Susie Andries Nogueira

Pregnancy outcome in women infected with HIV-1 receiving combination antiretroviral therapy before versus after conception

Objective: The potential adverse effects of antiretroviral drugs during pregnancy are discrepant and few studies, mostly from Europe, have provided information about pregnancy outcomes of those already on treatment at conception. The aim of this study was to investigate the impact of antiretrovirals (ARVs) on pregnancy outcome according to the timing of treatment initiation in a cohort of pregnant women from Brazil infected with HIV. Methods: A prospective cohort of 696 pregnant women followed up in one single centre between 1996 and 2006 was studied. Patients who had ARV treatment before pregnancy were compared with those treated after the first trimester. The outcomes evaluated were preterm delivery (PTD) (<37 weeks), severe PTD (<34 weeks), low birth weight (LBW) (<2500 g) and very LBW (<1500 g). Results: Patients who were using ARVs pre-conception had higher rates of LBW (33.3% vs 16.5%; p<0.001) and a similar trend for PTD (26.3% vs 17.7%; p = 0.09). Stratification by type of therapy (dual vs highly active antiretroviral therapy (HAART)) according to timing of initiation of ARVs showed that patients who use HAART pre-conception have a higher rate of PTD (20.2% vs 10.2%; p = 0.03) and LBW (24.2% vs 10.2%; p = 0.002). After adjusting for several factors, HAART used pre-conception was associated with an increased risk for PTD (AOR 5.0; 95% CI 1.5 to 17.0; p = 0.009) and LBW (OR 3.6; 95% CI 1.7 to 7.7; p = 0.001). Conclusions: We identified an increased risk for LBW and PTD in patients who had HAART prior to pregnancy.

Successful prevention of HIV transmission from mother to infant in Brazil using a multidisciplinary team approach

OBJECTIVES To determine the HIV vertical transmission rate (VTR) and associated risk factors by use of zidovudine and infant care education in Brazil. METHODS Since 1995, a prospective cohort of HIV infected pregnant women has been followed at the Federal University of Rio de Janeiro. A multidisciplinary team was established to implement the best available strategy to prevent maternal-infant HIV transmission. Patients with AIDS or low CD(4) and high viral load received anti-retroviral drugs in addition to zidovudine. Children were considered infected if they had 2 positive PCR-RNA tests between 1 and 4 months of age, or were HIV antibody positive after 18 months. Education regarding infant treatment and use of formula instead of breast feeding was provided. RESULTS Between 1995 and August, 2000, HIV status was determined for 145 infants. Compliance with intra-partum treatment, infant treatment and use of formula was 88.2%. Intra-partum zidovudine treatment was completed in 134/145 (92.6%) of patients; 88.1% had rupture of membranes < 4 hours; 85.4% of mothers were asymptomatic. The mean CD(4) count was 428.4 cells and mean viral load 39,050 copies. HIV vertical transmission rate was 4/145 (2.75%; CI: 0.1%-5.4%). The only risk factor significantly associated with transmission was a failure to use zidovudine intra-partum in 2 of the 4 mothers (50% versus 6.4% in non-transmitting mothers). A trend toward low CD(4) and high viral load at entry, and rupture of membranes > 4 hours were associated with increased HIV transmission. CONCLUSION HIV vertical transmission in Brazil was reduced to a level similar to other countries with the most effective prevention programs using a multidisciplinary team approach. A high level of compliance for use of anti-retroviral drugs, the provision of health education to mothers, and use of formula for all exposed infants.

Clinical and epidemiological features of 123 cases of cryptococcosis in Mato Grosso do Sul, Brazil.

