Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis.

This article aims to provide an update on the prevention of mother-to-child transmission of syphilis by drawing upon some important basic concepts and reviewing the most recent literature on the diagnosis and treatment of syphilis in pregnancy. New technologies, such as automated and point-of-care immunologic tests, are shifting some paradigms, which will certainly be further investigated in the forthcoming years. This is the time to carefully evaluate traditional as well as new strategies to prevent congenital syphilis. Adverse outcomes of mother-to-child transmission of syphilis can be prevented with antenatal screening and penicillin therapy, which proved to have an excellent cost-benefit ratio even in populations with a low prevalence of syphilis. However, syphilis epidemiology is influenced by socioeconomic and cultural factors, and major challenges are faced by poor and developing countries in which the severity of the problem is extremely alarming. On the other hand, the emergence of new technologies has raised doubts about the best algorithm to be used when proper laboratory resources are available. Conditions are quite heterogeneous across populations, and some procedures should not be generalized while there is no evidence that supports some changes and while in-depth studies about local conditions are not conducted. Official organizations need to be alert in order to avoid isolated decisions and ensure that evidence-based guidelines be used in the management of syphilis in pregnancy.

Presence and duration of anti-Toxoplasma gondii immunoglobulin M in infants with congenital toxoplasmosis / Presença e duração da imunoglobulina M anti-Toxoplasma gondii em lactentes com toxoplasmose congênita

OBJECTIVES: to investigate the rate of positivity for immunoglobulin M anti-Toxoplasma gondii (Toxo-IgM) in newborns with congenital toxoplasmosis, and the age when these antibodies become negative. METHODS: patients with congenital toxoplasmosis who started monitoring in a congenital infection clinic between 1998 and 2009 were included. Inclusion criteria were routine maternal or neonatal serological screening; diagnostic confirmation by persistence of immunoglobulin G anti-Toxoplasma gondii at age > 12 months, and Toxo-IgM screening in the neonatal period. To calculate the frequency of positive Toxo-IgM, cases detected by neonatal screening were excluded. For the study of the age when Toxo-IgM results became negative, patients with negative Toxo-IgM since birth and those in whom it was not possible to identify the month when the negative result was achieved were excluded. RESULTS: among the 28 patients identified through maternal screening, 23 newborns had positive Toxo-IgM (82.1%, 95% CI: 64.7-93.1%). When adding the 37 patients identified by neonatal screening, Toxo-IgM was positive in the first month of life in 60 patients, and it was possible to identify when the result became negative in 51 of them. In 19.6% of patients, these antibodies were already negative at 30 days of life; and in 54.9%, at 90 days. Among the 65 patients included in the study, 40 (61.5%) had some clinical alteration. CONCLUSIONS: even with high sensitivity methods, newborns with congenital toxoplasmosis can have negative Toxo-IgM at birth. In those who have these antibodies, the positive period may be quite short. It is important not to interrupt the monitoring of infants with suspected congenital toxoplasmosis simply because they present a negative Toxo-IgM result. .

OBJETIVOS: investigar a taxa de positividade para imunoglobulina M anti-Toxoplasma gondii (Toxo-IgM) em recém-nascidos com toxoplasmose congênita, e a idade de negativação desses anticorpos. MÉTODOS: foram incluídos pacientes com toxoplasmose congênita que iniciaram acompanhamento em uma clínica de infecções congênitas entre 1998 e 2009. Os critérios de inclusão foram toxoplasmose congênita detectada por triagem sorológica materna ou neonatal de rotina, confirmação diagnóstica por persistência de imunoglobulina G anti-Toxoplasma gondii com >12 meses e pesquisa de Toxo-IgM no período neonatal. Para o cálculo da frequência de positividade da Toxo-IgM foram excluídos os detectados por triagem neonatal. Para o estudo da época de negativação da Toxo-IgM foram excluídos os pacientes com Toxo-IgM negativa desde o nascimento e aqueles em que não foi possível identificar o mês da negativação. RESULTADOS: entre 28 pacientes detectados por triagem materna, 23 recém-nascidos tiveram Toxo-IgM positiva (82,1%, IC 95%: 64,7-93,1%). Somando-se os 37 pacientes detectados por triagem neonatal, a Toxo-IgM foi positiva no primeiro mês de vida em 60 pacientes e em 51 foi possível identificar a época de negativação. Em 19,6% dos pacientes esses anticorpos já eram negativos aos 30 dias e em 54,9% aos 90 dias. Entre os 65 pacientes incluídos no estudo, 40 (61,5%) apresentaram alguma alteração clínica. CONCLUSÕES: mesmo com métodos de alta sensibilidade, recém-nascidos com toxoplasmose congênita podem ter Toxo-IgM negativa ao nascer. Nos que apresentam esses anticorpos, o período de positividade pode ser bastante fugaz. É importante não interromper o monitoramento dos lactentes com suspeita de toxoplasmose ...

