Research ArticleEpidemiology of American Tegumentary Leishmaniasis andTrypanosoma cruzi Infection in the Northwestern Argentina

Carlos L Hoyos1 Silvana P Cajal1 Marisa Juarez1

Jorge D Marco12 Anahiacute M Alberti DrsquoAmato2 Melina Cayo3 Irma Torrejoacuten3

Rubeacuten O Cimino14 Patricio Diosque2 Alejandro J Krolewiecki12

Julio R Nasser14 and Joseacute F Gil15

1 Instituto de Investigaciones en Enfermedades Tropicales Sede Regional Oran Universidad Nacional de Salta 4530 Salta Argentina2Instituto de Patologıa Experimental (IPE-CONICET) Facultad de Ciencias de la Salud Universidad Nacional de Salta4400 Salta Argentina3Instituto de Biologıa de la Altura (InBiAl) Universidad Nacional de Jujuy Jujuy Argentina4Catedra de Quımica Biologica Facultad de Ciencias Naturales Universidad Nacional de Salta 4400 Salta Argentina5Instituto de Investigaciones en Energıa noConvencional (INENCO-CONICET) UniversidadNacional de Salta 4400 Salta Argentina

Correspondence should be addressed to Jose F Gil jgilconicetgovar

Received 23 July 2016 Accepted 7 September 2016

Academic Editor Jose Vasconcelos

Copyright copy 2016 Carlos L Hoyos et alThis is an open access article distributed under theCreative CommonsAttribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background Endemic areas of tegumentary leishmaniasis (TL) in Salta Argentina present some overlap zones with thegeographical distribution of Chagas disease with mixed infection cases being often detected Objectives The purpose of this studywas to determine the magnitude of Leishmania sp infection and potential associated risk factors the serologic prevalence of Tcruzi and the presence of T cruzi-Leishmania sp mixed infection in a region of the northwest of Argentina Methods Cross-sectional studies were conducted to detect TL prevalence and T cruzi seroprevalence A case-control study was conducted toexamine leishmaniasis risk factors Results Prevalence of TL was 017 seroprevalence of T cruzi infection was 973 and mixedinfection proportionmdashwithin the leishmaniasic patients groupmdashwas 1667The risk factors associated with TL transmission weresex age exposure to bites at work staying outdoors more than 10 hoursday bathing in the river and living with people whohad lesions or were infected during the study Discussion The endemic pattern of TL seems to involve exposure of patients tovectors in wild as well as peridomestic environment Cases of T cruzi infection are apparently due tomigrationTherefore a carefulepidemiological surveillance is necessary due to the contraindication of antimonial administration to chagasic patients

1 Introduction

Tegumentary leishmaniasis (TL) is caused by protozoanparasites belonging to the genus Leishmania Clinical man-ifestations of this disease include single multiple dissemi-nated cutaneous and mucocutaneous forms [1] The speciesLeishmania (Viannia) braziliensis L (V) guyanensis L (L)amazonensis and L (V) panamensis have been reportedfrom northern Argentina [2ndash4] although the vast majorityis caused by L (V) braziliensis In this region Leishma-nia spp are transmitted by the bite of the female sandflybelonging to the genus Lutzomyia (Diptera Psychodidae

and Phlebotominae) Migonemyia migonei (Franca 1920)Evandromyia cortelezzii (Brethes 1923) Evandromyia sallesi(Galvao amp Coutinho 1940) Psathyromyia shannoni (Dyar1929) Psathyromyia punctigeniculata (Floch amp Abonnenc1944) and Nyssomyia neivai (Pinto 1926) have been reportedin northern Argentina [5 6] and particularly Ny neivaiMg migonei and cortelezzii complex have been proposed aspotential vectors [7 8]

The described scenarios of TL transmission in Argentinainclude four cyclesrsquo patterns (a) wild cycle with transmissionin primary or residual vegetation (b) with eventual perido-mestic transmission due to wild or secondary vegetation

Hindawi Publishing CorporationBioMed Research InternationalVolume 2016 Article ID 6456031 8 pageshttpdxdoiorg10115520166456031

2 BioMed Research International

changes (c) with peridomestic transmission in contiguousdomiciles with the residual vegetation and (d) peridomesticcycle in rural ruralized periurban or urban-rural inter-face environment [9] However the potential existence ofurban transmission has been reported which representsan important change in the transmission pattern paradigmof this disease at the regional scale [10] Oran and SanMartin departments (Salta province) are the areas with thegreatest risk of transmission in the country which reportedthe highest number of cases to the overall TL incidence inArgentina [10 11]

In several areas of Latin America (including northernArgentina) the geographical distribution of TL overlaps withtransmission areas of American trypanosomiasis (Chagasdisease) The World Health Organization estimates that 8 to10 million people are infected worldwide mostly in LatinAmerica where the disease is endemic [12] this is caused byTrypanosoma cruzi and it is transmitted by several speciesof triatomine insects Triatoma infestans being the mostimportant in Argentina In the last century the progres-sive urbanization and the intensive migration of infectedindividuals increased the risk of transmission by bloodtransfusion and congenital route in nonendemic regions[13] In restricted areas located in the east and northeast ofSalta province corresponding to the Gran Chaco ecoregionvectorial transmission of T cruzi still occurs but not in therain forest ecoregion (Yunga ecoregion)

Mixed infections due to Leishmania sp and T cruzihave been reported in patients showing clinical symptomsof TL ranging between 12 and 70 [2 14ndash16] Prevalenceof Leishmania sp and T cruzi mixed infection is unknownfor northern Salta Cross-reactivity between T cruzi andLeishmania sp infections has been reported when someserological tests were evaluated [2 16 17] possibly due to theclose phylogenetic relationship between these parasites Theoccurrence of Leishmania sp and T cruzi mixed infectionsalso has therapeutic implications Antimonial drugs used totreat leishmaniasis have potential cardiac toxicity [18ndash20]which is an important concern in patients infected by T cruzibecause about 30 of people infected by this parasite developchronic cardiomyopathy [21]

In the present study we examined the prevalence ofsingle infections by Leishmania sp and T cruzi as well asthe proportion of mixed infections due to both parasites inpeople living in the northern of Argentina Demographicbehavioral and environmental variables have also beenstudied as potential risk factors associated with transmissionof cutaneous leishmaniasis The epidemiologic pattern hereobserved can occur in several countries in Latin America andthis research can provide information to optimize global andlocal prevention measures of public health

2 Materials and Methods

21 Area and Population Studied Hipolito Yrigoyen (OranDepartment Salta Argentina) is located at 23∘141015840S 64∘161015840W323masl in large-scale farming and forest exploitation areawith subtropical climate It is within the perimeter of thePedemontana rain forest This urban place has a population

of 10 363 inhabitants (Primary Health Care Record 2009)The study population included people who lived in HipolitoYrigoyen between 2001 and 2011

22 Study Design This research included two cross-sectionalstudies a tegumentary leishmaniasis case-control study andthe report of mixed infection for Leishmania sp and T cruzi

A cross-sectional study was conducted in 2009 to deter-mine the prevalence of Leishmania sp (LP) taking intoaccount the active cases of TL (ACTL) and total population ofHipolito Yrigoyen (HYTP population censed by the PHC)

LP = ACTLHYTPtimes 100 =

ACTL10363times 100 (1)

The seroprevalence of T cruzi infection (TCSP) cor-responding to 2009 was also calculated through a cross-sectional study The sample size was 113 people It wascalculated considering an expected prevalence 5with 4 ofaccuracy and confidence level of 95 using the Epidat soft-ware v31 (Epidat Xunta de Galicia Santiago de CompostelaSpain and Pan-American Health Organization WashingtonDC) Seventy-nine quasi-randomly selected households werestudied (Figure 1(b)) Of all household members only thosewho wanted to participate voluntarily were selected (oneperson or more per household) The seroprevalence (TCSP)was calculated as the number of seropositive people for Tcruzi infection (TCP) over the sample size (SS)

TCSP = TCPSStimes 100 =

TCP113times 100 (2)

Also the mixed infection proportion within group ofpatients with TL in 2009 was calculated (Figure 2)

An unmatched case-control study was conducted toidentify risk factors associated with TL cases The TL casesincluded in the case-control study were patients living inHipolito Yrigoyen and diagnosed between 2001 and 2009Thecontrol population was selected within the cross-sectionalsample used to calculate the T cruzi seroprevalence infection(Figure 2) A survey was conducted in both cases and onthe control people through a structured epidemiologicalquestionnaire After each person was interviewed 6mL ofvenous blood was drawn by clinical laboratory techniciansand allowed to clot at room temperature The sera wereobtained by centrifugation at 3500 rotations per min for5min then aliquoted into 15mL tubes and stored at minus20∘Cuntil tested

The variables registered were age sex occupation (expo-sure to vector bites at work) recreational habits (staying out-doors for more than 10 h and bathing in the river) personalpreventivemeasures household data (ie location construc-tion material proximity to sites of possible development ofsandflies distance from crop fields and primary vegetationknowledge about and application of preventive measures)living with people who were infected or had lesions andaspects indicating knowledge about TL [22ndash24] The datafrom the questionnaire were managed using the applicationEpiData Entry version 31 [25] the resulting database wasexported to the R statistical software for respective analysis

BioMed Research International 3

Hipoacutelito Yrigoyen locality

(a)

Households sampledIrrigation channel

0 05 1025(km)

N

(b)

Figure 1 (a) HYwithin Argentina (b)The black dots indicate householdsrsquo distribution where the sampling was conducted in theHY locality

The people included in each study group mentionedabove were defined according to the diagnostic criteriadescribed below

23 Diagnostic Procedures The patients were evaluated inthe field by the personnel at Instituto de Investigaciones enEnfermedades Tropicales (IIET) at Universidad Nacional deSalta the SanVicente de PaulHospital inOran andEvaPeronHospital in Hipolito Yrigoyen

The sera and blood samples collected in the field weretransported to the IIET for processing The parasitologicaldiagnostic of Leishmania was made in the IIET and thepatients were derived from Hipolito Yrigoyen Hospital Bothdiagnostic procedures such as serological parasitologicaland molecular techniques were performed following theprotocols established in previous studiesThe commercial kitswere applied according to manufacturerrsquos instructions

24 Diagnostic Criteria Diagnostic criteria included the fol-lowing

241 Leishmaniasis Cases Included were individuals whohad lesions clinically compatible with TL and visualizationof amastigotes of Leishmania sp in Giemsa-stained smearsandor positive reaction of serum samples by enzyme-linkedimmunosorbent assay (ELISAg) homogenate protein of L (V)guyanensis [15] andor positive reaction to leishmanin skintest [4 5]

242T cruzi Infection The subjectswere considered infectedwith T cruzi when serum samples by ELISA and Indirecthemagglutination (IHA) tests (Wiener Lab Argentina) werereactive The samples with discordant results between ELISAand IHA were examined by recombinant ELISA 30 (WienerLab Argentina) and Immunofluorescence test [26] or Poly-merase Chain Reaction (PCR) [27] The recombinant ELISA30was reported as specific test forT cruzi infection detectionwithout cross-reaction with Leishmania [17 28]

243 Mixed Infections Included were patients with TL andpositive results for at least two tests for T cruzi infectionmentioned above

244 Controls in Case-Control Study Included were individ-uals living in Hipolito Yrigoyen who were not grouped asleishmaniasis cases andor T cruzi infected

25 Data Analysis The prevalence of Leishmania sp sero-prevalence of T cruzi infections and mixed infection pro-portion with 95 Confidence Intervals (CI) were calculatedusing the EPIDAT software version 31

In the case-control study the independent continuousand discreet variables were respectively categorized ordichotomized Univariate andmultivariate logistic regression(LR) analysis were carried out The Odds Ratios (OR) and95 CI were calculated to assess the link between the TLcases and potential risk factors The variables with OR gt 1

4 BioMed Research International

Patients with active lesionfor leishmaniasis (n = 18)clinical form + smear + LST(2009)

Population size of HipoacutelitoYrigoyen locality Data of

Primary Health Care (2009)

100 people withoutleishmania clinical form +13 leishmaniasic patientswith sera and bloodsample n = 113 year 2009

Patients with leishmaniasis(n = 33)Clinical form + smear + LST(2001ndash2009)

Controls (n = 88)Excluding the people withT cruzi infection

Leishmaniasis prevalence(LP) year 2009 (1)

Mixed infectionsLeishmania sp and T cruziwithin the leishmaniasicpatients (2009)

Diagnosis ofT cruzi infection

Estimation ofseroprevalence of T cruziinfection (TCSP)(2009) (2)

Case-control study

Figure 2 Flow chart showing the groups of patients and noninfected people included in prevalence (LP) and case-control study ofleishmaniasis and T cruzi seroprevalence (TCSP) infection Mixed infections detected (T cruzi-Leishmania) from 13 patients with activeleishmaniasis ulcer in 2009 are also shown Diagnostic of T cruzi infection applied to the 100 people to detect both seropositive people tocalculate T cruzi seroprevalence and select the negative control people for the case-control study People positive for ELISA-leishmaniasis orleishmanin skin test (LST) may have been exposed to the Leishmania parasite The cross-reaction of both ELISA and leishmanin skin testwith chagasic infection does not distinguish whether the person was exposed to Leishmania parasite or is infected with T cruzi Due to thisthe people positive for Chagas lab tests were not included as controls in the case-control study

and 119901 lt 005 in univariate logistic regression analysis weretested in amultivariate analysis to establish amodel involvingthe least number of variables that best explains the dependentvariable (TL cases)

The final model was obtained using the stepwise tech-nique a procedure that combines forward method (it startsfrom amodel only with the constant or independent variablefollowed by progressive introduction of variables in the equa-tion provided they are significant) and backward method(all the variables are initially considered in the model andthose lacking significance are then progressively eliminated)[29] The Akaike Information Criterion (AIC) was used asselection criterion AIC calculation is based onminimizationof the loss of information function penalizing for the numberof variables introduced that seeks the model that best adjuststo the data with the minimum number of possible variablesthus producing simpler models [30 31] The model thathas been chosen minimizes the AIC Data were consideredstatistically significant if 119901 lt 005 All statistical analysis forcase-control study was performed using R software version2152 [32]

26 Ethical Approval All the people included in the studyagreed to participate by signing an informed consent form(ICF) The project and ICF were approved by the EthicsCommittee of the School of Health Sciences at the NationalUniversity of Salta and the ldquoFundacion Huespedrdquo

3 Results

In 2009 only 18 cases of TL were diagnosed in HipolitoYrigoyen which represented a TL prevalence of 017 (CI009ndash026) The age range of study patients was 7ndash69 yearswith an average of 3545 plusmn 1669 (SD)

Of the 113 samples analyzed to detectT cruzi infection 67(59) corresponded to females and 46 (41) to males Theirage ranged between 7 and 74 with an average of 375 plusmn 173(SD) years There was no statistically significant differencein prevalence between males and females (119901 = 073) Theseroprevalence for this infection was 973 (CI 383ndash1564)in 2009The frequencies of cases according to age and sex aresummarized in Table 1

BioMed Research International 5

Table 1 Number of individuals included in the study percentage() of individuals infected with T cruzi according to sex and agegroup aIndication of the overall prevalence in Hipolito Yrigoyen for2009 119894 infected individuals according to sex and age 119899 total samplein seroprevalence of T cruzi study

Sex Female119894119899 ()

Male119894119899 ()

Total infected 567 (7) 646 (13)Age 119899 Infected ()10ndash35 62 4 (645)36ndash55 28 3 (107)gt55 23 4 (104)Total 113 11 (973)a

Positive results were obtained for T cruzi infection inthree patients with TL in 2009 (Table 2) which represents amixed infection proportion of 1667 CI (358ndash4142) withinthe group of 18 patients with TL

The samples for the case-control study included 33 casesof TL (18 actives cases in 2009 and 15 cases registered in the2001ndash2008 period) and 88 controls (Figure 2) The controlgroup consisted of individuals without positive diagnosis forleishmaniasis andChagas diseases according to criteria abovedescribed

The variables that showed significant association (119901 lt005) with the presence of TL (case) in univariate LR analysiswere sex age exposure to vector bites at work stayingoutdoors for more than 10 h (so) bathing in the river andliving with people who were infected or had lesions duringthe study period (Table 3) These variables were includedin a multivariate logistic regression analysis and final modelobtained using the stepwise method This model includesonly 3 predictive variables (sex age and so) that explainedthe occurrence of TL cases (Table 3)The AIC value was 1222

The selected model 119862119860119878119864 = minus282 + 180 lowast 119878119864119883 +204 lowast 119860119866119864 + 142 lowast 119878119874

4 Discussion

In the north of Salta province TL levels are hyperendemic insome sites and periods [33 34] This situation is worsened bythe presence of cases of Chagas disease which may furthergenerate cases of mixed infections causing a synergisticproblem for the health care system In the locality HipolitoYrigoyen TL prevalence values of 017 079 and 018 werepreviously reported [33 34]The prevalence calculated in thepresent study (017 CI 008ndash026) is similar which indicatesa level of active transmission that persists over timeHoweverhigh incidence foci are likely to occur in short exposureperiods in this area [5]

In the case-control study the associated variables wouldbe reflecting the existence of a complex pattern of trans-mission Male sex and staying outdoors for more than 10hours would be indicators of a sylvatic mode of transmissionfacilitated by labour subsistence or recreational activities (in

rural environments andor deforestation areas or huntingand fishing activities) as it is indicated in regions where TLis endemic [9 24 33] The significantly higher proportion ofinfected children compared to that of adults found in thisanalysis (OR = 773 CI 205ndash2916) suggests the existenceof other patterns of transmission in Hipolito Yrigoyen Theincidence of TL in children has been cited as an indicator ofperidomiciliary transmission especially in localities adjacentto primary andor secondary vegetation [4 22ndash24 33]

