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Asthma; Asthma worsening; Eosinophilic asthma Asma; Empitjorament de l'asma; Asma eosinofílica Asma; Empeoramiento del asma; Asma eosinofílica Background Prostaglandin D2 receptor 2 (DP2) antagonists inhibit prostaglandin D2-induced effects, including recruitment and activation of cells driving asthma pathogenesis. However, challenges identifying target population and end points persist. Research Question What is the effect of the DP2 antagonist GB001 on asthma worsening in patients with moderate to severe eosinophilic asthma? Study Design and Methods In this phase IIb, randomized, double-blind, placebo-controlled, dose-ranging, parallel-group, multicenter study, GB001 or placebo was added to standard-of-care treatment in patients with moderate to severe asthma with a blood eosinophil count ≥ 250 cells/μL. Patients aged ≥ 18 years to < 75 years received one of four once-daily treatments (GB001 20 mg, 40 mg, or 60 mg or placebo). The primary end point was the proportion of patients who experienced asthma worsening by 24 weeks. Efficacy analyses were performed for the intention-to-treat population and safety analyses for patients who received at least one dose of study treatment. Results A total of 480 patients were treated. The ORs for asthma worsening for GB001 20 mg, 40 mg, and 60 mg vs placebo were 0.674 (95% CI, 0.398-1.142), 0.677 (95% CI, 0.399-1.149), and 0.651 (95% CI, 0.385-1.100), respectively. Analysis according to baseline blood eosinophil levels and/or fractional exhaled nitric oxide did not show greater treatment effects with higher values. Elevated liver aminotransferase levels and adverse events leading to discontinuation were more frequent for GB001 60 mg than with placebo, GB001 20 mg, and GB001 40 mg. Interpretation Although GB001 did not significantly reduce the odds of asthma worsening, reductions favoring GB001 were observed. Treatment effects were consistent regardless of high/low type 2 phenotype. The overall safety profile was acceptable, although GB001 60 mg was associated with risk of liver injury. This work was supported by GB001, Inc., a wholly owned subsidiary of Gossamer Bio, Inc.

A esquistossomose é uma doença parasitária crônica causada pelo platelminto Schistosoma mansoni da classe trematoda. Sua disseminação ocorre por um ciclo heteroxeno: com presença de hospedeiro intermediário que é o molusco do gênero Biomphalaria, popularmente conhecido como caramujo e por um hospedeiro definitivo que é o homem. Segundo a Organização Mundial de Saúde, 6 milhões de indivíduos são portadores da forma intestinal da doença no Nordeste; principalmente em Alagoas, um estado endêmico, banhado por rios, lagos, açudes e com sistema de saneamento básico deficiente, o que justifica a alta incidência, prevalência e sua classificação em área de risco. Os índices epidemiológicos que foram avaliados em 70 dos 102 municípios trazem valores de 12.652 casos em 2013 com, 49 mortes notificadas no mesmo ano. Outros índices apresentados mostram que, em 2014, Alagoas ainda era a região do Nordeste e do Brasil com mais notificações de casos de esquistossomose. O estudo objetiva analisar a atuação do sistema imune humano durante a fase aguda de infecção por esquistossomose e compreender o processo da eosinofilia causada pela presença do Schistosoma mansoni no organismo infectado. Então, compreender o curso e fisiologia da infecção, assim como o mecanismo de resposta do sistema imune no combate a parasitemia é fundamental frente aos dados alarmantes de casos, a fim de auxiliar em novas descobertas contra a infecção, melhorar as formas de tratamento e qualidade de vida do portador.

Asma eosinofílica greu; Comparació indirecta del tractament; Mepolizumab Severe eosinophilic asthma; Indirect treatment comparison; Mepolizumab Asma eosinofílica severa; Comparación de tratamiento indirecto; Mepolizumab Aim To analyse the cost-effectiveness of MEP with standard of care (SoC) versus other anti-IL-5 therapies approved for the treatment of severe eosinophilic asthma (SEA) patients, within the Spanish National Health System (NHS) perspective. Methods A Markov model with a 4-week cycle length was used to compare MEP with BEN and RES as therapies added to SoC in the management of SEA, in terms of cost per QALY gained and incremental cost-effectiveness ratio (ICER). Costs (€2019) were obtained from public sources, while utilities and transition probabilities were retrieved from literature, e.g. network meta-analysis. Continuation criteria for biological treatment and reduction of oral corticosteroids (OCS) was set at 50% minimum reduction of exacerbation rate. Adverse events related to chronic OCS use included diabetes, osteoporosis, cataracts, acute myocardial infarct, and peptic ulcer. The analysis was performed over a 5-year time horizon from the National Healthcare System (NHCS) perspective, with a yearly discount rate of 3% applied to both costs and QALYs. Probabilistic sensitivity analysis and univariate deterministic sensitivity analysis were performed to address uncertainty around the cost-effectiveness results. Results On top of SoC, the model indicates that MEP is dominant (lower cost, higher benefit) compared to BEN and RES: For BEN and RES, respectively, treatment with MEP had a point estimate of 0.076 and 0.075 additional QALYs, and savings of €3,173.47 and €7,772.95 per patient. The findings were robust to variation as estimated using sensitivity analysis. Conclusions MEP is a cost-effective treatment in comparison with BEN and RES added to SoC for patients with SEA in the Spanish setting. This study was funded by GlaxoSmithKline [Study code: HO-19-19968].

Eosinófilos; Morfología; Neoplasia mieloide Eosinòfils; Morfologia; Neoplàsia mieloide Eosinophil; Morphology; Myeloid neoplasia Morphological features of eosinophils in patients with reactive eosinophilia (28 patients) and clonal eosinophilia (26 patients) have been compared with each other and with the eosinophil characteristics of healthy volunteers (three subjects) and of patients with the idiopathic hypereosinophilic syndrome (three patients). Morphological features, assessed in isolation from other haematological abnormalities, were found to have poor specificity for a myeloid neoplasm. The most useful feature was the presence of basophilic granules in mature eosinophils, which was associated particularly with acute myeloid leukaemia with inv(16). Marked reduction in granules occurred more often in some subsets of the myeloid neoplasm group but nevertheless was lacking in specificity since it was not infrequently seen in reactive eosinophilia. Although experienced morphologists more often considered that a myeloid neoplasm was likely in patients in whom this was the diagnosis (69%), myeloid neoplasia was also considered likely in a considerable proportion (39%) of patients with reactive eosinophilia. Morphological abnormalities of eosinophils therefore cannot be assessed in isolation in seeking to make a diagnosis of a myeloid neoplasm. Morphology is, however, needed and should be integrated with the results of other investigations.

A 77-year-old male, with a history of heart failure and atrial fibrillation receiving warfarin, hypothyroidism, diabetes mellitus and hyperuricaemia, with a one-year history of erythematous and desquamative skin lesions in the trunk, pruritic and moderate recurrent eosinophilia. After allergic, parasitic, autoimmune and neoplastic causes were ruled out, the diagnosis of idiopathic hypereosinophilic syndrome was done. He was treated with prednisone and hydroxyurea, resulting in complete remission of eosinophilia and progressive improvement of dermal lesions. Varón de 77 años de edad, con antecedentes de insuficiencia cardiaca y fibrilación auricular recibiendo warfarina, hipotiroidismo, diabetes mellitus e hiperuricemia, con historia de un año de lesiones dérmicas eritematosas y descamativas en el tronco, pruriginosas y con moderada eosinofilia recurrente. Después de descartarse causas alérgicas, parasitarias, autoinmunes y neoplásicas, se hizo el diagnóstico de síndrome hipereosinofílico idiopático. Recibió tratamiento con prednisona e hidroxiurea, consiguiéndose una remisión completa de la eosinofilia y mejoría progresiva de las lesiones dérmicas.

To evaluate co-infection of Strongyloides stercoralis and Trypanosoma cruzi and to assess eosinophilia as a screening test for the detection of S. stercoralis infection in patients with Chagas disease (CD).A retrospective diagnostic validation study was performed on serum samples from primary care patients diagnosed with CD in the southern Barcelona metropolitan area. All samples with eosinophilia (n = 87) and a random sample of non-eosinophilic sera (n = 180) were selected. Diagnosis of CD was based on positive serology by means of two tests: ORTHO® T. cruzi ELISA test, and BIO-FLASH® Chagas or Bioelisa CHAGAS. SCIMEDX ELISA STRONGY-96 was used to diagnose strongyloidiasis.Strongyloides stercoralis serology was positive in 15% of patients of whom 95% showed eosinophilia, vs. 21% of those with negative serology (P 0.001), with differences in the mean eosinophil count (0.49 vs. 0.27 × 10The prevalence of co-infection by T. cruzi and S. stercoralis is not negligible and has probably been underestimated for years in many areas, due to frequently subclinical infections. Therefore, serology seems mandatory for these patients and the use of eosinophilia as initial screening could facilitate the task, decreasing the number of analyses to be performed.Evaluer la coinfection par Strongyloides stercoralis et Trypanosoma cruzi et évaluer éosinophilie comme un test de dépistage pour la détection de l’infection à S. stercoralis chez les patients atteints de la maladie de Chagas (MC). MÉTHODES: Une étude de validation diagnostique rétrospective a été réalisée sur des échantillons de sérum de patients de soins primaires diagnostiqués avec la MC dans la région métropolitaine du sud de Barcelone. Tous les échantillons avec éosinophilie (n = 87) et un échantillon aléatoire de sérums non éosinophiliques (n = 180) ont été sélectionnés. Le diagnostic de la MC était basé sur une sérologie positive au moyen de deux tests: le test ELISA ORTHO® T. cruzi et le test BIO-FLASH® Chagas ou Bioelisa CHAGAS. SCIMEDX ELISA STRONGY-96 a été utilisé pour diagnostiquer la strongyloïdose. RÉSULTATS: La sérologie de S. stercoralis était positive chez 15% des patients dont 95% présentaient une éosinophilie, contre 21% de ceux avec une sérologie négative (P0,001), avec des différences dans le taux moyen d'éosinophiles (0,49 contre 0,27 × 10La prévalence de la coinfection par T. cruzi et S. stercoralis n'est pas négligeable et a probablement été sous-estimée depuis des années dans de nombreuses régions, en raison d'infections fréquemment infracliniques. Par conséquent, la sérologie semble obligatoire pour ces patients et l'utilisation de l'éosinophilie comme dépistage initial pourrait faciliter la tâche, diminuant le nombre d'analyses à effectuer.

