Clinical, cerebrospinal fluid, and neuroimaging findings in COVID-19 encephalopathy: a case series.

OBJECTIVE: To describe the clinical, neurological, neuroimaging, and cerebrospinal fluid (CSF) findings associated with encephalopathy in patients admitted to a COVID-19 tertiary reference center. METHODS: We retrospectively reviewed records of consecutive patients with COVID-19 evaluated by a consulting neurology team from March 30, 2020 through May 15, 2020. RESULTS: Fifty-five patients with confirmed SARS-CoV-2 were included, 43 of whom showed encephalopathy, and were further divided into mild, moderate, and severe encephalopathy groups. Nineteen patients (44%) had undergone mechanical ventilation and received intravenous sedatives. Eleven (26%) patients were on dialysis. Laboratory markers of COVID-19 severity were very common in encephalopathy patients, but did not correlate with the severity of encephalopathy. Thirty-nine patients underwent neuroimaging studies, which showed mostly non-specific changes. One patient showed lesions possibly related to CNS demyelination. Four had suffered an acute stroke. SARS-CoV-2 was detected by RT-PCR in only one of 21 CSF samples. Two CSF samples showed elevated white blood cell count and all were negative for oligoclonal bands. In our case series, the severity of encephalopathy correlated with higher probability of death during hospitalization (OR = 5.5 for each increment in the degree of encephalopathy, from absent (0) to mild (1), moderate (2), or severe (3), p < 0.001). CONCLUSION: In our consecutive series with 43 encephalopathy cases, neuroimaging and CSF analysis did not support the role of direct viral CNS invasion or CNS inflammation as the cause of encephalopathy.

Plasma and Cerebrospinal Fluid Candidate Biomarkers of Neonatal Encephalopathy Severity and Neurodevelopmental Outcomes.

OBJECTIVES: To identify candidate biomarkers in both plasma and cerebrospinal fluid (CSF) that are associated with neonatal encephalopathy severity measured by encephalopathy grade, seizures, brain injury by magnetic resonance imaging (MRI), and neurodevelopmental outcomes at 15-30 months. STUDY DESIGN: A retrospective cohort study of plasma (N = 155, day of life 0-1) and CSF (n = 30, day of life 0-7) from neonates with neonatal encephalopathy and healthy neonates born at term (N = 30, ≥36 weeks of gestation) was conducted. We measured central nervous system necrosis (glial fibrillary acidic protein [GFAP], neurogranin [NRGN], tau), inflammatory (interleukin [IL]-6, IL-8, IL-10), and trophic (brain-derived neurotrophic factor [BDNF], vascular endothelial growth factor) proteins. Clinical outcomes were Sarnat scores of encephalopathy, seizures, MRI scores, and Bayley Scales of Infant and Toddler Development III at 15-30 months. RESULTS: Plasma NRGN, tau, IL-6, IL-8, and IL-10 were greater, whereas BDNF and vascular endothelial growth factor were lower in patients with neonatal encephalopathy vs controls. In plasma, tau, GFAP, and NRGN were directly and BDNF inversely associated with encephalopathy grade. IL-6 was inversely related to seizures. Tau was directly related to MRI abnormalities. Tau was inversely associated with Bayley Scales of Infant and Toddler Development III cognitive and motor outcomes. In CSF, NRGN was inversely associated with cognitive, motor, and language measures. GFAP, IL-6, and IL-10 were inversely related to cognitive and motor outcomes. IL-8 was inversely related to motor outcomes. CSF candidate biomarkers showed no significant relationships with encephalopathy grade, seizures, or MRI abnormalities. CONCLUSIONS: Plasma candidate biomarkers predicted encephalopathy severity, seizures, MRI abnormalities, and neurodevelopmental outcomes at 15-30 months.

Importance of cerebrospinal fluid investigation during dengue infection in Brazilian Amazonia Region.

