An inexpensive and worldwide available digital image analysis technique for histological fibrosis quantification in chronic hepatitis C.

Hepatic fibrosis staging is based on semiquantitative scores. Digital imaging analysis (DIA) appears more accurate because fibrosis is quantified in a continuous scale. However, high cost, lack of standardization and worldwide unavailability restrict its use in clinical practice. We developed an inexpensive and widely available DIA technique for fibrosis quantification in hepatitis C, and here, we evaluate its reproducibility and correlation with semiquantitative scores, and determine the fibrosis percentage associated with septal fibrosis and cirrhosis. 282 needle biopsies staged by Ishak and METAVIR scores were included. Images of trichrome-stained sections were captured and processed using Adobe(®) Photoshop(®) CS3 and Adobe(®) Bridge(®) softwares. The percentage of fibrosis (fibrosis index) was determined by the ratio between the fibrosis area and the total sample area, expressed in pixels calculated in an automated way. An excellent correlation between DIA fibrosis index and Ishak and METAVIR scores was observed (Spearman's r = 0.95 and 0.92; P < 0.001, respectively). Excellent intra-observer reproducibility was observed in a randomly chosen subset of 39 biopsies with an intraclass correlation index of 0.99 (95% CI, 0.95-0.99). The best cut-offs associated with septal fibrosis and cirrhosis were 6% (AUROC 0.97, 95% CI, 0.95-0.99) and 27% (AUROC 1.0, 95% CI, 0.99-1), respectively. This new DIA technique had high correlation with semiquantitative scores in hepatitis C. This method is reproducible, inexpensive and available worldwide allowing its use in clinical practice. The incorporation of DIA technique provides a more complete evaluation of fibrosis adding the quantification to architectural patterns.

Eicosanoid-mediated proinflammatory activity of Pseudomonas aeruginosa ExoU.

As Pseudomonas aeruginosa ExoU possesses two functional blocks of homology to calcium-independent (iPLA(2)) and cytosolic phospholipase A(2) (cPLA(2)), we addressed the question whether it would exhibit a proinflammatory activity by enhancing the synthesis of eicosanoids by host organisms. Endothelial cells from the HMEC-1 line infected with the ExoU-producing PA103 strain exhibited a potent release of arachidonic acid (AA) that could be significantly inhibited by methyl arachidonyl fluorophosphonate (MAFP), a specific PLA(2) inhibitor, as well as significant amounts of the cyclooxygenase (COX)-derived prostaglandins PGE(2) and PGI(2). Cells infected with an isogenic mutant defective in ExoU synthesis did not differ from non-infected cells in the AA release and produced prostanoids in significantly lower concentrations. Infection by PA103 induced a marked inflammatory response in two different in vivo experimental models. Inoculation of the parental bacteria into mice footpads led to an early increase in the infected limb volume that could be significantly reduced by inhibitors of both COX and lipoxygenase (ibuprofen and NDGA respectively). In an experimental respiratory infection model, bronchoalveolar lavage (BAL) from mice instilled with 10(4) cfu of PA103 exhibited a marked influx of inflammatory cells and PGE(2) release that could be significantly reduced by indomethacin, a non-selective COX inhibitor. Our results suggest that ExoU may contribute to P. aeruginosa pathogenesis by inducing an eicosanoid-mediated inflammatory response of host organisms.

[Clinical profile of cytomegalovirus (CMV) enterocolitis in acquired immunodeficiency syndrome]. / Perfil clínico da Enterocolite por Citomegalovírus (CMV) na síndrome da imunodeficiência adquirida (Aids).

OBJECTIVE: To determine the clinical profile of CMV colitis in AIDS patients, comparing clinical, endoscopic parameters and survival time between 2 groups of AIDS patients having chronic diarrhea. Group A being CMV colitis and group B without CMV colitis. METHODS: 48 patients with diarrhea that lasted more than 30 days, being 27 in Group A and 21 in Group B, were studied. Age, risk factors, interval time between the diagnosis of HIV infection and the beginning of diarrhea, hematochesia, the endoscopic findings and life table in both groups, were analysed. All of them were diagnosed by stool culture and stools for ovum and parasites, along colonoscopy with biopsies. The unpaired t test was used to assess statistical significance of differences observed in the means of continuous and the chi-square with Yates correction for non-parametric variables. The survival curves were assessed by the Kaplan-Meier and the Mantel-Haenszel's tests. A P value of less than 0,05 was considered to indicate statistical significance. RESULTS: The mucosal lesions associated with the CMV infection are typically ulcerative on a background of hemorrhagic erythema 14 (51,8%) p < 0,01. The life table analysis disclosed shorter survival time in the CMV colitis group 0,005> P>0,001. The others studied data did not achieve statistical significance. CONCLUSIONS: AIDS patients with CMV colitis have a poorer long-term survival. Among the colonoscopic findings, ulcerations with hemorrhagic background were the most common lesions.

