Late diagnosis: a factor associated with death from visceral leishmaniasis in elderly patients

Abstract

Introduction: Visceral leishmaniasis (VL) is among the seven global endemic diseases assigned a high priority by the World Health Organization. In Latin America, most cases occur in Brazil. Despite the availability of intensive treatment resources and protocols for specific treatment, lethality rates for VL have increased in several regions in the country over the past 10 years, particularly in patients under one and over 50 years of age. As the growth of the elderly population accelerates in Brazil, VL poses a greater challenge to public health. Given the scarcity of studies addressing the disease in this age group, the purpose of this study was to identify factors associated with VL lethality among the elderly. Methods/Key findings: This analytical, cross-sectional epidemiological study comprised 80 elderly patients who sought treatment at the teaching hospital of the Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil, in the period 2000-2013.Clinical, laboratory and treatment variables were investigated from records of elderly patients with VL diagnosis confirmed by at least one laboratory test positive (culture for parasite or direct parasitological examination; reactive immunofluorescence; immunochromatographic test with recombinant antigens) or patients without laboratory confirmation who lived in endemic areas and responded favorably to therapeutic trial, as defined by the Brazilian Ministry of Health. Of the 80 patients included, 78 tested positive to at least one exam; in two cases, diagnosis was based on clinical and epidemiological criteria. The lethality rate was 20%. Multivariate analysis revealed an association between death and time elapsed from symptom onset.

The direct costs of treating human visceral leishmaniasis in Brazil

“…The social and economic impact of VL is significant because of the increased number of cases and rate of transmission in recent years 18 ; in addition to the high morbidity and mortality associated with VL 19,20 . The effects of VL on the economy are evident because this disease mainly affects low-income populations, and the direct and indirect costs related to diagnosis and treatment are high [21][22][23] .…”

Hematological Characteristics of Yemeni Adults and Children With Visceral Leishmaniasis. Could Eosinopenia Be a Suspicion Index?

“… 8 , 9 Higher rates of morbidity and mortality are consequences of the delay in diagnosis. 10 , 11 , 12 VL is also reported to be one of the most common causes of fever of unknown origin causing troublesome diagnosis in a European low-income country. 13 In addition to the non-specificity of clinical and general laboratory features of VL, the confirmatory laboratory tests with the exception of identification of the parasites in Giemsa stained tissue aspirates, are usually interpreted in the light of clinical and epidemiological data which are not helpful in non-endemic areas.…”

The older traveller

“…A higher lethality is connected with late diagnosis, atypical presentations and multimorbidity. Despite the fact that multidrug therapy is associated with higher risk of drug interactions and cumulative toxicity, it was not found to influence the mortality rate in VL patients [23].…”

“…As a result, the immunity conferred through vaccinations received in the past may become impaired, a response to more recently received vaccines may be decreased and the duration of immunity is generally shorter. Also noteworthy are the changes in cytokine production, including lower level of Th1 cytokines (IL-12 and IFN-G) and an increased production of Th2 cytokines (IL-10 and TGF-B) [23]. Due to the dysfunction of the immune system elderly patients are more susceptible to infections, e.g.…”

“…However, 90% of VL cases (the most severe form of leishmaniasis) are reported from several countries only; these countries however are popular travel destinations, e.g. Brazil, India or Nepal [23,50,51]. According to Montalvo et al [52] high human global mobility is one of the factors which have led to an increase in the number of cases in non-endemic regions such as Cuba.…”