Presence and duration of anti-Toxoplasma gondii immunoglobulin M in infants with congenital toxoplasmosis.

OBJECTIVES: to investigate the rate of positivity for immunoglobulin M anti-Toxoplasma gondii (Toxo-IgM) in newborns with congenital toxoplasmosis, and the age when these antibodies become negative. METHODS: patients with congenital toxoplasmosis who started monitoring in a congenital infection clinic between 1998 and 2009 were included. Inclusion criteria were routine maternal or neonatal serological screening; diagnostic confirmation by persistence of immunoglobulin G anti-Toxoplasma gondii at age ≥ 12 months, and Toxo-IgM screening in the neonatal period. To calculate the frequency of positive Toxo-IgM, cases detected by neonatal screening were excluded. For the study of the age when Toxo-IgM results became negative, patients with negative Toxo-IgM since birth and those in whom it was not possible to identify the month when the negative result was achieved were excluded. RESULTS: among the 28 patients identified through maternal screening, 23 newborns had positive Toxo-IgM (82.1%, 95% CI: 64.7-93.1%). When adding the 37 patients identified by neonatal screening, Toxo-IgM was positive in the first month of life in 60 patients, and it was possible to identify when the result became negative in 51 of them. In 19.6% of patients, these antibodies were already negative at 30 days of life; and in 54.9%, at 90 days. Among the 65 patients included in the study, 40 (61.5%) had some clinical alteration. CONCLUSIONS: even with high sensitivity methods, newborns with congenital toxoplasmosis can have negative Toxo-IgM at birth. In those who have these antibodies, the positive period may be quite short. It is important not to interrupt the monitoring of infants with suspected congenital toxoplasmosis simply because they present a negative Toxo-IgM result.

Clinical features and follow-up of congenital syphilis.

OBJECTIVE: The aim of this study was to investigate clinical features and outcomes of children treated for congenital syphilis (CS). METHODS: Infants born alive in the public sector of São Lucas Hospital, Porto Alegre, Brazil, 1997 to 2004, whose mothers had syphilis and neonates with CS born in other facilities and admitted during this period were included. Follow-up was performed from birth up to 5 years. RESULTS: Among 24,920 live births, 379 (1.5%) met the criteria for CS. A further 19 infants born in other hospitals were included, for a total of 398 with CS. We compared infants with CS with 120 infants whose mothers received adequate treatment of syphilis before delivery (total sample, 518 infants). Congenital syphilis was associated with delivery before 34 weeks, low birth weight, and small for gestational age. During the study period, 37 stillbirths with CS were detected. Result from the serum venereal disease research laboratory test was negative at birth in 17.5% of the neonates with CS, and in 4 infants, it became positive after the second day. Thirty percent of the infants with CS were reevaluated between 8 and 60 months, and most had a good outcome when managed according to standard guidelines. Sixteen infants (13.3%) had sequelae. Of these, 8 were symptomatic in the neonatal period, and 13 (81%) of 16 had laboratory/x-ray findings. All asymptomatic and 78% of symptomatic infants had nonreactive fluorescent treponemal antibody absorption test after 12 months of age. CONCLUSIONS: Congenital syphilis remains an impacting disease that causes fetal and neonatal deaths, prematurity, low birth weight, and severe and irreversible sequelae in some children. This study confirms the value of standard guidelines for its management.

