Top 10 evidence-based recommendations from the Brazilian Society of Infectious Diseases for the Choosing Wisely Project.

The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.

Confirmatory molecular method for HTLV-1/2 infection in high-risk pregnant women.

Human T-cell lymphotropic virus types 1/2 (HTLV-1/2) are transmitted through sexual intercourse, transfusion of blood components, and vertical transmission, predominantly through breastfeeding. Six hundred forty-three pregnant women from a high-risk prenatal care unit at a general hospital were tested by serological tests using chemiluminescence (CMIA) for screening, followed by a molecular confirmatory test. Four patients (0.6%) tested positive for HTLV-1/2 by CMIA, two samples (0.3%) for each patient were confirmed as having HTLV-1 or HTLV-2 by PCR. The results show the importance of inclusion of HTLV-1/2 screening for pregnant women in high-risk prenatal care and the need for a molecular biological method to confirm HTLV-1/2 infection.

Impact and seasonality of human rhinovirus infection in hospitalized patients for two consecutive years / Impacto e sazonalidade da infecção por rinovírus humano em pacientes internados por dois anos consecutivos

Abstract Objectives: To report epidemiological features, clinical characteristics, and outcomes of human rhinovirus (HRV) infections in comparison with other community acquired respiratory virus (CRV) infections in patients hospitalized for two consecutive years. Methods: This was a cross-sectional study. Clinical, epidemiological, and laboratory data of patients hospitalized with acute respiratory syndrome in a tertiary care hospital from 2012 to 2013 were reviewed. Results: HRV was the most common CRV observed (36%, 162/444) and was present in the majority of viral co-detections (69%, 88/128), mainly in association with human enterovirus (45%). Most HRV-infected patients were younger than 2 years (57%). Overall, patients infected with HRV had a lower frequency of severe acute respiratory infection than those infected with other CRVs (60% and 84%, respectively, p = 0.006), but had more comorbidities (40% and 27%, respectively; p = 0.043). However, in the adjusted analysis this association was not significant. The mortality rate within the HRV group was 3%. Detection of HRV was more prevalent during autumn and winter, with a moderately negative correlation between viral infection frequency and temperature (r = −0.636, p < 0.001) but no correlation with rainfall (r = −0.036, p = 0.866). Conclusion: HRV is usually detected in hospitalized children with respiratory infections and is often present in viral co-detections. Comorbidities are closely associated with HRV infections. These infections show seasonal variation, with predominance during colder seasons.

Resumo Objetivos: Relatar as características epidemiológicas, as características clínicas e os resultados das infecções por rinovírus humano (RVH) em comparação a outras infecções por vírus respiratórios adquiridos na comunidade (VRCs) em pacientes internados por dois anos consecutivos. Métodos: Este foi um estudo transversal. Foram revisados os dados clínicos, epidemiológicos e laboratoriais de pacientes internados com síndrome respiratória aguda em um hospital terciário de 2012 a 2013. Resultados: O RVH foi o VRC mais comum observado (36%, 162/444) e esteve presente na maior parte das codetecções virais (69%, 88/128), principalmente em associação ao enterovírus humano (45%). A maioria dos pacientes infectados por RVH possuía menos de 2 anos (57%). De modo geral, os pacientes com RVH apresentaram uma menor frequência de infecção respiratória aguda grave que os pacientes infectados por outros VRCs (60% e 84%, respectivamente, p = 0,006), porém mais comorbidades (40% e 27%, respectivamente; p = 0,043). Contudo, em uma análise ajustada, essa associação não foi significativa. A taxa de mortalidade no grupo RVH foi 3%. A detecção de RVH foi mais prevalente durante o outono e inverno, com uma correlação negativa moderada entre a frequência de infecção viral e a temperatura (r = -0,636, p < 0,001), porém nenhuma correlação com a precipitação (r = −0,036, p = 0,866). Conclusão: O RVH é normalmente detectado em crianças internadas com infecções respiratórias e normalmente está presente em codetecções virais. As comorbidades estão estreitamente associadas a infecções por RVH. Essas infecçõesmostram variação sazonal, com predominância durante as estações mais frias.

Flavivirus cross-reactivity in serological tests and Guillain-Barré syndrome in a hematopoietic stem cell transplant patient: A case report.