Resumen La gnatostomiasis es una parasitosis emergente en países no endémicos. Este nematodo zoonótico requiere de agua dulce para su ciclo de vida, donde sus larvas se enquistan principalmente en peces. La migración subcutánea de las larvas produce habitualmente una paniculitis eosinofílica de rápido avance. Se describe un caso clínico de un paciente con una lesión migratoria, sin mejoría clínica con terapia antibacteriana. La búsqueda de factores de riesgo, sumado a la evolución y a los hallazgos de laboratorio hizo sospechar el diagnóstico. La gnatostomiasis debe ser sospechado en pacientes con lesiones de piel migratorias, que han consumido pescado crudo durante viajes a países endémicos en Sudamérica o Asia.

Orientadores: Marlene Tiduko Ueta, Lucia Helena Faccioli Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Biologia Resumo: Neste estudo mostramos que camundongos infectados com as linhagens L-2 ou L-49 de Strongyloides venezuelensis induzem aumento de leucócitos totais, eosinófilos (EO) e células mononucleares (MO) no sangue, na cavidade peritoneal (LCP) e espaço broncoalveolar (LBA) de formas semelhantes. Ambas linhagens estimularam síntese de citocinas do padrão TH1 ou TH2 da resposta imune, com maior tendência para TH2. L-2 foi mais infectante que L-49, induzindo precocemente maior síntese de IL-4, IL-5 e IFNy e anticorpos. Houve correlação positiva entre indução de maior síntese de IL-4 e de IgG e maior expulsão do parasita pela L-2. Não houve correlação entre indução de maior síntese de IL-5 e maior proliferação e recrutamento de EO e MO. O tempo e a temperatura de manutenção das culturas influenciaram na infectividade do parasita. Com menor tempo de permanência das larvas nas culturas estas induziram resposta imune inata mais intensa no sangue e no LCP, com eliminação mais rápida dos parasitas. Larvas obtidas a temperatura mais alta induziram eosinofilia mais intensa e precoce no LCP, e sob temperatura mais baixa, a eosinofilia foi menor e tardia. Larvas mantidas por menor tempo nas culturas estimularam resposta imune celular capaz de expulsar mais rapidamente as fêmeas parasitas, e as mantidas por maior tempo e sob temperaturas mais altas induziram maior síntese de anticorpos e de IL-4 e IL-10. Larvas mantidas por menor tempo nas culturas induziram maior síntese de IL-12, e as de maior tempo, maior produção de IFN-y. O tempo e/ou temperatura não influenciaram a síntese de IL-5. Observamos que leucotrienos participam do aumento de leucócitos totais, EO e MO no sangue, no LCP e LBA na estrongiloidíase. A IL-5 também participa no aumento de leucócitos nesses compartimentos. IL-12 e IFN-y protegem o parasita contra as defesas do hospedeiro. Verificamos que as oito linhagens de S. venezuelensis apresentaram antigenicidade semelhante, detectada por imunofluorescência indireta, ELISA e "Immunoblot". O anticorpo IgG anti-S. stercotalis reconheceu a fração antigênica de peso molecular aparente de 45 kDa. Assim, antígenos destas linhagens podem ser usados no imunodiagnóstico da estrongiloidíase humana. Palavras chave: Strongyloides venezue/ensis, estrongiloidíase, leuc6citos totais, eosinofilia, células mononucleares, citocinas, anticorpos, leucotrienos, imunodiagnóstico Abstract: In this study, we have shown that, in mice, L-2 and L-49 strains of S. venezuelensis induced an increase in the total number of leukocytes, eosinophils (EO) and mononuclear cells in blood, peritoneal cavity (LCP) and in the bronchoalveolar space (LBA), in a similar manner. Both strains stimulated synthesis of TH1 or TH2 type immune response cytokines, with a greater tendency to TH2. L-2 strain was more infective than L-49, inducing earlier synthesis of IL-4, IL-5 and IFN-y, and antibodies. In L-2, there was a direct correlation between greater production of IL-4 and IgG and expulsion of parasites, but no correlation to greater synthesis of IL-5 or proliferation and recruitment of EO and MO. Time and temperature had influence on parasite infectivity. Larvae that remained in the cultures for shorter periods of time had their infectivity affected, inducing a more intense innate immune response in blood and LCP, with rapid elimination of the parasites. Parasites kept in higher temperatures rapidly induced higher eosinophil levels in LCP, while for low temperatures, eosinophils appeared later and in lower numbers. When larvae were cultured for shorter periods of time, they stimulated a cellular immune response capable of quickly expelling female parasites, while those submitted to shorter periods and high temperatures induced a higher synthesis of antibodies, IL-4 and IL-10. Larvae kept in culture for short periods induced greater synthesis of IL-12, while longer periods lead to greater IFN-y production. Neither time nor temperature affected IL-5 synthesis. It was observed that, in strongyloidiasis, leukotrienes participate on the increase of total leukocyte numbers, EO, and MO in blood, LCP and LBA. IL-5 is also involved in the increase of leukocyte numbers in these compartments. 80th IL-12 and IFN-y protect the parasite against host defense. It was also verified, through indirect immunofluorescence, ELISA, and Immunoblot, that eight strains of S. venezuelensis presented similar antigenicity. The antibody anti-S. stercoralis IgG was able to recognize the antigenic fraction with apparent molecular weight of 45 kDa. Therefore, antigens to these strains may be used for the immunodiagnosis of human strongyloidiasis. Key words: S. venezue/ensis, strongyloidiasis, leukocytes, eosinophils, mononuclear cells, cytokines, antibody, leukotrienes, immunodiagnosis, mice Doutorado Doutor em Parasitologia

Orientadores: Antonia Teresinha Tresoldi, Gil Guerra Junior Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas Resumo: A Paracoccidioidomicose é uma infecção causada pelo Paracoccidioides brasiliensis, que tem distribuição geográfica bem delimitada. Poucos são os casos na faixa etária pediátrica. O objetivo deste trabalho foi de analisar a apresentação clínica, evolução e seguimento de crianças com PCM e avaliar a função da supra-renal em um grupo de dessas crianças relacionando as concentrações hormonais com as manifestações clínicas e laboratoriais. A avaliação da função supra-renal foi realizada com a dosagem basal de cortisol, ACTH, renina, aldosterona e cortisol pós-estímulo com ACTH. Foram estudados 70 episódios de PCM. A proporção meninos: meninas foi de 1,3: 1. A idade variou de 2 a 15 anos (média de 8 +/- 3 anos, mediana de 8 anos). À admissão, a maioria dos pacientes apresentava algum grau de desnutrição protéico-calórica (70%). As principais queixas foram adenomegalia e febre com duração média de 84,3 dias (mediana 60 dias). A maioria (84,2%) dos diagnósticos foi realizada pela biópsia ganglionar. Os achados laboratoriais mais importantes foram: anemia, leucocitose com eosinofilia, hipoalbuminemia e hipergamaglobulinemia. A droga de escolha para o tratamento foi a associação sulfametoxazol-trimetoprina. Ocorreram seis óbitos. Demonstrou-se que a normalização dos exames laboratoriais (hemograma e eletroforese de proteínas) acontece até o sexto mês de tratamento. A avaliação da função supra-renal foi realizada em 23 crianças, sendo oito em fase aguda de doença. As médias (+/- desvio padrão) de cortisol, cortisol pós-estímulo, ACTH, renina e aldosterona foram, respectivamente, 12,88 (+/- 1,35) 'mu¿g/dl, 30,53 (+/- 2,12) 'um¿g/dl, 23,31 (+/- 1,72) pg/dl, 4,34 (+/- 5,75) ng/ml/h e 118,6 (+/- 98,0) pg/rnl, todos dentro dos limites da normalidade. Nenhum paciente apresentou hipotensão arterial aferida. Em todos os pacientes as dosagens de sódio e potássio séricos foram normais. Três pacientes apresentaram níveis elevados de aldosterona e/ou renina, sendo que esses resultados puderam ser explicados pela hipoalbuminemia e ascite apresentada por um paciente e pela importante hepatite fúngica apresentada pelo outro. Mesmo sendo rara em Pediatria a PCM deve ser lembrada nos casos de síndrome linfoproliferativa febril, em especial, nos casos que apresentam eosinofilia. A associação sulfametoxazol-trimetoprina se mostrou eficaz e o seguimento pode ser realizado com hemograma e eletroforese de proteínas. Os resultados mostram que na população estudada não ocorreu acometimento supra-renal Abstract: Paracoccidioidomycosis is a deep mycosis caused by Paracoccidioides brasiliensis, endemic in various regions of Latin América. The infection is thought to initiate in the lungs and then eventualy disseminate, via the bloodstream and/or lymphatics to alI parts of body. Few cases are describe in pediatric age. The objective of this work was to evaluate the clinical aspects, evolution, and follow up of children with Paracoccidioidomycosis and evaluate their adrenal function, related with basal concentration of cortisol, ACTH, renin, aldosterone, and cortisol response to ACTH. In this study, 70 cases of PCM were evaluated. The proportion between male female was 1.3:1. The children ranged in age from 2 to 15 years, with a mean of 8 +/- 3 and a median of 8. The majority of patients presented some degree of malnutrition as they arrived at the hospital. The main complain was adenomegalia and fever, reported to be present for at a mean of 84.3 days (median of 60 days). The majority of diagnosis (84.2%) was confirmed by lymph nodes biopsy. Anemia, eosinophilia, hypoalbuminemia hypergammaglobulinemia were frequently found. The drug of choice for treatment was an association of trimethoprim-sulfamethoxazole. Six deaths were observed. It was demonstrated that the laboratorial exams normalization (hemogram and protein electrophoresis) ocurred within 6 months of treatment. The adrenal assessment was performed in 23 children, 8 of them at the acute stage of the disease. The mean (± SD) of cortisol, post-stimulus cortisol, ACTH, renin, and aldosterone were, respectively, 12.88 (±1.35) 'mu¿/dI. 23.31 (±1.72) pg/dl, 4.34 (±5.75) ng/ml/h and 118.6 (±98.0) pg/mI. All these parameters were within the normal limits. None of the patients presented arterial hypotension. In alI patients, the serum levels of sodium and potassium were also normal. Tree patients presented higl levels of aldosterone and/or rennin. These results can be explained by the hipoalbulminemia and ascite presented by one of the patients, and by the fungal hepatitis presented by the other. Even being arare disease in pediatrics, Paracoccidioidomycosis must be considered in cases where a febrile lymphoproliferative syndrome, specialIy when eosinophilia occurs. The association of trimethoprim-sulfamethoxazole was safe and effective. The follow-up can be performed with protein eletrophoresis and hemogram. The results also shown that, in this population, the supra-renal was not compromised. Doutorado Pediatria Doutor em Saúde da Criança e do Adolescente

