Clearance of Persistent SARS-CoV-2 RNA Detection in a NFκB-Deficient Patient in Association with the Ingestion of Human Breast Milk: A Case Report.

Currently, there are no evidence-based treatment options for long COVID-19, and it is known that SARS-CoV-2 can persist in part of the infected patients, especially those with immunosuppression. Since there is a robust secretion of SARS-CoV-2-specific highly-neutralizing IgA antibodies in breast milk, and because this immunoglobulin plays an essential role against respiratory virus infection in mucosa cells, being, in addition, more potent in neutralizing SARS-CoV-2 than IgG, here we report the clinical course of an NFκB-deficient patient chronically infected with the SARS-CoV-2 Gamma variant, who, after a non-full effective treatment with plasma infusion, received breast milk from a vaccinated mother by oral route as treatment for COVID-19. After such treatment, the symptoms improved, and the patient was systematically tested negative for SARS-CoV-2. Thus, we hypothesize that IgA and IgG secreted antibodies present in breast milk could be useful to treat persistent SARS-CoV-2 infection in immunodeficient patients.

Recommendations from the Brazilian Society of Nephrology for approaching Covid-19 Diagnostic Testing in Dialysis Units.

The Covid-19 pandemic brought several challenges to the healthcare system: diagnosis, treatment and measures to prevent the spread of the disease. With the greater availability and variety of diagnostic tests, it is essential to properly interpret them. This paper intends to help dialysis units concerning the use of clinical criteria and diagnostic tests for decision making regarding the discontinuation of isolation of patients with suspected or confirmed Covid-19, as well as the return to work activities for employees with suspected or confirmed Covid-19.

Recommendations from the Brazilian Society of Nephrology for approaching Covid-19 Diagnostic Testing in Dialysis Units / Recomendações da Sociedade Brasileira de Nefrologia para abordagem de exames diagnósticos da Covid-19 nas unidades de diálise

ABSTRACT The Covid-19 pandemic brought several challenges to the healthcare system: diagnosis, treatment and measures to prevent the spread of the disease. With the greater availability and variety of diagnostic tests, it is essential to properly interpret them. This paper intends to help dialysis units concerning the use of clinical criteria and diagnostic tests for decision making regarding the discontinuation of isolation of patients with suspected or confirmed Covid-19, as well as the return to work activities for employees with suspected or confirmed Covid-19.

RESUMO A pandemia da Covid-19 trouxe desafios ao sistema de saúde em diversas esferas: diagnóstico, tratamento e medidas para evitar a disseminação da doença. Com a maior disponibilização e variedades de testes diagnósticos, torna-se fundamental sua adequada interpretação. Este posicionamento pretende orientar unidades de diálise em relação ao uso de critérios clínicos e testes diagnósticos para a tomada de decisão referente à descontinuação do isolamento de pacientes com suspeita ou confirmação de Covid-19, assim como para o retorno às atividades laborais de colaboradores com suspeita ou confirmação de Covid-19.

Controlled attenuation parameter for steatosis grading in chronic hepatitis C compared with digital morphometric analysis of liver biopsy: impact of individual elastography measurement quality.

BACKGROUND AND OBJECTIVE: Controlled attenuation parameter (CAP) diagnostic performance for steatosis grading has been controversial and considerable observer-related variability in liver biopsy has been reported. This is a subanalysis of a larger chronic hepatitis C study on noninvasive fibrosis staging. MATERIALS AND METHODS: Patients were prospectively enrolled for paired liver biopsy and transient elastography. Biopsy fragments were subjected to digital morphometric steatosis quantification. Associated patient and technical factors, including a newly described elastogram quality score, were evaluated. RESULTS: A total of 312 patients were included in the final analysis. The mean liver stiffness was 8.7±2.1 kPa. Morphometry showed S0 in 19.2% of patients, S1 in 28.5%, S2 in 31.1%, and S3 in 21.2%. CAP showed S0 in 11.2% of patients, S1 in 26.6%, S2 in 56.7%, and S3 in 5.4%. Spearman coefficient showed a positive and independent correlation between CAP and morphometric analysis (r=0.48, P<0.05), except for distinguishing S1 and S2 (P=0.11). Area under the receiver operating characteristic curves for the presence or absence of steatosis was 0.944; differentiation between levels I, II, and III were 0.776, 0.812, and 0.879. Elastogram quality independently predicted accuracy [odds ratio (OR): 6.95, 95% confidence interval (95%CI): 4.45-9.06 as well as CAP interquartile range OR: 2.81, 95%CI: 1.67-3.99] and liver stiffness (OR: 0.78, 95%CI: 0.51-0.80). CONCLUSION: We present an external validation for CAP against the objective steatosis quantification provided by digital morphometry. Fairly good performance indicators were found, except for S1 versus S2 differentiation. Variability and higher liver stiffness were associated with lower performance. Achieving higher quality measurements, however, overcame such limitations with excellent accuracy.

