Predictors of Neurodevelopment in Microcephaly Associated with Congenital Zika Syndrome: A Prospective Study.

The municipality of Salvador, situated in Brazil, distinguished itself as the epicenter of the emergence of microcephaly related to congenital manifestations of Zika syndrome. Despite the anticipated significant developmental setbacks in these children, research has indicated a varied range of outcomes, with certain instances even reflecting minimal developmental delay. Our objective was to pinpoint determinants that could forecast developmental anomalies in children diagnosed with microcephaly associated with congenital Zika syndrome (CZS). METHODOLOGY: A forward-looking clinical and neurodevelopmental examination was conducted focusing on neonates diagnosed with microcephaly with CZS, birthed between September 2015 and April 2016 at the Hospital Geral Roberto Santos, in Salvador city. That infants were monitored up to their third year by a multiprofessional team. Child development was assessed using the composite Bayley III score. Undertaken by two blinded experts, cranial CT scan analysis was performed during the neonate period for the detection of brain abnormalities and to quantify ventricle enlargement, measured by Evans' index (EI). RESULTS: Fifty newborns were evaluated with a median head circumference of 28 cm (interquartile range 27-31 cm). EI was associated with neurodevelopmental delay at three years and remained significant after adjustment for head circumference. A 0.1-point increase in EI was associated with a delay of 3.2 months in the receptive language (p = 0.016), 3.4 months in the expressive language (p = 0.016), 3.4 months in the cognitive (p = 0.016), 2.37 months in the gross motor (p = 0.026), and 3.1 months in the fine motor (p = 0.021) domains. CONCLUSIONS: EI predicted neurodevelopmental delay in all Bayley domains in children with microcephaly associated with CZS.

Unequal burden of Zika-associated microcephaly among populations with public and private healthcare in Salvador, Brazil.

OBJECTIVES: To describe the differences in clinical presentation and relative disease burden of congenital Zika syndrome (CZS)-associated microcephaly at 2 large hospitals in Salvador, Brazil that serve patients of different socioeconomic status (SES). METHODS: Clinical and serologic data were collected prospectively from pregnant women and their infants, who delivered at 2 study centers during the 2015-2016 Zika virus (ZIKV) epidemic in Salvador, Brazil. RESULTS: Pregnant women from Salvador, Brazil delivering in a low SES hospital had 3 times higher ZIKV exposure rate than women at a high SES hospital. However, different SES hospitals had similar prevalence of infants with CZS-associated microcephaly (10% vs 6%, p = 0.16) after controlling for ZIKV exposure in their mothers. CONCLUSIONS: Our study supports the positive association between low SES, high maternal ZIKV exposure, and high rates of CZS-associated microcephaly.

The Characterisation of the Craniofacial Morphology of Infants Born With Zika Virus; Innovative Approach for Public Health Surveillance and Broad Clinical Applications.

Background: This study was carried out in response to the Zika virus epidemic, which constituted a public health emergency, and to the 2019 WHO calling for strengthened surveillance for the early detection of related microcephaly. The main aim of the study was to phenotype the craniofacial morphology of microcephaly using a novel approach and new measurements, and relate the characteristics to brain abnormalities in Zika-infected infants in Brazil to improve clinical surveillance. Methods: 3D images of the face and the cranial vault of 44 Zika-infected infants and matched healthy controls were captured using a 3D stereophotogrammetry system. The CT scans of the brain of the infected infants were analysed. Principal component analysis (PCA) was applied to characterise the craniofacial morphology. In addition to the head circumference (HC), a new measurement, head height (HH), was introduced to measure the cranial vault. The level of brain abnormality present in the CT scans was assessed; the severity of parenchymal volume loss and ventriculomegaly was quantified. Student's t-test and Spearman's Rho statistical test have been applied. Findings: The PCA identified a significant difference (p < 0.001) between the cranial vaults and the face of the Zika infants and that of the controls. Spearman's rank-order correlation coefficients show that the head height (HH) has a strong correlation (0.87 in Zika infants; 0.82 in controls) with the morphology of the cranial vaults, which are higher than the correlation with the routinely used head circumference (HC). Also, the head height (HH) has a moderate negative correlation (-0.48) with the brain abnormalities of parenchymal volume loss. Interpretation: It is discovered that the head height (HH) is the most sensitive and discriminatory measure of the severity of cranial deformity, which should be used for clinical surveillance of the Zika syndrome, evaluation of other craniofacial syndromes and assessment of various treatment modalities.

Urological profile of children with microcephaly and congenital zika syndrome.