BACKGROUND Amazon, the largest tropical forest of the world, has suffered from dengue outbreaks since 1998. Cerebrospinal fluid (CSF) of patients, from Amazonas state, suspected of central nervous system (CNS) viral infection was studied using molecular and immunological methods. OBJECTIVE To evaluate the importance of CSF investigation in patients with acute dengue virus (DENV) infection of CNS. METHODS CSF samples of 700 patients were analysed by reverse transcription polymerase chain reaction (RT-PCR) to detect the presence of dengue virus (DENV) RNA and by enzyme-linked immunosorbent assay (ELISA) to detect presence of DENV specific IgM. FINDINGS DENV infection was detected in 4.3% of the CSF samples; 85.7% (24/28) by DENV IgM and 14.3% (4/28) by viral RNA. DENV detected by viral RNA were to be found serotypes DENV-2 (three patients) and DENV-1 (one patient). The neurological diagnosis in patients CNS infection of DENV included encephalitis (10), meningoencephalitis (10), meningitis (6), acute myelitis (1), and encephalomyelitis (1). The majority (89.3%) had intrathecal inflammation: pleocytosis, hyperproteinorrachia and DENV IgM antibodies. Hypoglycorrhachia and/or high levels of lactate in CSF were found in 36% of the patients. Co-infection (CMV, HIV, EBV, and/or Mycobacterium tuberculosis) was observed in eight (28.6%) cases. CONCLUSIONS We found intense inflammatory CSF that is unusual in CNS disorders caused by dengue infection. It may be due co-infections or the immunogenetic background of the local Amerindian Brazilian population. CSF examination is an important diagnostic support tool for neurological dengue diagnosis.

Fungal colonization of the brain: anatomopathological aspects of neurological cryptococcosis.

Brain infection by the fungus Cryptococcus neoformans results in an estimated 500,000 human deaths per annum. Colonization of the central nervous system (CNS) by C. neoformans causes different clinical syndromes that involve interaction of a number of fungal components with distinct brain cells. In this manuscript, our literature review confirmed the notion that the Cryptococcus field is expanding rapidly, but also suggested that studies on neuropathogenesis still represent a small fraction of basic research activity in the field. We therefore discussed anatomical and physiological aspects of the brain during infection by C. neoformans, in addition to mechanisms by which brain resident cells interact with the fungus. This review suggests that multiple efforts are necessary to improve the knowledge on how C. neoformans affects brain cells, in order to enable the generation of new therapeutic tools in a near future.

Oligoclonal bands in the cerebrospinal fluid and increased brain atrophy in early stages of relapsing-remitting multiple sclerosis.

OBJECTIVE: To determine if the presence of oligoclonal bands (OB) at early stages of multiple sclerosis was associated with higher brain atrophy, when compared with patients without OB. METHODS: Relapsing-remitting multiple sclerosis (RRMS) patients with less than two years of disease onset and OB detection in cerebrospinal fluid (CSF) were included. SIENAX was used for total brain volume (TBV), gray matter volume (GMV), and white matter volume (WMV). RESULTS: Forty patients were included, 29 had positive IgG-OB. No differences were found between positive and negative patients in gender, expanded disability status scale (EDSS), treatment received, and T2/T1 lesion load. TBV in positive IgG-OB patients was 1.5 mm³ x 10(6) compared with 1.64 mm³ x 10(6) in the negative ones (p=0.02). GMV was 0.51 mm³ x 10(6) in positive IgG-OB compared with 0.62 mm³ x 10(6) in negative ones (p=0.002). No differences in WMV (p=0.09) were seen. CONCLUSIONS: IgG-OB in the CSF was related to neurodegeneration magnetic resonance (MR) markers in early RRMS.

Oligoclonal bands in the cerebrospinal fluid and increased brain atrophy in early stages of relapsing-remitting multiple sclerosis / Bandas oligoclonales en líquido cefalorraquídeo y incremento de la atrofia cerebral en estadios tempranos de pacientes con esclerosis múltiple forma recaída-remisión

OBJECTIVE: To determine if the presence of oligoclonal bands (OB) at early stages of multiple sclerosis was associated with higher brain atrophy, when compared with patients without OB. METHODS: Relapsing-remitting multiple sclerosis (RRMS) patients with less than two years of disease onset and OB detection in cerebrospinal fluid (CSF) were included. SIENAX was used for total brain volume (TBV), gray matter volume (GMV), and white matter volume (WMV). RESULTS: Forty patients were included, 29 had positive IgG-OB. No differences were found between positive and negative patients in gender, expanded disability status scale (EDSS), treatment received, and T2/T1 lesion load. TBV in positive IgG-OB patients was 1.5 mm³ x 10(6) compared with 1.64 mm³ x 10(6) in the negative ones (p=0.02). GMV was 0.51 mm³ x 10(6) in positive IgG-OB compared with 0.62 mm³ x 10(6) in negative ones (p=0.002). No differences in WMV (p=0.09) were seen. CONCLUSIONS: IgG-OB in the CSF was related to neurodegeneration magnetic resonance (MR) markers in early RRMS.

