The impact of highly active antiretroviral therapy on the survival of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil.

The use of highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV)-infected patients has reduced the number of acquired immune deficiency syndrome-related deaths worldwide. This study assessed the impact of HAART on the survival and death rates of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil. Data were obtained from a historic cohort of vertically HIV-infected children and adolescents aged zero-19 years old who were admitted from March 1989-December 2004 and were followed until June 2006. Patients who used HAART were included if they were treated for at least 12 weeks. Of 359 patients, 320 patients met the inclusion criteria. The overall mortality rate was 9.7% [31/320; 95% confidence interval (CI): 6.0-13%]. The median survival for the non-HAART and HAART groups was 31.5 and 55.9 months, respectively (log rank = 22.11, p < 0.0001). In the multivariate analysis, the statistically significant variables were HAART and the weight-for-age Z score < -2, with HAART constituting a protective factor [relative risk (RR): 0.13; CI 95%: 0.05-0.33] and malnutrition constituting a risk factor (RR: 3.44; CI 95%: 1.60-7.40) for death. The incidence of death was 5.1/100 person-years in the non-HAART group and 0.8/100 person-years in the HAART group (p < 0.0001).

The impact of highly active antiretroviral therapy on the survival of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil

The use of highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV)-infected patients has reduced the number of acquired immune deficiency syndrome-related deaths worldwide. This study assessed the impact of HAART on the survival and death rates of vertically HIV-infected children and adolescents in Belo Horizonte, Brazil. Data were obtained from a historic cohort of vertically HIV-infected children and adolescents aged zero-19 years old who were admitted from March 1989-December 2004 and were followed until June 2006. Patients who used HAART were included if they were treated for at least 12 weeks. Of 359 patients, 320 patients met the inclusion criteria. The overall mortality rate was 9.7% [31/320; 95% confidence interval (CI): 6.0-13%]. The median survival for the non-HAART and HAART groups was 31.5 and 55.9 months, respectively (log rank = 22.11, p < 0.0001). In the multivariate analysis, the statistically significant variables were HAART and the weight-for-age Z score < -2, with HAART constituting a protective factor [relative risk (RR): 0.13; CI 95%: 0.05-0.33] and malnutrition constituting a risk factor (RR: 3.44; CI 95%: 1.60-7.40) for death. The incidence of death was 5.1/100 person-years in the non-HAART group and 0.8/100 person-years in the HAART group (p < 0.0001).

Cerebral infection caused by Cryptococcus gattii: a case report and antifungal susceptibility testing.

We report a clinical case of cerebral infection caused by Cryptococcus gattii in a 10 year-old boy. Clinical and laboratory exams did not demonstrate any apparent immunosuppressed state (HIV antibody and the tuberculin skin tests, both negative, were performed; blood cells count and immunoglobulin levels were within normality). Treatment was begun with amphotericin B-deoxycholate but renal toxicity signs led to its substitution by fluconazole. The infection proceeded even after treatment with fluconazole. In vitro determination of minimum inhibitory concentration values were high for itraconazole (= or > 2 microg/ml), fluconazole and 5-flucytosine (= or > 64 microg/ml) and low for amphotericin B (1.0 microg/ml). Renal toxicity signs, induced by amphotericin B, progression of infection after fluconazole, and likely in vivo resistance to this triazole made this case difficult to treat. In vitro drug interaction tests confirmed probable synergism between amphotericin B and 5-flucytosine (frational inhibitory concentration - FIC = 0.375). In contrast, a probable additive effect was observed for amphotericin B and fluconazole (FIC = 0.75). Initial treatment of persistent high intracranial pressure was insufficient and neurological surgery was necessary. Antifungal susceptibility tests and Cryptococcus species identification were important in selecting appropriate antifungal therapy.

Cerebral infection caused by Cryptococcus gattii: a case report and antifungal susceptibility testing

Relatamos un caso clínico de infección cerebral provocada por Cryptococcusgattii en un niño de 10 años. Los exámenes clínicos y de laboratorio nodemostraban ningún estado aparente de inmunosupresión (anticuerpos VIH yprueba de tuberculina negativos, recuento sanguíneo y niveles deinmunoglobulinas dentro de la normalidad). El tratamiento comenzó conanfotericina B desoxicolato, pero la toxicidad renal condujo a su sustitución porfluconazol. La infección persistió después del tratamiento con fluconazol.La determinación in vitro de los valores de la concentración inhibitoria mínimamostraron valores altos para el itraconazol (>= 2 μg/ml), el fluconazol y la5-fluorocitosina (>= 64 μg/ml), y bajos para la anfotericina B (1 μg/ml).Los signos de intoxicación renal inducidos por la anfotericina B, el avance de lainfección después del tratamiento con fluconazol y probablemente la resistenciain vivo a este triazol hacen que éste sea un caso difícil de tratar. Las pruebasde interacción in vitro entre las drogas confirman un probable sinergismo entrela anfotericina B y la 5-fluorocitosina (concentración inhibitoria fraccionaria -CIF = 0,375). Sin embargo, se ha observado un probable efecto aditivo para laanfotericina B y fluconazol (CIF = 0,75). El tratamiento inicial de la alta presiónintracraneal persistente fue insuficiente y fue necesaria cirugía neurológica.Las pruebas de sensibilidad antifúngica y de identificación de las especies deCryptococcus fueron importantes en la selección de la terapia antifúngicaapropiada(AU)

We report a clinical case of cerebral infection caused by Cryptococcus gattii ina 10 year-old boy. Clinical and laboratory exams did not demonstrate anyapparent immunosuppressed state (HIV antibody and the tuberculin skin tests,both negative, were performed; blood cells count and immunoglobulin levelswere within normality). Treatment was begun with amphotericin B-deoxycholatebut renal toxicity signs led to its substitution by fluconazole. The infectionproceeded even after treatment with fluconazole. In vitro determination ofminimum inhibitory concentration values were high for itraconazole (>= 2 μg/ml),fluconazole and 5-flucytosine (>= 64 μg/ml) and low for amphotericin B(1.0 μg/ml). Renal toxicity signs, induced by amphotericin B, progression ofinfection after fluconazole, and likely in vivo resistance to this triazole made thiscase difficult to treat. In vitro drug interaction tests confirmed probablesynergism between amphotericin B and 5-flucytosine (frational inhibitoryconcentration - FIC = 0.375). In contrast, a probable additive effect wasobserved for amphotericin B and fluconazole (FIC = 0.75). Initial treatment ofpersistent high intracranial pressure was insufficient and neurological surgerywas necessary. Antifungal susceptibility tests and Cryptococcus speciesidentification were important in selecting appropriate antifungal therapy(AU)

Toxoplasmose congênita: orientação prática sobre prevenção e tratamento / Congenital toxoplasmosis: treatment and prevention guideline

A toxoplasmose, parasitose prevalente em todo o mundo, quando adquirida durante a gestação pode ser transmitida ao feto e causar, dentre outros problemas, atraso no desenvolvimento neuropsicomotor, estrabismo, déficit visual e perdas auditivas. A prevenção da transmissão vertical deve ser iniciada antes da con- cepção ou o mais precocemente possível durante o pré-natal. A identificação de gestantes susceptíveis (soronegativas) deve ser acompanhada de orientações escritas e verbais sobre as formas de aquisição da infecção (profilaxia primária) e, se bem realizada, tem se mostrado eficaz. As mulheres com contato prévio com o parasito, antes da gestação, se imunocompetentes, apresentam muito baixo risco de infectar o concepto. Mas, as gestantes agudamente infectadas devem ser identificadas precocemente para instituição de terapêutica adequada (profilaxia secundária) com o objetivo de evitar a infecção ou diminuir as suas conseqüências para o feto. Considerando-se que a infecção adquirida, assim como a congênita, são geralmente assintomáticas, devemos utilizar a triagem sorológica da mãe e, posteriormente da criança suspeita, para diagnosticar e tratar esses casos. Os autores se pro- põem a apresentar uma orientação prática para abordagem do binômio mãe/filho suspeitos de toxoplasmose, com base nos conhecimentos disponíveis no momento e de acordo com o protocolo utilizado no Serviço de Doenças Infecciosas e Parasitárias, setor de Infectologia Pediátrica, do Hospital das Clínicas da Universidade Federal de Minas Gerais.

The toxoplasmosis, a prevalent parasitosis throughout the world, when acquired during pregnancy can be transmítted to the fetus and cause, among other problems, delay in the neuropsychomotor development, strabismus and visual and hearing impairment. The vertical transmission prevention must be initiated before conception or as early as possible in the prenatal assessment. The identification of susceptible pregnant woman (nega tive blood test) must be accompanied by written and verbal orientation about how the disease can be acquired (primary prophylaxis) and, if well per- formed, has showed good efficacy. Women with previous contact with the parasite, before pregnancy, if imunecompetents, show a very low risk of infecting the child. But, the pregnant women acutely infected must be identified early for the implementation of adequa te therapeutics (secondary prophylaxis) aiming to avoid infection ar at least decrease its consequence to the fetus. Considering that the acquired infection as well as the congenital are usually assymptomatic, we should use the mother's serological screening and, afterwards the child's to diagnose and treat these cases. The authors intend to show a public guideline in the assessment of the mother/child suspects of being infected with toxoplasmosis, based in the current available knowledge and according to the protocol used in the Serviço de Doenças Infecciosas e Parasitárias, Setor de Infectologia Pediátrica, Hospital das Clínicas da Universidade Federal de Minas Gerais.

Imunização: respostas a questões frequentes na prática pediátrica / Imunization: answers to common paediatrician questions

Os anos recentes trouxeram avanços enormes no campo da imunização, com melhoria na eficácia de algumas vacinas e disponibilização de novas vacinas, significando melhoria na prevenção de doenças infecciosas e conseqüentemente melhor qualidade de vida de crianças e adultos. O calendário vacinal recomendado para uso em pediatria deve ser dinâmico e adaptado às peculiaridades do indivíduo e da situação epidemiol6gica do momento. O objetivo desta revisão é oferecer ao pediatra uma atualização sobre as vacinas para uso nas redes pública e privada de saúde e responder a algumas dúvidas que freqüentemente o preocupam no exercício profissional.

