Acquired Hip Dysplasia in Children with Congenital Zika Virus Infection in the First Four Years of Life.

Acquired hip dysplasia has been described in children with cerebral palsy (CP); periodic surveillance is recommended in this population to prevent hip displacement and dislocation. Children with congenital zika syndrome (CZS) may present a spectrum of neurological impairments with changes in tonus, posture, and movement similar to children with CP. However, the relationship between CZS and hip dysplasia has not been characterized. In this prospective cohort study, we aimed to describe the occurrence of hip dysplasia in patients with CZS. Sixty-four children with CZS from 6 to 48 months of age were included and followed at a tertiary referral center in Rio de Janeiro, Brazil, with periodic radiologic and clinical hip assessments. Twenty-six (41%) patients were diagnosed with hip dysplasia during follow-up; mean age at diagnosis was 23 months. According to the Gross Motor Function Classification System (GMFCS), 58 (91%) patients had severe impairment (GMFCS IV and V) at the first evaluation. All patients with progression to hip dysplasia had microcephaly and were classified as GMFCS IV or V. Pain and functional limitation were reported by 22 (84%) caregivers of children with hip dysplasia. All patients were referred to specialized orthopedic care; eight (31%) underwent surgical treatment during follow-up. Our findings highlight the importance of implementing a hip surveillance program and improving access to orthopedic treatment for children with CZS in order to decrease the chances of dysplasia-related complications and improve quality of life.

Characterizing Disabilities in Preschool Aged Children with Congenital Zika Virus Syndrome with the ICF Model.

Understanding functioning and disabilities in children with Congenital Zika Syndrome (CZS) is essential for health planning. We describe disabilities present in children with CZS followed in a reference hospital in Rio de Janeiro, Brazil, based on the biopsychosocial model of the International Classification of Functioning, Disability and Health (ICF). This was a cohort study of children >3 years of age with CZS. Disability was characterized through outcomes related to ICF components assessed via clinical and motor development evaluations. Among 50 children, with a median age of 40 months, 47 (94%) presented with severe impairment and 46 (92%) had microcephaly. Damage to the head and neck was found in most children, with abnormal central nervous system imaging universally present. Most children had cognitive impairment (92%), muscle tone problems (90%), and speech deficits (94%). We found movement limitations in all categories but more pervasively (80−94%), in postural transfers and displacements. The main environmental factors identified in the ICF model were the use of products or substances for personal consumption and access to health services. Children with CZS have extremely high rates of disability beyond aged 3 years, particularly regarding motor activity. ICF-based models can contribute to the assessment of health domains.

Anthropometric Parameters of Children with Congenital Zika Virus Exposure in the First Three Years of Life.

Little is known about the impact of congenital Zika virus (ZIKV) exposure on growth in the first years of life. In this prospective cohort study,201 ZIKV antenatally-exposed children were followed at a tertiary referral center in Rio de Janeiro, Brazil. Eighty-seven were classified as congenital Zika syndrome (CZS) patients and 114 as not congenital Zika syndrome (NCZS); growth parameters were described and compared between groups and with WHO standard growth curves. Thirty-four (39%) newborns with CZS and seven (6%) NCZS were small for gestational age (p < 0.001). NCZS mean weight measures ranged from −0.45 ± 0.1 to 0.27 ± 0.2 standard deviations (SD) from the WHO growth curve median during follow-up, versus −1.84 ± 0.2 to −2.15 ± 0.2 SD for the CZS group (p < 0.001). Length mean z-scores varied from −0.3 ± 0.1 at 1 month to 0.17 ± 0.2 SD between 31 and 36 months in the NCZS group, versus −2.3 ± 0.3 to −2.0 ± 0.17 SD in the CZS group (p < 0.001). Weight/height (W/H) and BMI z-scores reached -1.45 ± 0.2 SD in CZS patients between 31 and 36 months, versus 0.23 ± 0.2 SD in the NCZS group (p < 0.01). Between 25 and 36 months of age, more than 50% of the 70 evaluated CZS children were below weight and height limits; 36 (37.1%) were below the W/H cut-off. Gastrostomy was performed in 23 (26%) children with CZS. During the first three years of life, CZS patients had severe and early growth deficits, while growth of NCZS children was normal by WHO standards.

ZIKA Virus Neutralizing Antibody Kinetics in Antenatally Exposed Infants.

BACKGROUND: Zika virus (ZIKV) is associated with severe congenital abnormalities and laboratory diagnosis of antenatal infection is difficult. Here we evaluated ZIKV neutralizing antibody (nAb) kinetics in infants born to mothers with PCR-confirmed ZIKV infection during pregnancy. METHODS: Neonates (n = 98) had serum specimens tested repeatedly for ZIKV nAb over the first 2 years of life using virus neutralization test (VNT). ZIKV neonatal infection was confirmed by RT-PCR in blood or urine and/or presence of ZIKV IgM antibodies, and results were correlated with infant clinical features. RESULTS: Postnatal laboratory evidence of ZIKV vertical transmission was obtained for 60.2% of children, while 32.7% exhibited clinical abnormalities. Congenital abnormalities were found in 37.3% of children with confirmed ZIKV infection and 31.0% of children without confirmed infection (P = .734). All but 1 child displayed a physiologic decline in ZIKV nAb, reflecting maternal antibody decay, despite an early ZIKV-IgM response in one-third of infants. CONCLUSIONS: Infants with antenatal ZIKV exposure do not develop ZIKV nAb despite an early IgM response. Therefore, ZIKV VNT in children is not useful for diagnosis of congenital infection. In light of these findings, it remains to be determined if children infected in utero are potentially susceptible to reinfection.