OBJETIVO: Evaluar si la presencia de bandas oligoclonales (BO) en líquido cefalorraquídeo (LCR) de pacientes con esclerosis múltiple recaídaremisión (EMRR) se asociaba con mayor atrofia cerebral al inicio de la enfermedad. MÉTODOS: Pacientes con EMRR con menos que dos años del inicio de la enfermedad y en quiénes se realizó la búsqueda de IgG-BO en LCR fueron incluidos. SIENAX fue usado para la medición del volumen cerebral total (VCT), volumen de substancia gris (VSG) y volumen de sustancia blanca (VSB). RESULTADOS: Cuarenta pacientes fueron incluidos, 29 tenían IgG-BO positivo. No fueron encontradas diferencias entre pacientes positivos y negativos en: género, expanded disability status scale (EDSS), tratamiento recibido y carga lesional en resonancia magnética. El VCT en pacientes IgG-BO positivos fue de 1,5 mm³ x 10(6) versus 1,64 mm³ x 10(6) en BO negativo (p=0,02). El VSG fue 0,51 mm³ x 10(6) BO positivo versus 0,62 mm³ x 10(6) BO negativo (p=0,002). No fueron encontradas diferencias en VSB (p=0,09). CONCLUSIONES: La presencia de IgG-BO en el LCR se asoció con signos de neurodegeneración temprana en este estudio.

Neurosífilis meningovascular y gomatosa cerebral concomitante, en paciente seronegativo para virus de inmunodeficiencia humana / Meningovascular neurosyphilis and concomitant syphilitic gummata in hiv-seronegative patients

Neurosyphilis (NS) is caused by the presence of Treponema Pallidum (TP) spirochete within the Central Nervous System (CNS), mainly affecting the meninges and cerebrospinal fluid (CSF). 5 percent to 10 percent of untreated syphilitic patients are deemed to develop symptomatic NSÕ. Its incidence and clinical spectrum have changed over the years with prevalence of early clinical stages of meningitic and meningovascular (MV) NS and exceptional occurrence of late clinical stages (tabes dorsalis, general paresis, and gummata) in the age of antibiotics. The case under analysis deals with aggressive MV and concomitant brain gumma (BG) NS. The case subject is a human inmunodeficiency virus (HIV)-seronegative, 44-year-old woman with 2-year symptomatic latency. Her medical record showed recurrent sensorimotor vascular involvement, fast cognitive damage and chronic, daily cephalea. She met clinical diagnosis, cerebrospinal fluid and serologic criteria for NS. Brain computerized tomography (CT) and magnetic resonance (MR) reported lenticulostriate artery infarction and bilateral ganglionic syphilitic gummata. She underwent Penicillin G-based treatment, making progress with neurological, cognitive-motor sequelae. Although NS has anticipated and speeded up its several clinical stages in connection with HIV/Syphilis co-infection, the peculiarity of this case is the concurrence of early and late NS manifestations in HIV-seronegative patient. The conclusion is that NS is a disease that still prevails and that appropriate diagnosis and treatment prevent irreversible neurological sequelae.

