Scielo RSS <![CDATA[Brazilian Journal of Infectious Diseases]]> vol. 9 num. 6 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<B>Should tenofovir ever be used in association with didanosine?</B>]]> <![CDATA[<B>Adherence to an occupational blood borne pathogens exposure management program among healthcare workers and other groups at risk in Argentina</B>]]> We conducted a retrospective review of 130 occupational blood borne pathogens exposure (BBP-OE) records at Centro de Estudios Médicos e Investigaciones Clínicas, a university hospital with an ongoing educational program and a postexposure management program for healthcare workers (HCWs) since 1995, in order to evaluate adherence to a hospital BBP-OE management program. We compared HCWs from our institution (Group 1) and HCWs from independent institutions that contract our postexposure management program (Group 2). Compliance with standard precautions in Group 1 was inadequate in 77%, 23%, and 16% of nurses, physicians, and others, respectively. A greater proportion of HCWs in Group 1 (74% vs. 40%) reported occupational accidents within two hours after exposure (p = 0.0001). No difference was observed regarding compliance with adherence to schedule, partial adherence, and loss at follow-up (14%, 33%, and 53%; p > 0.05). Adherence to the standard of care for BBP-OE, including postexposure prophylaxis, was low (HIV: 53% and HBV: 63%). Knowledge of the seropositive status of the source patient did not improve adherence. We conclude that postexposure programs do not guarantee appropriate behavior by HCWs. General interventions and ongoing personnel education to modify individual attitudes are needed, as are continued efforts to assess HCWs' experiences with these programs, as well as the identification of strategies to improve adherence. <![CDATA[<B>Prevalence of <I>Mycobacterium avium </I>and <I>Mycobacterium tuberculosis </I>in blood cultures of Brazilian AIDS patients after introduction of highly active retroviral therapy</B>]]> The use of highly active antiretroviral therapy (HAART) for the treatment of HIV infection has been associated with a marked reduction in the incidence of most opportunistic infections. From April 2001 to February 2002, 80 blood samples from patients who were suspected to have disseminated mycobacterial infection, presenting fever and (preferably) a CD4 T cell count < 100.0 cell/mL were investigated. Twelve (15%) of the 80 blood cultures were positive for mycobacteria, with Mycobacterium avium being identified in 7 (8.8%) samples and M. tuberculosis in 5 (6.2%). The TCD4+ count at the time of M. avium bacteremia ranged from 7cells/µL (average of 48.5 cell/µL), while in M. tuberculosis bacteremia it ranged from 50.0 cells/µL (average of 80.0 cell/µL). The prevalence of M. avium bacteremia in our study follows the expected decline in opportunistic infections observed after the introduction of HAART; however, mycobacteremia by M. tuberculosis still indicates a high prevalence of tuberculosis infection in AIDS patients. <![CDATA[<B>Clinical forms and outcome of tuberculosis in HIV-infected patients in a tertiary hospital in São Paulo - Brazil</B>]]> Tuberculosis (TB)/HIV co-infection significantly changes the natural history of both diseases. Proper comprehension and clinical management of co-infected TB/HIV patients is still a challenge, particularly in places like Brazil, where both types of infection are prevalent. OBJECTIVES: Evaluate the frequency of the clinical forms of TB in HIV-infected patients; correlate the clinical forms of TB with the level of immunodeficiency; evaluate the response to therapy with different regimens for the treatment of TB; identify potential prognostic factors in TB/HIV patients. MATERIAL AND METHODS: The following data were collected at the beginning of the study: medical history, epidemiological background, physical examination, and laboratory evaluation (complete blood cell count, T lymphocyte subsets, viral load and tuberculin test). Monthly clinical follow-up was performed, with attention to adverse reactions to tuberculostatic drugs. TCD4+/CD8+ lymphocyte counts and quantification of the viral load were performed after 2, 4, 6, 10 and 15 months of follow-up. RESULTS: The study population consisted of 78 patients (45 males and 33 females) and their mean age was 36.4 ± 7.9 years The mean TCD4+ count values were higher in patients with the cavitary pulmonary form and lower in patients with disseminated forms. There were no significant differences in the mean TCD8+ cells counts . in the different clinical forms of TB. However, the mean laboratory values for hemoglobin, hematocrit and leucocytes at study entry did differ significantly among the various clinical forms of TB. At the end of the trial, the Tb recovery rate was of 78%, with four cases (5%) of treatment failure, eight (11%) treatment discontinuations and five deaths (6.4%). The highest rate of treatment failure (75%) was observed among patients with the disseminated form. Lower TCD4+ mean values were observed in cases of treatment failure and death. There was a correlation between the TCD4+ cell values and the TB outcome at the six time points. TCD8+ (cells/mm³) mean values assessed at the six time points in relation to the TB outcome indicated (non-significantly) lower values in patients who progressed to treatment failure. Considering the different TB outcomes, there was a significant correlation between TCD8+ values at the first and third assessments. Lower mean values of hemoglobin, hematocrit, platelet and leukocytes were observed among the cases of treatment failure than in patients who recovered. The variables hemoglobin, hematocrit, leukocytes and platelets were significantly different among the groups. CONCLUSIONS: The pulmonary forms of TB were most frequent in HIV infected patients; the extrapulmonary, associated and disseminated forms were predominantly seen in patients with a more severe level of immunosuppression. The TB recovery rate in HIV infected patients was similar to the expected rate in non-infected individuals. The best results were obtained when regimens containing rifampicin were used. Pancytopenia and low levels of TCD4+ and TCD8+ lymphocytes at the initial time point of the study were correlated with an unfavorable outcome of TB, and therefore they can be considered potential prognostic factors. However, the of TCD8+ lymphocyte values were the most important variable assessed. <![CDATA[<B>Evaluation of AIDS-related disability in a general hospital in southern, Brazil</B>]]> The increase in survival rates of patients affected by AIDS is associated with physical disabilities that can compromise their functional independence. We examined the degree and types of disabilities in hospitalized AIDS patients , as well the clinical and immunological parameters associated with disability. The lowered functional status was associated with increased time since AIDS had been diagnosed, with complaints of weakness, and with the involvement of more than one set of systems in the definition of AIDS. The inability to perform daily living activities was associated with higher viral loads (log) c/mL, lower CD4+/mL and CD4+/CD8+ ratios, and with involvement of the central nervous system, in the cause of hospitalization. Both the inability to perform daily living activities and low functional status were associated with muscle strength alteration and with being unemployed. <![CDATA[<B>Estimation of the residual risk for the transmission of HIV in blood donors from the mountain region of Santa Catarina</B>]]> The HIV, in hemotheraphy, may be transmitted by erythrocyte, platelets, crioprecipitated, frozen fresh plasma and possibly, by other blood components. Appropriate legislations for this new reality were elaborated normatizing the hemotheraphy practices in Brazil, creating a set of procedures and actions aiming at guaranteeing the quality of the blood, during, during the whole process. However, the residual risk remains, and it can be calculated as a product of the incidence and period of the immunological window. The objetive of the present study was to determine the rate of residual risk of the HIV blood transmission, in the blood donors from the Mountain Region of Santa Catarina. In order to calculate the residual risk of the HIV markers, 4,857 donors of repetition from the 24,969 individuals who donated blood from 2000 to 2003 were evaluated, and the results showed a serumconversion, in one case. The method used to calculate the residual risk followed the model of the immunological incidence window used by Schreiber (1996), in the USA. A estimate risk of 1:50,000 was verified. The case was considered as confirmed when one of the HIV, in the Hemocenter, is considered one of the HIV markers, in 1:50.000, which confirms the hypothesis that the new legislation related to the Blood National Politics, with the introduction of more sensible tests is decreasing the immunological window, diminishing the residual and, consequently, intensifying the transfusion security. <![CDATA[<B>Lack of effect of motivation on the adherence of HIV-positive/AIDS patients to antiretroviral treatment</B>]]> As a result of the potent drug combinations of reverse transcriptase inhibitors and protease inhibitors currently available, it is now possible to achieve extreme reductions in the numbers of viral particles in the peripheral blood of HIV-positive patients undergoing treatment, to the point that they are undetectable. Moreover, the immunological recovery resulting from continued and prolonged use of these drugs significantly reduces both mortality and the incidence of opportunistic infections. However, the strict therapeutic regimens required, the number of pills, adverse events and the stigma of a disease that requires the patient to introduce pill-taking into his/her lifestyle brings into question one aspect of mental health, which is motivation to do that which is being proposed. We investigated the influence of each of the components of the adherence trilogy: information, motivation and behavioral abilities, as risk factors in a population of HIV-positive/AIDS patients undergoing antiretroviral treatment in the city of Salvador, Bahia, Brazil. MATERIAL AND METHODS: An intervention study was carried out by introducing motivational assistance into the routine recommendations for the treatment of patients who were initiating antiretroviral (ARV) therapy. Seventy-six treatment-naive patients, who had been selected to initiate ARV therapy, were included. These patients were divided into two groups. Group A, in which the regular routine of the institution was followed, received information on the disease and its treatment;patients in group B had the same routine, but they were also followed-up fortnightly and given motivational intervention. Evaluations of viral load and CD4 count before and following treatment were used to measure adherence. RESULTS: There was no significant difference between the two groups. CONCLUSIONS: As the rates of non-adhesion were at the lower limits of the ranges reported in the literature, it would appear that providing motivation and information can be of help to the patient. <![CDATA[<B>HIV frequency among female sex workers in Imbituba, Santa Catarina, Brazil</B>]]> We examined HIV frequency and probable risk factors among female sex workers in the port city of Imbituba, Southern Brazil. From December 2003 through February 2004, 90 female sex workers were interviewed in order to investigate demographic, socioeconomic and behavioral variables related to HIV infection. A blood sample of each woman was also collected to test for HIV antibodies. Six (6.7%) of the sex workers were HIV-positive; the significantly-correlated risk factors were the daily number of clients (p = 0.008), the use of inhaled illicit drugs by the sex workers (P = 0.053) and by their clients (p = 0.005), and the lack of condom use in sexual relations (p = 0.015). The HIV infection rate in these sex workers was higher than that in the general population and similar to that found in other studies made with Brazilian populations presenting the same characteristics. This highlights the need for preventative measures, especially in this port area, in order to reduce transmission and to deter the introduction and dissemination of HIV. <![CDATA[<B>Prevalence of indeterminate human immunodeficiency virus western blot results in pregnant women attended at a public hospital in Presidente Prudente, Brazil</B>]]> The AIDS epidemic is spreading rapidly among women worldwide, offering increasing opportunities for vertical transmission of HIV. In Brazil, the prevalence of HIV infection among pregnant women is less than 1%. Therefore, the positive predictive value of an HIV EIA test tends to be lower than the more frequent indeterminate Western blot result. Pregnant women receiving antenatal care, from 2000 to 2004, at a public secondary hospital in the city of Presidente Prudente, São Paulo, Brazil, were systematically screened for HIV by means of two distinct EIA tests, in order to determine the prevalence of indeterminate Western blot results among pregnant women showing discordance in both HIV EIA tests and indirect immunofluorescence assay. Confirmatory indirect immunofluorescence was performed on material for all women with positive results in both EIA tests. Whenever there were positive results in EIA and IIA, the applicant was retested by the initial screening assay. Only those not showing concordance in results in EIA and IAA had a Western blot performed. The viral load was measured in pregnant women with positive or indeterminate Western blot results. Out of 9,786 sera, 105 (1.0%) were positive in the two HIV EIA screening tests, confirmed by indirect immunofluorescence. Among these women, Western blot was interpreted as indeterminate in 11 (0.1%) cases and their viral load was <50 copies/mL. We found a prevalence of 0.1% HIV indeterminate Western blots in pregnant women from Presidente Prudente and the surrounding region; none of these pregnant women had positive HIV viral loads. <![CDATA[<B>Spontaneous neutrophil activation in HTLV-1 infected patients</B>]]> Human T cell lymphotropic Virus type-1 (HTLV-1) induces lymphocyte activation and proliferation, but little is known about the innate immune response due to HTLV-1 infection. We evaluated the percentage of neutrophils that metabolize Nitroblue tetrazolium (NBT) to formazan in HTLV-1 infected subjects and the association between neutrophil activation and IFN-gamma and TNF-alpha levels. Blood was collected from 35 HTLV-1 carriers, from 8 patients with HAM/TSP (HTLV-1- associated myelopathy); 22 healthy individuals were evaluated for spontaneous and lipopolysaccharide (LPS)-stimulated neutrophil activity (reduction of NBT to formazan). The production of IFN-gamma and TNF-alpha by unstimulated mononuclear cells was determined by ELISA. Spontaneous NBT levels, as well as spontaneous IFN-gamma and TNF-alpha production, were significantly higher (p<0.001) in HTLV-1 infected subjects than in healthy individuals. A trend towards a positive correlation was noted, with increasing percentage of NBT positive neutrophils and levels of IFN-gamma. The high IFN-gamma producing HTLV-1 patient group had significantly greater NBT than healthy controls, 43&plusmn;24% and 17&plusmn;4.8% respectively (p< 0.001), while no significant difference was observed between healthy controls and the low IFN-gamma-producing HTLV-1 patient group (30&plusmn;20%). Spontaneous neutrophil activation is another marker of immune perturbation resulting from HTLV-1 infection. In vivo activation of neutrophils observed in HTLV-1 infected subjects is likely to be the same process that causes spontaneous IFN-gamma production, or it may partially result from direct IFN-gamma stimulation. <![CDATA[<B>Record linkage and capture-recapture estimates for underreporting of human leptospirosis in a Brazilian health district</B>]]> Record linkage and capture-recapture models were used to estimate the number of cases of human leptospirosis in the health district of Santa Maria, RS in southern Brazil. Twelve months of laboratory, hospital and epidemiological surveillance data were matched by name, age, residence and the month of diagnosis. Only laboratory-confirmed cases were considered. The record linkage revealed more than 20 times more cases than the official estimate for the health district, indicating a leptospirosis epidemic, with an annual incidence of more than 3 per 1,000 inhabitants and a case fatality of 0.37%. Severe cases were predominantly found through hospital records, overlapping to some extent with the epidemiological surveillance data, whereas less severe cases were found almost exclusively through laboratory logs. Different combinations of data sources influenced the detection rate for low versus high severity cases. Based on log-linear capture-recapture models, stratified by case severity and taking into account possible dependencies between the data sources, an insignificant number of cases were missed by all sources. <![CDATA[<B>Double-stranded RNA viral infection in Cuban <I>Trichomonas vaginalis</I> isolates</B>]]> Trichomonas vaginalis can be infected with double-stranded RNA (dsRNA) viruses designated T. vaginalis virus (TVV), which may have important implications for trichomonal virulence and disease pathogenesis. We tested for TVV in 40 fresh T. vaginalis isolates from Cuban patients by total extraction of nucleic acids (DNA and RNA). TVV was detected in 22 (55%) of the 40 T. vaginalis isolates. This gives an estimate of the infection rate of Cuban T. vaginalis isolates by the dsRNA virus. Future research should focus on the association between trichomonosis symptoms and the presence of TVV. <![CDATA[<B>Clinical and epidemiological aspects of children hospitalized with severe rotavirus-associated gastroenteritis in Salvador, BA, Brazil</B>]]> Little is known about the epidemiology of severe rotavirus-associated gastroenteritis in Brazil. Given the morbidity associated with this condition and the importance of having detailed knowledge about the impact of rotavirus infection on the epidemiology of acute diarrhea in children, especially those with the most severe diarrheal conditions, we retrospectively reviewed the medical records of all pediatric patients admitted to a tertiary hospital in Salvador, Brazil, due to rotavirus-associated gastroenteritis during one year. It was observed that rotavirus was responsible for 15.6% of the hospitalizations caused by diarrhea and/or vomiting during the period of the study and that 87 of 218 (39.1%) patients seen at the emergency room with rotavirus-associated gastroenteritis needed to be hospitalized, comprising the population of our study. Most patients presented signs of dehydration, and 41% of them had metabolic acidosis. Most patients (79%) were between six months and four years of age and 72% of the cases occurred in June and July. Gastrointestinal symptoms were rarely present at the beginning of the clinical presentation, and they normally did not last for more than one week. <![CDATA[<B><I>Acremonium kiliense </I>infection in a child with chronic granulomatous disease</B>]]> Infection by unusual microorganisms can be one of the clinical manifestations of primary immunodeficiency (PID). We report on a four-month-old child with pneumonia caused by the fungus Acremonium kiliense as the first clinical manifestation of chronic granulomatous disease. We emphasize the importance of an active search for unusual organisms in immunodeficient patients, and a precise diagnosis and early institution of specific treatment against such microorganisms for the reduction of the morbidity and mortality of these patients.