Ligação de um instrumento de avaliação clínica de exposição ao vírus Zika com a Classificação Internacional de Funcionalidade, Incapacidade e Saúde / Linking a clinical assessment instrument for Zika virus exposure with the International Classification of Functioning, Disability and Health

Instrumentos de avaliação clínica foram criados a partir de experiências prévias de cuidados para outras condições crônicas complexas da infância, de modo a planejar e sistematizar ações. Contudo, é importante que tais instrumentos tenham validação externa e contemplem o atual conceito de saúde biopsicossocial. Uma interlocução com a Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) poderia dar subsídio teórico e validação aos instrumentos criados. Objetivo: Identificar o conteúdo comum da CIF com o instrumento de avaliação clínica aplicado em população exposta ao vírus Zika em um ambulatório de doenças infecciosas em pediatria de um hospital de referência no Estado do Rio de Janeiro. Métodos: A Ligação com a CIF foi realizada por dois revisores independentes, segundo a proposta de Cieza e colaboradores. O coeficiente Kappa foi utilizado para análise da concordância interobservadores. Resultados: O instrumento de avaliação clínica utilizado no ambulatório de referência é composto principalmente por categorias da CIF de estruturas do corpo (46,4%). Observou-se poucas categorias relacionadas aos fatores contextuais (13,1%). E, não foram encontrados itens relacionados às categorias de atividade e participação. Conclusão: A ferramenta de avaliação apresenta principalmente informações sobre as funções e estruturas do corpo, voltando-se a um olhar puramente restrito as funções fisiológicas e as estruturas anatômicas. A inexistência de categorias de atividade e participação pode comprometer a percepção das experiências vividas pelas crianças que foram expostas ao vírus Zika

The Zika epidemic and the emergence of a new health condition in Brazil, imposed a rapid organization on services to meet the current demand for care. Clinical assessment instruments were created, based on previous care experiences for other complex chronic conditions in order to plan and systematize actions. However, it is important that these instruments have external validation and include the current concept of health, biopsychosocial. An interlocution with the International Classification of Functioning, Disability and Health (CIF) could provide theoretical support and validation to the instruments created. Objective: To identify the common content among the clinical evaluation instrument applied to the population exposed to the Zika virus in a pediatric infectious disease outpatient clinic in a reference hospital in the State of Rio de Janeiro with the ICF. Methods: The link with the ICF was carried out by two independent reviewers, according to Cieza's proposal and the Kappa coefficient was used for interobserver analysis. Results: It was identified that the instrument is mainly composed of items of body structure (39; 46.4%). There were few categories related to contextual factors (11; 13.1%). And there were no items related to the categories of activity and participation. Conclusion: The assessment tool presents mainly domains of function and structure of the body, turning to a biomedical look. The lack of categories of activity and participation can compromise the perception of health status. A line of care in the light of the biopsychosocial model provides advantages for health services planning and actions

24-hour Holter findings in infants with in-utero exposure to the Zika virus: a series of cases.

Severe neurological problems and other special manifestations such as high prevalence of structural cardiac changes has been described in infants vertically exposed to the Zika virus (ZIKV) and has been called congenital Zika virus syndrome (CZS). Previous studies have shown that the 24-hour Holter heart rate variability (HRV) analysis allows the prediction of worse outcomes in infants with neurological impairment and higher risk of sudden infant death syndrome (SIDS), hypertension, diabetes mellitus and other cardiovascular diseases. This study describes the 24-hour Holter findings of infants with confirmed vertical exposure to the ZIKV by positive polymerase chain reaction (PCR) assays in the mother's blood during pregnancy and/or in the urine or cerebrospinal fluid of the newborn. Data analysis was descriptive and included two subgroups according to the presence of fetal distress, positive PCR to ZIKV in the newborn, CZS and severe microcephaly. Heart rate, pauses, arrhythmias, ST segment and QT interval analyses and HRV evaluation through R-R, SDNN, pNN50 and rMMSD were described. The Mann-Whitney test was performed to assess differences between the two subgroups. The sample consisted of 15 infants with a mean age of 16 months, nine of whom were male. No arrhythmias or QT interval changes were observed. The comparison of HRV through the Mann-Whitney test showed a significant difference between patients with and without CZS, with and without severe microcephaly, with lower HRV in the groups with severe microcephaly and CZS. The study suggests that there is an increased risk of SIDS and cardiovascular diseases in this group of patients.

Neurodevelopment of children exposed intra-uterus by Zika virus: A case series.