La Neurosífilis (NS) es causada por la invasión del Sistema Nervioso Central (SNC) por la espiroqueta Treponema Pallidum (TP), afectando primariamente las meninges y líquido cefalorraquídeo. Entre 5 a 10 por ciento de los pacientes sifilíticos no tratados desarrollarán una NS sintomáticaÕ. Su incidencia y espectro clínico ha cambiado a lo largo del tiempo, siendo las formas clínicas precoces meníngea y meningovascular (MV) las más prevalentes. En contraste, las formas tardías (tabes dorsal, parálisis general y gomas) son de ocurrencia excepcional en la era antibiótica. Se analiza un caso de NS menigovascular y gomas cerebrales concomitantes, de curso clínico agresivo. En una mujer de 44 años, seronegativa para virus de inmunodeficiencia humana (VIH), con latencia sintomática de dos años. Presentaba una historia de focalidad sensitivo-motor de perfil vascular recurrente, rápido deterioro cognitivo-motor y cefalea crónica diaria. Cumplía criterios diagnósticos clínicos, licuorales y serológicos para NS. La Tomografía computada (TC) y Resonancia Magnética (RM) cerebral mostró infartos arteriolares lentículo-estriados y gomas sifilíticas ganglionares bilaterales. Recibió tratamiento con Penicilina G, evolucionando con secuelas neurológicas cognitivas-motoras. Si bien, la NS actualmente, ha anticipado y acelerado sus diferentes formas clínicas en relación a co-infección VIH/Sífilis. Lo llamativo de este caso, es la presentación concomitante de con manifestaciones precoces y tardías de NS en paciente VIH seronegativo. Se concluye que la NS sigue siendo una enfermedad vigente y su diagnóstico y tratamiento oportuno previene secuelas neurológicas irreversibles.

Imaging findings in neurocysticercosis.

The diagnosis of neurocysticercosis was greatly improved by the introduction of computed tomography (CT) and magnetic resonance imaging (MRI). These techniques demonstrate the number and topography of lesions, their stage of involution, and the degree of inflammatory reaction of the host against the parasites and have largely replaced previous radiological procedures such as plain roentgenograms, pneumoencephalograms, cerebral angiography and myelography. In general, MRI provides better image detection and definition. The possibility of multiplanar reconstruction of images, its capability to visualize the posterior fossa without bone artifacts, and its high contrast resolution (far superior to that of CT) allow MRI to recognize many forms of cysticercosis not visualized on CT. However, the costs of MRI are high and the equipment is scarcely available in many endemic countries, and its sensitivity for the detection of calcified lesions is poor. CT remains the best screening neuroimaging procedure for patients with suspected neurocysticercosis, and MRI is the imaging modality of choice for the evaluation of patients with intraventricular cysticercosis, brainstem cysts and small cysts located over the convexity of cerebral hemispheres. Its better image definition also suggests that MRI is superior to CT in the follow-up of the patients after therapy.

The spectrum of computerized tomography (CT) findings in central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii in immunocompetent children.

Cranial CT scans of eleven immunocompetent children with central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii were retrospectively reviewed. These children had an average age of 8.8 years and positive culture for C. n. var. gattii in cerebrospinal fluid. The most common signs and symptoms were headache, fever, nuchal rigidity, nausea and vomiting. No normal cranial CT was detected in any patient. Hypodense nodules were observed in all patients. The remaining scan abnormalities were as follows: nine had diffuse atrophy, six had hydrocephalus, and five had hydrocephalus coexistent with diffuse atrophy.

Enantioselective distribution of albendazole metabolites in cerebrospinal fluid of patients with neurocysticercosis.

AIMS: Albendazole (ABZ) is effective in the treatment of neurocysticercosis. ABZ undergoes extensive metabolism to (+) and (-)-albendazole sulphoxide (ASOX), which are further metabolized to albendazole sulphone (ASON). We have investigated the distribution of (+)-ASOX (-)-ASOX, and ASON in cerebrospinal fluid (CSF) of patients with neurocysticercosis. METHODS: Twelve patients with a diagnosis of active brain parenchymal neurocysticercosis treated with albendazole for 8 days (15 mg kg(-1) day(-1)) were investigated. On day 8, serial blood samples were collected during the dose interval (0-12 h) and one CSF sample was taken from each patient by lumbar puncture at different time points up to 12 h after the last albendazole dose. Albendazole metabolites were determined in CSF and plasma samples by h.p.l.c. using a Chiralpak AD column and fluorescence detection. Population curves for CSF albendazole metabolite concentration vs time were constructed. RESULTS: The mean plasma/CSF ratios were 2.6 (95% CI: 1.9, 3.3) for (+)-ASOX and 2.7 (95% CI: 1.8, 3.7) for (-)-ASOX, with the two-tailed P value of 0.9873 being non-significant. These data indicate that the transport of ASOX through the blood-brain barrier is not enantioselective, but rather depends on passive diffusion. The present results suggest the accumulation of the (+)-ASOX metabolite in the CSF of patients with neurocysticercosis. The CSF AUC(+)/AUC(-) ratio was 3.4 for patients receiving albendazole every 12 h. The elimination half-life of both ASOX enantiomers in CSF was 2.5 h. ASOX was the predominant metabolite in the CSF compared with ASON; the CSF AUC(ASOX)/AUC(ASON) ratio was approximately 20 and the elimination half-life of ASON in CSF was 2.6 h. CONCLUSIONS: We have demonstrated accumulation of the (+)-ASOX metabolite in CSF, which was about three times greater than the (-) antipode. ASOX concentrations were approximately 20 times higher than those observed for the ASON metabolite.