Mais um passo importante da Scientia Medica: [editorial] / One further important step for Scientia Medica: [editorial]

É com satisfação que comunicamos aos usuários da Scientia Medica, especialmente aos autores que a prestigiam com a publicação de seus trabalhos, que a revista foi indexada na Scopus. Essa base de dados, oficialmente denominada SciVerse Scopus e pertencente ao grupo editorial Elsevier, é a maior base indexadora de resumos e citações da literatura científica revisada por pares.

Carta de Búzios: proposta para o controle da toxoplasmose no Brasil / Letter of búzios: proposition for the control of toxoplasmosis in Brazil

Nos dias 20 e 21 de setembro de 2008, em Armação dos Búzios, Rio de Janeiro, por ocasião do Congresso Centenário do Toxoplasma, foi realizado o Primeiro Simpósio Nacional de Toxoplasmose, que reuniu profissionais que se dedicam ao estudo da toxoplasmose. Foi criada a Rede Brasileira de Toxoplasmose, com finalidade de incrementar a parceria em pesquisa e a troca de experiências assistenciais, de forma a encontrar soluções mais abrangentes, que possam beneficiar o maior número possível de brasileiros. Este documento sintetiza as preocupações desse grupo de especialistas e propõe a inclusão dos itens descritos abaixo na pauta dos órgãos oficiais.

In September 20-21, 2008, in the city of Armação dos Búzios, Rio de Janeiro, Brazil, during the Toxoplasma Centennial Congress, the First National Symposium of Toxoplasmosis was held, which congregated professionals who are dedicated to the study of toxoplasmosis. The Brazilian Network of Toxoplasmosis was created, with the aims of developing research partnership and exchanging clinical experiences, which may lead to comprehensive solutions with benefits for the largest possible number of Brazilians. This document summarizes the concerns of this group of experts, and recommends the inclusion of the items described below in the agenda of the official organizations.

Ocular sequelae of congenital toxoplasmosis in Brazil compared with Europe.

BACKGROUND: Toxoplasmic retinochoroiditis appears to be more severe in Brazil, where it is a leading cause of blindness, than in Europe, but direct comparisons are lacking. Evidence is accumulating that more virulent genotypes of Toxoplasma gondii predominate in South America. METHODS: We compared prospective cohorts of children with congenital toxoplasmosis identified by universal neonatal screening in Brazil and neonatal or prenatal screening in Europe between 1992 and 2003, using the same protocol in both continents. RESULTS: Three hundred and eleven (311) children had congenital toxoplasmosis: 30 in Brazil and 281 in Europe, where 71 were identified by neonatal screening. Median follow up was 4.1 years in Europe and 3.7 years in Brazil. Relatively more children had retinochoroiditis during the first year in Brazil than in Europe (15/30; 50% versus 29/281; 10%) and the risk of lesions by 4 years of age was much higher: the hazard ratio for Brazil versus Europe was 5.36 (95%CI: 3.17, 9.08). Children in Brazil had larger lesions, which were more likely to be multiple and to affect the posterior pole (p<0.0001). In Brazil, visual impairment (<6/12 Snellen) was predicted for most affected eyes (87%, 27/31), but not in Europe (29%; 20/69, p<0.0001). The size of newly detected lesions decreased with age (p = 0.0007). CONCLUSIONS: T. gondii causes more severe ocular disease in congenitally infected children in Brazil compared with Europe. The marked differences in the frequency, size and multiplicity of retinochoroidal lesions may be due to infection with more virulent genotypes of the parasite that predominate in Brazil but are rarely found in Europe.

Congenital toxoplasmosis: late pregnancy infections detected by neonatal screening and maternal serological testing at delivery.