The main goal of this manuscript was to investigate the neurodevelopment of children exposed by Zika virus in the intrauterine period who are asymptomatic at birth. Newborns with documented Zika virus exposure during the intrauterine period who were asymptomatic at birth were followed in the first two years of life for neurodevelopment using Bayley III test. Children were classified as having normal or delayed neurodevelopment for age based on most recent Bayley III evaluation results. Eighty-four infants were included in the study. The first Bayley III evaluation was performed at a mean chronological age of 9.7±3.1 month; 13 children (15%) had a delay in one of the three domains, distributed as follow: 10 (12%) in the language domain and 3 (3.5%) in the motor domain. The most recent Bayley III evaluation was performed at a mean age 15.3±3.1 months; 42 children (50%) had a delay in one of the three domains: 4 (5%) in cognition, 31 (37%) in language, and 20 (24%) in motor performance. There were no statistical differences in Gender, Gestational Age, Birth Weight and Head Circurference at birth between children with normal and delayed neurodevelopment for age. A very high proportion of children exposed ZIKV during pregnancy who were asymptomatic at birth demonstrated a delay in neurodevelopment, mainly in the language domain, the first two years of life.

Eye Findings in Infants With Suspected or Confirmed Antenatal Zika Virus Exposure.

: media-1vid110.1542/5804915134001PEDS-VA_2018-1104Video Abstract OBJECTIVES: To characterize ophthalmic manifestations of confirmed or suspected antenatal Zika virus (ZIKV) exposure. METHODS: Infants with antenatal ZIKV exposure were referred for evaluation during the 2015-2016 Rio de Janeiro outbreak. Mothers with symptomatic ZIKV infection during pregnancy and/or infants with microcephaly or other findings that were suggestive of suspected antenatal exposure were tested with reverse transcriptase polymerase chain reaction (RT-PCR). Complete eye examinations were performed by pediatric ophthalmologists between January 2016 and February 2017. The main outcome measure was eye abnormalities in RT-PCR-positive and suspected (ie, not tested or RT-PCR-negative) antenatal ZIKV cases. RESULTS: Of 224 infants, 189 had RT-PCR testing performed. Of 189 patients, 156 had positive RT-PCR results in their blood, urine, and/or placenta. Of 224 infants, 90 had central nervous system (CNS) abnormalities, including microcephaly (62 infants). Eye abnormalities were present in 57 of 224 (25.4%) infants. Optic nerve (44 of 57; 77.2%) and retina abnormalities (37 of 57; 64.9%) were the most common. The group with suspected ZIKV infection (68 infants) had proportionally more eye (36.8% vs 20.5%; P = .022) and CNS abnormalities (68.3% vs 28.1%; P = .008), likely because of referral patterns. Eye abnormalities consistent with ZIKV infection were clinically comparable in both RT-PCR-positive and unconfirmed groups, including 4 RT-PCR-positive infants of 5 without any CNS abnormalities. CONCLUSIONS: Similar eye manifestations were identified regardless of laboratory confirmation. Well-appearing infants were also found to have eye abnormalities. Therefore, all infants born after ZIKV outbreaks should be universally screened for eye abnormalities.

Congenital Zika virus syndrome in infants: repercussions for the promotion of families' mental health. / Síndrome congênita do Zika vírus em lactentes: repercussões na promoção da saúde mental das famílias.

This article aims to discuss the impacts of the promotion of families' mental health following the diagnosis of Zika virus infection in the pregnant woman and/or congenital Zika virus syndrome (CZVS) in the infant. The study also aims to foster reflection on mother-infant bonding in this context. The study is relevant not only because there is still so much to learn about CZVS, with its enormous capacity for dispersion and many doubts as to the physical consequences and psychological impacts, but also due to the urgent need to provide families and/or caregivers with guidelines for care and alternatives for dealing with the illness. The study was conducted in an outpatient clinic specifically providing care to children with CZVS at the Unit for Infectious Diseases in Pediatrics in a tertiary hospital of the Brazilian Unified National Health System (SUS) in Rio de Janeiro, Brazil. The team is multidisciplinary, and each member conducts an assessment based on their specific field of knowledge. This qualitative study drew on participant observation, and the data analysis showed that the use of virtual social networks, which function (independently of the medicine approaches) as channels for communication and collective discussion of the different experiences, in order to share strategies to overcome the diagnosed impossibilities.

Este artigo tem como objetivo discutir os impactos na promoção da saúde mental nas famílias a partir do diagnóstico de infecção pelo vírus Zika na gestante e/ou a presença da síndrome congênita do Zika vírus (SCZV) na criança. Busca ainda favorecer uma reflexão a respeito da construção do vínculo mãe-bebê nesse cenário. A relevância do estudo se dá não somente pelo fato de a SCZV ser ainda pouco conhecida, com uma enorme capacidade de dispersão e com muitas dúvidas quanto às consequências físicas e ao impacto psíquico causado, como também pela urgência em ser dada às famílias e/ou cuidadores diretrizes de acolhimento e alternativas para lidar com a doença. O estudo foi desenvolvido em ambulatório específico para o cuidado de crianças com SCZV da Unidade de Doenças Infecciosas em Pediatria de um hospital terciário do Sistema Único de Saúde (SUS) no Rio de Janeiro, Brasil. A equipe é caracterizada como multiprofissional e cada um de seus integrantes faz uma avaliação com base no campo de saber específico. A pesquisa de cunho qualitativo foi realizada valendo-se da observação participante, e a análise dos dados revelou que a utilização das redes sociais virtuais, as quais independentemente dos caminhos seguidos pela medicina, funcionam como veículo de comunicação e discussão coletiva de diferentes vivências, no intuito de compartilhar estratégias para a superação de impossibilidades diagnosticadas.