In addition a high density of sandflies has been detectedin the vegetation near to the irrigation channels located in theoutskirts of the city (Figure 1) [35] showing a species diversitysimilar to that found in a nearby place where there was a highrate of infection [5 36] Many families go to these sites forrecreational purposes in times of high temperature and riskleishmaniasis transmission (7 pm to 10 pm approximately)with the consequent risk of being bitten by infected sandfliesand contracting leishmaniasis as reported in a study of spatialdistribution of TL cases [37]

The presence of active TL cases among elderly peoplethat remain mostly in their houses and of sandflies in thecenter of the town [35] offers another plausible epidemiologicsituation of disease transmission (but with low probability)in urban environments because lower abundance of sandflieswas recorded here [35] Indeed in Hipolito Yrigoyen housecourtyards have vegetation patches that can be colonized bysandflies from the periphery according to the characteristicsof metapopulation dynamics [10]

On the other hand in the study area the possibility ofvector-borne transmission of T cruzi has been discardedbecause no insects or indicators of their presence have beenfound in the annual activities of entomological surveillanceof triatomines carried out by Primary Health Care Systemin recent and historical monitoring Thus cases of T cruziinfection in Hipolito Yrigoyen would be associated withmigratory processes (movement principally of rural pop-ulations from Argentina and Bolivia of the Gran Chacoecoregion where Chagas disease is endemic) [13]The T cruziseroprevalence found in this work is low compared with theprevalence value observed in rural populations of endemicareas (25) [38] and it is high compared with other regionswithout endemic transmission [39] In turn infected childrenmay have acquired infection by congenital transmission asreported in previous studies of this type of transmission inthe province of Salta [40]

Theproportion ofT cruzi-Leishmania spmixed infectionwithin the group of patients with TL reported in the northof Salta reaches 30 and 40 [2 14 15] and does notshow differences from the percentage obtained in this studyKnowing the level of this condition in the population allowsus to explore the factors involved in the origin and persistenceof mixed infections In addition because antimonials arecardiotoxic a careful diagnosis and implementation of alter-native treatments are needed to avoid further complications

The complex situation in Hipolito Yrigoyen in referenceto TL is aggravated by the coexistence of T cruzi infectionThe transmission pattern involves mainly natural areasbut the possibility of a peridomiciliary transmission in theoutskirts of the city cannot be ruled out This situation

6 BioMed Research International

Table 2 Results of samples with mixed infection SMEAR visualization of amastigotes of Leishmania sp in Giemsa-stained smears ELISAgELISA based on homogenate protein of L (V) guyanensis LST reaction to leishmanin skin test ELISA Rec recombinant ELISA Kit IHAindirect hemagglutination TIF test of Immunofluorescence PCR Polymerase Chain Reaction nd no data (samples were not evaluated withTIF)

Leishmania infection tests T cruzi infection testsSmear ELISAg LST ELISA Rec IHA TIF PCR

Patient codeHI 54 + + + + + + minus

HI 55 + + + minus + nd +HI 58 + + + + + nd +

Table 3 Crude OR and adjusted OR for the factors associated withthe presence of tegumentary leishmaniasis OR Odds Ratio CIConfidence Interval aSignificant association at 119901 lt 005 bhighlysignificant association at 119901 lt 001 chighly significant association at119901 lt 0001

Logistic regression OR (CI 95)univariate analysis

OR (CI 95)multivariate analysis

SexFemale 1 1Male 547 (221ndash1354)a 605 (22ndash1664)c

Age (years)gt16 1 17ndash15 437 (139ndash138)b 773 (205ndash2916)b

Exposure to vector bitesat work

Unexposed 1Exposed 268 (114ndash63)a

Permanence gt 10 hoursoutdoors (SO)

No 1 1Yes 467 (123ndash1778)a 416 (097ndash1777)a

Bathing in the riverNo 1Yes 389 (159ndash954)a

Living with infectedpeople

No 1Yes 317 (123ndash815)a

demands the involvement of different stakeholders to controlthe magnitude of disease incidence implementing preven-tion strategies and taking into account biogeographical andsociocultural characteristics as well as human-induced envi-ronmental changes and situations that pose a risk

The present work provides epidemiological informationof potential determinants of TL occurrence in HipolitoYrigoyen its magnitude and situation of T cruzi infectionin the same area This information is useful for the localhealth system because it may contribute to a better planningof the surveillance systems and to the design of preven-tion strategies in the area These epidemiological patternsof mixed infections can occur in other countries wereT cruzi transmission does not exist or was interrupted andtegumentary leishmaniasis is endemic

Competing Interests

The authors declare that they have no competing interests

Acknowledgments

The authors wish to thank Carlos Villalpando ElizabethCorro Yolanda Aban Nadia Gonzalez and Norma Acostafor their support during fieldwork and the Med NicanorSosa of the Municipality of Hipolito Yrigoyen for logisticsupport during permanence in the study areaThis study wassupported by the Consejo de Investigacion de la UniversidadNacional de Salta (CIUNSa) the PICT 2013-3213 PICT 2014-1579 and Fundacion Mundo Sano

References

[1] A J Krolewiecki H D Romero S P Cajal et al ldquoA randomizedclinical trial comparing oral azithromycin andmeglumine anti-moniate for the treatment of American cutaneous leishmaniasiscaused by Leishmania (Viannia) braziliensisrdquo The AmericanJournal of TropicalMedicine andHygiene vol 77 no 4 pp 640ndash646 2007

[2] F M Frank M M Fernandez N J Taranto et al ldquoChar-acterization of human infection by Leishmania spp in theNorthwest of Argentina immune response double infectionwith Trypanosoma cruzi and species of Leishmania involvedsrdquoParasitology vol 126 no 1 pp 31ndash39 2003

[3] J D Marco P A Barroso T Mimori et al ldquoPolymorphism-specific PCR enhances the diagnostic performance of Americantegumentary leishmaniasis and allows the rapid identification ofLeishmania species from Argentinardquo BMC Infectious Diseasesvol 12 article 191 2012

[4] F M Locatelli S P Cajal P A Barroso et al ldquoThe isola-tion and molecular characterization of Leishmania spp frompatients with American tegumentary leishmaniasis in north-west Argentinardquo Acta Tropica vol 131 no 1 pp 16ndash21 2014

[5] A J Krolewiecki J F Gil M Quipildor et al ldquoRestricted out-break of American tegumentary leishmaniasis with highmicro-focal transmissionrdquo American Journal of Tropical Medicine andHygiene vol 88 no 3 pp 578ndash582 2013

[6] O D Salomon M L Wilson L E Munstermann and B LTravi ldquoSpatial and temporal patterns of phlebotomine sand flies(Diptera Psychodidae) in a cutaneous leishmaniasis focus innorthern Argentinardquo Journal of Medical Entomology vol 41 no1 pp 33ndash39 2004

[7] D de Pita-Pereira C R Alves M B Souza et al ldquoIdentificationof naturally infected Lutzomyia intermedia and Lutzomyiamigoneiwith Leishmania (Viannia) braziliensis in Rio de Janeiro

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(Brazil) revealed by a PCRmultiplex non-isotopic hybridisationassayrdquo Transactions of the Royal Society of Tropical Medicine andHygiene vol 99 no 12 pp 905ndash913 2005

[8] E Cordoba-Lanus M L De Grosso J E Pinero B Valladaresand O D Salomon ldquoNatural infection of Lutzomyia neivaiwithLeishmania spp in northwestern Argentinardquo Acta Tropica vol98 no 1 pp 1ndash5 2006

[9] O D Salomon P W Orellano M G Quintana et al ldquoTrans-mission of tegumentary leishmaniasis in ArgentinardquoMedicinavol 66 no 3 pp 211ndash219 2006

[10] J F Gil J R Nasser S P Cajal et al ldquoUrban transmission ofamerican cutaneous leishmaniasis in Argentina spatial analysisstudyrdquoThe American Journal of Tropical Medicine and Hygienevol 82 no 3 pp 433ndash440 2010

[11] O D Salomon J R Rosa M Stein et al ldquoPhlebotominae(Diptera Psycodidae) fauna in theChaco region andCutaneousLeishmaniasis transmission patterns in Argentinardquo Memoriasdo Instituto Oswaldo Cruz vol 103 no 6 pp 578ndash584 2008

[12] World Health Organization ldquoResearch priorities for chagasdisease human african trypanosomiasis and leishmaniasisrdquoWHOTechnical Report Series 975WorldHealthOrganizationGeneva Switzerland 2013

[13] J C P Dias ldquoHuman chagas disease and migration in thecontext of globalization some particular aspectsrdquo Journal ofTropical Medicine vol 2013 Article ID 789758 9 pages 2013

[14] M G Chiaramonte F M Frank G M Furer N J TarantoR A Margni and E L Malchiodi ldquoPolymerase chain reactionreveals Trypanosoma cruzi infection suspected by serology incutaneous and mucocutaneous leishmaniasis patientsrdquo ActaTropica vol 72 no 3 pp 295ndash308 1999

[15] J F Gil C L Hoyos R O Cimino et al ldquoRole of threeELISA tests using promastigote homogenates of Leishmaniabraziliensis L amazonensis and L guyanensis in the diagnosisof tegumentary leishmaniasisrdquoMedicina vol 71 no 5 pp 420ndash428 2011

[16] A F Vega Benedetti R O Cimino P S Cajal et al ldquoPerfor-mance of different Trypanosoma cruzi antigens in the diag-nosis of Chagas disease in patients with American cutaneousleishmaniasis from a co-endemic region in Argentinardquo TropicalMedicine amp International Health vol 18 no 9 pp 1103ndash11092013

[17] J F Gil R O Cimino I Lopez Quiroga et al ldquoReactivityof GST-SAPA antigen of Trypanosoma cruzi against sera frompatients with Chagas disease and leishmaniasisrdquoMedicina vol71 no 2 pp 113ndash119 2011

[18] S D Lawn M Armstrong D Chilton and C J MWhitty ldquoElectrocardiographic and biochemical adverse effectsof sodium stibogluconate during treatment of cutaneous andmucosal leishmaniasis among returned travellersrdquo Transactionsof the Royal Society of Tropical Medicine and Hygiene vol 100no 3 pp 264ndash269 2006

[19] L F Oliveira A O Schubach M M Martins et al ldquoSystematicreview of the adverse effects of cutaneous leishmaniasis treat-ment in the NewWorldrdquo Acta Tropica vol 118 no 2 pp 87ndash962011

[20] L F Gamboa Latorre and J A Becerra Mateus ldquoCardiotoxici-dad por antimonialesrdquo Revista Salud Bosque vol 2 no 2 pp69ndash74 2012

[21] L H Malik G D Singh and E A Amsterdam ldquoThe epidemi-ology clinical manifestations and management of chagas heartdiseaserdquo Clinical Cardiology vol 38 no 9 pp 565ndash569 2015

[22] S Sosa-Estani E L Segura A Gomez et al ldquoCutaneousleishmaniasis in Northern Argentina identification of riskfactors in a case-cohort study of three municipalities in SaltardquoRevista da Sociedade Brasileira deMedicina Tropical vol 34 no6 pp 511ndash517 2001

[23] Z E Yadon L C Rodrigues C R Davies and M A QuigleyldquoIndoor and peridomestic transmission of American cutaneousleishmaniasis in northwestern Argentina a retrospective case-control studyrdquo American Journal of Tropical Medicine andHygiene vol 68 no 5 pp 519ndash526 2003

[24] F D A Pedrosa and R A D A Ximenes ldquoSociodemographicand environmental risk factors for American cutaneous leish-maniasis (ACL) in the State of Alagoas Brazilrdquo AmericanJournal of Tropical Medicine and Hygiene vol 81 no 2 pp 195ndash201 2009

[25] J M Lauritsen and M Bruus EpiData Entry Version 31 AComprehensive Tool for Validated Entry and Documentation ofData The EpiData Association Odense Denmark 2005

[26] M Alvarez J A Cerisola and R W Rohwedder ldquoImmunoflu-orescence test in the diagnosis of Chagasrsquo diseasesrdquo BoletınChileno de Parasitologıa vol 23 no 1 pp 4ndash8 1968

[27] C Britto M A Cardoso C M Monteiro Vanni et alldquoPolymerase chain reaction detection of Trypanosoma cruzi inhuman blood samples as a tool for diagnosis and treatmentevaluationrdquo Parasitology vol 110 no 3 pp 241ndash247 1995

[28] Z C Caballero O E Sousa W P Marques A Saez-Alquezarand E S Umezawa ldquoEvaluation of serological tests to identifyTrypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spprdquoClinical and Vaccine Immunology vol 14 no 8 pp 1045ndash10492007

[29] S Domınguez-Almendros N Benıtez-Parejo and A RGonzalez-Ramirez ldquoLogistic regressionmodelsrdquoAllergologia etImmunopathologia vol 39 no 5 pp 295ndash305 2011

[30] V ChongsuvivatwongAnalysis of Epidemiological Data Using Rand Epicalc Epidemiology Unit Prince of Songkla UniversitySongkhla Thailand 2008

[31] M M Rodrıguez del Aguila and N Benıtez-Parejo ldquoSimplelinear and multivariate regression modelsrdquo Allergologia etImmunopathologia vol 39 no 3 pp 159ndash173 2011

[32] R Core Team ldquoR A language and environment for statisticalcomputingrdquo 2012 R Foundation for Statistical ComputingVienna Austria httpwwwR-projectorg

[33] S Sosa-Estani E L Segura O D Salomon et al ldquoTegumentaryleishmaniasis in Northern Argentina distribution of infectionand disease in three municipalities of Salta 1990ndash1992rdquo Revistada Sociedade Brasileira de Medicina Tropical vol 33 no 6 pp573ndash582 2000

[34] O D Salomon S S Estani L Canini and E C LanusldquoTegumentary leishmaniasis in an area with epidemic levels oftransmission Salta Argentina 1998rdquoMedicina B Aires vol 61no 3 pp 284ndash290 2001

[35] M M Chanampa Monitoring sandflies of Lutzomyia genusand associated environmental variables in the town of HipolitoYrigoyen [MS Biologist thesis] Biology School Facultad deCiencias Naturales de la Universidad Nacional de Salta SaltaArgentina 2012

[36] M G Quintana O D Salomon and M S De Grosso ldquoDis-tribution of phlebotomine sand flies (Diptera Psychodidae) ina primary forest-crop interface Salta Argentinardquo Journal ofMedical Entomology vol 47 pp 1003ndash1010 2010

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

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2 BioMed Research International

changes (c) with peridomestic transmission in contiguousdomiciles with the residual vegetation and (d) peridomesticcycle in rural ruralized periurban or urban-rural inter-face environment [9] However the potential existence ofurban transmission has been reported which representsan important change in the transmission pattern paradigmof this disease at the regional scale [10] Oran and SanMartin departments (Salta province) are the areas with thegreatest risk of transmission in the country which reportedthe highest number of cases to the overall TL incidence inArgentina [10 11]

In several areas of Latin America (including northernArgentina) the geographical distribution of TL overlaps withtransmission areas of American trypanosomiasis (Chagasdisease) The World Health Organization estimates that 8 to10 million people are infected worldwide mostly in LatinAmerica where the disease is endemic [12] this is caused byTrypanosoma cruzi and it is transmitted by several speciesof triatomine insects Triatoma infestans being the mostimportant in Argentina In the last century the progres-sive urbanization and the intensive migration of infectedindividuals increased the risk of transmission by bloodtransfusion and congenital route in nonendemic regions[13] In restricted areas located in the east and northeast ofSalta province corresponding to the Gran Chaco ecoregionvectorial transmission of T cruzi still occurs but not in therain forest ecoregion (Yunga ecoregion)

Mixed infections due to Leishmania sp and T cruzihave been reported in patients showing clinical symptomsof TL ranging between 12 and 70 [2 14ndash16] Prevalenceof Leishmania sp and T cruzi mixed infection is unknownfor northern Salta Cross-reactivity between T cruzi andLeishmania sp infections has been reported when someserological tests were evaluated [2 16 17] possibly due to theclose phylogenetic relationship between these parasites Theoccurrence of Leishmania sp and T cruzi mixed infectionsalso has therapeutic implications Antimonial drugs used totreat leishmaniasis have potential cardiac toxicity [18ndash20]which is an important concern in patients infected by T cruzibecause about 30 of people infected by this parasite developchronic cardiomyopathy [21]

In the present study we examined the prevalence ofsingle infections by Leishmania sp and T cruzi as well asthe proportion of mixed infections due to both parasites inpeople living in the northern of Argentina Demographicbehavioral and environmental variables have also beenstudied as potential risk factors associated with transmissionof cutaneous leishmaniasis The epidemiologic pattern hereobserved can occur in several countries in Latin America andthis research can provide information to optimize global andlocal prevention measures of public health

2 Materials and Methods

21 Area and Population Studied Hipolito Yrigoyen (OranDepartment Salta Argentina) is located at 23∘141015840S 64∘161015840W323masl in large-scale farming and forest exploitation areawith subtropical climate It is within the perimeter of thePedemontana rain forest This urban place has a population

of 10 363 inhabitants (Primary Health Care Record 2009)The study population included people who lived in HipolitoYrigoyen between 2001 and 2011

22 Study Design This research included two cross-sectionalstudies a tegumentary leishmaniasis case-control study andthe report of mixed infection for Leishmania sp and T cruzi

A cross-sectional study was conducted in 2009 to deter-mine the prevalence of Leishmania sp (LP) taking intoaccount the active cases of TL (ACTL) and total population ofHipolito Yrigoyen (HYTP population censed by the PHC)

LP = ACTLHYTPtimes 100 =

ACTL10363times 100 (1)

