Postgraduate Program in Tropical Diseases, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil.
Department of Veterinary Hygiene and Public Health, Veterinary Faculty, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil.
Int J Infect Dis. 2020 Jun;95:44-49. doi: 10.1016/j.ijid.2020.02.028. Epub 2020 Feb 20.
Visceral leishmaniasis (VL) is a public health threat for several tropical countries, including Brazil. Therapy failures and relapses aggravate VL morbidity and mortality. Our study aimed at identifying predictors of relapse and thus contributes to directing therapeutic options and patient follow-up.
A nonconcurrent cohort of 571 subjects who completed successful therapy for VL in the city of Bauru, São Paulo State, Brazil, was followed for 24 months in order to identify the incidence and predictors of relapse. Extensive review of medical charts and laboratory files was conducted. Univariate and multivariable Cox regression models were used to identify predictors for the outcome of interest. A hierarchical strategy was used for variable selection in multivariable models.
Relapses occurred in 6.8% of treated subjects, after a median of 6 months (interquartile range, 4-9). In a comprehensive multivariable model, relapse was associated with: HIV-coinfection (hazard ratio [HR], 7.47; 95% confidence interval [CI], 2.58-21.55); the presence of lower limb edema (HR, 6.06; 95%CI, 1.38-26.77) and low platelet count upon admission (HR for platelet count × 1000, 0.99; 95%CI, 0.98-0.99) ; and secondary pneumonia (HR, 5.49; 95%CI, 1.49-20.18). On the other hand, therapy with Liposomal Amphotericin (as opposed to Antimoniate) was not independently associated with relapse (HR, 5.97; 95%CI, 0.63-56.29).
Besides reinforcing the impact of HIV coinfection on the outcome of VL, our study points to clinical and laboratory findings that characterize patients who were more likely to relapse. Those groups should be more closely followed, and possibly could benefit from novel therapeutic options.
内脏利什曼病（VL）是包括巴西在内的几个热带国家的公共卫生威胁。治疗失败和复发加重了 VL 的发病率和死亡率。我们的研究旨在确定复发的预测因素，从而有助于指导治疗选择和患者随访。
对巴西伯鲁市成功治疗 VL 的 571 例患者进行了非同期队列研究，随访 24 个月，以确定复发的发生率和预测因素。对病历和实验室档案进行了广泛的审查。使用单变量和多变量 Cox 回归模型来确定对感兴趣结局的预测因素。在多变量模型中使用分层策略进行变量选择。
治疗后 6 个月（中位数，四分位距，4-9），6.8%的患者出现复发。在综合多变量模型中，复发与以下因素相关：HIV 合并感染（危险比[HR]，7.47；95%置信区间[CI]，2.58-21.55）；下肢水肿（HR，6.06；95%CI，1.38-26.77）和入院时血小板计数低（血小板计数×1000 的 HR，0.99；95%CI，0.98-0.99）；以及继发性肺炎（HR，5.49；95%CI，1.49-20.18）。另一方面，用脂质体两性霉素（与锑剂相反）治疗与复发无独立相关性（HR，5.97；95%CI，0.63-56.29）。
除了强调 HIV 合并感染对 VL 结局的影响外，我们的研究还指出了一些临床和实验室发现，这些发现可用于识别更有可能复发的患者。这些患者应更密切地随访，可能受益于新的治疗选择。
