Robério Dias Leite

Persistent diarrhea in Northeast Brazil: etiologies and interactions with malnutrition

With the improved control of acute diarrheal illness mortality with oral rehydration therapy, persistent diarrhea is now emerging as a major cause of childhood mortality in tropical developing areas like the impoverished populations in Brazils Northeast. “Graveyard surveillance” in the rural community of Guaiuba in northeastern Brazil revealed fully half of the 70% diarrhea mortality was due to persistent diarrheal illnesses. Furthermore, 11% of 14 or more diarrheal illnesses per child per year in an urban slum in Fortaleza persisted beyond 14 days, a definition that clearly identified the high risk children for heavy diarrhea burdens. Not only did heavy diarrhea burdens ablate the key “catch‐up” growth seen in severely malnourished children and in children following previous diarrheal illnesses, but malnutrition significantly predisposed children to a greater incidence and duration of diarrhea as well as a greater incidence of persistent diarrhea. Etiologic studies of 37 children presenting with persistent diarrhea to Hospital das Clinicas in Fortaleza revealed that Cryptosporidium (in 13%) and enteroadherent E. coli (36% with aggregative, 29% with diffuse and 13% with localized adherence to HEp‐2 cells) were the predominant potential pathogens found in the stool or upper small bowel. These findings suggest that persistent diarrhea is emerging as an important health problem in Brazils Northeast, that it identifies a high risk child for heavy diarrhea burdens, that important interactions occur with malnutrition and that Cryptosporidium and enteroadherent E. coli warrant further study as potential etiologies of this major cause of morbidity and mortality.

Diarrhea and Reduced Levels of Antiretroviral Drugs: Improvement with Glutamine or Alanyl-Glutamine in a Randomized Controlled Trial in Northeast Brazil

The effects of therapy with glutamine and alanyl-glutamine on diarrhea and antiretroviral drug levels in patients with acquired immune deficiency syndrome (AIDS) were examined in a randomized, double-blinded, placebo-controlled study in northeast Brazil. Patients with AIDS and with diarrhea and/or wasting were randomized into 4 groups to determine the efficacy of glutamine or high- or low-dose alanyl-glutamine given for 7 days, compared with isonitrogenous glycine given to control subjects. All patients in whom baseline antiretroviral drug levels were determined had low levels 2 h after dosing. Gastrointestinal symptom scores improved with receipt of high-dose alanyl-glutamine (P<.05) or glutamine (P<.01). Antiretroviral drug levels increased in patients given alanyl-glutamine (P=.02) or glutamine (P=.03) by 113% (P=.02) and 14% (P=.01), respectively. Antiretroviral drug resistance mutations were common in all groups. The dose-related efficacy of alanyl-glutamine and glutamine in treating diarrhea and in increasing antiretroviral drug levels shows that these supplements may help to improve therapy for patients with AIDS who have diarrhea and/or wasting in developing, tropical areas.

Condições sociodemográficas de crianças de zero a dois anos filhas de mães com HIV/Aids, Fortaleza, CE, Brasil

OBJECTIVES: to ascertain the socio-demographic conditions of children aged between 0 and 2 years born to mothers testing positive for HIV / AIDS in the city of Fortaleza, in the Northeastern Brazilian State of Ceara. METHODS: a cross-sectional study was conducted involving the application of a semi-structured questionnaire to women caring for children (63 mothers and 5 grandmothers) at a State hospital outpatient clinic, between December 2005 and April 2006. RESULTS: the mean age of the mothers was 26 years. Approximately 16% were illiterate; 57.3% were married and 5.9% widows. More than two thirds (79.4%) of the women taking part in the study first became aware of their HIV status during their last delivery. 51.5% reported not having received any kind of social assistance from the government. The mean age of children was 15.6 months and 13% had not been tested for HIV. Most women came from rural communities (60.3%), and had a mean household income of R

Measles Reemergence in Ceará, Northeast Brazil, 15 Years after Elimination

446.32. 57.9% of the children lived in a household of five individuals or more and 31% reported having four or more children living in the same residence. CONCLUSIONS: there is a need for health promotion and disease prevention strategies to be implemented that take into account the social context of families living with HIV/AIDS.