INTRODUCTION: An outbreak of Zika virus disease, a self-limiting arbovirus infection involving skin rash and fever, occurred in Brazil in 2015 and was followed by an increase in newborns with microcephaly and brain malformations. Although two recent studies reported neurogenic bladder in children with microcephaly and congenital Zika syndrome (CZS), urologic evaluation is not yet routine. OBJECTIVE: To investigate the urological profile of children with microcephaly and CZS. STUDY DESIGN: A descriptive, cross-sectional study conducted with children with microcephaly undergoing clinical, laboratory, urodynamic and ultrasonographic evaluation at a center for childhood urinary disorders in Salvador, Bahia, Brazil. RESULTS: Thirty-three children were evaluated. Mean age was 40.3 ± 3.2 months (range 35-47 months). Twenty-one (63.6%) were female. None urinated voluntarily. Urine stream was continuous in 22 (66.7%) and intermittent in 3 (9.1%), with no information in 8 cases (24.2%). Abdominal straining during voiding was absent in 27 (81.8%) and present in 3 (9.1%), with no information in 3 cases (9.1%). Upper urinary tract dilatation was not detected in any of the 27 ultrasounds performed. Twenty-two urine cultures were performed, with no cases of bacterial growth. Renal function was normal in all cases (mean creatinine 0.41 ± 0.1 mg/dl, range 0.29-0.79 mg/dl and urea 20 ± 7 mg/dl, 6-36 mg/dl). Mean maximum bladder capacity was lower than expected for age: 46.4 ± 25.6 mL range 15-110 mL versus 135.2 ± 6.6 mL, 125.5-153 mL, respectively (p < 0.0001). Sixteen patients (59.2%) had immature and reflex bladder, 3 (11.1%) had neurogenic bladder with small bladder compliance, 5 (18.5%) had neurogenic bladder and detrusor overactivity and 1 (3.7%) had normal bladder capacity and compliance, but urinated with abdominal straining and a significant residue. Urodynamic evaluation was normal in only two children (7.4%). DISCUSSION: Most children evaluated had immature and reflex bladder, with no repercussions on the upper urinary tract. Literature on urological complications in children with microcephaly is sparse; however, the present results differ from cases of neurogenic bladder in children with neural tube closure defects. Microcephaly in CZS involves a neurological and urodynamic pattern very similar to that found in children with cerebral palsy. Study limitations include the absence of a control group and neurological data with which to correlate these findings. CONCLUSION: Neurogenic bladder in children with CZS-associated microcephaly was much less common than recently reported. Most patients had no kidney abnormalities, but small bladder capacity and reflex bladder, with non-significant post-void residual urine.

Oral and maxillofacial outcomes in children with microcephaly associated with the congenital Zika syndrome.

INTRODUCTION: The objective of this study is to assess the oral and maxillofacial characteristics of microcephalic children associated with congenital Zika syndrome (CZS). METHODS: A cross-sectional, observational study was carried out with 61 patients with microcephaly/CZS born between June 2015 and September 2017 (29 boys and 32 girls, average age of 22.8 months) and a control group with 58 non-CZS children born in the same period (25 boys and 33 girls, average age of 23.8 months). The functional clinical analysis considered the labial and lingual frena, tongue anterior projection, oral escape, palate form, and first tooth eruption. For the craniofacial analysis, facial anthropometric points and the cephalic perimeter at the time were measured. Demographic data were collected from medical records, and a clinical exam was performed in order to register the intrabuccal characteristics and craniofacial measures. The chi-square test and Student's t-test were used with a significance level of 0.05. RESULTS: The narrow palate form, tongue anterior projection, oral escape, and late first tooth eruption were significantly more present in the group with microcephaly/CZS. As for the craniofacial analysis, face width (Bi-Zi), mandible width (Go-Go), height of face upper third (Tr-G), and monthly growth of cephalic perimeter were significantly smaller, whereas height of face lower third (Sn-Gn) was significantly bigger in the group with microcephaly/CZS (P < 0.05). CONCLUSION: Children with microcephaly resulting from a congenital Zika infection showed functional, oral, and maxillofacial changes and smaller facial development in comparison with non-CZS children in the same age group.

Risk of Zika microcephaly correlates with features of maternal antibodies.

Zika virus (ZIKV) infection during pregnancy causes congenital abnormalities, including microcephaly. However, rates vary widely, and the contributing risk factors remain unclear. We examined the serum antibody response to ZIKV and other flaviviruses in Brazilian women giving birth during the 2015-2016 outbreak. Infected pregnancies with intermediate or higher ZIKV antibody enhancement titers were at increased risk to give birth to microcephalic infants compared with those with lower titers (P < 0.0001). Similarly, analysis of ZIKV-infected pregnant macaques revealed that fetal brain damage was more frequent in mothers with higher enhancement titers. Thus, features of the maternal antibodies are associated with and may contribute to the genesis of ZIKV-associated microcephaly.