Characterising the eosinophilic profile represents the main step in chronic rhinosinusitis (CRS) endotyping. The aim of the study is to verify the correlation between different methods for tissue eosinophilia quantification.33 CRS patients undergoing endoscopic sinus surgery and 30 controls undergoing non-CRS surgeries were enrolled. Blood venous sampling, nasal biopsy on uncinate process (UP), nasal cytology on inferior turbinate (IT) and middle meatus (MM) were performed.Differences in eosinophil count in blood (P=0.0001), UP (P#x003C;0.0001), IT (P = 0.01) and MM (P = 0.0006) were significant between CRS cases and controls. A weak correlation was found between UP and blood eosinophil count (r = 0.34, P = 0.006) and between UP and IT eosinophil count (r = 0.30, P = 0.017). Moderate correlation between UP and MM (r = 0.51, P #x003C; 0.0001) was shown. ROC analysis predicted eosinophilic CRS with an overall low sensitivity. Once allergic patients were excluded from the analysis, the sensitivity decreased for sampling on IT and increased for MM sampling.This study suggests that MM cytology gives more accurate information on the degree of tissue eosinophilia. Replication in wide and unbiased cohorts is necessary to verify these results and define accurate thresholds.Il ruolo della citologia nasale nella rinosinusite cronica.L’identificazione del profilo eosinofilico è uno step fondamentale nell’endotipizzazione della rinosinusite cronica (RSC). Lo scopo dello studio è verificare il grado di correlazione tra le diverse metodiche di quantificazione dell’eosinofilia.Sono analizzati, per 33 pazienti RSC candidati a chirurgia endoscopica nasosinusale e 30 controlli sottoposti a chirurgia non RSC-correlata, un campione di sangue venoso periferico, una biopsia del processo uncinato (PU), un citologico sul turbinato inferiore (TI) e un citologico nel meato medio (MM).Differenze tra RSC e controlli negli eosinofili su sangue periferico (P = 0,0001), PU (P #x003C; 0,0001), TI (P = 0,01) e MM (P = 0,0006) sono risultate statisticamente significative. È stata dimostrata una correlazione debole tra sangue periferico e PU (r = 0.34, P = 0,006) e tra PU e IT (r = 0,30, P = 0,017), e una correlazione moderata tra PU e MM (r = 0,51, P #x003C; 0,0001). Le curve ROC hanno predetto forme di RSC eosinofila con una sensibilità globalmente bassa. Escludendo i pazienti allergici la sensibilità si riduce ulteriormente per TI mentre aumenta per MM.Il presente studio suggerisce di eseguire il prelievo citologico nel MM al fine di identificare le RSC eosinofile. Sono necessari studi più ampi per verificare i risultati e definire valori limite adeguati.

RESUMEN El síndrome de Wells o celulitis eosinofílica es una rara entidad cutánea, caracterizada por el polimorfismo de sus lesiones y por la presencia aumentada de eosinófilos tanto en las lesiones como en sangre periférica. Su etiología permanece desconocida, y la falta de especificidad de sus lesiones hace que en ocasiones su diagnóstico resulte difícil, representando la biopsia cutánea una prueba clave (figuras en llama). Su tratamiento inicial son los corticoides, aunque puede autolimitarse sin nuevos brotes. Presentamos el caso de una paciente con lesiones cutáneas asociado a eosinofilia en el contexto de un síndrome de Wells.

INTRODUCCIÓN: Las agudizaciones de EPOC representan un 1-2% de las atenciones en los Servicios de Urgencias Hospitalarios. OBJETIVO: Describir las características de la atención a pacientes con Enfermedad Pulmonar Obstructiva Crónica con exacerbación (aguda) y conocer la adecuación a las actuales recomendaciones de guías de referencia en relación al tratamiento farmacológico que reciben los pacientes. MATERIAL Y MÉTODOS: Estudio observacional descriptivo retrospectivo realizado a pacientes con diagnóstico de EPOC con exacerbación aguda atendidos entre enero y agosto de 2019 en el Servicio de Urgencias del Hospital Universitario de La Ribera (Azlira-Valencia-Spain). Las variables a estudio fueron: sexo, edad, prioridad de atención asignada, lugar y tiempo de atención, solicitud de pruebas complementarias, valor de eosinófilos, tratamiento prescrito y adecuación del mismo a las recomendaciones. RESULTADOS: Se estudiaron 111 pacientes en un porcentaje muy superior varones con una edad media de 73,13 ± 11,764 años. El nivel de prioridad asignado osciló entre P2 y P4. Los pacientes fueron atendidos principalmente en la zona de consultas y permanecieron de media 315,26 minutos. Los grupos farmacológicos más pautados fueron 80,2% LABA, 72% LAMA. La combinación más frecuente fue LABA-LAMA-CI en un 32,43% seguido de la LABA-LAMA en un porcentaje del 28,83%. El valor de eosinófilos fue igual o superior a 300 células/ul en 26 pacientes y de ellos a 17 se les pautó corticoide inhalado siguiendo las recomendaciones de la guía Gold. CONCLUSIONES: Se observó una pauta de tratamiento no acorde con las recomendaciones en el 34,6% de los pacientes. Resulta imprescindible la realización y actualización de protocolos en los servicios de urgencias sobre patologías prevalentes que se adapten a las últimas recomendaciones y guías como la GOLD para la atención a pacientes con Enfermedad Pulmonar Obstructiva Crónica. BACKGROUND: Chronic Obstructive Pulmonary Disease exacerbations represents around 1-2% overall services at the Emergency Department. OBJECTIVE: To describe the characteristics of the attention to the patients with Chronic Obstructive Pulmonary Disease with exacerbation (acute) and to know the adequacy of the actual guideline’s recommendations related to the pharmacological treatment prescribed to the patients. MATERIAL AND METHODS: Retrospective descriptive observational study performed to patients diagnosed with COPD exacerbation seen between January-August 2019 at the emergency department in La Ribera University Hospital (Alzira-Valencia-Spain). The variables used for the study were: sex, age, assigned priority of care, place and time of care, request of additional test, eosinophil value, prescribed treatment and adequacy of the same regarding to the recommendations. RESULTS: 111 patients were studied having the males ,with a mean age of 73,13 ± 11,764 years, a much higher percentage. The assigned priority level ranged between P2 and P4. The patients were attended mainly in the consultation area and stayed 315,25 minutes on average. Main pharmacological groups administered were 80,2% LABA and 72% LAMA. Most frequent combination used was LABA-LAMA-ICS in a 32,43% of the cases followed by LABA-LAMA- in a 28,83% of the cases. The eosinophil value was equal to or superior to 300 cells/ul in 26 patients, and 17 of them recieved inhaled corticosteroids following GOLD guidelines recommendations. CONCLUSIONS: It was observe a treatment regimen not in accordance with the recommendations in 34,6% of the patients It is essential to carry out and update protocols in the emergency department on prevalent pathologies that adapt to the latest recommendations and guidelines such as GOLD for the care of the patient with Chronic Obstructive Pulmonary Disease. Enfermería

Objective: To evaluate the relationship between obesity and asthma. Methods: This was a preliminary cross-sectional analysis involving 925 subjects with mild-to-moderate or severe asthma evaluated between 2013 and 2015. Obesity was defined on the basis of body mass index (BMI) and abdominal circumference. We collected clinical, laboratory, and anthropometric parameters, as well as pulmonary function test results and data regarding comorbidities. The subjects also completed asthma control and quality of life questionnaires. Results: Obese individuals had a significantly higher number of neutrophils in peripheral blood than did nonobese individuals (p = 0.01). Among the obese individuals, 163 (61%) had positive skin-prick test results, as did 69% and 71% of the individuals classified as being overweight or normal weight, respectively. Obese individuals showed lower spirometric values than did nonobese individuals, and 32% of the obese individuals had uncontrolled asthma, a significantly higher proportion than that found in the other groups (p = 0.02). Conclusions: Obese individuals with asthma seem to present with poorer asthma control and lower pulmonary function values than do nonobese individuals. The proportion of subjects with nonatopic asthma was higher in the obese group. Our results suggest that obese individuals with asthma show a distinct inflammatory pattern and are more likely to present with difficult-to-control asthma than are nonobese individuals. RESUMO Objetivo: Avaliar a relação entre obesidade e asma. Métodos: Análise preliminar transversal de dados de um estudo de caso-controle com 925 pacientes com asma leve a moderada ou grave, avaliados entre 2013 e 2015. A classificação de obesidade levou em conta o índice de massa corpórea (IMC) e a circunferência abdominal. Foram coletados parâmetros clínicos, laboratoriais, medidas antropométricas e de função pulmonar, assim como resultados de questionários de controle da asma e de qualidade de vida e presença de comorbidades. Resultados: Os indivíduos obesos apresentaram um número significativamente maior de neutrófilos no sangue periférico que os não obesos (p = 0,01). Entre os obesos, 163 (55%) apresentaram positividade no teste alérgico, enquanto os grupos com sobrepeso e IMC normal apresentaram positividade em 62% e 67%, respectivamente. Os parâmetros espirométricos dos indivíduos obesos foram mais baixos que os dos não obesos, e 97 obesos (32%) apresentaram asma não controlada, uma proporção significativamente maior do que a observada nos demais grupos de estudo (p = 0,02). Conclusões: Indivíduos asmáticos e obesos têm pior controle da asma e valores mais baixos de parâmetros de função pulmonar que os não obesos. A proporção de pacientes sem atopia entre asmáticos obesos foi maior que entre os não obesos. Nossos resultados sugerem que indivíduos asmáticos obesos podem apresentar um padrão inflamatório diferente do habitual e doença de mais difícil controle quando comparados com indivíduos asmáticos não obesos.