The seroprevalence of T cruzi infection (TCSP) cor-responding to 2009 was also calculated through a cross-sectional study The sample size was 113 people It wascalculated considering an expected prevalence 5with 4 ofaccuracy and confidence level of 95 using the Epidat soft-ware v31 (Epidat Xunta de Galicia Santiago de CompostelaSpain and Pan-American Health Organization WashingtonDC) Seventy-nine quasi-randomly selected households werestudied (Figure 1(b)) Of all household members only thosewho wanted to participate voluntarily were selected (oneperson or more per household) The seroprevalence (TCSP)was calculated as the number of seropositive people for Tcruzi infection (TCP) over the sample size (SS)

TCSP = TCPSStimes 100 =

TCP113times 100 (2)

Also the mixed infection proportion within group ofpatients with TL in 2009 was calculated (Figure 2)

An unmatched case-control study was conducted toidentify risk factors associated with TL cases The TL casesincluded in the case-control study were patients living inHipolito Yrigoyen and diagnosed between 2001 and 2009Thecontrol population was selected within the cross-sectionalsample used to calculate the T cruzi seroprevalence infection(Figure 2) A survey was conducted in both cases and onthe control people through a structured epidemiologicalquestionnaire After each person was interviewed 6mL ofvenous blood was drawn by clinical laboratory techniciansand allowed to clot at room temperature The sera wereobtained by centrifugation at 3500 rotations per min for5min then aliquoted into 15mL tubes and stored at minus20∘Cuntil tested

The variables registered were age sex occupation (expo-sure to vector bites at work) recreational habits (staying out-doors for more than 10 h and bathing in the river) personalpreventivemeasures household data (ie location construc-tion material proximity to sites of possible development ofsandflies distance from crop fields and primary vegetationknowledge about and application of preventive measures)living with people who were infected or had lesions andaspects indicating knowledge about TL [22ndash24] The datafrom the questionnaire were managed using the applicationEpiData Entry version 31 [25] the resulting database wasexported to the R statistical software for respective analysis

BioMed Research International 3

Hipoacutelito Yrigoyen locality

(a)

Households sampledIrrigation channel

0 05 1025(km)

N

(b)

Figure 1 (a) HYwithin Argentina (b)The black dots indicate householdsrsquo distribution where the sampling was conducted in theHY locality

The people included in each study group mentionedabove were defined according to the diagnostic criteriadescribed below

23 Diagnostic Procedures The patients were evaluated inthe field by the personnel at Instituto de Investigaciones enEnfermedades Tropicales (IIET) at Universidad Nacional deSalta the SanVicente de PaulHospital inOran andEvaPeronHospital in Hipolito Yrigoyen

The sera and blood samples collected in the field weretransported to the IIET for processing The parasitologicaldiagnostic of Leishmania was made in the IIET and thepatients were derived from Hipolito Yrigoyen Hospital Bothdiagnostic procedures such as serological parasitologicaland molecular techniques were performed following theprotocols established in previous studiesThe commercial kitswere applied according to manufacturerrsquos instructions

24 Diagnostic Criteria Diagnostic criteria included the fol-lowing

241 Leishmaniasis Cases Included were individuals whohad lesions clinically compatible with TL and visualizationof amastigotes of Leishmania sp in Giemsa-stained smearsandor positive reaction of serum samples by enzyme-linkedimmunosorbent assay (ELISAg) homogenate protein of L (V)guyanensis [15] andor positive reaction to leishmanin skintest [4 5]

242T cruzi Infection The subjectswere considered infectedwith T cruzi when serum samples by ELISA and Indirecthemagglutination (IHA) tests (Wiener Lab Argentina) werereactive The samples with discordant results between ELISAand IHA were examined by recombinant ELISA 30 (WienerLab Argentina) and Immunofluorescence test [26] or Poly-merase Chain Reaction (PCR) [27] The recombinant ELISA30was reported as specific test forT cruzi infection detectionwithout cross-reaction with Leishmania [17 28]

243 Mixed Infections Included were patients with TL andpositive results for at least two tests for T cruzi infectionmentioned above

244 Controls in Case-Control Study Included were individ-uals living in Hipolito Yrigoyen who were not grouped asleishmaniasis cases andor T cruzi infected

25 Data Analysis The prevalence of Leishmania sp sero-prevalence of T cruzi infections and mixed infection pro-portion with 95 Confidence Intervals (CI) were calculatedusing the EPIDAT software version 31

In the case-control study the independent continuousand discreet variables were respectively categorized ordichotomized Univariate andmultivariate logistic regression(LR) analysis were carried out The Odds Ratios (OR) and95 CI were calculated to assess the link between the TLcases and potential risk factors The variables with OR gt 1

4 BioMed Research International

Patients with active lesionfor leishmaniasis (n = 18)clinical form + smear + LST(2009)

Population size of HipoacutelitoYrigoyen locality Data of

Primary Health Care (2009)

100 people withoutleishmania clinical form +13 leishmaniasic patientswith sera and bloodsample n = 113 year 2009

Patients with leishmaniasis(n = 33)Clinical form + smear + LST(2001ndash2009)

Controls (n = 88)Excluding the people withT cruzi infection

Leishmaniasis prevalence(LP) year 2009 (1)

Mixed infectionsLeishmania sp and T cruziwithin the leishmaniasicpatients (2009)

Diagnosis ofT cruzi infection

Estimation ofseroprevalence of T cruziinfection (TCSP)(2009) (2)

Case-control study

Figure 2 Flow chart showing the groups of patients and noninfected people included in prevalence (LP) and case-control study ofleishmaniasis and T cruzi seroprevalence (TCSP) infection Mixed infections detected (T cruzi-Leishmania) from 13 patients with activeleishmaniasis ulcer in 2009 are also shown Diagnostic of T cruzi infection applied to the 100 people to detect both seropositive people tocalculate T cruzi seroprevalence and select the negative control people for the case-control study People positive for ELISA-leishmaniasis orleishmanin skin test (LST) may have been exposed to the Leishmania parasite The cross-reaction of both ELISA and leishmanin skin testwith chagasic infection does not distinguish whether the person was exposed to Leishmania parasite or is infected with T cruzi Due to thisthe people positive for Chagas lab tests were not included as controls in the case-control study

and 119901 lt 005 in univariate logistic regression analysis weretested in amultivariate analysis to establish amodel involvingthe least number of variables that best explains the dependentvariable (TL cases)

The final model was obtained using the stepwise tech-nique a procedure that combines forward method (it startsfrom amodel only with the constant or independent variablefollowed by progressive introduction of variables in the equa-tion provided they are significant) and backward method(all the variables are initially considered in the model andthose lacking significance are then progressively eliminated)[29] The Akaike Information Criterion (AIC) was used asselection criterion AIC calculation is based onminimizationof the loss of information function penalizing for the numberof variables introduced that seeks the model that best adjuststo the data with the minimum number of possible variablesthus producing simpler models [30 31] The model thathas been chosen minimizes the AIC Data were consideredstatistically significant if 119901 lt 005 All statistical analysis forcase-control study was performed using R software version2152 [32]

26 Ethical Approval All the people included in the studyagreed to participate by signing an informed consent form(ICF) The project and ICF were approved by the EthicsCommittee of the School of Health Sciences at the NationalUniversity of Salta and the ldquoFundacion Huespedrdquo

3 Results

In 2009 only 18 cases of TL were diagnosed in HipolitoYrigoyen which represented a TL prevalence of 017 (CI009ndash026) The age range of study patients was 7ndash69 yearswith an average of 3545 plusmn 1669 (SD)

Of the 113 samples analyzed to detectT cruzi infection 67(59) corresponded to females and 46 (41) to males Theirage ranged between 7 and 74 with an average of 375 plusmn 173(SD) years There was no statistically significant differencein prevalence between males and females (119901 = 073) Theseroprevalence for this infection was 973 (CI 383ndash1564)in 2009The frequencies of cases according to age and sex aresummarized in Table 1

BioMed Research International 5

Table 1 Number of individuals included in the study percentage() of individuals infected with T cruzi according to sex and agegroup aIndication of the overall prevalence in Hipolito Yrigoyen for2009 119894 infected individuals according to sex and age 119899 total samplein seroprevalence of T cruzi study

Sex Female119894119899 ()

Male119894119899 ()

Total infected 567 (7) 646 (13)Age 119899 Infected ()10ndash35 62 4 (645)36ndash55 28 3 (107)gt55 23 4 (104)Total 113 11 (973)a

Positive results were obtained for T cruzi infection inthree patients with TL in 2009 (Table 2) which represents amixed infection proportion of 1667 CI (358ndash4142) withinthe group of 18 patients with TL

The samples for the case-control study included 33 casesof TL (18 actives cases in 2009 and 15 cases registered in the2001ndash2008 period) and 88 controls (Figure 2) The controlgroup consisted of individuals without positive diagnosis forleishmaniasis andChagas diseases according to criteria abovedescribed

The variables that showed significant association (119901 lt005) with the presence of TL (case) in univariate LR analysiswere sex age exposure to vector bites at work stayingoutdoors for more than 10 h (so) bathing in the river andliving with people who were infected or had lesions duringthe study period (Table 3) These variables were includedin a multivariate logistic regression analysis and final modelobtained using the stepwise method This model includesonly 3 predictive variables (sex age and so) that explainedthe occurrence of TL cases (Table 3)The AIC value was 1222

The selected model 119862119860119878119864 = minus282 + 180 lowast 119878119864119883 +204 lowast 119860119866119864 + 142 lowast 119878119874

4 Discussion

In the north of Salta province TL levels are hyperendemic insome sites and periods [33 34] This situation is worsened bythe presence of cases of Chagas disease which may furthergenerate cases of mixed infections causing a synergisticproblem for the health care system In the locality HipolitoYrigoyen TL prevalence values of 017 079 and 018 werepreviously reported [33 34]The prevalence calculated in thepresent study (017 CI 008ndash026) is similar which indicatesa level of active transmission that persists over timeHoweverhigh incidence foci are likely to occur in short exposureperiods in this area [5]

In the case-control study the associated variables wouldbe reflecting the existence of a complex pattern of trans-mission Male sex and staying outdoors for more than 10hours would be indicators of a sylvatic mode of transmissionfacilitated by labour subsistence or recreational activities (in

rural environments andor deforestation areas or huntingand fishing activities) as it is indicated in regions where TLis endemic [9 24 33] The significantly higher proportion ofinfected children compared to that of adults found in thisanalysis (OR = 773 CI 205ndash2916) suggests the existenceof other patterns of transmission in Hipolito Yrigoyen Theincidence of TL in children has been cited as an indicator ofperidomiciliary transmission especially in localities adjacentto primary andor secondary vegetation [4 22ndash24 33]

In addition a high density of sandflies has been detectedin the vegetation near to the irrigation channels located in theoutskirts of the city (Figure 1) [35] showing a species diversitysimilar to that found in a nearby place where there was a highrate of infection [5 36] Many families go to these sites forrecreational purposes in times of high temperature and riskleishmaniasis transmission (7 pm to 10 pm approximately)with the consequent risk of being bitten by infected sandfliesand contracting leishmaniasis as reported in a study of spatialdistribution of TL cases [37]

The presence of active TL cases among elderly peoplethat remain mostly in their houses and of sandflies in thecenter of the town [35] offers another plausible epidemiologicsituation of disease transmission (but with low probability)in urban environments because lower abundance of sandflieswas recorded here [35] Indeed in Hipolito Yrigoyen housecourtyards have vegetation patches that can be colonized bysandflies from the periphery according to the characteristicsof metapopulation dynamics [10]

On the other hand in the study area the possibility ofvector-borne transmission of T cruzi has been discardedbecause no insects or indicators of their presence have beenfound in the annual activities of entomological surveillanceof triatomines carried out by Primary Health Care Systemin recent and historical monitoring Thus cases of T cruziinfection in Hipolito Yrigoyen would be associated withmigratory processes (movement principally of rural pop-ulations from Argentina and Bolivia of the Gran Chacoecoregion where Chagas disease is endemic) [13]The T cruziseroprevalence found in this work is low compared with theprevalence value observed in rural populations of endemicareas (25) [38] and it is high compared with other regionswithout endemic transmission [39] In turn infected childrenmay have acquired infection by congenital transmission asreported in previous studies of this type of transmission inthe province of Salta [40]

Theproportion ofT cruzi-Leishmania spmixed infectionwithin the group of patients with TL reported in the northof Salta reaches 30 and 40 [2 14 15] and does notshow differences from the percentage obtained in this studyKnowing the level of this condition in the population allowsus to explore the factors involved in the origin and persistenceof mixed infections In addition because antimonials arecardiotoxic a careful diagnosis and implementation of alter-native treatments are needed to avoid further complications

The complex situation in Hipolito Yrigoyen in referenceto TL is aggravated by the coexistence of T cruzi infectionThe transmission pattern involves mainly natural areasbut the possibility of a peridomiciliary transmission in theoutskirts of the city cannot be ruled out This situation

6 BioMed Research International

Table 2 Results of samples with mixed infection SMEAR visualization of amastigotes of Leishmania sp in Giemsa-stained smears ELISAgELISA based on homogenate protein of L (V) guyanensis LST reaction to leishmanin skin test ELISA Rec recombinant ELISA Kit IHAindirect hemagglutination TIF test of Immunofluorescence PCR Polymerase Chain Reaction nd no data (samples were not evaluated withTIF)

Leishmania infection tests T cruzi infection testsSmear ELISAg LST ELISA Rec IHA TIF PCR

Patient codeHI 54 + + + + + + minus

HI 55 + + + minus + nd +HI 58 + + + + + nd +

Table 3 Crude OR and adjusted OR for the factors associated withthe presence of tegumentary leishmaniasis OR Odds Ratio CIConfidence Interval aSignificant association at 119901 lt 005 bhighlysignificant association at 119901 lt 001 chighly significant association at119901 lt 0001

Logistic regression OR (CI 95)univariate analysis

OR (CI 95)multivariate analysis

SexFemale 1 1Male 547 (221ndash1354)a 605 (22ndash1664)c

Age (years)gt16 1 17ndash15 437 (139ndash138)b 773 (205ndash2916)b

Exposure to vector bitesat work

Unexposed 1Exposed 268 (114ndash63)a

Permanence gt 10 hoursoutdoors (SO)

No 1 1Yes 467 (123ndash1778)a 416 (097ndash1777)a

Bathing in the riverNo 1Yes 389 (159ndash954)a

Living with infectedpeople

No 1Yes 317 (123ndash815)a

demands the involvement of different stakeholders to controlthe magnitude of disease incidence implementing preven-tion strategies and taking into account biogeographical andsociocultural characteristics as well as human-induced envi-ronmental changes and situations that pose a risk

The present work provides epidemiological informationof potential determinants of TL occurrence in HipolitoYrigoyen its magnitude and situation of T cruzi infectionin the same area This information is useful for the localhealth system because it may contribute to a better planningof the surveillance systems and to the design of preven-tion strategies in the area These epidemiological patternsof mixed infections can occur in other countries wereT cruzi transmission does not exist or was interrupted andtegumentary leishmaniasis is endemic

Competing Interests

The authors declare that they have no competing interests

Acknowledgments

The authors wish to thank Carlos Villalpando ElizabethCorro Yolanda Aban Nadia Gonzalez and Norma Acostafor their support during fieldwork and the Med NicanorSosa of the Municipality of Hipolito Yrigoyen for logisticsupport during permanence in the study areaThis study wassupported by the Consejo de Investigacion de la UniversidadNacional de Salta (CIUNSa) the PICT 2013-3213 PICT 2014-1579 and Fundacion Mundo Sano

References

[1] A J Krolewiecki H D Romero S P Cajal et al ldquoA randomizedclinical trial comparing oral azithromycin andmeglumine anti-moniate for the treatment of American cutaneous leishmaniasiscaused by Leishmania (Viannia) braziliensisrdquo The AmericanJournal of TropicalMedicine andHygiene vol 77 no 4 pp 640ndash646 2007

[2] F M Frank M M Fernandez N J Taranto et al ldquoChar-acterization of human infection by Leishmania spp in theNorthwest of Argentina immune response double infectionwith Trypanosoma cruzi and species of Leishmania involvedsrdquoParasitology vol 126 no 1 pp 31ndash39 2003

[3] J D Marco P A Barroso T Mimori et al ldquoPolymorphism-specific PCR enhances the diagnostic performance of Americantegumentary leishmaniasis and allows the rapid identification ofLeishmania species from Argentinardquo BMC Infectious Diseasesvol 12 article 191 2012

[4] F M Locatelli S P Cajal P A Barroso et al ldquoThe isola-tion and molecular characterization of Leishmania spp frompatients with American tegumentary leishmaniasis in north-west Argentinardquo Acta Tropica vol 131 no 1 pp 16ndash21 2014

[5] A J Krolewiecki J F Gil M Quipildor et al ldquoRestricted out-break of American tegumentary leishmaniasis with highmicro-focal transmissionrdquo American Journal of Tropical Medicine andHygiene vol 88 no 3 pp 578ndash582 2013

[6] O D Salomon M L Wilson L E Munstermann and B LTravi ldquoSpatial and temporal patterns of phlebotomine sand flies(Diptera Psychodidae) in a cutaneous leishmaniasis focus innorthern Argentinardquo Journal of Medical Entomology vol 41 no1 pp 33ndash39 2004

[7] D de Pita-Pereira C R Alves M B Souza et al ldquoIdentificationof naturally infected Lutzomyia intermedia and Lutzomyiamigoneiwith Leishmania (Viannia) braziliensis in Rio de Janeiro

BioMed Research International 7

(Brazil) revealed by a PCRmultiplex non-isotopic hybridisationassayrdquo Transactions of the Royal Society of Tropical Medicine andHygiene vol 99 no 12 pp 905ndash913 2005

[8] E Cordoba-Lanus M L De Grosso J E Pinero B Valladaresand O D Salomon ldquoNatural infection of Lutzomyia neivaiwithLeishmania spp in northwestern Argentinardquo Acta Tropica vol98 no 1 pp 1ndash5 2006

