Seroepidemiological and clinical study of Chagas' disease in Nicaragua

With the aim of determining the prevalence, immunological profile, and knowing the electrocardiographic alterations, a clinical and Seroepidemiological study of Chagas' disease was performed in three rural settlements located at the North, East and West of Nicaragua. Anti T. cruzi antibodies were searched by indirect immunofluorescence (IFI) and hemagglutination (IHA) in a total of 803 subjects. Seropositives and the same number of seronegatives, matched by age and sex, were included in a case-control design for the electrocardiographic assessment. Antibody prevalence was 13.1, 4.3 and 3.2% in the respective settlements. In the first two the immunological profile corresponds to that of an endemic zone of long standing, were transmission has decreased, and in the third the pattern is of a zone under control. Electrocardiographic changes compatible with Chagas' disease were found in seropositive individuals, but difference with control group was not statistically significant. It is concluded that the disease is endemic in the three settlements and the clinical aspect requires further evaluation, including additional cardiologic techniques.

MICROCIRCULATION AND CHAGAS' DISEASE: HYPOTHESIS AND RECENT RESULTS

This review focuses on studies that support the microvascular hypothesis, as well as on immunological and neurogenic mechanisms, and the role of the parasite itself, to explain further the pathology and clinical course of myocardial involvement in chagasic cardiomyopathy. The salient features of coronary microcirculation and Chagas' disease are discussed.

Group B streptococcal neonatal infections in Rio Grande do Sul, Brazil

Group B Streptococcus is the most common pathogen found in neonatal sepsis in North America. OBJECTIVES: We describe 15 cases of neonatal infections by Group B Streptococcus (Streptococcus agalactiae) at a Neonatal Intensive Care Unit of a public and teaching hospital. METHODS: We conducted a study at Hospital de Clínicas de Porto Alegre, from January 1st, 1996 to June 30, 1999. Diagnosis of neonatal infection was established according to the findings of Group B Streptococcus in blood culture associated with alterations resembling sepsis on the basis of clinical picture and laboratory findings. RESULTS: Fifteen cases of neonatal infections by Group B Streptococcus were detected. Eleven cases consisted of early-onset sepsis, 2 cases of occult bacteremia and 2 cases of late-onset sepsis. Eight cases had septic shock (53%), 8 cases had pneumonia (53%), and 4 cases had meningitis (27%). Fourteen cases were diagnosed from a positive blood culture, and 1 case from evidence of these bacteria in pulmonary anatomopathological examination. Thirteen cases (87%) were diagnosed before 72 hours of life. We had 3 deaths (20%), and 3 cases of meningitis developing neurological deficits. CONCLUSIONS: Streptococcus Group B is one of the most important pathogens in the etiology of early-onset neonatal sepsis at our hospital, with high mortality and morbidity. However, we do not know the incidence of GBS neonatal infections at other hospitals. More data are needed to establish a basis for trials of different strategies to reduce these infections.

Fatal disseminated paracoccidioidomycosis in a two-year-old child

A two year-old female child was admitted at the Pediatric Intensive Care Unit in a septic shock associated with a lymphoproliferative syndrome, with history of fever, adynamia and weight loss during the last two months. On admission, the main clinical and laboratory manifestations were: pallor, jaundice, disseminated enlarged lymph nodes, hepatosplenomegaly, crusted warts on face, anemia, eosinophilia, thrombocytopenia, increased direct and indirect bilirubin, alkaline phosphatase, and gammaglutamyl transpeptidase. A parenteral administration of fluids, dobutamine and mechanical ventilation was started, without improvement of the clinical conditions. A direct examination of exsudate collected from cervical lymph node revealed numerous oval-to-around cells with multiple budding, like a "pilot wheel" cell, suggesting Paracoccidioides brasiliensis. Even though treatment with intravenous sulfamethoxazole-trimethoprine was soon started, the child died 36 hours after hospital admission. Disseminated paracoccidioidomycosis was confirmed in the autopsy. This is the youngest case of paracoccidioidomycosis in children reported in the literature.

