Mycobacteremia in patients with the acquired immunodeficiency syndrome.

BACKGROUND: Bacillemia is a key event in the pathogenesis of tuberculosis. Although current evidence indicates that Mycobacterium tuberculosis bacteremia is rare in patients seronegative for the human immunodeficiency virus, it has been increasingly reported in patients with the acquired immunodeficiency syndrome (AIDS). OBJECTIVE: To determine clinical and laboratory characteristics of patients with AIDS and tuberculosis with and without bacillemia. METHODS: Fifty patients with AIDS with clinical suspicion of disseminated mycobacterial disease were prospectively selected. Three consecutive blood samples were collected for culture using a standardized protocol. RESULTS: Mycobacterium was isolated from any body site in 42 patients (84%). Bacillemia was detected in 30 (71.4%) of these 42 patients: 11 (28.2%) caused by Mycobacterium avium-intracellulare complex and 19 (71.8%) caused by M tuberculosis. Blood culture was the only method used to confirm the diagnosis in 5 (15%) of the 33 tuberculosis cases. Tuberculosis in patients with AIDS developed with nonspecific insidious symptoms, a remarkable elevated alkaline phosphatase level, and without the classic miliary radiological pattern. We could demonstrate 2 previously unrevealed clinical characteristics of bacteremic tuberculosis in patients with AIDS: a shift to the left in the white blood cell count and abdominal lymph node enlargement. In patients with tuberculosis, the in-hospital mortality rate was higher among patients with bacillemia, although the posttreatment survival rate was comparable. CONCLUSIONS: Blood culture is a valuable tool to confirm the clinical diagnosis of disseminated tuberculosis in patients with AIDS and can distinguish patients with characteristic clinical findings and outcome. Abdominal ultrasonography may be an additional helpful tool to identify these patients.

Microbiota oral e retal de calitriquídeos (Callithrix sp) em área antropizada de Mata Atlântica, Rio de Janeiro, Brasil / [Oral and rectal microbiota of callitrichids (Callithrix sp) in an anthropized area of the Atlantic Forest in Rio de Janeiro, Brazil]

A proximidade dos primatas não humanos (PNH) com o ser humano pode ser considerada um fator de risco para transmissão de bactérias entre essas duas populações. Neste estudo, foi investigada a microbiota anfibiôntica aeróbica oral e retal de calitriquídeos em um fragmento de Mata Atlântica localizado no Rio de Janeiro, Brasil, e foram realizados testes fenotípicos para detecção de bactérias multirresistentes nos isolados encontrados. Foram capturados 14 calitriquídeos e coletadas 21 amostras (14 de cavidade oral e sete de cavidade retal) em dois pontos da mata próximos às habitações humanas. As espécies mais frequentes, na cavidade oral, foram Klebsiella oxytoca (50,0%), K. pneumoniae (28,6%), Kluyvera ascorbata (21,4%) e Stenotrophomonas maltophilia (21,4%) e, na cavidade retal, K. pneumoniae (85,7%), Escherichia coli (28,6%) e Enterobacter spp. (42,9%). Todos os 48 isolados da família Enterobacteriaceae foram negativos para ESBL (betalactamase de espectro ampliado), mostrando-se não produtores da enzima nos dois métodos utilizados: disco-aproximação e método de detecção automatizado. Na pesquisa de ERC (enterobactérias resistentes a carbapenêmicos), esses mesmos isolados não apresentaram resistência aos antibióticos imipenem, meropenem e ertapenem. Todas as bactérias isoladas apresentam um potencial zoonótico, o que representa um risco à saúde pública e à conservação das espécies.(AU)

Proximity of nonhuman primates (NHP) to humans can be considered a risk factor for transmission of pathogens between these two populations. This study investigated the oral and rectal aerobic bacterial microbiota of marmosets in an anthropized area of the Atlantic Forest located in Rio de Janeiro, Brazil, and performed phenotypic tests for detection of multidrug-resistant bacteria. Twenty-one samples (14 from the oral cavity and seven from the rectum) were collected from 14 Callithrix sp. captured in two sites of the forest near human dwellings. The most frequent species identified from the oral cavity swabs were Klebsiella oxytoca (50.0%), K. pneumoniae (28.6%), Kluyvera ascorbata (21.4%) and Stenotrophomonas maltophilia (21.4%), whereas the species most commonly identified from the rectum swabs were K. pneumoniae (85.7%), Enterobacter spp. (42.9%) and Escherichia coli (28.6%). All isolates of family Enterobacteriaceae showed no extended spectrum ß-lactamase production by disk-diffusion and automated detection tests. In the search for carbapenem-resistant enterobacteriaceae these isolates presented no resistance to the imipenem, meropenem and ertapenem antibiotics. The isolate of Staphylococcus aureus was susceptible to oxacillin and the isolate of Enterococcus was susceptible to vancomycin. All isolated bacteria showed zoonotic potential, thus posing a risk to species conservation and public health.(AU)

Emergence of a methicillin-resistant Staphylococcus aureus clone related to the Brazilian epidemic clone III::B:A causing invasive disease among AIDS patients in a Brazilian hospital.

