Clinical-laboratorial characteristics Toxocara canis serology and ...

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Rev Panam Infectol 2010;12(1):47-53. fatores predisponentes com a presença de anticorpo anti-Toxocara canis (T. canis). A piomiosite tropical predominou no gênero masculino (69,5%). Os sinais e sintomas mais frequentes foram enduração (95,8%) e febre (90,7%). O comprometimento muscular foi único em 66,1% dos casos, sendo encontrado envolvimento de múltiplos grupos musculares em 33,9%. Foram observados trauma fechado (39,8%), baixo peso (62,2%), linfoma (0,8%) e uso de corticosteroide (0,8%). A sorologia para T. canis foi positiva em 52,6% dos pacientes. A anemia foi complicação frequente no estágio tardio da doença (x² = 6.23, p = 0.044). O Staphylococcus aureus (S. aureus) foi isolado em 83,3% das culturas de abscessos e em 90% das hemoculturas. Em quatro pacientes classificados com escore de gravidade moderada e severo, três tinham sorologia positiva para T. canis, em comparação com 14 com escore leve, dos quais sete tinham sorologia positiva. Este estudo alerta para a importância da piomiosite tropical e infecção por T. canis na população pediátrica, ambas as patologias infecciosas curáveis, no entanto, de alta incidência em regiões tropicais. Palavras-chave: Piomiosite, população pediátrica, Staphylococcus aureus, estafilococcia, miosite. Introduction Conceptualized as a pyogenic infection which affects the skeletal musculature, by the non-contiguous septic focus expansion, or resulting from non-penetrating traumas, very rare in low temperate or cold weather regions, but relatively common in certain hot and wet tropical regions. But it has an increasing description in temperate regions and developed countries, being so called non-tropical pyomyositis, and in this case, it’s most part related to an immunodepressor factor. (1-5) The disease can occur in any age, being more common in male young adults. The causative agent is, in the most parts of cases, the S. aureus. (4-6) For the majority of authors the closed trauma upon the muscles is the initial lesion to the pyomyositis development. The trauma theory is well accepted when it’s about abscesses involving only one muscle group. However, when the myositis is diffuse and takes multiple muscle groups, this theory is more difficult to be explained as an exclusive cause. (6-10) Toxocariases has been suggested in the tropical pyomyositis pathogenesis. The migration of T. canis larvae to the skeletal musculature would cause structural and immunological alterations, which in the presence of the concomitant bacteremia, would favor development of the pyomyositis. (11-12) The clinical and the severity of case depend on the patient’s disease. The pyomyositis treatment is based on beta-lactamic antibiotics, as the main isolated germ is 48 S. aureus. The invasive process, abscesses drainage and myonecrosed tissues debridement, depend on the patient’s historic and may be always searched when there is maintenance of fever. (3,6,7,9) The complications are rare and occur more frequently within the supurative and late stages. The prognostic is excellent and the mortability is low. (1,2,5,6,8,9) The aim of this study was to evaluate the clinical and laboratorial situation and the mortality rate, upon the different rolling stages of tropical pyomyositis, of hospitalized children in the public health care of Manaus, Amazonas, during 1997 January to 2008 July. Patients and methods Study design A descriptive and analytical cross sectional study was performed, divided in two phases: retrospective phase comprehended medical files of pyomyositis diagnosed children, hospitalized in the Amazonas’ Tropical Medicine Foundation (FMTAM), from January 1997 to December 2006; and prospective phase from July 2007 to July 2008. Criteria of the eligibility Inclusion criteria: Children between < 1 year old and = 14 years old and clinical diagnostic of pyomyositis confirmed by ultrasound exam or surgery intervention. Exclusion criteria: Children < 1 year old and > 14 years old; hospital skeletal muscle infection; superficial dermal infections with only skin or subcutaneal involvement, such as abscesses, boil, impetigo, pyodermitis and cellulites; soft tissues secondary infections or contiguous to penetrating or drilled traumas; soft tissues secondary infections to accidents with venomous animals. Clinical diagnosis The diagnosis was based on clinical criteria: local edema with muscle indurations or fluctuance, hyperemia, local pain and hyperthermia or fever, muscle involvement confirmed by ultrasound exams or invasive surgery procedure. Predispose factors for the development of infection were investigated such as closed trauma background, dermal lesions, diabetes or family diabetes historical, malnutrition, neutropenia, Acquired Human Immunodeficiency Syndrome (AIDS), diseases, chemotherapies, use the immunosupressors and steroids, viral and parasitic infections. The clinical stratification was based on the Gibson RK et al., (2) definition which divides the disease in: 1 - Early or invasive stage – all patients with fever, muscle pain, hyperemia, firm indurations, with up to 10 days of evolution; 2 - Supurative stage – included