Mutilations Due to Medical Disorders in Children

Soft-tissue and bone necrosis, although rare in childhood, occasionally occur in the course of infectious diseases, either viral or bacterial, and seem to be the result of hypoperfusion on a background of disseminated intravascular coagulation. Treatment consists in correction of septic shock and control of necrosis. Necrosis, once started, shows extraordinarily rapid evolution, leading to soft-tissue and bone destruction and resulting in anatomic, functional, psychological, and social handicaps. Ten mutilated children were treated from January 1986 to January 1999 in Hospital de Dona Estefaˆ nia, Lisbon, Portugal. One was recovering from hemolytic-uremic syndrome with a severe combined immunodeficiency, another malnourished, anemic child had malaria, and three had chicken pox (in one case complicated by meningococcal septicemia). There were three cases of meningococcal and two of pyocyanic septicemia (one in a burned child and one in a patient with infectious mononucleosis). The lower limbs (knee,leg, foot) were involved in five cases, the face (ear, nose, lip) in four, the perineum in three, the pelvis (inguinal region, iliac crest) in two, the axilla in one, and the upper limb (radius, hand) in two. Primary prevention is based on early recognition of risk factors and timely correction. Secondary prevention consists of immediate etiologic and thrombolytic treatment to restrict the area of necrosis. Tertiary prevention relies on adequate rehabilitation with physiotherapy and secondary operations to obtain the best possible functional and esthetic result.

Correlação da Variação dos Níveis de NT-ProBNP com a Modificação da Capacidade Funcional em Doentes com Insuficiência Cardíaca Crónica

OBJECTIVE: We set out to evaluate whether changes in N-terminal pro-brain natriuretic peptide (proBNP) can predict changes in functional capacity, as determined by cardiopulmonary exercise testing (CPET), in patients with chronic heart failure (CHF) due to dilated cardiomyopathy (DCM). METHODS: We studied 37 patients with CHF due to DCM, 81% non-ischemic, 28 male, who performed symptom-limited treadmill CPET, with the modified Bruce protocol, in two consecutive evaluations, with determination of proBNP after 10 minutes rest prior to CPET. The time between evaluations was 9.6+/-5.5 months, and age at first evaluation was 41.1+/-13.9 years (21 to 67). RESULTS IN THE FIRST AND SECOND EVALUATIONS RESPECTIVELY WERE: NYHA functional class >II 51% and 16% (p<0.001), sinus rhythm 89% and 86.5% (NS), left ventricular ejection fraction 24.9+/-8.9% and 26.6+/-8.6% (NS), creatinine 1.03+/-0.25 and 1.09+/-0.42 mg/dl (NS), taking ACE inhibitors or ARBs 94.5% and 100% (NS), beta-blockers 73% and 97.3% (p<0.001), and spironolactone 89% and 89% (NS). We analyzed the absolute and percentage variation (AV and PV) in peak oxygen uptake (pVO2--ml/kg/min) and proBNP (pg/ml) between the two evaluations. RESULTS: (1) pVO2 AV: -17.4 to 15.2 (1.9+/-5.7); pVO2 PV: -56.1 to 84% (11.0+/-25.2); proBNP AV: -12850 to 5983 (-778.4+/-3332.5); proBNP PV: -99.0 to 379.5% (-8.8+/-86.3); (2) The correlations obtained--r value and p value [r (p)]--are shown in the table below; (3) We considered that a coefficient of variation of pVO2 PV of >10% represented a significant change in functional capacity. On ROC curve analysis, a proBNP PV value of 28% showed 80% sensitivity and 79% specificity for pVO2 PV of >10% (AUC=0.876, p=0.01, 95% CI 0.75 to 0.99). CONCLUSIONS: In patients with CHF due to DCM, changes in proBNP values correlate with variations in pVO2, as assessed by CPET. However, our results suggest that only a proBNP PV of >28% predicts a significant change in functional capacity.

