Compar ative clinical and ultr asound study of egg-negative and
egg-positive individuals fr om
Schistosom a m an son i
low mor bidity
endemic ar eas, and hospitalized patients with hepatosplenic disease
Estudo clínico comparativo e ultra-sonografia entre indivíduos negativos e positivos para
Schisto so m a m a nso ni
em áreas endêmicas de baixa morbidade e pacientes
hospitalizados com doença hepatosplênica
Telcia V.B. Magalhães
1, Giovanni Gazzinelli
1 , 7, Mar ia Car olina B. Alvar ez
1, F.C. Lima e Silva
1,
Lucia Alves Oliveir a Fr aga
2, Alda Mar ia S. Silveir a
2, Andr ea Gazzinelli
3, Jeffr ey Bethony
5,
Philip LoVer de
6, Ir amaya R. Caldas
7, Rodr igo Cor r ea-Oliveir a
7and Aluízio Pr ata
4ABSTRACT
Two h u n d re d a n d twe n ty th re e su b je c ts f ro m a Schisto so ma ma nso ni lo w m o rb i d i ty e n d e m i c a re a a n d n i n e h o sp i ta li ze d h e p a to sp le n i c p a ti e n ts we re su b m i tte d to sto o l te st a n d c li n i c a l e x a m i n a ti o n a n d a b d o m e n u ltra so u n d a sse ssm e n ts. Ac c o rd i n g to sto o l e x a m i n a ti o n a n d u ltra so u n d re su lts, th e y we re gro u p e d a s f o llo ws: G1 - 6 3 Schisto so ma ma nso ni
e gg- n e ga ti ve i n d i vi d u a ls; G2 - 1 4 1 e gg- p o si ti ve p a ti e n ts a n d wi th o u t e vi d e n c e o f p e ri p o rta l f i b ro si s; G3 - 1 9 e gg- p o si ti ve pa ti e n ts wi th pe ri po rta l e c ho ge n i c i ty ( 3- 6m m ) ; a n d G4 - 9 he pa to sple n i c pa ti e n ts wi th pe ri po rta l e c ho ge n i c i ty ( > 6m m ) . He p a to m e ga ly d e te c te d b y p h ysi c a l e x a m i n a ti o n o f th e a b d o m e n e va lu a te d i n th e m i d c la vi c u la r li n e wa s ve ri f i e d i n G1 , G2 a n d G3 , re sp e c ti ve ly, i n 1 1 .1 , 1 2 .1 a n d 2 6 .3 %. In G1 , G2 a n d G3 , p e ri p o rta l th i c k e n i n g o c c u rre d o n ly i n sc h i sto so m a l p a ti e n ts ( 8 .5 %) . Mi ld p a th o lo gi c a l a lte ra ti o n s i n p a ti e n ts th a t c a n n o t ye t b e d e te c te d b y c li n i c a l e x a m i n a ti o n we re d e te c ta b le i n th e li ve r b y u ltra so u n d a n d c a n b e d u e to f i b ro si s. Th e d e gre e o f m i ld p e ri p o rta l f i b ro si s wa s d i m i n i sh e d i n 5 7 .9 % o f p a ti e n ts 1 2 m o n th s a f te r tre a tm e n t o f sc h i sto so m i a si s wi th o x a m n i q u i n e . At u ltra so n o gra p h y, th e m e a n li ve r le f t lo b e m e a su re m e n t o f G3 wa s la rge r th a n th a t o f G1 , a n d th a t o f G4 la rge r th a n th a t o f G1 a n d G2 . Th e m e a n si ze o f th e sp le e n o f G4 wa s si gn i f i c a n tly la rge r th a n th a t o f th e o th e r th re e gro u p s, a n d th a t o f G3 la rge r th a n th a t o f G1 a n d G2 .
Ke y-words: Sc h i sto so m i a si s m a n so n i . Ultra so n o gra p h y. Pe ri p o rta l f i b ro si s.
