Roberto da Justa Pires Neto

Dengue infection in children and adolescents: Clinical profile in a reference hospital in northeast Brazil

INTRODUCTION This study aimed to describe the clinical spectrum of dengue in children and adolescents from a hyperendemic region who were admitted for hospitalization. METHODS A retrospective study was conducted on patients diagnosed with dengue infection upon admission to a reference center in Fortaleza, Brazil. RESULTS Of the 84 patients included, 42 underwent confirmatory testing. The main symptoms were fever, abdominal pain and vomiting. The median level of serum aspartate aminotransferase was 143.5±128mg/dL. CONCLUSIONS A peculiar clinical profile was evident among children and adolescents with dengue infection in a reference center in northeast Brazil, including gastrointestinal symptoms and liver involvement.

Pandemic influenza A (H1N1) 2009: epidemiological analysis of cases in a tropical/semi-arid region of Brazil

INTRODUCTION The year 2009 marked the beginning of a pandemic caused by a new variant of influenza A (H1N1). After spreading through North America, the pandemic influenza virus (H1N1) 2009 spread rapidly throughout the world. The aim of this study was to describe the clinical and epidemiological characteristics of cases of pandemic influenza in a tropical/semi-arid region of Brazil. METHODS A retrospective study analyzed all suspected cases of pandemic influenza (H1N1) 2009 reported in the Ceará State through the National Information System for Notifiable Diseases during the pandemic period between 28 April, 2009 and November 25, 2010. RESULTS A total of 616 suspected cases were notified, 58 (9.4%) in the containment phase and 558 (90.6%) in the mitigation phase. Most cases were of affected young people resident in the City of Fortaleza, the largest urban center in the State of Ceará. The most frequent symptoms presented by the cases with confirmed infection were fever, cough, myalgia, arthralgia, and nasal congestion. Mortality rate was 0.0009/1,000 inhabitants and lethality was 5.6%. Deaths were observed only in the mitigation phase. Mortality rates were similar for both sexes but were higher in the age group under 5 years. CONCLUSIONS The study suggests that the influenza A (H1N1) pandemic in this tropical/semi-arid region had a lower magnitude when compared to states in the Southern and Southeastern regions of Brazil.

Long-Term Follow-Up of Patients with Chronic Chagas Disease and Implantable Cardioverter-Defibrillator

Chronic Chagas heart disease (ChHD) is associated with ventricular tachyarrhythmias and an increased risk of sudden cardiac death. Little is known about the effectiveness of implantable cardioverter‐defibrillator (ICD) therapy in this population. The objective of this study was to evaluate the efficacy of ICD in patients with ChHD and to identify predictors of mortality and appropriate ICD shocks.

Leprosy nephropathy: a review of clinical and histopathological features.

Leprosy is a chronic disease caused by Mycobacterium leprae, highly incapacitating, and with systemic involvement in some cases. Renal involvement has been reported in all forms of the disease, and it is more frequent in multibacillary forms. The clinical presentation is variable and is determined by the host immunologic system reaction to the bacilli. During the course of the disease there are the so called reactional states, in which the immune system reacts against the bacilli, exacerbating the clinical manifestations. Different renal lesions have been described in leprosy, including acute and chronic glomerulonephritis, interstitial nephritis, secondary amyloidosis and pyelonephritis. The exact mechanism that leads to glomerulonephritis in leprosy is not completely understood. Leprosy treatment includes rifampicin, dapsone and clofazimine. Prednisone and non-steroidal anti-inflammatory drugs may be used to control acute immunological episodes.

Acute kidney injury in HIV-infected children: comparison of patients according to the use of highly active antiretroviral therapy

OBJECTIVE To assess clinical and laboratory data, and acute kidney injury (AKI) in HIV-infected children using and not using highly active antiretroviral therapy (HAART) prior to admission. METHODS A retrospective study was conducted with HIV-infected pediatric patients (<16 years). Children who were using and not using HAART prior to admission were compared. RESULTS Sixty-three patients were included. Mean age was 5.3±4.27 years; 55.6% were females. AKI was observed in 33 (52.3%) children. Patients on HAART presented lower levels of potassium (3.9±0.8 vs. 4.5±0.7mEq/L, p=0.019) and bicarbonate (19.1±4.9 vs. 23.5±2.2mEq/L, p=0.013) and had a higher estimated glomerular filtration rate (102.2±36.7 vs. 77.0±32.8mL/min/1.73m2, p=0.011) than those not on HAART. In the multivariate analysis, the use of HAART prior to the admission was a protective factor for AKI (p=0.036; OR=0.30; 95% CI=0.097-0.926). CONCLUSION AKI is a common complication of pediatric HIV infection. Use of HAART prior to the admission preserved glomerular filtration and was a protective factor for AKI, but increased medication side effects, such as hypokalemia and renal metabolic acidosis.