[9] O D Salomon P W Orellano M G Quintana et al ldquoTrans-mission of tegumentary leishmaniasis in ArgentinardquoMedicinavol 66 no 3 pp 211ndash219 2006

[10] J F Gil J R Nasser S P Cajal et al ldquoUrban transmission ofamerican cutaneous leishmaniasis in Argentina spatial analysisstudyrdquoThe American Journal of Tropical Medicine and Hygienevol 82 no 3 pp 433ndash440 2010

[11] O D Salomon J R Rosa M Stein et al ldquoPhlebotominae(Diptera Psycodidae) fauna in theChaco region andCutaneousLeishmaniasis transmission patterns in Argentinardquo Memoriasdo Instituto Oswaldo Cruz vol 103 no 6 pp 578ndash584 2008

[12] World Health Organization ldquoResearch priorities for chagasdisease human african trypanosomiasis and leishmaniasisrdquoWHOTechnical Report Series 975WorldHealthOrganizationGeneva Switzerland 2013

[13] J C P Dias ldquoHuman chagas disease and migration in thecontext of globalization some particular aspectsrdquo Journal ofTropical Medicine vol 2013 Article ID 789758 9 pages 2013

[14] M G Chiaramonte F M Frank G M Furer N J TarantoR A Margni and E L Malchiodi ldquoPolymerase chain reactionreveals Trypanosoma cruzi infection suspected by serology incutaneous and mucocutaneous leishmaniasis patientsrdquo ActaTropica vol 72 no 3 pp 295ndash308 1999

[15] J F Gil C L Hoyos R O Cimino et al ldquoRole of threeELISA tests using promastigote homogenates of Leishmaniabraziliensis L amazonensis and L guyanensis in the diagnosisof tegumentary leishmaniasisrdquoMedicina vol 71 no 5 pp 420ndash428 2011

[16] A F Vega Benedetti R O Cimino P S Cajal et al ldquoPerfor-mance of different Trypanosoma cruzi antigens in the diag-nosis of Chagas disease in patients with American cutaneousleishmaniasis from a co-endemic region in Argentinardquo TropicalMedicine amp International Health vol 18 no 9 pp 1103ndash11092013

[17] J F Gil R O Cimino I Lopez Quiroga et al ldquoReactivityof GST-SAPA antigen of Trypanosoma cruzi against sera frompatients with Chagas disease and leishmaniasisrdquoMedicina vol71 no 2 pp 113ndash119 2011

[18] S D Lawn M Armstrong D Chilton and C J MWhitty ldquoElectrocardiographic and biochemical adverse effectsof sodium stibogluconate during treatment of cutaneous andmucosal leishmaniasis among returned travellersrdquo Transactionsof the Royal Society of Tropical Medicine and Hygiene vol 100no 3 pp 264ndash269 2006

[19] L F Oliveira A O Schubach M M Martins et al ldquoSystematicreview of the adverse effects of cutaneous leishmaniasis treat-ment in the NewWorldrdquo Acta Tropica vol 118 no 2 pp 87ndash962011

[20] L F Gamboa Latorre and J A Becerra Mateus ldquoCardiotoxici-dad por antimonialesrdquo Revista Salud Bosque vol 2 no 2 pp69ndash74 2012

[21] L H Malik G D Singh and E A Amsterdam ldquoThe epidemi-ology clinical manifestations and management of chagas heartdiseaserdquo Clinical Cardiology vol 38 no 9 pp 565ndash569 2015

[22] S Sosa-Estani E L Segura A Gomez et al ldquoCutaneousleishmaniasis in Northern Argentina identification of riskfactors in a case-cohort study of three municipalities in SaltardquoRevista da Sociedade Brasileira deMedicina Tropical vol 34 no6 pp 511ndash517 2001

[23] Z E Yadon L C Rodrigues C R Davies and M A QuigleyldquoIndoor and peridomestic transmission of American cutaneousleishmaniasis in northwestern Argentina a retrospective case-control studyrdquo American Journal of Tropical Medicine andHygiene vol 68 no 5 pp 519ndash526 2003

[24] F D A Pedrosa and R A D A Ximenes ldquoSociodemographicand environmental risk factors for American cutaneous leish-maniasis (ACL) in the State of Alagoas Brazilrdquo AmericanJournal of Tropical Medicine and Hygiene vol 81 no 2 pp 195ndash201 2009

[25] J M Lauritsen and M Bruus EpiData Entry Version 31 AComprehensive Tool for Validated Entry and Documentation ofData The EpiData Association Odense Denmark 2005

[26] M Alvarez J A Cerisola and R W Rohwedder ldquoImmunoflu-orescence test in the diagnosis of Chagasrsquo diseasesrdquo BoletınChileno de Parasitologıa vol 23 no 1 pp 4ndash8 1968

[27] C Britto M A Cardoso C M Monteiro Vanni et alldquoPolymerase chain reaction detection of Trypanosoma cruzi inhuman blood samples as a tool for diagnosis and treatmentevaluationrdquo Parasitology vol 110 no 3 pp 241ndash247 1995

[28] Z C Caballero O E Sousa W P Marques A Saez-Alquezarand E S Umezawa ldquoEvaluation of serological tests to identifyTrypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spprdquoClinical and Vaccine Immunology vol 14 no 8 pp 1045ndash10492007

[29] S Domınguez-Almendros N Benıtez-Parejo and A RGonzalez-Ramirez ldquoLogistic regressionmodelsrdquoAllergologia etImmunopathologia vol 39 no 5 pp 295ndash305 2011

[30] V ChongsuvivatwongAnalysis of Epidemiological Data Using Rand Epicalc Epidemiology Unit Prince of Songkla UniversitySongkhla Thailand 2008

[31] M M Rodrıguez del Aguila and N Benıtez-Parejo ldquoSimplelinear and multivariate regression modelsrdquo Allergologia etImmunopathologia vol 39 no 3 pp 159ndash173 2011

[32] R Core Team ldquoR A language and environment for statisticalcomputingrdquo 2012 R Foundation for Statistical ComputingVienna Austria httpwwwR-projectorg

[33] S Sosa-Estani E L Segura O D Salomon et al ldquoTegumentaryleishmaniasis in Northern Argentina distribution of infectionand disease in three municipalities of Salta 1990ndash1992rdquo Revistada Sociedade Brasileira de Medicina Tropical vol 33 no 6 pp573ndash582 2000

[34] O D Salomon S S Estani L Canini and E C LanusldquoTegumentary leishmaniasis in an area with epidemic levels oftransmission Salta Argentina 1998rdquoMedicina B Aires vol 61no 3 pp 284ndash290 2001

[35] M M Chanampa Monitoring sandflies of Lutzomyia genusand associated environmental variables in the town of HipolitoYrigoyen [MS Biologist thesis] Biology School Facultad deCiencias Naturales de la Universidad Nacional de Salta SaltaArgentina 2012

[36] M G Quintana O D Salomon and M S De Grosso ldquoDis-tribution of phlebotomine sand flies (Diptera Psychodidae) ina primary forest-crop interface Salta Argentinardquo Journal ofMedical Entomology vol 47 pp 1003ndash1010 2010

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

BioMed Research International 3

Hipoacutelito Yrigoyen locality

(a)

Households sampledIrrigation channel

0 05 1025(km)

N

(b)

Figure 1 (a) HYwithin Argentina (b)The black dots indicate householdsrsquo distribution where the sampling was conducted in theHY locality

The people included in each study group mentionedabove were defined according to the diagnostic criteriadescribed below

23 Diagnostic Procedures The patients were evaluated inthe field by the personnel at Instituto de Investigaciones enEnfermedades Tropicales (IIET) at Universidad Nacional deSalta the SanVicente de PaulHospital inOran andEvaPeronHospital in Hipolito Yrigoyen

The sera and blood samples collected in the field weretransported to the IIET for processing The parasitologicaldiagnostic of Leishmania was made in the IIET and thepatients were derived from Hipolito Yrigoyen Hospital Bothdiagnostic procedures such as serological parasitologicaland molecular techniques were performed following theprotocols established in previous studiesThe commercial kitswere applied according to manufacturerrsquos instructions

24 Diagnostic Criteria Diagnostic criteria included the fol-lowing

241 Leishmaniasis Cases Included were individuals whohad lesions clinically compatible with TL and visualizationof amastigotes of Leishmania sp in Giemsa-stained smearsandor positive reaction of serum samples by enzyme-linkedimmunosorbent assay (ELISAg) homogenate protein of L (V)guyanensis [15] andor positive reaction to leishmanin skintest [4 5]

242T cruzi Infection The subjectswere considered infectedwith T cruzi when serum samples by ELISA and Indirecthemagglutination (IHA) tests (Wiener Lab Argentina) werereactive The samples with discordant results between ELISAand IHA were examined by recombinant ELISA 30 (WienerLab Argentina) and Immunofluorescence test [26] or Poly-merase Chain Reaction (PCR) [27] The recombinant ELISA30was reported as specific test forT cruzi infection detectionwithout cross-reaction with Leishmania [17 28]

243 Mixed Infections Included were patients with TL andpositive results for at least two tests for T cruzi infectionmentioned above

244 Controls in Case-Control Study Included were individ-uals living in Hipolito Yrigoyen who were not grouped asleishmaniasis cases andor T cruzi infected

25 Data Analysis The prevalence of Leishmania sp sero-prevalence of T cruzi infections and mixed infection pro-portion with 95 Confidence Intervals (CI) were calculatedusing the EPIDAT software version 31

In the case-control study the independent continuousand discreet variables were respectively categorized ordichotomized Univariate andmultivariate logistic regression(LR) analysis were carried out The Odds Ratios (OR) and95 CI were calculated to assess the link between the TLcases and potential risk factors The variables with OR gt 1

4 BioMed Research International

Patients with active lesionfor leishmaniasis (n = 18)clinical form + smear + LST(2009)

Population size of HipoacutelitoYrigoyen locality Data of

Primary Health Care (2009)

100 people withoutleishmania clinical form +13 leishmaniasic patientswith sera and bloodsample n = 113 year 2009

Patients with leishmaniasis(n = 33)Clinical form + smear + LST(2001ndash2009)

Controls (n = 88)Excluding the people withT cruzi infection

Leishmaniasis prevalence(LP) year 2009 (1)

Mixed infectionsLeishmania sp and T cruziwithin the leishmaniasicpatients (2009)

Diagnosis ofT cruzi infection

Estimation ofseroprevalence of T cruziinfection (TCSP)(2009) (2)

Case-control study

Figure 2 Flow chart showing the groups of patients and noninfected people included in prevalence (LP) and case-control study ofleishmaniasis and T cruzi seroprevalence (TCSP) infection Mixed infections detected (T cruzi-Leishmania) from 13 patients with activeleishmaniasis ulcer in 2009 are also shown Diagnostic of T cruzi infection applied to the 100 people to detect both seropositive people tocalculate T cruzi seroprevalence and select the negative control people for the case-control study People positive for ELISA-leishmaniasis orleishmanin skin test (LST) may have been exposed to the Leishmania parasite The cross-reaction of both ELISA and leishmanin skin testwith chagasic infection does not distinguish whether the person was exposed to Leishmania parasite or is infected with T cruzi Due to thisthe people positive for Chagas lab tests were not included as controls in the case-control study

and 119901 lt 005 in univariate logistic regression analysis weretested in amultivariate analysis to establish amodel involvingthe least number of variables that best explains the dependentvariable (TL cases)

The final model was obtained using the stepwise tech-nique a procedure that combines forward method (it startsfrom amodel only with the constant or independent variablefollowed by progressive introduction of variables in the equa-tion provided they are significant) and backward method(all the variables are initially considered in the model andthose lacking significance are then progressively eliminated)[29] The Akaike Information Criterion (AIC) was used asselection criterion AIC calculation is based onminimizationof the loss of information function penalizing for the numberof variables introduced that seeks the model that best adjuststo the data with the minimum number of possible variablesthus producing simpler models [30 31] The model thathas been chosen minimizes the AIC Data were consideredstatistically significant if 119901 lt 005 All statistical analysis forcase-control study was performed using R software version2152 [32]

26 Ethical Approval All the people included in the studyagreed to participate by signing an informed consent form(ICF) The project and ICF were approved by the EthicsCommittee of the School of Health Sciences at the NationalUniversity of Salta and the ldquoFundacion Huespedrdquo

3 Results

In 2009 only 18 cases of TL were diagnosed in HipolitoYrigoyen which represented a TL prevalence of 017 (CI009ndash026) The age range of study patients was 7ndash69 yearswith an average of 3545 plusmn 1669 (SD)

Of the 113 samples analyzed to detectT cruzi infection 67(59) corresponded to females and 46 (41) to males Theirage ranged between 7 and 74 with an average of 375 plusmn 173(SD) years There was no statistically significant differencein prevalence between males and females (119901 = 073) Theseroprevalence for this infection was 973 (CI 383ndash1564)in 2009The frequencies of cases according to age and sex aresummarized in Table 1

BioMed Research International 5

Table 1 Number of individuals included in the study percentage() of individuals infected with T cruzi according to sex and agegroup aIndication of the overall prevalence in Hipolito Yrigoyen for2009 119894 infected individuals according to sex and age 119899 total samplein seroprevalence of T cruzi study

Sex Female119894119899 ()

Male119894119899 ()

Total infected 567 (7) 646 (13)Age 119899 Infected ()10ndash35 62 4 (645)36ndash55 28 3 (107)gt55 23 4 (104)Total 113 11 (973)a

Positive results were obtained for T cruzi infection inthree patients with TL in 2009 (Table 2) which represents amixed infection proportion of 1667 CI (358ndash4142) withinthe group of 18 patients with TL

The samples for the case-control study included 33 casesof TL (18 actives cases in 2009 and 15 cases registered in the2001ndash2008 period) and 88 controls (Figure 2) The controlgroup consisted of individuals without positive diagnosis forleishmaniasis andChagas diseases according to criteria abovedescribed

The variables that showed significant association (119901 lt005) with the presence of TL (case) in univariate LR analysiswere sex age exposure to vector bites at work stayingoutdoors for more than 10 h (so) bathing in the river andliving with people who were infected or had lesions duringthe study period (Table 3) These variables were includedin a multivariate logistic regression analysis and final modelobtained using the stepwise method This model includesonly 3 predictive variables (sex age and so) that explainedthe occurrence of TL cases (Table 3)The AIC value was 1222

The selected model 119862119860119878119864 = minus282 + 180 lowast 119878119864119883 +204 lowast 119860119866119864 + 142 lowast 119878119874

4 Discussion

In the north of Salta province TL levels are hyperendemic insome sites and periods [33 34] This situation is worsened bythe presence of cases of Chagas disease which may furthergenerate cases of mixed infections causing a synergisticproblem for the health care system In the locality HipolitoYrigoyen TL prevalence values of 017 079 and 018 werepreviously reported [33 34]The prevalence calculated in thepresent study (017 CI 008ndash026) is similar which indicatesa level of active transmission that persists over timeHoweverhigh incidence foci are likely to occur in short exposureperiods in this area [5]

In the case-control study the associated variables wouldbe reflecting the existence of a complex pattern of trans-mission Male sex and staying outdoors for more than 10hours would be indicators of a sylvatic mode of transmissionfacilitated by labour subsistence or recreational activities (in

rural environments andor deforestation areas or huntingand fishing activities) as it is indicated in regions where TLis endemic [9 24 33] The significantly higher proportion ofinfected children compared to that of adults found in thisanalysis (OR = 773 CI 205ndash2916) suggests the existenceof other patterns of transmission in Hipolito Yrigoyen Theincidence of TL in children has been cited as an indicator ofperidomiciliary transmission especially in localities adjacentto primary andor secondary vegetation [4 22ndash24 33]

In addition a high density of sandflies has been detectedin the vegetation near to the irrigation channels located in theoutskirts of the city (Figure 1) [35] showing a species diversitysimilar to that found in a nearby place where there was a highrate of infection [5 36] Many families go to these sites forrecreational purposes in times of high temperature and riskleishmaniasis transmission (7 pm to 10 pm approximately)with the consequent risk of being bitten by infected sandfliesand contracting leishmaniasis as reported in a study of spatialdistribution of TL cases [37]

The presence of active TL cases among elderly peoplethat remain mostly in their houses and of sandflies in thecenter of the town [35] offers another plausible epidemiologicsituation of disease transmission (but with low probability)in urban environments because lower abundance of sandflieswas recorded here [35] Indeed in Hipolito Yrigoyen housecourtyards have vegetation patches that can be colonized bysandflies from the periphery according to the characteristicsof metapopulation dynamics [10]

On the other hand in the study area the possibility ofvector-borne transmission of T cruzi has been discardedbecause no insects or indicators of their presence have beenfound in the annual activities of entomological surveillanceof triatomines carried out by Primary Health Care Systemin recent and historical monitoring Thus cases of T cruziinfection in Hipolito Yrigoyen would be associated withmigratory processes (movement principally of rural pop-ulations from Argentina and Bolivia of the Gran Chacoecoregion where Chagas disease is endemic) [13]The T cruziseroprevalence found in this work is low compared with theprevalence value observed in rural populations of endemicareas (25) [38] and it is high compared with other regionswithout endemic transmission [39] In turn infected childrenmay have acquired infection by congenital transmission asreported in previous studies of this type of transmission inthe province of Salta [40]

Theproportion ofT cruzi-Leishmania spmixed infectionwithin the group of patients with TL reported in the northof Salta reaches 30 and 40 [2 14 15] and does notshow differences from the percentage obtained in this studyKnowing the level of this condition in the population allowsus to explore the factors involved in the origin and persistenceof mixed infections In addition because antimonials arecardiotoxic a careful diagnosis and implementation of alter-native treatments are needed to avoid further complications

