Otávio A. Moreno-Carvalho

Neuroschistosomiasis due to Schistosoma mansoni: a review of pathogenesis, clinical syndromes and diagnostic approaches

Neuroschistosomiasis (NS) is the second most common form of presentation of infection by the trematode, Schistosoma mansoni. Granulomatous inflammatory reaction occurs as a result of schistosome eggs being transmitted to spinal cord or brain via the vascular system, or by inadvertent adult worm migration to these organs. The two main clinical syndromes are spinal cord neuroschistosomiasis (acute or subacute myelopathy) and localized cerebral or cerebellar neuroschistosomiasis (focal CNS impairment, seizures, increased intracranial pressure). Presumptive diagnosis of NS requires confirming the presence of S. mansoni infection by stool microscopy or rectal biopsy for trematode eggs, and serologic testing of blood and spinal fluid. The localized lesions are identified by signs and symptoms, and confirmed by imaging techniques (contrast myelography, CT and MRI). Algorithms are presented to allow a stepwise approach to diagnosis.

Clinical and cerebrospinal fluid (CSF) profile and CSF criteria for the diagnosis of spinal cord schistosomiasis

OBJECTIVES To describe the clinical and CSF findings among patients with presumptive neuroschistosomiasis (NS) and to suggest a classification for the CSF diagnosis of presumptive NS. METHOD The charts of all patients whose CSF exam was performed at the CSF Lab, Jos Silveira Foundation, Salvador, Brazil, from 1988 to 2002 were reviewed. Those with clinically suspected NS whose indirect fluorescent antibody test (IFA) and or hemagglutination-inhibiting antibodies test (HAI) were positive to S. mansoni were identified. RESULTS Of 377 patients, 67.9% were males; the median age was 36 years (mean 37 + 16 yrs, range 3-82 yrs). The most frequent complaints were paraparesis (59.9%), urinary retention (36.2%), lower limb pain (22.8%). WBC of CSF (count/mm ) was > 4 in 66.0% (mean 83 + 124, median 40, range 4.3-1,100), protein (mg/dl) was > 40 in 84.6% (mean 185 + 519, median 81, range 41-6,800) and eosinophils were present in 46.9%. IFA and HAI were positive in 75.3%. WBC > 4 and presence of eosinophils were associated with IFA and HAI positive (67.3% versus 51.4%, p 0.014; 49.1% versus 23.0%, p 0.0001, respectively) and protein > 40 was not (85.4% versus 77.0%, p 0.09). Presence of WBC > 4, protein > 40 and eosinophils was associated with IFA and HAI positive (71.6% versus 38.2%, p 0.0003) but presence of eosinophils and any other combination of WBC and protein were not. CONCLUSION NS should be considered as a possible diagnosis in patients who had had contact with schistosome-infected water and present with spinal cord compromising. Presence of IFA and HAI positive to S. mansoni, WBC > 4, protein > 40 and presence of eosinophils in the CSF may be considered as a criterium of highly probable presumptive diagnosis.

Cepas invasivas de pneumococo isoladas de crianças e adolescentes em Salvador

OBJETIVOS: descrever resistencia antimicrobiana e sorotipos de cepas de pneumococo. METODOS: durante 57 meses, foi conduzida uma vigilância de cepas invasivas de pneumococo de pacientes com idade <20 anos. O pneumococo foi identificado pelos testes de solubilidade da bile e optoquina. A resistencia a penicilina foi avaliada com o disco de oxacilina (1µg) e, para as cepas nao suscetiveis, foi determinada a concentracao inibitoria minima. Provas de difusao de disco e de microdiluicao em placa foram utilizadas para avaliacao da resistencia a outros antimicrobianos. Reacao de Neufeld-Quellung foi realizada para sorotipagem. RESULTADOS: dos 70 pacientes, 57,1% eram do sexo masculino. A mediana da idade foi 1,92 anos (media 3,19 ± 3,66 anos, variando de um mes a 19,5 anos), tendo 52,9% e 81,4% dos pacientes idade <2 anos e <5 anos, respectivamente. As cepas foram isoladas do sangue (91,4%), liquor (2,9%), liquidos pleural (2,9%), peritonial (1,4%) ou de abscesso (1,4%), de pacientes com pneumonia (77,1%), febre sem sinais localizatorios (10,0%), meningite (4,3%) e outros diagnosticos (8,6%). Resistencia foi detectada a penicilina (20,0%), ao sulfametoxazol-trimetoprim (65,7%), a tetraciclina (21,4%), a ofloxacina (6,3%), a eritromicina (5,7%) e a clindamicina (2,9%). Nao houve resistencia ao cloranfenicol ou a vancomicina. Entre as cepas nao suscetiveis a penicilina, resistencia absoluta foi detectada em uma, a mesma que apresentou resistencia intermediaria a cefotaxima. Os sorotipos mais frequentes foram: 14 (22,9%), 5 e 6A (10,0% cada), 6B e 19F (8,6% cada), 9V, 18C e 23F (5,7% cada). Das cepas resistentes a penicilina, 71,4% pertenciam ao sorotipo 14, 14,3% aos sorotipos 6B e 19F (cada). CONCLUSOES: das 70 cepas, 67,2% tem sorotipos incluidos na vacina pneumococica heptavalente conjugada, assim como estao incluidos todos os sorotipos que apresentaram resistencia a penicilina.

