RESUMO
Leprosy affects skin and peripheral nerves, and acute inflammatory type 1 reactions (reversal reaction) can cause neurologic impairment and disabilities. Single skin lesion paucibacillary leprosy volunteers (N = 135) recruited in three Brazilian endemic regions, treated with single-dose rifampin, ofloxacin, and minocycline (ROM), were monitored for 3 years. Poor outcome was defined as type 1 reactions with or without neuritis. IgM anti-phenolic glycolipid I, histopathology, Mitsuda test, and Mycobacterium leprae DNA polymerase chain reaction (ML-PCR) were performed at baseline. chi(2) test, Kaplan-Meir curves, and Cox proportional hazards were applied. The majority of volunteers were adults with a mean age of 30.5 +/- 15.4 years; 44.4% were ML-PCR positive. During follow-up, 14.8% of the patients had a poor clinical outcome, classified as a type 1 reaction. Older age (> or = 40 years), ML-PCR positivity, and lesion size > 5 cm were associated with increased risk. In multivariate analysis, age (> or = 40 years) and ML-PCR positivity remained baseline predictors of type 1 reaction among monolesion leprosy patients.
Assuntos
DNA Bacteriano/isolamento & purificação , Eritema Nodoso/epidemiologia , Hanseníase/tratamento farmacológico , Hanseníase/microbiologia , Minociclina/uso terapêutico , Mycobacterium leprae/isolamento & purificação , Ofloxacino/uso terapêutico , Rifampina/uso terapêutico , Adolescente , Adulto , Envelhecimento , Estudos de Coortes , Eritema Nodoso/sangue , Eritema Nodoso/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Fatores de Risco , Fatores de TempoRESUMO
FUNDAMENTOS: A Organização Mundial da Saúde - OMS e o Ministério da Saúde do Brasil recomendam a adoção da classificação operacional para fins terapêuticos (multi ou paucibacilar). Discute-se a validade dessa classificação tomando como referência o resultado do exame baciloscópico. OBJETIVO: Verificar a sensibilidade e especificidade da classificação clínica operacional que leva em consideração exclusivamente o número de lesões cutâneas e daquela que considera o espessamento de troncos neurais, além do número de lesões cutâneas, relacionando-as com o resultado do exame baciloscópico. MÉTODO: Como fonte de informação foram consultados os prontuários de pacientes com diagnóstico de hanseníase no período de janeiro de 2000 a março de 2001, na Fundação Alfredo da Matta, em Manaus, AM, onde estavam registrados os dados demográficos, clínicos e laboratoriais. RESULTADOS: A classificação clínica baseada exclusivamente no número de lesões cutâneas mostrou sensibilidade de 73,6 por cento e especificidade de 85,6 por cento com relação à baciloscopia. A classificação que combina o número de lesões cutâneas e de nervos espessados demonstrou sensibilidade de 75,8 por cento e especificidade de 71,8 por cento. CONCLUSÃO: A classificação clínica da hanseníase baseada no número de lesões cutâneas mostrou, neste estudo, valores de sensibilidade e especificidade similares aos descritos em estudos realizados em outros países. Quando se acrescentou à classificação outro parâmetro clínico, a presença de nervos periféricos espessados, ocorreu significativa diminuição da especificidade, sem aumento estatisticamente significativo da sensibilidade.
RESUMO
This paper aims to describe the histomorphologic features of skin biopsies of single lesion leprosy patients recruited at outpatient clinics in four Brazilian states in the Northeast (Amazonas and Rondonia), Southeast (Rio de Janeiro) and Center-West (Goiás) between October 1997 and December 1998. Patients clinically diagnosed as single skin lesion paucibacillary (SSL-PB) leprosy had a standard 4-mm punch biopsy taken from the lesion before rifampin, ofloxacin, minocycline (ROM) therapy. The features of the cellular inflammatory infiltrates, the presence of nerve involvement and acid-fast bacilli (AFB) were used to categorize SSL-PB biopsies into different histopathological groups. Two-hundred-seventy-eight (93.0%) out of 299 patients had a skin biopsy available. Seven single lesion patients were diagnosed as BL or LL leprosy types (MB) by the histopathological exams and 12 cases were excluded due to other skin diseases. Therefore, 259 patients had skin lesions with histomorphological features compatible with PB leprosy categorized as follows: 33.6% (N = 87) of the biopsies represented well-circumscribed epithelioid cell granuloma (Group 1); 21.6% (N = 56) less-circumscribed epithelioid cell granuloma (Group 2); 12.0% (N = 31) were described as mononuclear inflammatory infiltrate permeated with epithelioid cells (Group 3), and 29.7% (N = 77) had perivascular/periadnexal mononuclear inflammatory infiltrate (Group 4). Minimal/no morphological alteration in the skin was detected in only 8 (3.1%) SSL-PB patients categorized as Group 5, who were considered to have leprosy by clinical parameters. SSL-PB leprosy patients recruited in a multicentric study presented histomorphology readings comprising the whole PB leprosy spectrum but also a few MB cases. These results indicate heterogeneity among SSL-PB patients, with a predominance of well-circumscribed and less-circumscribed epithelioid cell granulomas (Groups 1 and 2) in the sites studied and the heterogeneity of local cellular immune response.
Assuntos
Humanos , Hanseníase/etnologia , Hanseníase/fisiopatologiaRESUMO
In Brazil, there is little information about the clinical and epidemiological characteristics of paucibacillary, single skin lesion leprosy patients (SSL-PB). Only recently has the official notification system distinguished leprosy patients with a single lesion as a clinical entity, for whom the single-dose ROM (rifampin, ofloxacin and minocycline) regimen has been recommended. In this paper, we describe the baseline clinical features and the immunological background of a multicenter cohort of SSL-PB leprosy cases enrolled between December 1997-1998. Patients were recruited at health centers located in the following regions: Southeast = Rio de Janeiro; North = Amazon and Rondônia states and Center-West = Goiás state. Eligible cases were newly detected, untreated single-lesion leprosy patients without thickened nerve involvement, and were assessed by clinical, bacilloscopic and histopathological exams. The Mitsuda skin test and anti-PGL-I serology (ELISA) were also performed. Of the 299 SSL-PB leprosy patients, 259 (86.6%) fulfilled the criteria for single-dose ROM intervention. Our results showed that patients recruited from different sites had similar features, considering the clinical and immunological profiles. There was a predominance of adults (mean age 32.4; S.D. = 16.0), and a BCG scar was detected in 76.7% of the children ( or = 5 mm) and seropositivity for anti-PGL-I was detected in 17.3% of the patients. These data are compatible with effective cell-mediated immunity and low bacillary load, suggesting favorable clinical outcomes for most SSL-PB participants of this cohort.