The complex situation in Hipolito Yrigoyen in referenceto TL is aggravated by the coexistence of T cruzi infectionThe transmission pattern involves mainly natural areasbut the possibility of a peridomiciliary transmission in theoutskirts of the city cannot be ruled out This situation

6 BioMed Research International

Table 2 Results of samples with mixed infection SMEAR visualization of amastigotes of Leishmania sp in Giemsa-stained smears ELISAgELISA based on homogenate protein of L (V) guyanensis LST reaction to leishmanin skin test ELISA Rec recombinant ELISA Kit IHAindirect hemagglutination TIF test of Immunofluorescence PCR Polymerase Chain Reaction nd no data (samples were not evaluated withTIF)

Leishmania infection tests T cruzi infection testsSmear ELISAg LST ELISA Rec IHA TIF PCR

Patient codeHI 54 + + + + + + minus

HI 55 + + + minus + nd +HI 58 + + + + + nd +

Table 3 Crude OR and adjusted OR for the factors associated withthe presence of tegumentary leishmaniasis OR Odds Ratio CIConfidence Interval aSignificant association at 119901 lt 005 bhighlysignificant association at 119901 lt 001 chighly significant association at119901 lt 0001

Logistic regression OR (CI 95)univariate analysis

OR (CI 95)multivariate analysis

SexFemale 1 1Male 547 (221ndash1354)a 605 (22ndash1664)c

Age (years)gt16 1 17ndash15 437 (139ndash138)b 773 (205ndash2916)b

Exposure to vector bitesat work

Unexposed 1Exposed 268 (114ndash63)a

Permanence gt 10 hoursoutdoors (SO)

No 1 1Yes 467 (123ndash1778)a 416 (097ndash1777)a

Bathing in the riverNo 1Yes 389 (159ndash954)a

Living with infectedpeople

No 1Yes 317 (123ndash815)a

demands the involvement of different stakeholders to controlthe magnitude of disease incidence implementing preven-tion strategies and taking into account biogeographical andsociocultural characteristics as well as human-induced envi-ronmental changes and situations that pose a risk

The present work provides epidemiological informationof potential determinants of TL occurrence in HipolitoYrigoyen its magnitude and situation of T cruzi infectionin the same area This information is useful for the localhealth system because it may contribute to a better planningof the surveillance systems and to the design of preven-tion strategies in the area These epidemiological patternsof mixed infections can occur in other countries wereT cruzi transmission does not exist or was interrupted andtegumentary leishmaniasis is endemic

Competing Interests

The authors declare that they have no competing interests

Acknowledgments

The authors wish to thank Carlos Villalpando ElizabethCorro Yolanda Aban Nadia Gonzalez and Norma Acostafor their support during fieldwork and the Med NicanorSosa of the Municipality of Hipolito Yrigoyen for logisticsupport during permanence in the study areaThis study wassupported by the Consejo de Investigacion de la UniversidadNacional de Salta (CIUNSa) the PICT 2013-3213 PICT 2014-1579 and Fundacion Mundo Sano

References

[1] A J Krolewiecki H D Romero S P Cajal et al ldquoA randomizedclinical trial comparing oral azithromycin andmeglumine anti-moniate for the treatment of American cutaneous leishmaniasiscaused by Leishmania (Viannia) braziliensisrdquo The AmericanJournal of TropicalMedicine andHygiene vol 77 no 4 pp 640ndash646 2007

[2] F M Frank M M Fernandez N J Taranto et al ldquoChar-acterization of human infection by Leishmania spp in theNorthwest of Argentina immune response double infectionwith Trypanosoma cruzi and species of Leishmania involvedsrdquoParasitology vol 126 no 1 pp 31ndash39 2003

[3] J D Marco P A Barroso T Mimori et al ldquoPolymorphism-specific PCR enhances the diagnostic performance of Americantegumentary leishmaniasis and allows the rapid identification ofLeishmania species from Argentinardquo BMC Infectious Diseasesvol 12 article 191 2012

[4] F M Locatelli S P Cajal P A Barroso et al ldquoThe isola-tion and molecular characterization of Leishmania spp frompatients with American tegumentary leishmaniasis in north-west Argentinardquo Acta Tropica vol 131 no 1 pp 16ndash21 2014

[5] A J Krolewiecki J F Gil M Quipildor et al ldquoRestricted out-break of American tegumentary leishmaniasis with highmicro-focal transmissionrdquo American Journal of Tropical Medicine andHygiene vol 88 no 3 pp 578ndash582 2013

[6] O D Salomon M L Wilson L E Munstermann and B LTravi ldquoSpatial and temporal patterns of phlebotomine sand flies(Diptera Psychodidae) in a cutaneous leishmaniasis focus innorthern Argentinardquo Journal of Medical Entomology vol 41 no1 pp 33ndash39 2004

[7] D de Pita-Pereira C R Alves M B Souza et al ldquoIdentificationof naturally infected Lutzomyia intermedia and Lutzomyiamigoneiwith Leishmania (Viannia) braziliensis in Rio de Janeiro

BioMed Research International 7

(Brazil) revealed by a PCRmultiplex non-isotopic hybridisationassayrdquo Transactions of the Royal Society of Tropical Medicine andHygiene vol 99 no 12 pp 905ndash913 2005

[8] E Cordoba-Lanus M L De Grosso J E Pinero B Valladaresand O D Salomon ldquoNatural infection of Lutzomyia neivaiwithLeishmania spp in northwestern Argentinardquo Acta Tropica vol98 no 1 pp 1ndash5 2006

[9] O D Salomon P W Orellano M G Quintana et al ldquoTrans-mission of tegumentary leishmaniasis in ArgentinardquoMedicinavol 66 no 3 pp 211ndash219 2006

[10] J F Gil J R Nasser S P Cajal et al ldquoUrban transmission ofamerican cutaneous leishmaniasis in Argentina spatial analysisstudyrdquoThe American Journal of Tropical Medicine and Hygienevol 82 no 3 pp 433ndash440 2010

[11] O D Salomon J R Rosa M Stein et al ldquoPhlebotominae(Diptera Psycodidae) fauna in theChaco region andCutaneousLeishmaniasis transmission patterns in Argentinardquo Memoriasdo Instituto Oswaldo Cruz vol 103 no 6 pp 578ndash584 2008

[12] World Health Organization ldquoResearch priorities for chagasdisease human african trypanosomiasis and leishmaniasisrdquoWHOTechnical Report Series 975WorldHealthOrganizationGeneva Switzerland 2013

[13] J C P Dias ldquoHuman chagas disease and migration in thecontext of globalization some particular aspectsrdquo Journal ofTropical Medicine vol 2013 Article ID 789758 9 pages 2013

[14] M G Chiaramonte F M Frank G M Furer N J TarantoR A Margni and E L Malchiodi ldquoPolymerase chain reactionreveals Trypanosoma cruzi infection suspected by serology incutaneous and mucocutaneous leishmaniasis patientsrdquo ActaTropica vol 72 no 3 pp 295ndash308 1999

[15] J F Gil C L Hoyos R O Cimino et al ldquoRole of threeELISA tests using promastigote homogenates of Leishmaniabraziliensis L amazonensis and L guyanensis in the diagnosisof tegumentary leishmaniasisrdquoMedicina vol 71 no 5 pp 420ndash428 2011

[16] A F Vega Benedetti R O Cimino P S Cajal et al ldquoPerfor-mance of different Trypanosoma cruzi antigens in the diag-nosis of Chagas disease in patients with American cutaneousleishmaniasis from a co-endemic region in Argentinardquo TropicalMedicine amp International Health vol 18 no 9 pp 1103ndash11092013

[17] J F Gil R O Cimino I Lopez Quiroga et al ldquoReactivityof GST-SAPA antigen of Trypanosoma cruzi against sera frompatients with Chagas disease and leishmaniasisrdquoMedicina vol71 no 2 pp 113ndash119 2011

[18] S D Lawn M Armstrong D Chilton and C J MWhitty ldquoElectrocardiographic and biochemical adverse effectsof sodium stibogluconate during treatment of cutaneous andmucosal leishmaniasis among returned travellersrdquo Transactionsof the Royal Society of Tropical Medicine and Hygiene vol 100no 3 pp 264ndash269 2006

[19] L F Oliveira A O Schubach M M Martins et al ldquoSystematicreview of the adverse effects of cutaneous leishmaniasis treat-ment in the NewWorldrdquo Acta Tropica vol 118 no 2 pp 87ndash962011

[20] L F Gamboa Latorre and J A Becerra Mateus ldquoCardiotoxici-dad por antimonialesrdquo Revista Salud Bosque vol 2 no 2 pp69ndash74 2012

[21] L H Malik G D Singh and E A Amsterdam ldquoThe epidemi-ology clinical manifestations and management of chagas heartdiseaserdquo Clinical Cardiology vol 38 no 9 pp 565ndash569 2015

[22] S Sosa-Estani E L Segura A Gomez et al ldquoCutaneousleishmaniasis in Northern Argentina identification of riskfactors in a case-cohort study of three municipalities in SaltardquoRevista da Sociedade Brasileira deMedicina Tropical vol 34 no6 pp 511ndash517 2001

[23] Z E Yadon L C Rodrigues C R Davies and M A QuigleyldquoIndoor and peridomestic transmission of American cutaneousleishmaniasis in northwestern Argentina a retrospective case-control studyrdquo American Journal of Tropical Medicine andHygiene vol 68 no 5 pp 519ndash526 2003

[24] F D A Pedrosa and R A D A Ximenes ldquoSociodemographicand environmental risk factors for American cutaneous leish-maniasis (ACL) in the State of Alagoas Brazilrdquo AmericanJournal of Tropical Medicine and Hygiene vol 81 no 2 pp 195ndash201 2009

[25] J M Lauritsen and M Bruus EpiData Entry Version 31 AComprehensive Tool for Validated Entry and Documentation ofData The EpiData Association Odense Denmark 2005

[26] M Alvarez J A Cerisola and R W Rohwedder ldquoImmunoflu-orescence test in the diagnosis of Chagasrsquo diseasesrdquo BoletınChileno de Parasitologıa vol 23 no 1 pp 4ndash8 1968

[27] C Britto M A Cardoso C M Monteiro Vanni et alldquoPolymerase chain reaction detection of Trypanosoma cruzi inhuman blood samples as a tool for diagnosis and treatmentevaluationrdquo Parasitology vol 110 no 3 pp 241ndash247 1995

[28] Z C Caballero O E Sousa W P Marques A Saez-Alquezarand E S Umezawa ldquoEvaluation of serological tests to identifyTrypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spprdquoClinical and Vaccine Immunology vol 14 no 8 pp 1045ndash10492007

[29] S Domınguez-Almendros N Benıtez-Parejo and A RGonzalez-Ramirez ldquoLogistic regressionmodelsrdquoAllergologia etImmunopathologia vol 39 no 5 pp 295ndash305 2011

[30] V ChongsuvivatwongAnalysis of Epidemiological Data Using Rand Epicalc Epidemiology Unit Prince of Songkla UniversitySongkhla Thailand 2008

[31] M M Rodrıguez del Aguila and N Benıtez-Parejo ldquoSimplelinear and multivariate regression modelsrdquo Allergologia etImmunopathologia vol 39 no 3 pp 159ndash173 2011

[32] R Core Team ldquoR A language and environment for statisticalcomputingrdquo 2012 R Foundation for Statistical ComputingVienna Austria httpwwwR-projectorg

[33] S Sosa-Estani E L Segura O D Salomon et al ldquoTegumentaryleishmaniasis in Northern Argentina distribution of infectionand disease in three municipalities of Salta 1990ndash1992rdquo Revistada Sociedade Brasileira de Medicina Tropical vol 33 no 6 pp573ndash582 2000

[34] O D Salomon S S Estani L Canini and E C LanusldquoTegumentary leishmaniasis in an area with epidemic levels oftransmission Salta Argentina 1998rdquoMedicina B Aires vol 61no 3 pp 284ndash290 2001

[35] M M Chanampa Monitoring sandflies of Lutzomyia genusand associated environmental variables in the town of HipolitoYrigoyen [MS Biologist thesis] Biology School Facultad deCiencias Naturales de la Universidad Nacional de Salta SaltaArgentina 2012

[36] M G Quintana O D Salomon and M S De Grosso ldquoDis-tribution of phlebotomine sand flies (Diptera Psychodidae) ina primary forest-crop interface Salta Argentinardquo Journal ofMedical Entomology vol 47 pp 1003ndash1010 2010

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

4 BioMed Research International

Patients with active lesionfor leishmaniasis (n = 18)clinical form + smear + LST(2009)

Population size of HipoacutelitoYrigoyen locality Data of

Primary Health Care (2009)

100 people withoutleishmania clinical form +13 leishmaniasic patientswith sera and bloodsample n = 113 year 2009

Patients with leishmaniasis(n = 33)Clinical form + smear + LST(2001ndash2009)

Controls (n = 88)Excluding the people withT cruzi infection

Leishmaniasis prevalence(LP) year 2009 (1)

Mixed infectionsLeishmania sp and T cruziwithin the leishmaniasicpatients (2009)

Diagnosis ofT cruzi infection

Estimation ofseroprevalence of T cruziinfection (TCSP)(2009) (2)

Case-control study

Figure 2 Flow chart showing the groups of patients and noninfected people included in prevalence (LP) and case-control study ofleishmaniasis and T cruzi seroprevalence (TCSP) infection Mixed infections detected (T cruzi-Leishmania) from 13 patients with activeleishmaniasis ulcer in 2009 are also shown Diagnostic of T cruzi infection applied to the 100 people to detect both seropositive people tocalculate T cruzi seroprevalence and select the negative control people for the case-control study People positive for ELISA-leishmaniasis orleishmanin skin test (LST) may have been exposed to the Leishmania parasite The cross-reaction of both ELISA and leishmanin skin testwith chagasic infection does not distinguish whether the person was exposed to Leishmania parasite or is infected with T cruzi Due to thisthe people positive for Chagas lab tests were not included as controls in the case-control study

and 119901 lt 005 in univariate logistic regression analysis weretested in amultivariate analysis to establish amodel involvingthe least number of variables that best explains the dependentvariable (TL cases)

The final model was obtained using the stepwise tech-nique a procedure that combines forward method (it startsfrom amodel only with the constant or independent variablefollowed by progressive introduction of variables in the equa-tion provided they are significant) and backward method(all the variables are initially considered in the model andthose lacking significance are then progressively eliminated)[29] The Akaike Information Criterion (AIC) was used asselection criterion AIC calculation is based onminimizationof the loss of information function penalizing for the numberof variables introduced that seeks the model that best adjuststo the data with the minimum number of possible variablesthus producing simpler models [30 31] The model thathas been chosen minimizes the AIC Data were consideredstatistically significant if 119901 lt 005 All statistical analysis forcase-control study was performed using R software version2152 [32]

26 Ethical Approval All the people included in the studyagreed to participate by signing an informed consent form(ICF) The project and ICF were approved by the EthicsCommittee of the School of Health Sciences at the NationalUniversity of Salta and the ldquoFundacion Huespedrdquo

3 Results

In 2009 only 18 cases of TL were diagnosed in HipolitoYrigoyen which represented a TL prevalence of 017 (CI009ndash026) The age range of study patients was 7ndash69 yearswith an average of 3545 plusmn 1669 (SD)

Of the 113 samples analyzed to detectT cruzi infection 67(59) corresponded to females and 46 (41) to males Theirage ranged between 7 and 74 with an average of 375 plusmn 173(SD) years There was no statistically significant differencein prevalence between males and females (119901 = 073) Theseroprevalence for this infection was 973 (CI 383ndash1564)in 2009The frequencies of cases according to age and sex aresummarized in Table 1

BioMed Research International 5

Table 1 Number of individuals included in the study percentage() of individuals infected with T cruzi according to sex and agegroup aIndication of the overall prevalence in Hipolito Yrigoyen for2009 119894 infected individuals according to sex and age 119899 total samplein seroprevalence of T cruzi study

Sex Female119894119899 ()

Male119894119899 ()

Total infected 567 (7) 646 (13)Age 119899 Infected ()10ndash35 62 4 (645)36ndash55 28 3 (107)gt55 23 4 (104)Total 113 11 (973)a

Positive results were obtained for T cruzi infection inthree patients with TL in 2009 (Table 2) which represents amixed infection proportion of 1667 CI (358ndash4142) withinthe group of 18 patients with TL

The samples for the case-control study included 33 casesof TL (18 actives cases in 2009 and 15 cases registered in the2001ndash2008 period) and 88 controls (Figure 2) The controlgroup consisted of individuals without positive diagnosis forleishmaniasis andChagas diseases according to criteria abovedescribed

The variables that showed significant association (119901 lt005) with the presence of TL (case) in univariate LR analysiswere sex age exposure to vector bites at work stayingoutdoors for more than 10 h (so) bathing in the river andliving with people who were infected or had lesions duringthe study period (Table 3) These variables were includedin a multivariate logistic regression analysis and final modelobtained using the stepwise method This model includesonly 3 predictive variables (sex age and so) that explainedthe occurrence of TL cases (Table 3)The AIC value was 1222

The selected model 119862119860119878119864 = minus282 + 180 lowast 119878119864119883 +204 lowast 119860119866119864 + 142 lowast 119878119874

4 Discussion

In the north of Salta province TL levels are hyperendemic insome sites and periods [33 34] This situation is worsened bythe presence of cases of Chagas disease which may furthergenerate cases of mixed infections causing a synergisticproblem for the health care system In the locality HipolitoYrigoyen TL prevalence values of 017 079 and 018 werepreviously reported [33 34]The prevalence calculated in thepresent study (017 CI 008ndash026) is similar which indicatesa level of active transmission that persists over timeHoweverhigh incidence foci are likely to occur in short exposureperiods in this area [5]