[ES] Algunas enfermedades infecciosas han adquirido más relevancia por el aumento de los movimientos poblacionales. La eosinofilia es un hallazgo frecuente en inmigrantes y en viajeros. Una de las causas más frecuentes de eosinofilia es la infección por helmintos y algunos protozoos intestinales. El objetivo de este trabajo es describir las características epidemiológicas de los casos con eosinofilia y su asociación con la presencia de parásitos en la red de datos REDIVI. Se trata de un estudio observacional multicéntrico prospectivo, donde se incluyen los casos diagnosticados de eosinofilia registrados en la Red cooperativa para el estudio de las infecciones importadas por viajeros e inmigrantes (+REDIVI) desde enero de 2009 hasta diciembre de 2012. Se registraron en la red un total de 5.255 episodios durante el periodo de estudio, y la eosinofilia fue un hallazgo en el 8,1 al 31,3% de los casos (dependiendo del tipo migratorio). Fueron hombres el 60,2%, con una mediana de 31,0 años, inmigrantes el 72,4% y asintomáticos el 81,2%. Los parásitos más frecuentemente identificados fueron S. stercoralis (34,4%), Schistosoma sp. (11,0%) y uncinarias (8,6%). Existía asociación entre eosinofilia y presencia de parásitos para todos los helmintos (excepto para larva migrans cutánea). La sintomatología y la duración del viaje no determinaron significativamente la presencia de eosinofilia. Ante una eosinofilia en una persona que ha vivido en zonas endémicas de helmintiasis es aconsejable realizar estudios dirigidos para su diagnóstico, independientemente del tipo migratorio, la duración de la estancia o la presencia de sintomatología., [EN] The population movements during the last decades have resulted in a progressively increasing interest in certain infectious diseases. Eosinophilia is a common finding in immigrants and travellers. One of the most common causes of eosinophilia is helminth infection, and some intestinal protozoa. The aim of this paper is to describe the epidemiological characteristics of cases with eosinophilia and its association with the presence of parasites in the REDIVI data network. This is a multicentre prospective observational study that includes patients diagnosed with eosinophilia registered in the cooperative network for the study of infectious diseases in travellers and immigrants (+REDIVI) from January 2009 to December 2012. A total of 5,255 episodes were recorded in the network during the study period, and eosinophilia was observed in 8.1-31.3% of cases (depending on the immigration group). There were 60.2% men, with a median age of 31 years. There were 72.4% immigrants, and 81.2% were asymptomatic. The most commonly identified parasites were S. stercoralis (34.4%), Schistosoma sp. (11.0%), and hookworm (8.6%). The relationship between eosinophilia and parasite infection was significant for all helminths (except for cutaneous larva migrans). The symptoms and duration of the journey did not significantly determine the presence of eosinophilia. In the case of eosinophilia in a person who has lived in helminth endemic areas, it is advisable to carry out targeted studies to diagnose the infection, regardless of immigration type, length of stay, or the presence of symptoms.

A cistite eosinofílica é uma doença inflamatória rara caracterizada por infiltração eosinofílica de todas as camadas da parede da bexiga. Essa enfermidade já foi descrita em adultos, crianças e cães. No entanto, não há um consenso de diretrizes sobre o seu tratamento. Mesmo que as literaturas humana e veterinária mostrem alguma eficácia no manejo com corticosteroides, anti-histamínicos e antibióticos, uma variedade de efeitos colaterais graves e frequentes estão associados à terapia com esteróides. Dessa forma, seu uso é relativamente contra-indicado para pacientes com diabetes mellitus e síndrome de Cushing, por exemplo. Um chow-chow, macho, castrado, de cinco anos e diabético estável foi encaminhado para atendimento com histórico de urina fétida, hematúria macroscópica e disúria não responsiva a antibióticos há 18 meses. A avaliação dos parâmetros físicos estava dentro dos padrões, exceto por desconforto abdominal suprapúbico. O hemograma e o perfil bioquímico estavam dentro dos valores de referência, exceto por eosinofilia periférica leve. Embora a ultrassonografia, a radiografia contratada da bexiga e os achados da urinálise indicassem malignidade, a histopatologia confirmou o diagnóstico definitivo de cistite eosinofílica. O manejo com ciclosporina foi satisfatório, com remissão completa da hematúria. Este relato de caso apresenta o primeiro uso documentado de ciclosporina para o tratamento de cistite eosinofílica, com sucesso, em um cão com diabetes. Eosinophilic cystitis is a rare inflammatory disorder characterized by eosinophilic infiltration of entire layers of the bladder wall. The condition has been described in adults, children, and dogs. However, there are no consensus guidelines for treatment of eosinophilic cystitis and although human and veterinary literature reviews show some effectiveness in management with corticosteroids, antihistamines, and antibiotics, a variety of serious and frequent side effects are associated with steroid therapy. As a result, steroids are relatively contraindicated for patients with diabetes mellitus and Cushing’s syndrome. A five-year-old neutered male chow-chow with controlled diabetes was referred with an 18-month history of malodorous urine, gross haematuria, and dysuria that were nonresponsive to antibiotics. The findings on general examination were unremarkable except for abdominal suprapubic discomfort. The complete blood count and biochemical profile were normal except for mild peripheral eosinophilia. Although ultrasonography, bladder contrast radiography, and urine cytology findings indicated malignancy, histopathology confirmed eosinophilic cystitis. Management with cyclosporine was adequate with complete remission of haematuria. This case report presents the first reported successful use of cyclosporine for treatment of eosinophilic cystitis in a dog with diabetes.

La celulitis eosinofílica es un trastorno infrecuente, inflamatorio y crónico de etiología desconocida. Actualmente, se considera que los corticosteroides son el tratamiento de primera línea, pero no carecen de desventajas significativas, como las contraindicaciones en los casos resistentes a esteroides y los pacientes con recidivas frecuentes. Divulgamos a un paciente que sufre del síndrome de Wells con una historia de 24 años de lesiones cutáneas sintomáticas y generalizadas. Después de la consulta en nuestro servicio, se prescribió tratamiento con colchicina 1 mg / día, lo que resultó en una gran mejoría clínica. No se han registrado efectos secundarios. Hasta donde sabemos, este es un enfoque de enfermedad original. Aunque pequeña, nuestra experiencia clínica respalda la inclusión de colchicina en el arsenal farmacológico cuando se trata a pacientes con síndrome de Wells. De hecho, su excelente perfil de seguridad lo hace muy atractivo para los pacientes con episodios recurrentes frecuentes que necesitan opciones seguras para el control de la enfermedad a mediano y largo plazo A celulitis eosinofílica é un trastorno infrecuente, inflamatorio e crónico de etioloxía descoñecida. Actualmente, considérase que os corticosteroides son o tratamento de primeira liña, pero non carecen de desvantaxes significativas, como as contraindicacións nos casos resistentes a esteroides e os pacientes con recidivas frecuentes. Divulgamos a un paciente que sofre da síndrome de Wells cunha historia de 24 anos de lesións cutáneas sintomáticas e xeneralizadas. Despois da consulta no noso servizo, prescribiuse tratamento con colchicina 1 mg / día, o que resultou nunha gran melloría clínica. Non se rexistraron efectos secundarios. Ata onde sabemos, este é un enfoque da enfermidade orixinal. Aínda que pequena, a nosa experiencia clínica apoia a inclusión de colchicina no arsenal farmacolóxico cando se trata a pacientes con síndrome de Wells. De feito, o seu excelente perfil de seguridade faio moi atractivo para os pacientes con episodios recorrentes frecuentes que necesitan opcións seguras para o control da enfermidade a mediano e longo prazo Eosinophilic cellulitis is an uncommon, inflammatory and chronic disorder of unknown etiology. Corticosteroids are currently considered as the first-line treatment but they are not without significant disadvantages such as contraindications in steroid-resistant cases and patients with frequent recurrences. We report a patient suffering from Wells’ syndrome with a 24-year history of symptomatic and generalized skin lesions. After consultation in our department, treatment with colchicine 1 mg/day was prescribed resulting in large clinical improvement. No side effects have been recorded. To our knowledge, this is an original disease approach. Although small, our clinical experience supports the inclusion of colchicine in the drug armamentarium when treating patients suffering from Wells’ syndrome. Indeed, its excellent safety profile makes it very attractive for patients with frequent recurrent episodes who need secure options for the medium- and long-term disease control

In this cross-sectional study, we investigated the relationship that levels of vitamin D had with eosinophil counts and IgE levels in 26 children with asthma (6-12 years of age) in the city of Londrina, Brazil. Vitamin D levels were found to correlate significantly, albeit moderately, with age (r = −0.51) and eosinophilia (r = −0.49), although not with IgE levels (r = −0.12). When we stratified the sample into two groups by the median vitamin D level (< or ≥ 24 ng/mL), we found that those in the < 24 ng/mL group were older, had higher eosinophil counts, and had higher IgE levels. To our knowledge, this is the first study to show an association between low levels of vitamin D and more pronounced eosinophilia in children with asthma in Brazil. RESUMO A associação entre níveis de vitamina D, eosinófilos e IgE foi analisada transversalmente em 26 crianças (6-12 anos) com asma na cidade de Londrina (PR). Foram observadas correlações moderadas dos níveis de vitamina D com idade (r = −0,51) e eosinofilia (r = −0,49), mas não com IgE (r = −0,12). Ao separar a amostra pelo ponto de corte obtido com a mediana dos níveis de vitamina D (< ou ≥ 24 ng/mL), valores mais altos de idade, eosinófilos e IgE ocorreram no grupo abaixo desse ponto. Pelo que sabemos, este estudo exploratório é o primeiro a mostrar uma associação entre níveis baixos de vitamina D e eosinofilia mais acentuada em crianças asmáticas no Brasil.

Rhinitis is the leading cause for consultation in the allergy department. It consists in chronic inflammation of the nasal mucosa. Non-allergic rhinitis with eosinophilic syndrome is characterized by chronic inflammation of the nasal mucosa (20% of eosinophils in nasal cytology) in the absence of demonstrable allergy (negative in vivo and in vitro tests); often it is accompanied by other sinonasal conditions (nasal polyposis, chronic rhinosinusitis), and it constitutes a risk factor for the development of obstructive sleep apnea.Seven-year old girl with rhinorrhea, nasal obstruction, nasopalatine itching, and severe sneezing that limited sleep and school activities. This condition had a seasonal pattern, with important blood (800 eosinophils/μL) and nasal (30%) eosinophilia and absence of demonstrable allergy (negative skin tests, negative specific nasal challenge tests); the non-allergic rhinitis with eosinophilic syndrome diagnosis was verified.Non-allergic rhinitis with eosinophilic syndrome is considered to be a highly underdiagnosed disease owing to the lack of in vivo nasal tests' performance; to this underestimation, incorrect nasal etiology and lack of local in vivo tests (nasal specific IgE) are added, which warrants a high degree of diagnostic suspicion by the specialist physician.Antecedentes: La rinitis es la primera causa de consulta en el servicio de alergia. Se trata de una inflamación crónica de la mucosa nasal. La rinitis no alérgica con síndrome eosinofílico se caracteriza por eosinofilia crónica (20 % de eosinófilos en citología nasal) sin que pueda comprobarse la existencia de alergia (pruebas in vivo e in vitro negativas); frecuentemente se acompaña de otras enfermedades sinonasales (poliposis nasal, rinosinusitis crónica) y constituye un factor de riesgo para desarrollar apnea obstructiva del sueño. Caso clínico: Niña de siete años de edad con rinorrea, obstrucción nasal, prurito nasopalatino y estornudos de intensidad severa que limitaban sueño y actividades escolares, de patrón estacional con importante eosinofilia sanguínea (800 eosinófilos/μL) y nasal (30 %), sin alergia demostrable (pruebas cutáneas negativas y pruebas de provocación nasal específicas negativas); se comprobó el diagnóstico de rinitis no alérgica con síndrome eosinofílico. Conclusiones: La rinitis no alérgica con síndrome eosinofílico se considera una enfermedad altamente infradiagnosticada debido a la falta de realización de pruebas nasales in vivo. A la infravaloración se suma la incorrecta etiología nasal y la inexistencia de pruebas in vitro locales (IgE nasal específica), por lo que amerita un alto grado de sospecha diagnóstica por parte del médico especialista.

