Jayme Neves
Docente Livre na Regência da Cátedra
RESUMO
Com a finalidade de caracterizar efetivamente a septicemia na salmonelose prolongada, em 6 pacientes, dos quais 2 com resistência antibiótica e quimioterápica, procedeu-se a hemoculturas seriadas, consecutivas ou não, durante um período que oscilou entre 25 e 113 dias. Em cada paciente, numa média de 7 hemoculturas, foram isoladas, respectivamente, as seguintes salmonelas: S. typhi, S. paratyphi C, S. panamá, S. cholerae-suis var. Kunzendorf e S. paratyphi A. No caso em que se isolou a S. paratyphi A, em uma das hemoculturas isolou-se, também, a S. montevideo.
A duração média da septicemia nos 6 pacientes foi de 73 dias. A se considerarem procedentes os informes dos pacientes quanto ao início da doença, a septicemia, com tôda a probabilidade, deve ter tido a duração média de 4 meses. Por outro lado, tomando por base a identidade do quadro clínico e a coincidência fisiopatológica dos casos estudados, é possível admitir-se a ocorrência de septicemias de longa duração nos demais 31 casos pelas seguintes salmonelas: S. newport, S. dublin, S. cholerae-suis, S. typhimurium, S. anatum, S. derby, e Salmonellas sp (não sorològicamente identificadas).
Com base nestes achados, o A. acredita não ser possível admitir-se, na salmonelose em estudo, a diferença fundamental entre salmonelas adaptadas ou não à espécie humana, conforme preceitua a Doutrina de Kiel; considera, também, limitadas as restrições preconizadas pela Doutrina de Montevidéu aos conceitos fisiopatogenéticos da escola alemã. De fato, salmonelas do grupo tifiparatifi e outras consideradas adaptadas aos animais têm produzido, indistintamente em crianças e em adultos, quadros clínicos indistinguíveis, nos quais transcende a septicemia de longa duração e tornam-se manifestas a disproteinemia marcante e a hiperplasia do S.R.E.
Finalmente, discute-se no trabalho o papel representado por uma série de fatores que podem atuar, acarretando alterações no organismo parasitado e criando condições à multiplicação das salmonelas e à manutenção da infecção. Dentre êles foram ressaltados: a associação parasitária, especialmente a esquistossomose mansoni; a desnutrição crônica; a disproteinemia marcante, seja devida à deficiência de prótides, seja em decorrência ao estado reacional do S.R.E., seletivamente agredido pelas salmonelas; modificações do estado imunitário, quer por inibição da anticorpogênese e da fagocitose, quer devida à inadequada propriedade imunológica das globulinas, extraordinariamente aumentadas na doença.
ABSTRACT
In our previous paper on protracted course Salmonellosis we have tried to demonstrate that Salmonella organisms may be able to produce a reticuloendothelial-like infection with septicemia as one of its most striking characteristics.
It has also been stated that this septicemia phase runs a long course and differs from those observed during typhoid fever. This has been affirmed based on the clinical manifestations of the disease.
In the present paper it was tried to demonstrate the duration of the salmonellotic septicemia. Several blood cultures from four patients were performed over a period of time from 25 to 52 days before antibiotic therapy was started. Serial blood cultures were obtained of two other cases in which there was no antibiotic and chemotherapeutic response over a longer period of time (58 to 113 days). Table II shows these results. S. typhi was isolated in ali the blood cultures of two patients over a period from 52 to 113 days; S. paratyphi A was isolated in seven blood samples and S. montevideo in one sample from the same patient during 58 days of observation. Positive blood cultures for S. parathyphi C, S. cholerae.suis var. Kunzendorf and S. panama were found in three other patients before chloromycetin was started.
The findings obtained from serial blood cultures and from the clinical manifestations of this infection provide the following informations on the involvement of the salmonellae in the protracted salmonellosis syndrome:
a) The average duration of salmonellotic septicemia in the six studied cases was 73 days. If we consider the beginning of the disease as related by the patients it is to be supposed that this septicemia runs a longer period of time (about four months).
b) These six studied cases have had the same clinical and physiopathological picture as that of 33 other patients from which a single blood culture has shown S. newport, S. dublin, S. choleraesuis, S. typhimurium, S. anatum, S. derby and Salmonella sp (not identified serologically).
c) The clinical and physiopathological features of the chronic protracted salmonellosis do not reproduce the classic picture of either typhoid fever or of the so called “acute food poisoning” type.
d) Based on the available data it is not possible to support in this Salmonellosis the fundamental differentiation of salmonella organisms in accordance with its capacity of adaptation to man and to other kind of animals as the Kiel doctrine postulates. The fact is that other salmonellae besides S. typhi and S. paratyphi group have been able to produce in adults as well as in children indistinguishable clinical pictures in which protracted septicemia, hyperplasy of reticuloendothelial system and severe dysproteinemia are the prominent features.
e) Apart from the virulence of salmonellae other factors are note-worthy for the physiopathogenetic interpretation of this condition and need to be investigated. Some characteristics which may modify the bodily defensive mechanisms, allow condftions for the multiplication of salmonellae and sustains the infection, have to be emphasized, as associated parasitic infections, particularly the constant S. mansoni intercurrent infection, chronic malnutrition, severe dysproteinemia either due to protein deplefron or to a reactirnary staie of the reticuloendotheüal system triggered by the seletive salmonellotic agression, change in the immunological process due to an inhibition of antibody svnthesis and phagocytosis or to an insufficient immunological property of globulins, despite these serum proteins being highly increased in this disease.
f) A number of reports have been published giving the proportion of different clinical aspects of typhoid lever with co-existence of S. haematobium and S. japonicum infections. Despite the constant finding of S. mansoni infection in our cases, the available data are not sufficient to evaluate the role it plays in the pathogenesis of protracted course salmonellosis and particularly to explain the possible links between Schistosomiasis and the alteration of human sensitivity to salmonellae adapted to other animals.
Finally we would like to emphasize that considerable attention must be direct towards the possibility of a relationship between salmonellotic infection and nutritive states, schistosoma infections and the resistence-susceptibility reaction.
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Trabalho da Clínica das Doenças Infectuosas e Parasitárias da Faculdade de Medicina da Universidade Federal de Minas Gerais, Brasil (Serviço do Prof. Oscar Versiani Caldeira).
