Helio Hehl Caiaffa Filho

Cytomegalovirus infection in transplant recipients

Cytomegalovirus infection is a frequent complication after transplantation. This infection occurs due to transmission from the transplanted organ, due to reactivation of latent infection, or after a primary infection in seronegative patients and can be defined as follows: latent infection, active infection, viral syndrome or invasive disease. This condition occurs mainly between 30 and 90 days after transplantation. In hematopoietic stem cell transplantation in particular, infection usually occurs within the first 30 days after transplantation and in the presence of graft-versus-host disease. The major risk factors are when the recipient is cytomegalovirus seronegative and the donor is seropositive as well as when lymphocyte-depleting antibodies are used. There are two methods for the diagnosis of cytomegalovirus infection: the pp65 antigenemia assay and polymerase chain reaction. Serology has no value for the diagnosis of active disease, whereas histology of the affected tissue and bronchoalveolar lavage analysis are useful in the diagnosis of invasive disease. Cytomegalovirus disease can be prevented by prophylaxis (the administration of antiviral drugs to all or to a subgroup of patients who are at higher risk of viral replication) or by preemptive therapy (the early diagnosis of viral replication before development of the disease and prescription of antiviral treatment to prevent the appearance of clinical disease). The drug used is intravenous or oral ganciclovir; oral valganciclovir; or, less frequently, valacyclovir. Prophylaxis should continue for 90 to 180 days. Treatment is always indicated in cytomegalovirus disease, and the gold-standard drug is intravenous ganciclovir. Treatment should be given for 2 to 3 weeks and should be continued for an additional 7 days after the first negative result for viremia.

Epidemiology of human infection with the novel virus influenza A (H1H1) in the Hospital das Clínicas, São Paulo, Brazil - june-september 2009

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July 16, 2009. Since then, 46,810 cases of acute respiratory syndrome have been reported in Brazil, most of them concentrated in São Paulo. Through September 16, we have confirmed 9,249 cases of novel influenza A H1N1in Brazil, including 699 deaths. The mortality rate observed in Brazil is 0.47/100,000 inhabitants and varies according to region. In this period, São Paulo registered 3733 cases (40.3% of the total) of novel influenza A (H1N1) infection and 327 deaths, reflecting a mortality rate of 0.79/100,000 inhabitants. The Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC) is a reference center for H1N1 cases in São Paulo. During the winter of 2009, 472 patients in this hospital were diagnosed with H1N1 infection; of these, 210 were admitted, and 16 died. To control this pandemic and to provide adequate care for these patients, the Hospital das Clínicas implemented “bundles” including prevention strategies, an epidemiologic surveillance service, availability of fast diagnosis, antiviral treatment and training of staff. The purpose of this manuscript is to describe the epidemiologic features of novel human influenza A (H1N1) infection in the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo during the winter period of the 2009 pandemic.

Herpes Simplex Virus in the saliva of peripheral Bell's palsy patients

UNLABELLED The first herpes virus to be described was types 1 and 2, whose denomination is herpes simplex 1 and 2 or HSV-1 and HSV-2. These viruses have specific biological characteristics, such as the ability to cause different kinds of diseases, as well as to establish hosts latent or persistent lifetime infections and also of being reactivated, causing lesions that can be located at the same site of the initial primary infection or close to it. It is suggested that this virus reactivation in the geniculate ganglion may be related to Bells palsy. In this situation, the viruses that would be latent in this ganglion, would suffer reactivation and replication, then be diffused through the facial nerve and its branches, among them the chorda tympani nerve, which by stimulating salivary secretion would enable the identification of the viral DNA in the patients saliva. Until recently, a great number of patients was diagnosed as holders of this kind of paralysis, named idiopathic or Bells palsy. With the introduction of the technique studying the viral DNA by Polymerase Chain Reaction (PCR), several authors have found herpes simplex virus type I DNA in the cerebrospinal fluid, in the lachrymal secretion, in the saliva and in the geniculate ganglia of patients with Bells palsy. AIM observe the occurrence of herpes simplex type I virus using PCR technique in the saliva of patients with Bells palsy and relating it to the clinical evolution of these cases. METHODOLOGY We evaluated 38 patients with Bells palsy submitted to anamnesis, clinical and ENT examination and saliva sampling for viral DNA detection by PCR technique. The control group was ten normal adults. RESULTS We found positive viral DNA in 11 cases out of the 38, which corresponded to 29% of the sample. This result was statistically significant if compared to the control group, in which we did not find any positive case. CONCLUSION The end result was that the presence of HSV-1 in the saliva of patients with Bells palsy indicating that the viral reactivation can be the etiology of this disease. The detection of the virus in these patients saliva does not influence the disease prognosis.

Detection of human herpesvirus 8 DNA and antibodies to latent nuclear and lytic-phase antigens in serial samples from aids patients with Kaposi's sarcoma.