The aim of this study was to analyze whether FeNO levels in acute exacerbation of COPD (AECOPD) with hospital admission have better diagnostic value than eosinophilia in blood, and to evaluate its usefulness in predicting a better clinical response. An observational prospective study of patients with AECOPD was carried out. FeNO determinations were made on arrival at the emergency room (ER), at discharge and during stability 3-6 months after discharge. Co-morbidities, bronchodilators, inhaled (IGC) and systemic (SGC) glucocorticoids, eosinophils, systemic inflammation markers (procalcitonin, C-reactive protein), eosinophil cationic protein, and total IgE were collected. Fifty consecutive patients (92% men, mean age 75 ± 6 years) were included in this study. Phenotypes were 26% Asthma-COPD Overlap Syndrome (ACOS), 42% chronic bronchitis (CB) and 32% emphysema. ACOS patients showed significantly higher levels of FeNO (73 ppb) and eosinophils (508 cells/mm3) than the rest (CB: 23 ppb, 184 cells/mm3, emphysema: 27 ppb, 159 cells/mm3; p < 0.05). A significant correlation between FeNO levels measured in ER and eosinophils was observed (r = 0.7; p < 0.001), but not at discharge or in stable phase. No significant association was found with parameters of systemic inflammation and mean stay. In conclusion, the determination of FeNO in AECOPD does not offer advantages over the evaluation of eosinophilia. These parameters rise at arrival in ER, descend at discharge, and remain unchanged in the stable phase. Both present similar diagnostic utility and are able to better identify the ACOS phenotype, which helps select a population that could benefit from a glucocorticoids therapy. Sin financiación 2.503 JCR (2018) Q3, 37/63 Respiratory System 1.034 SJR (2018) Q1, 526/2488 Medicine (miscellaneous) No data IDR 2018 UEM

A 39-year-old caucasian man presented to our hospital in Barcelona with fever, dry cough, headache and weight loss of 4 kg. Symptoms started 5 days after returning from a 21-day travel to Malaysia. His physical examination was unremarkable except for a splenomegaly. Laboratory tests showed mild elevation of transaminases, elevated levels of lactate dehydrogenase (468 UI/L) and a normal blood cell count. Blood cultures, thick and thin blood smear and serologic tests for dengue, chikungunya, HIV, cytomegalovirus, Epstein-Barr virus, herpes virus 6, parvovirus B19, Toxoplasma spp and Rickettsia conorii were negative.

A 43-year-old male with a history of eosinophilic angiocentric fibrosis presented with headache and double vision since 48 h. Idiopathic hypertrophic pachymeningitis was diagnosed based on nuclear magnetic resonance and comprehensive systemic study findings. Eosinophilic angiocentric fibrosis and idiopathic hypertrophic pachymeningitis have been associated with IgG4-related diseases, but this was the first case in which they coexisted in the same patient. After steroid treatment failure, rituximab was used with excellent results. RESUMO Um homem de 43 anos, com história de fibrose angiocêntrica eosinofílica, apresentou cefaléia e visão dupla com 48 horas. A paquimeningite hipertrófica idiopática foi diagnosticada com base na ressonância magnética nuclear e em achados sistêmicos abrangentes no estudo. A fibrose angiocêntrica eosinofílica e a paquimeningite hipertrófica idiopática foram associadas a doenças relacionadas à IgG4, mas este foi o primeiro caso em que elas coexistiram no mesmo paciente. Após a falha do tratamento com esteroides, o rituximabe foi usado com excelentes resultados.

Human toxocariasis is a parasitic zoonosis mainly caused by Toxocara canis or Toxocara cati and is acquired by ingestion of the parasite's embryonated eggs. Arthralgia and/or arthritis were reported in up to 17% of the cases, generally with acute duration (less than 6 weeks). However, to our knowledge, chronic polyarthritis, as the isolated presentation of Toxocara infection, was not reported. One of the 5809 patients that was followed up at our service (0.017%) had chronic polyarthritis as the single manifestation of toxocariasis and was described herein. A 3-year-old girl was referred to our service with severe painful chronic polyarthritis for a period longer than 10 weeks and morning stiffness of 30min. Dog contact exposure history in the recreational areas of neighborhood was reported. Her exams showed high levels of eosinophils in peripheral blood (29%), bone marrow aspirate revealed marked eosinophilia (32%) and Toxocara enzyme-linked immunosorbent assay (Elisa) was positive (1:1280). She was treated with paracetamol (40mg/kg/day) and thiabendazole (25mg/kg/day) for 10 days, and all manifestations reduced. After eight months of follow-up, she was on clinical and laboratorial remission. In conclusion, we described a case of chronic polyarthritis, as isolated manifestation of toxocariasis, mimicking juvenile idiopathic arthritis and leukemia. Importantly, this zoonosis should be considered in patients with arthritis and eosinophilia.

ResumoA toxocaríase é uma zoonose parasitária causada principalmente pelo Toxocara canis ou pelo T. cati. É adquirida pela ingestão de ovos embrionados do parasita. A artralgia e/ou artrite foram relatadas em até 17% dos casos, geralmente com duração aguda (menos de seis semanas). No entanto, que se tem conhecimento, a poliartrite crônica como manifestação isolada da infecção por Toxocara ainda não foi descrita na literatura. Um dos 5.809 pacientes acompanhados em nosso serviço (0,017%) exibiu poliartrite crônica como manifestação única da toxocaríase e foi descrito neste estudo. Uma menina de três anos foi encaminhada ao nosso serviço com poliartrite crônica dolorosa grave por um período superior a 10 semanas e rigidez matinal diária de 30 minutos. Foi relatada história de exposição a contato com cão nas áreas de lazer do bairro. Seus exames revelaram níveis elevados de eosinófilos no sangue periférico (29%), o aspirado de medula óssea revelou eosinofilia acentuada (32%) e o ensaio imunoenzimático ligado a enzima (ELISA) para Toxocara foi positivo (1:1.280). A criança foi tratada com paracetamol (40 mg/kg/dia) e tiabendazol (25 mg/kg/dia) durante 10 dias e houve regressão de todas as manifestações. Depois de oito meses de seguimento, a pequena paciente estava em remissão clínica e laboratorial. Em conclusão, descreve‐se um caso de poliartrite crônica como manifestação isolada da toxocaríase, que mimetizou uma artrite idiopática juvenil e leucemia. É importante ressaltar que essa zoonose deve ser considerada em pacientes com artrite e eosinofilia.AbstractHuman toxocariasis is a parasitic zoonosis mainly caused by Toxocara canis or T. cati and is acquired by ingestion of the parasite's embryonated eggs. Arthralgia and/or arthritis were reported in up to 17% of cases, generally with acute duration (less than 6 weeks). However, to our knowledge, chronic polyarthritis, as the isolated presentation of Toxocara infection, was not reported. One of 5,809 patients that was followed up at our service (0.017%) had chronic polyarthritis as the single manifestation of toxocariasis and was described herein. A 3‐year‐old girl was referred to our service with severe painful chronic polyarthritis for a period longer than 10 weeks and morning stiffness of 30minutes. Dog contact exposure history in the recreational areas of neighborhood was reported. Her exams showed high levels of eosinophils in peripheral blood (29%), bone marrow aspirate revealed marked eosinophilia (32%) and Toxocara enzyme‐linked immunosorbent assay (Elisa) was positive (1:1,280). She was treated with paracetamol (40 mg/kg/day) and thiabendazole (25 mg/kg/day) for 10 days, and all manifestations reduced. After eight months of follow‐up, she was on clinical and laboratorial remission. In conclusion, we described a case of chronic polyarthritis, as isolated manifestation of toxocariasis, mimicking juvenile idiopathic arthritis and leukemia. Importantly, this zoonosis should be considered in patients with arthritis and eosinophilia.

La asistencia a niños inmigrantes que llegan por primera vez a España continúa siendo una práctica diaria en Pediatría. En la práctica totalidad de centros de salud existen protocolos que contemplan la atención inicial de estos pacientes a su llegada. En la atención inicial a estos niños es básica la anamnesis, una exploración completa y la solicitud de pruebas complementarias específicas. Pese a que la mayoría de estos niños están asintomáticos, la aplicación de estos protocolos puede poner de manifiesto enfermedades como la malnutrición, parasitosis o anemias de diversas etiologías, que de otra forma podrían pasar desapercibidas. Se presenta un caso de un niño de diez años asintomático, procedente de Guinea Ecuatorial, que consulta por primera vez en el centro de salud tras su llegada a España. Assistance to immigrant children arriving for the first time in Spain continues to be a daily practice in Pediatrics. In nearly all Health Care Centers there are protocols that contemplate the initial care of these patients upon arrival. Anamnesis, a complet examination and the request for specific complementary tests are basic for the initial care of these children. Although most of these children are asymptomatic, the application of these protocols may reveal diseases such as malnutrition, parasitosis or anemias of different etiologies, which could otherwise go unnoticed. We present a case of an asymptomatic ten-year-old boy from Equatorial Guinea, who consulted for the first time at the Health Care Center after his arrival in Spain.

Diagnosis and treatment of eosinophilia. A case report La eosinofilia es el aumento del numero total de eosinofilos por encima de 500/μl. En la edad pediatri- ca la causa mas frecuente es la parasitosis por helmintos; otras causas frecuentes son la ingesta de al- gunos farmacos y las enfermedades alergicas. Presentamos el caso de una nina de cinco anos con dolor abdominal y analitica con eosinofilia mode- rada en repetidas ocasiones, sin causa secundaria aparente y con normalidad en el resto de las pruebas complementarias realizadas en el centro de salud y en el hospital de referencia. Ante una eosinofilia persistente sin causa secundaria que la explique y con normalidad de las pruebas complementarias indicadas, se recomienda tratamiento empirico con antiparasitarios.

