Eleonor Gastal Lago

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 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 US

Clinical features and follow-up of congenital syphilis.

30 (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.

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

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.

Amyotrophic lateral sclerosis and riluzole use during pregnancy: a case report.

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.

Congenital syphilis: an emerging emergency also in Brazil

arteri osus without clinical symptoms or haemody-namic repercussion. Association between ALS and pregnancy has rarely been described. Since 1977, 19 pregnancies in 16 women have been reported, including the present case (2 6). As foetal growth can be affected by mul-tiple factors, it is diffi cult to attribute this fi nding to the drug use. This is the fi rst report of association between riluzole use and cardiac malformation, although prevalence of cardiac malformations in the general population is considerable. Riluzole use during pregnancy is thought to be harmless, but foetal effects are unknown. It is catego-rized as a Class C drug by the Food and Drug Administration (FDA) (7). The only case of riluzole use throughout pregnancy reported a low birth weight of the newborn, but IURG was not consid-ered because of an uncertain gestational age (2). There has been another case in which riluzole was used until pregnancy diagnosis, at nine weeks GA, when the drug was discontinued (3). ALS seems not to cause obstetric complications. In advanced cases, respiratory complications have been described (4). This was not seen in our patient, whose neurological evaluation deteriorated as a normal progression. Also, uterine contractions seem not to be adversely affected by ALS (5). No clear evidence exists as to the better method of delivery. Besides incipient respiratory failure, caesarean delivery indication should follow obstetrics routine (6).

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

OBJECTIVE: To highlight to the fact that some newborns are not identified as having congenital syphilis, and will present to an emergency room within a few months with a severe disease. METHOD: Review of the charts concerning 3 patients with congenital syphilis, as well as review of the literature using Medline and Lilacs databases, covering the period from 1988 to 1999. RESULTS: We describe the case of 3 infants whose diagnosis of congenital syphilis was only established after the neonatal period, when they presented to the emergency room and were admitted to the pediatric intensive care unit. The first patient had neurosyphilis and nephrotic syndrome, the second had neurosyphilis, and the third had hepatitis. We discuss the clinical aspects of the cases, and comment on other clinical manifestations of congenital syphilis that should be within the purview of pediatric emergency medicine. We analyze the reasons for the failure to diagnose syphilis at birth, and describe some risk factors for gestational syphilis. CONCLUSIONS: Considering the rising incidence of syphilis in Brazil, and the possibility that the congenital infections are not recognized at birth, emergency physicians must keep a high degree of suspicion and an awareness of maternal risk factors, prenatal serology pitfalls, as well as of the several clinical presentations of congenital syphilis that can develop in the first months of life.

Toxoplasmosis, interdisciplinarity and geography

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.

Gestações subsequentes em mulheres que tiveram sífilis na gestação

This special issue of Scientia Medica, a journal that has been increasingly standing out in interdisciplinarity, brings together original articles from several areas of knowledge and different geographical origin, which have in common the approach to toxoplasmosis. Some of the articles address basic or clinical topics of universal nature, while others have a definite regional character. These latter, being of utmost importance to the respective communities, will also bring valuable information for researchers and professionals from other regions. Additionally, review articles in this issue, written by experts, will be useful to update professionals and students from different areas of life and health sciences.

Current trends: Ahead-of-print and article-based publishing

This study included data on syphilis-positive pregnant women seen for delivery or miscarriage, between 1997 and 2004, in Sao Lucas Hospital, Porto Alegre, RS. Their subsequent obstetric outcomes were studied, until December 2011, to see if the disease recurred. From 450 pregnant women with positive syphilis serology, seen from 1997 to 2004, 166 had at least one more obstetric attendance until December 2011, with 266 new obstetric outcomes. Congenital syphilis (CS) was demonstrated in 81.9% of the initial pregnancies and in 68.4% of the subsequent ones. The main causes of CS in subsequent pregnancies were a negative VDRL that turned positive at delivery, and undocumented treatment. VDRL titers were higher than 1:4 in 50.4% of the initial and 13.3% of the subsequent pregnancies (p < 0.01). Perinatal mortality rate was 119/1000 in initial and 41/1000 in subsequent pregnancies (p < 0.01). CS recurrence was frequent in subsequent pregnancies of women who tested positive for syphilis in a preceding pregnancy. No or inadequate prenatal care was the main risk factor for CS, both in initial and in subsequent pregnancies. These data suggest that non-infected neonates could have been defined as CS cases because of insufficient information about the mothers history.This study included data on syphilis-positive pregnant women seen for delivery or miscarriage, between 1997 and 2004, in Sao Lucas Hospital, Porto Alegre, RS. Their subsequent obstetric outcomes were studied, until December 2011, to see if the disease recurred. From 450 pregnant women with positive syphilis serology, seen from 1997 to 2004, 166 had at least one more obstetric attendance until December 2011, with 266 new obstetric outcomes. Congenital syphilis (CS) was demonstrated in 81.9% of the initial pregnancies and in 68.4% of the subsequent ones. The main causes of CS in subsequent pregnancies were a negative VDRL that turned positive at delivery, and undocumented treatment. VDRL titers were higher than 1:4 in 50.4% of the initial and 13.3% of the subsequent pregnancies (p < 0.01). Perinatal mortality rate was 119/1000 in initial and 41/1000 in subsequent pregnancies (p < 0.01). CS recurrence was frequent in subsequent pregnancies of women who tested positive for syphilis in a preceding pregnancy. No or inadequate prenatal care was the main risk factor for CS, both in initial and in subsequent pregnancies. These data suggest that non-infected neonates could have been defined as CS cases because of insufficient information about the mothers history.