What do anti-Toxoplasma gondii IgA and IgG subclasses in human saliva indicate?

Diagnostic tests for toxoplasmosis are based on serological techniques due to their high sensitivity. Some IgG subclasses are related to clinical outcome in the congenital form. In this work, we determined the levels of IgG, IgA, IgG1, IgG2, IgG3 and IgG4 anti-Toxoplasma gondii antibodies in paired saliva and serum samples from 91 women by indirect ELISA using a crude extract of the RH strain. The levels of IgA, IgG2, IgG3 and IgG4 antibodies and, to a lesser extent, IgG1 did not correlate between saliva and serum, that is, most cases that were positive for one Ig class in a sample were negative or very low in the other, and vice versa. We also observed that most samples of saliva that were positive for one IgG subclass were also positive for at least 2 of the other 3; this contrasted with findings in serum, wherein each person was positive almost exclusively for one subclass, as demonstrated before by us and other researchers. Although these findings are disappointing for the use in diagnosis, the richer response in saliva might indicate local exposure to T. gondii antigens without systemic infection; thus, saliva might be reflecting a local (protective?) response against this protozoan.

Toxoplasmosis in pregnancy: determination of IgM, IgG and avidity in filter paper-embedded blood.

OBJECTIVE: To detect immunoglobulin M (IgM) anti-Toxoplasma gondii antibodies and determine immunoglobulin G (IgG) titer and avidity in filter paper-embedded blood (FPEB) samples of pregnant women. STUDY DESIGN: A total of 100 FPEB samples of pregnant women (30 positive and 70 negative) were analyzed for anti-T. gondii-specific IgM antibodies. Eleven and nine pairs of serum and FPEB samples were used to standardize IgG titration and avidity, respectively. Then, the correlation of avidity results was determined with 23 serum/FPEB pairs from IgG-positive cases. RESULT: IgM detection in FPEB was 92% sensitive and 100% specific. The titration of IgG antibodies in FPEB correlated with that of serum (r >or=0.9). Significant difference in avidity between the acute and the undetermined/chronic cases was observed in both samples. As expected, no correlation was found between IgM levels and avidity. CONCLUSION: The FPEB is useful to infer infection phase, and thus to speed clinical decisions in congenital toxoplasmosis management.

[Clinical manifestations and lethality of descending necrotizing mediastinitis]. / Manifestaciones clínicas y letalidad de la mediastinitis necrosante descendente.

OBJECTIVE: To describe the clinical manifestations, treatment and lethality of a series of patients with descending necrotizing mediastinitis (DNM). DESIGN: Retrospective study of a series of cases. SITE OF STUDY: The Infectious Diseases Hospital (IDH) of the Mexican Social Security Institute, Mexico City; a national reference hospital. PATIENTS AND METHODS: From January 1996 through December 1998, 18 consecutive patients with diagnostic criteria for DNM were treated in the IDH. Demographic variables, precedents, clinical manifestations, characteristics of paraclinical studies, and treatment results were recollected from the chart of each patient. We made a comparison between patients who survived and the patients who died. RESULTS: The mean age of the patients was 48.8 +/- 19.1 years; 13 (72.5%) were men. Nine (50%) had an underlying disease, being diabetes mellitus the most frequent one. In 13 (72.5%) cases an odontogenic abscess was the original infection; three (16.6%) patients had retropharyngeal abscesses. The mean time between the beginning of symptoms and admission to the hospital was 10.6 +/- 6.7 days. The most frequent symptoms were fever, dyspnea, dysphagia, and hypotension. The treatment was medical and surgical in all cases, with antibiotics, thoracotomy, drainage and debridement. The most frequent complications were septic shock, nosocomial pneumonia and ARDS. Nine patients died, the lethality rate was 50%. Patients who died had, at admission lower leukocytes and platelets counts; higher glycemia, and developed more frequently cardiovascular complications and septic shock. CONCLUSIONS: Odontogenic abscesses are the most frequent primary infections in patients with DNM. This is an infectious problem with high lethality. Septic shock is the principal cause of death.

