey with the ML Flow test in 450 health professionals (doctors, nurses and nursing assistants), in order to detect seropositivity in areas of high and low endemicity in municipalities from three Brazilian states (RJ, MS and RS). RESULTS The results showed general 16% seropositivity, higher in low endemic areas, regardless of whether there was direct care for leprosy patients. Paradoxically, a statistical association was observed between the area studied and seropositivity, as the place with the lowest endemicity (CA) had the highest seropositivity rate (p = 0.033). CONCLUSION The authors suggest these results are associated with a presence of an unspecified link to bovine serum albumin (BSA), carrier of PGL-1 in the ML Flow test, and recommend expanded seroepidemiological research utilizing tests with human and bovine albumin.