Serological diagnosis of flavivirus infection is a challenge, particularly in the context of a disease associated with immune response enhancement in a transplant patient, where aspects such as previous flavivirus infections may be involved with the outcome. We report a case of a pediatric patient who developed Guillain-Barré syndrome (GBS) after matched-unrelated hematopoietic stem cell transplantation (HSCT). The patient lives in a Brazilian region that is experiencing an epidemic of Zika virus (ZIKV) and dengue virus (DENV). Because an increasing number of cases of GBS, likely triggered by ZIKV infection, are being reported in Brazil, samples from the patient were tested for both ZIKV and DENV infection. Serological assays strongly suggested a recent ZIKV infection, although infection by DENV or co-infection with both viruses cannot be ruled out. The presence of anti-DENV immunoglobulin-G in donor serum led to the hypothesis that antibodies from the donor could have enhanced the severity of the ZIKV infection. This hypothesis is in agreement with the recent findings that DENV sero-cross-reactivity drives antibody-dependent enhancement of ZIKV infection. These findings highlight the need for discussion of the indication to perform previous flavivirus tests in HSCT donors, especially in areas where ZIKV and other flaviviruses co-circulate.

Biomarkers of chemotaxis and inflammation in cerebrospinal fluid and serum in individuals with HIV-1 subtype C versus B.

A defective chemokine motif in the HIV-1 Tat protein has been hypothesized to alter central nervous system cellular trafficking and inflammation, rendering HIV-1 subtype C less neuropathogenic than B. To evaluate this hypothesis, we compared biomarkers of cellular chemotaxis and inflammation in cerebrospinal fluid (CSF) and serum in individuals infected with HIV-1 subtypes B (n = 27) and C (n = 25) from Curitiba, Brazil. None had opportunistic infections. Chemokines (MCP-1, MIP-1α, MIP-1ß, RANTES, IP-10) and cytokines (TNF-α, IFN-γ, IL-1ß, IL-2, IL-4, IL-6, IL-7, IL-10) were measured using the multiplex bead suspension array immunoassays or ELISA HD. CSF and serum biomarker concentrations were compared between subtype B and C groups and HIV-positive and HIV-negative subjects (N = 19) using an independent group t test (unadjusted analysis) and linear regression (adjusted analysis), controlling for nadir CD4 and CSF and plasma HIV RNA suppression. CSF levels of cytokines and chemokines were significantly (p < 0.05) elevated in HIV-positive versus HIV-negative participants for 7/13 biomarkers measured, but levels did not differ for subtypes B and C. Serum levels were significantly elevated for 4/13 markers, with no significant differences between subtypes B and C. Although pleocytosis was much more frequent in HIV-positive than in HIV-negative individuals (27 vs. 0 %), subtypes B and C did not differ (32 and 22 %; p = 0.23). We did not find molecular evidence to support the hypothesis that intrathecal chemotaxis and inflammation is less in HIV-1 subtype C than in subtype B. Biomarker changes in CSF were more robust than in serum, suggesting compartmentalization of the immunological response to HIV.

Clinical and epidemiological features of respiratory virus infections in preschool children over two consecutive influenza seasons in southern Brazil.

This study reports the results of a systematic screening for respiratory viruses in pediatric outpatients from an emergency department (ED) in southern Brazil during two consecutive influenza seasons. Children eligible for enrollment in this study were aged 24-59 months and presented with acute respiratory symptoms and fever. Naso- and oropharyngeal swabs were collected and multiplex reverse transcription PCR (RT-PCR) was performed to identify the respiratory viruses involved. In total, 492 children were included in this study: 248 in 2010 and 244 in 2011. In 2010, 136 samples (55%) were found to be positive for at least one virus and the most frequently detected viruses were human rhinovirus (HRV) (18%), adenovirus (AdV) (13%), and human coronavirus (CoV) (5%). In 2011, 158 samples (65%) were found to be positive for at least one virus, and the most frequently detected were HRV (29%), AdV (12%), and enterovirus (9%). Further, the presence of asthma (OR, 3.17; 95% CI, 1.86-5.46) was independently associated with HRV infection, whereas fever was associated with AdV (OR, 3.86; 95% CI, 1.31-16.52) and influenza infections (OR, 3.74; 95% CI, 1.26-16.06). Ten patients (2%) were diagnosed with pneumonia, and six of these tested positive for viral infection (4 HRV, 1 RSV, and 1 AdV). Thus, this study identified the most common respiratory viruses found in preschool children in the study region and demonstrated their high frequency, highlighting the need for improved data collection, and case management in order to stimulate preventive measures against these infections. J. Med. Virol. 88:1325-1333, 2016. © 2016 Wiley Periodicals, Inc.

Human cytomegalovirus detection by real-time PCR and pp65-antigen test in hematopoietic stem cell transplant recipients: a challenge in low and middle-income countries.