Seizures as a Complication of Congenital Zika Syndrome in Early Infancy.

Zika virus transmission in Brazil was linked to a large outbreak of microcephaly but less is known about longer term anthropometric and neurological outcomes. We studied a cohort of infants born between October 31, 2015, and January 9, 2016, in a state maternity hospital, followed up for 101 ± 28 days by home visits. Microcephaly (< 2 standard deviations, Intergrowth standard) occurred in 62 of 412 (15%) births. Congenital Zika syndrome (CZS) was diagnosed in 29 patients. Among CZS patients, we observed a significant gain in anthropometric measures (P < 0.001) but no significant gain in percentile for these measures. The main neurological outcome was epilepsy, occurring in 48% of infants at a rate of 15.6 cases per 100 patient-months, frequently requiring multiple anti-seizure medications. The cumulative fatality rate was 7.4% (95% confidence interval: 2.1-23.4%). Health-care professionals should be alerted on the high risk of epilepsy and death associated with CZS in early infancy and the need to actively screen for seizures and initiate timely treatment.

PEGylation of interleukin-10 improves the pharmacokinetic profile and enhances the antifibrotic effectivity in CCl4-induced fibrogenesis in mice.

Liver fibrosis represents a scar formation process as a response to chronic injury and a major cause of death worldwide. To date, no drug is available for this condition. Interleukin-10 (IL-10) has potent anti-inflammatory and antifibrotic properties but its short half-life in the circulation hampers its clinical use. Our aim was therefore to modify IL-10 with polyethylene glycol (PEG) to prolong its circulation time and enhance its effectivity. IL-10 was modified with 5 or 20 kDa PEG. The biological activity was preserved after PEGylation as assessed by inhibition of TNF-α production by macrophages. In vivo, during CCl(4)-induced fibrogenesis in mice, both 5PEG-IL-10 and 20PEG-IL-10 showed a longer circulation time compared to IL-10, which was associated with a significant increased liver accumulation. Immunohistochemical analysis of fibrotic livers of mice receiving treatment with IL-10 or its PEGylated forms, revealed a decrease in markers reflecting HSC and KC activation induced by 5PEG-IL10. Transcription levels of IL-6 were decreased upon treatment with IL-10 and both PEGylated forms, whereas IL-1ß levels were only down-regulated by 5PEGIL-10 and 20PEGIL-10. We conclude that PEGylation of IL-10 is a good strategy to attenuate liver fibrosis and that 5PEGIL-10 is the most effective conjugate.

Diversity and uncommon HPV types in HIV seropositive and seronegative women attending an STI clinic

Given the causal relationship between specific types of HPV with cervical cancer and precursor lesions, it is important to identify the viral type involved. The aim of this study is to access the prevalence of HPV types in HIV seropositive and seronegative women. Accordingly, 77 HPV positive cervical samples were obtained from 284 women (seropositive (n=112) and seronegative (n=172) for HIV) who attended a Sexually Transmitted Infection clinic, in Vitoria, Southeastern Brazil. Viral DNA was amplified by PCR using MY09/MY11 degenerated primers and the genotyping was performed by Restriction Fragment Length Polymorphism. Seventy five out of the 77 HPV samples were genotyped: 6, 11, 13, 16, 18, 26, 31, 31b, 32, 33, 34, 35, 52, 53, 55, 56, 58, 59, 61, 62, 64, 66, 71, 81, 83, 84. The most prevalent type was HPV16 followed by HPV types 6, 11 and 53. Fifty five percent and 45 percent belonged to high and low risk types, respectively. High risk types corresponded to 59 percent and 54.5 percent of the HPV detected in HIV seronegative and seropositive women, respectively. The uncommon HPV 13 type in cervical samples was also observed in this study. The oncogenic types were more common in the HIV seronegative samples and the number of cases with multiple infections was similar for the two groups. HPV typing is not only important clinically for the establishment of monitoring and treatment of a patient, it also provides knowledge of the viral types circulating in a population, which is of interest in the development of prevention and treatment programs for this disease.

Diversity and uncommon HPV types in HIV seropositive and seronegative women attending an STI clinic.

