Cutaneous leishmaniasis (CL) can occur in skin and mucosa, causing disfiguring lesions. The laboratory diagnosis of CL involves immunological methods and optical detection of the parasite, al of which have limitations. There is a need for more effective diagnostic methods for CL which wil allow treatment to be initiated more promptly in order to help prevent the development of severe forms of mucosal disease, and to estimate the prognosis of the infection. The polymerase chain reaction (PCR) has been widely used to diagnose CL, because of its higher sensitivity. This study estimated the accuracy and compared PCRs of samples from lesion scarification (PCR-L) and blood sample-enriched leukocytes (PCR-B) with three conventional diagnostic techniques: parasite direct search (DS), Montenegro skin test (MST), and indirect immunofluorescence reaction (IIF). The study included 276 patients under suspicion of CL. We conducted a cross-sectional study, in which patients were selected by convenience sampling. We used MP3H/MP1L primers to generate a Leishmania (Viannia) (minicircle kDNA) fragment of 70-bp. Of 106 patients with CL, 83.87%, 51.67%, 64.52%, 85.71%, or 96.10% tested positive by PCR-L, PCR-B, DS, IIF, or MST, respectively. Five patients tested positive only by PCR-L, and two other patients only by PCR-B. PCR-L is indicated for use in patients with chronic lesions or Leishmania reinfection, which may progress to mucosal lesion. PCR-B is indicated for use in patients with negative results in conventional tests or for patients with no apparent lesion. PCR is not only useful in diagnosing CL but also helps to identify the infecting species.

Sandflies transmit pathogens of leishmaniasis. The natural infection of sandflies by Leishmania (Viannia) was assessed in municipalities, in the state of Paraná, in Southern Brazil. Sandflies were collected with Falcão and Shannon traps. After dissection in search of flagellates in digestive tubes and identification of the species, female sandflies were submitted to the Multiplex Polymerase Chain Reaction (multiplex PCR) for detection of the fragment of the kDNA of Leishmania (Viannia) and the fragment from the IVS6 cacophony gene region of the phlebotomine insects. The analysis was performed in pools containing seven to 12 guts from females of the same species. A total of 510 female sandflies were analyzed, including nine Migonemyia migonei, 17 Pintomyia fischeri, 216 Nyssomyia neivai, and 268 Nyssomyia whitmani. Although none of the females was found naturally infected by flagellates through dissection, the fragment of DNA from Leishmania (Viannia) was shown by multiplex PCR in one sample of Ny. neivai (0.46%) and three samples of Ny. whitmani (1.12%). It was concluded that Ny. neivai and Ny. whitmani are susceptible to Leishmania infection, and that multiplex PCR can be used in epidemiological studies to detect the natural infection of the sandfly vector, because of its sensitivity, specificity and feasibility.

This case report alerts to the existence of atypical forms of cutaneous leishmaniasis (CL). A woman with nodular cutaneous lesions over a neck with papules and pustules located deep in the hypodermis that formed plaques with subcutaneous induration and satellite papules was confirmed to have CL. After confirmation, the patient was treated with remission of the lesions, scarring and thickening of the skin.

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BACKGROUNDChanges in the fetal heart rate occur in approximately 1% of all pregnancies and in an autoimmune context with positive anti-Ro/ SSA and anti-La/SSB antibodies, the incidence is estimated to be 2-4%. The involvement of neonatal organs, especially heart and skin, is presumed to result from the transplacental passage of these antibodies. It is important to rule out undiagnosed maternal connective tissue diseases, such as systemic lupus erythematosus, Sjögren's syndrome, mixed connective tissue disease and leukocytoclastic vasculitis. The case presented shows an asymptomatic mother that had no criteria to any connective tissue diseases or any other pathologies, and became aware of these antibody reactivities solely based upon the finding of a bradyarrhythmia in her fetus. CASE REPORTA 28-year-old primigravida, with a singleton pregnancy of 25 weeks and without comorbidities, arrived at the rheumatology outpatient clinic referred by the obstetrician due to fetal bradycardia with a heart rate of 55-59 bpm verified on fetal echocardiogram performed 3 days ago. The patient denied any symptoms or previous diagnoses and did not use any medication or drugs. After performing laboratory tests, anti-Ro/SSA antibodies were detected in high titers (> 240) and anti-La/SSB in lower titers (30). Thus, hydroxychloroquine and betamethasone were started. After one week, the patient returned for consultation with a new echocardiogram showing complete atrioventricular block. Due to good fetal development, the pediatric cardiologist opted to indicate the placement of a pacemaker after birth. At 32 weeks of gestation, it was decided to discontinue betamethasone and maintain hydroxychloroquine. At 45 days of birth, the newborn underwent pacemaker placement. Currently, the patient remains asymptomatic, in follow-up and without the use of any medication, as well her son. CONCLUSIONThe prenatal diagnosis of the ethology of conceived heart diseases allows early treatment and the guarantee of intrauterine development. This will allow not only treatment during pregnancy, but also delivery assistance to these pregnant women in a tertiary perinatal center with a multidisciplinary team trained in the care of these infants and the implantation of a pacemaker, which is necessary in two thirds of cases. There is presence of bradycardia, ventricular dysfunction and the prolongation QT complications in these cases. Therefore, an accurate diagnosis of the etiology of fetal heart block is very necessary.

BACKGROUND Chronic nonbacterial osteomyelitis (CNO), alternatively known as chronic recurrent multifocal osteomyelitis (CRMO), is a rare autoinflammatory bone disorder that causes multifocal aseptic lytic lesions in bone biopsy. The course of the disease is caracterized by exacerbations and remissions, mostly affecting children and adolescents. MATERIALS AND METHODS Retrospective descriptive review of six cases of CNO in children and adolescents, treated at a specialized center, between 2010 and 2018. RESULTS Four (66%) out of 6 patients were girls with mean age at evaluation of 15.5 years (range 11-20.4) and mean follow-up time of 5.1 years (range 1.5-10.2). Mean age of first symptoms was 10.3 years (range 0.7-15.3) and mean age at diagnosis was 12.8 years (range 9.5-16). The most affected sites were metaphysis and diaphysis of long bones. Median number of initial bony lesions was 2.8 (range 1-7) at onset and 3.5 (range 1-8) during the follow up. Two (33.3%) patients had recurrence in clavicle, two in mandible and one (16.6%) in temporomandibular joint. One (16.6%) patient presented with fever and dyserythropoietic anemia, and was diagnosed as Majeed syndrome. Five (83.3%) patients presented with arthralgia and bone pain, and two (33.3%) had acute migratory polyarthritis. All patients had increased acute phase reactants and radiographic and magnetic resonance imaging alterations. All patients received NSAIDs therapy (indomethacin) with clinical remission in half of the cases. Three (50%) patients received bisphosphonates (alendronate), and one took methotrexate associated with alendronate. All patients had good clinical response and two achieved clinical remission. CONCLUSION The awareness of characteristic features of CNO is important for an early diagnosis and can help avoiding unnecessary diagnostic procedures and prolonged antibiotic therapy.