[Factors associated with acceptance of postpartum tubal ligation among HIV-infected women]. / Factores asociados a la aceptación de salpingoclasia posparto entre mujeres infectadas por el VIH.

OBJECTIVE: To identify the factors associated with the acceptance of tubal ligation after childbirth among HIV-infected patients. MATERIAL AND METHODS: A case-control study was conducted from March 1988 to February 1999, at Mexico's National Institute of Perinatology (INPer), in 72 HIV-positive pregnant women. Cases were 49 women who accepted postpartum tubal ligation after childbirth, and controls were 23 women who refused this birth control method. Data collected for each patient were demographic characteristics, sexual and reproductive history, and HIV status. Statistical analysis consisted of descriptive measures, Chi 2 or Fisher's exact test for categorical variables, and Student's t test for continuous variables. Odds ratios (OR) with 95% CI were used to compare groups and potential confounders were assessed by stratified analysis with the Mantel-Haenszel method. RESULTS: The patients' mean age was 25.5 +/- 5.5 years. The median gestation period was 27 weeks (range 7 to 40 weeks); 16 women (22.2%) had no prenatal care visits at INPer. The median time of HIV positivist awareness was 9 months (range 1 to 108). Variables associated with acceptance of tubal ligation were: having a prior childbirth (OR 11.1, 95% CI 3.4 to 36), pregnancy care from 1995 onward (OR 4.7, 95% CI 1.7 to 13.3), and having given birth to an HIV-infected child (OR 4.6, 95% CI 1.05 to 23.1). Stratified analysis showed no modification of the strength of association of these variables with acceptance of tubal ligation. CONCLUSIONS: A prior childbirth was the most important predictor of tubal ligation acceptance. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

Neonatal outcome of children born to women with tuberculosis.

BACKGROUND: As the incidence of tuberculosis (TB) has increased worldwide, it is expected that pregnant women will acquire this infection more frequently. Mycobacterium tuberculosis infection during pregnancy may represent a risk for maternal and neonatal complications. METHODS: We studied the perinatal events of 35 consecutive pregnancies complicated by TB from March 1990 to June 1998; 105 apparently healthy pregnant women were included as controls, matched in age, gestational age upon arrival at the Institute, and socioeconomic status. Frequency and type of neonatal complications were recorded. Relative risk (RR) with 95% confidence interval (CI) was calculated. To control potentially confounding variables, a stratified analysis was performed. RESULTS: Seventeen (48.5%) tuberculous mothers had a pulmonary infection and 18 (51.5%), an extrapulmonar localization of the TB. The neonatal morbidity rate in children born to women with TB was 23% against 3.8% of the children of the control cohort (p <0.05). Average weight of newborn infants of tuberculous mothers was 2,859 +/- 78.5 g, while average weight at birth of control neonates was 3,099 +/- 484 g (p = 0.03). Newborns of women with TB had a higher risk of prematurity (RR 2.1; 95% CI 1-4.3), perinatal death (RR 3.1; 95% CI 1.6-6), and weight at birth less than 2,500 g (RR 2.2; 95% CI 1.1-4.9). Pulmonary localization of the TB and late start of the treatment in the mothers increase the risk of perinatal death and neonatal morbidity. CONCLUSIONS: Children born to women with TB have an increased risk of morbidity and mortality in the neonatal period.

Demographic and clinical profile of human immunodeficiency virus-infected postpartum women who undergo sterilization.

The decision of human immunodeficiency virus (HIV)-infected women to accept a contraceptive method has implications related to the prevention of HIV infection to their children. A case-control study was performed in 57 HIV seropositive pregnant women with prenatal care and delivery at the National Institute of Perinatology, Mexico City. Thirty-five cases were women who accepted postpartum sterilization and twenty-two controls were women who refused this method. The acceptance of tubal occlusion was statistically more frequent in multiparous women, and in those with previous children infected with HIV. The antecedent of at least one previous pregnancy had an association with the acceptance of tubal occlusion with an OR of 11.2 (CI 95% 2.9 to 42.9); having at least one previous child HIV-infected had an OR of 4.6 (CI 95% 1.3 to 23.1). The stratified analysis did not show modification of the association strength between previous pregnancy and the precedent of previous children HIV-infected with the acceptance of sterilization.

