Alexandre Sampaio Moura

Clinical and radiographic features of HIV-related pulmonary tuberculosis according to the level of immunosuppression

Medical charts and radiographs from 38 HIV-infected patients with positive cultures for Mycobacterium tuberculosis from sputum or bronchoalveolar lavage were reviewed in order to compare the clinical, radiographic, and sputum bacilloscopy characteristics of HIV-infected patients with pulmonary tuberculosis according to CD4+ lymphocyte count (CD4). The mean age of the patients was 32 years and 76% were male. The median CD4 was 106 cells/mm(3) and 71% had CD4 < 200 cells/mm(3). Sputum bacilloscopy was positive in 45% of the patients. Patients with CD4 < 200 cells/mm(3) showed significantly less post-primary pattern (7% vs. 63%; p = 0.02) and more frequently reported weight loss (p = 0.04). Although not statistically significant, patients with lower CD4 showed lower positivity of sputum bacilloscopy (37% vs. 64%; p = 0.18). HIV-infected patients with culture-confirmed pulmonary tuberculosis had a high proportion of non-post-primary pattern in thoracic radiographs. Patients with CD4 lower than 200 cells/mm(3) showed post-primary patterns less frequently and reported weight loss more frequently.

Health related quality of life among patients with chronic hepatitis C: a cross-sectional study of sociodemographic, psychopathological and psychiatric determinants

INTRODUCTION Chronic hepatitis C virus infection patients have higher rates of psychiatric disorders than the general population. Chronic hepatitis C virus infection is known to be associated with impaired health related quality of life. To our knowledge, there is no previous research of health related quality of life in chronic hepatitis C patients that combined structured psychiatric interview and careful psychopathological evaluation, including depression, anxiety and fatigue instruments. The aim of this study was to evaluate health related quality of life of chronic hepatitis C patients and to investigate the association with sociodemographic, psychopathological and psychiatric factors. MATERIALS AND METHODS Eighty-one individuals with chronic hepatitis C virus infection receiving care at a Brazilian public university-based outpatient service for infectious diseases were enrolled in the study. The World Health Organization Quality of Life Scale Brief Version was used to assess health related quality of life. Standard psychiatric interview (Mini International Neuropsychiatric Interview-Plus) was conducted to establish Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I psychiatric diagnosis. Further instruments completed psychopathological investigation: Beck Depression Inventory, Hospital Anxiety and Depression Scale, Brief Fatigue Inventory, Hamilton Depression Scale and Hamilton Anxiety Scale. Pearson Chi-Square and Kruskal-Wallis were performed for categorical and continuous univariate analysis, respectively. Correlation between psychopathological and health related quality of life scores was performed according to Spearmans correlation. Multivariate analysis was performed according to stepwise forward ordinal logistic regression. The significance threshold was fixed at α=0.05. RESULTS Depressive disorders were associated with worse scores in overall health related quality of life and in all domains. Fatigue was associated with lower scores in physical and psychological domains, and married status with higher scores in psychological health related quality of life. We found strong correlation among scores of depression, fatigue and health related quality of life. CONCLUSION Depression and fatigue must be properly investigated and managed in HCV patients in order to improve HRQL. WHOQOL-BREF proved to be a useful instrument to assess HRQL in HCV patients.

The influence of HCV coinfection on clinical, immunological and virological responses to HAART in HIV-patients

The potential impact of the hepatitis C virus (HCV) on clinical, immunological and virological responses to initial highly active antiretroviral therapy (HAART) of patients infected with human immunodeficiency virus (HIV) is important to evaluate due to the high prevalence of HIV-HCV coinfection. A historical cohort study was conducted among 824 HIV-infected patients starting HAART at a public referral service in Belo Horizonte, Brazil, to assess the impact of HCV seropositivity on appearance of a new AIDS-defining opportunistic illness, AIDS-related death, suppression of viral load, and an increase in CD4-cell count. A total of 76 patients (9.2%) had a positive HCV test, 26 of whom (34.2%) had a history of intravenous drug use. In multivariate analysis, HCV seropositivity was associated with a smaller CD4-cell recovery (RH=0.68; 95% CI [0.49-0.92], but not with progression to a new AIDS-defining opportunistic illness or to AIDS-related death (RH=1.08; 95% CI [0.66-1.77]), nor to suppression of HIV-1 viral load (RH=0.81; 95% CI [0.56-1.17]) after starting HAART. These results indicate that although associated with a blunted CD4-cell recovery, HCV coinfection did not affect the morbidity or mortality related to AIDS or the virological response to initial HAART.