In the case-control study the associated variables wouldbe reflecting the existence of a complex pattern of trans-mission Male sex and staying outdoors for more than 10hours would be indicators of a sylvatic mode of transmissionfacilitated by labour subsistence or recreational activities (in

rural environments andor deforestation areas or huntingand fishing activities) as it is indicated in regions where TLis endemic [9 24 33] The significantly higher proportion ofinfected children compared to that of adults found in thisanalysis (OR = 773 CI 205ndash2916) suggests the existenceof other patterns of transmission in Hipolito Yrigoyen Theincidence of TL in children has been cited as an indicator ofperidomiciliary transmission especially in localities adjacentto primary andor secondary vegetation [4 22ndash24 33]

In addition a high density of sandflies has been detectedin the vegetation near to the irrigation channels located in theoutskirts of the city (Figure 1) [35] showing a species diversitysimilar to that found in a nearby place where there was a highrate of infection [5 36] Many families go to these sites forrecreational purposes in times of high temperature and riskleishmaniasis transmission (7 pm to 10 pm approximately)with the consequent risk of being bitten by infected sandfliesand contracting leishmaniasis as reported in a study of spatialdistribution of TL cases [37]

The presence of active TL cases among elderly peoplethat remain mostly in their houses and of sandflies in thecenter of the town [35] offers another plausible epidemiologicsituation of disease transmission (but with low probability)in urban environments because lower abundance of sandflieswas recorded here [35] Indeed in Hipolito Yrigoyen housecourtyards have vegetation patches that can be colonized bysandflies from the periphery according to the characteristicsof metapopulation dynamics [10]

On the other hand in the study area the possibility ofvector-borne transmission of T cruzi has been discardedbecause no insects or indicators of their presence have beenfound in the annual activities of entomological surveillanceof triatomines carried out by Primary Health Care Systemin recent and historical monitoring Thus cases of T cruziinfection in Hipolito Yrigoyen would be associated withmigratory processes (movement principally of rural pop-ulations from Argentina and Bolivia of the Gran Chacoecoregion where Chagas disease is endemic) [13]The T cruziseroprevalence found in this work is low compared with theprevalence value observed in rural populations of endemicareas (25) [38] and it is high compared with other regionswithout endemic transmission [39] In turn infected childrenmay have acquired infection by congenital transmission asreported in previous studies of this type of transmission inthe province of Salta [40]

Theproportion ofT cruzi-Leishmania spmixed infectionwithin the group of patients with TL reported in the northof Salta reaches 30 and 40 [2 14 15] and does notshow differences from the percentage obtained in this studyKnowing the level of this condition in the population allowsus to explore the factors involved in the origin and persistenceof mixed infections In addition because antimonials arecardiotoxic a careful diagnosis and implementation of alter-native treatments are needed to avoid further complications

The complex situation in Hipolito Yrigoyen in referenceto TL is aggravated by the coexistence of T cruzi infectionThe transmission pattern involves mainly natural areasbut the possibility of a peridomiciliary transmission in theoutskirts of the city cannot be ruled out This situation

6 BioMed Research International

Table 2 Results of samples with mixed infection SMEAR visualization of amastigotes of Leishmania sp in Giemsa-stained smears ELISAgELISA based on homogenate protein of L (V) guyanensis LST reaction to leishmanin skin test ELISA Rec recombinant ELISA Kit IHAindirect hemagglutination TIF test of Immunofluorescence PCR Polymerase Chain Reaction nd no data (samples were not evaluated withTIF)

Leishmania infection tests T cruzi infection testsSmear ELISAg LST ELISA Rec IHA TIF PCR

Patient codeHI 54 + + + + + + minus

HI 55 + + + minus + nd +HI 58 + + + + + nd +

Table 3 Crude OR and adjusted OR for the factors associated withthe presence of tegumentary leishmaniasis OR Odds Ratio CIConfidence Interval aSignificant association at 119901 lt 005 bhighlysignificant association at 119901 lt 001 chighly significant association at119901 lt 0001

Logistic regression OR (CI 95)univariate analysis

OR (CI 95)multivariate analysis

SexFemale 1 1Male 547 (221ndash1354)a 605 (22ndash1664)c

Age (years)gt16 1 17ndash15 437 (139ndash138)b 773 (205ndash2916)b

Exposure to vector bitesat work

Unexposed 1Exposed 268 (114ndash63)a

Permanence gt 10 hoursoutdoors (SO)

No 1 1Yes 467 (123ndash1778)a 416 (097ndash1777)a

Bathing in the riverNo 1Yes 389 (159ndash954)a

Living with infectedpeople

No 1Yes 317 (123ndash815)a

demands the involvement of different stakeholders to controlthe magnitude of disease incidence implementing preven-tion strategies and taking into account biogeographical andsociocultural characteristics as well as human-induced envi-ronmental changes and situations that pose a risk

The present work provides epidemiological informationof potential determinants of TL occurrence in HipolitoYrigoyen its magnitude and situation of T cruzi infectionin the same area This information is useful for the localhealth system because it may contribute to a better planningof the surveillance systems and to the design of preven-tion strategies in the area These epidemiological patternsof mixed infections can occur in other countries wereT cruzi transmission does not exist or was interrupted andtegumentary leishmaniasis is endemic

Competing Interests

The authors declare that they have no competing interests

Acknowledgments

The authors wish to thank Carlos Villalpando ElizabethCorro Yolanda Aban Nadia Gonzalez and Norma Acostafor their support during fieldwork and the Med NicanorSosa of the Municipality of Hipolito Yrigoyen for logisticsupport during permanence in the study areaThis study wassupported by the Consejo de Investigacion de la UniversidadNacional de Salta (CIUNSa) the PICT 2013-3213 PICT 2014-1579 and Fundacion Mundo Sano

References

[1] A J Krolewiecki H D Romero S P Cajal et al ldquoA randomizedclinical trial comparing oral azithromycin andmeglumine anti-moniate for the treatment of American cutaneous leishmaniasiscaused by Leishmania (Viannia) braziliensisrdquo The AmericanJournal of TropicalMedicine andHygiene vol 77 no 4 pp 640ndash646 2007

[2] F M Frank M M Fernandez N J Taranto et al ldquoChar-acterization of human infection by Leishmania spp in theNorthwest of Argentina immune response double infectionwith Trypanosoma cruzi and species of Leishmania involvedsrdquoParasitology vol 126 no 1 pp 31ndash39 2003

[3] J D Marco P A Barroso T Mimori et al ldquoPolymorphism-specific PCR enhances the diagnostic performance of Americantegumentary leishmaniasis and allows the rapid identification ofLeishmania species from Argentinardquo BMC Infectious Diseasesvol 12 article 191 2012

[4] F M Locatelli S P Cajal P A Barroso et al ldquoThe isola-tion and molecular characterization of Leishmania spp frompatients with American tegumentary leishmaniasis in north-west Argentinardquo Acta Tropica vol 131 no 1 pp 16ndash21 2014

[5] A J Krolewiecki J F Gil M Quipildor et al ldquoRestricted out-break of American tegumentary leishmaniasis with highmicro-focal transmissionrdquo American Journal of Tropical Medicine andHygiene vol 88 no 3 pp 578ndash582 2013

[6] O D Salomon M L Wilson L E Munstermann and B LTravi ldquoSpatial and temporal patterns of phlebotomine sand flies(Diptera Psychodidae) in a cutaneous leishmaniasis focus innorthern Argentinardquo Journal of Medical Entomology vol 41 no1 pp 33ndash39 2004

[7] D de Pita-Pereira C R Alves M B Souza et al ldquoIdentificationof naturally infected Lutzomyia intermedia and Lutzomyiamigoneiwith Leishmania (Viannia) braziliensis in Rio de Janeiro

BioMed Research International 7

(Brazil) revealed by a PCRmultiplex non-isotopic hybridisationassayrdquo Transactions of the Royal Society of Tropical Medicine andHygiene vol 99 no 12 pp 905ndash913 2005

[8] E Cordoba-Lanus M L De Grosso J E Pinero B Valladaresand O D Salomon ldquoNatural infection of Lutzomyia neivaiwithLeishmania spp in northwestern Argentinardquo Acta Tropica vol98 no 1 pp 1ndash5 2006

[9] O D Salomon P W Orellano M G Quintana et al ldquoTrans-mission of tegumentary leishmaniasis in ArgentinardquoMedicinavol 66 no 3 pp 211ndash219 2006

[10] J F Gil J R Nasser S P Cajal et al ldquoUrban transmission ofamerican cutaneous leishmaniasis in Argentina spatial analysisstudyrdquoThe American Journal of Tropical Medicine and Hygienevol 82 no 3 pp 433ndash440 2010

[11] O D Salomon J R Rosa M Stein et al ldquoPhlebotominae(Diptera Psycodidae) fauna in theChaco region andCutaneousLeishmaniasis transmission patterns in Argentinardquo Memoriasdo Instituto Oswaldo Cruz vol 103 no 6 pp 578ndash584 2008

[12] World Health Organization ldquoResearch priorities for chagasdisease human african trypanosomiasis and leishmaniasisrdquoWHOTechnical Report Series 975WorldHealthOrganizationGeneva Switzerland 2013

[13] J C P Dias ldquoHuman chagas disease and migration in thecontext of globalization some particular aspectsrdquo Journal ofTropical Medicine vol 2013 Article ID 789758 9 pages 2013

[14] M G Chiaramonte F M Frank G M Furer N J TarantoR A Margni and E L Malchiodi ldquoPolymerase chain reactionreveals Trypanosoma cruzi infection suspected by serology incutaneous and mucocutaneous leishmaniasis patientsrdquo ActaTropica vol 72 no 3 pp 295ndash308 1999

[15] J F Gil C L Hoyos R O Cimino et al ldquoRole of threeELISA tests using promastigote homogenates of Leishmaniabraziliensis L amazonensis and L guyanensis in the diagnosisof tegumentary leishmaniasisrdquoMedicina vol 71 no 5 pp 420ndash428 2011

[16] A F Vega Benedetti R O Cimino P S Cajal et al ldquoPerfor-mance of different Trypanosoma cruzi antigens in the diag-nosis of Chagas disease in patients with American cutaneousleishmaniasis from a co-endemic region in Argentinardquo TropicalMedicine amp International Health vol 18 no 9 pp 1103ndash11092013

[17] J F Gil R O Cimino I Lopez Quiroga et al ldquoReactivityof GST-SAPA antigen of Trypanosoma cruzi against sera frompatients with Chagas disease and leishmaniasisrdquoMedicina vol71 no 2 pp 113ndash119 2011

[18] S D Lawn M Armstrong D Chilton and C J MWhitty ldquoElectrocardiographic and biochemical adverse effectsof sodium stibogluconate during treatment of cutaneous andmucosal leishmaniasis among returned travellersrdquo Transactionsof the Royal Society of Tropical Medicine and Hygiene vol 100no 3 pp 264ndash269 2006

[19] L F Oliveira A O Schubach M M Martins et al ldquoSystematicreview of the adverse effects of cutaneous leishmaniasis treat-ment in the NewWorldrdquo Acta Tropica vol 118 no 2 pp 87ndash962011

[20] L F Gamboa Latorre and J A Becerra Mateus ldquoCardiotoxici-dad por antimonialesrdquo Revista Salud Bosque vol 2 no 2 pp69ndash74 2012

[21] L H Malik G D Singh and E A Amsterdam ldquoThe epidemi-ology clinical manifestations and management of chagas heartdiseaserdquo Clinical Cardiology vol 38 no 9 pp 565ndash569 2015

[22] S Sosa-Estani E L Segura A Gomez et al ldquoCutaneousleishmaniasis in Northern Argentina identification of riskfactors in a case-cohort study of three municipalities in SaltardquoRevista da Sociedade Brasileira deMedicina Tropical vol 34 no6 pp 511ndash517 2001

[23] Z E Yadon L C Rodrigues C R Davies and M A QuigleyldquoIndoor and peridomestic transmission of American cutaneousleishmaniasis in northwestern Argentina a retrospective case-control studyrdquo American Journal of Tropical Medicine andHygiene vol 68 no 5 pp 519ndash526 2003

[24] F D A Pedrosa and R A D A Ximenes ldquoSociodemographicand environmental risk factors for American cutaneous leish-maniasis (ACL) in the State of Alagoas Brazilrdquo AmericanJournal of Tropical Medicine and Hygiene vol 81 no 2 pp 195ndash201 2009

[25] J M Lauritsen and M Bruus EpiData Entry Version 31 AComprehensive Tool for Validated Entry and Documentation ofData The EpiData Association Odense Denmark 2005

[26] M Alvarez J A Cerisola and R W Rohwedder ldquoImmunoflu-orescence test in the diagnosis of Chagasrsquo diseasesrdquo BoletınChileno de Parasitologıa vol 23 no 1 pp 4ndash8 1968

[27] C Britto M A Cardoso C M Monteiro Vanni et alldquoPolymerase chain reaction detection of Trypanosoma cruzi inhuman blood samples as a tool for diagnosis and treatmentevaluationrdquo Parasitology vol 110 no 3 pp 241ndash247 1995

[28] Z C Caballero O E Sousa W P Marques A Saez-Alquezarand E S Umezawa ldquoEvaluation of serological tests to identifyTrypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spprdquoClinical and Vaccine Immunology vol 14 no 8 pp 1045ndash10492007

[29] S Domınguez-Almendros N Benıtez-Parejo and A RGonzalez-Ramirez ldquoLogistic regressionmodelsrdquoAllergologia etImmunopathologia vol 39 no 5 pp 295ndash305 2011

[30] V ChongsuvivatwongAnalysis of Epidemiological Data Using Rand Epicalc Epidemiology Unit Prince of Songkla UniversitySongkhla Thailand 2008

[31] M M Rodrıguez del Aguila and N Benıtez-Parejo ldquoSimplelinear and multivariate regression modelsrdquo Allergologia etImmunopathologia vol 39 no 3 pp 159ndash173 2011

[32] R Core Team ldquoR A language and environment for statisticalcomputingrdquo 2012 R Foundation for Statistical ComputingVienna Austria httpwwwR-projectorg

[33] S Sosa-Estani E L Segura O D Salomon et al ldquoTegumentaryleishmaniasis in Northern Argentina distribution of infectionand disease in three municipalities of Salta 1990ndash1992rdquo Revistada Sociedade Brasileira de Medicina Tropical vol 33 no 6 pp573ndash582 2000

[34] O D Salomon S S Estani L Canini and E C LanusldquoTegumentary leishmaniasis in an area with epidemic levels oftransmission Salta Argentina 1998rdquoMedicina B Aires vol 61no 3 pp 284ndash290 2001

[35] M M Chanampa Monitoring sandflies of Lutzomyia genusand associated environmental variables in the town of HipolitoYrigoyen [MS Biologist thesis] Biology School Facultad deCiencias Naturales de la Universidad Nacional de Salta SaltaArgentina 2012

[36] M G Quintana O D Salomon and M S De Grosso ldquoDis-tribution of phlebotomine sand flies (Diptera Psychodidae) ina primary forest-crop interface Salta Argentinardquo Journal ofMedical Entomology vol 47 pp 1003ndash1010 2010

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

BioMed Research International 5

Table 1 Number of individuals included in the study percentage() of individuals infected with T cruzi according to sex and agegroup aIndication of the overall prevalence in Hipolito Yrigoyen for2009 119894 infected individuals according to sex and age 119899 total samplein seroprevalence of T cruzi study

Sex Female119894119899 ()

Male119894119899 ()

Total infected 567 (7) 646 (13)Age 119899 Infected ()10ndash35 62 4 (645)36ndash55 28 3 (107)gt55 23 4 (104)Total 113 11 (973)a

Positive results were obtained for T cruzi infection inthree patients with TL in 2009 (Table 2) which represents amixed infection proportion of 1667 CI (358ndash4142) withinthe group of 18 patients with TL

The samples for the case-control study included 33 casesof TL (18 actives cases in 2009 and 15 cases registered in the2001ndash2008 period) and 88 controls (Figure 2) The controlgroup consisted of individuals without positive diagnosis forleishmaniasis andChagas diseases according to criteria abovedescribed

The variables that showed significant association (119901 lt005) with the presence of TL (case) in univariate LR analysiswere sex age exposure to vector bites at work stayingoutdoors for more than 10 h (so) bathing in the river andliving with people who were infected or had lesions duringthe study period (Table 3) These variables were includedin a multivariate logistic regression analysis and final modelobtained using the stepwise method This model includesonly 3 predictive variables (sex age and so) that explainedthe occurrence of TL cases (Table 3)The AIC value was 1222

The selected model 119862119860119878119864 = minus282 + 180 lowast 119878119864119883 +204 lowast 119860119866119864 + 142 lowast 119878119874

4 Discussion

In the north of Salta province TL levels are hyperendemic insome sites and periods [33 34] This situation is worsened bythe presence of cases of Chagas disease which may furthergenerate cases of mixed infections causing a synergisticproblem for the health care system In the locality HipolitoYrigoyen TL prevalence values of 017 079 and 018 werepreviously reported [33 34]The prevalence calculated in thepresent study (017 CI 008ndash026) is similar which indicatesa level of active transmission that persists over timeHoweverhigh incidence foci are likely to occur in short exposureperiods in this area [5]

In the case-control study the associated variables wouldbe reflecting the existence of a complex pattern of trans-mission Male sex and staying outdoors for more than 10hours would be indicators of a sylvatic mode of transmissionfacilitated by labour subsistence or recreational activities (in

rural environments andor deforestation areas or huntingand fishing activities) as it is indicated in regions where TLis endemic [9 24 33] The significantly higher proportion ofinfected children compared to that of adults found in thisanalysis (OR = 773 CI 205ndash2916) suggests the existenceof other patterns of transmission in Hipolito Yrigoyen Theincidence of TL in children has been cited as an indicator ofperidomiciliary transmission especially in localities adjacentto primary andor secondary vegetation [4 22ndash24 33]

