OBJECTIVES: Dengue cases range from asymptomatic to severe, eventually leading to hospitalization and death. Timely and appropriate management is critical to reduce morbidity. Since 1980, dengue has spread throughout Brazil, affecting an increasing number of individuals. This paper describes age and regional differences in dengue’s clinical presentation and associated risk of hospitalization based on more than 5 million cases reported to the Brazilian Ministry of Health from 2000-2014. METHODS: We performed a retrospective analysis of ∼5,450,000 dengue cases, relating clinical manifestations and the risk of hospitalization to age, gender, previous infection by dengue, dengue virus serotype, years of formal education, delay to first attendance and the occurrence of dengue during outbreaks and in different Brazilian regions. RESULTS: Complicated forms of dengue occurred more frequently among those younger than 10 years (3.12% vs 1.92%) and those with dengue virus 2 infection (7.65% vs 2.42%), with a delay to first attendance >2 days (3.18% vs 0.82%) and with ≤4 years of formal education (2.02% vs 1.46%). The risk of hospitalization was higher among those aged 6-10 years old (OR 4.57; 95% CI 1.43-29.96) and those who were infected by dengue virus 2 (OR 6.36; 95% CI 2.52-16.06), who lived in the Northeast region (OR 1.38; 95% CI 1.11-2.10) and who delayed first attendance by >5 days (composite OR 3.15; 95% CI 1.33-8.9). CONCLUSIONS: In Brazil, the occurrence of severe dengue and related hospitalization is associated with being younger than 10 years old, being infected by dengue virus 2 or 3, living in the Northeast region (the poorest and the second most populated) and delaying first attendance for more than 2 days.

Potent antimicrobial agents have been developed as a response to the development of antibiotic-resistant bacteria, which especially affect patients with prolonged hospitalization in Intensive Care Units (ICU) and who had been previously treated with antimicrobials, especially third-generation cephalosporins.This study was to determine how changes in the empirical treatment of infections in ICU patients affect the incidence of Gram-negative bacteria species and their susceptibility to antimicrobials, and examine the impact of these changes on nosocomial infections. A prospective interventional study was performed in a university hospital during two periods: 1) First period (September 1999 to February 2000); and 2) Second period (August 2000 to December 2000); empirical treatment was changed from ceftriaxone and/or ceftazidime in the first period to piperacillin/tazobactam in the second. ICU epidemiological and infection control rates, as well as bacterial isolates from upper airways were analyzed. Ceftazidime consumption dropped from 34.83 to 0.85 DDD/1000 patients per day (p=0.004). Piperacillin/tazobactam was originally not available; its consumption reached 157.07 DDD/1000 patients per day in the second period (p=0.0002). Eighty-seven patients and 66 patients were evaluated for upper airway colonization in the first and second periods, respectively. There was a significant decrease in the incidence of K. pneumoniae (p=0.004) and P. mirabilis (p=0.036), restoration of K. pneumoniae susceptibility to cephalosporins (p<0.0001) and reduction of ventilator-associated pneumonia rates (p<0.0001). However, there was an increase in P. aeruginosa incidence (p=0.005) and increases in ceftazidime (p=0.003) and meropenem (p<0.0001) susceptibilities. Changing antimicrobial selective pressure on multi-resistant Gram-negative bacteria helps control ventilator-associated pneumonia and decreases antimicrobial resistance.