Abstract Background : human herpesvirus 8 (HHV-8) have recently implicated in the etiology of Kaposis sarcoma (KS), but the pathophysiologic and immunologic interactions between HHV-8 and the human host are incompletely understood. Objective : this paper intends to present partial results of a follow-up study of KS patients, designed to investigate HHV-8 viremia and antibody response. Methods : ninety-six paired serial samples (PBMCs and sera) were obtained from 12 aids patients with KS who received HAART prior or just after entry in the study. HHV-8 DNA was detected by nested-PCR and antibodies to HHV-8 latent nuclear antigen (LANA) and lytic antigen by immunofluorescence assay (IFA). Results : HHV-8 DNA was detected in 33.3% of the first PBMC samples. Among the eight PCR negative patients, four presented positive samples during the follow-up and four remained negative. Five patients had intermittent viremia. Fifteen of the 96 PBMC samples were PCR positive (15.6%). Four of 39 samples (10.2%) from patients classified as stadio II and 11 of the 53 samples (20.7%) from patients in stadio IV were PCR positive ( P =0.2). Six patients (50%) had anti-LANA antibodies at the entry in the study. Among the six seronegative patients, two seroconverted 2 months later and four patients remained seronegative during the 5–8 months of follow-up. All patients had anti-lytic antibodies since the first sample. Conclusion : the presence of HHV-8 viremia could be related to the severity of KS and could be intermittent even under HAART. A longer follow-up is needed to confirm these results.

Haemophilus influenzae Type b Immunization in Adults Infected with the Human Immunodeficiency Virus

The purpose of this study was to assess the influence of Haemophilus influenzae type b conjugate vaccine on HIV-1 RNA level, CD4 count, and anti-Hib polysaccharide (PRP) antibody concentration. Eighty HIV-infected adults were randomized to receive Hib conjugate vaccine or not. Twenty HIV-seronegative controls were also vaccinated. Blood samples were taken before and after vaccination, with a follow-up period of 6 months. HIV infection markers and anti-PRP antibodies were monitored. There was no change in either HIV-1 viremia or CD4 count after vaccination. Immunization immunogenicity was superior in HIV-uninfected than in HIV-infected individuals (p < 0.01). Hib vaccination was safe but induced suboptimal antibody response in HIV-infected adults.

Pesquisa do vírus herpes simples na saliva de pacientes com paralisia facial periférica de Bell

Os primeiros herpes-virus a serem descritos foram os tipos 1 e 2, cuja denominacao e herpes simplex 1 e 2 ou HSV-1 e HSV-2. Estes virus possuem caracteristicas biologicas particulares, tais como a capacidade de causar diferentes tipos de doencas, assim como estabelecer infeccoes latentes ou persistentes por toda a vida dos hospedeiros e de serem reativados causando lesoes que podem se localizar no sitio da infeccao primaria inicial ou proxima a ele. Postula-se que a reativacao deste virus no gânglio geniculado esteja relacionada com a paralisia de Bell. Nesta situacao, os virus, que estariam latentes neste gânglio, sofreriam reativacao e replicacao difundindo-se pelo nervo facial e seus ramos, dentre eles o nervo corda do timpano, que ao estimular a secrecao salivar possibilitaria a identificacao do DNA viral na saliva dos pacientes. Ate recentemente, um grande numero de pacientes eram diagnosticados como portadores de uma forma desta paralisia, chamada de idiopatica ou de paralisia de Bell. Com o advento da tecnica de estudo do DNA viral pelo metodo da reacao da polimerase em cadeia (PCR), diversos autores encontraram DNA do virus herpes simplex tipo I no liquido cefalorraquidiano, na secrecao lacrimal, na saliva e nos gânglios geniculados de pacientes com paralisia de Bell. OBJETIVO: observar a prevalencia do virus herpes simplex tipo I pela tecnica de PCR, na saliva de pacientes com PFP de Bell, relacionando-a com a evolucao clinica destes casos. METODOLOGIA: Avaliamos 38 pacientes portadores de Paralisia Facial Periferica de Bell, que foram submetidos a anamnese, exame medico geral e otorrinolaringologico e coleta de saliva para deteccao do DNA viral pela tecnica de PCR. O grupo controle correspondeu a 10 adultos normais. RESULTADOS: Obtivemos positividade para o DNA viral em 11 casos dos 38 avaliados, o que corresponde a 29% da amostra. Este resultado foi estatisticamente significante se comparado ao grupo controle, no qual nao foi obtido nenhum caso de positividade. CONCLUSAO: Concluiu-se que a presenca do HSV-1 na saliva de pacientes portadores de PFP de Bell indica que a reativacao viral pode ser a etiologia desta doenca. A deteccao do virus na saliva destes pacientes nao influencia o prognostico da doenca.