Association of cytokines, neurological disability, and disease duration in HAM/TSP patients

OBJECTIVE To identify clinical and immunological markers associated with HTLV-I associated myelopathy/tropical spastic paraparesis (HAM/TSP). METHOD 237 HTLV-I infected individuals were clinically assessed. They were classified according to the Expanded Disability Status Scale (EDSS) and Osames Motor Disability Score (OMDS). Cytokine levels were determined in HTLV-I seropositive individuals. RESULTS 37 patients had HAM/TSP. There was a correlation between the degrees of disability assessed by both scales. There was also a correlation between the duration of HAM/TSP and the severity of disability assessed by either EDSS or OMDS. Higher levels of IFN-gamma were detected in unstimulated peripheral blood mononuclear cells (PBMC) from HAM/TSP patients as compared with HTLV-I carriers. CONCLUSION This study shows the validity of the neurological scales to classify the degree of neurological disability in HTLV-I carriers and suggests a progressive behavior of HAM/TSP. This study also shows that IFN-gamma in PBMC supernatants are markers of HAM/TSP.

HTLV-I associated tropical spastic paraparesis: cerebral spinal fluid evolutive aspects in 128 cases

In order to evaluate if there is variation on the intensity of cerebral spinal fluid (CSF) response during HTLV-I associated tropical spastic paraparesis (TSP) evolution we retrospectively reviewed 128 cases. The results indicate that although CSF inflammatory alterations can persist over a 10-year period, they tend to become slight or even absent after the second year of TSP evolution.

Neuroesquistossomose mansônica: aspectos clínicos, laboratoriais e terapêuticos

The authors report 16 patients bearing the meningomyeloradicular form of Mansonic neuroschistosomiasis diagnosed according to clinical, laboratorial and image criteria. Patients have been observed at the Neurology Ambulatory of the Federal University of Bahia, within the period of April/91 to December/93. They have been treated with praziquantel, associated to corticosteroids. The aim has been to evaluate the drugs efficiency and safety in decreasing the neurological signs and symptoms.The authors report 16 patients bearing the meningomyeloradicular form of Mansonic neuroschistosomiasis diagnosed according to clinical, laboratorial and image criteria. Patients have been observed at the Neurology Ambulatory of the Federal University of Bahia, within the period of April/91 to December/93. They have been treated with praziquantel, associated to corticosteroids. The aim has been to evaluate the drugs efficiency and safety in decreasing the neurological signs and symptoms.

Clinical and Cerebrospinal Fluid Findings in Patients less than 20 Years Old with a Presumptive Diagnosis of Neuroschistosomiasis

CNS manifestations are rarely attributable to Schistosoma mansoni infection although systemic distribution of S. mansoni eggs is well recorded. We describe 73 patients aged less than 20 years who presented S. mansoni eggs in the stool or rectal biopsy and IFA and/or HAI positive CSF tests to S. mansoni, and who had neurological signs and symptoms. Paraparesis (54.8 per cent), urinary retention (53.4 per cent), and paraplegia (20.5 per cent) were the most commonly observed CNS manifestations. In the CSF, pleocytosis (range 7-560 WBC/mm3) associated with eosinophilia (85.7 per cent vs. 50.0 per cent, p = 0.02) and elevated protein concentration (96.8 per cent vs. 40.0 per cent, p = 0.00003) were observed. We conclude that in areas of the world where infection by S. mansoni is common, neuroschistosomiasis should be an important diagnostic consideration in children with neurological signs and symptoms.