Candidemia in Acute Leukemia Patients

Fungal infections are an important cause of morbidity and mortality in patients with acute leukemia (AL). Candidemia, once rare, is now a common nosocomial infection because of the intensity of chemotherapy, prolonged neutropenia, administration of broad-spectrum antibiotics and use of central venous catheters (CVC). We retrospectively identified patients treated for AL from 6/86 to 6/95 who also had candidemia. We describe 28 patients (incidence 6.3%) with a median age of 39 years, 24 of whom were on remission induction and 4 on postremission chemotherapy. All patients had CVC and empiric antimicrobial therapy, 4 had been given prophylactic antifungal drugs, and 2 had parenteral nutrition. Neutropenia was profound (median leukocyte nadir 200/microliters, median duration 19 days). Candida was isolated in blood cultures 10 days (median) after the start of neutropenia. The clinical presentation included fever (100%), respiratory symptoms (71.4%), skin lesions (39.2%) and septic shock (17.8%). Amphotericin B was given to 17 patients and liposomal amphotericin to 5 patients. Infection resolved in 18 patients (64.2%). 10 of whom were in complete remission. Mortality from candidemia was 17.8% (5/28). In conclusion, fungal infections are responsible for death in a significant number of patients. In our series treatment success was related to its rapid onset and to the recovery of neutropenia.

Utilidade de Ecocardiografia da Sobrecarga Farmacológica com Dobutamina nas Cardiomiopatias Dilatadas não Isquémicas

INTRODUCTION: Low-dose dobutamine stress echocardiography is a common and useful technique to assess myocardial viability in patients with ischemic cardiomyopathy. OBJECTIVE: To evaluate the use of low-dose dobutamine stress echocardiography in determining the functional status of patients with idiopathic dilated cardiomyopathy (IDCM). METHODS: Prospective study of 28 patients with IDCM by transthoracic echocardiography (2D), low-dose dobutamine stress echocardiography, cardiopulmonary exercise testing (CPET) and measurement of pro-BNP. RESULTS: The mean age of the population was 50.3 +/- 11.5 years, 9 female and 19 male. Mean ejection fraction was 32.1 +/- 9.8%. All were in sinus rhythm. The following parameters were analyzed in 2D echocardiography and after dobutamine: dimensions of left atrium (LA) and of left ventricle in diastole and systole, shortening fraction (%), left ventricular end-diastolic (EDV) and end-systolic volumes (ESV), ejection fraction (EF), and mitral inflow (E, A, E/A ratio and deceleration time). In CPET, we considered the following parameters: peak VO2 and % maximal peak VO2 attained. We compared echo results with CPET. There was a correlation between age and peak VO2 (r = -0.38 with p = 0.049). In 2D echo, there was a correlation between baseline EF and LA dimensions and peak VO2 (r = 0.45 / p = 0.004 and r = -0.49 / p = 0.014, respectively). After dobutamine echo, there was a correlation between some echo parameters and peak VO2: EF - r = 0.59 / p = 0.001, LA dimensions - r = 0.56 / p = 0.007, and ESV - r = -0.45 / p = 0.026. Percentage maximal peak VO2 attained correlated with LA dimensions measured in 2D echo and after dobutamine (r = -0.398 / p = 0.036 and r = -0.674 / p = 0.02 respectively) and EF after dobutamine (r = -0.389 / p = 0.04). The value of pro-BNP correlated with LA dimensions and baseline EF (r = 0.44 / p = 0.02 and r = -0.57 / p = 0.002, respectively), and the correlation was maintained after inotropic stimulation with dobutamine (r = 0.57 / p = 0.001 and r = -0.55 / p = 0.0039). CONCLUSION: Low-dose dobutamine stress echocardiography showed stronger correlations with cardiopulmonary exercise testing than the parameters evaluated by conventional echocardiography and could be used to determine the functional status of patients with dilated cardiomyopathy; patients with greater ejection fraction after inotropic stimulation had better cardiopulmonary tests.

Valor Prognóstico da Normalização da Resposta Ventilatória ao Exercício para o Consumo Máximo de Oxigénio na Insuficiência Cardíaca

Cardiopulmonary exercise testing (CPET) is an objective method for assessment of functional capacity and for prognostic stratification of patients with chronic heart failure (CHF). In this study, we analyzed the prognostic value of a recently described CPET-derived parameter, the minute ventilation to carbon dioxide production slope normalized for peak oxygen consumption (VE/VCO2 slope/pVO2). METHODS: We prospectively studied 157 patients with stable CHF and dilated cardiomyopathy who performed maximal CPET using the modified Bruce protocol. The prognostic value of VE/VCO2 slope/pVO2 was determined and compared with traditional CPET parameters. RESULTS: During follow-up 37 patients died and 12 were transplanted. Mean follow-up in surviving patients was 29.7 months (12-36). Cox multivariate analysis revealed that VE/VCO2 slope/pVO2 had the greatest prognostic power of all the parameters studied. A VE/VCO2 slope/pVO2 of > or = 2.2 signaled cases at higher risk. CONCLUSION: Normalization of the ventilatory response to exercise for peak oxygen consumption appears to increase the prognostic value of CPET in patients with CHF.

