Leishmaniose visceral: avaliação das repercussões cardiovasculares secundárias à doença e ao tratamento em crianças e adolescentes tratadas com três esquemas terapêuticos

Abstract

Introduction: visceral Leishmaniasis is endemic in all continents and about 90% of cases occur in five countries: Northeast India, Bangladesh, Nepal, Sudan and northeastern Brazil. It is estimated the worldwide prevalence of approximately 12 million cases, with annual mortality of 60,000. The constant search for better understanding of the disease and better treatments is a lack of detailed analysis about the effects on the cardiovascular system, particularly with the use of the most recent methodologies and accuracy. Objectives: to investigate the VL treatment effectiveness and effects on the cardiovascular system, on children and adolescents, analyzing the changes in chest radiography, electrocardiogram, doppler echocardiogram, Holter and serum troponin I and CK-MB, of three treatments: N-metil glucamin, amphotericin B and the association of the two drugs. Population and Methods: open randomized clinical trial in 78 children aged up to 19 years, conducted from November 2007 to March 2010, at University Hospital Clemente de Faria UNIMONTES. The VL diagnosis was carried out by clinical exam and identification of Leishmania in the mielogram direct exam and/or positive TRALd. It was ineligible for evidence of congenital or acquired cardiopaty prior to the VL. The cure control was based on clinical and hematological criteria during the 12 months follow up. Results: The VL treatment with metilglucamin and the drugs association was highly effective, with cure rates of 100% and 96,3%, respectively - cure rate of amphotericin B as monotherapy: 76%. In 7,4% patients under the use of drugs association there was transitory acute renal failure and fatal hepatic failure. Pericardial effusion of slight to mild was frequent manifestation (78.2%) in these patients, with improvement in the specific treatment. Extrasystoles were frequent (44.9%), with a peak during treatment, regardless of the regimen. The QTc interval prolongation was little expressive during the VL treatment. The QTc and QT interval dispersion was prolonged on about 20% patients at the diagnosis and 27% during the treatment, regardless of the regimen, with significant normalization in the after treatment control. The labile T wave was significantly more frequent at the end of treatment, regardless of the regimen. There was association of malnutrition with prolongation of QTc and QT intervals dispersion and with atrioventricular conduction disturbances. The chest radiography showed no cardiac abnormalities, but was significant for monitoring the VL pulmonary effects and the associated pulmonary infections. The Troponin I and CK-MB enzymes dosage had no change either in the VL or during the treatment. Conclusion: the Metilglucamin and the drugs association were highly effective in the treatment, with lower cure rates with the amphotericin B. There was no clinical or laboratory signs related to cardiovascular side effects in the three treatment regimens. Pericardial effusion and QTc and QT intervals dispersion prolongation have been present since the diagnosis and decreased after the treatment. Extrasystiole and labile T wave increased during the treatment, regardless of the regimen.