RESUMO
In November 2001, a cyanobacterial bloom dominated by Microcystis and Anabaena occurred in the Funil Reservoir and the Guandu River, both of which supply drinking water to Rio de Janeiro, Brazil. Using ELISA, microcystins were detected at a concentration of 0.4 microg/L in the drinking water, whereas a concentration of 0.32 microg/L was detected in activated carbon column-treated water for use at the renal dialysis center of Clementino Fraga Filho Hospital (HUCFF) at the Federal University of Rio de Janeiro. A total of 44 hemodialysis patients who received care at this center were believed to be exposed. Initial ELISA analyses confirmed the presence of serum microcystin concentrations > or = 0.16 ng/mL in 90% of serum samples collected from these patients. Twelve patients were selected for continued monitoring over the following 2-month period. Serum microcystin concentrations ranged from < 0.16 to 0.96 ng/mL during the 57 days after documented exposure. ELISA-positive samples were found throughout the monitoring period, with the highest values detected 1 month after initial exposure. ESI LC/MS analyses indicated microcystins in the serum; however, MS/MS fragmentation patterns typical of microcystins were not identified. LC/MS analyses of MMPB for control serum spiked with MCYST-LR. and patient sera revealed a peak at retention time of 8.4 min and a mass of 207 m/z. These peaks are equivalent to the peak observed in the MMPB standard analysis. Taken together ELISA, LC/MS, and MMPB results indicate that these renal dialysis patients were exposed to microcystins. This documents another incident of human microcystin exposure during hemodialysis treatment.
Assuntos
Toxinas Bacterianas/intoxicação , Exposição Ambiental , Peptídeos Cíclicos/intoxicação , Insuficiência Renal/complicações , Toxemia/microbiologia , Microbiologia da Água , Toxinas Bacterianas/sangue , Brasil , Ensaio de Imunoadsorção Enzimática , Unidades Hospitalares de Hemodiálise , Humanos , Microcistinas , Microcystis/isolamento & purificação , Peptídeos Cíclicos/análise , Peptídeos Cíclicos/sangue , Diálise Renal , Toxemia/complicaçõesRESUMO
In February 1996, an outbreak of illness occurred at a hemodialysis clinic in Caruaru, Pernambuco State-Brazil. At this clinic 116 (89%) of 131 patients experienced visual disturbances, nausea, vomiting, and muscle weakness, following routine haemodialysis treatment. Subsequently, 100 patients developed acute liver failure. As of December 1996, 52 of the deaths could be attributed to a common syndrome now called 'Caruaru Syndrome'. Examination of previous years' phytoplankton counts showed that cyanobacteria were dominant in the water supply reservoir since 1990. Analyses of carbon and other resins from the clinic's water treatment system plus serum and liver tissue of patients led to the identification of two groups of hepatotoxic cyanotoxins: microcystins (cyclic heptapeptides) in all of these samples and cylindrospermopsin (alkaloid hepatotoxic) in the carbon and resins. Comparison of victims symptoms and pathology with animal studies on these two cyanotoxins, leads us to conclude that the major contributing factor to death of the dialysis patients was intravenous exposure to microcystins, specifically microcystin-YR, -LR and -AR. In 2000, a review of the Brazilian regulation for drinking water quality, promoted by Brazilian Health Ministry with collaboration of PAHO, incorporated cyanobacteria and cyanotoxins into this new regulation as parameters that must to be monitored for water quality control.
Assuntos
Carcinógenos , Peptídeos Cíclicos/intoxicação , Diálise Renal/efeitos adversos , Animais , Brasil , Doença Hepática Induzida por Substâncias e Drogas/etiologia , Doença Hepática Induzida por Substâncias e Drogas/patologia , Eutrofização , Humanos , Fígado/química , Fígado/patologia , Microcistinas , Peptídeos Cíclicos/sangue , Fitoplâncton , Ratos , Microbiologia da Água , Abastecimento de Água/análiseRESUMO
BACKGROUND: After a drought in February, 1996, all 126 patients in a haemodialysis unit in Caruaru, north-east Brazil, developed signs and symptoms of acute neurotoxicity and subacute hepatotoxicity following the use of water from a lake with massive growth of cyanobacteria (blue-green algae). 60 patients died. METHODS: Besides recording clinical details and outcome at follow-up, we arranged laboratory, radiological, and histological investigations on the patients and toxicological studies of serum and haemodialysis water filters. FINDINGS: The acute presentation was with malaise, myalgia and weakness, nausea and vomiting, and tender hepatomegaly, with a range of neurological symptoms from tinnitus, vertigo, headaches, and deafness to blindness and convulsions. Liver injury ranged from abnormal liver-function test results to rapidly progressive and fatal hepatic failure. Biochemical investigations revealed gross hyperbilirubinaemia, abnormal liver enzyme activities, and hypertriglyceridaemia, but there was no evidence of haemolysis or microangiopathy. Histology revealed a novel acute toxic hepatitis with diffuse panlobular hepatocyte necrosis, neutrophil infiltration, canalicular cholestasis, and regenerative multinucleate hepatocytes. Samples of serum, dialysis filters, and water-treatment columns contained microcystins, the highly toxic low-molecular-weight hepatotoxins produced by cyanobacteria. INTERPRETATION: Cyanobacteria present water-borne hazards to health via drinking water and recreational water. Haemodialysis presents an additional high-risk exposure route: when they enter directly into the circulation, microcystins can lead to fatal clinical syndromes ranging from acute neurotoxic illness to subacute liver failure.