Seventy-nine patients with cutaneous (62) or mucosal (17) infection with Leishmania (Viannia) braziliensis in Três Braços, Bahia, Brazil, were followed for at least 4 years after initiating treatment with antimony. Cutaneous relapses occurred in 6/62 (10%), mucosal relapse after cutaneous infection in 2/62 (3%), and mucosal relapse after mucosal disease in 2/17 (17%). It is concluded that relapse (cutaneous and mucosal) is rare after adequate antimony therapy and that no definite prediction of relapse (clinical, serological or by skin reaction) is possible.

Biopsies of skin and mucosal lesions were made on 60 well documented Brazilian patients with untreated cutaneous or mucocutaneous leishmaniasis, whose response to treatment was subsequently evaluated in 38 cases. The biopsies were examined with a view to classification after correlation with clinical and immunological findings. Although there was no simple or unified spectrum, five histological groups were defined and found to have some clinico-prognostic significance. In two groups the cases were all cutaneous with a relatively good prognosis. In another two groups they were evolving as mucocutaneous with a poor prognosis. The fifth group showed mixed characteristics with a tendency to relapse. There was no strong correlation with serum antibodies or Montenegro skin test, which were usually positive, or with parasite load, which was always low. The tissue response was distinguished from that in oriental sore by the degree of connective tissue involvement in all groups. It was the primary response in two groups, and subsidiary to a mono-nuclear response in the others. It suggested damage due to extra-cellular parasites or immune complexes. It did not correlate with the distinction between cutaneous and mucocutaneous disease. The single, most favourable, prognostic feature in either the cellular or connective tissue component was necrosis with a reactive response.

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Uma das mais importantes contribuições para o entendimento epidemiológico de uma doença infeccio sa advém, logicamente, de estudos realizados na área endêmica. Os dados assim obtidos podem ser muito úteis para um eventual controle da doença, levando-se em conta as peculiaridades da área Entretanto, as ati tudes, opiniões e crendices da população local, sujeitas ao risco de infecção, muitas vezes não têm sido levadas em consideração. Essas opiniões e crendices não são estáticas podendo, às vezes, serem modificadas à medida que pesquisadores permanecem trabalhando na área, divulgando informações entre a população. Por exemplo, em uma área de doença de Chagas (Mambaí-GO) notou-se um significante aumento de paredes rebocadas pela própria população, durante um trabalho epidemiológico realizado entre 1975 e 19797. Entretanto, mais tarde quando iniciado o com bate à doença pelo uso de inseticida, foi observado uma completa ignorância da população no conheci mento de como poderia ajudar no controle da doença8. considerando-se principalmente que até o presente momento nenhuma maneira de vacinação è possível. A despeito da considerável soma de trabalhos realiza dos nesta área ainda não foi(ram) identificado(s) o(s) inseto(s) vetor(es). Cães domésticos2 e mais recente mente uma espécie de roedor3 foram encontrados infectados com leishmânia.Em janeiro de 1983, julgamos que nossa aceita ção era suficientemente boa nesta área para montar mos uma investigação sobre as atitudes das pessoas em relação à leishmaniose cutâneo-mucosa doença bastante conhecida pela população local. M ATERIAL E MÉTODOSA investigação foi elaborada a partir de um questionário no qual foi estabelecido inicialmente, se a pessoa entrevistada tinha experiência pessoal com a leishmaniose ou conhecia casos em sua família ou entre seus conhecidos. A essa pessoa foram feitas questões referentes à transmissão, insetos vetores, reservatórios animais do parasito e tratamento. Seus conceitos relativos à doença de pele e mucosa reinfecção e maneiras de evitar a infecção foram regis trados. Também seus pontos de vista sobre o serviço oferecido pelo grupo de pesquisadores da Universida de de Brasília foram questionados. Deixamos espaço para que o entrevistado completasse com mais infor mações as suas respostas.As perguntas eram às vezes explicadas de forma a se adaptar ao vocabulário local o máximo possível dando-se a essência do que se queria perguntar, mas de modo a não sugerir a resposta. Os entrevistadores, os próprios autores do trabalho, fizeram as entrevistas em 33

The clinicai records o fl8 2 p a tie n ts with cutaneous leishm aniasisprobably due to Leishmania braziliensis braziliensis are analysed. 68% had a single lesion which was usually an ulceron the lower anterior tibial third. M an y had short histories ofone to two months and ali age groups were represented 13% had closed lesions o f a verrucose or plaque like nature.Evolution o f these skin lesions after treatment was related to the regularity o f antimony therapy. Although healing usually occurred in three months, the time to scarring after commencing treatment was variable and related to the size o fth e lesion (p < 0.01). Usually i f sufficient antimony treatment was given the lesion closed.Seven o f the ten patients with initially negative leishmanin skin tests converted to positive after treatment. A significant decline o f indirect fluorescent antibody titres occurred in patients followed, during and after therapy.

The occurrence of acute cutaneous leishmaniasis among inhabitants of 10 farms within 10 Km of the hamlet of Corte de Pedra, Bahia, Brazil was studied prospectively from 1984-1989. A mean population of 1,056 inhabitants living in 146 houses were visited every 6 months and the number of skin ulcers recorded. A leishmanin skin test survey was done people with suggestive skin scars or active disease in 1984. The incidence of skin ulcers due to Leishmania (Viannia) braziliensis (Lvb) reached 83/1,000 inhabitants but declined sharply in the subsequent 2 years. Retrospective data shows that leishmaniasis is a sporadic endemic disease. Although the reasons for this epidemic are unclear some possible aetiological factors are discussed.

L eishm a n ia lp a ra sites were detected in 71. 2% W e have presented evidence elsewhere4 that in this area L eish m a n ia braziliensis braziliensis (Lbb) is the parasite isolated from man in 96.7% of cases. W e will describe in these papers the clinicai presentation and initial evolution of this parasite in man. To date no animal model exists for Lbb and parasitological diagnosis in man is difficult1. Therefore in this first paper we discuss our diagnostic procedures in patients with cutaneous or mucosal disease consídered in the two subsequent papers. M A T E R IA L A N D M E T H O D SPatients on first consultation were alloted an LTB number (Leishm aniasis Três Braços) used for ali subsequent reference. A completed protocol included details of past and present residence for subsequent follow up and history of skin or mucosal lesions. Skin lesions were measured, their localisation recorded on a body map and their features described as regards morphology. A search for previous suggestive skin scars and evidence of mucosal disease was made.M ucosal lesions were examined using a good light source, nasal speculum, tongue depressor and indirect laryngoscopy. Exam ination of the post nasal space was not done.Recebido para publicação em 16/8/84.Two 4mm punch biopsies were taken from the 161

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