IMPROVEMENT OF INTESTINAL PERMEABILITY WITH ALANYL-GLUTAMINE IN HIV PATIENTS: a randomized, double blinded, placebo-controlled clinical trial

To the Editor: Measles was endemic in Brazil before 2000 and caused large outbreaks every 2 or 3 years (1). Although measles was eliminated in Brazil in 2000, cases have continued to be imported (2,3). During 2001–2014, the median annual number of measles cases reported in Brazil was 50 (range 2–712). The median annual number of Brazilian states with reported cases was 2.5 (range 1–7). Since elimination, the highest numbers of cases reported in Brazil occurred in 2013 (220) and in 2014 (712) (3–5). According to the Pan American Health Organization, endemic transmission is reestablished when epidemiologic and laboratory evidence indicate that a chain of transmission of a virus strain has continued uninterrupted for >12 months in a defined geographic area (6). From December 2, 2013, through December 31, 2014, in the state of Ceara, Brazil, 681 measles cases were reported. A measles case was considered confirmed when a patient exhibited fever, rash, and >1 of 3 symptoms and signs (i.e., cough, runny nose, conjunctivitis); was positive for IgM and negative for IgG against measles virus; and had not been vaccinated in the previous 21 days. D8 genotype, the same virus genotype that was circulating in Europe, was the only genotype identified, and how the virus was introduced into the region was not clear (4,5). From 2000 to 2013, vaccine coverage among children 12 months of age remained >95% in Ceara, although that coverage was not homogeneous for the whole state. In 14.7% (27/184) of municipalities, the vaccination coverage was much lower (4). Pernambuco, the state that borders southern Ceara, reported a measles outbreak with 222 confirmed cases from March 2013 through March 2014 (4,5,7). Thus, the timing of the 2 outbreaks overlapped. During December 2013–December 2014, Ceara’s outbreak seemed to evolve in 2 waves: the first from epidemiologic weeks 3 through 6 (mainly in Fortaleza, the capital of Ceara) and the second from epidemiologic weeks 27 through 53 (mainly on the northwest side of Ceara, an economically disadvantaged region, which also included the capital). Cases were confirmed in 15.8% (29/184) of all municipalities. Most patients (47.3%; 322) were from Fortaleza, followed by Massape (18.6%; 127) and Sobral (12.2%; 83) (Figure). Figure Measles cases reported in Brazil after elimination, 2001–2014. A) Cases and genotypes identified, by year. B) Spatial distribution of measles outbreaks in the states of Pernambuco and Ceara during 2013–2014, in which only genotype ... Children 1 year of age; unknown vaccination status, 27.4% (69/252); and received only 1 dose of vaccine, 18.7% (47/252) (8). No deaths were reported (4). The main reported symptoms were rash (100%), fever (100%), cough (84.5%), runny nose (68.2%), and conjunctivitis (60.3%) (8). Response vaccination activities have taken 10–20 weeks to be initiated in some municipalities after the first cases were recognized. Vaccination campaigns involving children 6–60 months of age are being intensified and surveillance for suspected cases has increased, but as of January 1, 2015, the chain of transmission appeared ongoing (4,5). In addition, one cannot underestimate the fact that health professionals in Ceara had not seen cases of measles for 15 years. Younger health professionals had never seen even 1 case, and this lack of familiarity may have had some effect on surveillance, rapid recognition of new cases, and adoption of control measures. This difficulty of recognition should be taken into account in regions that have been free of endemic measles transmission for many years. In conclusion, the measles outbreak in Ceara was probably imported directly from Europe or from there through the bordering state of Pernambuco (4,5,9). Cases were concentrated in Fortaleza and the northwest region of the state. Patient age distribution was significantly different between the capital, where the infection most affected children 95%. In addition, vaccination campaigns directed at children 12 months, Ceara’s current outbreak may represent the reestablishment of endemic transmission of measles in the Americas.