Volume da Aurícula Esquerda: um "Velho" Cálculo Ecocardiográfico com uma Importância Prognóstica Renovada. Um Estudo em Doentes com Miocardiopatia Dilatada

Recentemente, surgiram alguns trabalhos que ressaltaram a importância do cálculo do volume da aurícula esquerda (VAE) como um marcador de eventos cardíacos adversos. Foi objectivo deste estudo avaliar a importância prognóstica deste parâmetro em doentes (dts) com deficiente função ventricular esquerda e correlacioná-lo com outros parâmetros clássicos de prognóstico – consumo de O2 (VO2 max) e pro-BNP (pBNP). Métodos: Analisou-se o volume da aurícula esquerda (VAE) por método de Simpson, numa população de 35 dts com cardiopatia dilatada (idiopática e isquémica) com fracção de ejecção (FE) 31±9,6% doentes (dts) eram de sexo masculino e a média de idades foi de 50,5±10,5 anos. Toda a população efectuou estudos de ecocardiografia convencional (incluindo avaliação por M-mode, bidimensional e Doppler), prova cardiorespiratória (VO2max) e doseamento de pro-BNP. O tempo médio de seguimento foi de 24 ± 4 meses, tendo-se considerado como eventos cardíacos (EC): internamento por insuficiência cardíaca, transplante e morte. Resultados: Dos parâmetros da ecocardiografia - o diâmetro da AE foi de 46,6±5,7mm, as dimensões do VE em diástole – 73,5±10mm e em sístole -58,9±11mm, a média da fracção de ejecção foi de 31±9,6%, o VAE foi de 78,6±33 ml, os volumes do VE foram de 214±82ml em diástole e de 153±75ml em sístole, 15 dts tinham padrão restritivo de enchimento ventricular (E/A>2), a média da área (Doppler cor) da insuficiência mitral foi de 4±3,3cm2, 14 dts tinham E/E’>15. O VO2 max médio foi de 20±5,8ml/kg/min e o pro-BNP de 3146±4629pg/mL. Para além da correlação de outros parâmetros clássicos ecocardiográficos com o prognóstico (volumes VE, FE e E/E’), o VAE e o volume indexado da AE (VAE/SC) mostraram uma correlação com o prognóstico (EC) com r=0,4 (p=0,02) que não se verificou para o diâmetro da AE (p=ns). Em relação à tolerância ao esforço, houve uma correlação inversa entre o diâmetro, o volume e o volume indexado da AE e o VO2max, com maior significado estatístico para o VAE e VAE/SC com r=-0,48, p=0,008. Quanto ao pro-BNP, quer o diâmetro, quer o VAE (ou volume indexado) tiverem o mesmo nível de significado estatístico (r=0,43; p=0,02). O valor predictivo de eventos (curvas ROC) para o VAE foi de 70ml e de 37ml/m2 para o VAE/m2. Conclusão: O volume da aurícula esquerda/volume indexado é um parâmetro ecocardiográfico com significado prognóstico em dts com deficiente função ventricular esquerda, correlacionando-se com a tolerância ao esforço e pro-BNP.

