Nutritional status and vitamin A and zinc levels in patients with kala-azar in Piauí, Brazil

Monteiro, Mísia Joyner de Sousa Dias; Silva, Maria Nauside Pessoa da; Paiva, Adriana de Azevedo; Marreiro, Dilina do Nascimento; Luzia, Liania Alves; Henriques, Gilberto Simeone; Rondó, Patrícia Helen de Carvalho; Sene, Ingridi de Souza; Almeida, Ana Tárcila Alves de; Costa, Carlos Henrique Nery; Costa, Dorcas Lamounier

doi:10.1590/0037-8682-0800-2020

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Major Article • Rev. Soc. Bras. Med. Trop. 54 • 2021 • https://doi.org/10.1590/0037-8682-0800-2020 linkcopy

Nutritional status and vitamin A and zinc levels in patients with kala-azar in Piauí, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

INTRODUCTION: Malnutrition and kala-azar (or visceral leishmaniasis) are significant public health problems in different parts of the world. Immunity and susceptibility to infectious and parasitic diseases are directly linked to the host’s nutritional state, but little is known about the interaction between nutrition and kala-azar. This study aimed to evaluate nutritional status with kala-azar and correlate these findings with the clinical and laboratory manifestations of the disease, and zinc and retinol levels.

METHODS: This was a cross-sectional study of 139 patients with kala-azar. Nutritional status classification was performed according to international recommendations. Parametric or nonparametric tests were applied whenever indicated in a two-sided test with a 5% significance level.

RESULTS: Weight loss and malnutrition were more frequent in adults. Body mass index-for-age, fat area of the arm, and upper arm muscle area were significantly associated with probability of death. The presence of human immunodeficiency virus, hepatomegaly, and splenomegaly was correlated with nutritional assessment. Blood leukocyte and lymphocyte, serum creatine, and vitamin A levels were significantly higher in adult men. Vitamin A levels were highly associated with the level of hemoglobin and C-reactive protein (CRP) in multivariate analysis. All patients had reduced plasma zinc levels, but this finding had no association with the outcome variables.

CONCLUSIONS: Malnutrition was correlated with severe disease and was more prevalent in older people with kala-azar. Vitamin A deficiency was associated with hemoglobin and CRP. Zinc levels were reduced in patients with kala-azar.

Keywords:
Leishmaniasis; Visceral; Kala-azar; Malnutrition; Vitamin A; Zinc

Characteristic	n	%
Sex
Male	102	73.4
Female	37	26.6
Age (m, 95%CI) ¹
< 18 y.o.	4.3	3.3-5.4
≥ 18 y.o.	39.0	35.9-42.1
Origin
Urban	99	71.2
Rural	40	28.8
Diagnostic method
Parasitological	97	69.8
Molecular	30	21.6
Immunological	12	8.6
Duration of illness (days)²(m, 95%CI)	30.5	24.9-36.2
Signs and symptoms
Fever	133	95.7
Anemia	133	95.7
Splenomegaly	135	97.1
Thrombocytopenia	99	71.2
Neutrophils < 1000 cel/mm³	60	43.1
CRP³ >10 mg/dL	133	95.7
CRP > 50 mg/dL	81	60.9
Risk of death ⁴
> 0.10	34	26.5
> 0.30	8	5.8

Variables	Male		Female		Total
	mean	95%CI	mean	95%CI	mean	95%CI	p-value
Age (years)	24.0	20.0-28.0	13.9	8.5-19.3	21.3	18.0- 25.0	0.007
Age < 14	4.5	3.1-5.9	4.0	2.3-5.8	4.35	3.3-5.4	0.66
Age ≥ 14	39.4	35.8-42.9	37.2	32.2-42.1	39.0	35.9-42.1	0.38
BMI (Kg/m²)	19.2	18.4-20.1	17.1	15.9-18.4	18.6	17.9-19.4	0.01
BC (cm)	20.6	19.4-21.8	17.5	15.5-19.5	19.8	18.8-20.9	0.01
TSF (cm)	7.4	6.3-8.5	10.0	7.7-12.2	8.0	7.0-9.0	0.03
SSF (cm)	7.9	7.0-8.6	8.4	5.7-11.1	7.9	7.1-8.8	0.57
BMC (cm)	19.5	18.4-20.6	15.2	13.5-16.9	18.5	17.5-19.5	0.0001
BA (cm²)	36.3	32.2-40.4	26.7	20.0- 33.3	33.9	30.4-37.4	0.02
BFA (cm²)	7.4	6.2 -8.8	9.5	6.2-12.7	8.0	6.7 -9.2	0.18
% BFA	18.8	17.1 -20.5	29.7	26.5-32.9	21.5	19.8 -23.2	<0.0001

Parameter	¹ BMI for age		Upper arm muscle area		Upper arm fat area
	r	p-value	r	p-value	r	p-value

²weight loss (grams)	0.16	0.09	-0.22	0.04	0.03	0.73
Spleen extension (cm)	0.14	0.16	-0.24	0.03	-0.21	0.03
Liver extension (cm)	- 0.02	0.80	-0.04	0.72	-0.33	0.005
Leukocytes (cels/mm³)	- 0.23	0.006	-0.30	0.0008	0.20	0.04
Neutrophils (cels/mm³)	0.17	0.05	0.05	0.53	0.17	0.10
Lymphocytes (cels/mm³)	-0.17	0.04	-0.41	<0.0001	-0.31	0.001
Platlets (cels/mm³)	0.01	0.90	0.06	0.46	0.04	0.67
³CRP (mg/L)	0.11	0.22	0.21	0.04	0.19	0.06
Serum creatinine	0.24	0.02	0.67	<0.0001	0.30	0.01
Erythrocyte zinc (mg/dL)	-0.01	0.86	-0.01	0.99	-0.06	0.54

	Serum				⁴ Vitamin A deficiency
	Vitamin A				Univariate analysis		Multivariate analysis
	n=138	mean (mmol / L)	95% CI	¹ p-value	Odds ratio	² p-value	Odds ratio	³ p-value
Sex
Male	102	1.11	0.92-1.31	0.04	0.46	0.05	0.34	0.26
Female	36	0.72	0.51-0.93
Age
< 18 y.o.	71	0.88	0.69-1.09	0.11	1.60	0.17	2.15	0.38
≥ 18 y.o.	67	0.97	0.90-1.38
HIV coinfection
Absent	121	1.02	0.85-1.20	0.78	2.95	0.20	-	-
Present	17	0.96	0.62-1.30
Hemoglobin (mg/dL)
< 9	38	0.66	0.45-0.87	0.007	1.35	0.002	6.58	0.004
≥ 9	101	1.15	0.95-1.35
⁵ CRP (mg/L)
≥50	103	0.91	0.70-1.12	0.07	0.49	0.04	0.12	0.008
<50	29	1.20	0.95-1.46
Albumin (g/dL)
< 2.5	29	0.89	0.20-1.83	0.54	2.68	0.11	3.03	0.16
≥ 2.5	25	1.47	0.90-1.58

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[TFN1] ¹age (mean, 95% confidence interval); ²Days from first symptoms to diagnosis; ³C-reactive protein; ⁴Risk of death calculated by KalaCal^® software.