Given the causal relationship between specific types of HPV with cervical cancer and precursor lesions, it is important to identify the viral type involved. The aim of this study is to access the prevalence of HPV types in HIV seropositive and seronegative women. Accordingly, 77 HPV positive cervical samples were obtained from 284 women (seropositive (n=112) and seronegative (n=172) for HIV) who attended a Sexually Transmitted Infection clinic, in Vitoria, Southeastern Brazil. Viral DNA was amplified by PCR using MY09/MY11 degenerated primers and the genotyping was performed by Restriction Fragment Length Polymorphism. Seventy five out of the 77 HPV samples were genotyped: 6, 11, 13, 16, 18, 26, 31, 31b, 32, 33, 34, 35, 52, 53, 55, 56, 58, 59, 61, 62, 64, 66, 71, 81, 83, 84. The most prevalent type was HPV16 followed by HPV types 6, 11 and 53. Fifty five percent and 45% belonged to high and low risk types, respectively. High risk types corresponded to 59% and 54.5% of the HPV detected in HIV seronegative and seropositive women, respectively. The uncommon HPV 13 type in cervical samples was also observed in this study. The oncogenic types were more common in the HIV seronegative samples and the number of cases with multiple infections was similar for the two groups. HPV typing is not only important clinically for the establishment of monitoring and treatment of a patient, it also provides knowledge of the viral types circulating in a population, which is of interest in the development of prevention and treatment programs for this disease.

Human papillomavirus in women with and without HIV-1 infection attending an STI clinic in Vitoria, Brazil.

We conducted a cross-sectional study in Vitória, Brazil, to assess the prevalence of human papillomavirus (HPV) infection in HIV-positive and HIV-negative women attending a sexually transmitted infection (STI)/AIDS clinic. We also investigated the presence of HPV genotypes and assessed covariates for HIV infection. Enrolled patients received a gynecological evaluation, and cervical scrape samples were collected for cytological analysis and HPV-DNA polymerase chain reaction (PCR). A blood sample was obtained to determine HIV status. HPV infection and squamous intraepithelial lesions were studied in 284 women, 112 (39.4%) HIV-positive women and 172 (60.5%) HIV-negative women. HPV-DNA was detected in 133 (46.8%). HIV-infected women were almost twice as likely to be concurrently infected with HPV than HIV-negative women (OR = 1.87 95% CI: 1.16-3.03). The high proportion of HPV detected among women attending an STI/AIDS clinic, particularly among HIV-infected women, proves the importance of screening this high-risk group in the hope of earlier detection and treatment of cervical intraepithelial neoplasia (CIN).

Proteus syndrome associated with hemimegalencephaly and Ohtahara syndrome: report of two cases.

The authors report two cases of Brazilian children with most of the common syndromic features of Proteus syndrome, such as asymmetric overgrowth of tissues, skin abnormalities, hypotonia and mental retardation. In both patients, a refractory epilepsy, compatible with Ohtahara syndrome, as well as hemimegalencephaly, with asymmetric distribution of facial fat, were also diagnosed.

Targeting 15d-prostaglandin J2 to hepatic stellate cells: two options evaluated.

PURPOSE: Delivery of apoptosis-inducing compounds to hepatic stellate cells (HSC) may be an effective strategy to reverse liver fibrosis. The aim of this study was therefore to examine the selective targeting of the apoptosis-inducing drug 15-deoxy-delta12,14-prostaglandin J2 (15dPGJ2) with two different HSC-carriers: human serum albumin modified with the sugar mannose-6-phosphate (M6PHSA) or albumin modified with PDGF-receptor recognizing peptides (pPBHSA). METHODS AND RESULTS: After chemical conjugation of 15dPGJ2 to the carriers, the constructs displayed pharmacological activity and specific receptor-mediated binding to HSC in vitro. Unlike 15dPGJ2-pPBHSA, the cellular binding of 15dPGJ2-M6PHSA was reduced by a scavenger receptor antagonist. In vivo, both conjugates rapidly accumulated in fibrotic livers. Intrahepatic analysis revealed that 15dPGJ2-M6PHSA mainly accumulated in HSC, and to a lesser extent in Kupffer cells. 15dPGJ2-pPBHSA also predominantly accumulated in HSC with additional uptake in hepatocytes. Assessment of target receptors in human cirrhotic livers revealed that M6P/IGFII-receptor expression was present in fibrotic areas. PDGF-P receptor expression was abundantly expressed on human fibroblasts. CONCLUSIONS: These studies show that 15dPGJ2 coupled to either M6PHSA or pPBHSA is specifically taken up by HSC and is highly effective within these cells. Both carriers differ with respect to receptor specificity, leading to differences in intrahepatic distribution. Nevertheless, both carriers can be used to deliver the apoptosis-inducing drug 15dPGJ2 to HSC in vivo.