Scielo RSS <![CDATA[Revista da Sociedade Brasileira de Medicina Tropical]]> vol. 49 num. 5 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[Zika and chikungunya infections in Brazil: reviewing the epidemic and treatment options]]> <![CDATA[One year after the Zika virus outbreak in Brazil: from hypotheses to evidence]]> Abstract Zika virusis an arbovirus of the Flaviviridae family with two major strains, an Asian and an African strain. The main vectors involved in the transmission of Zika virus are the Aedes aegypti and Aedes albopictus mosquitoes. Despite its identification, discovered in 1947 in the Zika forest in Uganda, only isolated and sporadic occurrences of human infection were reported within a largely asymptomatic proportion of individuals. The first reported outbreak occurred in 2007 in the Yap Island, which belongs to the Federated States of Micronesia in the Pacific Ocean, and in French Polynesia, where high attack rates occurred and the first cases of associated Guillain-Barré syndrome were reported. From November 2014 to early 2015, the Northeast states of Brazil reported the first outbreaks of Zika virus infection, with laboratory confirmation of Zika virus circulation in April 2015. In the second quarter of 2015, the association between Zika virus infection and neurological symptoms was confirmed in adults. Moreover, in October 2015 a novel suspicion was raised based on clinical and epidemiological observations: that an association between Zika virus infection and neonatal microcephaly may exist. A year after the first reports on Zika virus in Brazil, many hypotheses and much evidence on the patterns of involvement of the disease and its complications have been produced, both in this country and others; other hypotheses still need to be clarified. This review is a synthesis of a new chapter in the history of medicine; it outlines the main results produced. <![CDATA[Frequency and diversity of phlebotomine sand flies (Diptera: Psychodidae) in Sinop, State of Mato Grosso, Brazil]]> Abstract INTRODUCTION: Understanding the diversity of sand flies is important for the epidemiology and control of leishmaniasis. This study aimed to understand the frequency, diversity, and seasonality of medically important sand flies in the municipality of Sinop, State of Mato Grosso, Brazil. METHODS: The study was conducted in an urban area, including four ecotypes with different levels of urbanization. The sand flies were collected using light traps for three nights per month, from May 2014 to April 2015. RESULTS: A total of 62,745 sand flies was collected, 52.34% of which were female. The frequency and diversity of sand flies was the highest in areas of permanent preservation (APPs) (96.85%), and was lower in more urbanized areas. Lutzomyia dasypodogeton was the most frequent species in the APPs. Lutzomyia antunesi was the most frequent in neighborhoods with forest fragments and neighborhoods around APPs, and L. aragaoi was the most frequent in completely urbanized neighborhoods. A higher frequency and diversity of sand flies was observed in the rainy season (87.92%) than in the dry season (12.08%). Eight medically important species were captured, and Lutzomyia antunesi, which is associated with American cutaneous leishmaniasis and visceral leishmaniasis, was observed in all ecotypes throughout the year. CONCLUSIONS: We observed a high frequency and diversity of sand flies in all urban areas, and some species collected were major vectors of leishmaniasis. These results support the need for further studies of the natural rates of infection of these insects and the circulation of the disease in hosts and vectors. <![CDATA[Zika in Pernambuco: rewriting the first outbreak]]> Abstract INTRODUCTION: A Zika virus epidemic was registered in 2015 in Northeast Brazil. In the State of Pernambuco, thousands of classical cases transpired, and in the following months, neurological disturbances in adults and microcephaly in newborns emerged as complications. After the peak of the epidemic, the official system reported only four cases of Zika virus but over 100,000 cases of dengue virus. The vigilance system was unable to retrospectively estimate cases or to issue an alert to officially notified cases with possible inconsistence concerning specific arbovirosis diagnoses. METHODS: To evaluate the frequency of different arbovirosis diagnoses based on clinical-epidemiologic criteria, from January to April 2015, we conducted a hospital-based cross-sectional