In addition a high density of sandflies has been detectedin the vegetation near to the irrigation channels located in theoutskirts of the city (Figure 1) [35] showing a species diversitysimilar to that found in a nearby place where there was a highrate of infection [5 36] Many families go to these sites forrecreational purposes in times of high temperature and riskleishmaniasis transmission (7 pm to 10 pm approximately)with the consequent risk of being bitten by infected sandfliesand contracting leishmaniasis as reported in a study of spatialdistribution of TL cases [37]

The presence of active TL cases among elderly peoplethat remain mostly in their houses and of sandflies in thecenter of the town [35] offers another plausible epidemiologicsituation of disease transmission (but with low probability)in urban environments because lower abundance of sandflieswas recorded here [35] Indeed in Hipolito Yrigoyen housecourtyards have vegetation patches that can be colonized bysandflies from the periphery according to the characteristicsof metapopulation dynamics [10]

On the other hand in the study area the possibility ofvector-borne transmission of T cruzi has been discardedbecause no insects or indicators of their presence have beenfound in the annual activities of entomological surveillanceof triatomines carried out by Primary Health Care Systemin recent and historical monitoring Thus cases of T cruziinfection in Hipolito Yrigoyen would be associated withmigratory processes (movement principally of rural pop-ulations from Argentina and Bolivia of the Gran Chacoecoregion where Chagas disease is endemic) [13]The T cruziseroprevalence found in this work is low compared with theprevalence value observed in rural populations of endemicareas (25) [38] and it is high compared with other regionswithout endemic transmission [39] In turn infected childrenmay have acquired infection by congenital transmission asreported in previous studies of this type of transmission inthe province of Salta [40]

Theproportion ofT cruzi-Leishmania spmixed infectionwithin the group of patients with TL reported in the northof Salta reaches 30 and 40 [2 14 15] and does notshow differences from the percentage obtained in this studyKnowing the level of this condition in the population allowsus to explore the factors involved in the origin and persistenceof mixed infections In addition because antimonials arecardiotoxic a careful diagnosis and implementation of alter-native treatments are needed to avoid further complications

The complex situation in Hipolito Yrigoyen in referenceto TL is aggravated by the coexistence of T cruzi infectionThe transmission pattern involves mainly natural areasbut the possibility of a peridomiciliary transmission in theoutskirts of the city cannot be ruled out This situation

6 BioMed Research International

Table 2 Results of samples with mixed infection SMEAR visualization of amastigotes of Leishmania sp in Giemsa-stained smears ELISAgELISA based on homogenate protein of L (V) guyanensis LST reaction to leishmanin skin test ELISA Rec recombinant ELISA Kit IHAindirect hemagglutination TIF test of Immunofluorescence PCR Polymerase Chain Reaction nd no data (samples were not evaluated withTIF)

Leishmania infection tests T cruzi infection testsSmear ELISAg LST ELISA Rec IHA TIF PCR

Patient codeHI 54 + + + + + + minus

HI 55 + + + minus + nd +HI 58 + + + + + nd +

Table 3 Crude OR and adjusted OR for the factors associated withthe presence of tegumentary leishmaniasis OR Odds Ratio CIConfidence Interval aSignificant association at 119901 lt 005 bhighlysignificant association at 119901 lt 001 chighly significant association at119901 lt 0001

Logistic regression OR (CI 95)univariate analysis

OR (CI 95)multivariate analysis

SexFemale 1 1Male 547 (221ndash1354)a 605 (22ndash1664)c

Age (years)gt16 1 17ndash15 437 (139ndash138)b 773 (205ndash2916)b

Exposure to vector bitesat work

Unexposed 1Exposed 268 (114ndash63)a

Permanence gt 10 hoursoutdoors (SO)

No 1 1Yes 467 (123ndash1778)a 416 (097ndash1777)a

Bathing in the riverNo 1Yes 389 (159ndash954)a

Living with infectedpeople

No 1Yes 317 (123ndash815)a

demands the involvement of different stakeholders to controlthe magnitude of disease incidence implementing preven-tion strategies and taking into account biogeographical andsociocultural characteristics as well as human-induced envi-ronmental changes and situations that pose a risk

The present work provides epidemiological informationof potential determinants of TL occurrence in HipolitoYrigoyen its magnitude and situation of T cruzi infectionin the same area This information is useful for the localhealth system because it may contribute to a better planningof the surveillance systems and to the design of preven-tion strategies in the area These epidemiological patternsof mixed infections can occur in other countries wereT cruzi transmission does not exist or was interrupted andtegumentary leishmaniasis is endemic

Competing Interests

The authors declare that they have no competing interests

Acknowledgments

The authors wish to thank Carlos Villalpando ElizabethCorro Yolanda Aban Nadia Gonzalez and Norma Acostafor their support during fieldwork and the Med NicanorSosa of the Municipality of Hipolito Yrigoyen for logisticsupport during permanence in the study areaThis study wassupported by the Consejo de Investigacion de la UniversidadNacional de Salta (CIUNSa) the PICT 2013-3213 PICT 2014-1579 and Fundacion Mundo Sano

References

[1] A J Krolewiecki H D Romero S P Cajal et al ldquoA randomizedclinical trial comparing oral azithromycin andmeglumine anti-moniate for the treatment of American cutaneous leishmaniasiscaused by Leishmania (Viannia) braziliensisrdquo The AmericanJournal of TropicalMedicine andHygiene vol 77 no 4 pp 640ndash646 2007

[2] F M Frank M M Fernandez N J Taranto et al ldquoChar-acterization of human infection by Leishmania spp in theNorthwest of Argentina immune response double infectionwith Trypanosoma cruzi and species of Leishmania involvedsrdquoParasitology vol 126 no 1 pp 31ndash39 2003

[3] J D Marco P A Barroso T Mimori et al ldquoPolymorphism-specific PCR enhances the diagnostic performance of Americantegumentary leishmaniasis and allows the rapid identification ofLeishmania species from Argentinardquo BMC Infectious Diseasesvol 12 article 191 2012

[4] F M Locatelli S P Cajal P A Barroso et al ldquoThe isola-tion and molecular characterization of Leishmania spp frompatients with American tegumentary leishmaniasis in north-west Argentinardquo Acta Tropica vol 131 no 1 pp 16ndash21 2014

[5] A J Krolewiecki J F Gil M Quipildor et al ldquoRestricted out-break of American tegumentary leishmaniasis with highmicro-focal transmissionrdquo American Journal of Tropical Medicine andHygiene vol 88 no 3 pp 578ndash582 2013

[6] O D Salomon M L Wilson L E Munstermann and B LTravi ldquoSpatial and temporal patterns of phlebotomine sand flies(Diptera Psychodidae) in a cutaneous leishmaniasis focus innorthern Argentinardquo Journal of Medical Entomology vol 41 no1 pp 33ndash39 2004

[7] D de Pita-Pereira C R Alves M B Souza et al ldquoIdentificationof naturally infected Lutzomyia intermedia and Lutzomyiamigoneiwith Leishmania (Viannia) braziliensis in Rio de Janeiro

BioMed Research International 7

(Brazil) revealed by a PCRmultiplex non-isotopic hybridisationassayrdquo Transactions of the Royal Society of Tropical Medicine andHygiene vol 99 no 12 pp 905ndash913 2005

[8] E Cordoba-Lanus M L De Grosso J E Pinero B Valladaresand O D Salomon ldquoNatural infection of Lutzomyia neivaiwithLeishmania spp in northwestern Argentinardquo Acta Tropica vol98 no 1 pp 1ndash5 2006

[9] O D Salomon P W Orellano M G Quintana et al ldquoTrans-mission of tegumentary leishmaniasis in ArgentinardquoMedicinavol 66 no 3 pp 211ndash219 2006

[10] J F Gil J R Nasser S P Cajal et al ldquoUrban transmission ofamerican cutaneous leishmaniasis in Argentina spatial analysisstudyrdquoThe American Journal of Tropical Medicine and Hygienevol 82 no 3 pp 433ndash440 2010

[11] O D Salomon J R Rosa M Stein et al ldquoPhlebotominae(Diptera Psycodidae) fauna in theChaco region andCutaneousLeishmaniasis transmission patterns in Argentinardquo Memoriasdo Instituto Oswaldo Cruz vol 103 no 6 pp 578ndash584 2008

[12] World Health Organization ldquoResearch priorities for chagasdisease human african trypanosomiasis and leishmaniasisrdquoWHOTechnical Report Series 975WorldHealthOrganizationGeneva Switzerland 2013

[13] J C P Dias ldquoHuman chagas disease and migration in thecontext of globalization some particular aspectsrdquo Journal ofTropical Medicine vol 2013 Article ID 789758 9 pages 2013

[14] M G Chiaramonte F M Frank G M Furer N J TarantoR A Margni and E L Malchiodi ldquoPolymerase chain reactionreveals Trypanosoma cruzi infection suspected by serology incutaneous and mucocutaneous leishmaniasis patientsrdquo ActaTropica vol 72 no 3 pp 295ndash308 1999

[15] J F Gil C L Hoyos R O Cimino et al ldquoRole of threeELISA tests using promastigote homogenates of Leishmaniabraziliensis L amazonensis and L guyanensis in the diagnosisof tegumentary leishmaniasisrdquoMedicina vol 71 no 5 pp 420ndash428 2011

[16] A F Vega Benedetti R O Cimino P S Cajal et al ldquoPerfor-mance of different Trypanosoma cruzi antigens in the diag-nosis of Chagas disease in patients with American cutaneousleishmaniasis from a co-endemic region in Argentinardquo TropicalMedicine amp International Health vol 18 no 9 pp 1103ndash11092013

[17] J F Gil R O Cimino I Lopez Quiroga et al ldquoReactivityof GST-SAPA antigen of Trypanosoma cruzi against sera frompatients with Chagas disease and leishmaniasisrdquoMedicina vol71 no 2 pp 113ndash119 2011

[18] S D Lawn M Armstrong D Chilton and C J MWhitty ldquoElectrocardiographic and biochemical adverse effectsof sodium stibogluconate during treatment of cutaneous andmucosal leishmaniasis among returned travellersrdquo Transactionsof the Royal Society of Tropical Medicine and Hygiene vol 100no 3 pp 264ndash269 2006

[19] L F Oliveira A O Schubach M M Martins et al ldquoSystematicreview of the adverse effects of cutaneous leishmaniasis treat-ment in the NewWorldrdquo Acta Tropica vol 118 no 2 pp 87ndash962011

[20] L F Gamboa Latorre and J A Becerra Mateus ldquoCardiotoxici-dad por antimonialesrdquo Revista Salud Bosque vol 2 no 2 pp69ndash74 2012

[21] L H Malik G D Singh and E A Amsterdam ldquoThe epidemi-ology clinical manifestations and management of chagas heartdiseaserdquo Clinical Cardiology vol 38 no 9 pp 565ndash569 2015

[22] S Sosa-Estani E L Segura A Gomez et al ldquoCutaneousleishmaniasis in Northern Argentina identification of riskfactors in a case-cohort study of three municipalities in SaltardquoRevista da Sociedade Brasileira deMedicina Tropical vol 34 no6 pp 511ndash517 2001

[23] Z E Yadon L C Rodrigues C R Davies and M A QuigleyldquoIndoor and peridomestic transmission of American cutaneousleishmaniasis in northwestern Argentina a retrospective case-control studyrdquo American Journal of Tropical Medicine andHygiene vol 68 no 5 pp 519ndash526 2003

[24] F D A Pedrosa and R A D A Ximenes ldquoSociodemographicand environmental risk factors for American cutaneous leish-maniasis (ACL) in the State of Alagoas Brazilrdquo AmericanJournal of Tropical Medicine and Hygiene vol 81 no 2 pp 195ndash201 2009

[25] J M Lauritsen and M Bruus EpiData Entry Version 31 AComprehensive Tool for Validated Entry and Documentation ofData The EpiData Association Odense Denmark 2005

[26] M Alvarez J A Cerisola and R W Rohwedder ldquoImmunoflu-orescence test in the diagnosis of Chagasrsquo diseasesrdquo BoletınChileno de Parasitologıa vol 23 no 1 pp 4ndash8 1968

[27] C Britto M A Cardoso C M Monteiro Vanni et alldquoPolymerase chain reaction detection of Trypanosoma cruzi inhuman blood samples as a tool for diagnosis and treatmentevaluationrdquo Parasitology vol 110 no 3 pp 241ndash247 1995

[28] Z C Caballero O E Sousa W P Marques A Saez-Alquezarand E S Umezawa ldquoEvaluation of serological tests to identifyTrypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spprdquoClinical and Vaccine Immunology vol 14 no 8 pp 1045ndash10492007

[29] S Domınguez-Almendros N Benıtez-Parejo and A RGonzalez-Ramirez ldquoLogistic regressionmodelsrdquoAllergologia etImmunopathologia vol 39 no 5 pp 295ndash305 2011

[30] V ChongsuvivatwongAnalysis of Epidemiological Data Using Rand Epicalc Epidemiology Unit Prince of Songkla UniversitySongkhla Thailand 2008

[31] M M Rodrıguez del Aguila and N Benıtez-Parejo ldquoSimplelinear and multivariate regression modelsrdquo Allergologia etImmunopathologia vol 39 no 3 pp 159ndash173 2011

[32] R Core Team ldquoR A language and environment for statisticalcomputingrdquo 2012 R Foundation for Statistical ComputingVienna Austria httpwwwR-projectorg

[33] S Sosa-Estani E L Segura O D Salomon et al ldquoTegumentaryleishmaniasis in Northern Argentina distribution of infectionand disease in three municipalities of Salta 1990ndash1992rdquo Revistada Sociedade Brasileira de Medicina Tropical vol 33 no 6 pp573ndash582 2000

[34] O D Salomon S S Estani L Canini and E C LanusldquoTegumentary leishmaniasis in an area with epidemic levels oftransmission Salta Argentina 1998rdquoMedicina B Aires vol 61no 3 pp 284ndash290 2001

[35] M M Chanampa Monitoring sandflies of Lutzomyia genusand associated environmental variables in the town of HipolitoYrigoyen [MS Biologist thesis] Biology School Facultad deCiencias Naturales de la Universidad Nacional de Salta SaltaArgentina 2012

[36] M G Quintana O D Salomon and M S De Grosso ldquoDis-tribution of phlebotomine sand flies (Diptera Psychodidae) ina primary forest-crop interface Salta Argentinardquo Journal ofMedical Entomology vol 47 pp 1003ndash1010 2010

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

6 BioMed Research International

Table 2 Results of samples with mixed infection SMEAR visualization of amastigotes of Leishmania sp in Giemsa-stained smears ELISAgELISA based on homogenate protein of L (V) guyanensis LST reaction to leishmanin skin test ELISA Rec recombinant ELISA Kit IHAindirect hemagglutination TIF test of Immunofluorescence PCR Polymerase Chain Reaction nd no data (samples were not evaluated withTIF)

Leishmania infection tests T cruzi infection testsSmear ELISAg LST ELISA Rec IHA TIF PCR

Patient codeHI 54 + + + + + + minus

HI 55 + + + minus + nd +HI 58 + + + + + nd +

Table 3 Crude OR and adjusted OR for the factors associated withthe presence of tegumentary leishmaniasis OR Odds Ratio CIConfidence Interval aSignificant association at 119901 lt 005 bhighlysignificant association at 119901 lt 001 chighly significant association at119901 lt 0001

Logistic regression OR (CI 95)univariate analysis

OR (CI 95)multivariate analysis

SexFemale 1 1Male 547 (221ndash1354)a 605 (22ndash1664)c

Age (years)gt16 1 17ndash15 437 (139ndash138)b 773 (205ndash2916)b

Exposure to vector bitesat work

Unexposed 1Exposed 268 (114ndash63)a

Permanence gt 10 hoursoutdoors (SO)

No 1 1Yes 467 (123ndash1778)a 416 (097ndash1777)a

Bathing in the riverNo 1Yes 389 (159ndash954)a

Living with infectedpeople

No 1Yes 317 (123ndash815)a

demands the involvement of different stakeholders to controlthe magnitude of disease incidence implementing preven-tion strategies and taking into account biogeographical andsociocultural characteristics as well as human-induced envi-ronmental changes and situations that pose a risk

The present work provides epidemiological informationof potential determinants of TL occurrence in HipolitoYrigoyen its magnitude and situation of T cruzi infectionin the same area This information is useful for the localhealth system because it may contribute to a better planningof the surveillance systems and to the design of preven-tion strategies in the area These epidemiological patternsof mixed infections can occur in other countries wereT cruzi transmission does not exist or was interrupted andtegumentary leishmaniasis is endemic

Competing Interests

The authors declare that they have no competing interests

Acknowledgments

The authors wish to thank Carlos Villalpando ElizabethCorro Yolanda Aban Nadia Gonzalez and Norma Acostafor their support during fieldwork and the Med NicanorSosa of the Municipality of Hipolito Yrigoyen for logisticsupport during permanence in the study areaThis study wassupported by the Consejo de Investigacion de la UniversidadNacional de Salta (CIUNSa) the PICT 2013-3213 PICT 2014-1579 and Fundacion Mundo Sano

References

[1] A J Krolewiecki H D Romero S P Cajal et al ldquoA randomizedclinical trial comparing oral azithromycin andmeglumine anti-moniate for the treatment of American cutaneous leishmaniasiscaused by Leishmania (Viannia) braziliensisrdquo The AmericanJournal of TropicalMedicine andHygiene vol 77 no 4 pp 640ndash646 2007

[2] F M Frank M M Fernandez N J Taranto et al ldquoChar-acterization of human infection by Leishmania spp in theNorthwest of Argentina immune response double infectionwith Trypanosoma cruzi and species of Leishmania involvedsrdquoParasitology vol 126 no 1 pp 31ndash39 2003