Amniotic fluid interleukin-6 and the risk of early-onset sepsis among preterm infants.

BACKGROUND: High concentrations of interleukin-6 (IL-6) have been demonstrated in amniotic fluid (AF) from women with intra-amniotic infection. Recent studies have reported that IL-6 levels in AF were related to an increase in neonatal morbidity; moreover, higher IL-6 plasma levels have been observed in neonates with sepsis. METHODS: A cohort study was carried out at the National Institute of Perinatology in Mexico City. Inclusion criteria were the following: 1) preterm singleton pregnancy; 2) intact membranes at time of enrollment, and 3) written informed consent. Women with other complications of pregnancy were excluded. Newborn sepsis during the first 72 h was defined as early-onset sepsis. Amniotic fluid was obtained at the moment of delivery. Amniotic fluid IL-6 (AF IL-6) was determined by enzyme-linked immunoassays. RESULTS: Ninety-three women met the criteria for enrollment in the study and 31 (33%) of their newborns had early-onset neonatal sepsis. The mean AF IL-6 in mothers of septic newborns was 5779 +/- 2804 pg/ml compared to 729 +/- 382 pg/ml in mothers with non-infected neonates (p < 0.001). AF IL-6 concentrations higher than 1250 pg/ml were significantly associated with early-onset sepsis (OR 33.3; 95% CI 9.4-117.3) (p < 0.001). Gestational age under 32 weeks was also associated with neonatal sepsis (OR 2.56; 95% CI 1.2-9) (p = 0.002). Women whose infants developed neonatal sepsis had a higher frequency of clinical chorioamnionitis (p = 0.02). CONCLUSIONS: IL-6 determination in AF may be a useful indicator to identify neonates with higher risk of in utero bacterial infection.

[Pregnancy outcome in women infected with the human immunodeficiency virus]. / Evolución de los embarazos de mujeres infectadas por el virus de la inmunodeficiencia humana.

OBJECTIVE: To identify the medical complications in a cohort of HIV-infected, pregnant women and to determine the risk of having the virus in the development of these complications. MATERIAL AND METHODS: A cohort study of 44 HIV-infected and 88 seronegative pregnant women was performed. Pregnancy was followed and perinatal results were compared. HIV-infected women were asymptomatic with CD4 count > 200 mm3. Patients were matched for age and socioeconomic status. RESULTS: In 42 (95.4%) of HIV patients the disease had been transmitted sexually; 35 (79.5%) had been infected for less than one year and 15 (34%) received antiviral treatment during pregnancy. HIV-infected patients showed greater risk of infectious disorders (RR3.1, CI95% 1.9-52), cervical infections (RR 2.2, CI95% 1-48) and sexually transmitted diseases (RR 18, CI95% 2.3-137). Newborns showed low birth weight and were premature, and neonatal affections were similar in the two groups compared. Stratified analysis showed that no antiretroviral treatment and more than three sexual partners increase the risk of infections. CONCLUSIONS: HIV-seropositive, asymptomatic, pregnant women with > 200/mm3 CD4 count did not show greater medical risk along pregnancy and birth, although higher incidence of infections was detected.

[The outcome of pregnancies complicated by rubella, 1990-1997]. / Resultado de los embarazos complicados con rubéola, 1990-1997.