Screening inventories to detect depression in chronic hepatitis C patients.

OBJECTIVE To settle the best cutoffs for inventories to diagnose depression in chronic hepatitis C (CHC) patients. METHOD Seventy-five CHC patients were assessed using a standard psychiatric interview (Mini International Neuropsychiatric Interview) to establish Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) major depression diagnosis and the following inventories: the Beck Depression Inventory (BDI), its short form for Primary Care (BDI-PC) and the Hospital Anxiety and Depression Subscale for Depression (HAD-D). According to the receiver operative characteristic (ROC) curve, the best cutoff to screen for depression was settled, and sensitivity, specificity, and positive and negative predictive values were calculated. Agreement between each inventory and the diagnosis of depression was calculated through Cohens Kappa. Internal consistency was measured through Cronbachs alpha. RESULTS Twenty-one (28%) individuals met criteria for a depressive disorder. BDI, BDI-PC and HAD-D best scores were settled at 18, 5 and 8 points, respectively. They showed the following discriminative properties: sensitivity 81%, 76.2%, 85.7%; specificity 92.6%, 88.9%, 77.8%; positive predictive value 81%, 72.7%, 60%; negative predictive value 92.6%, 90.6%, 93.3%, respectively. ROC curve areas were similar between BDI and BDI-PC, but slightly lower for HAD-D. The agreement between inventories and DSM-IV depression diagnosis was substantial for BDI (0.91) and BDI-PC (0.91) and moderate for HAD-D (0.86). Internal consistency was 0.90, 0.86 and 0.75, respectively. CONCLUSION BDI, BDI-PC and HAD-D showed good discriminative properties to screen for depression in CHC patients and should be considered in clinical practice.

Soluble inflammatory markers as predictors of hepatocellular damage and therapeutic response in chronic hepatitis C

Hepatitis C is an important burden worldwide being an important cause of cirrhosis and liver cancer in different parts of the world. Host immune response, especially T helper type 1 (Th1) cell-mediated, seems to play an important role in disease progression but is also crucial for viral elimination following specific therapy. Immune activation can be evaluated using peripheral levels of different cytokines, such as different chemokines (e.g. CCL5, CXCL10) and tumor necrosis factor alpha (TNF-alpha), and their soluble receptors (e.g. soluble TNF-alpha receptors 1 (sTNF-R1) and 2 (sTNF-R2). This review article focuses on the potential use of peripheral inflammatory markers as predictors of liver histological changes and therapeutic response among patients with chronic hepatitis C.

Syphilitic meningitis in HIV-patients with meningeal syndrome: report of two cases and review.

Few patients with symptomatic neurosyphilis present with signs and symptoms of acute meningitis. Here we report two cases of syphilitic meningitis diagnosed in HIV patients with meningeal syndrome. The first case, a 30-year-old black bisexual male, had concurrent meningeal and ocular syphilis with persistent unusually low CSF glucose levels. He responded well to 21 days of intravenous penicillin therapy. The second case was a 55-year-old female with epilepsy, depression, behavioral disorder and confusion. The diagnosis of HIV infection was made after onset of the syphilitic meningitis. She was treated with 21 days i.v. penicillin with improvement in her clinical condition. The clinical aspects of combined neurosyphilis and HIV infection, plus special features of diagnosis and treatment are discussed.

Impulsiveness in chronic hepatitis C patients

OBJECTIVE The objective was to investigate impulsiveness among chronic hepatitis C (CHC) patients and its association with sociodemographic, clinical and psychopathological factors. METHOD Ninety-one CHC individuals were enrolled in a cross-sectional study at a Brazilian public university-based outpatients service for infectious diseases. They were assessed using the Barrat Impulsiveness Scale, Brief Fatigue Inventory, Beck Depression Inventory and Hamilton Anxiety Scale. Structured psychiatric interview was performed according to the Mini International Neuropsychiatric Interview. Multivariate analysis was performed according to linear stepwise forward regression. RESULTS The total score of impulsiveness according to BIS in studied population was 64.6±9.8. The scores for the nonplanning, cognitive-attentional and motor domains were 23.8±5, 19.4±2.9 and 21.4±5, respectively. Impulsiveness was associated with lower educational level, current interferon-α (IFN) use, attention-deficit/hyperactivity disorder, alcohol use disorder, mixed anxiety and depressive disorder, specific phobia, bipolar spectrum disorders and anxiety symptoms. During IFN treatment, impulsiveness was also associated with suicide risk. CONCLUSION Impulsiveness was frequent in CHC patients and was associated with several psychopathological alterations. Impulsiveness management should be considered when attending CHC patients.