study retrospectively analyzing suspected cases of arbovirosis. RESULTS: Of 1 , 046 total suspected cases of arbovirus, 895 (86%) were classified as probable Zika virus cases, and 151 (14%) as probable dengue virus cases. The most frequent manifestations in probable Zika virus cases were exanthema (100%), pruritus (50.7%), fever (20.4%) and arthralgia (27.7%). CONCLUSIONS: In contrast to the official data, during the peak months of the arbovirosis epidemic of 2015, most cases were compatible with Zika virus infections. Hospital-based studies, although retrospective and based on secondary data from clinical files, might provide a better estimate of the number of cases relative to currently available data, if derived from several urgent care units of representative areas of a city or state.This would partially retrospectively correct some inconsistences regarding official notifications. <![CDATA[A randomized clinical trial on the effectiveness of a symbiotic product to decolonize patients harboring multidrug-resistant Gram-negative bacilli]]> Abstract INTRODUCTION: We aimed to evaluate the effectiveness of a symbiotic product to decolonize the intestinal tract of patients harboring multidrug-resistant (MDR) Gram-negative bacilli and to prevent nosocomial infections. METHODS: This was a randomized, double blind, placebo-controlled clinical trial, conducted in a tertiary-care university hospital. All adult hospitalized patients with a positive clinical culture and a positive rectal swab for any MDR Gram-negative bacilli were potentially eligible. Exclusion criteria were pregnancy, immunosuppression, and bowel obstruction/perforation. The intervention consisted of administering a symbiotic product (Lactobacillus bulgaricus, Lactobacillus rhamnosus, and fructo-oligosaccharides) twice a day for seven days via the oral/enteral route. RESULTS: Between August 1, 2012 and December 22, 2013, 116 of 275 eligible patients were allocated to treatment (n=57) and placebo (n=59). Overall, 101 patients received at least four doses of the study products and were included in the modified intention-to-treat analysis. The primary study outcome, a negative rectal swab for MDR Gram-negative bacilli after treatment, was identified in 16.7% (8/48) and 20.7% (11/53) of patients in the experimental and placebo group, respectively (p=0.60). The secondary outcome, the combined incidence of nosocomial respiratory and urinary tract infections, was 37.5% (18/48) in the experimental group versus 22.6% (12/53) in the control group (adjusted odds ratio: 1.95, 95% confidence interval: 0.69-5.50, p=0.21). Length of stay after the beginning of the intervention, incidence of adverse events, and in-hospital mortality rates were similar in both study groups. CONCLUSIONS: Under the present study conditions, symbiotic administration was not effective for decolonizing hospitalized patients harboring MDR Gram-negative bacilli. <![CDATA[Antibodies for <strong><em>Rickettsia</em></strong> spp. in patients with negative serology for dengue virus, leptospirosis, and meningococcal disease in municipalities of São Paulo State, Brazil]]> Abstract INTRODUCTION Brazilian spotted fever is an infectious disease with a high mortality rate if not treated early. Differential diagnosis is difficult, as the first clinical signs are non-specific and can be confused with other diseases. The aim of the study was to investigate evidence of infection with Rickettsia rickettsii and Rickettsia parkeri in negative sera samples, collected in 2014, from patients with suspected leptospirosis, dengue fever, and meningococcal disease in Atibaia and Bragança Paulista municipalities of the State of São Paulo. METHODS The samples stored at the Institute Adolfo Lutz in Campinas were tested using an indirect immunofluorescence assay (IFA) with IgG and IgM against R. rickettsii and R. parkeri. Real-time polymerase chain reaction (PCR) testing was performed for the sera samples of patients who died (n = 3), those with initial suspicion of meningococcal disease (n = 6), and those with positive IFA results. RESULTS Of 258 samples from Bragança Paulista, 4 (1.6%) were positive, with IgG titers of 1:64 and 1:128 against R. rickettsii and R. parkeri, respectively. Of 155 samples from Atibaia, 2 (1.3%) were positive, with IgG titers of 1:64 and 1:128 against R. rickettsii and R. parkeri, respectively. No sample showed positive PCR results. CONCLUSIONS This serological investigation suggests there is evidence of exposure to