Recommendations for Management of Endemic Diseases and Travel Medicine in Solid-Organ Transplant Recipients and Donors: Latin America.

The Recommendations for Management of Endemic Diseases and Travel Medicine in Solid-Organ Transplant Recipients and Donors: Latin America clinical practice guideline is intended to guide clinicians caring for solid-organ transplant (SOT) donors, candidates and recipients regarding infectious diseases (ID) issues related to this geographical region, mostly located in the tropics. These recommendations are based on both systematic reviews of relevant literature and expert opinion from both transplant ID and travel medicine specialists. The guidelines provide recommendations for risk evaluation and laboratory investigation, as well as management and prevention of infection of the most relevant endemic diseases of Latin America. This summary includes a brief description of the guideline recommendations but does not include the complete rationale and references for each recommendation, which is available in the online version of the article, published in this journal as a supplement. The supplement contains 10 reviews referring to endemic or travel diseases (eg, tuberculosis, Chagas disease [ChD], leishmaniasis, malaria, strongyloidiasis and schistosomiasis, travelers diarrhea, arboviruses, endemic fungal infections, viral hepatitis, and vaccines) and an illustrative section with maps (http://www.pmourao.com/map/). Contributors included experts from 13 countries (Brazil, Canada, Chile, Denmark, France, Italy, Peru, Spain, Switzerland, Turkey, United Kingdom, United States, and Uruguay) representing four continents (Asia, the Americas and Europe), along with scientific and medical societies.

Immunization in end stage renal disease: The perception of waiting list patients.

BACKGROUND: The number of patients with chronic kidney disease is increasing worldwide, as well as the number of patients in kidney transplant waiting lists. In order to prevent infections related to immunosuppressive therapy, immunization guidelines for CKD patients before transplantation have been proposed. The aim of the present study was to evaluate adherence to immunization in a cohort of CKD patients in transplant waiting list and their renal replacement therapy clinics. METHODS: CKD patients older than 18 years old, receiving renal replacement therapy longer than 12 months and included in kidney transplant waiting list at University of Campinas (Unicamp) were enrolled. RESULTS: From February 2014 to December 2015, 105 patients fulfilled the inclusion criteria. Complete hepatitis B vaccination was observed in 73% and influenza vaccine in 67%. None of the other vaccine protocols reached 50% of coverage. Patients receiving immunization at primary health units presented higher coverage for diphtheria, tetanus (dT), measles, mumps, rubella (MMR), and hepatitis B vaccines, while patients immunized at renal replacement therapy clinics showed higher prevalence of pneumococcus (pneumo23). CONCLUSION: The low rates of immunization could reflect the RRT's clinics knowledge about the vaccines guidelines and its application on daily care. We suggest an integration between transplant center and RRT clinics, through lectures, periodic checking of vaccination cards, and easy to follow guidelines in order to provide a better vaccine coverage and to obtain higher immunization rates.

Predictors of early discontinuation of interferon-free direct antiviral agents in patients with hepatitis C virus and advanced liver fibrosis: results of a real-life cohort.