To identify the clinical and epidemiological profile of cryptococcosis diagnosed at the University Hospital of the Federal University of Mato Grosso do Sul, Brazil, medical records of 123 patients admitted from January 1995 to December 2005 were analyzed. One hundred and four cases (84.5%) had HIV infection, six (4.9%) had other predisposing conditions and 13 (10.6%) were immunocompetent. Male patients predominated (68.3%) and their age ranged from 19 to 69 years (mean: 35.9). Most patients (73.2%) were born and lived lifelong in the state of Mato Grosso do Sul. Involvement of the central nervous system occurred in 103 patients (83.7%) and headache and vomiting were the most frequent symptoms. In 77 cases it was possible to identify the Cryptococcus species: 69 (89.6%) C. neoformans and eight (10.4%) C. gattii. Amphotericin B was the drug of choice for treatment (106/123), followed by fluconazole in 60% of cases. The overall lethality rate was 49.6%, being 51% among the HIV infected patients and 41.2% among the non-HIV infected (p > 0.05). Although cryptococcosis exhibited in our region a similar behavior to that described in the literature, the detection of an important rate of immunocompetent individuals and five C. gattii cryptococcosis in HIV-infected patients is noteworthy.

Lack of technical specificity in the molecular diagnosis of toxoplasmosis

The polymerase chain reaction amplification of a fragment of the B1 gene of Toxoplasma gondii coupled to hybridization was performed in 42 patients from Rio de Janeiro, Brazil. The results showed 50% of positivity in the IgM positive toxoplasmosis group, and 12.5% in the positive IgG and negative IgM individuals. The data presented here revealed a lack of specificity of the molecular approach, clearly indicating that the primers used may co-amplify human sequences.

Bacillary angiomatosis: description of 13 cases reported in five reference centers for AIDS treatment in Rio de Janeiro, Brazil

The aim of this case series was to describe the clinical, laboratory and epidemiological characteristics and the presentation of bacillary angiomatosis cases (and/or parenchymal bacillary peliosis) that were identified in five public hospitals of Rio de Janeiro state between 1990 and 1997; these cases were compared with those previously described in the medical literature. Thirteen case-patients were enrolled in the study; the median age was 39 years and all patients were male. All patients were human immunodeficiency virus type 1 (HIV-1) infected and they had previous or concomitant HIV-associated opportunistic infections or malignancies diagnosed at the time bacillary angiomatosis was diagnosed. Median T4 helper lymphocyte counts of patients was 96 cells per mm(3). Cutaneous involvement was the most common clinical manifestation of bacillary angiomatosis in this study. Clinical remission following appropriate treatment was more common in our case series than that reported in the medical literature, while the incidence of relapse was similar. The frequency of bacillary angiomatosis in HIV patients calculated from two of the hospitals included in our study was 1.42 cases per 1000 patients, similar to the frequencies reported in the medical literature. Bacillary angiomatosis is an unusual opportunistic pathogen in our setting.

Prospective study on the prevention of vertical transmission of HIV in Campo Grande, Mato Grosso do Sul, Brazil, from 1996 to 2001

This prospective study, involving 76 pregnant women infected with HIV, paired with their 79 exposed infants, was carried out between May 1996 and October 2001, at the Reference Department for Pregnant Women Infected with HIV in Campo Grande, Mato Grosso do Sul. The mean age of the pregnant women was 24 years; 88% (67/76) apparently were infected due to sexual practices; 88% (67/76) were housewives; 823% (63/76) graduated from junior high school; 14.5% (11/76) reported co-infection with Hepatitis C, 9.2% with Syphilis; 51% (39/76) learned the diagnosis during prenatal care; 67% (51/76) reported HIV clinical symptomatology and 9.2% (7/76) reported opportunistic infections. Elective cesareans were performed in 57% (43/76). The mean gestational age at delivery was 38 weeks and we found 12.5% (10/80) pronatis; 97% (74/76) had a ruptured membrane time after less than four hours and one child (1.3%) was nursed. ACTG 076 Protocol (AIDS Clinical Trial Group 076) was used in 80% (61/76) of the pregnant women, with 100% adherence; 62% (38/61) used zidovudine plus another antiretroviral in the gestation; 92% (73/79) of the infants used zidovudine after the birth and 19% (14/73) used zidovudine and lamivudine. The transmission rate in this study was 2.5%.