El objetivo de este artículo es discutir impactos en la promoción de la salud mental dentro de las familias a cuyas gestantes se les ha diagnosticado infección por el virus Zika, y/o la presencia del síndrome congénito del virus Zika (SCZV, por sus siglas en portugués) en el niño. También pretende favorecer la reflexión respecto a la construcción del vínculo madre-bebé en este escenario. La relevancia del estudio se produce no solamente por el hecho de que el SCZV sea todavía poco conocido, con una enorme capacidad de dispersión, y con muchas dudas respecto a las consecuencias físicas y el impacto psíquico causado, sino también por la urgencia en proporcionar a las familias y/o cuidadores directrices de acogida y alternativas para enfrentarse a esta enfermedad. El estudio se desarrolló en un ambulatorio específico para el cuidado de niños con SCZV de la Unidad de Enfermedades Infecciosas en Pediatría de un hospital terciario del Sistema Único de Salud (SUS) en Río de Janeiro, Brasil. El equipo estaba caracterizado como multiprofesional y cada uno de sus integrantes realizó una evaluación a partir de un campo de saber específico. La investigación de cuño cualitativo se realizó a partir de la observación participante. El análisis de datos reveló que la utilización de las redes sociales virtuales, independientemente de los caminos seguidos por la medicina, funciona como un vehículo de comunicación y discusión colectiva sobre diferentes vivencias, con el fin de compartir estrategias para la superación de las imposibilidades diagnosticadas.

Retrospective analysis of risk factors and gaps in prevention strategies for mother-to-child HIV transmission in Rio de Janeiro, Brazil.

BACKGROUND: Despite great progress made in methods to prevent mother-to-child transmission of HIV (MTCT), delivery and uptake of these measures remains a challenge in many countries. Although the Brazilian Ministry of Health aimed to eliminate MTCT by 2015, infection still occured in 15-24% of infants born to HIV-infected mothers. We sought to identify remaining factors that constrain MTCT elimination. METHODS: We conducted a retrospective, matched case-control study by reviewing hospital charts of infants born to HIV-infected mothers between 1997 and 2014 at three MTCT reference hospitals in the Rio de Janeiro metropolitan area. Cases were defined as HIV-exposed children with two positive HIV tests before 18 months of age; controls were defined as HIV-exposed children with two negative HIV tests before 18 months of age. We performed bivariate and MTCT cascade analyses to identify risk factors for MTCT and gaps in prevention services. RESULTS: We included 435 infants and their mothers (145 cases, 290 controls). Bivariate analyses of MTCT preventative care (PMTCT) indicated that cases were less likely to complete all individual measures in the antenatal, delivery, and postnatal period (p < 0.05). Assessing completion of the PMTCT cascade, the sequential steps of PMTCT interventions, we found inadequate retention in care among both cases and controls, and cases were significantly less likely than controls to continue receiving care throughout the cascade (p < 0.05). Motives for incompletion of PMTCT measures included infrastructural issues, such as HIV test results not being returned, but were most often due to lack of care-seeking. Over the course of the study period, PMTCT completion improved, although it remained below the 95% target for antenatal care, HIV testing, and antenatal ART set by the WHO. Adding concern, evaluation of co-infections indicated that case infants were also more likely to have congenital syphilis (OR: 4.29; 95% CI: 1.66 to 11.11). CONCLUSIONS: While PMTCT coverage has improved over the years, completion of services remains insufficient. Along with interventions to promote care-seeking behaviour, increased infrastructural support for PMTCT services is needed to meet the HIV MTCT elimination goal in Brazil as well as address rising national rates of congenital syphilis.

Persistence of Zika Virus After Birth: Clinical, Virological, Neuroimaging, and Neuropathological Documentation in a 5-Month Infant With Congenital Zika Syndrome.

During the Zika epidemic in Brazil, a baby was born at term with microcephaly and arthrogryposis. The mother had Zika symptoms at 10 weeks of gestation. At 17 weeks, ultrasound showed cerebral malformation and ventriculomegaly. At 24 weeks, the amniotic fluid contained ZIKV RNA and at birth, placenta and maternal blood were also positive using RT-qPCR. At birth the baby urine contained ZIKV RNA, whereas CSF at birth and urine at 17 days did not. Seizures started at 6 days. EEG was abnormal and CT scan showed cerebral atrophy, calcifications, lissencephaly, ventriculomegaly, and cerebellar hypoplasia. Bacterial sepsis at 2 months was treated. A sudden increase in head circumference occurred at 4 months necessitating ventricle-peritoneal shunt placement. At 5 months, the infant died with sepsis due to bacterial meningitis. Neuropathological findings were as severe as some of those found in neonates who died soon after birth, including hydrocephalus, destructive lesions/calcification, gliosis, abnormal neuronal migration, dysmaturation of nerve cells, hypomyelination, loss of descending axons, and spinal motor neurons. ZIKV RNA was detected only in frozen brain tissue using RT-qPCR, but infected cells were not detected by in situ hybridization. Progressive gliosis and microgliosis in the midbrain may have contributed to aqueduct compression and subsequent hydrocephalus. The etiology of progressive disease after in utero infection is not clear and requires investigation.

