Intestinal spirochetosis: first cases reported in Brazil and the use of immunohistochemistry as an aid in histopathological diagnosis

Colonization of the colon and rectum by intestinal spirochetes is detected for the first time in Brazil in 4 of 282 (1.41%) patients who had undergone sigmoidoscopy and/or colonoscopy with a histopathological diagnosis of chronic non specific-colitis. This frequency is probably understimated, since surgically obtained specimens were not considered in the present study. Histopathological diagnosis was performed using routine stains like hematoxylin-eosin which showed the typical, of 3-µm thick hematoxyphilic fringe on the brush border of the surface epithelium, and by silver stains like the Warthin-Starry stain. Immunohistochemical procedures using two, polyclonal, primary antibodies, one against Treponema pallidum and the other against Leptospira interrogans serovar copenhageni serogroup Icterohaemorrhagiae cross-reacted with spirochetal antigen/s producing a marked contrast of the fringe over the colonic epithelium, preserving the spiral-shaped morphology of the parasite. In one case with marked diarrhea, immunohistochemistry detected spirochetal antigen/s within a cell in an intestinal crypt, thus demonstrating that the infection can be more widely disseminated than suspected using routine stains. Immunohistochemical procedures, thus, greatly facilitate the histological diagnosis of intestinal spirochetosis and may contribute to a better understanding of the pathogenesis of the disease. Transmission and scanning electron microscopy performed in one case showed that the spirochete closely resembled the species designated as Brachyspira aalborgi.

Epidemiology of neurocysticercosis in Brazil

A revision of literature was done with the objective of tracing an epidemiologic profile of neurocysticercosis (NCC) in Brazil. The prevalence was 0.12-9% in autopsies. The frequency was 0.03-7.5% in clinical series and 0.68-5.2% in seroepidemiological studies. The disease corresponds to 0.08-2.5% of admissions to general hospitals. Patient origin was rural in 30-63% of cases. The most involved age range (64-100%) was 11 to 60 years, with a predominance (22-67%) between 21 and 40 years. The male sex was the most affected (51-80%). In the severe forms there was a predominance of urban origin (53-62%) and of the female sex (53-75%). The period of hospitalization ranges from 1 to 254 days and 33 to 50% of patients suffer 1.7 ± 1.4 admissions. The clinical picture was variable, with a predominance of epileptic syndrome (22-92%) and intracranial hypertension (19-89%). Psychiatric manifestations were associated in 9-23% of patients. Lethality was 0.29% in terms of all diseases in general and 4.8-25.9% in terms of neurologic diseases. The asymptomatic form was detected in 6% of patients in clinical serie and in 48.5% of case from autopsies. The racemose form and ventricular localization also was observed as asymptomatic form. Among the patients with cutaneous cysticercosis 65% of them showed neurologic manifestations.

Hepatitis G virus / GB virus C in Brazil. Preliminary report

Hepatitis G virus/ GB virus C is a novel flavivirus recently detected in hepatitis non A-E cases. In this study, the presence of this virus in chronic non-B, non-C hepatitis patients was evaluated using GBV-C specific PCR and this virus was detected in one out of thirteen patients. This patient has presented a severe liver failure, has lived for a long time in the Western Amazon basin and no other cause for this clinical picture was reported. The impact of the discovery of this new agent is still under evaluation throughout the world. The study of the prevalence of this virus among chronic hepatitis patients and healthy individuals (as blood donors) will furnish subside to evaluate its real pathogenicity.

Isoenzyme profile as parameter to differentiate pathogenic strains of Entamoeba histolytica in Brazil

The isoenzyme profiles (IP) of 33 strains of Entamoeba histolytica isolated from patients and carriers of two regions in Brazil (Amazonia and Southeast) were determined. The enzymes phosphoglucomutase, glucose-phosphate isomerase, hexokinase and malic enzyme were considered. IP of the strains was correlated with culture conditions, time of maintenance in laboratory and clinical history of patients. The strains were maintained under polyxenic, monoxenic and axenic culture conditions: 27 polyxenic, 1 polyxenic and monoxenic, 1 polyxenic, monoxenic and axenic and 4 axenic only. The patients were symptomatic and asymptomatic. The symptomatic patients presented either non dysenteric (NDC) or dysenteric colitis (DC), associated or not with hepatic abscess (HA). One patient presented anal amoeboma (AM). The analysis of IP for isolates maintained in polyxenic culture showed non pathogenic IP (I) for strains from carriers and patients with NDC, while the strains isolated from patients presenting DC, HA and AM resulted in isolates II or XIX pathogenic IP. This parameter was not able to differentiate strains from carriers from symptomatic patients when these strains were found in axenic or monoxenic culture. All these strains displayed pathogenic IP (II), demonstrating the inability of this parameter to classifying for virulence since it showed identical IP for strains isolated from carriers or symptomatic patients.

