Chagas disease is a pleomorphic clinical entity that has several unique features. The aim of this study is to summarise some of the recent contributions from our research group to knowledge of the morbidity and prognostic factors in Chagas heart disease. A retrospective study suggested that ischaemic stroke associated with left ventricular (LV) apical thrombi is the first clinical manifestation of Chagas disease observed in a large proportion of patients. LV function and left atrial volume (LAV) are independent risk factors for ischaemic cerebrovascular events during follow-up of Chagas heart disease patients. Pulmonary congestion in Chagas-related dilated cardiomyopathy is common but usually mild. Although early right ventricular (RV) involvement has been described, we have shown by Doppler echocardiography that RV dysfunction is evident almost exclusively when it is associated with left ventricle dilatation and functional impairment. In addition, RV dysfunction is a powerful predictor of survival in patients with heart failure secondary to Chagas disease. We have also demonstrated that LAV provides incremental prognostic information independent of clinical data and conventional echocardiographic parameters that predict survival.

The potential impact of the hepatitis C virus (HCV) on clinical, immunological and virological responses to initial highly active antiretroviral therapy (HAART) of patients infected with human immunodeficiency virus (HIV) is important to evaluate due to the high prevalence of HIV-HCV coinfection. A historical cohort study was conducted among 824 HIV-infected patients starting HAART at a public referral service in Belo Horizonte, Brazil, to assess the impact of HCV seropositivity on appearance of a new AIDS-defining opportunistic illness, AIDS-related death, suppression of viral load, and an increase in CD4-cell count. A total of 76 patients (9.2%) had a positive HCV test, 26 of whom (34.2%) had a history of intravenous drug use. In multivariate analysis, HCV seropositivity was associated with a smaller CD4-cell recovery (RH=0.68; 95% CI [0.49-0.92], but not with progression to a new AIDS-defining opportunistic illness or to AIDS-related death (RH=1.08; 95% CI [0.66-1.77]), nor to suppression of HIV-1 viral load (RH=0.81; 95% CI [0.56-1.17]) after starting HAART. These results indicate that although associated with a blunted CD4-cell recovery, HCV coinfection did not affect the morbidity or mortality related to AIDS or the virological response to initial HAART.

Estudo caso-controle, para análise de características clínicas e epidemiológicas foi conduzido em 842 indivíduos atendidos em Ambulatório de Referência de Doença de Chagas, em Belo Horizonte, no período de 1985/92. Verificou-se que os chagásicos apresentaram média de idade mais elevada (37,78 anos); menor escolaridade, independente da cor, e desempenhavam atividades de maior esforço (p<0,05). A via vetorial mostrou ser o principal mecanismo de transmissão. As queixas específicas predominaram nos chagásicos (p<0,05). A ausculta cardíaca (OR:2,29 IC95%: 1,29-4,09) e presença de extra-sístoles (OR:7,16 IC95%:1,59- 45,07) foram as alterações mais importantes ao exame clínico. A IF1 apresentou maior sensibilidade (94%), especificidade (96%); VPP(99%) e VPN(83%). A reação de Elisa realizada em 43 indivíduos não mostrou falsos resultados. Houve predomínio da FCI(56%) ou formas clínicas iniciais. A importância de realizar propedêutica mais complexa em situações específicas foi reforçada pelo encontro de ECGs normais e alteração em 30% dos Holter, 41 % dos TE e 33% dos ECOs, além de 48% de Rx de tórax normal e ECO alterado. Propõe-se modelo de atenção ao chagásico integrado no SUS valorizando a confirmação sorológica, a preparação de recursos humanos capacitados e comprometidos com o desenvolvimento de ações integrais de saúde e a organização do sistema de referência e contra-referência, garantindo o acesso do chagásico aos vários níveis de atenção.