Zika virus infection in children: epidemiology and clinical manifestations.

PURPOSE: The purpose of this review is to comprehensively review Congenital Zika Syndrome in regard to their epidemiology and clinical manifestations. METHODS: This subject review of congenital Zika syndrome was composed after conducting a thorough review of the available literature on this topic using PubMed and other primary sources. RESULTS: The first epidemic of Zika virus infection in Brazil was followed by an unexpected sharp increase in the incidence of infants born with microcephaly and the description of a new disease, the congenital Zika syndrome. This review focuses on the epidemiological and clinical aspects of Zika infection in children. We conducted a brief historical account of the virus description in 1947, the rare cases of Zika infection occurring up to 2007, and the first epidemics in the Pacific between 2007 and 2014. We also discussed the isolation of the virus in Brazil in 2015 and its spread in the Americas, the microcephaly outbreak in Brazil and its association with Zika virus, and the current epidemiological panorama. We address the known clinical spectrum of Zika virus infection in the pediatric population, including manifestations of acute infection and congenital Zika syndrome, with emphasis on cranial, ophthalmic, and orthopedic abnormalities. CONCLUSION: While much has been learned about congenital Zika syndrome, the full spectrum of this infection is not yet known. This review is based on current, limited data about Zika vírus infection. As more information becomes available, we will have a more accurate picture of this new disease.

Síndrome congênita do Zika vírus em lactentes: repercussões na promoção da saúde mental das famílias / Síndrome congénito por el virus Zika en lactantes: repercusiones en la promoción de la salud mental de las familias / Congenital Zika virus syndrome in infants: repercussions for the promotion of families' mental health

Resumo: Este artigo tem como objetivo discutir os impactos na promoção da saúde mental nas famílias a partir do diagnóstico de infecção pelo vírus Zika na gestante e/ou a presença da síndrome congênita do Zika vírus (SCZV) na criança. Busca ainda favorecer uma reflexão a respeito da construção do vínculo mãe-bebê nesse cenário. A relevância do estudo se dá não somente pelo fato de a SCZV ser ainda pouco conhecida, com uma enorme capacidade de dispersão e com muitas dúvidas quanto às consequências físicas e ao impacto psíquico causado, como também pela urgência em ser dada às famílias e/ou cuidadores diretrizes de acolhimento e alternativas para lidar com a doença. O estudo foi desenvolvido em ambulatório específico para o cuidado de crianças com SCZV da Unidade de Doenças Infecciosas em Pediatria de um hospital terciário do Sistema Único de Saúde (SUS) no Rio de Janeiro, Brasil. A equipe é caracterizada como multiprofissional e cada um de seus integrantes faz uma avaliação com base no campo de saber específico. A pesquisa de cunho qualitativo foi realizada valendo-se da observação participante, e a análise dos dados revelou que a utilização das redes sociais virtuais, as quais independentemente dos caminhos seguidos pela medicina, funcionam como veículo de comunicação e discussão coletiva de diferentes vivências, no intuito de compartilhar estratégias para a superação de impossibilidades diagnosticadas.

Resumen: El objetivo de este artículo es discutir impactos en la promoción de la salud mental dentro de las familias a cuyas gestantes se les ha diagnosticado infección por el virus Zika, y/o la presencia del síndrome congénito del virus Zika (SCZV, por sus siglas en portugués) en el niño. También pretende favorecer la reflexión respecto a la construcción del vínculo madre-bebé en este escenario. La relevancia del estudio se produce no solamente por el hecho de que el SCZV sea todavía poco conocido, con una enorme capacidad de dispersión, y con muchas dudas respecto a las consecuencias físicas y el impacto psíquico causado, sino también por la urgencia en proporcionar a las familias y/o cuidadores directrices de acogida y alternativas para enfrentarse a esta enfermedad. El estudio se desarrolló en un ambulatorio específico para el cuidado de niños con SCZV de la Unidad de Enfermedades Infecciosas en Pediatría de un hospital terciario del Sistema Único de Salud (SUS) en Río de Janeiro, Brasil. El equipo estaba caracterizado como multiprofesional y cada uno de sus integrantes realizó una evaluación a partir de un campo de saber específico. La investigación de cuño cualitativo se realizó a partir de la observación participante. El análisis de datos reveló que la utilización de las redes sociales virtuales, independientemente de los caminos seguidos por la medicina, funciona como un vehículo de comunicación y discusión colectiva sobre diferentes vivencias, con el fin de compartir estrategias para la superación de las imposibilidades diagnosticadas.