Hepatocellular carcinoma in Brazil: report of a national survey (Florianópolis, SC, 1995)

In order to investigate epidemiological aspects of hepatocellular carcinoma (HCC) in Brazil, basic informations about cases diagnosed from January 1992 to December 1994 were requested to several medical centers of different Brazilian States. A simple questionnaire included age, sex, alcohol abuse (over 80g/day), associated liver cirrhosis, persistent HBV infection (HBsAg), HCV infection (anti-HCV) and serum levels of alpha fetoprotein. 287 cases, over 16 years old, from 19 medical centers of 8 States (Pará, Bahia, Minas Gerais, Espirito Santo, Rio de Janeiro, São Paulo, Paraná and Rio Grande do Sul) were analysed. The results showed: (a) Mean age was 56.3 ± 14.4 for men and 54.7 ± 16.8 yr for women and the male/female ratio was 3.4:1. (b) 69.6% were caucasians, 21.8% mullatoes, 4.8% orientals and 3.7% blacks. (c) HBsAg (+) in 77/236 cases (41.6%) without differences between males and females. (d) Anti-HCV (+) in 52/193 cases (26.9%). (e) 7/180 cases were positive both for HBsAg and anti-HCV (3.8%). (f) There was chronic alcoholism in 88/235 cases (37%). (g) HCC was found in cirrhotic livers in 71.2% of 202 cases in which the presence or absence of cirrhosis was reported. (h) Alpha-fetoprotein above 20 ng/ml was found in 124/172 cases (72%) and above 500 ng/ml only in 40 cases (23.2%). These results showed that the HCC in Brazil has an intermediate epidemiological pattern as compared to those from areas of low and high incidence of the tumor. In spite of the high frequency of the association of HCC with the HBV and/or HCV infections, 42% of 180 cases were negative both for HBsAg and anti-HCV, indicating the possible role of other etiological factors. The comparison of data from different States showed some regional differences: higher frequency of associated HBsAg in Pará, Bahia, Minas Gerais and Espírito Santo, higher frequency of associated HCV infection in Rio de Janeiro, São Paulo and States of the Southern region and low frequency of associated liver cirrhosis in Salvador and Rio de Janeiro (55.5 and 50% respectively). Further investigation will be necessary to study the presence of other possible etiological factors as aflatoxins, suggested by the favourable climatic conditions for food contamination by fungi in the majority Brazilian regions

Genomic characterization of adenovirus serotype 7 isolated in Brazil from acute respiratory disease patients during the period from 1980 to 1991

Forty isolates of adenovirus type 7 were analized by restriction enzyme digestion with BamHI, SmaI, EcoRI and HindIII. These isolates were obtained from acute respiratory disease patients during the years 1980 to 1991. Only two genomic types were found: Ad7b and Ad7e, with Ad7b (87.5%) being more frequent than Ad7e (12.5%). The genomic type Ad7e appeared in the years 1980, 1981 and 1983. Ad7b appeared in 1982 and it was the only genomic type found from 1984 to 1991. Both genomic types were responsible for lower (LRTI) and upper (URTI) respiratory tract infection, but the proportion LRTI/URTI is higher for Ad7b (25/6) than for Ad7e (1/4).

