Clinical-laboratorial characteristics Toxocara canis serology and ...

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Rev Panam Infectol 2010;12(1):47-53. traumas and physical effort related to sport practicing. We observed predominance between the female gender in age range 6 to 10 years old in the prospective phase of the study, also reported by Ryan. (14) There are some differences pointed in the literature, suggesting some distinction between tropical and non-tropical pyomyositis, such as age, number muscle and areas affected. The tropical pyomyositis, prevails in adults, with characteristic involvement of multiple muscle groups, generally in inferior members; nontropical pyomyositis occurs more frequently in children, with single muscle involvement and predominantly in thighs. (4,5) In our sample, the muscular involvement was single, with predominance of the inferior members and pelvis, which is in agreement with literature. (2,5,6-9,15) The pyomyositis occurrence in non-tropical countries is related with immunosupression factors such as: diabetes mellitus, a leukemia, aplastic anemia, malnutrition, use of corticotherapy, auto-immune diseases, HIV/AIDS and injectable drug users. (5,6,9) Among these risk factors we found one child using corticotherapy for long period and another with lymphoma, and no child presented diabetes or positive for HIV. We observed that 62.2% of the children presented low nutritional status, in agreement of 70.3% described previously. (5) Concerning the pathogeneses of the disease, muscle lesion seems to occur after closed trauma, ischemia, muscle fatigue, metabolic stress, responding to the sepses/SIRS presence (Systemic Inflammatory Syndrome). Further, there are recent evidences of association between T. canis infection and the occurrence of “pyogenic” abscesses, suggesting the hypothesis that infected individuals by T. canis are more predisposed to Staphylococcus infections. The L3 larvae migration to the skeletal muscle would lead to structural and immunological alterations, which, in the presence of bacteria would favor bacteria adherence and pyomyositis development. In this experimental study using mice corroborates to the muscular damage in the pyomyositis development hypothesis. The authors observed a higher frequency of muscle abscesses among the T. canis and S. aureus double infected group. (11,12) In this study, T. canis serology was positive in 52.6% (10/18) of children affected by pyomyositis. Interestingly, a parallel study from our group revealed serum positivity for T. canis in 48.5% (16/33) of a pediatric control population without pyomyositis recruited from the same geographic region. (16) This powerfully contrasts with previous data showing 1% of positivity for T. canis sorology in a population of 20 individuals from 8 to 16 years old from southeastern Brazilian state of Minas Gerais. (12) It is possible to hypothesize that the high prevalence of positive T. canis sorology in the Amazonic population may be directly related to an increased risk of pyomyositis in 52 the same population. However, it is also possible that this hypothetical correlation may be confounded by the high frequency of T. canis exposed individuals, due to lower socio-economical status of the northern pediatric population as compared to Brazilian southern regions. Several studies have demonstrated that toxocariases is a relevant public health problem and largely distributed, prevalence varying from less than 1% in the developed countries reaching 92.8% in poorer and developing countries. (17) Seems that children are exposed to T. canis because they have more soil and pet contact, in addition, pets are a common contamination way. The seroprevalence T. canis reported in two studies involving children were similar to our results, 39% of cases in Vitória, Espirito Santo (18) and 52% in a rural population of Presidente Figueiredo, Amazonas. (16) Controversially, seroprevalence among healthy individuals of all ages, in five municipalities of São Paulo, showed low seroprevalence, 2.2% to 5.7%. (19) The co-infection with bacterial and