Importância Prognóstica do Doppler Tecidular nos Doentes com Miocardiopatia Dilatada

Previous studies have shown that a ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/E') of > 15, obtained by tissue Doppler imaging (TDI), correlates with left ventricular filling pressure. OBJECTIVE: The aim of our study was to assess whether E/E' provides prognostic information in patients with dilated cardiomyopathy. METHODS: We studied 33 patients with dilated cardiomyopathy and mean ejection fraction of 31%. All the patients underwent routine two-dimensional and Doppler echocardiographic examination and TDI to determine early peak velocity of the mitral annulus. Pro-B-type natriuretic peptide (pro-BNP) and peak oxygen consumption (VO2max) were also measured. Patients were divided into two groups according to the value of E/E': Group I (n = 15 patients) with E/E' > or = 15 and Group II (n = 18 patients) with E/E' < 15. Patients were followed for 12+/-4 months; new hospital admission due to heart failure, heart transplantation and death were considered as cardiac events. RESULTS: There were significant differences between the two groups in conventional two-dimensional echocardiographic measurements (dimensions and ejection fraction) and Doppler parameters (mitral inflow). With regard to mitral annular velocities obtained by TDI at two different points (septum and lateral wall), the E', A' and S' velocities differed significantly between the two groups, with lower velocities in Group I. Systolic velocity measured in the lateral portion of the mitral annulus showed the most significant difference: Group I - 4.46 cm/sec versus Group II - 7.19 cm/sec, p < 0.00001. Pro-BNP was 5622 pg/ml in Group I, and 1254 pg/ml in Group II, p = 0.004. VO2 max was significantly different between the two groups: Group I - 17.6 ml/kg/min versus Group II - 22.8 ml/kg/min, p = 0.004. During follow-up, events were more common in Group I, with 9 patients (60%) having events, while in Group II, the event rate was 11.1% (2 patients), p = 0.004. CONCLUSION: The ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus is a powerful predictor of clinical outcome. Lower velocities of mitral annulus on TDI are expected in patients with E/E' > or = 15. Systolic velocities of under 5 cm/sec measured in the lateral portion of the mitral annulus appeared to be strongly related to prognosis.

Benefícios da Terapêutica de Ressincronização Cardíaca na «Miocardiopatia Muito Dilatada»

INTRODUCTION: Recent clinical trials have studied parameters that could predict response to cardiac resynchronization therapy (CRT) in patients with advanced heart failure. Left ventricular end-diastolic dimension (LVEDD) is regarded as a possible predictor of response to CRT. OBJECTIVE: To study the response to CRT in patients with very dilated cardiomyopathy, i.e. those at a more advanced stage of the pathology, analyzing both the responder rate and reverse remodeling in two groups of patients classified according to LVEDD. METHODS: We performed a retrospective analysis of 71 patients who underwent CRT (aged 62 +/- 11 years; 65% male; 93% in NYHA functional class > or = III; 31% with ischemic cardiomyopathy; left ventricular ejection fraction [LVEF] 25.6 +/- 6.8%; 32% in atrial fibrillation; QRS 176 +/- 31 ms). Twenty-two (31%) patients with LVEDD > or = 45 mm/m2 (49.2 +/- 3.5 mm/m2) were considered to have very dilated cardiomyopathy (Group A) and 49 patients had LVEDD > 37 mm/m2 and < 45 mm/m2 (39.4 +/- 3.8 mm/m2) (Group B). All patients were assessed by two-dimensional echocardiography at baseline and six months after CRT. The following parameters were analyzed: NYHA functional class, LVEF and LVEDD. Responders were defined clinically (improvement of > or = 1 NYHA class) and by echocardiography, with a minimum 15% increase over baseline LVEF combined with a reduction in LVEDD (reverse remodeling). RESULTS: There were no significant differences in baseline demographic characteristics between the two groups. At six-month followup, we observed an improvement in LVEF (delta 8.5 +/- 11.8%) and a reduction in LVEDD (delta 3.7 +/- 6.8 mm/m2), with fifty-seven (79%) patients being classified as clinical responders. The percentage of patients with reverse remodeling was similar in both groups (64% vs. 73%, p = NS), as were percentages of improved LVEF (delta 6.3 +/- 11% vs. delta 9.6 +/- 12%; p = NS) and decreased LVEDD (delta 3.7 +/- 5.5 mm/m2 vs. delta 3.7 +/- 7.4 mm/m2; p = NS). We found a higher percentage of clinical responders in patients with very dilated cardiomyopathy (96% vs. 72%, p < 0.05). CONCLUSION: In this study, a significant number of responders showed reverse remodeling after CRT. Although a higher percentage of patients with very dilated cardiomyopathy showed improvement in functional class, the extent of reverse remodeling was similar in both groups.