Chronic pulmonary histoplasmosis in Brazil: report of two cases with cavitation diagnosed by transthoracic needle biopsy

Two cases of Chronic Pulmonary Histoplasmosis are reported and other eleven cases, collected from Brazilian literature, are commented. After being clinically cured, one of our patients presented an Aspergillus fungus ball inside a cavitation in the wall of which H. capsulatum was disclosed. Comments are also done on the diagnosis of the mycosis

Coccidioidomycosis in Brazil. A case report

Coccidioidomycosis is an endemic infection with a relatively limited geographic distribution: Mexico, Guatemala, Honduras, Colombia, Venezuela, Bolivia, Paraguai, Argentina and the southwest of the United States. In these countries, the endemic area is restricted to the semiarid desert like regions which are similar to the northeast of Brazil. Case report: The patient is a 32 year-old male, born in the state of Bahia (Northeast of Brazil) and has been living in São Paulo (Southeast) for 6 years. He was admitted at Hospital das Clínicas, at the Department of Pneumology in October 1996, with a 6 month history of progressive and productive cough, fever, malaise, chills, loss of weight, weakness and arthralgia in the small joints. Chest x-rays and computerized tomography disclosed an interstitial reticulonodular infiltrate with a cavity in the right upper lobe. The standard potassium hydroxide preparation of sputum and broncoalveolar lavage demonstrated the characteristic thickened wall spherules in various stages of development. Sabouraud dextrose agar, at 25° C and 30° C showed growth of white and cottony aerial micelium. The microscopic morphology disclosed branched hyphae characterized by thick walled, barrel shaped arthroconidia alternated with empty cells. The sorological studies with positive double immunodiffusion test, and also positive complement fixation test in 1/128 dilution confirmed the diagnosis. The patient has been treated with ketoconazole and presents a favorable clinical and radiological evolution

QUESTIONNAIRES IN THE SCREENING FOR Schistosoma mansoni INFECTION: A STUDY OF SOCIO DEMOGRAPHIC AND WATER CONTACT VARIABLES IN FOUR COMMUNITIES IN BRAZIL

The use of questionnaires has been recommended for identifying, at a lower cost, individuals at risk for schistosomiasis. In this study, validity of information obtained by questionnaire in the screening for Schistosoma mansoni infection was assessed in four communities in the State of Minas Gerais, Brazil. Explanatory variables were water contact activities, sociodemographic characteristics and previous treatment for schistosomiasis. From 677, 1474, 766 and 3290 individuals eligible for stool examination in the communities, 89 to 97% participated in the study. The estimated probability of individuals to be infected, if they have all characteristics identified as independently associated with S.mansoni infection, varied from 15% in Canabrava, to 42% in Belo Horizonte, 48% in Comercinho and 80% in São José do Acácio. Our results do not support the hypothesis that a same questionnaire on risk factors could be used in screening for S.mansoni infection in different communities.

EPIDEMIOLOGIC SURVEYS OF HISTOPLASMIN AND PARACOCCIDIOIDIN SENSITIVITY IN BRAZIL

We report here the results obtained in epidemiologic surveys of histoplasmosis and paracoccidioidomycosis carried out in Brazil using the histoplasmin and paracoccidioidin delayed hypersensitivity skin tests. Most of these data have not been previously published in scientific journals and are now reported here in two tables respectively concerning histoplasmosis (88 surveys) and paracoccidioidomycosis (58 surveys). The guidelines to be followed in surveys of this nature are also commented upon.

TRANFUSION-TRANSMITED VIRUS (TTV) IN BRAZIL. PRELIMINARY REPORT

TTV is a recently discovered DNA virus, isolated from a patient with post-transfusion hepatitis of unknown etiology by Japanese researchers. In the present study, we evaluated the presence of TTV among chronic liver diseases patients in São Paulo and Pará states, representing two geographically distinct Brazilian regions. TTV DNA was found in 21/105 (20%) and 9/20 (45%) cases from São Paulo and Pará States, respectively. DNA sequence data confirmed the presence of TTV genotypes 1a and 2a, as well as other genotypes not yet described. In conclusion, TTV is present in chronic liver diseases cases from Southeast and North Brazil. However, further studies involving healthy populations are necessary before establishing any causal relationship among TTV and human hepatitis.

