Hepatitis C virus (HCV) viremia in HIV-infected patients without HCV antibodies detectable by third-generation enzyme immunoassay.

BACKGROUND: The detection of hepatitis C virus antibody (anti-HCV) by enzyme immunoassay to screen HCV infection in HIV-1-infected individuals may yield false negative results, especially in patients with advanced immunosuppression. In such cases, a diagnosis would be possible only by use of a viral RNA detection technique. Third-generation anti-HCV enzyme immunoassays seem to have superior performance compared to second-generation immunoassays in this context. METHODS: A cross-sectional study was conducted to ascertain the presence of HCV by polymerase chain reaction (PCR) in 61 HIV-1-infected patients with CD(4)(+) cell counts <200 cells/mm(3), and no detectable HCV antibodies by a third-generation enzyme immunoassay. RESULTS: Six (10%) of 61 patients tested HCV-RNA positive by PCR assay. There was one patient who seroconverted during observation. Hence, there were five patients with HCV viremia without detectable antibodies to HCV throughout the study, which represents 8.2% (95% confidence interval: 2.8-18.4) of 61 HIV-1-infected patients. All five carriers of HCV viremia had CD4 counts <100 cells/mm(3) and were diagnosed with an opportunistic disease at some stage. CONCLUSIONS: The HCV viremia and no detectable HCV antibodies by third-generation immunoassay were found only in individuals with a CD(4) count of <100 cells/mm(3). Molecular assays to detect HCV-RNA should be considered as an important tool to diagnose hepatitis C in HIV-1-infected patients with advanced immunosuppression.

Esophageal ulcers caused by reactivation of ganglionary tuberculosis: a case report.

The involvement of the esophagus in tuberculosis (TB) is extremely rare. This is a case report of an immunocompetent male patient, who presented ganglionary TB reactivation, with the development of extensive esophageal ulcers. The endoscopic approach made the diagnosis possible and there was a total resolution of the symptoms after the treatment.

Esophageal ulcers caused by reactivation of ganglionary tuberculosis: a case report

The involvement of the esophagus in tuberculosis (TB) is extremely rare. This is a case report of an immunocompetent male patient, who presented ganglionary TB reactivation, with the development of extensive esophageal ulcers. The endoscopic approach made the diagnosis possible and there was a total resolution of the symptoms after the treatment.

O uso de nutrição enteral precoce pós-transplante hepático adulto / The use of early enteral feeding post orthotopic liver transplantation in adults

RACIONAL: O transplante hepático é o tratamento de escolha para várias doenças hepáticas terminais. A desnutrição nesta população é freqüente. O uso de nutrição enteral precoce não é rotina nos grupos de transplante. OBJETIVO: Relatar a experiência do uso de nutrição enteral precoce em indivíduos transplantados hepáticos e avaliar sua segurança. PACIENTES/MÉTODOS: Foram estudados 35 adultos submetidos a transplante hepático. A avaliação do estado nutricional pré-transplante hepático foi realizada pela avaliação nutricional subjetiva global e força do aperto da mão não-dominante, aferida pela dinamometria. A dieta enteral foi iniciada em até 12 horas. A via oral foi iniciada assim que houvesse ruídos hidroaéreos. RESULTADOS: A média de idade dos indivíduos avaliados foi de 45,5 anos (± 8,93). De acordo com a avaliação nutricional subjetiva global, a prevalência de desnutrição pré-transplante foi de 77,1 por cento e pela força do aperto da mão não-dominante de 100 por cento. A nutrição enteral precoce foi iniciada em até 12 horas, moda de 10,9 horas e mantida exclusivamente por período médio de 2,6 dias (± 2,2). Via oral exclusiva foi obtida no período médio de 9,5 dias (± 9,7). A nutrição enteral precoce proveu o aporte calórico estimado em 97 por cento dos casos. Intolerância à dieta enteral ocorreu em cinco indivíduos (14,2 por cento), sendo que em quatro foi reinstituída com sucesso após intervalo de 12 horas. A prevalência de infecção respiratória foi de 28,6 por cento. Em apenas dois pacientes (5,7 por cento) houve broncopneumonia com aspecto aspirativo ao estudo radiológico do tórax. CONCLUSÕES: A nutrição enteral precoce foi um método eficaz na provisão de calorias e seguro em sua aplicação a pacientes transplantados hepáticos.

[The use of early enteral feeding post orthotopic liver transplantation in adults]. / O uso de nutrição enteral precoce pós-transplante hepático adulto.