RESUMO
Duze nto s e vinte e trê s indivíduo s de á re a e ndê m ica de b a ixa m o rb ida de pa ra e sq uisto sso m o se e no ve pa cie nte s ho spita liza do s c o m a fo rm a he pa to e splê n ic a fo ra m su b m e tido s a o e xa m e de fe ze s e c lín ic o e à u ltra - so n o gra fia do a b dô m e n . De a c o rdo c o m o s re su lta do do s e xa m e s de fe ze s e do u ltra - so m e le s fo ra m a gru pa do s do se gu in te m o do : G1 - 63 in divídu o s se m o vo s de Schisto so ma manso ni n a s fe ze s; G2 - 141 in divídu o s a pre se n ta n do o vo s de Schisto so ma manso ni n a s fe ze s, se m e c o ge n ic ida de pe ripo rta l. G3 – 19 in divídu o s c o m o vo s de Schisto so ma manso ni n a s fe ze s e e c o ge n ic ida de pe ripo rta l e n tre 3- 6m m .; G4 – 9 pa c ie n te s he pa te splê n ic o s c o m e c o ge n ic ida de pe ripo rta l > 6m m . Pe lo e xa m e físic o do a b dô m e n , a he pa to m e ga lia n a lin ha he m ic la vic u la r dire ita fo i c o n sta ta da e m G1, G2 E G3, re spe c tiva m e n te , e m 11,1, 12,1 e 26,3%. No s gru po s G1, G2 e G3, ho u ve e spe ssa m e n to pe ripo rta l so m e n te e m e sq u isto sso m á tic o s ( 8,5%) . Alte ra ç õ e s pa to ló gic a s le ve s e m pa c ie n te s, a s q u a is n ã o pu de ra m se r de te c ta da s pe lo e xa m e c lín ic o , fo ra m e vide n c ia da s n o fíga do pe lo u ltra - so m e po de m se r de vida s à fib ro se . O gra u de fib ro se pe ripo rta l le ve fo i dim inuído e m 57,9% do s pa c ie nte s 12 m e se s a pó s tra ta m e nto da e sq u isto sso m o se c o m o xa m n iq u in e . Na u ltra - so n o gra fia , a m é dia da m e dida do lo b o e sq u e rdo do fíga do do s in divídu o s de G3 fo i m a io r q u e a de G1 e , a de G4 m a io r q u e a de G1 e G2. O ta m a n ho m é dio do b a ç o de G4 fo i sign ific a tiva m e n te m a io r q u e o do s o u tro s gru po s e o de G3 fo i m a io r q u e o de G1 e G2.
Pal avr as-chave s: Esq u i sto sso m o se m a n so n i . Ultra - so n o gra f i a . Fi b ro se p e ri p o rta l.
1. Santa Casa Hospital de Belo Horizonte, MG, Belo Horizonte, MG. 2. Universidade Vale do Rio Doce, Governador Valadares, MG. 3. Escola de Enfermagem da Universidade Federal de Minas Gerais, Belo Horizonte, MG. 4. Faculdade de Medicina do Triângulo Mineiro, Uberaba, MG. 5.The George Washington University Medical Center, Washington DC, USA. 6. Department of Microbiology School of Medicine and Biomedical Sciences, Buffalo New York, USA. 7. Centro de Pesquisas René Rachou da Fundação Oswaldo Cruz, Belo Horizonte, MG.
Suppo r te d b y CNPq , FAPEMIG, NIH gr ant AI4 5 4 5 1 , UNDP/Wo r ld B ank /WHO Spe c ial Pr o gr am fo r Re se ar c h and Tr aining in Tr o pic al Dise ase s.