In a previous study we described the extensive geographic spread of a multidrug-resistant methicillin-resistant Staphylococcus aureus (MRSA) clone in hospitals located in the southern, southeastern, and northern parts of Brazil. In this study we used a set of molecular markers to demonstrate the emergence of a novel MRSA clone distinct from but closely related to the widely spread Brazilian epidemic clone. The new MRSA clone caused an outbreak among acquired immunodeficiency syndrome patients in a Brazilian hospital specializing in tropical diseases and human immunodeficiency virus- and human T-cell leukemia virus (HLTV)-related infections.

Poor response to tuberculosis treatment with regimens without rifampicin in immunosuppressed AIDS patients.

A prospective study was conducted on 79 advanced immunosuppressed AIDS patients from 1997 to 1999, during which nine cases of tuberculosis (TB) were diagnosed. The main clinical and laboratory characteristics and the response to TB treatment were reviewed. The clinical manifestations of TB were: pulmonary (six cases), extrapulmonary (two cases) and disseminated (one case). These patients were being treated with highly active antiretroviral treatment (HAART) and were not responding. In three cases an optional regimen without rifampicin (RMP) was indicated to maintain HAART during TB treatment. A clinical response to TB treatment (disappearance of fever) was observed in 6/9 patients during a mean of 73 days (SD = 96). The three unresponsive patients were those treated without RMP. A switch to TB regimens containing RMP was proposed and successful. In our study, though it was limited by a small sample size, the response to TB regimens without rifampin was poor in immunosupressed patients failing HAART.

Design and operation of a whole-body monitoring system for the Goiânia radiation accident.

With as many individuals involved in the Goiânia 137Cs accident who had high levels of internal contamination, it was necessary to improvise a whole-body counter installation in loco. The in-vivo counting system was located in a 4.0 X 3.5 X 3.5-m room, where seven layers of 2-mm lead sheets with dimensions of 2.0 m X 1.0 m were overlaid on the floor at loci that were equidistant from the walls. A 20-cm diameter NaI (Tl) detector was installed at a height of 2.05 m above the floor at the center of the room. The detector was shielded and collimated with 5 cm of lead. The enormous amounts of activity in the subjects required the detector to be positioned at a height of 2.05 m. Subjects were required to wear disposable clothing and lie on a reclining, fiberglass chair. Counting time for the subjects was 2 min (live-time). The minimum detectable 137Cs activity for this counting time was 7.3 kBq* (0.05 significance level). Besides the accident victims, all individuals who had direct or indirect contact with contaminated people or areas were also monitored. More than 300 people of both sexes, with ages varying from a few months to 72 y, were measured for whole-body radioactivity. The observed activities ranged from less than the minimum detectable activity (MDA) to 59 MBq.

Requirements for authorisation of internal dosimetry services.

In order to ensure that a facility is in compliance with the occupational exposure requirements established by regulatory authorities, the measurements and dose assessments specified in the individual monitoring programme need to be reliable. There are two important questions that shall be addressed here: one is how the licensed facilities can demonstrate to their workers and regulatory bodies compliance with the regulatory limits and the reliability of the results of the individual monitoring programmes; the other concerns the mechanisms used to demonstrate to a facility in another country the reliability of the measurement results of an individual monitoring bioassay programme. The accreditation of the bioassay laboratory, according to ISO/IEC 17025, shall be the basic requirement for obtaining the authorisation granted by the national regulatory authority. For the second question, such confidence can be achieved through International Laboratory Accreditation Cooperation (ILAC).

Performance of IRD-WBC HPGe detection system for low energy photon emitters in lungs.

The Whole Body Counter Facility (WBC) of IRD-CNEN in Brazil has been operating since 1986. The first system installed to perform in vivo measurements of low energy photon emitters radionuclides used Phoswich detectors. In 1998, the WBC unit was upgraded by the installation of an array of four low energy high purity germanium detectors. The performance and suitability of the detection system for lung measurements were evaluated by comparison with the annual dose limits and the detection limits obtained for 238U, 235U, 226Ra and 241Am. This evaluation determined whether the in vivo measurements are adequate. In order to compare the dose limit of 20 mSv y(-1), recommended by the International Commission on Radiological Protection (ICRP), with the in vivo monitoring technique, the minimum detectable intake (MDI) was calculated using the appropriate biokinetic models described in the ICRP Publications. The results were obtained for a single intake through inhalation. The AMAD considered was 5 microm.

