Revista Do Instituto De Medicina Tropical De Sao Paulo最新文献

Cat-transmitted sporotrichosis is one of the fastest spreading zoonosis in Rio de Janeiro State, Brazil. A retrospective study was conducted with analysis of incidence of human sporotrichosis complemented with spatial methodologies. Data from case reported to the Notifiable Diseases Information System (SINAN) from 2007 to 2023 were studied. Incidence, demographic variables, temporal, and spatial dynamics of this endemic disease were investigated. During 2007-2023, 15,401 cases of sporotrichosis were reported. Most cases (64.4%) occurred with women. The annual incidence from 2007 to 2023 was 5.6 cases per 100,000 inhabitants. The incidence in 2016-2023 was 2.3 times higher than in 2007-2015. No significant differences were found regarding age between the two periods, but there were differences regarding gender: with a higher proportion of women in 2007-2015. The endemic is heterogenous with variations in time and space. Spatial analysis showed statistically significant clusters spread throughout Rio de Janeiro, in the periods of low incidence (2007-2015) and high incidence (2016-2023). In the period of high incidence, clusters were more numerous and had a greater range. In conclusion, the incidence levels and the proportion of affected territories increased over time. This study may contribute to understanding the dynamics of the endemic disease in the Rio de Janeiro State and guide control actions in places where they are most needed.

In 2020, Sao Caetano do Sul city, located in the metropolitan region of Sao Paulo State, Brazil, established a web-based platform to provide primary care to suspected COVID-19 patients, integrating clinical and demographic data and sample metadata. Here we describe lineage-specific spatiotemporal dynamics of infections, clinical symptoms, and disease severity during the first year of the epidemic, which included circulation of the poorly characterised Gamma variant of concern. From April 6, 2020, to April 30, 2021, we gathered clinical, demographic, spatial and epidemiological data from the city's platform. We selected and sequenced 879 PCR+ swab samples (8% of all reported cases), obtaining a spatially and temporally representative set of sequences. Daily lineage-specific prevalence was estimated with a moving-window approach, allowing inference of cumulative cases and symptom probability stratified by lineage using integrated data from the platform. Most infections were caused by B.1.1.28 (41.3%), followed by Gamma (31.7%), Zeta (9.6%), and B1.1.33 (9.0%). Gamma and Zeta correlated with larger prevalence of dyspnoea (respectively, 81.3% and 78.5%) and persistent fever (84.7% and 61.1%) compared with B.1.1.28 and B.1.1.33. Ageusia, anosmia, and coryza were respectively 18.9%, 20.3%, and 17.8% less commonly caused by Gamma, whereas altered mental status was 108.9% more common in Zeta. Case incidence was spatially heterogeneous and larger in poorer and younger districts. Our study reveals that Gamma was associated with more severe presentation of the disease, emphasising its role in the heightened mortality levels in Brazil.

Leptospirosis is a neglected zoonotic disease caused by bacteria of the genus Leptospira, mainly acquired via direct contact with water and soil contaminated by the urine of infected animals. This is most observed in tropical and subtropical regions, and it is strongly associated with urban population growth in areas lacking adequate sanitation conditions. Leptospira infection can lead to several clinical manifestations in humans, ranging from a nonspecific febrile illness to severe complications such as jaundice, renal failure, and life-threatening pulmonary disease. One of the most severe forms is leptospirosis-associated pulmonary hemorrhagic syndrome (LPHS), characterized by coughing, chest pain, dyspnea, and massive pulmonary hemorrhage. The mortality rate of LPHS is approximately 50%, with death generally occurring within 72 hours after symptom onset. The etiopathogenesis of LPHS remains poorly understood. Some studies suggest that Leptospira spp. may directly damage blood capillaries and alter vascular permeability. Additionally, the host immune response, via the cytokine release, high expression of adhesion molecules, and activation of the Complement System, may further disrupt endothelial integrity, promoting vascular leakage and the systemic dissemination of leptospires. Animal models are essential for a better understanding of Leptospira transmission, colonization, and pathogenesis. This review aims to consolidate current understanding of LPHS, with emphasis on its pathogenesis, immune mechanisms, clinical manifestations, virulence factors, and experimental models.