Addr e ss to: Pr o f. Gio vanni Gazzine lli. Av. Augusto de Lima 1 7 1 5 , B ar r o Pr e to , 3 0 1 9 0 - 0 0 2 B e lo Ho r izo nte , MG, B r azil Te l: 5 5 3 1 3 2 9 5 - 3 5 6 6 , Fax: 5 1 3 1 3 2 9 5 - 3 1 1 5
Ma ga lhã e s TVB e t al
Schisto so m a m a nso ni has a wide geographical distribution in Africa, South America and the Caribbean. The disease is mainly
due to eggs deposited in the host tissue by the adult female whose
antigens induce granuloma formation and fibrosis, essentially in intestine and liver portal system. Most of the infected individuals
living in endemic areas are asymptomatic but a few develop
Symmers’ periportal fibrosis of the liver, that results in the severe
fo r m o f the dise ase with sub se q ue nt po r tal hype r te nsio n, splenomegaly, esophageal varices and recurrent hematemesis. The
hepatointestinal and compensated hepatosplenic clinical forms
represent early forms of the severe clinical disease found in the
ho spital ( de c o m pe nsate d he pato sple nic )5. The se q ue ntial
development of hepatosplenic disease was well demonstrated and anato mic o patho lo gic ally pr o ve n1 5. The se c o nc lusio ns we r e
o b taine d fr o m c linic al diagno sis b ase d o n live r le ft lo b e
enlargement, consistency, as well as spleen size detected by physical examination1 5. However, when ultrasound was used for abdominal
evaluation in field surveys in endemic areas for schistosomiasis, it
became clear that the physical examination of the patients did not
always reflect the stage of the disease1. This conclusion is based
on the thickness of periportal fibrosis as determined by ultrasound
echogenicity which correlates with liver biopsies in pathological
studies9. However, there is a variation on the assessment of images
provided by ultrasound8, especially in mild pathology, frequently
seen in field surveys. In these cases, the interpretation of ultrasound images has been discussed.
In o r de r to ide ntify the me aning o f so me findings, we
c ompared several c linic al and ultrasound parameters of distinc t
groups of schisto so m ia sis patients with an egg-negative group from the same endemic area. These groups were also c ompared
with hospitalized patients with the severe hepatosplenic form of
the disease.
MATERIAL AND METHODS
Studied po pulatio n. This study was performed in two localities endemic for schistosomiasis ( Dionísio and Melquiades)
in the state of Minas Gerais, Brazil. A sc histosomiasis program aimed at studying several aspec ts of the disease has been ac tive
in these two loc alities sinc e 1 9 9 5 . The volunteers ( n = 2 2 3 )
we r e sub mitte d to par asito lo gic al, c linic al and ultr aso und
e xa m in a tio n s . Nin e pa tie n ts with a c lin ic a l dia gn o s is o f hepatosplenic sc histosomiasis from the Sa nta Ca sa Ho spita l o f Be lo Ho rizo nte c ity ( Brazil) were also inc luded in this study.
It is impo r tant to me ntio n that malar ia is no t e nde mic in
th e s e a r e a s ; th e r e fo r e it is n o t a c o n fo un din g dis e a s e .
Pr o to c o ls invo lving human sub j e c ts we r e appr o ve d b y the institutio nal r e vie w and e thic al c o mmitte e o f the Fu n d a ç ã o Osw a ld o Cru z ( FIOCRUZ). Tr e a tm e nt wa s o ffe r e d to a ll i n di vi du a l s i n de p e n de n t o f wh e th e r th e y c o n s e n te d to
par tic ipate in the study.
Pa r a sito lo gica l e x a mina tio n. Sc h i sto so m a m a n so n i
infe c tio n was e valuate d b y individual fe c al e gg e xaminatio ns de te r m in e d b y th e Ka to - Ka tz m e th o d o n s to o l s a m p le s
o b taine d o n thr e e c o nse c utive days1 1.
Clinical examination. Clinical examination of 2 2 3 subjects was performed by two physicians. One examined patients from Dionisio and, the other those from Melquiades. Both physicians were
blind to the results of the feces and ultrasonographic examinations.
Hepatosplenic patients were examined by other physicians.
At abdominal examination, palpation of the right lobe of the
liver was evaluated in the midc lavic ular line and the left lobe in the epigastrium at inspiration; the enlargement, c onsistenc y and
surface were recorded. The spleen was examined below left costal
margin at inspiration.
Based on c linic al c riteria, the patients were c onsidered as
intestinal ( liver < 2 c m under the c ostal edge) , hepatointestinal ( liver palpable > 2 c m under the c ostal edge) and hepatosplenic .