Voxel phantoms and Monte Carlo methods applied to in vivo measurements for simultaneous 241Am contamination in four body regions.

A Monte Carlo program, Visual Monte Carlo (VMC) in vivo, was written to simulate photon transport through an anthropomorphic phantom and to detect radiation emitted from the phantom. VMC in vivo uses a voxel phantom provided by Yale University and may be used to calibrate in vivo systems. This paper shows the application of VMC in vivo to the measurement of 241Am deposited simultaneously in the thoracic region, the bones, the liver and in the rest of the body. The percentages of 241Am in the four body regions were calculated using the biokinetic models established by the ICRP, for a single intake via inhalation. The four regions of the voxel phantom were then 'contaminated' in accordance with the calculated percentages. The calibration factor of the in vivo system was then obtained. This procedure was repeated for the radionuclide distributions obtained 5, 30, 120, 240 and 360 days after intake. VMC in vivo was also used to calculate the calibration factor of the in vivo system in which the radionuclide was assumed to be deposited only in the lung, as is normally done. The activities calculated with the radionuclide distributed in the four body regions as a factor of time, and the activities calculated with the radionuclide deposited in the lung only are compared.

Tuberculosis is associated with non-tuberculosis-related deaths among HIV/AIDS patients in Rio de Janeiro.

SETTING: Human immunodeficiency virus (HIV) infected patients followed in a large cohort in Rio de Janeiro, Brazil. OBJECTIVE: To evaluate the association of tuberculosis (TB) and other covariables with non-TB-related (NTR) causes of death (CODs). DESIGN: Patients aged >18 years were followed from 1997 to 2009, until death or 31 December 2009, whichever was earlier. CODs were ascertained using a standardised algorithm. TB diagnosis and prophylaxis followed Brazilian guidelines. Poisson models were used to calculate adjusted rate ratios (aRRs). RESULTS: Of 2887 patients included in the study, 761 had TB (26.4%). NTR death rates were twice as high among patients with TB (4/100 vs. 2.09/100 patient-years). TB was associated with NTR deaths (aRR 1.4, 95%CI 1.05-1.86, P = 0.01). Highly active antiretroviral treatment (HAART) was protective against NTR (aRR 0.46, 95%CI 0.34-0.61, P < 0.001). Among patients who had never had active TB, prophylaxis was also protective against NTR (aRR 0.45, P = 0.04). The CD4 cell count increase was very modest for both TB and NTR CODs compared to those who did not die (0 vs. 249 cells, P < 0.001). CONCLUSIONS: TB was significantly associated with increased NTR CODs, indicating rapid progression of disease and increased long-term risk of mortality, probably related to persistent immunodeficiency or incomplete immune recovery. Our results confirm the benefits of HAART and TB prophylaxis.

PCR-based identification of Mycobacterium murphy causing Canine Leproid Granuloma Syndrome in Niterói, southeast Brazil - case report / Identificação baseada em PCR de Mycobacterium murphy causando Síndrome do Granuloma Lepróide Canino em Niterói, sudeste do Brasil ˗ Relato de Caso

Canine Leproid Granuloma Syndrome (CLGS), also known as canine leprosy, is a cutaneous nodular infectious disease caused by Mycobacterium sp.. Despite being reported worldwide, it is still quite unknown and underdiagnosed. Diagnosis may be achieved by cytopathology or histopathology of skin lesions, but identification of the infectious agent is complex, since bacterial in vitro growth is not possible, relying upon molecular techniques such as PCR to confirm Mycobacterium DNA in the sample. We report a CLGS case in Niteroi, Rio de Janeiro state, Brazil, diagnosed by cytopathology and submitted to molecular identification of the agent. PCR amplification of hsp65 gene was performed and revealed 100% genetic homology to M. murphy strain. This is the first CLGS report with molecular identification in Rio de Janeiro state, and this finding should raise awareness about CLGS as a differential diagnosis among granulomatous skin diseases in this region.(AU)