Analisou-se o comportamento da LTA em crianças e adolescentes na faixa etária de 0-15 anos, provenientes das áreas endêmicas de Buriticupu (MA) e Corte de Pedra (BA). Nestas regiões, foram cadastrados 214 pacientes no periodo de 1982 a 1993, sendo 78 (36,4%) oriundos de Corte de Pedra e 136 (63,6%) de Buriticupu. Em Corte de Pedra a faixa etária predominante foi de 0-5 anos com 29 (37,2%) casos. Destes, 62% pertenciam ao sexo masculino. Na região de Buriticupu, 88 (64,7%) casos ocorreram na faixa etária de 11-15 anos, sendo 73,8% do sexo masculino. Nas regiões estudadas, houve predomínio da cor parda com 65,4% em Corte de Pedra, e 75% em Buriticupu. Vinte e seis (33,3%) crianças provenientes de Corte de Pedra eram lavradores, sendo o sexo masculino maioria (57,7%), existindo diferença estatística significante (c2 = 11,21 p = 0,05). Vinte e um (80,8%) casos da ocupação lavrador pertenciam a faixa etária de 11-15 anos. Em Buriticupu 37,5% das crianças eram estudantes, destes 30,2% foram lavradores, todos do sexo masculino (c2 = 32,3 p = 0,05). A maioria dos lavradores, 39 (44,3%) casos eram da faixa etária de 11-15 anos. Tanto em Buriticupu como Corte de Pedra houve predomínio da lesão única, 57,7% e 53,7% dos casos, respectivamente. A duração das lesões destacou-se no período de 1 a 3 meses, com 54 (69,2%) casos em Corte de Pedra e 83 (61%) em Buriticupu (c2 = 11,82 p = 0,05). Quanto a localização das lesões, observou-se que nas duas regiões estudadas os MMII foram predominantes com 58,9% em Corte de Pedra e 77,2% em Buriticupu (c2 = 27,9 p = 0,05), havendo maior ocorrência de lesão ulcerada nas duas regiões. IDRM foi positiva em 61 (78,2%) crianças provenientes de Corte de Pedra, não havendo diferença estatística significativa entre as faixas etárias e a positividade do teste (c2 = 0,0669 p = 0,05).

A comparative study on children aged 0-15 years, with American tegumentary leishmaniasis (ATL), in the endemic regions of Buriticupu (MA) and Corte de Pedra (BA), whereby 214 cases were detected between 1982 and 1993, 78 (36.4%) of them originated from Corte de Pedra and 136 (63.6%) from Buriticupu. In Corte de Pedra, most cases were observed in patients aged between 0-5 years. Twenty nine (37.2%) cases; 62% of those were male. In the Buriticupu region, 88 (64.7%) cases occured in patients of 11-15 years of age, where in 73.8% consisted of male. In both researched regions, brunetts were predominant, with a ratio of 65.4% in Corte de Pedra and 75% in Buriticupu. Twenty six (33.3%) children in the village of Corte de Pedra were farmers, predominantly male (57.7%), generating statistical significance (c2 = 11.21). Twenty one (80.8%) farmers were aged 11-15 years. Thirty seven and a half per cent of the children from Buriticupu were students, however, 41 (30.2%) were farmers, representing 39 (44.3%) cases; all of them male. Both in Buriticupu and Corte de Pedra, the unique wound was predominant, corresponding to 57.7% and 53.7%, respectively. The wounding time stood out from one to three months, with 45 (69.2%) cases in Corte de Pedra and 73 (61%) in Buriticupu (c2 = 11.82). As to the wound locations, it has been observed that they were most constantly present on the lower limbs, with 77.2% in Corte de Pedra and 58.9% in Buriticupu (c2 = 27.9). The cutaneous case mostly found in Corte de Pedra was the ulcerous one (91%). IDRM was positive in 61 (78.2%) children originated from Corte de Pedra, wherein no statistical difference was detected between age ratio and positivity of the test (c2 = 0.0669).

Analisou-se o comportamento da leishmaniose visceral (LV) no Estado do Maranhão-Brasil, no período de 1982 a 1993. A enfermidade vem ocorrendo predominantemente na Ilha de São Luís-MA em áreas periurbanas, destacando, no período epidêmico, a capital São Luís como principal área endêmica. A maior freqüência de casos ocorreu em 1993, apesar do uso de inseticidas e controle dos cães. Houve predomíyiio na faixa etária de 0 a 4 anos de idade com 58,4% dos casos. Nem a doença humana nem o índice pluviométrico apresentaram variações sazonais significativas, entretanto estiveram moderadamente correlacionados, havendo quase sempre elevação do número de casos após o período de maior precipitação chuvosa. A partir deste estudo, poderão ser levantadas questões para o controle mais eficaz, consoante á urbanização da doença, aliada aos fatores da dinâmica de transmissão em áreas endêmicas do Estado.