[3] J D Marco P A Barroso T Mimori et al ldquoPolymorphism-specific PCR enhances the diagnostic performance of Americantegumentary leishmaniasis and allows the rapid identification ofLeishmania species from Argentinardquo BMC Infectious Diseasesvol 12 article 191 2012

[4] F M Locatelli S P Cajal P A Barroso et al ldquoThe isola-tion and molecular characterization of Leishmania spp frompatients with American tegumentary leishmaniasis in north-west Argentinardquo Acta Tropica vol 131 no 1 pp 16ndash21 2014

[5] A J Krolewiecki J F Gil M Quipildor et al ldquoRestricted out-break of American tegumentary leishmaniasis with highmicro-focal transmissionrdquo American Journal of Tropical Medicine andHygiene vol 88 no 3 pp 578ndash582 2013

[6] O D Salomon M L Wilson L E Munstermann and B LTravi ldquoSpatial and temporal patterns of phlebotomine sand flies(Diptera Psychodidae) in a cutaneous leishmaniasis focus innorthern Argentinardquo Journal of Medical Entomology vol 41 no1 pp 33ndash39 2004

[7] D de Pita-Pereira C R Alves M B Souza et al ldquoIdentificationof naturally infected Lutzomyia intermedia and Lutzomyiamigoneiwith Leishmania (Viannia) braziliensis in Rio de Janeiro

BioMed Research International 7

(Brazil) revealed by a PCRmultiplex non-isotopic hybridisationassayrdquo Transactions of the Royal Society of Tropical Medicine andHygiene vol 99 no 12 pp 905ndash913 2005

[8] E Cordoba-Lanus M L De Grosso J E Pinero B Valladaresand O D Salomon ldquoNatural infection of Lutzomyia neivaiwithLeishmania spp in northwestern Argentinardquo Acta Tropica vol98 no 1 pp 1ndash5 2006

[9] O D Salomon P W Orellano M G Quintana et al ldquoTrans-mission of tegumentary leishmaniasis in ArgentinardquoMedicinavol 66 no 3 pp 211ndash219 2006

[10] J F Gil J R Nasser S P Cajal et al ldquoUrban transmission ofamerican cutaneous leishmaniasis in Argentina spatial analysisstudyrdquoThe American Journal of Tropical Medicine and Hygienevol 82 no 3 pp 433ndash440 2010

[11] O D Salomon J R Rosa M Stein et al ldquoPhlebotominae(Diptera Psycodidae) fauna in theChaco region andCutaneousLeishmaniasis transmission patterns in Argentinardquo Memoriasdo Instituto Oswaldo Cruz vol 103 no 6 pp 578ndash584 2008

[12] World Health Organization ldquoResearch priorities for chagasdisease human african trypanosomiasis and leishmaniasisrdquoWHOTechnical Report Series 975WorldHealthOrganizationGeneva Switzerland 2013

[13] J C P Dias ldquoHuman chagas disease and migration in thecontext of globalization some particular aspectsrdquo Journal ofTropical Medicine vol 2013 Article ID 789758 9 pages 2013

[14] M G Chiaramonte F M Frank G M Furer N J TarantoR A Margni and E L Malchiodi ldquoPolymerase chain reactionreveals Trypanosoma cruzi infection suspected by serology incutaneous and mucocutaneous leishmaniasis patientsrdquo ActaTropica vol 72 no 3 pp 295ndash308 1999

[15] J F Gil C L Hoyos R O Cimino et al ldquoRole of threeELISA tests using promastigote homogenates of Leishmaniabraziliensis L amazonensis and L guyanensis in the diagnosisof tegumentary leishmaniasisrdquoMedicina vol 71 no 5 pp 420ndash428 2011

[16] A F Vega Benedetti R O Cimino P S Cajal et al ldquoPerfor-mance of different Trypanosoma cruzi antigens in the diag-nosis of Chagas disease in patients with American cutaneousleishmaniasis from a co-endemic region in Argentinardquo TropicalMedicine amp International Health vol 18 no 9 pp 1103ndash11092013

[17] J F Gil R O Cimino I Lopez Quiroga et al ldquoReactivityof GST-SAPA antigen of Trypanosoma cruzi against sera frompatients with Chagas disease and leishmaniasisrdquoMedicina vol71 no 2 pp 113ndash119 2011

[18] S D Lawn M Armstrong D Chilton and C J MWhitty ldquoElectrocardiographic and biochemical adverse effectsof sodium stibogluconate during treatment of cutaneous andmucosal leishmaniasis among returned travellersrdquo Transactionsof the Royal Society of Tropical Medicine and Hygiene vol 100no 3 pp 264ndash269 2006

[19] L F Oliveira A O Schubach M M Martins et al ldquoSystematicreview of the adverse effects of cutaneous leishmaniasis treat-ment in the NewWorldrdquo Acta Tropica vol 118 no 2 pp 87ndash962011

[20] L F Gamboa Latorre and J A Becerra Mateus ldquoCardiotoxici-dad por antimonialesrdquo Revista Salud Bosque vol 2 no 2 pp69ndash74 2012

[21] L H Malik G D Singh and E A Amsterdam ldquoThe epidemi-ology clinical manifestations and management of chagas heartdiseaserdquo Clinical Cardiology vol 38 no 9 pp 565ndash569 2015

[22] S Sosa-Estani E L Segura A Gomez et al ldquoCutaneousleishmaniasis in Northern Argentina identification of riskfactors in a case-cohort study of three municipalities in SaltardquoRevista da Sociedade Brasileira deMedicina Tropical vol 34 no6 pp 511ndash517 2001

[23] Z E Yadon L C Rodrigues C R Davies and M A QuigleyldquoIndoor and peridomestic transmission of American cutaneousleishmaniasis in northwestern Argentina a retrospective case-control studyrdquo American Journal of Tropical Medicine andHygiene vol 68 no 5 pp 519ndash526 2003

[24] F D A Pedrosa and R A D A Ximenes ldquoSociodemographicand environmental risk factors for American cutaneous leish-maniasis (ACL) in the State of Alagoas Brazilrdquo AmericanJournal of Tropical Medicine and Hygiene vol 81 no 2 pp 195ndash201 2009

[25] J M Lauritsen and M Bruus EpiData Entry Version 31 AComprehensive Tool for Validated Entry and Documentation ofData The EpiData Association Odense Denmark 2005

[26] M Alvarez J A Cerisola and R W Rohwedder ldquoImmunoflu-orescence test in the diagnosis of Chagasrsquo diseasesrdquo BoletınChileno de Parasitologıa vol 23 no 1 pp 4ndash8 1968

[27] C Britto M A Cardoso C M Monteiro Vanni et alldquoPolymerase chain reaction detection of Trypanosoma cruzi inhuman blood samples as a tool for diagnosis and treatmentevaluationrdquo Parasitology vol 110 no 3 pp 241ndash247 1995

[28] Z C Caballero O E Sousa W P Marques A Saez-Alquezarand E S Umezawa ldquoEvaluation of serological tests to identifyTrypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spprdquoClinical and Vaccine Immunology vol 14 no 8 pp 1045ndash10492007

[29] S Domınguez-Almendros N Benıtez-Parejo and A RGonzalez-Ramirez ldquoLogistic regressionmodelsrdquoAllergologia etImmunopathologia vol 39 no 5 pp 295ndash305 2011

[30] V ChongsuvivatwongAnalysis of Epidemiological Data Using Rand Epicalc Epidemiology Unit Prince of Songkla UniversitySongkhla Thailand 2008

[31] M M Rodrıguez del Aguila and N Benıtez-Parejo ldquoSimplelinear and multivariate regression modelsrdquo Allergologia etImmunopathologia vol 39 no 3 pp 159ndash173 2011

[32] R Core Team ldquoR A language and environment for statisticalcomputingrdquo 2012 R Foundation for Statistical ComputingVienna Austria httpwwwR-projectorg

[33] S Sosa-Estani E L Segura O D Salomon et al ldquoTegumentaryleishmaniasis in Northern Argentina distribution of infectionand disease in three municipalities of Salta 1990ndash1992rdquo Revistada Sociedade Brasileira de Medicina Tropical vol 33 no 6 pp573ndash582 2000

[34] O D Salomon S S Estani L Canini and E C LanusldquoTegumentary leishmaniasis in an area with epidemic levels oftransmission Salta Argentina 1998rdquoMedicina B Aires vol 61no 3 pp 284ndash290 2001

[35] M M Chanampa Monitoring sandflies of Lutzomyia genusand associated environmental variables in the town of HipolitoYrigoyen [MS Biologist thesis] Biology School Facultad deCiencias Naturales de la Universidad Nacional de Salta SaltaArgentina 2012

[36] M G Quintana O D Salomon and M S De Grosso ldquoDis-tribution of phlebotomine sand flies (Diptera Psychodidae) ina primary forest-crop interface Salta Argentinardquo Journal ofMedical Entomology vol 47 pp 1003ndash1010 2010

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

BioMed Research International 7

(Brazil) revealed by a PCRmultiplex non-isotopic hybridisationassayrdquo Transactions of the Royal Society of Tropical Medicine andHygiene vol 99 no 12 pp 905ndash913 2005

[8] E Cordoba-Lanus M L De Grosso J E Pinero B Valladaresand O D Salomon ldquoNatural infection of Lutzomyia neivaiwithLeishmania spp in northwestern Argentinardquo Acta Tropica vol98 no 1 pp 1ndash5 2006

[9] O D Salomon P W Orellano M G Quintana et al ldquoTrans-mission of tegumentary leishmaniasis in ArgentinardquoMedicinavol 66 no 3 pp 211ndash219 2006

[10] J F Gil J R Nasser S P Cajal et al ldquoUrban transmission ofamerican cutaneous leishmaniasis in Argentina spatial analysisstudyrdquoThe American Journal of Tropical Medicine and Hygienevol 82 no 3 pp 433ndash440 2010

[11] O D Salomon J R Rosa M Stein et al ldquoPhlebotominae(Diptera Psycodidae) fauna in theChaco region andCutaneousLeishmaniasis transmission patterns in Argentinardquo Memoriasdo Instituto Oswaldo Cruz vol 103 no 6 pp 578ndash584 2008

[12] World Health Organization ldquoResearch priorities for chagasdisease human african trypanosomiasis and leishmaniasisrdquoWHOTechnical Report Series 975WorldHealthOrganizationGeneva Switzerland 2013

[13] J C P Dias ldquoHuman chagas disease and migration in thecontext of globalization some particular aspectsrdquo Journal ofTropical Medicine vol 2013 Article ID 789758 9 pages 2013

[14] M G Chiaramonte F M Frank G M Furer N J TarantoR A Margni and E L Malchiodi ldquoPolymerase chain reactionreveals Trypanosoma cruzi infection suspected by serology incutaneous and mucocutaneous leishmaniasis patientsrdquo ActaTropica vol 72 no 3 pp 295ndash308 1999

[15] J F Gil C L Hoyos R O Cimino et al ldquoRole of threeELISA tests using promastigote homogenates of Leishmaniabraziliensis L amazonensis and L guyanensis in the diagnosisof tegumentary leishmaniasisrdquoMedicina vol 71 no 5 pp 420ndash428 2011

[16] A F Vega Benedetti R O Cimino P S Cajal et al ldquoPerfor-mance of different Trypanosoma cruzi antigens in the diag-nosis of Chagas disease in patients with American cutaneousleishmaniasis from a co-endemic region in Argentinardquo TropicalMedicine amp International Health vol 18 no 9 pp 1103ndash11092013

[17] J F Gil R O Cimino I Lopez Quiroga et al ldquoReactivityof GST-SAPA antigen of Trypanosoma cruzi against sera frompatients with Chagas disease and leishmaniasisrdquoMedicina vol71 no 2 pp 113ndash119 2011

[18] S D Lawn M Armstrong D Chilton and C J MWhitty ldquoElectrocardiographic and biochemical adverse effectsof sodium stibogluconate during treatment of cutaneous andmucosal leishmaniasis among returned travellersrdquo Transactionsof the Royal Society of Tropical Medicine and Hygiene vol 100no 3 pp 264ndash269 2006

[19] L F Oliveira A O Schubach M M Martins et al ldquoSystematicreview of the adverse effects of cutaneous leishmaniasis treat-ment in the NewWorldrdquo Acta Tropica vol 118 no 2 pp 87ndash962011

[20] L F Gamboa Latorre and J A Becerra Mateus ldquoCardiotoxici-dad por antimonialesrdquo Revista Salud Bosque vol 2 no 2 pp69ndash74 2012

[21] L H Malik G D Singh and E A Amsterdam ldquoThe epidemi-ology clinical manifestations and management of chagas heartdiseaserdquo Clinical Cardiology vol 38 no 9 pp 565ndash569 2015

[22] S Sosa-Estani E L Segura A Gomez et al ldquoCutaneousleishmaniasis in Northern Argentina identification of riskfactors in a case-cohort study of three municipalities in SaltardquoRevista da Sociedade Brasileira deMedicina Tropical vol 34 no6 pp 511ndash517 2001

[23] Z E Yadon L C Rodrigues C R Davies and M A QuigleyldquoIndoor and peridomestic transmission of American cutaneousleishmaniasis in northwestern Argentina a retrospective case-control studyrdquo American Journal of Tropical Medicine andHygiene vol 68 no 5 pp 519ndash526 2003

[24] F D A Pedrosa and R A D A Ximenes ldquoSociodemographicand environmental risk factors for American cutaneous leish-maniasis (ACL) in the State of Alagoas Brazilrdquo AmericanJournal of Tropical Medicine and Hygiene vol 81 no 2 pp 195ndash201 2009

[25] J M Lauritsen and M Bruus EpiData Entry Version 31 AComprehensive Tool for Validated Entry and Documentation ofData The EpiData Association Odense Denmark 2005

[26] M Alvarez J A Cerisola and R W Rohwedder ldquoImmunoflu-orescence test in the diagnosis of Chagasrsquo diseasesrdquo BoletınChileno de Parasitologıa vol 23 no 1 pp 4ndash8 1968

[27] C Britto M A Cardoso C M Monteiro Vanni et alldquoPolymerase chain reaction detection of Trypanosoma cruzi inhuman blood samples as a tool for diagnosis and treatmentevaluationrdquo Parasitology vol 110 no 3 pp 241ndash247 1995

[28] Z C Caballero O E Sousa W P Marques A Saez-Alquezarand E S Umezawa ldquoEvaluation of serological tests to identifyTrypanosoma cruzi infection in humans and determine cross-reactivity with Trypanosoma rangeli and Leishmania spprdquoClinical and Vaccine Immunology vol 14 no 8 pp 1045ndash10492007

[29] S Domınguez-Almendros N Benıtez-Parejo and A RGonzalez-Ramirez ldquoLogistic regressionmodelsrdquoAllergologia etImmunopathologia vol 39 no 5 pp 295ndash305 2011

[30] V ChongsuvivatwongAnalysis of Epidemiological Data Using Rand Epicalc Epidemiology Unit Prince of Songkla UniversitySongkhla Thailand 2008

[31] M M Rodrıguez del Aguila and N Benıtez-Parejo ldquoSimplelinear and multivariate regression modelsrdquo Allergologia etImmunopathologia vol 39 no 3 pp 159ndash173 2011

[32] R Core Team ldquoR A language and environment for statisticalcomputingrdquo 2012 R Foundation for Statistical ComputingVienna Austria httpwwwR-projectorg

[33] S Sosa-Estani E L Segura O D Salomon et al ldquoTegumentaryleishmaniasis in Northern Argentina distribution of infectionand disease in three municipalities of Salta 1990ndash1992rdquo Revistada Sociedade Brasileira de Medicina Tropical vol 33 no 6 pp573ndash582 2000

[34] O D Salomon S S Estani L Canini and E C LanusldquoTegumentary leishmaniasis in an area with epidemic levels oftransmission Salta Argentina 1998rdquoMedicina B Aires vol 61no 3 pp 284ndash290 2001

[35] M M Chanampa Monitoring sandflies of Lutzomyia genusand associated environmental variables in the town of HipolitoYrigoyen [MS Biologist thesis] Biology School Facultad deCiencias Naturales de la Universidad Nacional de Salta SaltaArgentina 2012

[36] M G Quintana O D Salomon and M S De Grosso ldquoDis-tribution of phlebotomine sand flies (Diptera Psychodidae) ina primary forest-crop interface Salta Argentinardquo Journal ofMedical Entomology vol 47 pp 1003ndash1010 2010

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

8 BioMed Research International

[37] J C Rosales H M Yang A Ibarra and R Barraza ldquoAnaliseda distribuicao espacial dos casos de leishmaniose tegumentaramericana em Hipolito Yrigoyen Oran Salta Argentina noperıodo 2005-2006rdquo Boletim Epidemiologico Paulista vol 5 pp4ndash9 2008

[38] P Diosque AM Padilla R O Cimino et al ldquoChagas disease inrural areas of Chaco Province Argentina epidemiologic surveyin humans reservoirs and vectorsrdquo The American Journal ofTropical Medicine and Hygiene vol 71 no 5 pp 590ndash593 2004

[39] N Klein I Hurwitz and R Durvasula ldquoGlobalization ofChagas disease a growing concern in nonendemic countriesrdquoEpidemiology Research International vol 2012 Article ID136793 13 pages 2012

[40] O S Negrette M C Mora and M A Basombrıo ldquoHighprevalence of congenital Trypanosoma cruzi infection andfamily clustering in Salta Argentinardquo Pediatrics vol 115 no 6pp e668ndashe672 2005

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

MEDIATORSINFLAMMATION

of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Behavioural Neurology

EndocrinologyInternational Journal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Disease Markers

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

OncologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

PPAR Research

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

OphthalmologyJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Diabetes ResearchJournal of

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAIDS

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Gastroenterology Research and Practice

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom