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Brazilian Journal of Infectious Diseases, Volume: 11, Número: 5, Publicado: 2007
  • Consensus of the Brazilian Society of Infectious Diseases on the management and treatment of hepatitis C Brief Communication

    Araújo, Evaldo Stanislau Affonso de; Mendonça, João Silva; Barone, Antonio Alci; Gonçales Junior, Fernando Lopes; Ferreira, Marcelo Simão; Focaccia, Roberto; Pawlotsky, Jean-Michel
  • Impact of the number of failed therapeutic regimes on the development of resistance mutations to HIV-1 in northeast Brazil Original Papers

    Medeiros, Melissa Soares; Arruda, Érico Antônio Gomes; Guerrant, Richard Littleton; Brown, Christopher Cooley; Lima, Aldo Ângelo Moreira

    Resumo em Inglês:

    Highly-potent antiretroviral therapy is necessary to avoid viral replication in HIV patients; however, it can favor the appearance of resistance mutations. The mutations 41L, 67N, 70R, 210W, 215Y/F, 219E/Q, 44D and 118I are defined as nucleoside analogous mutations (NAMs), because they affect the efficacy of all nucleoside reverse transcriptase inhibitors (NRTI). The mutation most frequently associated with non-nucleoside reverse transcriptase inhibitors (NNRTIs) is 103N. 33W/F, 82A/F/L/T, 84V and 90M are called protease inhibitor resistance-associated mutations (PRAM), because they are associated with resistance to several protease inhibitors (PI). This study evaluated the development of resistance mutations and examine the susceptibility of HIV with these mutations to antiretrovirals in HIV-1 patients who have failed one or more therapy regimes. Analyses were made of 101 genotypic tests of patients with therapeutic failure to 2 or 3-drug regimens with NRTI, NNRTI or PI. We used the Stanford database to define the susceptibility profile of the viruses. The samples were divided into three treatment-failure groups: first (F), second (S) and multi-failure (MF) to antiretroviral regimens, and we correlated these groups with resistance profiles and principal mutations. There was a significant increase in resistance mutations V82A/F/L/T, I84V, L90M, M41L, K70R, L210W, T215Y/F and K219Q/E in MF. We also found significantly higher resistance to zidovudine, didanosine, stavudine and abacavir in MF. There was no increase in resistance to tenofovir (p=0.28) and lopinavir (p=0.079) in MF. A high degree of resistance to NNRTIs was observed in all groups. Increased resistance mutations will affect future therapeutic options for HIV patients in Brazil because it results in a significant increase in resistance to antiretroviral drugs.
  • Prevalence of persistent proteinuria in stable HIV/AIDS patients and its association with HIV nephropathy Original Papers

    Cavalcante, Maria Alina Gomes de Mattos; Coelho, Sandra Neiva; Lacerda, Heloísa Ramos

    Resumo em Inglês:

    Human immunodeficiency virus (HIV)-related glomerular disease is a cause of end-stage renal disease, though there is no recent data from Brazil concerning this syndrome. Persistent proteinuria (PPt) is the main marker for glomerular disease, especially levels above 1.5 g. We examined the prevalence of and associated risk factors for PPt, along with the prevalence of HIV-associated nephropathy (HIVAN) among AIDS patients. We interviewed 411 patients who were attended at the HIV/AIDS section of the Clinical Hospital of the Federal University of Pernambuco (Brazil) from January through June 2004. PPt was defined as a positive urine dipstick exam on at least two occasions. The analyzed risk factors were: black race, a low CD4 lymphocyte count (<200 cells/mm³), an HIV RNA level of >100,000 copis/mL and patients on highly-active antiretroviral therapy (HAART). The patients were classified according to urineary protein/creatinine ratio (Up/Uc) < 1.0, 1.0-3.0 and > 3.0. Patients with Up/Uc >3.0 were submitted to renal biopsy. Among the 411 HIV/AIDS patients, the mean age was 37 years, 70% were male, 37.5% were black, the mean CD4 count was 363 cells/mm³ (± 95), the mean RNA HIV count was 44,475 copies/mL (± 40,369), and 92% were on HAART. The prevalence of PPt was 5.6% (95% CI = 3.6 to 8.3%), and it was significantly associated with a low CD4 lymphocyte count (p<0.048). HIVAN was found in just one patient, and two patients improved after HAART.
  • Immune reconstitution syndrome in patients treated for HIV and tuberculosis in Rio de Janeiro Original Papers

    Serra, Fabiana C.; Hadad, David; Orofino, Renata L.; Marinho, Flavia; Lourenço, Cristina; Morgado, Mariza; Rolla, Valeria

    Resumo em Inglês:

    We made a retrospective longitudinal study from January 2000 to January 2003 to examine cases of immune reconstitution syndrome (IRS) and its incidence rate in tuberculosis (TB)-human immunodeficiency virus (HIV) co-infected patients. The incidence rate (IR) was calculated using a Poisson regression. The confidence interval (CI) that was stipulated was 95%. IRS occurred in 10/84 HIV and TB-positive patients; nine of them were on highly active anti-retroviral therapy (HAART) during a mean of 61.7 (±59) days following the introduction of antiretrovirals. Lymph-node enlargement was the sole clinical manifestation. CD4 counts were <100 cells/mm³in 50% of the patients, at the time of TB diagnosis. All but two patients were treated with prednisone, and recovered from TB within a mean of 91 days (±30 days). One relapse of TB was observed, but there were no IRS-related deaths. The incidence rate was higher (IR=11.18; CI, 1.41-88.76) in patients that had superficial lymph node enlargement at the moment of TB diagnosis (not associated with TB), extrapulmonary TB (IR=1.97; CI, 0.44-8.79), were antiretroviral naive (IR=1.85; CI, 0.48-7.16), and CD4 counts <100 cells/mm³ (IR=1.50; CI, 0.40-5.59), although with a wide CI. IRS was frequent in our sample, occurred more frequently in HIV-naive patients with lymph-node enlargement and extrapulmonary TB. No cases of new pulmonary lesions or worsening of pulmonary infiltrates were observed.
  • Evaluating total lymphocyte counts as a substitute for CD4 counts in the follow up of AIDS patients Original Papers

    Angelo, Ana Luiza Dias; Angelo, Camila Dias; Torres, Alex José Leite; Ramos, André Maurício Costa; Lima, Márcia; Netto, Eduardo Martins; Brites, Carlos

    Resumo em Inglês:

    This study evaluated total lymphocyte count (TLC) as a substitute marker for CD4+ cell counts to identify patients who need prophylaxis against opportunistic infection (CD4 < 200 cells/mm³) and patients with CD4 < 350 cells/mm³ (Brazilian threshold value of CD4 count to define AIDS). We evaluated TLC and CD4+ cells count of 1,174 HIV-infected patients, in Salvador, Brazil, from May 2003 to September 2004. CD4+ cell counts were performed by flow cytometry, and TLC was measured with an automated hematological counter. The mean CD4 count was 430 cells/mm³ (range: 4 to 2,531 cells/mm³). Mean TLC was 1,900 cells/mm³ (range: 300 to 6,200 cells/mm³). Using a threshold value of 1,000 cells/mm³ for TLC, the positive predictive value (PPV) was 77% for CD4 < 200 cells/mm³, but the sensitivity was only 29%, while the negative predictive value (NPV) was 88%, with 98% specificity. Similar findings were observed for CD4 count < 350. Using the same threshold value of 1,000 cells/mm³ for TLC, sensitivity was 14%, and specificity 99% (PPV= 94%; NPV=62%). In 70/1,510 (5%) of the samples the sum of CD4 and CD8 cell counts was greater than the TLC and in 27% (419/1,510) this sum was below 65% of the TLC. TLC has a high specificity to identify patients for prophylaxis, but a quite low sensitivity. It is not useful as an alternative to CD4+ T-cell counts as a marker in HIV-infected patients.
  • Detection of HCV by PCR in serum and PBMC of patients with hepatitis C after treatment Original Papers

    Cavalheiro, Norma de Paula; Filgueiras, Thelma Cristina; Melo, Carlos Eduardo; Morimitsu, Suzana Rie; Araújo, Evaldo Stanislau Affonso de; Tengan, Fátima Mitiko; Barone, Antonio Alci

    Resumo em Inglês:

    Although hepatitis C is mainly hepatotropic, some studies suggest that hepatitis C virus (HCV) infects peripheral blood mononuclear cells (PBMC), using them as a reservoir, which might contribute to the development of resistance to treatment. Fifty-four hepatitis-C patients, who had been submitted to treatment, were selected. Blood samples were collected on the same day for the detection of HCV RNA in serum and PBMC by PCR, using the Amplicor HCV 2.0 assay (Roche Diagnostics). HCV genotyping was performed using the INNO-LiPA HCV kit (Versant, Bayer Diagnostics). HCV RNA was detected in both serum and PBMC in 35 (64%) patients and no RNA in 16 (29.6%). Disagreement between the serum and PBMC results was observed for three patients (5.6%), with HCV RNA being detected in PBMC but not in serum. Four months later, new serum and PBMC samples were collected from one of these patients and HCV RNA was detected in both samples, showing that PBMC can reveal signs of a lack of response to treatment. We conclude that the absence of HCV in the serum of patients with chronic hepatitis C by the end of treatment does not mean that there is no circulating virus. HCV in mononuclear cells may be an indicator of the persisting infection.
  • Prevalence and risk factors for chronic hepatitis B in HIV patients attended at a sexually-transmitted disease clinic in Vitoria, Brazil Original Papers

    Zago, Adriana Marchon; Machado, Thayla Ferrari; Cazarim, Flavia Lagrota; Miranda, Angélica Espinosa

    Resumo em Inglês:

    This study assessed the prevalence of and correlated factors for chronic hepatitis B infection (HBV) among HIV patients attending the Reference Center for Sexually Transmitted Infections (STI) and AIDS in Vitória, ES, Brazil. HIV patients were studied from 1993 to 2004, using information recorded in a database of the STI Clinic. Demographic data, clinical characteristics, patterns of risk behavior and test results (ELISA-HIV, IFA-HIV, HBsAg, viral load and CD4 counts) were analyzed. We analyzed 851 HIV patients. Median age was 35.0 (interquartile range 30; 42) years and median years of education was 8.0 (IQR 5; 11). The prevalence of chronic HBV was 3.8% (95% CI 2.5-5.1). Illicit drug use was reported in 185 (21.7%) cases, alcohol abuse in 80 (9.4%) cases, men who have sex with men in 116 (13.6%) cases, and past STI in 320 (37.6%) cases. Chronic HBV was associated with intravenous drug use, male gender, STI associated with HIV diagnosis, and death. There is a need for prevention and assistance strategies to control the evolution of this infection in HIV patients.
  • Evaluation of urinalysis parameters to predict urinary-tract infection Original Papers

    Santos, Juliana Conrad dos; Weber, Liliana Portal; Perez, Leandro Reus Rodrigues

    Resumo em Inglês:

    We evaluated the performance of automated-flow cytometry, urinalysis dipsticks and microscopic urine sediment analysis as predictors of urinary tract infection. Urine cultures were used as a reference method for comparison. Six-hundred-seventy-five urine samples from hospitalized and not hospitalized patients attended at Hospital Mãe de Deus, Porto Alegre, in south Brazil, were included in the study. Among the individual measures analyzed, intense bacteriuria in the microscopic analysis of urinary sediment gave an accuracy of 92.9%. A combination between intense bacteriuria (microscopic analysis) and >20 leukocytes per µL of urine (flow cytometry) gave a higher accuracy (97.3%). We conclude that though it is laborious, microscopic urinalysis is a good analytical tool. Taken together with flow cytometry and dipsticks, we obtained a clinically-acceptable prediction of urinary-tract infection.
  • Epidemiological and microbiological analysis of ventilator-associated pneumonia patients in a public teaching hospital Original Papers

    Silva Júnior, João Manoel da; Rezende, Ederlon; Guimarães, Thaís; Campos, Edvaldo V. dos; Magno, Luiz André; Consorti, Lívia; Pereira, Renata Andréa Pietro; Nascimento, Maria de Lourdes; Mendonça, João Silva de

    Resumo em Inglês:

    Ventilator-associated pneumonia (VAP) is the most commonly-acquired infection in patients in intensive care units. We analyzed epidemiological and microbiological characteristics and the outcome, in a cohort of critically-ill patients with confirmed diagnosis of VAP. All patients who had been on mechanical ventilation (MV) for more than 48 hours were included in our study; material collection for microbiological analysis was done within the first 24 hours after beginning treatment or after changing antibiotics. There were 55/265 (20.7%) VAP cases diagnosed, at a rate of 21.6 episodes per 1,000 days of mechanical ventilation. Mean age of the patients was 66 years, with a mean APACHE II score of 26.7 + 7.0; male patients were more prevalent. The mortality rates in the intensive care unit (ICU) and during the hospital stay were 71% and 80%, respectively. MV duration in patients with VAP was 17 (range 3-43) days and among patients who had not developed VAP, 6 (2-32) days (p < 0.0001). 98.2% of the samples were positive, with a high prevalence of Gram-negative bacteria, mainly Acinetobacter calcoaceticus. Risk factors for death included age, MV duration and surgery. VAP incidence in this sample of critically-ill patients was high, with a high mortality rate. Control and prevention strategies based on continuing education of healthcare workers, developed by a multidisciplinary team, should be encouraged to minimize morbimortality of this infection.
  • Laboratorial diagnosis of lymphocytic meningitis Review Papers

    Almeida, Sérgio Monteiro de; Nogueira, Meri Bordignon; Raboni, Sonia Mara; Vidal, Luine Rosele

    Resumo em Inglês:

    Meningitis is the main infectious central nervous system (CNS) syndrome. Viruses or bacteria can cause acute meningitis of infectious etiology. The term "Aseptic Meningitis" denotes a clinical syndrome with a predominance of lymphocytes in the cerebrospinal fluid (CSF), with no common bacterial agents identified in the CSF. Viral meningitis is considered the main cause of lymphocyte meningitis. There are other etiologies of an infectious nature. CSF examination is essential to establish the diagnosis and to identify the etiological agent of lymphocytic meningitis. We examined CSF characteristics and the differential diagnosis of the main types of meningitis.
  • Toxoplasma gondii infection in pregnancy Review Papers

    Lopes, Fabiana Maria Ruiz; Gonçalves, Daniela Dib; Mitsuka-Breganó, Regina; Freire, Roberta Lemos; Navarro, Italmar Teodorico

    Resumo em Inglês:

    Toxoplasmosis is caused by an intracellular protozoan, Toxoplasma gondii, which has a wide geographical distribution. The main infection routes are ingestion of cysts from raw or badly-cooked meat, ingestion of oocysts from substrates contaminated with the feces of infected felines and congenital transmission by tachyzoites. The congenital form results in a severe systemic disease, because if the mother is infected for the first time during gestation, she can present a temporary parasitemia that will infect the fetus. Many of the clinical symptoms are seen in congenitally-infected children, from a mild disease to serious signs, such as mental retardation. Early diagnosis during the pregnancy is highly desirable, allowing prompt intervention in cases of infection, through treatment of pregnant women, reducing the probability of fetal infection and consequent substantial damage to the fetus. Conventional tests for establishment of a fetal diagnosis of toxoplasmosis include options from serology to PCR. Prevention of human toxoplasmosis is based on care to avoid infection, understanding the disease and serological exams during gestation. Pregnant women should be tested serologically from three months gestation, until one month after childbirth. Inclusion of serology for congenital toxoplasmosis along with the basic Guthrie test for PKU is of fundamental importance for early diagnosis of infection and so that treatment is initiated, in order to avoid possible sequels in the infant.
  • Infection by Mycoplasma pneumoniae and its importance as an etiological agent in childhood community-acquired pneumonias Review Papers

    Vervloet, Letícia Alves; Marguet, Christophe; Camargos, Paulo Augusto Moreira

    Resumo em Inglês:

    This manuscript reviewed the literature on infection by Mycoplasma pneumoniae with emphasis on etiological aspects of childhood community-acquired pneumonias. Bibliographical research was carried out from Pubmed Medline, MDConsult, HighWire, LILACS, and direct research over the past 10 years with the following keywords: Mycoplasma pneumoniae, pneumonia, and childhood. Fifty-four articles were selected. Mycoplasma pneumoniae has a high incidence in childhood. Clinical presentation includes respiratory and extrarespiratory symptoms. Mycoplasma pneumoniae lung infection can be confused with viral or bacterial pneumonia and is unresponsive to beta-lactams. In addition, co-infections have been reported. Mycoplasma pneumoniae infection occurs in all age groups, being less frequent and more severe in children under the age of five. Its incidence as a causal agent is high. Mycoplasma pneumoniae infections constitute 20%-40% of all community-acquired pneumonias; the severity is highly variable, and this condition may lead to severe sequelae. Mycoplasma pneumoniae frequency is underestimated in clinical practice because of the lack of specific features and a diagnosis that needs serology or PCR. Effective management of M. pneumoniae infections can usually be achieved with macrolides. In Brazil, epidemiological studies are needed in order to assess the incidence of this bacterium.
  • Pediatric mortality due to nosocomial infection: a critical approach Review Papers

    Lopes, Julia Marcia Maluf; Goulart, Eugenio Marcos Andrade; Starling, Carlos Ernesto Ferreira

    Resumo em Inglês:

    Nosocomial infection is a frequent event with potentially lethal consequences. We reviewed the literature on the predictive factors for mortality related to nosocomial infection in pediatric medicine. Electronic searches in English, Spanish and Portuguese of the PubMed/MEDLINE, LILACS and Cochrane Collaboration Databases was performed, focusing on studies that had been published from 1996 to 2006. The key words were: nosocomial infection and mortality and pediatrics/neonate/ newborn/child/infant/adolescent. The risk factors found to be associated with mortality were: nosocomial infection itself, leukemia, lymphopenia, neutropenia, corticosteroid therapy, multiple organ failure, previous antimicrobial therapy, catheter use duration, candidemia, cancer, bacteremia, age over 60, invasive procedures, mechanical ventilation, transport out of the pediatric intensive care unit, methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and Burkholderia cepacia infections, acute physiology and chronic health evaluation (APACHE) II scores over 15. Among these factors, the only one that can be minimized is inadequate antimicrobial treatment, which has proven to be an important contributor to hospital mortality in critically-ill patients. There is room for further prognosis research on this matter to determine local differences. Such research requires appropriate epidemiological design and statistical analysis so that pediatric death due to nosocomial infection can be reduced and health care quality improved in pediatric hospitals.
  • Association between prostate cancer and schistosomiasis in young patients: a case report and literature review Case Reports

    Bacelar, Albert; Castro, Larissa G.M.C.; Queiroz, Aristides Cheto de; Café, Eduardo

    Resumo em Inglês:

    This case report refers to a 47-year old patient with prostate cancer associated with schistosomiasis mansoni, who was submitted to radical prostatectomy. This is the third report published in the literature with respect to this association, and up to the present time it is still not known whether a cause and effect relationship exists between the two pathologies. The association between schistosomiasis and cancer has been well-documented in bladder cancer; however, there are no data yet proving the association of this disease with prostatic neoplasia. In this report, a third documented case of prostatic adenocarcinoma and schistosomiasis mansoni is described and a literature review is performed.
  • Testicular schistosomiasis caused by Schistosoma mansoni: a case report from Brazil Case Reports

    Lopes, Roberto Iglesias; Leite, Kátia Ramos; Prando, Décio; Lopes, Roberto Nicomedes

    Resumo em Inglês:

    Testicular schistosomiasis by Schistosoma mansoni is exceedingly rare, with only 11 cases reported in PubMed. We report a new case from Brazil. A 31-year-old man from the northeast region of the country presented with a 2 cm nodule in the right testis. Ultrasonography showed a well-delimited hypoechoic tumor, suggestive of a granulomatous lesion. Magnetic resonance imaging revealed an irregular tunica albuginea signal. A biopsy showed interstitial tissue with schistosome ova and granuloma formation. The nodule was excised, and the patient was treated with oxamniquine. He has remained symptom free for 10 years. A testicular nodule should raise suspicion of numerous pathologies, including schistosomiasis. Treatment should include therapy with oxamniquine or praziquantel, and nodule excision should be done whenever possible.
  • Spondylodiscitis associated with recurrent Serratia bacteremia due to a transjugular intrahepatic portosystemic shunt (TIPS): a case report Case Reports

    Marques, Nuno; Sá, Rosa; Coelho, Filomena; Cunha, Saraiva da; Meliço-Silvestre, A.

    Resumo em Inglês:

    We report a case of spondylodiscitis caused by multiresistant Serratia marcescens in a cirrhotic patient who had several Serratia bacteremias after the placement of a transjugular intrahepatic portosystemic shunt (TIPS) device. We concluded that an endovascular stent that can not be removed makes management of recurrent bacteremia difficult. Furthermore, back pain due to bacteremia is indicative of spondylodiscitis. Serratia marcescens can be an aggressive pathogen, causing spinal infection.
  • ERRATA

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