Eddie Fernando Candido Murta

Failure of neutrophil chemotactic function in septic patients.

ObjectiveTo investigate the in vitro chemotactic function of neutrophils obtained from patients with sepsis. DesignProspective study in which purified neutrophils obtained from septic patients and nonseptic control volunteers were assayed for chemotactic function induced by N-formyl-l-methionyl-l-leucyl-l-phenylalanine (FMLP) and leukotriene B4. The sera nitrate concentrations also were quantified. SettingUniversity hospital. PatientsTwenty patients with sepsis caused by different infectious foci. InterventionsRoutine blood tests, blood or other site cultures, blood collection for neutrophil purification sera collection for nitrate assay. Measurements and Main ResultsNeutrophils from septic patients exhibited significantly less chemotactic activity than neutrophils obtained from healthy volunteers, in response to FMLP (93.4 ± 6.6 vs. 51 ± 8.3 migrated neutrophils) and leukotriene B4 (90.2 ± 10 vs. 42.4 ± 11.6 migrated neutrophils) stimuli, in a microchemotaxis chamber assay. The impaired chemotaxis occurred mainly in neutrophils from nonsurvivor patients. The extent of neutrophil chemotaxis inhibition (survivor/nonsurvivor) was 33.43%/61.67% and 43.4%/86.98%, in response to FMLP and leukotriene B4, respectively. Increased serum nitrate (micromoles of NO2 NO3) concentrations were detected in septic patients, compared with controls, but no differences were found between survivor (91.84 ± 14.12) and nonsurvivor (102.6 ± 17.36) groups. ConclusionsSeptic patients present suppressed neutrophil chemotactic responses to FMLP and leukotriene B4 stimuli compared with healthy controls. This is accompanied by increased serum concentrations of nitrate. The impairment of neutrophil chemotaxis was observed mainly in the cells obtained from nonsurvivor patients and may thus be an additional factor contributing to disease outcome.

Complete migration of retained surgical sponge into ileum without sign of open intestinal wall

Abstract A 24-year-old woman came to the emergency room with a history of diffuse abdominal pain in the form of colic, nausea, vomiting and intestinal constipation. Clinical and ultrasound findings suggested intestinal obstruction due to foreign body. She had been submitted to a cesarean section 4 months previously at another hospital. At laparotomy, a ileum loop was found to be distended by an inside large and hardened mass with another intestinal loops and omentum density adherent. An ileotomy was performed on the compromised segment with terminating anastomosis. When opened surgical specimen it was observed an intraluminal surgical sponge that had completely migrated into the interior of the ileum and stopped next to ileumcecal valve. No fistulas or open intestinal wall were observed.

Incidence of Gardnerella vaginalis, Candida sp and human papilloma virus in cytological smears

CONTEXT In spite of the wide-ranging literature on the microbiology of normal and abnormal flora of the vagina, there are few studies on the relationship between human papilloma virus (HPV) and other vaginal microorganisms. OBJECTIVE To analyze the frequency of infection by human papilloma virus (HPV) and other agents like Candida sp., Gardnerella vaginalis and Trichomonas vaginalis in cytological smears. DESIGN STUDY Retrospective study SETTING A public tertiary referral center. SAMPLE An analysis of 17,391 cytologies from outpatients seen between January 1997 and August 1998. The control group was made up of patients in the same age group and same period with no cytological evidence of HPV infection. Patients with a diagnosis of cervical intraepithelial neoplasia (CIN) II or III were excluded from this analysis. MAIN MEASUREMENTS The diagnosis of HPV infection was made in accordance with the criteria of Schneider et al. and the diagnosis of Gardnerella vaginalis was made with a finding of clue cells. RESULTS 390 (2. 24%) had alterations consistent with infection by HPV, sometimes associated with CIN I. The results showed that Gardnerella vaginalis was the most frequent agent in women with HPV infection (23.6% versus 17.4%; P <0.05), while in the control group the most frequent agent was Candida sp. (23.9% versus 13.8%; p <0.001). CONCLUSION In spite of this study being based solely on cytological criteria, in which specific HPV and Gardnerella diagnostic tests were not used, the cytological smear is widely used in clinical practice and the data presented in this investigation show that there is an association between Gardnerella vaginalis and HPV infection. It remains to be established whether the microorganisms favor each other.

