386

TRANSACTIONS OF THE ROYAL SOIZIETYOF TROPICAL MEDICINE AND HYGIENE (1994) 88, 386388

An urban outbreak of visceral leishmaniasis in Natal, Brazil

Selma M. B. Jeronimo’, Regina M. Oliveira2, Stacey Mackay4, Rosingela M. Costa3, Jon Sweet4, Eliana T.
Nascimento3, Kleber G. Luz3, Maria Z. Fernandes’ q ohn Jernigan4
- and Richard D. Pearson4 ‘Department of
Biochemistry, Universidade Federal do Rio Grande do Nor&, FundaGao Naczonal de Sazide, and 3HospitaE Gizelda Trigueiro,
Natal, RN, Brazil; 4Division of Geographic Medicine, Departments ofMedicine and Pathology, University of Virginia School
ofMedicine, Charlottesville, Virginia, USA

Abstract
The epide~ologic~ pattern of visceral leishm~iasis in north-eastern Brazil is changing. The diseasewas
typically seen in rural, endemic areas, but is now occurring as an epidemic in the city of Natal where 316
caseshave been reported since 1989; 49% were in children less than 5 years of age. The principle clinical
and laboratory findings were weight loss, fever, hepato-splenomegaly, anaemia, leucopenia and hypergam-
maglobulinaemia. Elevated transaminasesand hyperbilirubinaemia were also observed. The diagnosis was
confirmed in 87% of casesby identifying amastigotesin aspiratesfrom bone marrow or spleen Five isolates
were identified as Leishmania (L.) chagasi by isoenzyme analysis. The mortality rate was 9%; all deaths oc-
curred during the first week in hospital. One person had concurrent human immunodeficiency virus infec-
tion. Among 210 household contacts and neighbours of patients from the endemic area examined for
evidence of L. (L.) chagasi infection, 6 additional casesof visceral leishmaniasis were diagnosed. Thirty-
eight percent of house-matesand neighbours gave a positive Montenegro skin test reaction, indicating prior
snbciinicalinfection.

findings suggestive of active visceral leishmaniasis under-

American visceral leishm~ia~s was first observed in
north-eastern Brazil by PENNA (1934), when he found
Leishmania sp. amastigotesin the livers of people initially
suspected of dying from yellow fever. Subsequent
studies by DEANE & DEANE (1955a, 195513)and ALEN-
CAR (1962) in the state of Ceara, and others, indicated
that Leishmania (Leishmania) chagasi was the causative
agent of visceral leishmaniasis there, Lutzomyia Zongi-
pa&is was the vector, and domestic dogs and wild foxes
were the reservoirs. More than 90% of the casesof vis-
ceral leishmaniasis in Brazil have been reported from the
north-eastern region (VIEIRA et al, 1990). Most have oc-
curred in hilly or mountainous rural areas, but the pat-
tern of diseaseis changing.
Growth of the Brazilian population and massivemigra-
tion from rural areas have resulted in rapid and uncon-
trolled enlargement of cities in the north-east. Suburbs
have expanded into previously rural areas,bringing large
numbers of people into potential contact with L. chagusi
and changing the epidemiological pattern of visceral
leishmaniasis, as illustrated by the large outbreak in the
city of Natal.
went further diagnostic studies. In addition, biood was
taken from asymptomatic personswith splenomegaly and
~ti-leishmanial antibodies were measured by enzyme-
linked immunosorbent assay (ELBA), using a crude L.
chagasiantigen preparation as described by EVANS et al.
(1989). Finally, delayed type hypersensitivity responses
to L. chagusi were assessedin 13 normal household con-
tacts and 25 neighbours living in close proximity to pa-
tients in the Alvorada district by Montenegro skin testing
using 25 pg of L. chagasi protein (kindly provided by Dr
StevenReed, Seattle Biomedical Institute, Seattle, Wash-
ington, USA) inoculated intradermally. Skin tests were
read after 48 h. A positive test was defined as induration
greater than 5 mm maximum width.
200
180
160
140
120