Rickettsia spp. in residents of areas that have environmental conditions favorable to the spread of bacteria, in which Brazilian spotted fever incidence was not previously confirmed. <![CDATA[Assessment of the Housing Improvement Program for Chagas Disease Control in the Northwestern municipalities of Rio Grande do Sul, Brazil]]> Abstract INTRODUCTION: The Housing Improvement Program for Chagas Disease Control (HIPCDC) was established in 2001 in Northwestern Rio Grande do Sul State, aiming to improve the conditions of the domiciliary and peridomiciliary environments to make them resistant to triatomine colonization. This study aimed to assess the impact of the HIPCDC on triatomine control by developing local population and authority awareness on the issue. METHODS: The study was conducted by means of questionnaires applied to local authorities and the program beneficiaries. Three municipalities - Ajuricaba, Coronel Barros, and Crissiumal - were visited. RESULTS: A program coordinator from each municipality and 62 individuals from selected households were interviewed. The authorities reported difficulties in the implementation of the program due to differences between the project development period and financial resource availability, in addition to a lack of understanding by the community not included in the program. As for the houses, most improvements were made in the peridomiciliary environments; moreover, construction of 4 new residences, as well as the renovation of others, was also reported. Regarding suggestions to the program, requests for better planning (44.9%) and renovation quality (36.7%) were highlighted. With reference to the presence of triatomine bugs, prior to the HIPCDC adaptations, 12.9% of the respondents reported coming across at least one specimen at home, as compared to 22.6% who found these insects in peridomiciliary areas. CONCLUSIONS: Despite reports of difficulties in carrying out the HIPCDC, there was an improvement in the housing conditions, with no triatomine occurrence reports after the program implementation. <![CDATA[Screening of the <strong><em>in vitro</em></strong> antileishmanial activities of compounds and secondary metabolites isolated from <strong><em>Maytenus guianensis</em></strong> Klotzsch ex Reissek (Celastraceae) chichuá Amazon]]> Abstract INTRODUCTION Maytenus guianensis is a member of the Celastraceae family that is used in traditional medicine, particularly for its anti-parasitic and anti-cancer effects. To explore the ethnopharmacological potential of this plant, the present study was designed to screen the in vitro antileishmanial activities of extracts and compounds isolated from M. guianensis. METHODS Maytenus guianensis stems and leaves were extracted in acetone, followed by the preparation of eluates and isolation of secondary metabolites using chromatography on a glass column with silica gel as the fixed phase. The chemical components were identified using spectroscopic methods, including one- and two-dimensional nuclear magnetic resonance of hydrogen-1 and carbon-13, mass spectroscopy, and infrared spectroscopy. The anti-Leishmania amazonensis activities of these eluates and compounds were evaluated by direct promastigote counting and viability assays. RESULTS It was found that the hexane bark eluate produced the strongest anti-L. amazonensis effect, with 90-100% inhibition of the promastigote form. The isolated metabolite that produced the best result was tingenone B, followed by a compound formed by the union of tingenone and tingenone B (80-90% inhibition). CONCLUSIONS Maytenus guianensis shows anti-parasite activity that warrants further investigation to determine the mechanisms underlying this antileishmanial effect and to evaluate the pharmacological potential of these eluates and isolated secondary metabolites, while minimizing any adverse effects. <![CDATA[Evaluation of the antiplasmodial and leishmanicidal potential of <strong><em>Myrciaria dubia</em></strong> (Myrtaceae) extract]]> Abstract INTRODUCTION: Malaria and leishmaniasis are prevalent in tropical regions, which have environmental characteristics that are highly favorable to protozoa and vectors of these diseases; the transmission of these infections in sub-tropical regions, although recognized, represents only a small fraction of cases. Plants are constantly being used in the search for and acquisition of new drugs, and many compounds derived from them have been used to combat various diseases. In this study, we