The authors analysed the visceral leishmaniasis (VL) aspects in the State of Maranhão-Brazil, from 1982 to 1993. The disease happens to occur predominantly in São Luis, Island (MÁ) and during the epidemic period, town of São Luis was pointed out as the main endemic area. The greatest frequency of cases occured in 1993, despite the use of insecticid and dogs control. There was predominance of age between 0 to 4 year old population with 58.04% of cases. Neither the human disease nor the rainfall index had significant seasonal variation. However they were correlated moderately, with high number of cases after the period of great preciptation of rain. After this study, the data obtained will allow a better control of the disease, despite some factors such as: the urbanization, localization and dynamic of transmission in endemic areas in the Maranhão State.

Os autores relatam o caso de um paciente procedente de Bacabal, MA, portador de leishmaniose cutânea difusa (LCD) há 9 anos, apresentando um total de 168 lesões distribuídas pelo corpo, de caráter nódulo tumoral e algumas ulceradas, tendo sido submetido a tratamentos anteriores á base de antimonial pentavalente (gluc antime®) e associação interferom gamma+glucantime® com melhora e posterior recidiva das lesões. Recentemente quando da utilização do medicamento isotianato de pentamidina (pentacarinat® ) na dose de 4mg/kg/peso/dia, aplicados 1M em dias alternados em 3 séries de 20, 10, 10 aplicações com intervalos entre as séries de 3 meses. Na evolução do tratamento desenvolveu um quadro de perda de peso 10kg, polidpsia, poliúria, xerostomia, lesões de membros inferiores com sinais de atividade. Glicemia em jejum 420mg/dl, presença de glicose e corpos cetônicos na urina. Instituída insulinoterapia houve melhora do quadro e retorno dos níveis glicêmicos permanecendo estãvel até o presente momento. Alerta-se os clínicos que devido a disponibilidade da pentamidina como opção terapêutica, a mesma deve ser usada com critérios, obedecendo rigoroso controle laboratorial incluindo os níveis glicêmicos dos pacientes

The authors report a case of a male patient from Bacabal, MA with diffuse cutaneous leishmaniasis (DCL), for at least nine years, with 168 lesions on his body. These were tumour-like nodules with some ulceratmi. He usedpentavalent antimonial (glucantime®) and an association of gamma interferon plus glucantime with improvement of the lesions but relapsed later. Recently, pentamidine isethionate (pentacarinat®) was given a dosage of 4mg/kg/weight/day on alternate days for 20 applications. After 3 months a similar course of 10 application was given 2 times. Later he developed diabetic signs with weight loss of 10kg, polydypsia, polyuria and xerostomia. The lower limbs lesions showed signs of activity. Blood glucose levels normalised and remain like this at moment. Attention is drawn to the fact that pentamidine isethionate should be used as a therapy option with care, obeyng rigorous laboratory controls including a glucose tolerance test.

Os autores fazem um breve relato da evolução histórica da leishmaniose visceral no Estado do Maranhão, Brasil, avaliando as possíveis causas da expansão da referida doença no Estado, assim como as medidas de controle adotadas pelo Ministério da Saúde objetivando a diminuição da incidência da mesma.

The authors provide a brief report on the historical evolution of visceral leishmaniasis in the State of Maranhão, Brazil, evaluating possible factors for growth of the disease in the State and control measures by the Brazilian Ministry of Health to integrate health services finto the maintenance of control programs.

Os autores fazem um breve relato da evolução histórica da leishmaniose visceral no Estado do Maranhão, Brasil, avaliando as possíveis causas da expansão da referida doença no Estado, assim como as medidas de controle adotadas pelo Ministério da Saúde objetivando a diminuição da incidência da mesma.

The authors provide a brief report on the historical evolution of visceral leishmaniasis in the State of Maranhão, Brazil, evaluating possible factors for growth of the disease in the State and control measures by the Brazilian Ministry of Health to integrate health services finto the maintenance of control programs.