Padronizaçäo de índices tomográficos do IV§ ventrículo e suas características em doentes com neurocisticercose / Standardization of tomographic indexes of the fourth ventricle and its characteristics in patients with neurocysticercosis

A cisticercose do IV§ ventrículo cursa com manifestaçöes de hipertensäo intracraniana (HIC) de fossa posterior, conseqüente à obstruçäo da circulaçäo do líquido cefalorraqueano (LCR) pela gliose, ependimite granular ou à presença de cistos parasitários. Sua dilataçäo isolada constitui uma entidade clínico-patológica denominada IV§ ventrículo isolado, cuja fisiopatogenia permanece controvertida. A terapêutica, clínica ou cirúrgica, apresenta indicaçöes e contra-indicaçöes específicas à gravidade do quadro. O diagnóstico ainda está no campo da subjetividade. Várias modificaçöes do método de Evans, que tentou impor mais objetividade na definiçäo de hidrocefalia, surgiram. Pouco se relata sobre a metodologia para o diagnóstico de dilataçäo isolada do IV§ ventrículo. Os objetivos desse trabalho foram propor um padräo de normalidade de parâmetros representativos das dimensöes do IV§ ventrículo em indivíduos com tomografias computadorizadas em crânio (TC) normais e estudar as características do IV§ ventrículo em doentes com neurocisticercose (NCC). Foram realizadas medidas da distância fronto-polar dos ventrículos laterais (FP) e dos diâmetros craniano interno (Cr), antero-posterior (AP) e latero-lateral (LL) do IV§ ventrículo em 114 indivíduos com TCs normais (grupo CONTROLE, ou GC) e em 80 doentes com o diagnóstico de NCC (grupo com NCC, ou GN) e estabelecidos os índices FP/Cr, AP/Cr, LL/Cr, AP/FP, LL/FP e AP/LL. Após análise estatística, os índices AP/Cr, AP/LL e AP/FP foram considerados os mais representativos das dimensöes do IV§ ventrículo, permitidno selecionar 51 doentes com NCC que apresentavam, pelo menos, um desses índices com valores acima de dois desvios-padräo da média estatística obtida no GC - grupo com comprometimento do IV§ ventrículo (GN-IV§), que foi analisado mais detalhadamente. No GC, os valores obtidos dos índices estudados foram: FP/Cr = 0,244 ñ 0,034; AP/Cr = 0,063 ñ 0,020; LL/Cr = 0,109 ñ 0,026; AP/FP = 0,267 ñ 0,100; LL/FP = 0,458 ñ 0,136 e AP/LL = 0,582 ñ 0,139. No GN, mostraram outros valores: FP/Cr = 0,257 ñ 0,041; AP/Cr = 0,082 ñ 0,037; LL/Cr = 0,102 ñ 0,034; AP/FP = 0,323 ñ 0,143; LL/FP = 0,409 ñ 0,139 e AP/LL = 0,797 ñ 0,213. Com exceçäo de LL/Cr e de LL/FP, essas diferenças entre os dois grupos foram estatisticamente significantes (GN > GC), näo havendo diferença (p > 0,10) no que diz respeito a sexo e faixa etária, em ambos grupos. No GN, os índices encontrados antes do tratamento com albendazol näo diferiram...

Cerebral phaeohyphomycosis caused by Cladophialophora bantiana in a Brazilian drug abuser.

We present a case of cerebral phaeohyphomycosis caused by Cladophialophora bantiana in an apparently immunocompetent patient with a history of intravenous drug use. The diagnosis was achieved in specimens obtained at necropsy by histological and mycological examination, with subsequent identification of the isolate in culture.

[Evaluation of ELISA and counterimmunoelectrophoresis in diagnosis of human neurocysticercosis in Chile]. / Evaluación de ELISA y contrainmunoelectroforesis en el diagnóstico de la neurocisticercosis humana en Chile.