A síndrome de granuloma leproide canino (SGLC), também conhecida como lepra canina, é uma doença infecciosa cutânea nodular causada por Mycobacterium sp. Apesar de ser relatada mundialmente, ainda é bastante desconhecida e subdiagnosticada. O diagnóstico pode ser conseguido por citopatologia ou histopatologia de lesões cutâneas, mas a identificação do agente infeccioso é complexa, uma vez que o crescimento in vitro bacteriano não é possível, dependendo de técnicas moleculares como a PCR para confirmar o DNA de Mycobacterium na amostra. Relatou-se um caso da SGLC em Niterói, estado do Rio de Janeiro, Brasil, diagnosticado por citopatologia e submetido à identificação molecular do agente. Foi realizada amplificação por PCR do gene hsp65, que revelou 100% de homologia genética com a cepa M. murphy. Este é o primeiro relato da SGLC com identificação molecular no estado do Rio de Janeiro, o que mostra a importância de se acrescentar a SGLC ao diagnóstico diferencial das doenças granulomatosas de pele nessa região.(AU)

Synthesis and antimycobacterial evaluation of N'-(E)-heteroaromaticpyrazine-2-carbohydrazide derivatives.

A series of nine N'-(E)-heteroaromatic-pyrazine-2-carbohydrazide derivatives (5a-f and 6a-c) have been synthesized and evaluated against M. tuberculosis ATCC 27294 using the micro plate Alamar Blue assay (MABA), being the activities expressed as the minimum inhibitory concentration (MIC) in µg/ml. Compounds 5a and 5f exhibited potent activities (3.12 and 50µg/mL, respectively) when compared to the first line drug pyrazinamide (MIC>100 µg/mL). Afterwards, these compounds were evaluated for their cell viabilities in non-infected and infected macrophages with Mycobaterium bovis Bacillus Calmette-Guerin (BCG) and 5f was not cytotoxic to host cells in the effective concentration to inhibit the growth of M. tuberculosis.

Drug-resistant tuberculosis in six hospitals in Rio de Janeiro, Brazil.

SETTING: Tuberculosis (TB) drug resistance survey in six hospitals in Rio de Janeiro, Brazil. OBJECTIVE: To estimate resistance to at least one drug (DR) and multidrug resistance (MDR) and identify associated factors. DESIGN: One-year cross-sectional survey. Hospitals were included as a convenience sample. RESULTS: Of 595 patients investigated, 156 (26.2%) had previously undergone anti-tuberculosis treatment, 433 (72.8%) were not previously treated and information on the remaining 6 was not available. Overall, DR and MDR rates were high, at respectively 102 (17.1%, 95%CI 14.3-20.5) and 44 (7.4%, 95%CI 5.5-9.9) cases. Among individuals not previously treated, 17 had MDR (3.9%, 95%CI 2.4-6.3) and diagnosis in a TB reference hospital was independently associated with MDR (prevalence ratio [PR] 3.3, 95%CI 1.2-8.7) after multivariate analysis. Among previously treated individuals, 27 had MDR (17.3%, 95%CI 11.7-24.2). MDR-TB was independently associated with diagnosis in a TB reference hospital (PR 3.6, 95%CI 1.5-8.7), male sex (PR 2.3, 95%CI 1.2-4.4) and dyspnoea (PR 0.3, 95%CI 0.1-0.7). CONCLUSION: We found high levels of DR- and MDR-TB. Our study design did not permit us to determine the contribution of community versus nosocomial transmission. Further studies are needed to establish this. Nevertheless, hospitals should be recognised as a potential source of transmission of resistant TB strains and urgent measures to avoid nosocomial TB transmission should be taken.

Nosocomial occurrence of enterotoxigenic multiresistant Staphylococcus strains in Rio de Janeiro.

We studied 46 Staphylococcus aureus strains with three patterns of antimicrobial resistance (MARSA, MRSA and MSSA) obtained from inpatients of a large community hospital in Rio de Janeiro, Brazil. The strains showed a single biochemical pattern. On the contrary, remarkable phage-typing differences could be observed. Thirteen strains were associated to phagic group III and the remainder could not be typed even though most of them had shown a weak sensitivity to phage 54. Fourteen strains synthesized one or more enterotoxins. Enterotoxin D was synthesized more often. Neither was EEB produced nor TSSF-1. The results suggested the widespreading of different staphylococci strains in that hospital. There was strong evidence that some cases of nosocomial infections leading to death have been caused by the same S. aureus strain recovered from some inpatients in the intensive care unit.

Genotypic patterns of multiple isolates of M. tuberculosis from tuberculous HIV patients.