evaluated the action of the dichloromethanolic extract of Myrciaria dubia leaves against the protozoa Plasmodium falciparum, Leishmania amazonensis, Leishmania braziliensis, and Leishmania chagasi through bioassays. METHODS The extract from M. dubia was tested for its anti-P. falciparum activity in an anti-histidine-rich protein II immunosorbent assay. The antileishmanial assays were performed using the resazurin method, while cytotoxicity against human hepatoma (HepG2) strain was determined using the colorimetric MTT [3-(4, 5-dimethyl-2- thiazolyl)-2, 5-diphenyl-2H tetrazolium bromide] method. RESULTS The M. dubia extract presented a half-maximal inhibitory concentration equal to 2.35 (1.05)μg/mL for P. falciparum, 190.73 (6.41) μg/mL for L. amazonensis, and greater than equal to 200µg/mL for L. chagasi and L. braziliensis strains. The cytotoxic concentration for 50% of the cells was above 500μg/mL for HepG2, indicating no toxicity and greater selectivity against parasites. CONCLUSIONS The results obtained indicate the presence of antiplasmodial and leishmanicidal bioactive compounds in the dichloromethanolic extracts of M. dubia leaves, and point towards future studies to elucidate the mechanism of action for each physiological effect. <![CDATA[Clinical, laboratory, and therapeutic characteristics of American tegumentary leishmaniasis in the 15 <strong><sup>th</sup></strong> State Health Division, Northwest Paraná State, Southern Brazil]]> Abstract INTRODUCTION American tegumentary leishmaniasis (ATL) is an endemic disease in many regions of Brazil; however, only few reports on the actual epidemiological conditions are available. Here, we aimed to assess the clinical, epidemiological, and laboratory characteristics of ATL patients and their treatment in the 15th Regional Health Division of Paraná State, Maringá, Brazil. METHODS This epidemiological study included patients diagnosed with ATL from January 2010 to September 2014, from the 15th Regional Health Division database. RESULTS A total of 220 cases aged 3-84 years (85% male and 60.9% with up to 8 years of schooling) were included. The cases were classified as having the cutaneous form (n=183; 83.2%), mucosal form (n=26; 11.8%), mucocutaneous form (n=11; 5%), and relapses (n=21; 9.6%). Diagnosis was made via laboratory test results in 197 (89.5%) patients, and 172 (78.2%) completed the treatment within the study period. With regard to patients with the cutaneous form, 134 (95%) were cured, 131 (97.8%) were treated with Glucantime(r), and 47 (36.7%) received dosage of &gt;15 and &lt;20mg Sb5+/kg/day. Among the cases with mucosal involvement, 87.1% were cured and most were treated with &lt;20mg Sb5+/kg/day. Thus, the cure rate was 93.6%. CONCLUSIONS During the study period in the 15th Regional Health Division of Paraná State, ATL cases had a good response to treatment with a low rate of relapse or treatment failure, although a high percentage of mucosal or mucocutaneous form cases was also noted. <![CDATA[Genotyping of <strong><em>Toxoplasma gondii</em></strong> and <strong><em>Sarcocystis</em></strong> spp. in road-killed wild mammals from the Central Western Region of the State of São Paulo, Brazil]]> Abstract INTRODUCTION: Road-killed wild animals host zoonotic pathogens such as Toxoplasma gondii, offering a new opportunity for the epidemiological study of these infectious organisms. METHODS This investigation aimed to determine the presence of T. gondii and other apicomplexan parasites in tissue samples of 64 road-killed wild animals, using polymerase chain reaction (PCR). Positive samples were then typed by PCR-restriction fragment length polymorphism (RFLP) using 7 markers: SAG1, 5′-3′SAG2, SAG3, BTUB, c29-6, PK1, and Apico. PCR-RFLP targeting 18S ribosomal RNA (rRNA) genes was also performed on all samples to detect other apicomplexan parasites. RESULTS T. gondii DNA was detected in 16 tissue samples from 8 individual animals, as follows: 1 Cerdocyon thous (crab-eating fox), 1 Didelphis albiventris (white-eared opossum), 1 Lutreolina crassicaudata (lutrine opossum), 2 Myrmecophaga tridactyla (giant anteater), 1 Procyon cancrivorus (crab-eating raccoon), and 2 Sphiggurus spinosus (Paraguay hairy dwarf porcupine). Seven different T. gondii genotypes were identified, 6 of which were novel. Typing by 18S rRNA verified these 16 T. gondii-infected samples, and identified 1 Sarcocystis spp.