Clinical Course After Cardioverter-Defibrillator Implantation: Chagasic Versus Ischemic Patients

Background: The outcome of Chagas disease patients after receiving implantable cardioverter defibrillator (ICD) is still controversial. Objective: To compare clinical outcomes after ICD implantation in patients with chronic Chagas cardiomyopathy (CCC) and ischemic heart disease (IHD). Methods: Prospective study of a population of 153 patients receiving ICD (65 with CCC and 88 with IHD). The devices were implanted between 2003 and 2011. Survival rates and event-free survival were compared. Results: The groups were similar regarding sex, functional class and ejection fraction. Ischemic patients were, on average, 10 years older than CCC patients (p < 0.05). Patients with CCC had lower schooling and monthly income than IHD patients (p < 0.05). The number of appropriate therapies was 2.07 higher in CCC patients, who had a greater incidence of appropriate shock (p < 0.05). Annual mortality rate and electrical storm incidence were similar in both groups. There was no sudden death in CCC patients, and only one in IHD patients. Neither survival time (p = 0.720) nor event-free survival (p = 0.143) significantly differed between the groups. Conclusion: CCC doubles the risk of receiving appropriate therapies as compared to IHD, showing the greater complexity of arrhythmias in Chagas patients.

Avaliação de manifestações dolorosas em pacientes internados em hospital de referência, com diagnóstico provisório de dengue

JUSTIFICATIVA E OBJETIVOS: As manifestacoes algicas sao caracteristicas marcantes da dengue, tanto em criancas como em adultos, trazendo desconforto e sofrimento aos pacientes. O objetivo deste estudo foi analisar as principais queixas dolorosas em pacientes acometidos por essa afeccao, tornando possivel a elaboracao de medidas de diagnostico precoce e manuseio da dor. METODO: Estudo retrospectivo em 252 prontuarios de pacientes com diagnostico presuntivo de dengue, atendidos no Hospital Sao Jose de Fortaleza, referencia em doencas infecciosas no estado do Ceara, no periodo de janeiro de 2006 a dezembro de 2007. Foram incluidos no estudo os pacientes que apresentaram ao menos uma queixa algica. RESULTADOS: A maioria dos pacientes (94,84%) apresentou ao menos uma queixa algica, sendo a cefaleia a mais prevalente, seguida por mialgia e dor abdominal. Os pacientes diagnosticados com febre hemorragica da dengue (40,16%) cursaram com mais sintomas dolorosos que os pacientes com diagnostico de dengue classico. Sorologia para dengue foi positiva em 72,72% dos que apresentaram as cinco principais queixas algicas analisadas no estudo. CONCLUSAO: A dor mostrou-se bastante prevalente no quadro clinico da dengue, cabendo aos profissionais de saude o manuseio adequado da sintomatologia algica.

HIV or human papillomavirus co-infection among Brazilian individuals infected with hepatitis B and/or hepatitis C

To investigate the incidence of co‐infection with HIV and human papillomavirus (HPV) among Brazilian individuals with hepatitis B virus (HBV) or hepatitis C virus (HCV) infection.