BACKGROUND: Orthotopic liver transplantation is the treatment of choice for end-stage liver disease. Malnutrition is common in this population. Early enteral nutrition is not routine in the transplant groups. AIM: To report our experience with the use of early enteral nutrition in patients undergoing orthotopic liver transplantation and also evaluate its safety. PATIENTS/METHODS: We studied 41 adults submitted to orthotopic liver transplantation. Pre- orthotopic liver transplantation nutritional assessment was accomplished by the subjective global assessment and grip strength. Enteral nutrition was begun in 12 hours. Oral feeding was initiate gradually as soon as possible. RESULTS: We studied 35 individuals, with an average of age of 45.5 years (8.93). The prevalence of malnutrition in orthotopic liver transplantation was of 77.1% determined by subjective global assessment, and 100% by grip strength. Early enteral nutrition was begun in all of the individuals in up to 12 hours, mode 10.9 hours, and maintained exclusively by medium period of 2.6 days (2.2). Oral feeding was obtained in the medium period of 9.5 days (9.7). Early enteral nutrition provided total caloric intake in 97% of the cases. Intolerance to the enteral feeding occurred in five individuals (14.2%), and in four of them it was resumed successfully after 12 hours. The prevalence of respiratory infection was of 28.6%. In only two patients (5.7%) there was aspirative bronchopneumonia. CONCLUSIONS: Early enteral nutrition is an effective method in the provision of calories and safe in application to patients undergoing orthotopic liver transplantation.

Microbiology of choledochal bile in patients with choledocholithiasis admitted to a tertiary hospital.

AIM: The present study was designed to investigate the microbiology of choledochal bile of patients with cholangitis and choledocholithiasis. METHODS: We identified and determined the antimicrobial susceptibility of bacteria isolated in the bile of patients with cholangitis and choledocholithiasis diagnosed by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Nineteen (82.6%) of 23 patients with choledocholithiasis had positive bile cultures. A single agent was detected in 11 patients (57.9%), while a mixed growth, with pathogens ranging from two to three species, were seen in eight patients (42.1%). Patients with clinical manifestations of cholangitis had significantly higher counts of colonies per mL of bile (> 105 cfu/mL). The predominant Gram-negative aerobic bacteria isolated were Escherichia coli (9, 31.0%), Klebsiella pneumoniae (5, 17.2%), Enterobacter cloacae (2, 6.9%), Pantoea agglomerans (1, 3.4%), and Pseudomonas aeruginosa (1, 3.4%). The predominant Gram-positive bacteria were Enterococcus faecalis (5, 17.2%) and Streptococcus sp. (5, 17.2%). Bacteroides fragilis was isolated in one patient with mixed growth. All Gram-positive bacteria isolated in bile were sensitive to ampicillin, and all Gram-negative bacteria isolated were sensitive to gentamicin with a minimum inhibitory concentration (CIM90) ranging from 0.5 to 1.0- micro g/mL. Gram-negative bacteria were also sensitive to imipenem, fluorquinolones, second and third generation cephalosporins. Although all five isolates of E. faecalis were sensitive to ampicillin, two of five (40%) E. faecalis isolates demonstrated high levels of resistance to gentamicin. CONCLUSION: E. coli, K. pneumoniae, E. faecalis and Streptoccocus sp. were the most common bacteria isolated in the bile of patients with cholangitis and choledocholithiasis, which were sensitive to a simple therapeutic regimen, such as the combination of ampicilin and gentamicin.

Gastrostomia endoscópica percutânea (PEG): avaliação e perspectivas / Percutaneous endoscopic gastrostomy (PEG): assessment and prospects

Desde sua criação em 1980, a gastrostomia endoscópica percutânea (PEG) tem sido incorporada às rotinas de tratamento de pacientes criticamente enfermos com dificuldades na deglutição. A expectativa de tempo mínimo de uso deve ser de duas a quatro semanas, com média de tempo de permanência de cerca de 216 dias. As contra-indicações absolutas são peritonite difusa, expectativa de vida muito curta, anorexia nervosa. O procedimento de inserção é rápido (14 min em média), realizado com anestesia local, necessitando auxílio endoscópico para visualização e posicionamento do aparato; É recomendável o uso de antibiotico-profilaxia. Os índices de complicações variam de acordo com as co-morbidades dos pacientes submetidos à gastrostomia e com a experiência da equipe multidisciplinar que insere e mantém os cuidados pós-procedimento. Complicações leves são da ordem de 6 a 30 por cento e as graves de 3 a 8por cento. Quando comparadas com a técnica cirúrgica com anestesia geral, houve menor mortalidade e menor índice de complicações graves. Trata-se de uma opção com provável melhor resultado nutricional e estético, com o benefício de menor morbimortalidade em relação aos métodos cirúrgico