Pa tie n ts with s c h is to s o m ia s is we r e tr e a te d with o r a l
o xamniquine , in a single do se o f 1 5 mg/k g.
Ultr a so und. A c o nventio nal po r tab le Hitac hi EUB -2 0 0 ultrasound equipment ( Tokyo, Japan) was used in the field study
and a Sonoline Versa Plus, Siemens ultrasound with a transduc er o f 3 .5 MHz fo r ho spitalized patients. Liver size, po rtal-vein
diameter, thic kness of the walls of c entral and peripheral portal
branc hes, spleen size and splenic vein diameters were assessed
as desc ribed elsewhere1 9. Liver span was measured both in the
midc lavic ular line and the midline. The liver was also examined
for surfac e smoothness. Portal vein diameter was measured at
its entranc e into the liver and its bifurc ation inside the liver. The
spleen was evaluated by using oblique and longitudinal sc anning of the left upper quadrant. The gallbladder was examined for
wall thic kness and stones. The periportal thic kness was evaluated
ac c ording to established c riteria1 4 9, with few modific ations. The
two physic ians performing ultrasound examinations were neither aware of the infec tion status nor c linic al examinations of the
patients undergoing ultrasonography. The echo enhancer contrast
( Levovistâ) was used as desc ribed by Albrec ht et al2.
On e ye a r a fte r tr e a tm e n t, s o m e pa tie n ts we r e a ga in
sub mitte d to ultr aso und e valuatio n.
Cla ssifica tio n o f studie d po pula tio n. Ac c o r ding to the r e sult o f sto o l te st fo r Sc h i sto so m a m a n so n i e ggs and the pr e se nc e o f pe r ipo r tal fib r o sis, the individuals in the
e nde mic ar e as we r e c lassifie d into thr e e gr o ups.
Group 1 - Control subjects - S. m a nso ni egg-negative individuals at stool test. Group 2 - Patients eliminating S. m a nso ni eggs in the feces and without periportal thickening. Group 3 - Schisto so m a m a nso ni egg-positive patients at stool test and periportal thickening at ultrasound examination. A Group 4 was added to these three groups, composed of patients from Sa nta Ca sa Hospital of Belo Horizonte diagnosed with schistosomiasis hepatosplenic form.
Statistical methods . The data were analyzed by least square analysis of varianc e using general linear models proc edures. Tukey’s test was used to determine if significant statistical differences ( p < 0 .0 5 ) existed between groups in relation to hepatic left lobe, spleen size, portal and splenic vein diameters and central and
peripheral echogenicity, after data transformation. Since it was not possible to use analysis of variance in the analysis of age and spleen vein diameter, Kruskall-Wallis and Mann-Whitney
the r e latio nships amo ng se ve r al par ame te r s the Spe ar man
c o rrelatio n c o effic ient was used. Variables befo re and after treatment were examined by Student’s t-test. All the analyses were performed by using the SPSS software, release 8 .0 .
RESULTS
Characterization of the study sample based on clinical examinatio n and echo genicity. Group 1 -Consisted of 6 3 individuals without S. m a nso ni eggs in the fec es and without thickening of the portal vein wall ( periportal fibrosis) . At clinical
examination, the liver was palpable in 7 ( 1 1 .1 %) 2 -7 cm under
right costal edge at midclavicular line level. Group 2 - With 1 4 1
egg-positive patients without periportal fibrosis. In this Group there were 1 7 ( 1 2 .1 %) patients with right liver lobe palpable 2 -9 cm under
right costal edge. Group 3 - With 1 9 egg-positive patients with
periportal fibrosis. The periportal thickening varied from 3 to 6mm,
this being central in 1 5 and peripheral in 1 4 . In only 5 ( 2 6 .3 %) patients of this Group, the liver was palpable at right midclavicular
line. Group 4 - Composed of 9 patients. From these, 4 had digestive
hemorrhages and were hospitalized and 5 were cared for at the
out-patient clinic. The liver was palpated in 7 ( 7 7 .8 %) of them and the spleen in 8 ( 8 8 .8 %) . The central periportal thickening varied from
7 to 1 3 mm and the peripheral one from 3 .5 to 5 mm.