The first aim of this study was to determine the prevalence of congenital toxoplasmosis in newborn infants treated by the public health system in Porto Alegre, a city in southern Brazil, using neonatal screening for Toxoplasma gondii-specific IgM. The second aim was to investigate whether the cases detected by this approach could have been identified by the prenatal screening for antibodies to T. gondii that was performed in the same population. A fluorometric assay was used to analyse T. gondii-specific IgM in filter paper specimens obtained from newborn infants for routine screening for metabolic diseases. When the specific IgM was positive, serum samples from the infant and the mother were requested for confirmatory serological testing, and the infant underwent clinical examination. Among 10 000 infants screened for T. gondii-specific IgM, seven filter paper samples were positive, and congenital toxoplasmosis was confirmed in six patients. The prevalence of IgM specific for T. gondii was 6/10 000 [95% CI 2/10 000, 13/10 000]. One infected infant had already been identified in the maternity ward before birth, three had been identified by maternal serology at delivery, and two infants with congenital toxoplasmosis were identified solely through neonatal screening. Although four mothers of the patients with congenital toxoplasmosis received prenatal care, and three mothers had one or two serological tests for T. gondii-specific antibodies (one at first trimester, one at first and second trimesters, and the other at second and third trimesters), they were not identified during pregnancy as infected. Neonatal screening identified cases of infection not detected by obtaining only one or two serum samples from pregnant women for T. gondii serology, mainly when infection was acquired and transmitted in late pregnancy. Maternal serology at delivery and neonatal screening were especially useful in the identification of infants with congenital toxoplasmosis when the mother did not receive regular prenatal serological testing or prenatal care.

Congenital syphilis: identification of two distinct profiles of maternal characteristics associated with risk.

BACKGROUND: Behavioral and socioeconomic factors create considerable obstacles to the elimination of congenital syphilis. A clear understanding of maternal risk factors is important to define interventions in every community. GOAL: The goal of this study was to investigate maternal risk factors for congenital syphilis. STUDY DESIGN: We conducted a case-control and descriptive analysis of 3 groups of live born infants and their mothers consisting of: group I (cases of congenital syphilis), group II (neonates without congenital syphilis whose mothers had been adequately treated for syphilis), and group III (random sample of newborn infants whose mothers have not had syphilis). Data were prospectively collected from personal interview and antenatal records. RESULTS: In the case-control study, including groups I and III, the maternal characteristics independently associated with congenital syphilis in the logistic regression were monthly per capita income under 30 US dollars (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.1-7.4), single status (OR, 2.8; 95% CI, 1.1-7.8), and less than 6 prenatal visits (OR, 3.2; 95% CI, 1.3-8.1). Comparison between groups I and II (only mothers who have had syphilis) showed a strong protective association of prenatal care with congenital syphilis (OR, 0.05; 95% CI, 0.00-0.39). Additional analysis identified 2 separate profiles of maternal characteristics, one consisting of low socioeconomic status and the other of risk behaviors. Some women who had syphilis before or during pregnancy received adequate prenatal care and delivered infants without congenital syphilis. Most of these women had high-risk behaviors but they were, in general, less poor, older, and more educated than mothers of infants with congenital syphilis. CONCLUSIONS: Risk behaviors and low socioeconomic characteristics constituted 2 separate maternal profiles associated with congenital syphilis. Socioeconomic risk factors interfered more with prenatal care. To become more effective, the strategies for prevention of congenital syphilis should be targeted to each maternal profile.

Comparação entre as concentrações de IgG anti-toxoplasma gondii em recém-nascidos não-infectados e suas mães, no período pós-parto imediato / Comparison of anti-Toxoplasma gondii IgG concentrations at delivery in uninfected newborns and their mothers