Human T lymphotropic virus type I (HTLV-I) infection in neurological patients in Salvador, Bahia, Brazil.

HTLV-I infection represents a major health concern in endemic areas throughout the world, such as Salvador, the main city of Bahia State, with socio-demographic characteristics similar to sub-Saharan African cities, located in the Northeast of Brazil. In order to provide an estimate of the frequency distribution, and range of neurological manifestations potentially related to HTLV-I infection in this city, we conducted a cross-sectional clinical-epidemiological study to determine the prevalence of this infection in patients with neurological diseases. Patients exhibiting vascular diseases, tumoral diseases or trauma were excluded. Over a period of 16 months, we studied 322 consecutive patients with chronic neurological diseases, who attended the neurological clinics of two major hospitals in Salvador. Overall, the prevalence of HTLV-I infection among the patients was 20.9% (67/320). However, the prevalence among the 104 patients with chronic myelopathy was 50.0% (52/104). It was observed that the major prevalence of HTLV-I was between the ages of 40 and 60 years with a female predominance. Our data indicate that, in Salvador city, HTLV-I is associated with chronic myelopathies or myeloneuropathies, which seem to be the only neurological diseases associated with HTLV-I.

Normal cerebrospinal fluid values in full-term gestation and premature neonates

Results of cerebrospinal fluid (CSF) examinations from 77 high-risk neonates were reviewed. The mean CSF white cells (WBC) count was 4.5 cell/mm3, being two standard deviations above the mean 11.7 cells/mm3 in the full-term gestation neonate group; in the premature neonate one, the mean CSF WBC count was 5.1 cells/mm3, being two standard deviations above the mean 16.7 cell/mm3. PMNs (polymorphonuclear leukocytes) were present in less than 40% of those children, being the mean PMN percentage 4.2% and 0.6%, the mean ANC (absolute neutrophil count) was 0.3/mm3 and 0.06/mm3, in full-term gestation neonate group and premature neonate one, respectively. The mean CSF protein concentration is significantly greater in those premature neonates (101.2 mg/dl) compared with that in term neonates (77.6 mg/dl). The average glucose was just the same in both groups (67 mg/dl). All of these values were from patients who underwent nontraumatic cisternal puncture, with no red blood cells (RBC/mm3 = 0). Traumatic puncture, even up to 500 RBC/mm3, interfered on CSF parameters.

Etiology of bacterial meningitis among children aged 2-59 months in Salvador, Northeast Brazil, before and after routine use of Haemophilus influenzae type b vaccine

OBJECTIVE To describe the frequency of etiologic agents of bacterial meningitis (BM) among children aged 2-59 months in a sample of patients in Salvador, Northeast Brazil, with emphasis on the frequency of BM of unknown etiology (BMUE), just before, during and after the implementation of routine immunization of infants with Haemophilus influenzae type b (Hib) vaccination. METHOD Demographic, clinical and cerebrospinal fluid (CSF) information was collected from the chart of every patient, aged 2-59 months, whose CSF exam was performed at the CSF Lab - José Silveira Foundation, between January 1989 and December 2001. Every CSF exam was completely performed according to standard methods. The etiologic diagnosis was based on either culture and/or latex-agglutination test. When the agent was only seen on Gram stained smear, the diagnosis was descriptive. BMUE was defined as: glucose < 40mg / dl, protein > 100 mg / dl, white blood cell count > 20 cells / mm(3), percentage of neutrophils > 80%. RESULTS Of 1519 patients, 894 (58.9%) had normal exams and BM was diagnosed in 95 (6.2%). Etiologic agents were: Hib (44.2%), meningococcus (13.7%), Gram-negative bacilli (11.6%), Mycobacterium tuberculosis (6.3%), pneumococcus (4.2%), other agents (4.2%); BMUE was diagnosed in 15.8% of cases with BM. By analysing the frequency of BMUE and Hib among all exams performed yearly, the peaks were recorded in 1989 (5.3%) and 1990 (16.9%), respectively, decreasing to 0.7% and 0% in 2001. CONCLUSION It is possible that the implementation of the conjugate Hib vaccine during the 1990s has been decreasing not only the occurrence of Hib meningitis but also of BMUE.