Perfil clínico da enterocolite por Citomegalovírus (CMV) na síndrome da imunodeficiência adquirida (AIDS) / Clinical profile of Cytomegalovirus (CMV) enterocolitis in acquired immunodeficiency syndrome (AIDS)

Múltiplos agentes estão envolvidos na etiopatogenia da diarréia em Aids. O exame de fezes e a colonoscopia são elementos decisivos para o diagnóstico específico. A enterocolite por CMV pode cursar com febre, emagrecimento, diarréia intermitente e hematoquesia. Outros agentes causadores de diarréia podem ter o mesmo espectro de apresentação. OBJETIVO: Definir o perfil clínico da enterocolite por CMV em pacientes com Aids, comparando os parâmetros clínicos, endoscópicos e de tempo de sobrevida entre dois grupos com diarréia crônica, grupo A com CMV e grupo B sem CMV. MÉTODOS: Foram acompanhados 48 pacientes com Aids e diarréia de duração maior que 30 dias, sendo 27 do grupo A e 21 do grupo B. Os parâmetros analisados foram idade, situação de risco, duração da diarréia, hematoquesia, intervalo de tempo entre diagnóstico da infecção por HIV e início de diarréia, achados endoscópicos e sobrevida. Foram realizados exames parasitológicos, culturas e colonoscopia com biópsias. Foi utilizado o teste "t-student" para amostras não pareadas e o teste Qui-Quadrado com correção de Yates para variáveis não paramétricas. Foram construídas curvas de sobrevida pelo método descrito por Kaplan-Meier e aplicado o teste de Mantel - Haenszel. Foi assumido como nível de significância estatística o valor de P menor que 0.05. RESULTADOS: O padrão endoscópico da infecção por CMV correspondeu a ulcerações associadas a hemorragia de submucosa 14 (51.8 por cento) P < 0.01. O tempo de sobrevida do grupo B após o diagnóstico do HIV e após o diagnóstico específico da diarréia foi maior que o do grupo A (0.005 > P > 0.001). Os outros parâmetros estudados não mostraram significância estatística. CONCLUSÕES: A presença de enterocolite por CMV em Aids é marcador de mau prognóstico e menor sobrevida. Existe um padrão endoscópico sugestivo da infecção por CMV.

Clinical and diagnostic aspects of intestinal microsporidiosis in HIV-infected patients with chronic diarrhea in Rio de Janeiro, Brazil.

The objectives of this study were to determine both the prevalence of microsporidial intestinal infection and the clinical outcome of the disease in a cohort of 40 HIV-infected patients presenting with chronic diarrhea in Rio de Janeiro, Brazil. Each patient, after clinical evaluation, had stools and intestinal fragments examined for viral, bacterial and parasitic pathogens. Microsporidia were found in 11 patients (27.5%) either in stools or in duodenal or ileal biopsies. Microsporidial spores were found more frequently in stools than in biopsy fragments. Samples examined using transmission electron microscopy (n=3) or polymerase chain reaction (n=6) confirmed Enterocytozoon bieneusi as the causative agent. Microsporidia were the only potential enteric pathogens found in 5 of the 11 patients. Other pathogens were also detected in the intestinal tract of 21 patients, but diarrhea remained unexplained in 8. We concluded that microsporidial infection is frequently found in HIV infected persons in Rio de Janeiro, and it seems to be a marker of advanced stage of AIDS.

A 3-year follow-up of a Brazilian AIDS patient with protracted diarrhea caused by Enterocytozoon bieneusi.

Enterocytozoon bieneusi is the most prevalent microsporidian parasite that causes gastrointestinal infection in persons with AIDS. Microsporidia are increasingly recognized as important opportunistic pathogens all over the world but in Brazil only few cases have been reported due either to the non awareness of the clinical presentation of the disease or to difficulties in the laboratory diagnosis. We report a 3-year follow-up of a Brazilian HIV-positive patient in whom microsporidial spores were detected in stools and were identified as E. bieneusi using electron microscopy and PCR. The patient presented with chronic diarrhea, CD4 T-lymphocytes count below 100/mm3 and microsporidial spores were consistently detected in stools. Albendazole was given to the patient in several occasions with transient relief of the diarrhea, which reappeared as soon as the drug was discontinued. Nevertheless, a diarrhea-free period with weight gain up to 18 Kg occurred when a combination of nucleoside and protease inhibitors was initiated as part of the antiviral treatment.

Spectrum of morphologic changes of lymph nodes in HIV infection

Cervical lymph nodes biopsies from 31 HIV positive patients (with or without AIDS) were studied by histologic methods and immunohistochemistry (StreptABC staining of paraffin sections) to identify cellular and extracellular matrix components. The results were the following: (1) the biopsies were included in the stages of follicular hyperplasia without fragmentation FH-FF (4 cases); follicular hyperplasia with follicular fragmentation FH + FF (16 cases); follicular involution FI (6 cases) and diffuse pattern DP (5 cases); (2) the most important alteration was the germinal centers disruption due to follicle lysis, which began in the light zone; (3) there was coincidence between intrafollicular hemorrhages and segmental hyaline mycroangiopathy; (4) during the progression of the disease occurred; (a) an increase in the number of mast cells, CD68+ and Mac 387+ macrophages; (b) a diffuse augment of collagen III, elastic fibers, laminin, fibronectin and proteoglycans; (c) maintenance of Factor VIII-related antigens in the vascular endothelial cells, with decrease in the expression of Ulex-Europeus I lectin. Follicular hyperplasia (FH - FF or FH + FF) was the most common histologic pattern recognized in the lymph nodes of patients without AIDS and follicular involution and difuse pattern were seen in those who had AIDS. The results indicate that the lymph node biopsies may provide important information about the evolutive stage of the disease and its prognosis.