Refractory Congenital Chylous Ascites

CONTEXT Glutamine is the main source of energy of the enterocyte and diarrhea and weight loss are frequent in HIV infected patients. OBJECTIVE To determine the effect of alanyl-glutamine supplementation on intestinal permeability and absorption in these patients. METHODS Randomized double-blinded, placebo-controlled study using isonitrogenous doses of alanyl-glutamine (24 g/day) and placebo (glycine, 25 g/day) during 10 days. Before and after this nutritional supplementation lactulose and mannitol urinary excretion were determined by high performance liquid chromatography. RESULTS Forty six patients with HIV/AIDS, 36 of whom were male, with 37.28 ± 3 (mean ± standard error) years were enrolled. Twenty two and 24 subjects were treated with alanyl-glutamine and with glycine respectively. In nine patients among all in the study protocol that reported diarrhea in the 14 days preceding the beginning of the study, mannitol urinary excretion was significantly lower than patients who did not report this symptom [median (range): 10.51 (3.01-19.75) vs. 15.37 (3.93-46.73); P = 0.0281] and lactulose/mannitol ratio was significantly higher [median (range): 0.04 (0.00-2.89) vs. 0.02 (0.00-0.19); P = 0.0317]. There was also a significant increase in mannitol urinary excretion in the group treated with alanyl-glutamine [median (range): 14.38 (8.25-23.98) before vs 21.24 (6.27-32.99) after treatment; n = 14, P = 0.0382]. CONCLUSION Our results suggest that the integrity and intestinal absorption are more intensely affected in patients with HIV/AIDS who recently have had diarrhea. Additionally, nutritional supplementation with alanyl-glutamine was associated with an improvement in intestinal absorption.

Efficacy and safety of available treatments for visceral leishmaniasis in Brazil: A multicenter, randomized, open label trial.

Refractory congenital chylous ascites (CCA) is an uncommon clinical condition. Few cases have been described and no gold standard treatment has been defined so far. This report describes a case of refractory CCA in a newborn child which was treated by surgery. Preoperative lower-limb lymphoscintigraphy associated with intraoperative patent blue testing and fibrin glue application were useful in order to provide a successful outcome.

Acesso e utilização de fórmula infantil e alimentos entre crianças nascidas de mulheres com HIV/AIDS

Background There is insufficient evidence to support visceral leishmaniasis (VL) treatment recommendations in Brazil and an urgent need to improve current treatments. Drug combinations may be an option. Methods A multicenter, randomized, open label, controlled trial was conducted in five sites in Brazil to evaluate efficacy and safety of (i) amphotericin B deoxycholate (AmphoB) (1 mg/kg/day for 14 days), (ii) liposomal amphotericin B (LAMB) (3 mg/kg/day for 7 days) and (iii) a combination of LAMB (10 mg/kg single dose) plus meglumine antimoniate (MA) (20 mg Sb+5/kg/day for 10 days), compared to (iv) standard treatment with MA (20 mg Sb+5/kg/day for 20 days). Patients, aged 6 months to 50 years, with confirmed VL and without HIV infection were enrolled in the study. Primary efficacy endpoint was clinical cure at 6 months. A planned efficacy and safety interim analysis led to trial interruption. Results 378 patients were randomized to the four treatment arms: MA (n = 112), AmphoB (n = 45), LAMB (n = 109), or LAMB plus MA (n = 112). A high toxicity of AmphoB prompted an unplanned interim safety analysis and this treatment arm was dropped. Per intention-to-treat protocol final analyses of the remaining 332 patients show cure rates at 6 months of 77.5% for MA, 87.2% for LAMB, and 83.9% for LAMB plus MA, without statistically significant differences between the experimental arms and comparator (LAMB: 9.7%; CI95% -0.28 to 19.68, p = 0.06; LAMB plus MA: 6.4%; CI95% -3.93 to 16.73; p = 0.222). LAMB monotherapy was safer than MA regarding frequency of treatment-related adverse events (AE) (p = 0.045), proportion of patients presenting at least one severe AE (p = 0.029), and the proportion of AEs resulting in definitive treatment discontinuation (p = 0.003). Conclusions Due to lower toxicity and acceptable efficacy, LAMB would be a more suitable first line treatment for VL than standard treatment. ClinicalTrials.gov identification number: NCT01310738. Trial registration ClinicalTrials.gov NCT01310738