Descrevemos o primeiro caso brasileiro de Riquetsiose branda, agravada por monoartrite em joelho, em adulto jovem picado por carrapato na perna esquerda na região de Camburi, localizada no município de São Sebastião, sul da região costeira do estado de São Paulo, Mata Atlântica, Brasil. O paciente apresentou uma escara de inoculação no local da picada do carrapato, associada ao aumento ganglionar em virilha esquerda, febre, poliartralgia, cefaleia e erupção macular. Vinte dias após o episódio da picada de carrapato, o paciente apresentou monoartrite em joelho direito. O diagnóstico de Riquetsiose branda foi estabelecido pela análise imunológica sequencial em amostras de soro e líquido sinovial, tendo sido empregada a técnica de imunofluorescência (IF) indireta para anticorpos reativos contra Rickettsia parkeri e Rickettsia rickettsii. A Riquetsiose branda é uma zoonose emergente, que deve ser investigada pelos médicos, incluindo reumatologistas, em pacientes que apresentem erupção macular, febre e, eventualmente, artrite, após visita ao sul da região costeira da Mata Atlântica no Brasil.

We describe the first Brazilian case of mild Rickettsiosis, complicated by knee monoarthritis, in young adult bitten by a tick on his left leg in Camburi zone, located in São Sebastião municipality, southern coastal region of the State of São Paulo, in the Atlantic rainforest region, Brazil. The patient developed inoculation eschar at the tick bite site associated with enlarged lymph nodes in the left groin, fever, polyarthralgia, headache and macular rash. Twenty days after tick bite episode, he displayed monoarthritis in his right knee. The diagnosis of mild Rickettsiosis was established by sequential immunological analysis in serum and synovial fluid, using the indirect immunofluorescence (IF) assay for antibodies reactive with Rickettsia parkeri and Rickettsia rickettsii. The mild Rickettsiosis is an emerging zoonosis, that must be investigated by physicians, including rheumatologists, in patients that present macular rash, fever and eventually arthritis, after visiting the southern coastal Atlantic rainforest region in Brazil.

OBJECTIVES: To investigate the prevalence of dyslipoproteinemia in a homogeneous cohort of polyarticular juvenile idiopathic arthritis patients. METHODS: Based on the National Cholesterol Education Program, fasting lipoprotein levels and risk levels for coronary artery disease were determined in 28 patients with polyarticular juvenile idiopathic arthritis. The exclusion criteria included diabetes, thyroid dysfunction, smoking, proteinuria, lipid-lowering drugs, and hormone/diuretic therapy. Disease activity, disease duration, and therapy with corticosteroids and/or chloroquine were defined at the time of lipid measurements. RESULTS: Dyslipoproteinemia was identified in 20 of the 28 (71%) patients with polyarticular juvenile idiopathic arthritis. The primary lipoprotein risk factor was decreased high-density lipoprotein cholesterol (57%), followed by elevated levels of low-density lipoprotein cholesterol (18%), triglycerides (14%), and total cholesterol (7%). The male patients had decreased high-density lipoprotein cholesterol levels than the female patients (p<0.05). The incidence of decreased high-density lipoprotein cholesterol levels did not seem to be affected by disease activity or therapy because the incidence was similar in patients with active or inactive disease, with or without corticosteroid use and with or without chloroquine use. In addition, the frequency of decreased high-density lipoprotein cholesterol levels was similar in patients with short (≤5 years) vs. long (>5 years) disease duration. CONCLUSIONS: Dyslipoproteinemia is highly prevalent in patients with polyarticular juvenile idiopathic arthritis and is primarily related to decreased high-density lipoprotein cholesterol levels; therefore, early intervention is essential.

A Doença de Lyme (DL) é uma zoonose frequente no hemisfério Norte e considerada uma enfermidade infecciosa causada por espiroquetas do complexo Borrelia burgdorferi sensu lato e transmitida pela picada de carrapatos do grupo Ixodes ricinus. Os primeiros casos semelhantes à DL no Brasil foram descobertos, em 1992, em irmãos que após serem picados por carrapatos desenvolveram eritema migratório, sintomas gripais e artrite. Criteriosa análise da casuística brasileira, mostrou que os aspectos epidemiológicos, clínicos e laboratoriais no país, divergiam bastante dos exibidos pelos pacientes com DL nos Estados Unidos da América e Eurásia. Não foram encontrados carrapatos do complexo Ixodes ricinus hematófago ao homem nas áreas de risco; a enfermidade no país é recorrente; a Borrelia burgdorferi jamais foi isolada no Brasil e os ensaios sorológicos específicos exibem positividade baixa e oscilante. Além disso, o exame do sangue periférico dos pacientes quando analisados à microscopia eletrônica exibe estruturas sugestivas de Mycoplasma spp, Chlamydia spp e bacteroides. Na verdade, estas estruturas podem representar as formas latentes das espiroquetas (forma L ou bactérias desprovidas de parede), adaptadas a sobreviver em condições inóspitas em hospedeiros vertebrados e invertebrados. Assim, a zoonose presente no país recebeu a denominação de Síndrome Baggio-Yoshinari e definida como: "Enfermidade infecciosa nova e emergente brasileira, transmitida por carrapatos não pertencentes ao complexo Ixodes ricinus, causada por espiroquetas na sua morfologia atípica e latente, que origina manifestações clínicas semelhantes às observadas na DL, exceto pela ocorrência de recidivas clínicas e desordens autoimunes".

Lyme disease (LD) is a frequent zoonosis found in the Northern Hemisphere and is considered an infectious disease caused by spirochetes belonging sensu lato to the Borrelia burgdorferi complex transmitted by ticks of the Ixodes ricinus group. In 1992, first cases similar to LD were described in Brazil, when brothers, after a tick bite episode developed symptoms , as erythema migrans, general flu-like symptoms and arthritis. Careful analysis of Brazilian LD-like illness casuistry showed that epidemiological, clinical and laboratorial features in the country were very different from those exhibited by North American and Eurasian LD patients. Human blood-suckers Ixodes ricinus complex ticks were absent at risk areas; the disease is recurrent in the country; Borrelia burgdorferi was never isolated in Brazil and specific serologic tests have shown little positivity with inconsistent results. Furthermore, peripheral blood analysis of patients on electron microscopy exhibited structures resembling Mycoplasma spp, Chlamydia spp and spirochete-like microorganisms. In fact, they were assumed to be latent forms of spirochetes (L form or cell wall deficient bacteria) adapted to survive at inhospitable conditions in vertebrate and invertebrate hosts. For these reasons, the Brazilian zoonosis was named Baggio-Yoshinari Syndrome (BYS) and defined as: "Exotic and emerging Brazilian infectious disease, transmitted by ticks not belonging to the Ixodes ricinus complex, caused by latent spirochetes with atypical morphology, which originates LD-like symptoms, except for occurrence of relapsing episodes and auto-immune disorders".