all patients with 10 to 20 days of after symptoms appearance; 3 - Late or septicemic stage – patients with more than 21 days of evolution, with metastatic focus evidences or sepsis signals. In order to have homogeneity in the patient groups, the definition of clinical concepts, complications diagnosis and optimization of laboratorial finds were considered in the prospective and in the retrospective phase: Fever – temperature elevation upon 37,8ºC, measured in the axilla; Sepsis – evidence of infection associated with an systemic inflamatory syndrome (SIRS), characterized by tachycardia (heart rate > 90 beats/min), tachypnea (respiratory rate > 20) and temperature alteration with hypothermia (Temp. < 35ºC) or hyperthermia (Temp. > 38ºC) with clinical emphasis and not necessarily a positive blood culture; Septic shock – volume refractory hypotension, need of vasoative drugs, in patients with systolic pressure < 90 mmHg, associated to septic syndrome; Respiratory insufficiency – respiratory frequency < 20, description of dyspnea, or respiratory discomfort; Renal failure – description of oliguria, anuria, or serum increase of urea and creatinine; Transinfectious hepatitis - jaundice associated to hepatomegaly and alteration on the hepatic function exams, on the absence of viral hepatitis, congenital metabolic diseases, or hepatotoxic drugs use history, such as alcohol; Failure of multiple organs and systems (FMOS) – uncontrolled infectious process that have reached at least two or more organs producing failures. The severity of cases was scored based on the ODIN (Organ Dysfunctions and/or Infection) and SOFA (Sequential Organ Failure Assessment) with data up to 48 hours of hospitalization, for later analyses and prognostic. Laboratorial diagnosis For the prospective study, 16 ml of blood was collected in disposable syringe through venopunction and quoted for lab exams: 5 ml for hematologic and biochemistry exams; 3 ml for hemoculture; 3 ml of centrifugated blood for Toxocara and HIV serology. Biochemical and hematologic exams were performed using a DADE-BEHRING, model DIMENSION. It was considered: Anemia – hemoglobulin < 10,0g/dl; Leukocytosis – leucocytes count superior to 10.000/ mm³; Leukopenia – leucocytes count up to 4.000/mm³; Eosinophilia – eosinophiles count upon 6%. Biologic samples were processed in the FMTAM Bacteriology lab, according to routine that comprehend Gram bacterioscopy and solid culture media seeding in Blood Agar (BA) or Chocolate Agar to obtaining colonies, coagulase and catalase positive identification tests. Hemocultures were seeded in liquid culture media and done through automation method in BACTEC. For the sensibility study was used the quantitative Damian MM, et al • Clinical-laboratorial characteristics toxocara canis serology... Kirby-Bauer test. The results were interpreted conform the CLSI (Clinical and Laboratory Standards Institute). Ultrasound exam or computed tomography was performed for muscle involvement confirmation to find the best place to draining the abscess. The presence of Anti-HIV (Human Immunodeficiency virus) antibodies was investigated through Quick test in filter paper with soluble antigens (FIOCRUZ/BIOMANGUINHOS). The Toxocariases serology through investigation of anti-T. canis antibodies by ELISA technique using the RIDASCREEN ® commercial kit were performed. Statistical analyses The statistical analyses were performed with the SPSS version 9.0 program. The Chi square test was used with Yates correction, exact Fisher test and Mantel-Haenszel for tendencies. The results were considered significance if the p value was p = 0.05 (a-level) with confidence interval of 95%. Ethics aspect This study was approved by the ethical commission of FMTAM (protocol number 135, 1105/05 e 2477/06). All legal responsible persons for child consent term to subscribe. Results The distribution of 118 children diagnosed with tropical pyomyositis included was: 19.5% (23/118) in the prospective phase and 80.5% (95/118) in the retrospective phase, having a major male frequency 69.5% (82/118). The average age was 8.0 years old (SD 4.6). The demographic characteristics and results of lab examinations were similar between retrospective and prospective phases of the study (table 1). The most common signals and symptoms found were indurations 95.8% (113/118) and fever 90.7% (107/118). Fluctuations of the muscle abscesses were present in 20.3% (24/118). In 66.1% (78/118) of cases presented single muscle involvement and 33.9% (40/118) multiple muscle involvement. These were predominating in the inferior members and pelvis. Among predisposal factors described for the disease, the secondary muscle damage to closed trauma was found in 39.8% of cases, chickenpox provoking a viral myositis in 13.9%, 0.8 % lymphoma and 0.8% chronic using of corticosteroids because of a dermatitis contact. It wasn’t demonstrated family history of mellitus diabetes and the plasma glucose was normal in all patients. The nutritional status estimated by the ratio weight/age was evaluated in 38.1% (45/118). This relation was low in 62.2 % (28/45) of the children, using as reference the National Center of Health Statistics (NCHS) data. The HIV quick test was performed 49
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Page 5 and 6: Figure 1. Age average of 118 childr
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