AIM: The aim of this study was to determine risk factors for premature treatment discontinuation among patients with hepatitis C and advanced fibrosis with advanced fibrosis treated with interferon (IFN)-free direct antiviral agents (DAA)-based therapy. PATIENTS AND METHODS: We included all patients with chronic hepatitis C virus infection and advanced liver fibrosis in whom treatment was initiated with IFN-free DAA therapy at a university hospital from December 2015 through June 2016. We prospectively collected data from medical records using standardized questionnaires and evaluated them using Epi Info 7.1.2.0. The primary outcome was treatment interruption and associated factors. RESULTS: In total, 214 patients were included in this study; 180 patients were treated with sofosbuvir (SOF)+daclatasvir±ribavirin (RBV), 31 received SOF+simeprevir±RBV, and three were treated with SOF+RBV. Treatment discontinuation rate was 8.9% (19 patients) and cirrhotic decompensation was the main reason [8 (42.1%)]. Among patients with Child B or C cirrhosis (31), 10 (32.2%) prematurely interrupted treatment. The risk factors for treatment discontinuation in univariate analysis were older age (P=0.0252), higher comorbidity index (P=0.0078), higher model for end-stage liver disease (P<0.0001), higher fibrosis index based on the 4 factores (P=0.0122), and lower hemoglobin (P=0.0185) at baseline. Multivariate analysis showed that older age (odds ratio: 1.1, 95% confidence interval: 1.02-1.19) and higher model for end-stage liver disease (odds ratio: 1.27, 95% confidence interval: 1.03-1.56) were associated with premature treatment interruption. CONCLUSION: Older age and advanced liver disease were related to treatment interruption. Identification of risk factors associated with treatment discontinuation is important to recognize patients who should be followed up closely during treatment, ando those whom possibly may not benefit from immediate DAA treatment or should be followed up closely during treatment.

Probable transfusion-transmitted Zika virus in Brazil.

BACKGROUND: Zika virus (ZIKV) is an emerging arthropod-borne flavivirus transmitted by Aedes mosquitoes. Recent commentaries regarding ZIKV routes of transmission describe a potential transmission by transfusion. Herein, we report a probable case of transfusion-transmitted ZIKV infection through a platelet transfusion that was detected from postdonation information. CASE REPORT: A blood donor made a voluntary telephone report to the blood donor facility 3 days after donation and informed the facility of a febrile illness (fever, malaise, and headaches). Due to the ongoing dengue epidemic, the initial clinical investigation included dengue among other possible diagnoses. The serology and molecular laboratory results excluded dengue infection. However, stored samples from the donation were positive for ZIKV on reverse transcription-polymerase chain reaction (RT-PCR) analysis. A retrospective investigation demonstrated that the platelet concentrate, which was part of a pool, had been transfused after a liver transplantation. A physician had evaluated the patient 4 days after surgery. Laboratory investigation showed enzyme-linked immunosorbent assay results that were negative for dengue immunoglobulin M antibodies; however, the results were positive for hemagglutination inhibition antibodies against flavivirus. ZIKV RT-PCR and virus isolation analyses in cell cultures from recipient serum were both positive. The sequencing confirmed ZIKV in the donor and patient samples. Ten partial nucleotide sequences from the ZIKV strain that were detected in the donor were aligned and compared with the ZIKV genome detected in the recipient, revealing a 99.8% homology between the two strains. CONCLUSIONS: This is a case of probable transmission of ZIKV through blood transfusion. The patient had been transfused with the blood product from an infected donor, most likely in the incubation period after ZIKV infection but prior to clinical disease onset. This report emphasizes the importance of postdonation information and recipient investigations during outbreaks of potentially blood-borne infections.

Brazilian spotted fever: a case series from an endemic area in southeastern Brazil: epidemiological aspects.

Brazilian spotted fever (BSF) is the most important tick-borne disease in Brazil and is caused by Rickettsia rickettsii and transmitted by the Ixodid tick Amblyomma cajennense, its main vector. We present epidemiologic aspects of a case series of patients admitted to the Hospital das Clínicas da UNICAMP from 1985 to 2003 with a confirmed diagnosis of BSF either by a fourfold rise in indirect immunofluorescence (IFA) titers of IgG antibodies reactive with R. rickettsii or isolation of R. rickettsii from blood or skin specimens. Seasonal variation of case occurrence seems to be associated with the life cycle of the tick. The recent reemergence of cases seems to be associated with the growing numbers of the capybara (Hydrochaeris hydrochaeris) and their expansion into urban areas.

Brazilian spotted fever: a case series from an endemic area in southeastern Brazil: clinical aspects.