Recent years brought huge advances in the immunization field, with improved efficacy of some vaccines and availa- bility of new ones, meaning improvement on infectious diseases prevention and rherefore a better life to children and adults. The advised immunization schedule for pae- diatric use must be dynamic and adapted to the needs of each person and to rhe epidemiologic overview of the momento This review's objective is to offer to the paediatrician an update on vaccines for public and private health care and answer some doubrs that often embarrass the paediatrician on medica! practice.

Visceral leishmaniasis caused by Leishmania (Viannia) braziliensis in a patient infected with human immunodeficiency virus.

The current article reports the case of a 19-month-old-girl, from the state of Minas Gerais, Brazil, with visceral leishmaniasis, by Leishmania (Viannia) braziliensis, and Human Immunodeficiency Virus (HIV) co-infection. The child's mother and father, aged 22 and 27 years old, respectively, were both HIV positive. The child was admitted to the General Pediatric Center, in Belo Horizonte, presenting high fever, fatigue, weight loss and enlargement of liver and spleen. Indirect immunofluorescent test revealed a titer of 1:320 for Leishmania. Such result was confirmed by the presence of amastigotes in bone marrow aspirate samples and culture of promastigote forms. Parasites were identified as being Leishmania (Viannia) braziliensis through PCR, using a L. braziliensis complex primer and a generic primer, followed by hibridization. Specific leishmaniasis therapy (Glucantime register mark or target antimonial) was intravenously administered.

Visceral leishmaniasis caused by Leishmania (Viannia) braziliensis in a patient infected with human immunodeficiency virus

The current article reports the case of a 19-month-old-girl, from the state of Minas Gerais, Brazil, with visceral leishmaniasis, by Leishmania (Viannia) braziliensis, and Human Immunodeficiency Virus (HIV) co-infection. The child's mother and father, aged 22 and 27 years old, respectively, were both HIV positive. The child was admitted to the General Pediatric Center, in Belo Horizonte, presenting high fever, fatigue, weight loss and enlargement of liver and spleen. Indirect immunofluorescent test revealed a titer of 1:320 for Leishmania. Such result was confirmed by the presence of amastigotes in bone marrow aspirate samples and culture of promastigote forms. Parasites were identified as being Leishmania (Viannia) braziliensis through PCR, using a L. braziliensis complex primer and a generic primer, followed by hibridization. Specific leishmaniasis therapy (Glucantimeomicron antimonial) was intravenously administered

Toxoplasmose na gestante e no recém-nascido estudo de 86 pares de mãe-filho atendidos no período de 1996-99 no Ambulatório de Infectologia Pediátrica do HC-UFMG / Toxoplasmosis in pregnant and newborn infant- a study of 86 mother-infant pairs attended from 1996 to 1999 at the Ambulatory Of Pediatric Infectology of HC-UFMG

Pretendeu-se avaliar as condições do diagnóstico da toxoplasmose na gestante e sua relação com a infecção do recém-nascido em serviço de referência, em Belo Horizonte. Trata-se de estudo retrospectivo de 86 pares de mãe-filho, sendo as crianças suspeitas de toxoplasmose congênita devido a sorologia positiva de suas mães. O diagnóstico de toxoplasmose congênita foi excluído em 67 crianças e confirmado em 19. Nesses casos, a IgM positiva (p=0,28) e o ultra-som alterado (p=0,23), na gestação, não estiveram associados à infecção congênita. Em 27 gestantes foi realizada pesquisa do T. gondii no líquido amniótico, positiva em oito casos. O valor preditivo positivo do teste foi baixo (37,5%). Análise univariada mostrou que o tratamento da gestante por mais de três meses protegeu a criança da infecção (p=0,001). Cerca de 60% dos RN infectados estavam assintomáticos ao nascimento. Entre os parâmetros utilizados como preditores de infecção congênita, a pesquisa do T. gondii em liquido amniótico mostrou-se promissora. O diagnóstico e o tratamento precoces na gestante podem diminuir a ocorrência de infecção congênita.

This study discusses diagnostic procedures in pregnant women and its relation with congenital infection in a reference center in Belo Horizonte/MG, Brasil. A total of 86 mother-child couples were enrolled in this retrospective study. These children were suspected for congenital toxoplasmosis based on positive mother's serology. 19 kids were diagnosed and 67 were excluded for congenital infection. Positive IgM (p = 0,28) and alterations on ultrassonography (p = 0,23) during pregnancy had no association with congenital toxoplasmosis between the infected ones. Polymerase chain reaction (PCR) for T.gondii in amniotic fluid was performed in 27 pregnant, resulting positive in 8 but with a very low positive predictive value (37,5%). Univariable analisis shows that pregnant's treatment for at least 3 months protected Children from infection (p = 0,001). About 60% of newborns were clinically asymptomatic. PCR for T. gondii in amniotic fluid is promising as a diagnostic test. Early diagnosis and treatment of mothers may decrease occurrence of congenital infection.