Job's syndrome or Hyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency characterized by recurrent soft tissue infections, coarse face, skeletal and vascular abnormalities, and markedly high levels of Immunoglobulin E. Eczema that resembles atopic dermatitis but is refractory to traditional treatment and severe and recurrent bacterial pneumonias often recognized during childhood. Early diagnosis and treatment prevent progressive pulmonary sequellae and increase survival. About 200 cases of HIES has been reported worldwide. The authors report a new case of HIES with one of the worst pulmonary sequellae found in the literature on this subject and review this infrequent topic. Resumo: A síndrome de Job, ou síndrome de Hiperimunoglobulina E (HIES), é uma rara imunodeficiência primária caracterizada por infecções recorrentes de tecidos moles, anomalias grosseiras faciais, esqueléticas e vasculares, e níveis visivelmente elevados de Imunoglobulina E. O eczema semelhante à dermatite atópica, mas refractário ao tratamento tradicional e pneumonias graves e recorrentes são frequentemente reconhecidas durante a infância. Um diagnóstico e tratamento precoces impedem sequelas pulmonares progressivas e aumentam a sobrevivência. Foram relatados cerca de 200 casos de HIES em todo o mundo. Relatamos um novo caso de HIES com uma das sequelas pulmonares mais extensas encontradas na análise bibliográfica sobre este assunto, conjuntamente com uma revisão sobre esta patologia pouco frequente. Keywords: Job's syndrome, Hyperimmunoglobulin E syndrome, Bronchiectasis, Case report, Eosinophilia, Primary immunodeficiency, Palavrasâchave: Síndrome de Job, Síndrome de hiperimunoglobulina E, Bronquiectasia, Relatório de caso, Eosinofilia, Imunodeficiência primária

INTRODUCTION: Clozapine is the antipsychotic of choice in the treatment of refractory schizophrenia. However, its side effects, such as eosinophilia, may preclude its use. METHODS: Case report and literature review. RESULTS: Young woman, 19 years old, diagnosed with hebefrenic schizophrenia, admitted at Unicamp's psychiatry ward after psychotic symptoms relapse. Clozapine was started after unsuccessful attempts with risperidon and olanzapine. By the fourth week of clozapine use, eosinophils began to increase. Drug titration was stopped, but eosinophils counts continued to rise up, reaching the mark of 5200/mm³. Due to severity of psychotic symptoms and to the good response obtained with clozapine, we decided to investigate organs involvement before withdrawing the medication. As the patient had no organs involvement, clozapine was maintained and one month after eosinophils peak, it was already normalized. CONCLUSION: Eosinophilia should not necessarily lead to clozapine's withdrawal. Patients who present eosinophilia must be at rigorous observation for organs involvement, and if there is no such involvement, clozapine might be maintained, considering the possible benign and transitory nature of the eosinophils count elevation.

RESUMEN: La paragonimiasis es una zoonosis parasitaria, de transmisión alimentaria, causada por especies de tremátodos del género Paragonimus, presente en áreas tropicales y subtropicales de Asia, África y América. El ser humano se infecta mediante la ingestión de crustáceos de agua dulce crudos o mal cocidos. La infección afecta principalmente los pulmones, con desarrollo de múltiples manifestaciones clínicas y radiológicas, dependiendo del momento del ciclo vital del parásito. El diagnóstico diferencial más importante de esta enfermedad es la tuberculosis pulmonar. En este artículo se describe esta enfermedad en dos niñas con diferentes manifestaciones pulmonares. La paragonimiasis se debe sospechar en pacientes con tos crónica, esputo herrumbroso, dolor torácico, con o sin compromiso cerebral, que viven o han residido en una zona endémica y que presentan una eosinofília elevada, con cambios radiológicos sugestivos del síndrome de Loeffler. ABSTRACT: Paragonimiasis is a parasitic, food-borne zoonosis, caused by species of trematodes of the genus Paragonimus, found in tropical and subtropical areas of Asia, Africa and America. Human beings become infected by ingestion of raw or undercooked freshwater shellfish. The infection primarily affects the lungs, with the development of multiple clinical and radiological manifestations, depending on the moment in the life cycle of the parasite. The most important differential diagnosis of this disease is pulmonary tuberculosis. We report two cases of lung paragonimiasis in aboriginal Colombian girls with different pulmonary manifestations. Paragonimiasis should be suspected in patients with chronic cough, rusty sputum, chest pain, with or without brain involvement, who live or have lived in en-demic areas and have a highlevel eosinophilia with radiographic changes suggestive of Loeffler’s syndrome.

Resumen La pediculosis capitis es la infestación pediátrica más frecuente. Generalmente se considera una infestación banal y no se comentan las posibles complicaciones clínicamente relevantes. Se presenta el caso de una adolescente con historia de astenia, anemia moderada, importante adenopatía cervical y eosinofilia, finalmente achacada a la infestación por el parásito, no sospechada de entrada.

La presente Tesis Doctoral tiene por objetivo conocer el estado del parasitismo intestinal y su correlación con diferentes factores intrínsecos y extrínsecos en la población infantil ruandesa. Para ello, se ha estudiado un total de 674 escolares (330 niños y 344 niñas) del Colegio Nemba I (Nemba, Gakenke, Província Norte de Ruanda), con edades comprendidas entre los 6 y 18 años de edad. Se ha detectado un espectro parasitario de 17 especies (10 de protozoos y 7 de helmintos), con una prevalencia total de parasitación del 94,9% (94,5% para protozoos y 18,1% para helmintos). Las especies más prevalentes fueron: Endolimax nana (91,1%), Blastocystis hominis (89,9%) y Entamoeba coli (57,2%). Se ha detectado un predominio del multiparasitismo (83,8%). La eosinofilia y la anemia han resultado poco frecuentes en la población estudiada, aunque la desnutrición se ha observado especialmente sobre la forma de desmedro. Los resultados parasitológicos obtenidos han sido analizados en función del sexo, grupos de edad, grado escolar, eosinofilia, anemia, tipo de desnutrición y diferentes variables socioeconómicas e higienico-sanitárias, obteniéndose diferencias estadísticamente significativas en algunos de estos factores. Además, se ha aportado datos, con técnicas moleculares, sobre el “complejo Entamoeba” detectándose mayor prevalencia de Entamoeba histolytica que de Entamoeba dispar. Los resultados obtenidos han sido contrastados con la bibliografía existente hasta el momento en población infantil ruandesa y también en países fronterizos. El estudio llevado a cabo permite resaltar la eficacia de las campañas infantiles de desparasitación helmíntica llevadas a cabo por el gobierno de Ruanda, además de las estrictas leyes que hacen obligatorio el uso del calzado. Estos resultados permiten, además, plantear estrategias de intervención en Ruanda que impulsen programas de educación sanitaria y la mejoría de la calidad de vida de la población en general, y de la población infantil en particular. This Doctoral Thesis aims to know the intestinal parasitism and its correlation with various intrinsic and extrinsic factors in Rwandan children. A total of 674 students (330 boys and 344 girls) of Nemba I College (Nemba, Gakenke, Northern Province of Rwanda), aged between 6 and 18 years old were studied. It has been detected a parasitic spectrum of 17 species (10 species of protozoa and 7 of helminths), with a total prevalence of parasitism of 94.9% (94.5% for protozoa and helminths 18.1% for). The most prevalent species were: Endolimax nana (91.1%), Blastocystis hominis (89.9%) and Entamoeba coli (57.2%). It was also detected a predominance of multiparasitism (83.8%). Eosinophilia and anemia have been rare in the population studied, although malnutrition has been observed especially as stunting. Parasitological results were analyzed according to sex, age, grade, eosinophilia, anemia, malnutrition and type of different socioeconomic and hygienic variables, obtaining statistically significant differences in some of these factors. In addition, data has been analyzed with molecular techniques on "Entamoeba" and was detected a higher prevalence of Entamoeba histolytica than Entamoeba dispar. The results have been contrasted with the literature so far in Rwandan children and also in neighboring countries. The study conducted allows to highlight the effectiveness of child deworming campaigns carried out by the Rwandan government, in addition to the strict laws that make it mandatory the use of footwear. These results also raise Rwanda intervention strategies that promote health education programs and improving the quality of life of the population in general and of children in particular allowed.

A piodermatite-pioestomatite vegetante é uma rara dermatose inflamatória de etiologia desconhecida, com típico comprometimento mucocutâneo. Relatamos caso de paciente feminina com lesões pustulosas e vesiculosas em axilas, evoluindo com placas vegetantes e pústulas com agrupamento anular. Houve progressão com comprometimento vulvar, inguinal e mucosas oral, nasal e ocular. Proposto o diagnóstico, optou-se por iniciar prednisona 40mg ao dia, com remissão das lesões após um mês de uso da medicação. A associação com doença inflamatória intestinal ocorre em 70% dos casos. A imunofluorescência é um fator que ajuda a caracterizar a doença, sendo tipicamente negativa. A rápida resposta à terapêutica com corticosteroides sistêmicos é esperada. Pyodermatitis-pyostomatitis vegetans is a rare inflammatory dermatosis of unknown etiology, with a typical mucocutaneous involvement. We report the case of a woman with pustular and vesicular lesions in the axillae, evolving with vegetating plaques and pustules with annular grouping. The disease progressed with vulvar and inguinal involvement as well as involvement of the oral, nasal and ocular mucous membranes. She started the treatment with prednisone (40 mg/day), with remission of the lesions after one month of use of such medication. Association with inflammatory bowel disease occurs in 70% of the cases. Immunofluorescence, which is typically negative, helps to characterize the disease. A rapid res- ponse to systemic steroids is expected.

Objective: To study the association between the presence of eosinophilia and IgG antibodies to Toxocara spp. in children assisted by the public health service, in the northwestern region of Parana State, in southern Brazil. Methods: A retrospective study of children aged seven months to 12 years old assisted by the Public Health Service in northwest state of Parana, Brazil. ELISA test was performed in all children in order to detect IgG antibodies to Toxocara spp. and eosinophil amounts (eosinophilia ≥ 600 cells/mm3). Results: Among 1,199 screened children, 386 (32.2%) had IgG antibodies to Toxocara spp. The seroprevalence of Toxocara spp. and the eosinophilia were more common among children of seven months to five years old. Eosinophilia was observed in 7.8% of seropositive patients to Toxocara spp. Conclusions: There was a high prevalence of anti-Toxocara spp., mainly in children under five years old. With the Endereco para correspondencia: Ana Lucia F. Guilherme Avenida Colombo, 5.790,Bloco I-90, sala 11 CEP 87020-900 – Maringa/PR E-mail: alfguilherme@uem.br Fonte financiadora: Fundo Parana, o qual apoiou com verba a aquisicao de equipamentos e material de consumo para o projeto. Conflito de interesse: nada a declarar Recebido em: 16/10/2009 Aprovado em: 11/6/2010 Rev Paul Pediatr 2011;29(1):80-4. Artigo Original

Hemoglobin SD adalah suatu keadaan heterozigot HbS dan HbD yang merupakan bentuk penyakit sel sabit yang jarang. Pasien dengan Hb SD menunjukkan manifestasi klinis yang bervariasi. High performance liquid chromatography (HPLC) merupakan metode rujukan untuk membantu menegakkan diagnosis kelainan Hb saat ini. Anak laki-laki berusia 7 tahun mengeluh nyeri pada kedua tungkai sejak 5 hari sebelum masuk rumah sakit dan sudah muncul berulang sejak 4 tahun yang lalu. Keluhan disertai demam dan tampak pucat. Riwayat keluar cacing dari BAB usia 2 tahun. Pemeriksaan fisik menunjukkan hipertermia, konjungtiva anemis, limfadenopati dan hepatomegali. Hasil pemeriksaan hematologi menunjukkan anemia normositik normokrom dengan retikulositosis dan leukositosis dengan eosinofilia. Hasil pemeriksaan HPLC menunjukkan adanya S-window, D-window, dan peningkatan HbF. Nyeri pada kedua tungkai merupakan gambaran terjadinya proses vasooklusif akut yang dicetuskan oleh keadaan demam dan infeksi. Sumber infeksi pada pasien ini belum diketahui pasti namun diperkirakan adalah infestasi cacing yang didiagnosis banding dengan sindrom hipereosinofilik. Manifestasi klinis lainnya dihubungkan dengan anemia hemolitik yang dapat terjadi intravaskular maupun ekstravaskular.