We investigated whether the recurrence of tuberculosis in HIV-infected patients is due to an exogenous reinfection or relapses after antituberculosis chemotherapy. We reviewed clinical information on 32 patients at a Rio de Janeiro hospital from whom multiple Mycobacterium tuberculosis isolates were taken. All isolates were analysed by DRE-PCR fingerprinting technique, and those with identical DRE-PCR patterns were analysed by the RFLP method. Twenty patients had M. tuberculosis simultaneously isolated from different organs. These patients and nine others with sequential positive cultures after 2 months of therapy showed stable DRE-PCR and RFLP patterns. One patient's isolate became resistant to isoniazid, but the molecular pattern remained unchanged despite the development of drug resistance. In three patients, the DRE-PCR patterns of the isolates changed dramatically. Clinical and microbiological evidence was consistent with active tuberculosis caused by a new strain of M. tuberculosis. The exogenous reinfection of the three patients was not due to an outbreak, but the isolates from each patient showed unique patterns.

Diagnosis of disseminated mycobacterial infection: testing a simple and inexpensive method for use in developing countries.

With the development of the acquired immunodeficiency syndrome (AIDS) epidemic, the isolation of mycobacteria from blood has become a common problem for clinical laboratories. In this study two methods were used for the recovery of mycobacteria from blood specimens obtained from AIDS patients: (1) direct inoculation of a biphasic medium, and (2) a non-commercial lysis-centrifugation method. A total of 3 consecutive blood samples were taken at 15-minute intervals from each of 50 AIDS patients with clinical suspicion of disseminated mycobacterial disease. Mycobacterium growth was noted in 70/138 blood specimens from 30 (60%) patients. These cultures yielded Mycobacterium tuberculosis in 19 (63%) and Mycobacterium avium complex organisms in 11 (37%) patients. Cultures using the lysis-centrifugation method were positive in 54% of the patients while cultures using biphasic medium were positive in 44% (P > 0.05). The positivity for M. avium complex was higher with lysis-centrifugation (91%) than with biphasic medium (45.4%) (P < 0.05). However, the positivities for M. tuberculosis with the lysis-centrifugation method (89.5%) and direct inoculation in biphasic medium (100%) were similar (P > 0.05). The use of a non-commercial lysis-centrifugation technique is inexpensive, reliable, and can be an alternative method for the diagnosis of mycobacteraemia in developing countries.

Atividade antimicrobiana dos frutos de Syagrus oleracea e Mauritia vinifera / Antimicrobial activity of Syagrus oleracea and Mauritia vinifera fruits

As espécies pertencentes à família Palmae são muito interessantes do ponto de vista químico e farmacológico. Neste trabalho, foram estudados os frutos de duas espécies da família Palmae, Syagrus oleracea e Mauritia vinifera. Essas palmeiras foram escolhidas por serem espécies brasileiras, abundantes em nosso país, utilizadas popularmente no tratamento de algumas doenças e ainda pouco estudadas. Foram realizados ensaios farmacológicos para avaliação da atividade antimicrobiana dos extratos dos frutos das duas espécies em estudo. Para o teste de atividade antimicrobiana foram utilizadas cepas de bactérias Gram positivas e Gram negativas. A metodologia empregada foi a de Microdiluição em caldo. Foram testados os extratos etanólicos brutos do epicarpo/mesocarpo de S. oleracea e de M. vinifera, o extrato hexânico das amêndoas de S. oleracea, as partições hexânicas e em acetato de etila do epicarpo/mesocarpo de S. oleracea, do epicarpo/mesocarpo e mesocarpo/endocarpo de M. vinifera, na concentração de 100 mg/ml. Os extratos lipofílicos de S. oleracea apresentaram os melhores resultados para essa espécie. Nos testes realizados com M. vinifera, as partições lipofílicas foram as mais inibitórias para a cepa de S. aureus.

Palmae species are very interesting by the chemical and pharmacological points of view. Two species belonging to this family were chosen to initiate the chemical and pharmacological approach of their fruits: Syagrus oleracea (Martius) Beccari and Mauritia vinifera Martius, known in Brazil as Guariroba and Buriti, respectively. Those palm species can be found in several regions of Brazil, especially at the northeast and southeast of the country. They have been used in folk medicine to treat some diseases, however no toxicological and pharmacological studies have been done so far. For the two studied fruits, the antimicrobial activity tests were carried out by broth microdilution methodology. The objective of this work was to contribute for the pharmacological study of palm species, evaluating the antimicrobial activity of the extracts obtained from the fruits of S. oleracea and M. vinifera. The assays evaluated ethanol extracts of the epicarp/mesocarp of S. oleracea and epicarp/mesocarp of M. vinifera; hexane extract of the endosperm of S. oleracea; hexane and ethyl acetate fractions of the epicarp/mesocarp of S. oleracea, epicarp/mesocarp of M. vinifera and mesocarp/endocarp of M. vinifera. The lipophilic extracts of S. oleracea obtained the best results for the species. For M. vinifera, the lipophilic partitions have shown a high inhibitory percentage for S. aureus.