OBJECTIVE: To describe the experience of management of pregnant women complicated with rubella and to evaluate the perinatal outcome. MATERIAL AND METHODS: A total of 67 pregnant women with positive IgM test for rubella were studied in the period from January 1st, 1990 to October 31st, 1997. Sixty-six of these women were followed until the end of gestation, in 4 patients an elective abortion was performed and 1 patient had a molar pregnancy. The effects of rubella on gestation and on the product were evaluated in sixty-one of the patients. Anti-rubella IgM was determined at birth and positive infants were subjected to evaluation by echocardiogram, brainstem auditory evoked potentials (BAEP) and ophthalmological study. RESULTS: Mean age of the patients was 24.7 +/- 5.5 years; 28 patients were primigravidae. Pregnancies were normal showing no complications due to the rubella episode. In 35 cases (52.2%), the viral infection occurred during the first trimester of pregnancy, in 23 cases (34.5%) during the second and in 9 (13.3%) during the third. Seventy-one percent of infants born to mothers infected during the first trimester of pregnancy were also infected, and 51.6% developed congenital rubella syndrome. The most frequent manifestations of CRS were: prematurity, low birth weight and alterations of the BAEP. CONCLUSIONS: In Mexico, rubella is still a cause of fetal damage, which shows the need for preventive strategies, such as universal vaccination, to avoid rubella infection during pregnancy.

[Risk of transmission of infectious diseases by transfusion]. / El riesgo de transmisión de enfermedades infecciosas por vía de la transfusión.

In obstetric patients transfusion is a common procedure, it has many advantages but it also has severe risks. Since the observation that human immunodeficiency virus (HIV) infection is transmitted by transfusion, the number of preventive measures to reduce the infectious diseases transmission by this procedure has increased. The microorganisms that can be transmitted through transfusion include: human T lymphotropic virus (HTLV) I and II, hepatitis B virus, hepatitis C virus, hepatitis D virus, hepatitis G virus, HIV, cytomegalovirus, Treponema pallidum, Barucella sp, Toxoplasma gondii, Plasmodium sp, and Trypanosoma cruzi. The most important measure for reduce transfusion risks is the appropriate and careful use of this procedure. This article review transfusion's indication, describe the infectious diseases commonest transmitted by transfusion and analyze the preventive measures to put in practice.

Pregnancy and tuberculosis: influence of treatment on perinatal outcome.

The objective of this article is to evaluate the impact of tuberculosis (TB) on perinatal outcome in a cohort of 25 pregnant women with TB treated at the National Institute of Perinatology (Mexico, City) from March 1990 to September 1995. They were compared with a cohort of normal pregnant women; both cohorts were matched by age, gestational age, and socioeconomic status. For purposes of analysis, patients with TB were further stratified into two groups: one included 9 women who started treatment either before or at the beginning of pregnancy, and the other constituted 16 women who started treatment in either the second or third trimester of gestation. Thirteen women (52%) had pulmonary TB, 7 (28%) had renal infection, and the rest of patients had diverse extrapulmonary localization of the infection. Obstetrical morbidity and neonatal mortality were significantly higher in pregnant women with TB who started treatment late in pregnancy. Perinatal morbidity was similar in pregnant women receiving antituberculous drugs early during pregnancy to that in uninfected women. We conclude that TB represents a risk factor for pregnancy. Early treatment of the disease during gestation reverts its negative impact on perinatal outcome.

[AIDS and pregnancy]. / SIDA y embarazo.

Near 70 per cent of Mexican women infected by the Human Immunodeficiency virus (HIV) are between 15 and 44 years old, in this women sexual transmission are the most frequent route of infection. The objective of this article was to describe the obstetric course and perinatal repercussion of the HIV-Positive pregnant women with medical care at the Instituto Nacional de Perinatología, Mexico city between January 1994 to December 1996. Nineteen women were studied, sexual transmission was the route of infection in 16 of them. One had diagnostic criteria for AIDS, the others 18 had HIV asymptomatic infection. At delivery 18 a term products were born. The mean of the newborn weight was 3159 g. At moment of this report 4 children (22%) have been diagnosed as HIV infected, all of them dead during their first year of life.

Perinatal outcome of pregnancies complicated with varicella infection during the first 20 weeks of gestation.