Encephalitis and transverse myelitis in dengue and chikungunya coinfection

FIGURE 1: Brain MRI with punctiform areas with hyperintensity in T2wFLAIR on the deep white matter of the semioval center and parietal and frontal lobes (A), in the left temporal deep white matter (B), and in the parietal white matter and left radiated crown (C). MRI: magnetic resonance imaging; T2w-FLAIR: T2-weighted fluid-attenuated inversion recovery. FIGURE 2: Spinal cord MRI with extensive T2w-FLAIR hypersignal change in the anterior compartment (sagittal T2) (A). T2w-FLAIR axial acquisition confirming the involvement of the anterior horns of the spinal cord (motor neuron) (B). MRI: magnetic resonance imaging; T2w-FLAIR: T2-weighted fluid-attenuated inversion recovery. A 53-year-old man from Northeastern Brazil was admitted to the emergency room due to mental confusion and diffuse myalgia, adynamia, fever, and oliguria for 2 days. He had history of type 2 diabetes mellitus with nephropathy and peripheral neuropathy. Dengue immunoglobulin M (IgM) and immunoglobulin G (IgG) and chikungunya IgM serology were positive. Magnetic resonance imaging (MRI) of the brain revealed diffuse accentuation of grooves, which is unusual for this age group, and numerous punctiform areas with hyperintensity in T2-weighted fluid-attenuated inversion recovery (T2w-FLAIR) sequences in the supratentorial white matter, especially within the oval center, indicating encephalitis (Figure 1). MRI of the spinal cord revealed areas with hyperintensity in T2w-FLAIR sequences in the anterior portion in all segments, indicating transverse myelitis (Figure 2). Cerebrospinal fluid (CSF) analysis showed glicorraquia of 103mg/dL, proteinorraquia of 121mg/dL, and non-reagent VDRL. On the 58th day of hospitalization, the patient was discharged. Dengue and chikungunya coinfection may have a myriad of neurological presentations such as encephalopathy, myelopathy, Guillain-Barré syndrome, cranial neuropathy, cognitive, and psychiatric disorders1,2. Transverse myelitis is commonly caused by autoimmune diseases, although certain viral pathologies may also be involved3. The diagnosis of neurological manifestations associated with dengue virus/chikungunya virus coinfection may be determined by specific IgM antibodies and increasing IgG antibody titers. However, other methods such as polymerase chain reaction (PCR) in CSF samples may be necessary for the differential diagnosis2.

Acute kidney injury and other factors associated with mortality in hiv-infected patients

OBJECTIVE HIV-related mortality is still high, especially in developed countries. The aim of this study is to investigate factors associated to death in HIV-infected patients. METHODS This is a cross-sectional study with all HIV adult patients admitted to a tertiary infectious diseases hospital in Fortaleza, Northeast Brazil, from January 2013 to December 2014. Patients were divided into two groups: survivors and non-survivors. Demo-graphical, clinical and laboratory data were compared and a logistic regression was performed in order to investigate risk factors for death. P values ≤0.05 were considered statistically significant. RESULTS A total of 200 patients with mean age of 39 years were including in the study, 69.5% males. Fifteen patients (7.5%) died. Non-survivors presented a higher percentage of males (93.3 vs. 67.3%, p = 0.037). Non-survivors presented AKI (73.3 vs. 10.3%, p < 0.001), liver dysfunction (33.3 vs. 11.5, p = 0.031), dyspnea (73.3 vs. 33.0%, p = 0.002) and disorientation (33.3 vs. 12.4%, p = 0.025) more frequently. Non-survivors also had higher levels of urea (73.8 ± 52.7vs. 36.1 ± 29.1 mg/dL, p < 0.001), creatinine (1.98 ± 1.65 vs. 1.05 ± 1.07 mg/dL, p < 0.001), aspartate aminotransferase (130.8 vs. 84.8 U/L, p = 0.03), alanine aminotransferase (115.6 vs. 85.4 U/L, p = 0.045) and lactate dehydrogenase (LDH) (1208 vs. 608 U/L, p = 0.012), as well as lower levels of bicarbonate (18.0 ± 4.7 vs. 21.6 ± 4.6 mEq/L, p = 0.016) and PCO2 (27.8 ± 7.7 vs. 33.0 ± 9.3 mmHg, p = 0.05). In multivariate analysis, disorientation (p = 0.035, OR = 5.523, 95%CI = 1.130 - 26.998), dyspnoea (p = 0.046, OR = 4.064, 95%CI = 1.028 - 16.073), AKI (p < 0.001, OR = 18.045, 95%CI = 4.308 - 75.596) and disseminated histoplasmosis (p = 0.016, OR = 12.696, 95%CI = 1.618 - 99.646) and LDH > 1000 U/L (p = 0.038, OR = 4.854, 95%CI = 1.093 - 21.739) were risk factors for death.]CONCLUSION: AKI and disseminated histoplasmosis (DH) were the main risk factors for death in the studied population. Neurologic and respiratory impairment as well as higher levels of LDH also increased mortality in HIV-infected patients.