AIM: Cytomegalovirus (CMV) infection is one of the most common complications in patients submitted to hematopoietic stem cell transplant (HSCT). Pre-emptive therapy has been indicated in patients with laboratory evidence of CMV replication. The aims of this study were to compare real-time PCR or pp65 antigen assay methodologies to detect CMV replication in HSCT patients, define a viral load threshold for initiation of pre-emptive therapy, and assess the feasibility of its implementation in hospitals of countries with low and middle income. MATERIAL AND METHODS: Human CMV detection by real-time PCR and pp65 antigen assay was carried out in blood and plasma samples of HSCT patients collected weekly during 3 months. Pre-emptive therapy was based on CMV antigenemia results. RESULTS: Twenty-one patients were monitored with a total of 227 samples collected; 13 (62%) patients were children. A poor correlation was observed between qualitative results, though quantitative results showed statistically significant difference, with higher viral loads detected in patients with positive antigenemia. Compared to a positive antigenemia, a cutoff value of 1067·5 copies/ml, 3·03 log10/ml, for viral load was obtained with 100% sensitivity and 71% specificity. CONCLUSION: CMV real-time PCR in whole blood was suitable for monitoring HSCT patients. However, its high cost is a limiting factor, and it could be used to monitor selected patients, those with prolonged leukopenia and underweight children, and subsequently switched to pp65 antigen test. Further studies involving larger numbers of patients should be performed to confirm this statement.

Caracterização molecular dos genótipos do rotavírus em pacientes pediátricos imunossuprimidos e não imunossuprimidos / Molecular characterization of rotavirus genotypes in immunosuppressed and non-immunosuppressed pediatric patients

OBJETIVO: Descrever a variabilidade genotípica do rotavírus grupo A (RVA) encontrado em pacientes pediátricos imunocompetentes e imunocomprometidos tratados no Hospital de Clínicas/Universidade Federal do Paraná (HC/UFPR), Curitiba, Paraná. MÉTODOS: Foi realizado um estudo transversal com 1.140 amostras de fezes coletadas, de abril de 2001 a dezembro de 2008, em pacientes ambulatoriais e pacientes hospitalizados com gastroenterite aguda encaminhados ao hospital. As técnicas usadas foram o método da aglutinação do látex e imunoensaio enzimático para diagnóstico de RVA. Foi realizada transcrição reversa, seguida por PCR multiplex semi-nested e sequência de nucleotídeos para caracterização do genótipo. Foram relatados dados de combinações de genótipos, clínicos, epidemiológicos, laboratoriais e sobre a presença de infecções hospitalares. RESULTADOS: Foi analisado um total de 80 amostras de fezes positivas para rotavírus. As associações mais frequentes entre os genótipos G e P foram: G4 P[8] (38,9%), G1 P[8] (30,5%), G9 P[8] (13,9%), G2 P[4] (6.9 %) e G3 P[8] 1,4%). O genótipo prevalente foi G2 P[4] depois da implementação da vacina nos anos de 2006 e 2008. Verificou-se que um total de 62,5% das crianças com idade abaixo de 12 meses estavam infectadas. Destas, 55,6% tinham grave desidratação, e 26,7% precisaram de cuidados intensivos. Encontrou-se uma frequência de 12,5% de infecções hospitalares. Não se observou correlação entre o genótipo e a gravidade da infecção nos pacientes estudados. CONCLUSÃO: As infecções por RVA podem associar-se a manifestações clínicas graves e é crucial a vigilância da variabilidade genotípica desse vírus para monitorizar a emergência de novas cepas e o impacto da imunização nesses pacientes.

OBJECTIVE: To describe the genotypic variability of group A rotavirus (RVA) found in immunosuppressed and non-immunosuppressed pediatric patients treated at the Hospital de Clínicas da Universidade Federal do Paraná (HC-UFPR), Curitiba, Paraná. METHODS: A cross-sectional study was conducted with 1,140 stool samples collected from April, 2001 to December, 2008 in outpatients and hospitalized patients with acute gastroenteritis referred to the hospital. RVA diagnosis was performed through the latex agglutination method and enzyme immunoassay. Reverse transcription followed by multiplex hemi-nested polymerase chain reaction (PCR) and nucleotide sequencing were used for genotype characterization. Genotype combinations, clinical data, epidemiological data, laboratory data, and presence of hospital-acquired infections were reported. RESULTS: A total of 80 rotavirus-positive stool samples were analyzed. The most frequent associations between genotypes G and P were: G4 P[8] (38.9%), G1 P[8] (30.5%), G9 P[8] (13.9%), G2 P[4] (6.9%), and G3 P[8] (1.4%). G2 P[4] was the most prevalent genotype after the vaccine implementation in the years 2006 and 2008. A total of 62.5% of children aged less than 12 months were found to be infected. Of these, 55.6% had severe dehydration and 26.7% needed intensive care. A frequency of 12.5% of nosocomial infections was found. No correlation was observed between genotype and severity of infection in the study patients. CONCLUSION: RVA infections can be associated with severe clinical manifestations, and the surveillance of genotypic variability of this virus is crucial to monitor the emergence of new strains and the impact of the immunization in these patients.