Youth encompasses pre-adolescence (10-14 years), adolescence (15-17 years), and young adulthood (18-24 years). Adolescents in general, particularly those with comorbidities, appear more susceptible to severe COVID-19, a vulnerability also observed in newborns and young infants. The mechanisms underlying this increased risk remain unclear, highlighting the need for early disease biomarkers. Circulating cell-free mitochondrial DNA (ccf-mtDNA), a damage-associated molecular pattern (DAMP), has been linked to systemic inflammation and immune activation during viral infections. This study evaluated plasma ccf-mtDNA levels in pre-adolescents, adolescents, and young adults with and without COVID-19, all presenting respiratory symptoms and predominantly harboring comorbidities, some with coinfections by other respiratory viruses. In this prospective study of 88 participants aged 12-21 years, half tested positive and half negative for SARS-CoV-2 by Reverse-Transcribed Polymerase Chain Reaction (RT-PCR). Comorbidities were present in 75% of COVID-19-positive and 54.5% of COVID-19-negative participants. Coinfections were detected in 52.3% and 25% of tested participants, respectively. Plasma ccf-mtDNA was quantified by a quantitative Real Time PCR (qPCR) targeting the mitochondrial NADH dehydrogenase 2 (ND2) gene or MT-ND2. COVID-19-positive participants exhibited significantly higher ccf-mtDNA levels than both symptomatic COVID-19-negative individuals and healthy controls (p<0.001). Although median levels were numerically higher in severe/critical compared with mild/moderate cases (7,769 vs. 4,649 ccf-mtDNA/mL), the difference was not statistically significant, likely due to limited sample size. In conclusion, elevated ccf-mtDNA distinguishes young individuals with COVID-19 and comorbidities from non-COVID-19 symptomatic participants and healthy controls. Although not linked to disease severity in this preliminary study, ccf-mtDNA may serve as an early biomarker of SARS-CoV-2-induced hyperinflammation and immune activation, supporting further targeted clinical investigations.

Neurological manifestations remain a significant cause of hospitalization and in-hospital mortality among people living with HIV (PLWH), even in the era of antiretroviral therapy (ART). This study aims to describe the clinical and epidemiological profile of PLWH with neurological opportunistic infections (nOIs) and to identify factors associated with in-hospital mortality. We conducted a retrospective cohort study with PLWH aged >18 years hospitalized due to nOIs between November 2017 and December 2021 at a tertiary hospital in Brazil. Demographic, clinical, and laboratory data were extracted from electronic medical records. Logistic regression was used to evaluate associations between patient characteristics and in-hospital mortality. Among 237 hospitalized PLWH, 89 (37.6%) had nOIs. The median CD4 count at admission was 55 cells/mm³ (IQR 22.5-149), and 91.7% had previously used ART (only 22.7% used it regularly). The most frequent infections were cerebral toxoplasmosis (50.6%), cryptococcal meningitis (10.1%), and progressive multifocal leukoencephalopathy (9%). A total of 19 in-hospital deaths occurred. In the multivariate analysis, undefined neurological infections (aOR: 8.67; 95%CI: 1.23-61.17) and ICU admission (aOR: 58.61; 95% CI: 10.24-335.49) were independently associated with mortality. In conclusion, severe immunosuppression and low ART adherence were common in this cohort. Cerebral toxoplasmosis was the most prevalent neurological infection. ICU admission and undefined neurological syndromes were strong predictors of in-hospital mortality. Early diagnosis, prompt treatment, and strategies to improve ART adherence are essential to reduce fatal outcomes in this population.

Paracoccidioidomycosis (PCM) is a neglected tropical disease classified as acute/subacute and chronic. In people living with HIV/AIDS (PLWHA), coinfection can lead to severe clinical manifestations. We report the case of a 30-year-old immunosuppressed male presenting fever, weight loss, polymorphic skin lesions, diffuse lymphadenopathy, hepatosplenomegaly, and joint effusion. Histopathological analysis revealed fungal structures compatible with Paracoccidioides spp., and serology was positive at a titer of 1:16. Despite initial Amphotericin B and antiretroviral therapy, the patient developed a productive cough and persistent systemic symptoms. Initial sputum tests were negative for Mycobacterium tuberculosis, but subsequent bronchoalveolar lavage detected rifampin-resistant tuberculosis (TB). The remarkable overlap of clinical and radiological features of TB and PCM can significantly delay diagnosis, highlighting the need for high clinical suspicion and prompt investigation with bronchoalveolar lavage (BAL) testing. After one-month outpatient follow-up, the patient showed significant cutaneous improvement, undetectable HIV viral load, and a marked increase in CD4+ T-cell count. This report highlights the importance of recognizing the acute/subacute form of PCM as an AIDS-defining illness in endemic areas, enabling early treatment and improved outcomes.