FEVER OF UNDETERMINED ORIGIN IN PATIENTS WITH THE ACQUIRED IMMUNODEFICIENCY SYNDROME IN BRAZIL: REPORT ON 55 CASES

The medical records of patients with AIDS admitted to a general hospital in Brazil from 1989 to 1997 were reviewed retrospectively with the aim at defining the frequency and etiology of fever of undetermined origin (FUO) in HIV-infected patients of a tropical country and to evaluate the usefulness of the main diagnostic procedures. 188 (58.4%) out of 322 patients reported fever at admission to hospital and 55 (17.1%) had FUO. Those with FUO had a mean CD4+ cell count of 98/ml. A cause of fever was identified for 45 patients (81.8%). Tuberculosis (32.7%), Pneumocystis carinii pneumonia (10.9%), and Mycobacterium avium complex (9.1%) were the most frequent diagnoses. Other infectious diseases are also of note, such as cryptococcal meningitis (5.5%), sinusitis (3.6%), Salmonella-S. mansoni association (3.6%), disseminated histoplasmosis (3.6%), neurosyphilis (1.8%), and isosporiasis (1.8%). Four patients had non-Hodgkin's lymphoma (7.3%). We conclude that an initial aggressive diagnostic approach should be always considered because biopsies (lymph node, liver and bone marrow) produced the highest yield in the diagnosis of FUO and the majority of the diagnosed diseases are treatable. The association of diseases is common and have contributed to delay the final diagnosis of FUO in most cases. In our study area the routine request of hemocultures for Salmonella infection and the investigation of cryptococcal antigen in the serum should be considered.

Hantavirus pulmonary syndrome in Brazil: clinical aspects of three new cases

Hantavirus pulmonary syndrome (HPS) has been recognized recently in Brazil, where 28 cases have been reported as of September 1999. We report here the clinical and laboratory findings of three cases whose diagnoses were confirmed serologically. All the patients were adults who presented a febrile illness with respiratory symptoms that progressed to respiratory failure that required artificial ventilation in two of them. Laboratory findings were most of the time consistent with those reported in the United States in patients infected with the Sin Nombre virus, and included elevated hematocrit and thrombocytopenia; presence of atypical lymphocytes was observed in one patient. The chest radiological findings observed in all the patients were bilateral, diffuse, reticulonodular infiltrates. Two patients died. Histopathological examination of the lungs of these patients revealed interstitial and alveolar edema, alveolar hemorrhage, and mild interstitial pneumonia characterized by infiltrate of immunoblasts and mononuclear cells. In the epidemiologic investigation of one of the cases, serologic (ELISA) tests were positive in 3 (25%) out of 12 individuals who shared the same environmental exposure. HPS should be included in the differential diagnosis of interstitial pneumonia progressing to acute respiratory failure.

Chromobacterium violaceum infection in Brazil. A case report

We report the second case of infection with Chromobacterium violaceum that occurred in Brazil. A farm worker living in the State of São Paulo presented fever and severe abdominal pain for four days. At hospitalization the patient was in a toxemic state and had a distended and painful abdomen. Chest X-ray and abdominal ultrasound revealed bilateral pneumonia and hypoechoic areas in the liver. The patient developed failure of multiple organs and died a few hours later. Blood culture led to isolation of C. violaceum resistant to ampicillin and cephalosporins and sensitive to chloramphenicol, tetracyclin, aminoglicosydes, and ciprofloxacin. Autopsy revealed pulmonary microabscesses and multiple abscesses in the liver. The major features of this case are generally observed in infections by C. violaceum: rapid clinical course, multiple visceral abscesses, and high mortality. Because of the antimicrobial resistance profile of this Gram-negative bacillus, for appropriate empirical antibiotic therapy it is important to consider chromobacteriosis in the differential diagnosis of severe community infections in Brazil.

Congenital cytomegalovirus infection in a neonatal intensive care unit in Brazil evaluated by PCR and association with perinatal aspects

Cytomegalovirus (CMV) infection is the most common congenital infection, affecting 0.4% to 2.3% newborns. Most of them are asymptomatic at birth, but later 10% develop handicaps, mainly neurological disturbances. Our aim was to determine the prevalence of CMV shed in urine of newborns from a neonatal intensive care unit using the polymerase chain reaction (PCR) and correlate positive cases to some perinatal aspects. Urine samples obtained at first week of life were processed according to a PCR protocol. Perinatal data were collected retrospectively from medical records. Twenty of the 292 cases (6.8%) were CMV-DNA positive. There was no statistical difference between newborns with and without CMV congenital infection concerning birth weight (p=0.11), gestational age (p=0.11), Apgar scores in the first and fifth minutes of life (p=0.99 and 0.16), mother's age (p=0.67) and gestational history. Moreover, CMV congenital infection was neither related to gender (p=0.55) nor to low weight (<2,500g) at birth (p=0.13). This high prevalence of CMV congenital infection (6.8%) could be due to the high sensitivity of PCR technique, the low socioeconomic level of studied population or the severe clinical status of these newborns.