Abstract: This article aims to discuss the impacts of the promotion of families' mental health following the diagnosis of Zika virus infection in the pregnant woman and/or congenital Zika virus syndrome (CZVS) in the infant. The study also aims to foster reflection on mother-infant bonding in this context. The study is relevant not only because there is still so much to learn about CZVS, with its enormous capacity for dispersion and many doubts as to the physical consequences and psychological impacts, but also due to the urgent need to provide families and/or caregivers with guidelines for care and alternatives for dealing with the illness. The study was conducted in an outpatient clinic specifically providing care to children with CZVS at the Unit for Infectious Diseases in Pediatrics in a tertiary hospital of the Brazilian Unified National Health System (SUS) in Rio de Janeiro, Brazil. The team is multidisciplinary, and each member conducts an assessment based on their specific field of knowledge. This qualitative study drew on participant observation, and the data analysis showed that the use of virtual social networks, which function (independently of the medicine approaches) as channels for communication and collective discussion of the different experiences, in order to share strategies to overcome the diagnosed impossibilities.

Screening Criteria for Ophthalmic Manifestations of Congenital Zika Virus Infection.

Importance: Current guidelines recommend screening eye examinations for infants with microcephaly or laboratory-confirmed Zika virus infection but not for all infants potentially exposed to Zika virus in utero. Objective: To evaluate eye findings in a cohort of infants whose mothers had polymerase chain reaction-confirmed Zika virus infection during pregnancy. Design, Setting, and Participants: In this descriptive case series performed from January 2 through October 30, 2016, infants were examined from birth to 1 year of age by a multidisciplinary medical team, including a pediatric ophthalmologist, from Fernandes Figueira Institute, a Ministry of Health referral center for high-risk pregnancies and infectious diseases in children in Rio de Janeiro, Brazil. Participants: Mother-infant pairs from Rio de Janeiro, Brazil, who presented with suspected Zika virus infection during pregnancy were referred to our institution and had serum, urine, amniotic fluid, or placenta samples tested by real-time polymerase chain reaction for Zika virus. Main Outcomes and Measures: Description of eye findings, presence of microcephaly or other central nervous system abnormalities, and timing of infection in infants with confirmed Zika virus during pregnancy. Eye abnormalities were correlated with central nervous system findings, microcephaly, and the timing of maternal infection. Results: Of the 112 with polymerase chain reaction-confirmed Zika virus infection in maternal specimens, 24 infants (21.4%) examined had eye abnormalities (median age at first eye examination, 31 days; range, 0-305 days). Ten infants (41.7%) with eye abnormalities did not have microcephaly, and 8 (33.3%) did not have any central nervous system findings. Fourteen infants with eye abnormalities (58.3%) were born to women infected in the first trimester, 8 (33.3%) in the second trimester, and 2 (8.3%) in the third trimester. Optic nerve and retinal abnormalities were the most frequent findings. Eye abnormalities were statistically associated with microcephaly (odds ratio [OR], 19.1; 95% CI, 6.0-61.0), other central nervous system abnormalities (OR, 4.3; 95% CI, 1.6-11.2), arthrogryposis (OR, 29.0; 95% CI, 3.3-255.8), and maternal trimester of infection (first trimester OR, 5.1; 95% CI, 1.9-13.2; second trimester OR, 0.5; 95% CI, 0.2-1.2; and third trimester OR, 0.3; 95% CI, 0.1-1.2). Conclusions and Relevance: Eye abnormalities may be the only initial finding in congenital Zika virus infection. All infants with potential maternal Zika virus exposure at any time during pregnancy should undergo screening eye examinations regardless of the presence or absence of central nervous system abnormalities.

Clinical and laboratory signs associated to serious dengue disease in hospitalized children / Sinais clínicos e laboratoriais para o dengue com evolução grave em crianças hospitalizadas

Abstract Objective: To evaluate the validity of clinical and laboratory signs to serious dengue disease in hospitalized children. Methods: Retrospective cohort of children (<18 years) hospitalized with dengue diagnosis (2007-2008). Serious dengue disease was defined as death or use of advanced life support therapy. Accuracy measures and area under the receiver operating characteristic curve were calculated. Results: Of the total (n = 145), 53.1% were female, 69% aged 2-11 years, and 15.9% evolved to the worse outcome. Lethargy had the best accuracy (positive likelihood ratio >19 and negative likelihood ratio <0.6). Pleural effusion and abdominal distension had higher sensitivity (82.6%). History of bleeding (epistaxis, gingival or gastrointestinal bleeding) and severe hemorrhage (pulmonary or gastrointestinal bleeding) in physical examination were more frequent in serious dengue disease (p < 0.01), but with poor accuracy (positive likelihood ratio = 1.89 and 3.89; negative likelihood ratio = 0.53 and 0.60, respectively). Serum albumin was lower in serious dengue forms (p < 0.01). Despite statistical significance (p < 0.05), both groups presented thrombocytopenia. Platelets count, hematocrit, and hemoglobin parameters had area under the curve <0.5. Conclusions: Lethargy, abdominal distension, pleural effusion, and hypoalbuminemia were the best clinical and laboratorial markers of serious dengue disease in hospitalized children, while bleeding, severe hemorrhage, hemoconcentration and thrombocytopenia did not reach adequate diagnostic accuracy. In pediatric referral hospitals, the absence of hemoconcentration does not imply absence of plasma leakage, particularly in children with previous fluid replacement. These findings may contribute to the clinical management of dengue in children at referral hospitals.