Tuberculosis has increased all over the world. This paper reports the case of a male patient with tuberculous meningitis, spinal tuberculosis (Pott's disease) and severe adverse reactions to antituberculosis drugs. He had skin rash, hepatitis, eosinophilia and fever; all these signs make the diagnosis of DRESS syndrome. This syndrome is caused by a severe hypersensitivity reaction to different drugs. It is usually caused by anticonvulsants, sulfonamides and some antiviral drugs, among other drugs. Anti-tuberculosis drugs can also cause this potentially fatal syndrome. The importance of surveillance for early detection and treatment of adverse drug reactions is emphasized.La tuberculosis se ha incrementado en todo el mundo. Comunicamos el caso de un paciente con meningoencefalitis tuberculosa y tuberculosis de hueso (mal de Pott), que sufrió una reacción adversa grave a los fármacos antituberculosos. Inició con farmacodermia, hepatitis, leucocitosis, eosinofilia y fiebre, que constituyen el síndrome DRESS. Este síndrome es una reacción grave de hipersensibilidad a diferentes fármacos. Suele ser producido por anticonvulsivos, sulfonamidas y algunos fármacos antivirales, entre otros. Los fármacos antituberculosos también pueden producir este síndrome potencialmente fatal. Se destaca la importancia de la farmacovigilancia para su detección y tratamiento tempranos.

Headache as clinical presentation of neurocysticercosis Neurocysticercosis is the most common parasitic disease of the central nervous system. Its frequency in our country has increased due to migratory movements. We report the case of a 58-year-old woman from Ecuador, with a history of recurrent headache, presented to the Emergency Department with daily hemicranial headache that does not respond to common analgesics. The presumptive diagnosis is determined in the emergency room after a correct anamnesis and laboratory tests, being confirmed in the Neurology Department.

Relata-se um caso de síndrome hipereosinofílica idiopática associada à doença eosinofílica disseminada em um cão, macho, mestiço Pastor Alemão, com cinco anos de idade. Os sinais clínicos incluíam apatia, anorexia, intolerância ao exercício, caquexia, dispnéia e taquicardia. Laboratorialmente, havia reação leucemóide eosinofílica e na citologia da medula óssea observou-se acentuada hiperplasia eosinofílica. Radiologicamente, detectou-se uma área radiopaca intratorácica bilateral cranial ao coração. A punção aspirativa intratorácica demonstrou grande quantidade de eosinófilos, o que permitiu um diagnóstico clínico de infiltração pulmonar com eosinofilia. O diagnóstico foi confirmado histologicamente. A case of idiopathic hypereosinophilic syndrome associated with disseminated eosinophilic disease is described in a 5-year-old German Shepherd cross male dog. Clinical signs included apathy, intolerance to exercise, dyspnea, and tachicardia. Laboratory findings included eosinophilic leukemoid reaction and cytological evidence of marked marrow eosinophilic hyperplasia. A bilateral radiopaque area appeared cranial to the heart in the radiological examination of the thorax. An aspiration biopsy of the intrathoracic mass yielded large numbers of eosinophils that allowed a clinical diagnosis of pulmonary infiltration with eosinophilia, which was confirmed histologically.

Os autores apresentam dois casos de hiperplasia angiolinfóide com eosinofilia, doença relativamente rara. Uma das pacientes apresentava lesões exuberantes e de localização incomum, já que é em geral situada na cabeça e/ou no pescoço. A histopatologia corada com HE e a imuno-histoquímica com fator VIII confirmaram o diagnóstico e a origem endotelial das lesões de ambas as pacientes.

La realización de una sesión de hemodiálisis (HD) supone un cierto riesgo de aparición de reacciones adversas de hipersensibilidad, al estar en contacto abundantes cantidades de sangre con diferentes materiales de origen sintético. En HD han sido descritas reacciones de hipersensibilidad al óxido de etileno y a membranas no biocompatibles como el cuproamonio. También se han comunicado casos de hipersensibilidad con membranas biocompatibles como la polisulfona, e incluso con polisulfona asociada a polivinilpirrolidona. En este artículo queremos describir seis casos acontecidos en nuestro servicio de reacciones de hipersensibilidad mayoritariamente temprana a la sesión de HD, caracterizados por mal estado general, desaturación, broncoespasmo e hipotensión arterial, con buena respuesta a la suspensión temporal de la sesión y con reaparición en sesiones posteriores siempre que se utilizase un dializador sintético. Todas tienen en común no haberse dado de nuevo en sucesivas observaciones cuando las sesiones fueron realizadas con una membrana de celulosa.

Latar belakang. Interaksi antara infeksi, status gizi dan imunitas telah lama diketahui, tetapi penelitiantentang interaksi ini di daerah endemis malaria masih terbatas.Tujuan. Bertujuan untuk mengetahui hubungan kepadatan parasit malaria dengan status gizi, kadarhemoglobin dan respon eosinofilia pada anak sekolah dasar di daerah endemis malaria.Metode. Penelitian belah lintang pada anak SD yang dipilih secara cluster random sampling di KabupatenSumba Timur Nusa Tenggara Timur pada tahun 2003. Diambil data status gizi, kadar hemoglobin,kepadatan parasit malaria dan jumlah eosinofilia dari darah subjek.Hasil. Dari 137 anak (57 laki-laki dan 83 perempuan) dengan rerata umur (11,5 ± 1,37) tahun, didapatkangizi kurang 63,6%. Tiga belas persen anak terdapat parasit malaria pada sediaan darah, eosinofilia pada32,9% anak. Kepadatan parasit malaria tinggi 7,9%. Kepadatan parasit malaria tidak berhubungan denganjenis kelamin, suku bangsa dan status gizi, tetapi kepadatan parasit malaria tinggi meningkatkan risikoanemia 2,1 kali (RP 2,1; 95% KI 1,6-2,8 ; p=0,006) dan tidak terjadinya respon eosinofilia 2,9 kali (RP2,9; 95% KI 1,9-4,2 ; p=0,001) .Kesimpulan. Sebagian besar anak mempunyai status gizi kurang. Kepadatan parasit malaria tidakberhubungan dengan jenis kelamin, suku bangsa dan status gizi. Tetapi kepadatan parasit malaria yangtinggi akan meningkatkan risiko anemia 2,1 kali dan tidak adanya respon eosinofilia 2,9 kali.

A 25-year-old Spanish male travelled to Senegal in September 2009, where he swam near the Dindefelo fresh-water falls. Five weeks later, he presented with fever, myalgia, and dry cough. His complete blood count showed a hemoglobin level of 157 g/L, platelet count of 123.000 platelets/µL, and a leukocyte count of 8.670 cells/µL, with 9% eosinophils. Malaria smear, blood cultures, and serologies for common viral and bacterial infections were negative. Titers of an indirect hemagglutination test for Schistosoma mansoni were 1∶80. The patient was treated with a single dose of praziquantel (40 mg/kg) and prednisone (30 mg) for three days. After treatment, the dry cough increased and he developed moderate dyspnea, with increasing malaise and myalgia. A second blood sample revealed eosinophilia of 1.200 cells/µL. A chest X-ray showed patchy infiltrates in both lungs (Figure 1), and a CT scan showed multiple peripheral bilateral pseudonodular lesions with surrounding ground-glass-opacity halo.

El síndrome de DRESS es una toxicodermia asociada a eosinofilia con síntomas sistémicos. Presentamos un caso de dicho síndrome tras inicio de Levetiracetam con buena evolución tras inicio de corticoides y retirada del fármaco. Este síndrome, poco conocido y probablemente infradiagnosticado, puede ser potencialmente letal si no se trata de forma precoz.

FUNDAMENTOS: A reação a droga com eosinofilia e sintomas sistêmicos é uma reação medicamentosa severa com envolvimento de múltiplos órgãos. OBJETIVO: Avaliar as características epidemiológicas, clínicas, histológicas e o prognóstico dessa reação medicamentosa entre os pacientes atendidos pelo serviço da dermatologia. MÉTODOS: Levantamento retrospectivo dos prontuários de dez pacientes diagnosticados com reação a droga com eosinofilia e sintomas sistêmicos pelo serviço de dermatologia da Universidade Federal de São Paulo (UNIFESP), entre agosto de 2008 e maio de 2011. RESULTADOS: A fenitoína foi a principal causa de reação a droga com eosinofilia e sintomas sistêmicos entre os pacientes, seguida pelo alopurinol. A alteração das enzimas hepáticas foi observada em sete pacientes e diminuição da função renal em dois casos. Todos os pacientes estavam hospitalizados e o medicamento implicado foi suspenso. O principal tratamento foi corticóide sistêmico. Dois pacientes faleceram devido à síndrome reação a droga com eosinofilia e sintomas sistêmicos. A causa da morte foi choque séptico e falência hepática. CONCLUSÃO: A mortalidade de 20% entre os pacientes do estudo confirma que essa reação induzida por droga é grave e deve ser reconhecida por todos os dermatologistas. BACKGROUND: Drug reaction with eosinophilia and systemic symptoms is a severe form of drug-induced reaction with multiorgan involvement. OBJECTIVES: The aim of this study is to evaluate the epidemiological, clinical and pathological features and prognosis of this drug reaction among patients seen at a dermatology service. METHOD: Retrospective review of medical records of ten patients diagnosed with drug reaction with eosinophilia and systemic symptoms at the Federal University of São Paulo, from august 2008 to may 2011. RESULTS: Phenytoin was the leading cause of drug reaction with eosinophilia and systemic symptoms in our cases, followed by allopurinol. Abnormal liver function tests were observed in 7 patients and renal function impairment in 2 patients. In all cases, patients were hospitalized and the culprit drug was withdrawn. The main treatment was systemic corticosteroid. Drug reaction with eosinophilia and systemic symptoms resulted in death in 2 cases. The causes of death were septic shock and hepatic failure. CONCLUSION: Our mortality rate of 20%, supports that drug reaction with eosinophilia and systemic symptoms is a severe form of drug-induced reaction and must be recognized by all dermatologists. Universidade Federal de São Paulo (UNIFESP) Dermatology Department Universidade Federal de São Paulo (UNIFESP) Dermatology and Pathology Department UNIFESP, Dermatology Department UNIFESP, Dermatology and Pathology Department SciELO