With regard to the spleen, it was not palpated in any patient
of Groups 1 , 2 or 3 and in only one of Group 4 . As to the c linic al
fo r m s , i n Gr o u p 2 th e r e we r e 1 2 4 i n te s ti n a l a n d 1 7 hepatointestinal, and in Group 3 , respec tively 1 4 and 5 ; there
were no patients with the hepatosplenic form nor with hard or
nodular liver in Groups 2 and 3 . In Group 4 , all patients were
hepatosplenic .
I n s h o r t, c o m p a r i n g th e p a l p a ti o n o f l i ve r a t r i gh t midc lavic ular line, 2 c m or more under c ostal edge, with the
presenc e of periportal fibrosis ( c entral and/or peripheral) , it
was ve r ifie d that he pato me galy witho ut pe r ipo r tal fib r o sis
oc c urred in 2 4 individuals ( G1 and G2 ) and hepatomegaly in
5 /1 9 with periportal fibrosis.
The age of the individuals varied from 8 to 7 7 years and the
distribution according to age and sex in each group is presented in
Table 1 . Group 2 has the lowest mean age, but differed statistically
only from Group 1 . In relation to sex, the total sample is balanced with 5 4 % male and 4 6 % female. However, a statistical difference
was observed in Group 3 of which 8 9 .5 % were male.
Ultr a so und me a sur e me nts o f o r ga n siz e , a nd ve in dia me te r. The m e an value s fo r lo ngitudinal and ante r o -po ste r io r me asur e me nts o f live r le ft lo b e and sple e n as we ll
as the diame te r s o f po r tal and sple nic ve ins ar e pr e se nte d in
Tab le 2 . The statistic al diffe r e nc e s amo ng Gr o ups 1 , 2 , 3 and
4 ar e sho wn in Figur e 1 . In the statistic al analysis, the e ffe c t o f se x and age we r e c o ntr o lle d b y inc luding the se var iab le s
in the s ta tis tic a l m o de l. The m e a n le ft lo b e lo ngitudina l
me asur e me nt o f G3 diffe r e d statistic ally o nly fr o m Gr o up 1
( c o ntr o l) and the me an ante r o -po ste r io r me asur e me nt o f G4 differ ed fr o m G1 and G2 . The mean enlar gement o f the spleen
se e ms to b e a b e tte r par ame te r than that o f the live r to asse ss
mo r b idity b y physic al e xaminatio n. This is de mo nstr ate d b y
b o th me asur e me nts o f the sple e n, lo ngitudinal and ante r o -po ste r io r, o f patie nts in G4 who diffe r e d fr o m the o the r thr e e
gr o ups. In additio n, the me an lo ngitudinal me asur e me nt o f
the spleen fro m G3 patients was signific antly higher than tho se
o f G1 and G2 and lo we r than tho se o f G4 . The me an diame te r o f the po r tal ve in o f G3 was signific antly lar ge r than tho se o f
G1 and G2 , b ut the me an diame te r o f G4 did no t diffe r fr o m
G1 and G2 . The me an diame te r o f the sple nic ve in o f G4
diffe r e d statistic ally fr o m G2 , b ut no t fr o m the o the r two gr o ups. Par ame tr ic te st sho we d that b o th gr o ups diffe r e d
statistic ally ( p < 0 .0 5 ) fr o m e ac h o the r.
Table 1 - Distribu tion of the sample popu lation in the grou ps accordin g to sex an d age.
Groups Male Female Mean age ± SD
1 – Egg-negative 27 36 4 1 .2 7 ± 1 6 .3 9
2 – Egg-positive without fibrosis 75 66 3 0 .5 2 ± 1 8 .2 4
3 – Egg-positive with fibrosis 17 2 3 3 .3 7 ± 1 7 .9 2
4 – Hepatosplenic 06 3 3 8 .2 2 ± 1 2 .4 7
Table 2 - Measurements of liver left lobe, spleen, portal and splenic vein s by u ltrason ography.