helminthic diseases has been described in the literature. The intensity and the type of the immune response against an infectious agent can determinate the infection damage, rolling and prognostic. Lots of pathologies can be associated and the co-infection seems to exercise an immunomodulator role, with evidences in the helminthic infections, as S. mansoni and the nematode T. canis. (11) Three out of four cases with positive for T. canis serology had the worst severity score and one died, in this study. These children had their diagnostic in the early stage of the disease, fact that exclude the possibility of the severity being related to late treatment which is pointed as the main contributing factor to the disease morbidity and mortality. The early clinic diagnostic of the disease depends on a strong index suspicion, because the inflammatory signals are minimal and sometimes the muscle fiber involvement is too deep. Marques et al, 1995, in study involving 15 adults and 12 children, has demonstrated a low frequency of fluctuation of the muscle abscesses (11.1%), found more commonly in late stage of the disease. This, also, was demonstrated by Martinez-de Jesus et al, 1996, 40 cases of which 9 were children. Maybe, this study, it is also justified by early diagnosis. (6-8) Large casecontrol samples are necessary to formally investigate the real impact of T. canis infection as a risk factor for the development of tropical pyomyositis. S. aureus was the main isolated bacteria. Although, the low percentage of oxacilin resistance. S. aureus infection raised rate has been in headlines of several recent publications, because of the reduced sensibility profile to different antibiotics, leading to the difficult question about the treatment, specially in skin and soft parts infection. (20) Considered an opportunistic
agent, S. aureus often is associated to community acquired infections, or in a hospital environment. Some infections are acute, pyogenic and can disseminate to several tissues and to promote metastatic infectious focus leading to bacteremia episodes, pneumonia, endocarditic, pericarditis, meningitis, brain and of other organs abscesses as the skeletal muscle. (21) Tropical pyomyositis complications are rare and occur more often in the supurative or late stages, showing that the non establishment of a diagnostic in the early stage of the disease slows the antibiotic treatment and directly interfere in the patient’s evolution. It seems to be an increased susceptibility to osteomielitis and pyoartritis in children. However, our results are in disagreement regarding osteomielitis. Sepsis was the most common complication, followed by acute respiratory failure, shock, acute renal failure, disseminated intravascular coagulation and high digestive bleeding. These results agreed with most of the previous studies. (5-9,22,23) The fact that we used secondary data retrospectively, our serology sample size was limited. However, our results indicate that there is a relation among presence of antibody anti-T. canis and muscle abscess. Tropical pyomyositis has shown to be an important pediatric pathology which despites low mortality but may have serious clinical repercussion. We could not statistically demonstrate that T. canis co-infection contribute to disease morbidity. However, it was observed that three out of four cases classified as severe or moderate were seropositive to T. canis. These patients were diagnosed in the early stage of the disease, fact that exclude the possibility of the severity being related to late treatment which is pointed as the main contributing factor to the disease morbidity and mortality. Acknowledgments We thank Dr. Sinésio Talhari, Dr. Joaquim Alves Barros, and the multidisciplinary team who assisted the children, particularly nurses, pediatric doctors and orthopedists. We also thank the Fundação de Amparo à Pesquisa do Amazonas (FAPEAM) for the financial support. References 1. Shepherd J. Tropical myositis: Is it an entity and what it is cause? The Lancet 1983;1:1240-42. 