Resumo Objetivo Avaliar a validade dos sinais clínicos e laboratoriais para o dengue com evolução grave em crianças hospitalizadas. Métodos Coorte retrospectivo de crianças (<18 anos) internadas com dengue (2007-2008). Evolução grave foi definida como óbito ou pelo uso de terapia de suporte avançado de vida. Foram calculadas medidas de acurácia e área sob a curva ROC. Resultados Do total (n = 145), 53,1% casos eram do sexo feminino, 69% de 2 a 11 anos e 15,9% evoluíram para gravidade. Letargia obteve a melhor acurácia (razão de verossimilhança positiva RVP > 19 e RV negativa RVN < 0,6). Derrame pleural e distensão abdominal apresentaram maior sensibilidade (se = 82,6%). Relato de sangramentos (epistaxe, gengivorragia ou gastrointestinal) e hemorragia grave (pulmonar ou gastrointestinal) presente no exame físico foi mais frequente nos casos com evolução grave (p <0,01), porém com baixa acurácia (RVP = 1,89 e 3,89; RVN = 0,53 e 0,60, respectivamente). Os níveis de albumina sérica foram mais baixos nas formas graves (p <0,01). Ambos os grupos apresentaram trombocitopenia, apesar da diferença estatística (p <0,05). Contagem de plaquetas, hematócrito e hemoglobina apresentaram área sob a curva ROC < 0,5. Conclusões Letargia, distensão abdominal, derrame pleural e hipoalbuminemia foram os melhores marcadores clínicos e laboratoriais de dengue com evolução grave em crianças hospitalizadas, enquanto sangramento, hemorragia grave, hemoconcentração e trombocitopenia não tiveram boa acurácia diagnóstica. Em hospitais de referência pediátricos, a ausência de hemoconcentração não implica ausência de extravasamento plasmático, particularmente quando há reposição anterior de volume. Esses resultados podem contribuir para o manejo clínico do dengue em crianças em hospitais de referência.

Clinical and laboratory signs associated to serious dengue disease in hospitalized children.

OBJECTIVE: To evaluate the validity of clinical and laboratory signs to serious dengue disease in hospitalized children. METHODS: Retrospective cohort of children (<18 years) hospitalized with dengue diagnosis (2007-2008). Serious dengue disease was defined as death or use of advanced life support therapy. Accuracy measures and area under the receiver operating characteristic curve were calculated. RESULTS: Of the total (n=145), 53.1% were female, 69% aged 2-11 years, and 15.9% evolved to the worse outcome. Lethargy had the best accuracy (positive likelihood ratio >19 and negative likelihood ratio <0.6). Pleural effusion and abdominal distension had higher sensitivity (82.6%). History of bleeding (epistaxis, gingival or gastrointestinal bleeding) and severe hemorrhage (pulmonary or gastrointestinal bleeding) in physical examination were more frequent in serious dengue disease (p<0.01), but with poor accuracy (positive likelihood ratio=1.89 and 3.89; negative likelihood ratio=0.53 and 0.60, respectively). Serum albumin was lower in serious dengue forms (p<0.01). Despite statistical significance (p<0.05), both groups presented thrombocytopenia. Platelets count, hematocrit, and hemoglobin parameters had area under the curve <0.5. CONCLUSIONS: Lethargy, abdominal distension, pleural effusion, and hypoalbuminemia were the best clinical and laboratorial markers of serious dengue disease in hospitalized children, while bleeding, severe hemorrhage, hemoconcentration and thrombocytopenia did not reach adequate diagnostic accuracy. In pediatric referral hospitals, the absence of hemoconcentration does not imply absence of plasma leakage, particularly in children with previous fluid replacement. These findings may contribute to the clinical management of dengue in children at referral hospitals.

[Domestic violence and the adolescent that was infected with HIV through vertical transmission: analysis of protection and vulnerability factors]. / A violência intrafamiliar e o adolescente que vive com HIV/AIDS por transmissão vertical: análise dos fatores de proteção e de vulnerabilidade.

The scope of this study was to analyze protection and vulnerability factors in physical and psychological domestic violence among adolescents infected with HIV/AIDS through vertical transmission. This group is especially susceptible as they have vulnerability factors such as chronic disease, orphanhood with consequent change of caregivers and impaired body image. The research was conducted in a public hospital. The first stage used the Parent Child Conflict Tactics and the Degree of Psychological Violence Scale to determine what domestic violence occurred. In the second qualitative stage, the adolescents who scored the most or the least for violence in the quantitative instrument were interviewed. The questionnaires and the interviews revealed a high prevalence of physical and psychological violence and abusive domestic dynamics, thereby corroborating the extant literature. In view of the consequences of this kind of violence, it is essential that the health professional should be able to identify violent situations and recognize vulnerability factors and to promote protection factors against ill-treatment.