O objetivo deste artigo é avaliar a correlação entre as concentrações sérias de IgG anti-Toxoplasma em recém-nascidos (RN) sem infecção congênita e suas mães, logo após o nascimento. Levantamento retrospectivo da sorologia neonatal e materna de crianças no HSL-PUCRS nos últimos 4 anos e acompanhadas no Ambulatório de Infecções Congênitas, por suspeita de toxoplasmose congênita. Critérios de inclusão: 1) pacientes acompanhados até a negativação da sorologia, sendo excluída a infecção congênita; 2) que ao nascimento apresentavam apenas IgG positiva, não tendo recebido tratamento específico para toxoplasmose; 3) sorologias feitas na mãe e no RN pelo mesmo método, no laboratório do Hospital; 4) coleta do sangue materno entre 24 horas antes e 24 horas após o parto; 5) não mais de 72 horas de intervalo entre a coleta do sangue materno e a do RN. Foram calculados os coeficientes de variação dos testes e os valores foram considerados diferentes quando não havia sobreposição dos limites. Cinqüenta e dois pares RN/ mãe foram selecionados para o estudo. Vinte e seis apresentavam valor de IgG anti-Toxoplasma maior, 19 valor igual e 7 valor menor que o da mãe. A regressão linear calculada para a amostra (Y = 1,001X + 35,699) mostrou superioridade dos níveis neonatais quando comparados aos maternos. O nível de IgG anti-Tosoplasma no recém-nascido correlacionou-se positivamente com o materno e a previsibilidade de Y a partis de X apresentou alto nível de significância estatística (P < 0,000). O coeficiente de correlação de Pearson foi 0,86 (correlação forte) e o coeficiente de determinação foi de 0,74. Concluiu-se que mantendo correlação linear e positiva com os níveis maternos, os níveis de IgG anti-Tosoplasma dos RNs semtoxoplasmose congênita apresentaram-se, freqüentemente, superiores aos de suas respectivas mães.

Sífilis congênita: uma emergência emergente também no Brasil / Congenital syphilis: an emergency also in Brazil

Objetivo: Chamar a atenção para o fato de que alguns recém-nascidos com sífilis congênita podem não ser diagnosticada ao nascer, vindo a necessitar atendimento de emergência, já gravemente doentes, durante os primeiros meses de vida. Métodos: revisão dos prontuários de 3 pacientes com sífilis congênita e pesquisa bibliográfica, utilizando como bases de dados o Medline e o Lilacs, abragendo o período de 1988 a 1999. Resultados: descrevemos os casos de lactentes com sífiliscongênita que somente foram diagnosticados após o período neonatal, quando necessitaram atendimento em serviços de emergência e hospitalização em unidade pediátrica de tratamento intensivo. O primeiro caso apresentou neurossífilis e desenvolvimento de síndrome nefrótica, o segundo com neurossífilis; e o terceiro, predominio de hepatite sifilítica. Discutimos os quadros clínicos apresentados e comentamos outras manisfestações clínicas da sífilis congênita que podem levar à necessidade de consulta em serviços de emergência. Analisamos os motivos que podem levar ou não diagnóstico da infecção ao nascimento e descrevemos alguns fatores de risco para a sífilis gestacional. Conclusões: Tendo em vista a crescente incidência de sífilis no Brasil, assim como a possibilidade de que a infecção congênita passe despercebida no recém-nascido, os médicos dos serviços de emergência precisam manter um alto grau de suspeição e estar alertas para fatores de risco maternos, falha do diagnóstico sorológico pré-natal e diversas manifestações clínicas da sífilis congênita que podem se desenvolver nos primeiros meses de vida

Programa de eliminaçäo da sífilis congênita no Hospital Säo Lucas da PUCRS no ano de 1997 / Program for elimination of congenital syphilis at PUCRS's Sao LUcas's Hospital in 1997

Recentes observaçöes mostram que a incidência de sífilis entre as mulheres vem apresentando um aumento significativo nas últimas décadas, consequentemente elevando o número de casos de sífilis congênita. Este trabalho tem como objetivo alertar os pediatras e médicos em geral para a magnitude do problema, apresentar a abordagem atual na definiçÝo dos casos e nas condutas e mostrar alguns resultados dos primeiros 8 meses de implantaçäo do programa de eliminaçäo da sífilis congênita no Hospital Säo Lucas da PUCRS. Realizamos um levantamento prospectivo dos casos de sífilis congênita em recém-nascidos tratados em nosso Serviço no período de maio a dezembro de 1997, incluindo nascidos no HSL e transferidos de outros hospitais. Foram identificados 21 casos, sendo 19 nascidos no HSL (entre 2.368 nascidos vivos no mesmo período); a maioria (76 por cento) assintomáticos. Todos os casos sintomáticos estavam relacionados à ausência de tratamento materno. Concluímos que a sífilis congênita continua sendo uma doença importante e complicada, de alta morbidade, representando um difícil problema clínico e de saúde pública