Groups Liver ( cm) Spleen ( cm) Veins ( cm)
Lon AP Lon AP Portal Splenic
1 9 .1 7 ± 1 .5 6 5 .9 1 ± 1 .4 9 7 .1 9 ± 1 .5 4 6 .6 8 ± 1 .4 0 1 .1 2 ± 0 ,1 4 0 .7 6 ± 0 .1 3
2 9 .3 8 ± 1 .5 0 6 .1 4 ± 1 .2 2 7 .3 6 ± 1 .5 4 7 .0 6 ± 1 .2 8 1 .0 9 ± 0 .1 7 0 .7 3 ± 0 .1 4
3 9 .9 5 ± 1 .5 1 6 .4 9 ± 0 .8 7 8 .7 5 ± 2 .2 3 6 .8 3 ± 1 .4 3 1 .2 8 ± 0 .1 9 0 .8 0 ± 0 .1 6
4 1 0 .0 6 ± 1 .6 7 7 .5 4 ± 1 .6 9 1 3 .6 8 ± 3 .1 4 9 .2 0 ± 1 .5 0 1 .2 5 ± 0 .1 9 0 .9 8 ± 0 .2 9
Lon = longitudinal; AP = antero-posterior
Do pple r ultr aso no gr aphy using an e c ho e nhanc e r age nt
( Le vo vist) sho we d an impr o ve me nt in the visualizatio n o f the po r ta l h e pa tic ve in s , b ut did n o t pr e s e n t a n y a dditio n a l
info r matio n.
Ultr a so und a fte r tr e a tme nt. One ye ar afte r tr e atme nt, as sho wn in Tab le 3 , the r e was a signific ant de c r e ase in the
me asur e me nts o f po r tal and sple nic ve in diame te r s as we ll a s in c e n tr a l e c h o ge n ic ity. Afte r tr e a tm e n t, po r ta l ve in
e c ho ge nic ity was r e duc e d in 1 1 ( 5 7 .9 % ) patie nts, r e maine d
unalte r e d in 5 ( 2 6 .3 % ) and inc r e ase d in 3 ( 1 5 .8 % ) . In 1 4
patie nts, the pe r ipo r tal thic k e ning afte r tr e atme nt b e c ame < 3 mm, and in five it r e maine d b e twe e n 3 -6 mm.
Live r Sple e n Ve ins
Lo n Lo n Po r ta
G1 G2 G4 G3 G1 G2 G3 G4 G2 G1 G4 G3
Ap Ap Sple nic
G1 G2 G3 G4 G1 G2 G3 G4 G2 G1 G3 G4
DISCUSSION
Amo ng the vo lunte e r s o f the po pulatio ns in the e nde mic
ar e as studie d, in spite o f the high pr e vale nc e o f po sitive sto o l
te sts fo r Sc h i sto so m a m a n so n i, the r e was no patie nt with the he pato sple nic fo r m o f the dise ase . Thus, the ar e as ar e o f
lo w mo r b idity. No patie nt had har d no r no dular live r no r with
pr o mine nt le ft lo b e , whic h ar e the main c linic al fe atur e s fo r
suspic io n o f live r with pe r ipo r tal fib r o sis. Ho we ve r, e ve n
wi th o u t c l i n i c a l s u s p i c i o n , p e r i p o r ta l th i c k e n i n g wa s
e vide n c e d in 1 9 ( 8 . 5 % ) o f th e s c h is to s o m a l in dividua ls
e xamine d. It has lo ng b e e n k no wn1 4 that Symme r s’ fib r o sis
c o u l d o c c u r wi th o u t s p l e n o m e ga l y a n d wi th o u t p o r ta l
hype r te nsio n and that this was fr e que nt in e nde mic ar e as1 3
The ultr aso und e xaminatio n no t o nly allo ws c o nfir matio n o f
the diagno sis b ut sho ws that the finding is still mo r e fr e que nt
than it was e xpe c te d to b e1 2. And also , as c an b e se e n in this
wo r k , it o c c ur s e ve n in so me patie nts witho ut c linic al signs
sugge stive o f Symme r s’ fib r o sis.