Polyomavirus BK: possibly associated skin eruption in a patient with hemorrhagic cystitis.

A 14-year-old girl with Fanconi anemia was submitted to allogeneic hematopoietic stem cell transplantation. After 17 days she developed hemorrhagic cystitis due to polyoma BK virus (BKV), confirmed by PCR (polymerase chain reaction). Two weeks after the appearance of the urinary symptoms the patient presented numerous papules and vesicles on both hands and feet. PCR of the skin lesions and plasma was positive for BKV. The relationship of BKV with frequent infections in immunocompromised patients is well established. The positive PCR of vesicular fluid suggests that this was the causative agent of the skin lesion in this case. There are no reports of skin lesions with positive PCR for BKV.

Impact of human metapneumovirus infection on in and outpatients for the years 2006-2008 in Southern Brazil

The human metapneumovirus (hMPV), member of the Paramyxoviridae family, has been reported as an important agent involved with acute respiratory infections (ARIs). The aim of this study is to identify hMPV as the etiological agent of ARIs on in and outpatients in the city of Curitiba, Southern Brazil, and describe clinical data of hMPV subtyping. A retrospective study was performed in 1,572 respiratory samples over a period of three years. hMPV was detected by reverse transcription-polymerase chain reaction and subtyping was performed by nucleotide sequencing. hMPV was present in 61 (3.9 percent) samples and subtypes A1, A2a, B1 and B2 were detected. The incidence of hMPV was higher in outpatients (5.9 percent), whose mean age was 19.7 years (range 6 months-75 years old), than in inpatients (3 percent), whose mean age was 7.6 months (range 1 month-26 years old). The outpatients had upper respiratory tract infections with flu-like symptoms and all hospitalized children had lower respiratory tract infections. A pediatric patient died from complications associated with hMPV A2a infection. hMPV has been reported as a respiratory pathogen in all age groups. No correlation was observed between viral subtype and disease severity in the samples of this study.

Respiratory viruses in pediatric necropsies: an immunohistochemical study.

Infections of the respiratory system are responsible for the majority of hospitalizations and deaths in pediatric patients in developing countries. We selected 177 necropsies of pediatric patients who died as a result of serious respiratory infections. The histopathological findings and epidemiological data were reviewed, and lung tissue samples were separated for immunohistochemistry testing. Conventional immunohistochemistry techniques were used to detect viral antigens in formalin-fixed, paraffin-embedded (FF-PE) lung tissue samples using a pool of monoclonal antibodies against respiratory viruses (respiratory syncytial virus, influenza A and B, adenovirus, and parainfluenza 1, 2, and 3 viruses) as primary antibodies. The histopathological findings were classified into bronchopneumonia (BCP) and interstitial pneumonitis (IP) patterns. The immunohistochemistry results were compared with histopathological patterns and epidemiological data. Positive results for viruses were found in 34% and 62.5% of the BCP and IP cases, respectively. Males and infants below 1 year of age were more frequent in the group that had positive results for viruses. Acute enteritis was the main cause of hospitalization and sepsis the most frequent cause of death in this group. A clear seasonal distribution was observed, with the majority of cases occurring in the 2nd and 3rd trimesters (autumn and winter) of each year in the period studied. Immunohistochemistry is an affordable and easy-to-perform method for viral-antigen detection in FF-PE tissue samples. Although BCP is a classic histopathological pattern found in bacterial infections, it is possible that children with serious respiratory infections had concomitant viral and bacterial infections, regardless of their previous immunologic state.