-infected animal [Dasypus novemcinctus (nine-banded armadillo)]. The amplified T. gondii (GenBank accession No. L37415.1) and Sarcocystis spp. 18S rRNA products were confirmed by sequencing. CONCLUSIONS Our results indicate that T. gondii is commonly present in wild mammals, which act as sources of infection for humans and animals, including other wild species. The approach employed herein proved useful for detecting T. gondii and Sarcocystis spp. in the environment and identifying their natural reservoirs, contributing to our understanding of host-parasite interactions. <![CDATA[Spatial analysis for the identification of risk areas for schistosomiasis mansoni in the State of Sergipe, Brazil, 2005-2014]]> Abstract INTRODUCTION: Schistosomiasis is a parasitic infectious disease with a worldwide prevalence. The objective of this work is to identify risk areas for schistosomiasis mansoni transmission in the State of Sergipe, Brazil, during the period from 2005 to 2014. METHODS: We conducted an epidemiological study with secondary data from the Information System Control Program of Schistosomiasis [Sistema de Informação do Programa de Controle da Esquistossomose (SISPCE)]. Temporal trends were analyzed to obtain the annual percentage change (APC) in the rates of annual prevalence. In addition to the description of general indicators of the disease, the spatial analysis was descriptive, by means of the estimator of intensity kernel, and showed spatial dependence by indicators of global Moran (I) and Local Index of Spatial Association (LISA). Thematic maps of spatial distribution were made, identifying priority intervention areas in need of healthcare. RESULTS: There were 78,663 cases of schistosomiasis, with an average of 8.7% positivity recorded; 79.8% of the cases were treated, and Sergipe showed a decreasing positive trend (APC: -2.78). There was the presence of spatial autocorrelation and a significant global Moran index (I = 0.19; p-value = 0.03). We identified clusters of high-risk areas, mainly located in the northeast and southcentral of the state, which each had equally high infection rates. CONCLUSIONS: There was a decreasing positive trend of schistosomiasis in Sergipe. Spatial analysis identified the geographic distribution of risk and allowed the definition of priority areas for the maintenance and intensification of control interventions. <![CDATA[Presence of <strong><em>Lutzomyia longipalpis</em></strong> (Diptera: Psychodidae) in the Parque Estadual da Serra da Tiririca, State of Rio de Janeiro, Southeastern Brazil]]> Abstract INTRODUCTION: The sand fly, Lutzomyia longipalpis, is the main vector of Leishmania infantum in the Americas, primarily occurring in areas of apparent anthropomorphic modifications in several regions of Brazil. METHODS Sand flies were captured using light traps. RESULTS Out of all captured species, Lu. longipalpis numbers had increased within the park. CONCLUSIONS We report the occurrence of Lu. longipalpis in an area of Atlantic Forest, possibly representing the first sylvatic population of Lu. longipalpis in an area absent of peridomestic captures, but with the risk of L. infantum transmission in the areas of Niterói and Maricá. <![CDATA[Prevalence of human immunodeficiency virus infection and associated risk factors among prison inmates in the City of Florianópolis]]> Abstract INTRODUCTION This study aimed to estimate the prevalence of human immunodeficiency virus (HIV) infection among prison inmates and to define the behavioral profile of infected individuals. METHODS: In total, 147 individuals were interviewed and provided biological material. The study population consisted of male individuals who presented at the health unit of the Florianopolis State Penitentiary. RESULTS: The prevalence of HIV infection was 2.1% (95% confidence interval, 0.4-5.8). With respect to the behavioral profile of individuals, no variable showed statistical significance. CONCLUSIONS: The prevalence of HIV infection among prison inmates was higher than that reported for the general population. <![CDATA[Prevalence, and virulence determination of <strong><em>Listeria</em></strong> <strong><em>monocytogenes</em></strong> strains isolated from clinical and non-clinical samples by multiplex polymerase chain reaction]]> Abstract INTRODUCTION: This study aimed to determine the prevalence, and virulence factors of Listeria monocytogenes isolated from various samples by multiplex polymerase chain reaction (MPCR). METHODS: A total of 617 isolates were obtained and MPCR was employed for detection of the inlA, inlC, and inlJ genes. RESULTS: L. monocytogenes was detected in 46 (7.45%) of the 617 specimens. inlA, inlC, and inlJ were detected in 100%, 76.26%, and 71% isolates, respectively. CONCLUSIONS: This study validated MPCR in the analysis and rapid detection of L. monocytogenes. The role of the genes in pathogenesis of the strains can also be affirmed. <![CDATA[Seroprevalence of and risk factors for leptospirosis in the City of Manaus, State of Amazonas, Brazil]]> Abstract INTRODUCTION Leptospirosis is caused by a bacterium of the genus Leptospira. This study aimed at investigating the seroprevalence of and risk factors for leptospirosis in humans in Manaus, State of Amazonas. METHODS Interviews were performed, and 1,000 blood serum samples were examined using a microscopic agglutination test. RESULTS Forty-three cases were positive; there were 10 serotypes, with coagglutination in 8 cases. The most frequently occurring serotypes were Icterohaemorrhagiae (20.7%), Cynopteri (20.7%), Australis (18.8%), and Copenhageni (16.9%), and the Midwest (54.7%) and South (23.8%) had the most cases; these areas lack basic sanitation. CONCLUSIONS Disease occurrence might be reduced through improved basic infrastructural conditions. <![CDATA[Expression of co-stimulatory molecules CD80 and CD86 is altered in CD14 <strong><sup>+</sup></strong> HLA-DR <strong><sup>+</sup></strong> monocytes from patients with Chagas disease following induction by <strong><em>Trypanosoma cruzi</em></strong> recombinant antigens]]> Abstract INTRODUCTION The relationships between monocytes and lymphocytes through MHC class II molecules and costimulatory, are of utmost importance for the production of an efficient immune response. In this work, we assessed the expression of surface molecules CD80 and CD86 on CD14+HLA-DR+ monocytes from patients with Chagas disease. METHODS: The study population consisted of 31 patients with chronic clinical forms of Chagas disease. Patient blood samples were cultured in the presence of recombinant cytoplasmic repetitive antigen (CRA) and flagellar repetitive antigen (FRA). RESULTS: We found considerable differences in the expression profile of surface molecules involved in antigen presentation. CONCLUSIONS: CRA and FRA may contribute to host immune response evasion by Trypanozoma cruzi. <![CDATA[Absence of asymptomatic cases of malaria in a historically endemic indigenous locality of the Department of Caaguazú, Paraguay: moving toward elimination]]> Abstract INTRODUCTION: Paraguay was among the 16 countries that reported zero indigenous malaria cases in 2014. METHODS: A cross-sectional observational descriptive study was performed in 100 adults from Santa Teresa, Paraguay. Parasite detection was carried out using seminested multiplex polymerase chain reaction (PCR) and microscopy. RESULTS Among the participants, 44% were female and 56% were male, and 89% had a malaria history. No parasites were detected with either of the methods. CONCLUSIONS: There were no asymptomatic cases in Santa Teresa, and this finding is very promising. A longitudinal study should be performed to confirm that there are no asymptomatic cases in this locality. <![CDATA[<strong><em>Toxocara</em></strong> spp. seroprevalence in pregnant women in Brasília, Brazil]]> Abstract INTRODUCTION: The impact of gestational toxocariasis is an understudied topic on female reproductive health. We estimated anti-Toxocara IgG prevalence among pregnant women in Brasília, Brazil, and investigated the association of the infection with history of abortion and contact with pets. METHODS: Infection was diagnosed using ELISA with excretory/secretory antigens. Participant information was obtained via questionnaires. RESULTS: Of 311 pregnant women, 23 were anti-Toxocara IgG positive. Twenty-two percent of anti-Toxocara IgG-positive participants and 26% had previously miscarried. Previous contact with pets was associated with higher toxocariasis prevalence. CONCLUSIONS: A direct relationship between toxocariasis and contact with pets was observed, but there was no relationship with the miscarriage prevalence. <![CDATA[The influence of assistive technology on occupational performance and satisfaction of leprosy patients with grade 2 disabilities]]> Abstract INTRODUCTION: We aimed to investigate the feasibility of assistive technology (AT) devices to improve leprosy patients' occupational performances and satisfaction. METHODS: This is a pretest-posttest design study. The Canadian Occupational Performance Measure was used to