A case-control study to analyse clinical and epidemiological data of 842 patientes seen in an outpatient ward reference center for chagas disease in Belo Horizonte, Brazil,from 1985 to 1992. It was verified that these patients were in a average age of 37.78 years; lower literacy regardless of race, and, performed activities that demanded greater muscle effort (p <0.05). The main mechanism for disease transmission proved to be the vectorial route. Disease-especific complaints prevailed in the above mentioned patients (p<0.05). The most important abnormalities found in clinical examination were with cardiac sounds (OR:2.96 95%CI:1.29-4.09) and the presence of extrasystole (OR:7.16 95%Cl:1. 59-45.07). lmunofluorescence Test was more sensitive (94 %) and specific (96 %). It also had a PPV of 99% and e NPV of 83%. ELISA lest carried out in 43 patientes did not yield false results. Indeterminate chronic phase (56 %) or early stages of the disease prevailed. The findings of normal EKGs and abnormalities in 30%, of the Hotter tests, 41% of the exercise tests, 33% of the ECO tests and, 48% of normal chestx-ray with abnormal ECO, high lights the importance of caring out more detailed exams in specific situations. We hereby propose a care model for the Chagas disease patient, integrated to our State Health Plan stressing serologic tests, and training capable human resources committed to the development of integrated health care and the optimization of our referral and counter-referral system, thus issuing total care to the Chagas disease patient.

A análise epidemiológica da malária em Minas Gerais mostra a necessidade de divulgação permanente da situação da transmissão da doença, de forma a contribuir para a suspeita clínica em casos febris e para o diagnóstico precoce. A divulgação das informações técnicas sobre a malária visa ao melhor desempenho dos serviços de saúde locais, a fim de controlar os casos detectados e diminuir as taxas de morbi-mortalidade. Considera-se ser importante a manutenção de sistema organizado e ativo de vigilância epidemiológica de malária, mesmo em áreas endêmicas.

Epidemiological analysis of malaria in the State of Minas Gerais, Brazil, shows the need for permanent reporting of the endemic-related data in order to maintain clinical suspicion of the infection in any febrile patient. Moreover, it increases the possibility of early aetiological diagnosis. Such reporting aims at improving performance of the local health system. It is important to maintain a well-organized malaria epidemiological surveillance system even in non-endemic areas.

A análise epidemiológica da malária em Minas Gerais mostra a necessidade de divulgação permanente da situação da transmissão da doença, de forma a contribuir para a suspeita clínica em casos febris e para o diagnóstico precoce. A divulgação das informações técnicas sobre a malária visa ao melhor desempenho dos serviços de saúde locais, a fim de controlar os casos detectados e diminuir as taxas de morbi-mortalidade. Considera-se ser importante a manutenção de sistema organizado e ativo de vigilância epidemiológica de malária, mesmo em áreas endêmicas.

Epidemiological analysis of malaria in the State of Minas Gerais, Brazil, shows the need for permanent reporting of the endemic-related data in order to maintain clinical suspicion of the infection in any febrile patient. Moreover, it increases the possibility of early aetiological diagnosis. Such reporting aims at improving performance of the local health system. It is important to maintain a well-organized malaria epidemiological surveillance system even in non-endemic areas.

Foram estudadas as alterações clínicas e radiológicas pulmonares da fase inicial da esquistossomose mansoni em 30 indivíduos previamente sadios, que se infectaram simultaneamente. Os achados foram comparados aos de um grupo - controle e relacionados a possíveis fatores patogenéticos como carga parasitária, eosinofilia sangüínea e área de reação intradérmica imediata, esta como estimativa de IgE ligada a mastócito. As manifestações pulmonares foram de intensidade leve ou moderada, sendo a tosse seca o sintoma mais comum. As alterações radiológicas significativas constaram de espessamento de paredes brônquicas, micronodulação em rosário e micronodulação esparsa, localizadas predominantemente nas porções inferiores dos campos pulmonares. Verificou-se associação significativa de sibilos e área da reação intradérmica imediata, bem como entre o número de eosinófilos sangüíneos e a ocorrência de alterações radiológicas tomadas em conjunto. Houve correlação entre a carga parasitária, expressa pelo número de ovos eliminados nas fezes, e a presença de sibilos, dor torácica e micronodulação em rosário.