Differential diagnosis of axillary masses.

Axillary masses are uncommon alterations when detected as an isolated finding. We evaluated 31 patients with isolated axillary masses. Patients with alterations of the breasts or the upper limbs or with ipsilateral chest lesions were excluded from the study. Nine patients had occult breast cancer, 5 of them in the contralateral breast. Seven had metastatic lymph nodes of non-ductal origin, and 1 had carcinoma of apocrine cells with metastasis to the axilla. Four patients had benign lymphadenopathy which disappeared spontaneously, and 4 others had ruptured infundibular follicular cyst, nodular fibromatosis, inflammatory tuberculous and inflammatory rheumatoid lymphadenitis. Five had an ectopic breast (2 with a fibroadenoma and 3 with fibrocystic changes). One patient had an axillary lipoma. The mean age of patients with malignant pathology was 55.1 ± 10.9 years, and the mean age of patients with a benign pathology was 43.1 ± 14.7 (P <0.01). Chest X-ray and bilateral mammography are useful when the cause of the mass cannot be determined by taking a detailed history of neoplastic or infectious antecedents, by careful physical examination of the skin of the arms, trunk and neck, or by palpation of the breasts and thyroid. Fine needle aspiration biopsy distinguishes between benign and malignant pathologies. In cases of indeterminate neoplasia, complete axillary dissection for diagnosis is indicated.

Local cytokine profiles of patients with cervical intraepithelial and invasive neoplasia.

Several studies have suggested that patients with cervical intraepithelial and invasive neoplasia have reduced levels of Th1 cytokines, and increased levels of Th2 cytokines. Thus, the aim of this study was to delineate the immunological profile associated with lesion progression. Biopsies were obtained from 28 patients with low grade cervical intraepithelial lesions (LSILs), 53 patients with high grade cervical intraepithelial lesions (HSILs), 25 patients with invasive cancer (CA), and 20 healthy controls. Levels of IFN-γ, TNF-α, IL-2, IL-4, IL-10, IL-12, TGF-β1 and TGF-β2 were then assayed by RT-PCR and ELISA for each biopsy sample. For LSILs, higher levels of Th1 cytokines were detected, while HSILs were associated with a Th2 cytokine profile. In contrast, CA tissues were associated with the strongest expression of a Treg cytokine profile. In conclusion the most important contribution of these work is identification of the Treg cytokine profile in HPV progression lesions and in combination, these results suggested that tumor progression is dependent on suppression of cellular immunity.

Lymphocyte subpopulations in patients with advanced breast cancer submitted to neoadjuvant chemotherapy.

Aims and background There is an enhanced immune response in patients with breast cancer after the use of chemotherapy. The objective of this study was therefore to investigate alterations in the number of peripheral lymphocytes in patients with breast cancer after neoadjuvant chemotherapy (NC) and the relationship with prognosis. Methods Thirty women were analyzed. Their UICC staging was IIb (only T3N0 included) and III (N3 not included). Sample analysis was performed using flow cytometry before the first cycle and 18 to 21 days after the last cycle of NC. The lymphocyte subsets studied were: T (CD3, CD4, CD8), B (CD19, CD23), natural killer (NK) (CD56, CD16), and interleukin-2 (CD25). CD3, CD56, CD8, and CD16 lymphocytes were analyzed with double marking. After x = 3.8 ± 1.3 cycles of 5-fluorouracil, epirubicin and cyclophosphamide (FEC), 16 patients showed a complete or partial response (group 1). After three cycles 14 showed no response or tumor progression (group 2). A control group of healthy women was used for pretreatment analysis. Results Before NC there was a significant increase in B lymphocytes and NK cells in comparison to the control group. After NC there was a significant percentage increase in CD3, CD4, CD8, CD25 and CD3+CD56+ cells and a decrease in CD19, CD23, CD56, CD16 and CD16+CD8+ cells. There was a significant fall in the absolute number of CD4, CD19, CD23, CD56, CD16 and CD16+CD8+ lymphocytes and an increase in GD3+CD56+ lymphocytes. Before NC the ratio CD4/CD8 in group 1 was 2.25 ± 0.5 and in group 2 it was 1.79 ± 0.5 (P <0.05). Conclusions Patients with advanced breast cancer showed increases in B and NK lymphocytes. Neoadjuvant chemotherapy (FEC) caused an increase in CD3+CD56+ and a decrease in B lymphocytes. Patients with an increased CD4/CD8 ratio have a better chance of responding to neoadjuvant chemotherapy.