Varicella-Zoster (V-Z) virus infection during pregnancy is uncommon. Nevertheless, it has importance due to the risk of vertical transmission of the infection and also because of a higher morbidity rate among pregnant women. The cases of varicella infection that occur in the first and second trimesters of pregnancy are occasionally associated to the development of congenital varicella syndrome. We studied 22 women whose pregnancy was complicated with varicella during the first 20 weeks of gestation. The average age of these patients was 20 +/- 3.6 years with a range of 16 to 20 years. None of the patients presented complications due to the V-Z virus infection. Two pregnancies finalized in preterm labor. None of the newborns had congenital anormalies; one presented microcephaly, and another low birth weight. There was no significant difference between the infants of women with varicella and those of the controls in birth weight, size, and head circumference. We concluded that varicella infection during the first 20 weeks of gestation was not associated with serious maternal morbidity, and has low repercussion in the pregnancy outcome and the fetus.

[Diagnostic tests for amniotic infection: review of the literature]. / Pruebas diagnósticas de infección amniótica: revisión de la literatura.

The diagnosis of intraamniotic infection (IAI) is not difficult when clinical manifestations are present, but there are patients with subclinical infections, in these cases the examination of the amniotic fluid is the most important diagnostic procedure. We made a critical review of the medical literature of diagnostic tests of IAI, according to the analysis criterion of the medical articles of the Department of Clinical Epidemiology of the McMaster University. The articles were identified looking for in the MEDLINE-CD ROOM and INDEX MEDICUS from 1991 to 1995. We identified 19 articles, none of them complied with all of the analysis criterion, none of the studies were blinded nor independently compared with a gold standard test and only five articles studied a full spectrum of patients. The articles with better methodologic design were those that studied the interleukin-6 role as diagnostic test for IAI; they showed a sensibility between 75 to 89% and a specificity of 97 to 100%; nevertheless it is still necessary to standardize the cut-off point of the interleukin-6 levels.

[Hemorrhagic cystitis in pregnancy: report of a case and analysis of its treatment]. / Cistitis hemorrágica en el embarazo: informe de un caso y análisis del tratamiento.

Hemorrhagic cystitis is generally a benign self-limited disorder, however there are some severe cases which are associated to a significant blood loss. The etiology may be either bacterial, viral or chemical in origin; though the cause is not identified in most of the cases. Immunocompromised patients or patients who have undergone chemotherapy or radiation constitute the highest risk group. There are only a few articles about hemorrhagic cystitis in pregnancy, that is the reason why the therapy for this disorder is not uniform. Hemorrhagic cystitis in pregnant women frequently is associated with preterm labor. We describe one patient with a clinical status of hematuria, dysuria, frequency, urgency and premature labor. The cystoscopic study showed data that suggest hemorrhagic cystitis. The various treatment used in this disorder are reviewed here.

[Measles and pregnancy. Evolution and management]. / Sarampión y embarazo. Evolución y manejo.

Measles is a highly infectious disease. In Mexico, nevertheless the postvaccine era, continue being an endemic disease. It has been described that measles increase the maternal mortality, because pregnant women have a more severe clinical course of the disease; measles also has negative repercussion on pregnancy, increasing the frequency of premature labor. We report two pregnant women complicated with measles, both of them had a clinical course of the disease and they didn't have obstetric or neonatal complications.

[Prevalence of serologic markers of hepatitis A, B, C, and D viruses in pregnant women]. / Prevalencia de marcadores serológicos de los virus de la hepatitis A, B, C y D en embarazadas.

OBJECTIVE: To determine the seroprevalence of hepatitis A, B, C and D virus infection among pregnant women attending a perinatal care hospital. MATERIAL AND METHODS: A prospective study was carried out to determine the seroprevalence of hepatitis A virus IgG antibodies (anti-HAV), hepatitis B virus markers (anti-HBcAg and HBsAg) and hepatitis C virus antibodies (anti-HCV) in pregnant women. In HBsAg positive cases. HBeAg and hepatitis D virus antibodies (anti-HDV) were investigated. All analyses were performed with the ELISA technique. RESULTS: Of the 1500 pregnant women studied. 93.3% were positive for anti-HAV IgG. The HBsAg seroprevalence was 0.26% and anti-HCV seroprevalence was 0.53%. There were no patients with HBeAg or anti-HDV. CONCLUSIONS: A higher seroprevalence of HBsAg was found in this study than in other studies of pregnant Mexican women. We propose that HBsAg screening become a routine prenatal test.