Soluble inflammatory markers as predictors of virological response in patients with chronic hepatitis C virus infection treated with interferon-α plus ribavirin

The host immune response plays an important role in viral clearance in patients who are chronically infected with hepatitis C virus (HCV) and are treated with interferon and ribavirin. Activation of the immune system involves the release of pro and anti-inflammatory molecules that can be measured in plasma samples. The present study aimed to evaluate the association between pretreatment plasma levels of chemokines and soluble tumor necrosis factor receptors (sTNF-R) and the virological response in treated patients with chronic hepatitis C infection. Forty-one chronically-infected HCV patients that were being treated with interferon-α (IFN-α) plus ribavirin were included in the study. Socio-demographic, clinical and laboratory data were collected and pretreatment plasma levels of chemokine CCL2, CCL3, CCL11, CCL24, chemokine CXCL9, CXCL10, sTNF-R1 and sTNF-R2 were measured. The virological response was assessed at treatment week 12, at the end of treatment and 24 weeks after treatment. Pretreatment CXCL10 levels were significantly higher in patients without an early virological response (EVR) or sustained virological response (SVR) compared to responders [512.9 pg/mL vs. 179.1 pg/mL (p = 0.011) and 289.9 pg/mL vs. 142.7 pg/mL (p = 0.045), respectively]. The accuracy of CXCL10 as a predictor of the absence of EVR and SVR was 0.79 [confidence interval (CI) 95%: 0.59-0.99] and 0.69 (CI 95%: 0.51-0.87), respectively. Pretreatment plasma levels of the other soluble inflammatory markers evaluated were not associated with a treatment response. Pretreatment CXCL10 levels were predictive of both EVR and SVR to IFN-α and ribavirin and may be useful in the evaluation of candidates for therapy.

Clinical management of a patient with drug dependence who attempted suicide while receiving peginterferon therapy for chronic hepatitis C

Pegylated interferon-alpha combined with ribavirin is the current gold standard treatment for chronic hepatitis C. Illicit drug dependence is not a rare co-morbidity among chronic hepatitis C population, what can make antiviral treatment an outmost challenge. Despite high sustained virological response rate following antiviral treatment, serious psychiatric adverse reactions may occur, like depression and suicide attempt. We report a patient with recurrent depressive disorder, previous history of suicide attempt and illicit drug dependence. We discuss the singularities and challenges of managing this patient in order to complete the antiviral treatment.

Sexual dysfunction and dissatisfaction in chronic hepatitis C patients

INTRODUCTION The prevalence of sexual dysfunction (SD) and dissatisfaction with sexual life (DSL) in patients with chronic hepatitis C virus infection (CHC) was jointly investigated via a thorough psychopathological analysis, which included dimensions such as fatigue, impulsiveness, psychiatric comorbidity, health-related quality of life (HRQL) and sociodemographic and clinical characteristics. METHODS Male and female CHC patients from an outpatient referral center were assessed using the Brief Fatigue Inventory, the Barrat Impulsiveness Scale, the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale, the Hamilton Anxiety Scale (HAM-A), and the World Health Organization Quality of Life Scale-Brief Version (WHOQOL-BREF). Structured psychiatric interviews were performed according to the Mini-International Neuropsychiatric Interview. SD was assessed based on specific items in the BDI (item 21) and the HAM-A (item 12). DSL was assessed based on a specific question in the WHOQOL-BREF (item 21). Multivariate analysis was performed according to an ordinal linear regression model in which SD and DSL were considered as outcome variables. RESULTS SD was reported by 60 (57.1%) of the patients according to the results of the BDI and by 54 (51.4%) of the patients according to the results of the HAM-A. SD was associated with older age, female gender, viral genotype 2 or 3, interferon-α use, impulsiveness, depressive symptoms, antidepressant and benzodiazepine use, and lower HRQL. DSL was reported by 34 (32.4%) of the patients and was associated with depressive symptoms, anxiety symptoms, antidepressant use, and lower HRQL. CONCLUSIONS The prevalence of SD and DSL in CHC patients was high and was associated with factors, such as depressive symptoms and antidepressant use. Screening and managing these conditions represent significant steps toward improving medical assistance and the HRQL of CHC patients.