Materials and Methods 100

Natal is a city of 606 556 people (1991 census) located 80
on the shores of the Atlantic Ocean in the state of Rio
Grande do Norte in north-eastern Brazil. Patients treated 60
for visceral leishmaniasis in Brazil must be reported to 40
the FundagBoNacionai de Satide (FNS), This systemhas
been in place for more than a decade. Sporadic casesof 20
visceral leishmaniasis have been reported from the out- 0
skirts of Natal for many years, but a dramatic increase in 83 84 85 86 87 88 89 90 91 92
the number was observed, beginning in 1989(Fig. 1). In
order to characterize the outbreak, casesof visceral leish- YEAR
Fig. 1. The number oi cases &visceral leishmaniasis from Natal and the
maniasis reported to the FNS from Natal and the re- surrounding staxe of Rio Grande do Norte, Brazii, 1983-1992.
mainder of the state of Rio Grande do Norte were re-
viewed. The geographical locations of the cases were Results
mapped. The records of patients admitted to the 3 hospi-
tals in Natal, Hospital Gizelda Trigueiro, Hospital Infan- As shown in Fig. 1, small numbers of casesof visceral
til Varela Santiago and Department0 de Pediadtria, be- leishmaniasis were reported from Natal and elsewhere in
tween January and July 1991were reviewed to determine Rio Grande do Norte before 1989, but a dramatic in-
the clinical characteristics of the disease. creasebegan in 1989 and has contmued to the present.
In an attempt to determine whether visceral Ieishma- Of the casesreported in 1991 and 1992, 87% were diag-
niasis was under-reported, 210 household contacts and nosed on the basis of amastigotes in aspirates of the
immediate neighbours of 34 persons with visceral leish- spleen or bone marrow. In the remaining 13% the diag-
maniasis from the Alvorada district of Natal were ques- nosis was basedon clinical criteria. The increase in num-
tioned and examined. Persons with histories or physical ber of casesof visceral leishmaniasis in Natal from 1989
to 1992 was accompanied by a simiiar increase in the re-
Address for correspondence: Richard D. Pearson,MD, Univer- mainder of Rio Grande do Norte.
sity of Virginia, Division of Geographic Medicine, Health In Natal the majority of casescame from districts on
SciencesCenter 5485, Charlottesville, VA 2290,USA. the north and west sides of the city, which had a com-