Streptococcus agalactiae in Brazil: serotype distribution, virulence determinants and antimicrobial susceptibility

BackgroundGroup B Streptococcus (GBS) remains a major cause of neonatal sepsis and is also associated with invasive and noninvasive infections in pregnant women and non-pregnant adults, elderly and patients with underlying medical conditions. Ten capsular serotypes have been recognized, and determination of their distribution within a specific population or geographical region is important as they are major targets for the development of vaccine strategies. We have evaluated the characteristics of GBS isolates recovered from individuals with infections or colonization by this microorganism, living in different geographic regions of Brazil.MethodsA total of 434 isolates were identified and serotyped by conventional phenotypic tests. The determination of antimicrobial susceptibility was performed by the disk diffusion method. Genes associated with resistance to erythromycin (ermA, ermB, mefA) and tetracycline (tetK, tetL, tetM, tetO) as well as virulence-associated genes (bac, bca, lmb, scpB) were investigated using PCR. Pulsed-field gel electrophoresis (PFGE) was used to examine the genetic diversity of macrolide-resistant and of a number of selected macrolide-susceptible isolates.ResultsOverall, serotypes Ia (27.6%), II (19.1%), Ib (18.7%) and V (13.6%) were the most predominant, followed by serotypes IV (8.1%) and III (6.7%). All the isolates were susceptible to the beta-lactam antimicrobials tested and 97% were resistant to tetracycline. Resistance to erythromycin and clindamycin were found in 4.1% and 3% of the isolates, respectively. Among the resistance genes investigated, tetM (99.3%) and tetO (1.8%) were detected among tetracycline-resistant isolates and ermA (39%) and ermB (27.6%) were found among macrolide-resistant isolates. The lmb and scpB virulence genes were detected in all isolates, while bac and bca were detected in 57 (13.1%) and 237 (54.6%) isolates, respectively. Molecular typing by PFGE showed that resistance to erythromycin was associated with a variety of clones.ConclusionThese findings indicate that GBS isolates circulating in Brazil have a variety of phenotypic and genotypic characteristics, and suggest that macrolide-resistant isolates may arise by both clonal spread and independent acquisition of resistance genes.

Systemic leukocyte alterations are associated with invasive uterine cervical cancer.

Objective: The aim of the study was to evaluate blood leukocyte counts in patients with uterine cervical neoplasia. Methods: Patients treated at a university hospital were reviewed retrospectively. Disease progression was monitored, beginning in 1990 to 2002, for at least 5 years. Blood count parameters included absolute leukocyte, neutrophil and lymphocyte counts, leukocytosis (white blood cells >103/&mgr;L), neutrophilia (neutrophils ≥70% of leukocytes), lymphopenia (lymphocytes ≤ 15% of leukocytes), and the neutrophil-lymphocyte ratio (NLR), categorized as less than 5 or 5 or greater. Results: A total of 315 patients were enrolled: 182 (57.8%) with preinvasive neoplasia (cervical intraepithelial neoplasia [CIN] group), 95 (30.1%) with stages I to II (early group), and 38 patients (12.1%) with stages III to IV neoplasia (advanced group). Neutrophil and lymphocyte counts were elevated and reduced, respectively, at advanced stages compared with the CIN group (P < 0.05). Leukocytosis, neutrophilia, lymphopenia, and an NLR of 5 or greater were more frequent at advanced stages compared with the CIN and early-stage groups (P < 0.05). Moreover, neutrophilia was also significantly more frequent at early stage compared with the CIN group. The advanced group with neutrophilia had increased frequency of recidivism and metastasis than patients in the CIN group with neutrophilia (P < 0.05). Conclusions: Patients with advanced cervical cancer had significantly higher frequency of leukocyte alterations, although they may occur apart from the preinvasive stages. Overall, neutrophilia was the best indicator of cancer invasiveness.