Spectrum of morphologic changes of lymph nodes in HIV infection.

Cervical lymph nodes biopsies from 31 HIV positive patients (with or without AIDS) were studied by histologic methods and immunohistochemistry (StreptABC staining of paraffin sections) to identify cellular and extracellular matrix components. The results were the following: (1) the biopsies were included in the stages of follicular hyperplasia without fragmentation FH-FF (4 cases); follicular hyperplasia with follicular fragmentation FH + FF (16 cases); follicular involution FI (6 cases) and diffuse pattern DP (5 cases); (2) the most important alteration was the germinal centers disruption due to follicle lysis, which began in the light zone; (3) there was coincidence between intrafollicular hemorrhages and segmental hyaline mycroangiopathy; (4) during the progression of the disease occurred; (a) an increase in the number of mast cells, CD68+ and Mac 387+ macrophages; (b) a diffuse augment of collagen III, elastic fibers, laminin, fibronectin and proteoglycans; (c) maintenance of Factor VIII-related antigens in the vascular endothelial cells, with decrease in the expression of Ulex-Europeus I lectin. Follicular hyperplasia (FH - FF or FH + FF) was the most common histologic pattern recognized in the lymph nodes of patients without AIDS and follicular involution and difuse pattern were seen in those who had AIDS. The results indicate that the lymph node biopsies may provide important information about the evolutive stage of the disease and its prognosis.

Chagas' disease in the Brazilian Amazon. III. A cross-sectional study (1).

Two serological surveys for Chagas' infection were carried out, in 1991 and 1993, respectively, using a conglomerate family samples from the residents in the town of Barcelos (in the northern part of the State of Amazonas, on the right bank of the Rio Negro, 490 Km up-river from Manaus), using indirect immunofluorescent tests for anti-T. cruzi antibodies. In the first survey (1991), 628 blood samples from the residents of 142 dwellings were tested, showing positive in 12.7% for anti-T. cruzi antibodies and in 1993 an other 658 samples from residents of 171 dwellings showed positive in 13.7% of the tests, thus confirming the previous results. From 170 individuals with positive serology for T. cruzi antibodies, 112 (66%) were interviewed and submitted to electrocardiographic and clinical examinations; 82 (73.2%) of them gave consent for xenodiagnosis. From the 112 interviewed 52 (46.4%) recognized the triatomines as "piaçavas' lice", 48 (42.8%) knew the bugs from their work places being gatherers of piaçava fibers in rural areas and 19 (16.9%) said that have been bitten by bugs in their huts. Only 2 (2.4%) of 82 xenodiagnosis applied were positive for T. cruzi and 9 (8%) of the ECG had alterations compatible with Chagas' disease.

[Epidemiological, social, and sanitary aspects in an area of the Rio Negro, State of Amazonas, with special reference to intestinal parasites and Chagas' disease]. / Aspectos epidemiológicos, sociais e sanitários de uma área no Rio Negro, estado do Amazonas, com especial referência às parasitoses intestinais e à infecção chagásica.

A cross-sectional study was carried out on the residents of one in every four dwellings in the town of Barcelos (in the northern part of the State of Amazonas, on the right bank of the Rio Negro, 490 kilometers from Manaus by river), in order to evaluate social and sanitary conditions and specific indicators for intestinal parasites and Chagas' infection. During the survey, two questionnaires were applied, a household one to evaluate social and sanitary aspects, and an individual one, for social and epidemiological evaluation of the population conditions. A conglomerate family sample of 171 dwellings was studied. From each of the 658 habitants, a sample was requested for stool examination by Lutz sedimentation and Baermann-Moraes-Coutinho techniques modified by Willcox & Coura (1989), and blood was collected in filter paper for immunofluorescence test by Camargo (1966) and Souza & Camargo (1966) methods modified by Petana & Willcox (1975). The stool examination showed 69.4% of samples with one or more parasites. Ascaris lumbricoides was predominant with 51% of positivity and Entamoeba histolytica, although surveyed by a non-specific method, was present in 19.7%. Surprisingly, 20.1% of the 658 sera samples were reactive for T. cruzi antibodies at a dilution of 1:20 and 13.7% at 1:40. There was a strong correlation between this result and the level of human contact with wild triatomines, known locally as "piasava lice", and we succeeded in isolating by xenodiagnosis one strain of T. cruzi from one patient, a sixty-one-year old man (n. 209 -1), a native of the area, with positive serology for Chagas' disease and who worked in agriculture and transporting piasava and was very familiar with "piasava lice".