A violência intrafamiliar e o adolescente que vive com HIV/AIDS por transmissão vertical: análise dos fatores de proteção e de vulnerabilidade / Domestic violence and the adolescent that was infected with HIV through vertical transmission: analysis of protection and vulnerability factors

The scope of this study was to analyze protection and vulnerability factors in physical and psychological domestic violence among adolescents infected with HIV/AIDS through vertical transmission. This group is especially susceptible as they have vulnerability factors such as chronic disease, orphanhood with consequent change of caregivers and impaired body image. The research was conducted in a public hospital. The first stage used the Parent Child Conflict Tactics and the Degree of Psychological Violence Scale to determine what domestic violence occurred. In the second qualitative stage, the adolescents who scored the most or the least for violence in the quantitative instrument were interviewed. The questionnaires and the interviews revealed a high prevalence of physical and psychological violence and abusive domestic dynamics, thereby corroborating the extant literature. In view of the consequences of this kind of violence, it is essential that the health professional should be able to identify violent situations and recognize vulnerability factors and to promote protection factors against ill-treatment.

O objetivo deste trabalho foi o de analisar os fatores de proteção e de vulnerabilidade à violência intrafamiliar física e/ou psicológica entre adolescentes que vivem com HIV/Aids por transmissão vertical. Este grupo encontra-se especialmente suscetível por apresentar fatores de vulnerabilidade como doença crônica, orfandade com consequente troca de cuidadores e comprometimento da imagem corporal. A pesquisa foi realizada com adolescentes atendidos em um hospital de referência. A primeira etapa abrangeu a aplicação dos instrumentos Parent Child Conflict Tactics Scales e Escala de Violência Psicológica, para aferição do tipo de violência intrafamiliar acometida. A segunda parte, qualitativa, utilizou-se de entrevistas com os adolescentes, com os maiores e os menores escores para violência nos instrumentos quantitativos. Verificou-se uma alta prevalência de violência física e psicológica, bem como nas entrevistas realizadas foram detalhadas as dinâmicas familiares abusivas, corroborando a literatura. Tendo em vista as consequências deste tipo de violência, se torna fundamental que o profissional de saúde esteja atento à identificação das situações de violência, como também ao reconhecimento dos fatores de vulnerabilidade e ao incentivo aos fatores de proteção aos maus-tratos.

Abordagem diagnóstica e terapêutica da toxoplasmose em gestantes e as repercussões no recém-nascido / Diagnostic and therapeutic management of toxoplasmosis in pregnancy and the effect in the newborn

OBJETIVO:Avaliar a abordagem diagnóstica e terapêutica da toxoplasmose de gestantes que apresentaram IgM positiva para a doença e o acompanhamento de seus filhos em um hospital público no Rio de Janeiro, RJ. MÉTODOS: Estudo transversal retrospectivo de 2003 a 2006, realizado por meio da análise dos prontuários de 98 gestantes com sorologia IgM positiva para toxoplasmose e seus filhos (99 crianças). O seguimento das crianças com e sem infecção congênita foram analisados, assim como a apresentação clínica daquelas com infecção congênita e os testes diagnósticos utilizados para identificar a infecção pelo Toxoplasma gondii durante a gestação. RESULTADOS: O diagnóstico sorológico foi realizado em 76 pacientes no segundo e terceiro trimestre gestacional. Em 36 gestantes, a determinação dos níveis séricos de IgM foi o único teste diagnóstico realizado para infecção pelo toxoplasma. Em 49 gestantes, os índices de IgM, pela técnica ELFA, foram baixos. O teste de avidez de IgG foi realizado em 62 gestantes e somente 13 o realizaram no primeiro trimestre gestacional. O tratamento específico para toxoplasmose foi empregado em 93 gestantes. A taxa de transmissão vertical foi de 4 por cento. Manifestações clínicas de toxoplasmose congênita foram encontradas em todas as crianças infectadas. Todas as crianças não infectadas apresentaram declínio de IgG específica para toxoplasmose ao longo do acompanhamento ambulatorial; a idade média de IgG comprovadamente negativa nessas crianças foi de 5,4 meses. CONCLUSÕES: Os resultados sugerem que uma sorologia positiva para IgM, como um único marcador sorológico para detectar infecção recente, tem um valor limitado.

OBJECTIVE: To analyze the diagnostic and therapeutic approach of pregnant women with positive IgM test for toxoplasmosis and the follow-up of their children in a public hospital of Rio de Janeiro, Brazil. METHODS: This cross-sectional retrospective study from 2003 to 2006 enrolled 98 pregnant women with positive IgM test for toxoplasmosis and 99 children. The follow-up of the children with or without congenital infection was reviewed, as well as the clinical presentation of those with congenital infection and the laboratory tests used to diagnose the infection by Toxoplasma gondii during pregnancy. RESULTS: Toxoplasmosis was diagnosed in the second and third trimesters of pregnancy in 76 patients. In 36 pregnant women, determination of the serum levels of IgM was the only laboratory method used to diagnose the infection. Low IgM levels analyzed by ELFA were detected in 49 pregnant women. IgG avidity test was performed in 62 patients and in 13 percent of them the exam was carried out during the first trimester of pregnancy. Specific treatment for toxoplasmosis was applied in 93 women. Vertical transmission rate was 4 percent. Clinical manifestation of congenital toxoplasmosis was found in all infected children. All non-infected children showed a decrease in IgG serum levels for toxoplasmosis during the follow-up. The mean age for negativation of IgG serum levels in these children was 5.4 months. CONCLUSIONS: Our results suggest that the use of a positive IgM test to toxoplasmosis as the only antibody marker to detect recent infection has a limited value.