Table. Distribution of visceral ieis~maniasis cases in
Natal, Brazil, in 1991
Districts Population Cases/l00 000
North 146 854 51
South 147 531
East 128 665 i town State University, Youngstown, Ohio, USA and by
West 183 506 12
Total 606 556 19
bined population of 330 360 people, Table 1 shows the
distribution of casesof visceral leishmaniasis by district.
The outbreak occurred primarily in areasof sand dunes
from which vegetation had been cleared for houses. The
districts were approximately 15 km from the centre of
the city. The involved districts experienced tremendous
population growth during the 1980sas Natal spread out-
ward from its centre. For instance Pajucara, a district on
the northern side of the city, had a population of 485 in
1980and 13 250 by 1991. Similar growth occurred in ad-
jacent districts, while the populations of older districts to
the east and in the centre of Natal remained relatively
constant.
Sporadic cases of visceral leishma~asis had been re-
ported from the northern areas before the expansion of
Natal, suggesting that L. chug& was endemic there.
Some persons may have become infected in other areas
before moving to Natal, but a survey of residents in the
Alvorada district indicated that more than 83% had lived
there for over a year and 52% had lived in Natal for their
entire lives.
Although visceral leishmaniasis occurred in persons of
all ages, young children were the most frequently af-
fected; 49% of the caseswere in children less than 5 years
of age and 68% in children under 15 years old. The over-
all ratio of males to females was 1.7, but the ratio in
children under 5 years of age was 0.84. The distribution
of casesby age and the sex ratio were similar in other re-
gions of Rio Grande do Norte (Fig. 2).
80
60
40
Fig. 2. Theageandsexdistributionof patientsdiagnosed
with visceral
leishmaniasis
in 1991-1992
in thestateof RioGrande doNorte,Brazil.
The records for 52 of 100 patients admitted to hospital
between January and June 1991were available for exam-
ination. The diagnosis was confirmed parasitologically in
83% of casesby identifying amastigotesin bone marrow
or splenic aspirates. In the remaining casesthe diagnosis
was clinical. The most frequent complaints at the time of
admission were weight loss, fever, abdominal pain, and
fatigue. The principal laboratory findings were neutrope-
nia, elevated sedimentation rate, anaemia (mean haemo-
globin level 8.9 g/dL), and hypergammaglobulinaemia
(mean globulin ievel 4.4 g/dL). Elevated levels of liver
enzymes and hyperbilirubinaemia, primarily due to an
increase in the direct fraction, were prevalent. One pa-
387
tient was pregnant at the time of diagnosis and another
had concurrent human immunode~cien~y virus (HIV)
infection, which was identified by ELISA and confirmed
by Western blotting.
Parasite isolates were available from splenic aspirates
of 5 patients. All were typed as L. chug& by isoenzyme
analysis (kindly done by Dr Richard Kreutzer, Youngs-
Dr Isabel Vasconcelos, Universidade Federal do Ceara,
Fortaleza, Brazil).
The patients received meglumine antimoniate therapy
according to World Health Organization recommenda-
tions (20 mg of pentavalent ~~mony/kg body weight/d
for 20 d), in the hospital. The average hospital stay was
24-9 d. The death rate was 9%; all the deaths occurred
during the first week in hospital.
Lu. longipalpis, which is known to be a vector of L.
chug& in other areasof north-east Brazil, was identified
in the houses of some patients in Natal. In addition,
blood samples were obtained from 37 863 dogs by FNS
in various districts of the city in 1992. The seropositivity
rate, as determined by indirect immunofluorescence
assay,ranged from 0.8% to 9.6%. Seropositive dogs were
found in districts where human diseaseoccurred and in
areaswhere human caseshad not been reported.
Among the 210 household contacts and immediate
neighbours of patients from the Alvorada district, 6 had
splenomegaly and symptoms suggestive of visceral leish-
maniasis. The diagnosis was confirmed by demonstration
of amastigotes in smears from the spleen in 5 casesand
the bone marrow in one. In addition, 4 asymptomatic
personswith splenomegaly were found to have anti-leish-
mania1 antibodies by ELISA. One of those subsequently
developed symptomatic visceral leishmaniasis.
More than one-third of the household contacts and
neighbours tested gave a positive Montenegro skin test
reaction, suggesting that they had had prior subclinical,
self-resolving leishmanial infections. Signi~cantly more
housemates (9 of 13 [69%]) than neighbours (5 of 25
[20%]) had positive skin tests (P<O.OOl, Fisher’s exact
test).
Discussion
The epidemiological pattern of American visceral
leishmaniasis due to L. chagasi has changed in north-
eastern Brazil. Whereas it was once a disease of rural
populations, the large outbreak in Natal and an earlier
one in Terezina (COSTAet al., 1990) indicate that visceral
leishmaniasis has becomean important problem in urban
areas as well, placing thousands of people at potential
risk. In Natal the outbreak has occurred in the setting of
rapid population growth, urban migration, and expan-
sion of the city into previously sparsely populated sand
dune areaswhere visceral leishmaniasis was known to be
endemic.
Visceral leishmaniasis in Natal, as elsewhere in north-
eastern Brazil, is primarily a disease of children. Ap-
proximately half the caseswere in children less than 5
years of age; only 30% of the casesoccurred among ado-
lescents and adults. The number of diagnosed casesof
visceral leishmaniasis probably represents only a small
fraction of the persons in Natal infected with L. chug&
Third-eight percent of the healthy Alvorada residents
had positive Montenegro skin tests, indicating prior
leishmanial infection. That is consistent with prospective
studies in Bahia and CearB,which indicated that the ratio
of inapparent to apparent infections ranged from ap-
proximately 6:l to 18:1, depending on the age and loca-
tion of the population (BADAR~ et al., 1986; EVANSet
al., 1992). Also noteworthy was the significantly greater
number of persons with positive Montenegro skin tests
in patients’ households than in adjacent, neighbouring
households. The clustering of L. chagasi infections in
families has been noted elsewhere (EVANSet al., 1992),
and it is not unusual for more than one child in the same
household to develop visceral leishmaniasis. It is not
388
known whether this is due to genetically determined dif-
ferences in human susceptibility to L. c~~g~s~,to vari-
ations in the distribution of reservoir hosts or vectors be-
tween households, or to other factors.
The clinical characteristics of visceral leishmaniasis in
Natal are generally similar to those reported from Ceara,
Brazil (EVANS et al., 1985) and elsewhere. However,
elevated levels of liver enzymes and hyperbilirubinaemia
were suprisingly prevalent among patients in Natal.
These abno~a~ties were probably due to L. chagasiin-
fection since they improved with pentavalent antimony
therapy, but serological studies to exclude hepatitis A, B,
C and E were not possible. Liver enzyme abnormalities
have been previously reported in persons with visceral
leishmaniasis (KIIALDI et al., 1990). Amylase and lipase
were not measured during antimony therapy in Natal.
Clinic~ly apparent pancreatitis, which has been reported
with ~~rnony therapy elsewhere (HALIN et al., 1993),
was not observed in these patients.
Finally, the mortality rate of visceral leishmaniasis in
Natal approached 10%. Deaths occurred during the first
week in hospital, often of malnourished, debilitated
children. One patient with visceral leishmaniasis had
concurrent HIV infection. ~e~s~~u~~uspp. are recog-
nized as opport~stic pathogens in patients with HIV
(~ONTALABA~ et al., 1990; PETERS et al., 1990; ME-
DRANO, 1992). The high percentage of residents with
positive Montenegro skin tests in the Alvorada district
suggeststhat the number of casesof progressive visceral
leishmaniasis may increase in the future as HIV spreads
in Natal.
Acknowledgements
We thank Dr Thomas G. Evans, from the Salem Veterans’
Administration Hospital, Salem, Virginia, USA, for his helpful
suggestions; Dr Richard Kreutzer, from Youngstown State
University, and Dr Isabel Vasconcelos, from the Universidade
Federal do Ceara, for analysing the isoenzyme pattern of the
Leishmaniu isolates; Dr Jorge M. de Lima and Dona Albanise
Xavier, from Funda@o National de Satide, for their help in
locating the patients; and Mrs Denise Westover and Mrs Yatta
Jacob for their help m preparing the manuscript. This work was
funded in part by an ICIDR grant from the National Institutes
of Health (POl-AI-26512).
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