Introduction: Omalizumab has been demonstrated to be a successful therapy in the management of asthma through reduction of patient’s symptoms and use of inhaled corticosteroids. The effect of omalizumab is achieved by immunoglobulin E (IgE) blockage and other secondary mechanisms resulting from this blockage. Because other diseases have an important IgE mediation in their physiopathology, the question arises as to if omalizumab would be useful in the treatment of other IgE-mediated diseases. Objective: We present an overview of the experimental studies and clinical reports evaluating the use of omalizumab in diseases different to asthma including atopic dermatitis, urticaria, eosinophilic gastrointestinal disorders, idiopathic anaphylaxis, latex allergy, hymenoptera venom allergy, and other IgE diseases. Methods: We reviewed the literature using PUBMED, EMBASE, and LILACS for publications which used omalizumab in the treatment of patients with allergic diseases or any other diseases. Complete articles published in English, Spanish or Portuguese were included. Conclusion: There is not enough evidence to support the regular use of omalizumab in IgE diseases other than asthma. However, some experimental and clinical investigations indicate that omalizumab could be a therapeutic option in several allergic diseases like atopic dermatitis, urticaria, and eosinophilic gastrointestinal disorders. More control studies are needed in each IgE disease to evaluate the efficacy and safety of omalizumab in IgE mediated diseases. COL0059567

The Drug Reaction with Eosinophilia and Systemic Symptoms syndrome, also known as Drug Induced Hypersensitivity Syndrome presents clinically as an extensive mucocutaneous rash, accompanied by fever, lymphadenopathy, hepatitis, hematologic abnormalities with eosinophilia and atypical lymphocytes, and may involve other organs with eosinophilic infiltration, causing damage to several systems, especially to the kidneys, heart, lungs, and pancreas. Recognition of this syndrome is of paramount importance, since the mortality rate is about 10% to 20%, and a specific therapy may be necessary. The pathogenesis is related to specific drugs, especially the aromatic anticonvulsants, altered immune response, sequential reactivation of herpes virus and association with HLA alleles. Early recognition of the syndrome and withdrawal of the offending drug are the most important and essential steps in the treatment of affected patients. Corticosteroids are the basis of the treatment of the syndrome, which may be associated with intravenous immunoglobulin and, in selected cases, Ganciclovir. The article reviews the current concepts involving this important manifestation of adverse drug reaction. A síndrome Reação a Drogas com Eosinofilia e Sintomas Sistêmicos, também conhecida como Síndrome da Hipersensibilidade Induzida por Droga apresenta-se clinicamente como uma erupção cutâneomucosa extensa tipo exantemática, associada a febre, linfadenopatia, hepatite, anormalidades hematológicas com eosinofilia e linfócitos atípicos, e pode envolver outros órgãos, produzindo insuficiência renal, infiltrado eosinofílico cardíaco e pulmonar, além de pancreatite. O reconhecimento desta síndrome é de suma importância, uma vez que, a taxa de mortalidade é de cerca de 10% a 20% e uma terapia específica pode ser necessária. Sua etiopatogenia está relacionada a drogas específicas, principalmente os anticonvulsivantes aromáticos, alterações imunes, reativação sequencial de herpesvirus e associação com alelos do HLA. O pronto reconhecimento da síndrome e a retirada da droga desencadeante são os passos mais importantes e essenciais no tratamento dos doentes acometidos. Os corticosteróides são as medicações de escolha para o tratamento da síndrome, podendo ser associados imunoglobulina intravenosa e em, alguns casos selecionados, Ganciclovir. O artigo traz uma revisão dos conceitos atuais que envolvem essa importante manifestação de reação adversa a drogas.

Meningitis caused by Angiostrongylus cantonensis has recently been reported in patients resulting from the first outbreaks in subtropical regions of Ecuador. METHOD: Eight young adult patients from the two outbreaks were studied. IgA, IgM, IgG and albumin in cerebrospinal fluid and serum were quantified and plotted in cerebrospinal fluid/serum quotient diagrams (Reibergrams). The anamnesis on the patients included asking about any consumption of raw snails, symptoms and harm caused. RESULTS: Mean eosinophilia of 7.5% and 26% in serum and cerebrospinal fluid respectively was observed, as well as a moderate increase in total proteins. The most frequent pattern of intrathecal synthesis was observed in three classes of immunoglobulins. Intrathecal synthesis of IgM was observed in all cases two weeks after the first symptoms appeared. CONCLUSION: The intrathecal synthesis patterns of eosinophilic meningitis due to Angiostrongylus cantonensis, facilitated by cerebrospinal fluid analysis, were similar to those of previous cases from abroad. La meningitis provocada por Angiostrongylus cantonensis ha sido reportada recientemente en pacientes procedentes de los primeros brotes reportados en regiones subtropicales de Ecuador. MÉTODO: Ocho adultos jóvenes procedentes de dos brotes fueron estudiados. Se cuantificó IgA, IgM, IgG y albúmina en suero y líquido cefalorraquídeo y fueron colocados en los gráficos de las razones líquido cefalorraquídeo/suero (reibergramas). La anamnesia incluía ingestión de caracoles crudos, los síntomas y los daños provocados. RESULTADOS: Una eosinofílica promedio de 7,5 y 26% en suero y líquido cefalorraquídeo fue observada al igual que un moderado incremento en las proteínas totales. El patrón de síntesis intratecal predominante fue de tres clases de inmunoglobulinas. La síntesis intratecal de IgM se observó en todos los casos a las dos semanas después del inicio de los síntomas. CONCLUSIÓN: El patrón de síntesis intratecal de la meningitis eosinofílica por Angiostrongylus cantonensis facilitado por el análisis del líquido cefalorraquídeo fue similar a los casos previos reportados fuera del país.

OBJETIVOS Presentar un caso de enfermedad de Kimura asociada a la neoplasia de rinon. La enfermedad de Kimura se trata de una enfermedad inflamatoria rara, que se presenta comunmente con linfonodos aumentados y masas en regiones de la cabeza y del cuello. El diagnostico diferencial debe incluir linfomas, linfadenopatia reaccional a medicinas o parasitos. En masas y linfonodos aumentados se puede encontrar algun nodulo sugerente de neoplasia. Existe un caso en la literatura que describe a la Enfermedad de Kimura asociada a la neoplasia de rinon. METODOS Se presenta el caso de una paciente joven, con nodulaciones intra y retroperitoneales, incluyendo una de ellas en el polo inferior del rinon izquierdo. Tras el periodo de tratamiento con corticoides, la tomografia computadorizada del abdomen confirmo la presencia de la lesion, con caracteristicas de malignidad. Se realizo nefrectomia parcial izquierda y la evolucion postoperatoria ha sido favorable. RESULTADOS La paciente se encuentra sin manifestaciones de la Enfermedad de Kimura y sin signos de recidiva de la neoplasia 18 meses despues de la operacion. CONCLUSIONES La enfermedad de Kimura esta asociada a algunas neoplasias que deben ser investigadas por el equipo medico. La nefrectomia parcial parece ser una buena opcion terapeutica para nodulos neoplasicos bien definidos y ubicados en polos renales.

La esofagitis eosinofílica es una enfermedad inusual hasta el momento actual. Se sabe poco de su evolución natural, pero si no se trata puede provocar la formación de estenosis esofágicas. Presentamos el caso de un niño de 12 años que acude a urgencias por impactación alimentaria y presenta antecedentes de atopia y alergia, todo ello característico de esta entidad.

La esofagitis eosinofílica es una enfermedad inusual y emergente en los últimos años que se caracteriza por un infiltrado de más de 20 eosinófilos por campo de gran aumento en la biopsia del tejido esofágico. Se describe en todas las edades aunque aparentemente es más frecuente en niños. La etiología no está clara pero se sugiere que la atopia o las alergias juegan un rol importante en el desarrollo de la enfermedad. La presentación clínica es variada: la disfagia y la impactación alimentaria son las más frecuentes. No existe un tratamiento específico. Los corticoides tópicos deglutidos son los fármacos de elección, pero en niños con alergia alimentaria el tratamiento se basa en dietas de exclusión. Presentamos el caso clínico de un niño de 12 años con antecedente de dermatitis atópica y alergia que es hospitalizado por presentar un cuadro de melena con urticaria aguda. A su vez, se hace una breve revisión del diagnóstico y el tratamiento de esta patología.

Con la finalidad de comparar la efectividad de la prueba serológica ELISA y de la prueba de Woo para el diagnóstico de dirofilariosis canina se evaluaron muestras de sangre de 69 perros sintomáticos y asintomáticos. Para el análisis estadístico los perros fueron separados en dos grupos de diferentes edades y razas. El grupo I estuvo conformado por 49 perros sospechosos a dirofilariosis y fue seleccionado de los casos atendidos en la Policlínica Veterinaria Universitaria y en una clínica privada de la ciudad de Maracaibo. El grupo II, de 20 perros, fue seleccionado al azar en Santa Rosa de Agua en Maracaibo, Estado Zulia. Las muestras de sangre completa fueron obtenidas de la vena radial y colectadas en tubos estériles con EDTA. Se estudiaron las variables hematológicas: Hematocrito (Hct), Recuento de Glóbulos blancos (RGB) y el Hemograma (DIF). Para el diagnóstico de microfilarias circulantes se utilizó la técnica hematológica de Woo y para la determinación de los antígenos producidos por los parásitos adultos se uso la técnica serológica ELISA (ASSURE/CH de Synbiotics Corporation). Para evidenciar los cambios cardiovasculares producidos por los parásitos adultos en los animales positivos, se tomaron placas radiográficas laterales y dorsoventrales de tórax. Los datos fueron analizados mediante los Procedimientos PROC MEANS, Chicuadrado y una prueba de Probabilidad del Sistema de Análisis Estadístico SAS. En el total de 69 perros estudiados, se detectaron 2 casos (2,89%) negativos a ELISA y positivos a Woo y 14 casos positivos a ELISA y negativos a Woo, indicando 20,28% de dirofilariosis oculta. Se detectaron 15 casos positivos a ELISA y positivos a Woo (21,73%) y 38 casos negativos con ambos métodos (55%). El porcentaje de dirofilariosis detectado en el total de la población fue de 44,9%, correspondiendo 38,7% al grupo I y 55 % al grupo II, Se demostró 20% de dirofilariosis oculta. Eosinofilia estuvo presente en el 67,86% (P