Pediatric tuberculosis (TB) remains a diagnostic challenge in Brazil and worldwide. The Brazilian Ministry of Health recommends a clinical scoring system (S-MoH) for children and adolescents with suspected TB. Interpretation of radiographs within this scoring system may require specialist input. AI-based systems, such as CAD4TB (Delft Imaging Systems B.V.), approved by the WHO for adults, are not yet recommended for standalone use in children under 15 years of age. A retrospective study was conducted at a pediatric institute from January 31, 2017, to January 29, 2025, including 179 patients aged 0-14 years with pulmonary TB or other diseases. CAD4TBv7.1 analyzed chest radiographs using two cutoff points established by Youden's index: 53.48 for analyses against the S-MoH score and 53.89 for analyses against microbiological confirmation. Results were compared with both microbiological confirmation and S-MoH score. Among the 179 participants, 61 (34.1%) had TB, 25 of which were microbiologically confirmed. CAD4TBv7.1 showed an area under the ROC curve (AUROC) of 0.71, with a sensitivity of 52% and a specificity of 86.3% compared with microbiological diagnosis. Against S-MoH, AUROC was 0.59, with a sensitivity of 34.43% and a specificity of 86.44%. CAD4TBv7.1 demonstrated low sensitivity and high specificity, particularly regarding its overall discriminative capacity. Thus, CAD4TBv7.1 emerges as a promising complementary screening tool for pediatric TB. Although its standalone use is not yet recommended, it may complement S-MoH in settings lacking radiologists. Investments in AI must be accompanied by consistent pediatric validation and strategies that combine technological innovation with traditional and cost-effective clinical approach.

Spotted fever is a tick-borne rickettsiosis caused by several Rickettsia species-including R. rickettsii, R. parkeri, and others-with varying degrees of pathogenicity. Its nonspecific symptoms often lead to misdiagnosis such as dengue. This study investigated anti-R. rickettsii and R. parkeri antibodies in 152 patients with acute febrile illness who tested negative for dengue. Serological analysis using immunofluorescence assay found 29 reactive samples (19%) at a 1:64 dilution. Among them, 20.6% were male and 58.6% female, with an average age of 42.6 years. The average sample collection time totaled 14.6 days. Reactive samples included 13.1% for R. rickettsii and 5.9% for R. parkeri. These results suggest possible rickettsial infections in patients initially suspected of dengue.

Osteoarticular sporotrichosis is the most common extracutaneous type of the disease and may occur either concomitantly with cutaneous lesions or as isolated musculoskeletal disease, the latter frequently resulting in delayed diagnosis. We describe five confirmed cases of osteoarticular sporotrichosis diagnosed between 2002 and 2023 at a university hospital in Brazil. Diagnosis was confirmed by fungal culture, with serology and histopathology used as complementary methods. Clinical and epidemiological data, radiologic findings, treatment, and outcomes were analyzed. Patients were 39 to 67 years of age and all had chronic conditions or alcoholism. Joint involvement most frequently affected the knee (four cases), followed by the wrist (three cases), and small joint of the hands (two cases), often with bone and periarticular tissue involvement. Three patients had concomitant cutaneous involvement. Diagnostic delays were frequent, reflecting the nonspecific clinical presentation and the tendency to misattribute symptoms to other musculoskeletal conditions. All patients received antifungal therapy with itraconazole and/or amphotericin B. Relapses were recorded in two patients, and there were irreversible sequelae such as chronic arthritis, joint stiffness, or deformity in all cases. Osteoarticular sporotrichosis should be considered in the differential diagnosis of chronic musculoskeletal conditions, including arthritis, osteomyelitis, synovitis, bursitis, and tenosynovitis, particularly in endemic regions. Early recognition and prolonged antifungal therapy are essential to achieve cure and prevent complications.