Guidelines on management of human infection with the novel virus influenza A (H1N1): a report from the Hospital das Clínicas of the University of São Paulo

The pandemic novel influenza A (H1N1) infection was considered widespread in Brazil on July, 2009. Since then, 9.249 cases were confirmed in Brazil, most of them concentrated in São Paulo. The Hospital das Clínicas of the University of São Paulo is a reference center for H1N1 cases in São Paulo. The purpose of this review is to analyze the evidence concerning diagnosis, prevention, and treatment of novel influenza A (H1N1) infection. In addition, we propose guidelines for the management of this pandemic emphasizing Hospital das Clínicas “bundles” for the control of the pandemic novel influenza A (H1N1).

Varicella zoster virus in Bell's palsy: a prospective study

UNLABELLED Although Bells palsy is the major cause of acute peripheral facial palsy, its pathogenesis remains unknown. Reactivation of the varicella zoster virus has been implicated as one of the main causes of Bells palsy, however, studies which investigate the varicella zoster virus reactivation in Bells palsy patients are mostly Japanese and, therefore, personal and geographic characteristics are quite different from our population. AIMS To determine varicella zoster virus frequency in saliva samples from patients with Bells palsy, using PCR. MATERIAL AND METHOD One hundred seventy one patients with acute peripheral facial palsy were prospectively enrolled in this study. One hundred twenty were clinically diagnosed with Bells palsy, within one week of onset of the disease and no previous anti-viral therapy. We had 20 healthy adults as controls. Three saliva samples were collected from patients and controls at initial examination and at one and two weeks later. The detection of the varicella zoster virus DNA was performed using PCR. RESULTS Varicella zoster virus was detected in two patients (1.7%). The virus was not identified in saliva samples from the controls. CONCLUSIONS Varicella zoster virus was detected in 1.7% of saliva samples from patients with Bells palsy, using PCR.Embora a paralisia de Bell seja o tipo mais frequente de paralisia facial periferica,sua causa ainda e objeto de inumeros questionamentos. A reativacao do virus varicela zoster tem sido considerada uma das principais causas da paralisia de Bell, porem, os poucos trabalhos que estudam a prevalencia do VVZ como agente etiologico da PB sao japoneses, o que determina caracteristicas geograficas e populacionais bastante dispares de nossa populacao. OBJETIVOS: Verificar a frequencia do virus varicela zoster em saliva de individuos com PB, pela tecnica de PCR. MATERIAL E METODO: Estudo prospectivo com 171 pacientes com PFP, sendo 120 pacientes portadores de paralisia de Bell, com ate uma semana de evolucao, sem uso previo de drogas antivirais. O grupo controle foi composto de 20 adultos sadios. Nestes individuos foram coletadas tres amostras de saliva em semanas consecutivas, para pesquisa de DNA viral pela tecnica de PCR. RESULTADOS: O virus varicela zoster foi encontrado em amostras de saliva de dois pacientes com paralisia de Bell (1,7%). Nenhum virus foi identificado no grupo controle. CONCLUSAO: Foi verificada frequencia de 1,7% para virus varicela zoster em amostras de saliva de pacientes com paralisia de Bell, pela tecnica de PCR.

Pandemic 2009 H1N1 influenza among health care workers

To evaluate factors associated with pandemic influenza among health care workers (HCWs), a case-case-control study was conducted with 52 confirmed cases, 120 influenza-negative cases, and 102 controls. Comorbidities (odds ratio [OR], 19.05; 95% confidence interval [95% CI]: 4.75-76.41), male sex (OR, 5.11; 95% CI: 1.80-14.46), and being a physician (OR, 8.58; 95% CI: 2.52-29.27) were independent risk factors for pandemic influenza infection among HCWs. Contact with symptomatic coworker or social contact was protective (OR, 0.11; 95% CI: 0.04-0.29). To our knowledge, this is the first study of factors associated with acquiring influenza involving HCW in nonsevere cases.

Epidemiologic investigation of an outbreak of coagulase-negative Staphylococcus primary bacteremia in a newborn intensive care unit

Infections due to coagulase-negative Staphylococcus (CNS) are an ever-increasing nosocomial problem, particularly in the pediatric population. The authors describe a cluster of three primary bloodstream infections due to CNS in a newborn intensive care unit that occurred between November 23 and December 2, 1992. Two children died as a direct consequence of the bacteremia; at autopsy, one had a large bacteria-containing thrombus extending from the insertion site of a central catheter to the superior vena cava. The children were placed in isolation, and the nursing and medical staff were given topical nasal mupirocin. Plasmid analysis performed later disclosed three different blood isolates that also were different from any of the staffs nasal isolates. The authors concluded that molecular methods such as plasmid analysis are important tools in identifying true outbreaks and can prevent needless interventions, such as those during this cluster.