assess the occupational performance and satisfaction of five leprosy participants with grade 2 disabilities before and after ten 45-minute interventions using assistive technology devices. RESULTS: The data showed a statistically significant 7-point average improvement (p&lt;0.05) in participants' post-intervention performance and satisfaction scores. CONCLUSIONS: Assistive technology devices may be useful therapeutic tools to enhance autonomy/independence and satisfaction of leprosy patients with grade 2 disabilities. <![CDATA[Mayaro fever in an HIV-infected patient suspected of having Chikungunya fever]]> Abstract Arboviruses impose a serious threat to public health services. We report a case of a patient returning from a work trip to the Amazon basin with myalgia, arthralgia, fever, and headache. During this travel, the patient visited riverside communities. Both dengue and Chikungunya fevers were first suspected, tested for, and excluded. Mayaro fever was then confirmed by reverse transcription polymerase chain reaction followed by next-generation sequencing and phylogenetic reconstruction. The increased awareness of physicians and consequent detection of Mayaro virus in this case was only possible due a previous surveillance program with specific health personnel training about these neglected arboviruses. <![CDATA[A fatal case of Brazilian spotted fever in a non-endemic area in Brazil: the importance of having health professionals who understand the disease and its areas of transmission]]> Abstract Brazilian spotted fever (BSF) is caused by the bacterium Rickettsia rickettsii. Because of its high case-fatality rate and apparent increase in areas of transmission, it is considered to be the rickettsial illness of primary public health interest. Cases of this disease have historically occurred in Southeastern Brazil. This article reports the first fatal case of BSF in Southern Brazil. This case high lights the importance of BSF to be considered as a differential diagnosis for acute hemorrhagic fever in areas where cases of BSF may not be expected. <![CDATA[Acute pancreatitis complicating dengue hemorrhagic fever]]> Abstract Dengue infection can have spectrum of manifestations, often with an unpredictable clinical progression and outcome. There have been increasing reports of atypical manifestations. Abdominal pain or tenderness and persistent vomiting (warning signs) are present in the majority of cases with severe dengue prior to clinical deterioration. We report a 10-year-old child who presented with fever, persistent vomiting, and abdominal pain. A diagnosis of acute pancreatitis was made. This is a very infrequently reported complication of dengue hemorrhagic fever. <![CDATA[Human T-cell lymphotropic virus-1 infection: three infected generations in the same family]]> Abstract The human T-cell lymphotropic virus-1 (HTLV-1) affects worldwide population; the estimated number of currently infected individuals is 10-20 million. In this report, we describe the clinical findings of three family members with vertical transmission of HTLV-1. This case report highlights the importance of healthcare providers who have optimal knowledge about HTLV-1 including its transmission and pertinent attributes, and who are able to provide affected individuals with adequate information regarding their condition. <![CDATA[Enlarged hilar lymph node due to <strong><em>Histoplasma</em></strong>]]> Abstract The human T-cell lymphotropic virus-1 (HTLV-1) affects worldwide population; the estimated number of currently infected individuals is 10-20 million. In this report, we describe the clinical findings of three family members with vertical transmission of HTLV-1. This case report highlights the importance of healthcare providers who have optimal knowledge about HTLV-1 including its transmission and pertinent attributes, and who are able to provide affected individuals with adequate information regarding their condition. <![CDATA[Erratum]]> Abstract The human T-cell lymphotropic virus-1 (HTLV-1) affects worldwide population; the estimated number of currently infected individuals is 10-20 million. In this report, we describe the clinical findings of three family members with vertical transmission of HTLV-1. This case report highlights the importance of healthcare providers who have optimal knowledge about HTLV-1 including its transmission and pertinent attributes, and who are able to provide affected individuals with adequate information regarding their condition.