2. Gibson R, Rosental S, Lukert B. Pyomyositis: Increasing recognition in temperate climates. American Journal of Medicine 1984;77:768-72. 3. Chauhan S, Jain S, Varma S, Chauhan SS. Tropical pyomyositis (myositis tropicans): current perspective. Postgrad Medical Journal 2004;80:267-270. Available in: http://pmj.bmj.com/ cgi/content/full/80/943/267. 4. Crum-Cianflone NF. Infectious myositis. Best Practice & Resear cher Clinical Rheumatology 2006;20:1083-97. 5. Villamil-CajotoI, Maceiras-Pan F, Villacián-Vicedo MJ. Piomiositis: presentación de 17 casos en niños y adultos. Revista Médica Chile 2006;134:31-38. Damian MM, et al • Clinical-laboratorial characteristics toxocara canis serology... 6. Christin L, Sarosi GA. Pyomyositis in North America: Case reports and review. Clinical Infectious Diseases 1992;15:668-77. 7. Chiedozi L. Pyomiositis. Review of 205 cases in 112 patients. The American Journal of Surgery 1979;137:255-59. 8. Martinez-de Jesus F and Mendiola-Segura I. Clinical stage, age and treatmentin tropical pyomiositis: A retrospective study including forty cases. Archives of Medical Research 1996;27:165-70. 9. Marques G, Filho G, Valiatti M, Hamra A, Valiatti J, Mastrocola A et al. Piomiosite Tropical: Estudo Retrospectivo de 27 casos. Revista Brasileira de Reumatologia 1995;35:192-99. 10. Uribes-Flores J, Flores-Sobrevilla A. Piomiositis Tropical: Informe de 25 casos. Revista Médica del Instituto Mexicano del Seguro Social 1989;27:366-68. 11. Lambertucci JR, Rayes A, Serufo J, Nobre V. Pyogenic abscesses and parasitic diseases. Revista do Instituto de Medicina Tropical de São Paulo 2001;43:63-74. 12. Rayes A, Nobre V, Teixeira D, Serufo JC, Filho G, Antunes C et al. Tropical pyomyositis and human toxocariasis: A clinical and experimental study. The American Journal of Medicine 2000;109:422-25. 13. Gubbay AJ and Isaacs D. Pyomiositis in children. Pediatric Infectious Diseases Journal 2000;19:1009-13. 14. Ryan B. Pyomyositis in Papuan children. Transaction of the Royal Society of Tropical Medicine and Hygiene 1962;56:312. 15. Spiegel DA, Meyer JS, Dormans JP, Flynn JM, Drummond DS. Pyomiositis in children and adolescents: report of 12 cases and review of the literature. Journal Pediatric Orthopedic 1999;19:143-50. 16. Damian MM, Martins M, Sardinha JF, Souza LO, Chaves A, Tavares AM. Frequency of the antibody anti-Toxocara canis in a community along the Uatumã River, State of Amazonas. Revista da Sociedade Brasileira de Medicina Tropical 2007;6:661-64. 17. Andrade LD. Aspectos clínico-epidemiológicos da toxocaríase humana. Revista de Patologia Tropical 2000;29:147-59. 18. Moreira S, Leão M, Mendonça H, Pereira F. Prevalence of anti-Toxocara antibodies in a random sample of in patients at a children’s hospital in Vitoria, Espirito Santo, Brazil. Revista do Instituto de Medicina Tropical de São Paulo 1998;40:259-61. 19. Cieffi PP, Ueda M, Camargo E, Souza A, Guedes M, Gerbi L et al. Visceral Larva Migrans: A soroepedemiological survey in five Municipalities of São Paulo State, Brazil. Revista do Instituto de Medicina Tropical de São Paulo 1990;32:204-10. 20. Cosgrove SE, Sakoulas G, Perencevich EM, Schuwaber MJ, Karchmer AW, Carmeli Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clinical Infectious Diseases 2003;36:53-9. 21. Ribeiro A, Dias C, Silva-Carvalho MC, Berquó L, Ferreira FA, Santos RN et al. First Report of with Community Acquired Methicillin-Resistant Staphylococcus aureus in South America. Journal of Clinical Microbiology 2005;43:1985-88. 22. Vieira I, Franco G, Silva M, Medeiros S. Piomiosite tropical como causa de falência de múltiplos órgãos (FMOS). Revista Brasileira de Terapia Intensiva 1996;8:179-84. 23. Bikels J, Ben-Sira L, Kessler A, Wientroub S. Primary pyomyositis. Journal Bone Joint Surgery American 2002;84-A:2277-86. Correspondence: Dra. Márcia Melo Damian Fundação de Medicina Tropical do Amazonas, Departamento de Assistência Medica, Gerência de Bacteriologia e Coordenação de Mestrado e Doutorado da FMTAM. Av. Pedro Teixeira, 25 - Bairro D. Pedro I CEP 69000-40 - Manaus - Amazonas - Brasil. e-mail: jorgemarcia@uol.com.br 53
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