Origem Anómala da Artéria Coronária Esquerda a Partir da Artéria Pulmonar

OBJECTIVE: To assess the frequency and severity of the anomalous origin of the left coronary artery (ALCA) from the pulmonary artery (PA). DESIGN OF THE STUDY: Prospective study of case series between March 1991 and December 1994. SETTING: Referral-based Paediatric Cardiology Department of a Tertiary Care Center. PATIENTS AND METHODS: Five consecutive patients (pts) with anomalous origin of the LCA from the PA; there were three infants aged 4 months and two children one 8 year and one 9 year old. There were three girls and two boys. All pts had clinical and 2D-echo and Doppler investigation prior to cardiac catheterization (CC). Indication for CC was based in the association of symptoms and signs of myocarditis or dilated cardiomyopathy of acute or subacute onset and electrocardiographic (ECG) signs of ischemia in infants. In older patients (pts) diagnosis was suspected mainly from ECG. During CC in all pts, aortograms and when necessary selective coronary angiograms were performed. Surgical correction was performed in all children. In two pts stress exercise ECG and stress Thallium studies before and after surgery were performed. RESULTS: two pts had "adult" an three had "infantile" type of ALCA from the PA. CC was performed and diagnosis was confirmed at surgery in all cases. In one child, correct diagnosis was made by ECO prior to CC and in one case LCA to PA fistula was suspected on Colour-Doppler study. No complications were attributed to CC. Several types of surgery were performed: reimplantation of the ALCA from the PA to the aorta (three pts); tunnel connection of the aorta to the ALCA via the PA (one pt) and left internal mammary to LCA anastomosis (one pt). Two infants died intraoperatively due to extensive myocardial infarction and poor left ventricular function. All the three survivors are asymptomatic after a mean follow up of 34 months. Two oldest pts are currently in New York Heart Association functional class I with normal ECG and improved myocardial perfusion on Thallium scan despite almost total occlusion of LCA at the site of implantation in the aorta as diagnosed on coronary angiogram. CONCLUSIONS: ALCA from PA is associated with major morbidity and mortality. Diagnosis should be suspected in pts with unexplained myocardial ischemia on ECG and even more if it is associated to clinical signs of dilated cardiomyopathy or myocarditis. Careful assessment on ECO and pulsed Doppler and colour flow mapping should make the diagnosis in most cases. Although surgery can be performed based only on ECO diagnosis, we strongly advise for angiography in all cases as in our experience there are false negative diagnosis by ECO. Preoperative Thallium studies can be useful for the selection of the type of surgery as pts with very little viable myocardium will not survive the establishment of a direct systemic to coronary blood flow and may be candidates for heart transplantation.

Disseminated toxoplasmosis presenting as sepsis in two AIDS patients

This report describes two patients who presented acute disseminated and severe toxoplasmosis as the first opportunistic disease related to acquired immunodeficiency syndrome. At admission, clinical and laboratory findings were similar to sepsis or septic shock and a fast evolutive course to death occurred in both cases. At necropsy, an inflammatory reaction and presence of a great number of Toxoplasma gondii cysts and tachyzoites were observed in most organs examined.

The usefulness of adenosine deaminase in the diagnosis of tuberculous pericarditis

The objective of this study was to evaluate the adenosine deaminase (ADA) activity usefulness in the diagnosis of tuberculous pericarditis (TP), comparing its value with pericardial effusions (PE) caused by other pericardial diseases. A retrospective case-control study was conducted with nine cases of TP and 39 other than TP diseases (12 neoplastic, 11 septic and 16 unknown origin). Every patient included in this study had PE samples submitted to ADA activity measures and microbiological analysis, and then had pericardial tissue samples submitted to microbiological and histopathological examination. Considering the value of 40 U/L as the cut-off for the diagnosis of TP, the specificity and sensitivity were respectively of 72% and 89%. The specificity of ADA activity for the TP was best applied in the differential diagnosis from PE of unknown origin. The present study demonstrates the clinical value of the measurement of ADA activity in PE in the diagnosis of TP.