The aim of this work was to assess the diagnostic accuracy for neurocysticercosis, of ELISA and counterimmunoelectrophoresis techniques, in sera and cerebrospinal fluid. Two hundred eight serum samples (47 coming from patients with confirmed cysticercosis) and 87 cerebrospinal fluid samples (27 coming from patients with confirmed cysticercosis) were analyzed. A crude and standardized extract of swine muscle cysticercus cellulose was used as antigen. ELISA and counter immunoelectrophoresis had a 100% specificity in cerebrospinal fluid. In sera, counterimmunoelectrophoresis had a 94.1% specificity. In sera and cerebrospinal fluid, ELISA had a 85.1% sensitivity. Cross reactions were observed in sera of patients with confirmed hydatidosis. Thus, the high specificity of both techniques in cerebrospinal fluid is probably due to the low incidence of cerebral hydatidosis in Chile. It is concluded that for the diagnosis of neurocysticercosis, antibodies against cysticercus cellulosae must be sought paralelly in serum and cerebrospinal fluid using ELISA and counterimmunoelectrophoresis.

Neurocisticercose no Estado do Rio Grande do Norte: relato de 8 casos / Neurocysticercosis in the State of Rio Grande do Norte: report of 8 cases

Os autores apresentam o estudo de oito pacientes com neurocisticercose encefálica no Estado do Rio Grande do Norte. Fazem comentários sobre a incidência da parasitose e referem as convulsöes como o achado clínico mais freqüente, seguido pela cefaléia. O exame neurológico foi anormal em cinco dos oito pacientes. O diagnóstico foi baseado em achados da tomografia computadorizada em sete pacientes e do líquido cefalorraquidiano em três

[Comparison between the erythroimmunoadsorption test by capture, immunoenzymatic and passive hemagglutination tests used in the diagnosis of neurocysticercosis]. / Comparação entre os testes de eritroimunoadsorção por captura, imunoenzimático e hemaglutinação passiva utilizados no diagnóstico da neurocisticercose.

Comparisons were made among the erythroimmunoadsorption by capture (C-EIA), the immunoenzymatic (ELISA) and passive haemaglutination (P.H.A.) tests used in the diagnosis of neurocysticercosis. The three tests, two of them routine by in diagnosis, and the third one (C-EIA) recently, standardised were compared for the detection of anti-Cysticercus cellulosae antibodies. In the three reactions the antigen utilized was raw saline extract (R.S.E) with a yield of 0.1, 1 and 10 micrograms protein/cavity for the C-EIA, ELISA and P.H.A tests, respectively. In a group of 58 patients with neurocysticercosis, the sensitivity to the ELISA, C-EIA and P.H.A tests was of 98.2%, 84.5% and 77.2%, respectively. In the control group of 85 individuals, healthy or with encephalopathies other than neurocysticercosis, the sensitivity was of 98.27%, 84.48% and 79.63%, respectively, and the specificity was of 94.1%, 95.3% and 91.8%. This order of choice should be followed, depending on the resources available.

[Use of capture erytroimmunoadsorption test in the immunodiagnosis of neurocysticercosis]. / Utilização do teste de eritroimunoadsorção por captura no imunodiagnóstico da neurocisticercose.

The capture erytoimmunoadsorption (C-EIA) test was standardized for detection of Taenia solium cysticercus-IgG specific antibodies in cerebrospinal fluid (CSF) from patients with neurocysticercosis. For the C-EIA test performance a reagent for specific antibody detection was prepared using sheep's red blood cells (SRBC) in a concentration of 0.25% sensitized with crude saline extract antigen (SEA) obtained from Cysticercus cellulosae. The optimum concentration of SEA for SRBC sensitization was 40 micrograms/ml. The yield of SEA was 0.1 microgram protein/cavity. When 58 CSF samples from patients with neurocysticercosis were analysed the sensitivity of the test was found to be 84.5% and the confidence limit of 95% probability (CL95%) ranged from 75% to 94%. The specificity was 95.3% (CL 95% from 90.7% to 99.9%) when CSF samples from the control group were analysed. The C-EIA test was shown to be efficient for neurocysticercosis diagnosis and important for public health laboratories, because of its low cost, high reagent yield and case of use.