This case series study is based on a retrospective review of medical records and case notification files of patients admitted to The Hospital das Clínicas da UNICAMP from 1985 to 2003 with a confirmed diagnosis of BSF either by fourfold rise in indirect immunofluorescence assay (IFA) titers of IgG antibodies reactive with R. rickettsii or isolation of R. rickettsii from blood or skin specimens. A median lethality of 41.9 % was observed between 1985 and 2004. The case-fatality ratio of 30 % in our study, lower than the overall São Paulo state ratio, could be explained by a higher index of suspicion and a larger experience in our hospital, a regional referral center for BSF. The presence of the classical triad of fever, rash, and headache as described in RMSF was observed in fever than half (35.2%) of our patients.

A clinical, epidemological, laboratorial, histological and ultrasonographical evaluation of anti-HCV EIA-2 positive blood donors

Between 1992 and 1997, 790 blood donors with anti-HCV EIA-2 strongly reagent (relationship between the sample optical density/cut-off > 3) detected at the blood bank serological screening, were evaluated in ambulatory environment. They were all negative for Chagas disease, syphilis, hepatitis B (HBsAg) and AIDS. Blood samples were collected at the first ambulatorial evaluation, for hemogram, biochemical tests and new serological tests for HCV (anti-HCV EIA-2). In blood samples of 226 repeatedly reagent anti-HCV EIA-2 blood donors, supplementary "immunoblot" test for HCV (RIBA-2) was used. In 209 donors, the presence of HCV-RNA was investigated by the PCR test. The abdominal ultrasonography was realized in 366 donors. In 269 patients liver biopsy was performed for the histopathological study. The follow-up of blood donors showed that 95.6 percent were repeatedly EIA-2 reagent, 94 percent were symptomless and denied any hepatitis history, with only 2 percent mentioning previous jaundice. In 47 percent of this population at least one risk factor has been detected for the HCV transmission, the use of intravenous drugs being the main one (27.8 percent). Blood transfusion was the second factor for HCV transmission (27.2 percent). Hepatomegaly was detected in 54 percent of the cases. Splenomegaly and signs of portal hypertension have seldom been found in the physical examination, indicating a low degree of hepatic compromising in HCV. Abdominal ultrasound showed alterations in 65 percent of the subjects, being the steatosis the most frequent (50 percent). In 83.5 percent of the donors submitted to the liver biopsy, the histopathological exam showed the presence of chronic hepatitis, usually classified as active (89 percent) with mild or moderate grade in most of the cases (99.5 percent). The histopathological exam of the liver was normal in 1.5 percent of blood donors. The RIBA-2 test and the HCV-RNA investigation by PCR were positive in respectively 91.6 and 75 percent of the anti-HCV EIA-2 reagent donors. The HCV-RNA research was positive in 82 percent of the RIBA-2 positive subjects, in 37.5 percent of the indeterminate RIBA-2 donors and in 9 percent of the negative RIBA-2 donors. Chronic hepatitis has also been observed in 50 percent of the histopathological exams of the anti-HCV EIA-2 reagent donors which were indeterminate RIBA-2...

Hepatitis C virus in monozygotic twins

A case of a pregnant patient with chronic hepatitis C who gave birth to monozygotic twins that were infected with HCV is reported. One of the newborns was positive for HCV-RNA in blood sample collected 12 hours after delivery. The other newborn was negative for HCV-RNA at birth, but was detected HCV viremia at three months of age. The results have led to the conclusion that one of the twins was probably contaminated in the intrauterine period, while the other acquired the infection in the perinatal period. Both were negative for HCV-RNA and for anti-HCV in the serum samples collected at nine months of age. The report describes the changes in the laboratory tests conducted in mother and twins until 29 months after delivery.

Transfusion-transmited virus (TTV) in Brazil: preliminary report

TTV e um virus DNA recentemente descoberto no Japao a partir de um paciente portador de hepatite pos-transfusional de origem desconhecida. Neste estudo, avaliamos a presenca deste virus em pacientes com hepatopatias cronicas dos estados de Sao Paulo e do Para, representando duas regioes geograficamente diferentes. O DNA do TTV foi encontrado em 21/105 (20 por cento) e 9/20 (45 por cento) dos casos de Sao Paulo e do Para, respectivamente. O sequenciamento do DNA amplificado confirmou a presenca dos genotipos 1a e 2a, bem como de outros genotipos ainda nao descritos ate o momento. Em conclusao, TTV esta presente em casos de hepatopatias cronicas do Sudeste e do Norte do Brasil. por outro lado, maiores estudos ainda sao necessarios antes de se estabelecer relacao causal entre o TTV e a hepatite em seres humanos