The clinical and radiological pulmonary manifestations in the initial phase of schistosomiasis mansoni were studied in thirty previously healthy individuals who were simultaneously infected. The findings were compared with those concerning a control group and related to possible pathogenetic factors. The respiratory manifestations were of light or of moderate intensity, the dry cough being the most common symptom. The significant radiological alterations were: thickening of bronchial walls and beaded micronodulation, predominantly localized in the lower pulmonary fields. It was observed significant association between wheezing and IgE levels, estimated by the area of immediate intradermal reaction, as well as between the number of blood eosinophils and the occurrence of radiological changes. Moreover, there was correlation between the worm burden and the presence of wheezing, thoracic pain and beaded micronodulation. Thus, the clinical and radiological pulmonary manifestations described are significant part of the initial phase of schistosomiasis mansoni and present the worm burden, eosinophilia and levels of IgE as probable pathogenetic factors.

Os Autores descrevem um caso grave de esquistossomose mansoni (forma hepática com hipertensão portal associada a forma pulmonar com hipertensão pulmonar e cor pulmonalej sobre o qual evoluiu uma sindrome toxi-infectuosa grave e de longa duração. Sucessivos exames radiológicos do tórax revelaram acometimento predominantemente arteriolar, ao lado de uma micronodulação pulmonar grosseira e difusa em ambos os hemitóraces e configuração de coração pulmonar. A histopatologia de material de biópsia pulmonar identificou basicamente uma arterite pulmonar característica, inflamação granulomatosa atípica provocada principalmente por vermes e raros ovos de S. mansoni envolvidos por escassa reação inflamatória. Para explicar a origem de constelação clínica toxi-infectuosa, foram afastadas as hipóteses de associação da esquistossomose a concausas infectuosas ou não, mas de curso febril, e a superposição de uma forma toxêmica sobre outra crônica pré-existente. Com base em dados clínicos, particularmente em subsídios da laparoscopia, e anatômicos, concluiu-se tratar o caso de uma forma crônica de esquistossomose reativada, provavelmente em virtude de alterações imunológicas inusitadas do hospedeiro. Ao que tudo parece indicar, o desvio de ovos e de vermes aos pulmões deveu-se à sindrome de hipertensão portal, cujos shunts entre a circulação portal e sistêmica determinaram a rota preferencial da migração.

The Authors relate a case ofsevere schistosomiasis mansoni (hepatic form, with portal hypertension, associated with pulmonary form, with pulmonary hypertension and cor pulmonale), o ver which develloped a severe toxi-infectious syndrome of long duration. Serial chest X-rays showed that the arteriolae were predominantly affected, besides a gross and difuse pulmonary micronodulation in both hemithoraces, and pulmonary heart configuration. Histopathology of the pulmonary biopsy material identified basically a pulmonary arteritis characteristic of chronic pulmonary schistosomiasis and, simultaneously, the presence of schistosomatous granulomata in hyperergic reaction mainly produced by worms, one of the main anatômica! characteristics of the toxemic form. To explain the origin of the clinical toxi- infectious constelation, the hypotheses of an association with a co-existing infectious, or not infectious but fever producing cause, and of the superposition of a toxemic form over a pre-existing chronic one were eliminated. It was concluded, on the basis of clinical data, particularly those furnished by laparoscopy and the anatomical onas, that this a chronic case of schistosomiasis reactivated probably by the host uncommon immunological alteration. Everything points to the possibility that the unusual detour of the eggs, and of the worms to the lungs was due to the portal hypertension syndrome, and that the preferential route of this migration was determined by the shunts involving the portal and systemic circulations.