Increased Frequency of Bacterial Vaginosis and Chlamydia trachomatis in Pregnant Women with Human Papillomavirus Infection

The aim of this study was to verify the presence of bacterial vaginosis (BV), Candida sp, Chlamydia trachomatis, Neisseria gonorrhoeae, to determine the prevalence of tobacco use and measure vaginal pH (VpH) in pregnant women with (n = 26) and without (n = 26) human papillomavirus (HPV) infection, and make comparisons between these 2 groups. HPV, C. trachomatis and N. gonorrhoeae were diagnosed using hybrid capture, BV using clinical criteria, and Candida sp via cultures. A digital pH meter was used to measure VpH. The frequencies of Candida sp were 19.2 and 23.1% (p = 1), and VpH was 4.4 ± 0.4 and 4.3 ± 0.4 (p = 0.23), in the HPV-positive and HPV-negative groups, respectively. Compared to the group of pregnant women without HPV infection, those with HPV infection had a significantly higher prevalence of tobacco use (50 vs. 11.5%; p = 0.006), BV (53.8 vs. 15.4%; p = 0.007), and C. trachomatis (34.6 vs. 7.7%; p = 0.039). No case of N. gonorrhoeae was diagnosed. All cases of C. trachomatis and BV had high-grade HPV infection.

OUTCOME AFTER CONIZATION FOR CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE III: RELATION WITH SURGICAL MARGINS, EXTENSION TO THE CRYPTS AND MITOSES

Aims and Background Factors linked to residual neoplasia and recurrence following conization of the uterine cervix for treating cervical intraepithelial neoplasia grade III (CIN III), such as the surgical margins, extension of CIN into the crypts and the number of mitoses, have been studied with contradictory results. We evaluated patients submitted to conization for CIN III and analyzed the aforementioned factors, relating them to recurrence and residual neoplasia in hysterectomy specimens. Methods The surgical specimen of cold-knife conization for CIN III performed in 63 patients (average age, 37.3 ± 9.3 years) was fixed in 4% formaldehyde. The ectocervical and endocervical margins were removed and the cone was cut into fragments perpendicular to the surface of the endocervical mucosa (1 mm thick). One histological section (5 μm thick) was cut from each block and stained with hematoxylin-eosin. We studied the total number of fragments from each cone and affected by CIN, endocervical and ectocervical margins, extension to the crypts, number of mitoses and tripolar mitoses in 100 microscope fields using a 100x objective. Results The endocervical margin was involved in 34.9% vs 9.5% (P = 0.001) of ectocervical margins. Recurrence affected 53.8% of cases presenting involved margins versus 12.9% in the cases without involved margins (P = 0.0078). The average interval to recurrence was 3.2 years. CIN was present in 2.5 to 100% (median, 28%) of the cone fragments (median no., 28; range, 7-95). A median of 44.4% and 25% of cone fragments presented CIN with and without recurrence, respectively. Correlation of the number of mitoses with tripolar mitoses and the percentage of fragments involved by CIN with the number of mitoses and tripolar mitoses showed, respectively, P = 0.02, 0.05 and 0.005. A median of 142 mitosis and 4 tripolar mitosis were observed per case with disease recurrence versus 104 and 3 (P = 0.02, 0.6), respectively, when recurrence did not occur. Of 14 patients who underwent hysterectomy after conization (mean, 3.6 ± 3 months afterwards) for endocervical or both margins involved by CIN in the cone specimen, 8 (57.1%) presented CIN III and one (7.1%) microinvasive carcinoma. In 96.8% of the conizations, the CIN extended to the crypts. Conclusions Involved margins and mitoses are associated with a greater recurrence rate for CIN. Residual neoplasia in the hysterectomy specimen after an involved margin with conization is frequent.