The epidemiology and antigenic characterization of influenza viruses isolated in Curitiba, South Brazil

Several studies conducted all over the world have reported that the influenza virus is associated with great morbidity and mortality rates. In this study, we analyzed the incidence of the influenza virus between 2000 and 2003 in Curitiba. We studied 1621 samples obtained from outpatients and hospitalized patients of both sexes and all ages. The study was conducted at the local primary care health units (outpatients) and at the tertiary care unit (hospitalized) of the General Hospital of the Federal University in the state of Paraná, Brazil. Nasopharyngeal aspirates and, eventually, bronchoalveolar lavage were assayed for the presence of viral antigens, either by indirect immunofluorescence or cell culture. Of the samples studied, 135 (8.3 percent) were positive for influenza virus, and of those, 103 (76.3 percent) were positive for type A and 32 (23.7 percent) for type B. Additionally, positive samples were analyzed by reverse transcription followed by polymerase chain reaction and subtypes H1 and H3 were identified from this group. A high incidence of positive samples was observed mainly in the months with lower temperatures. Furthermore, outpatients showed a higher incidence of influenza viruses than hospitalized patients.

Viral respiratory infection in Curitiba, Southern Brazil.

OBJECTIVE: Viral infection is the major cause of respiratory tract pathology affecting individuals of all ages, especially children and immunocompromised patients. There is a paucity of data on etiological and epidemiological infection caused by virus, in Southern Brazil. The aim of this study was to evaluate the seasonality, and the incidence of the viruses involved in respiratory infections in Curitiba, South Brazil. METHODS: Two hundred seventy-three nasopharyngeal aspirates (NPA) from primary care health units and 1348 NPA or bronchoalveolar lavages from a tertiary-care teaching hospital were studied. Viruses were identified by indirect immunofluorescence and cellular culture. RESULTS: Thirty percent of tested samples scored positive for the presence of virions. The percentages of infection for each virus from outpatients and hospitalized, respectively, were 3.3, 19.3 for respiratory syncytial virus; 13.9, 3.5 for influenza A, 3.0, 1.7 for influenza B; 3.3, 5.6 for parainfluenza virus and 2.2, 0.8 for adenovirus. A higher incidence of positive results was found during the winter season, thus showing a pattern of seasonality. CONCLUSION: Viral agents are one of the main etiologies of respiratory tract pathology in the population studied.

Respiratory tract viral infections in bone marrow transplant patients.

BACKGROUND: Community respiratory viruses such as respiratory syncytial virus (RSV), adenovirus, influenza A, influenza B, and the parainfluenza group are frequent causes of respiratory disease in bone marrow transplant (BMT) patients. MATERIAL AND METHODS: During the period from March 1993 to August 1999, 810 samples of respiratory secretions, nasopharyngeal aspirate (NPA) or bronchoalveolar lavage (BAL), from 722 patients with upper respiratory infections symptoms at the BMT unit of the Federal University in the state of Paraná, Brazil were evaluated for respiratory virus infection. RESULTS: One hundred thirty-six (17%) samples were reactive in 62 patients. RSV was found in 30 of 62 (48%), influenza A in 14 of 62 (23%), influenza B in 9 of 62 (15%), parainfluenza group in 7 of 62 (11%), and adenovirus in 2 of 62 (3%) infected patients. The most frequent clinical manifestations were cough and fever. Pneumonia occurred in 19 of 62 (31%) cases. The mortality rate was 23 of 62 (37%), being higher among patients infected with adenovirus and influenza A. CONCLUSIONS: Infections in BMT patients occurred during the outbreak period of these viruses in the community, highlighting the need to establish surveillance measures in units with immunocompromised patients in addition to the development of sensitive and rapid diagnostic tests for the detection of these viruses in patients with respiratory symptoms.

Comparison of latex agglutination with enzyme immunoassay for detection of rotavirus in fecal specimens.

Human rotaviruses are the most important etiologic agents of acquired diarrhea in infants and young children worldwide. Early diagnosis is essentialfor effective patient treatment. The latex agglutination (LA) assays for rotavirus diagnosis are rapid, inexpensive, and the most widely used to screen specimens. The performance of the LA Rotagen (Biokit S.A., Barcelona, Spain) was evaluated for rotavirus detection infecal samples of outpatients with acute gastroenteritis. This assay was compared with the enzyme immunoassay (EIA) EIARA (Bio-Manguinhos, Rio de Janeiro, Brazil). From January to October 2000, 285 fecal specimens were analyzed. Forty-four samples (15.4%) were reactive, 214 (75.4%) were nonreactive, and 27 (9.5%) were indeterminate by LA. All LA-positive samples were positive by EIA, and 2 LA-negative samples were positive by EIA. Of specimens indeterminate by LA, 67% were positive by EIA. The sensitivity, specificity, and accuracy of LA were 69%, 100%, and 93%, respectively. These results indicate that assay is as sensitive and specific as the EIA, and it could be applied on a large scale for screening stool specimens in suspected rotavirus diarrhea. However, the indeterminate results must be confirmed by other methods, such as EIA.