Unlik e that whic h o c c ur r e d in he pato sple nic patie nts
( G4 ) , the e c ho ge nic ity de gr e e fo und in the e nde mic ar e as
( G3 ) was slight. The mild pe r ipo r tal fib r o sis and c e llular
infiltr atio n c an b e se e n in po r tal spac e s and altho ugh mo r e
fr equent in sc histo so miasis3, it had b een r epo r ted also in no n
sc histo so miasis patients3 1 6. It is nec essary to keep this in mind
whe n the inte r pr e tatio n o f the me aning o f mild pe r ipo r tal th i c k n e s s fo u n d i n m a n y p e o p l e i n e n d e m i c a r e a s i s
c o nside r e d. S. m a n so n i e gg-ne gative individuals at sto o l te st ( G1 ) , and the disappe ar anc e o f this thic k e ning in 5 7 .9 % o f
o ur patie nts afte r tr e atme nt ( G3 ) sugge st its c o nne c tio n with
sc histo so miasis.
In addition, the mean longitudinal measurement of the spleen
of G3 patients was signific antly higher than those of G1 and G2
a n d s m a lle r th a n th o s e o f G4 . J e s us e t a l1 0 o b s e r ve d in
hepatosplenic patients a c orrelation between the ec hogenic ity
of the portal trac t and spleen size. Our data also showed that the
portal and splenic vein diameters were slightly larger in G3 and
G4 groups but these results were not statistic ally signific ant.
Our studie s ar e in agr e e me nt with pr e vio us studie s b y
Doehring-Sc hwerdtfeger et al8, demonstrating that treatment
induc es signific ant dec rease in morbidity, in the group of patients where severe morbidity has not yet developed. Whether mild
periportal fibrosis is reinstalled when an individual is reinfec ted
is still to be evaluated. It is also important to evaluate whether in
patients with hepatosplenomegaly, the ultrasound c onfirms the same dec rease in morbidity evidenc ed by c linic al examination6.
Do pple r ultr aso no gr aphy using the e c ho e nhanc e r age nt
( Le vo vist) sho we d an impr o ve me nt in the visualizatio n o f the
po r tal he patic ve ins b ut did no t add any additio nal r e le vant
info r matio n.
In o ur study, the mo st pr e c ise data that allo we d us to de te r mine the stage o f patho lo gic al de ve lo pme nt we r e fr o m
a n a lys e s o f c e n tr a l a n d p e r ip h e r a l e c h o ge n ic ity o f th e
pe r ipo r tal r e gio n and sple e n size .
ACKNOWLEDGEMENTS
We thank Mar ia de Fátima da Silva, Mar luc y Ro dr igue s Li m a , Li l i a n Ca r d o s o Mo r e i r a a n d I va n e te d o s S a n to s Na s c i m e n to fo r fi e l d a n d l a b o r a to r y e x p e r t te c h n i c a l assistanc e .
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Table 3 - Ultrasou n d ( US) measu remen ts before an d on e year after specific chemotherapy of the patien ts in grou p 3.
US Variable Mean ( cm) ± SD
N B.T. A.T. P value
Liver Left Lobe
Lon 19 9 .9 5 ± 1 .5 1 9 .2 3 ± 1 .9 0 0 .1 6 7
AP 18 6 .4 9 ± 0 .8 7 6 .8 8 ± 1 .1 5 0 .1 6 1
Portal vein 18 1 .2 8 ± 0 .1 9 1 .0 9 ± 0 .2 5 0 .0 0 6
Splenic vein 18 0 .8 0 ± 0 .1 6 0 .6 9 ± 0 .1 6 0 .0 0 7
Spleen
Lon 19 8 .7 5 ± 2 .2 3 9 .4 5 ± 1 .6 5 0 .1 8 3
AP 11 6 .8 9 ± 0 .8 7 5 .8 7 ± 1 .9 1 0 .1 4 4
Echogenicity
Central 19 0 .3 5 ± 0 .1 3 0 .2 5 ± 0 .1 0 0 .0 0 1
Peripheral N.D. N.D.
Lon = longitudinal; AP = antero-posterior; B.T. - before treatment; A.T. - after treatment;
N.D. – Not done
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