Tuberculosis of the female reproductive tract: effect on function.

OBJECTIVE: To discuss the clinical presentation and consequences of genital tuberculosis (GTB), a known cause of infertility. Although it appears to be a rare entity, usually secondary to a primary site of infection by Mycobacterium tuberculosis, its true incidence is not known owing, in part, to inadequate diagnostic procedures, particularly in less developed areas of the world. PATIENTS AND METHODS: We present our experience with 25 cases of genital TB. Of these woman, 21 were seen for infertility; 3 were postmenopausal with uterine hemorrhage, and 1 was admitted with an acute abdomen. All women were treated medically and/or surgically. RESULTS: Only five women were found to be suitable for artificial insemination. Two of the women became pregnant but aborted. CONCLUSIONS: The incidence of genital TB may be higher than one might imagine, based on the lack of reports in the literature, and may account for a significant amount of female infertility.

PIP: During 1988-93, in Mexico City, the National Institute of Perinatology diagnosed 25 cases of female genital tuberculosis. Their age ranged from 21 to 42 years. The diagnostic procedures used to detect these cases included laparoscopy, PPD skin test reaction, hysterosalpingography (HSG), culture of tissue and fluid samples, and histopathological examination of tissue biopsies. 16% had a history of tuberculosis. 39.1% had a history of contact with a relative with tuberculosis. Three women were postmenopausal and suffered from uterine bleeding; they underwent a hysterectomy. 17 of 21 women who went on to infertility studies had suffered infertility for 2-14 years. HSG revealed abnormalities in 95.2%, especially bilateral tubal occlusion (57.1%) and deformity of the uterine cavity (54.5%). Mycobacterium tuberculosis was isolated in 4 women, all of whom had fluid in the pelvic cavity. 14 of the 16 patients who underwent the PPD skin test had an induration larger than 10 mm in diameter. 68% of the 19 patients who underwent endometrial biopsy had granulomas consistent with tuberculosis. All the women received antibiotics to treat female genital tuberculosis. Five of the 17 patients referred for infertility evaluation underwent in vitro fertilization and embryo transfer. Two of these women became pregnant but later suffered a spontaneous abortion. The other 3 women never conceived. These findings indicate that the incidence of female genital tuberculosis may be higher than expected and may be responsible for a substantial amount of female infertility. Pregnancy occurs when female genital tuberculosis is detected at an early stage and when no irreversible anatomical pathology is evident. Thus, it is important to determine the existence of tuberculosis early in cases of infertility and to begin therapy immediately.

[Pre- and postgestational vaccination]. / Vacunación pre y posgestacional.

Vaccination is one of the most important methods to prevent infectious diseases, it consist of application of an inactive but immunogenic antigen, with the objective of simulating a natural infection and originate an immunological response. Important vaccines used in women's reproductive age are: 1) antirubella, if the woman has not serum antibodies against rubella virus; 2) tetanus toxoid is indicated in all pregnant women which had not been vaccinated against tetanus in the last ten years; 3) hepatitis B vaccine, to be applicated in newborns of women with positive serological indicators of chronic hepatitis B infection; 4) antirabies vaccine and gamaglobulin hiperimmune must be used in women with a recent exposure to rabies virus.

[Current concepts on the course of pregnancies complicated by tuberculosis]. / Conceptos actuales sobre la evolución de los embarazos complicados con tuberculosis.

Tuberculosis is a public health problem in many countries, in the last ten years it has been a revival of this infection worldwide, including developed countries. Before chemotherapy emergency tuberculosis had a poor prognosis for the pregnancy, evolution change since the use of effective antituberculous drugs. In this moment if a pregnant woman receives a correct treatment, she will not experience an aggravation of the infection, nevertheless tuberculosis may cause an increase of the obstetric and neonatal mortality and morbidity rate, more frequently in women of developing countries or without treatment. Congenital tuberculosis is not frequent but is another risk for the newborns of tuberculous pregnant women.