Osteomyelitis caused by Paracoccidioides brasiliensis in a child from the metropolitan area of Rio de Janeiro.

The authors describe a case of paracoccidioidomycosis in a 7-year-old girl from the city of Rio de Janeiro who initially presented to her physician with a lesion in her calcaneous which was misdiagnosed and treated as bacterial osteomyelitis. Later, cutaneous manifestations, lymph node enlargement, and hepatosplenomegaly developed and biopsy of the skin and cervical lymph nodes showed the fungus which was also present in the sputum. It is emphasized that Paracoccidioides brasiliensis can be the cause of bone lesions in endemic areas of Latin America and that response to treatment with amphotercin B is good.

Growth parameters in HIV-vertically-infected adolescents on antiretroviral therapy in Rio de Janeiro, Brazil.

Abstract Background: Growth failure in HIV-infected children is an important factor in either initiating or changing antiretroviral therapy (ART). This study assesses the impact of HIV infection on growth parameters of adolescents who acquired HIV vertically. Methods: This retrospective, longitudinal study involved adolescents aged 10–20 years with vertically-acquired HIV infection who were followed up in one of the three main referral centres for paediatric HIV/AIDS in Rio de Janeiro, Brazil. Length, weight and variables related to demographic, clinical and laboratory issues were analysed. Results: 108 subjects were enrolled. Median age was 12.7 years, median duration of follow-up was 97.2 months and 61 (56.5%) were female. The difference between the baseline and final weight Z-scores was −0.31 (p=0.02). Patients with final weight Z-scores ≤ −2 used more ART regimens (average 4.13) than those with Z-scores > −2 (average 2.90, p<0.01) and also had a lower final CD4+ cell percentage — average 19% vs 24% (p<0.01), respectively. The difference between baseline and final-height Z-scores was −0.27 (p<0.01). Several factors were associated with a final-height Z-score ≤ −2: clinical stage C during follow-up (RR 1.60, 95% CI 1.11–2.31), chronic diarrhoea during follow-up (RR 2.02, 95% CI 1.04–3.90), HAART use (RR 1.41, 95% CI 1.16–1.71), number of ART regimens (p<0.01) and final CD4+ cell percentage (p<0.01). In multivariate analysis, presentation in clinical stage C during follow-up was the only significant variable (OR 4.04, 95% CI 1.23–13.28). Conclusion: Even on HAART, HIV-infected adolescents have lower growth parameters than the normal population and this is associated with a worse prognosis.

A pilot study to evaluate the safety and feasibility of the administration of AZT/3TC fixed dose combination to HIV infected pregnant women and their infants in Rio de Janeiro, Brazil

Objectives: To evaluate the safety and feasibility of zidovudine and lamivudine (AZT/3TC) given to HIV infected pregnant women and their infants in Rio de Janeiro, Brazil. Methods: This open label phase II study enrolled 40 HIV infected antiretroviral naive women ⩾20 weeks gestation, CD4 <500 cells ×106/l, from two public hospitals. Treatment: fixed dose AZT 300 mg/3TC 150 mg by mouth every 12 hours until labour; AZT 300 mg by mouth every 3 hours until delivery; infants: AZT 4 mg/kg every 12 hours plus 3TC 2 mg/kg every 12 hours for 6 weeks. Blood haematology and chemistry were monitored; adherence evaluated by pills count; efficacy measured by changes in lymphocyte (CD4) and viral load, and by HIV RNA-PCR tests performed at birth, 6 and 12 weeks, to diagnose infant infection. No women breast fed. Results: Patient characteristics: mean age 24.48 (SD 3.5) years; gestational age 24.5 (4.5) weeks; AZT/3TC duration 14.4 (4.4) weeks; vaginal delivery: 11/39; caesarean section: 28/39. Entry and pre-labour CD4: 310/486 cells ×106/l (p<0.001); entry and pre-labour viral load: 53 818/2616 copies/ml (p<0.001). Thirty nine women tolerated treatment with >80% adherence; one was lost to follow up. Five newborns were excluded from 3TC receipt. All 39 babies were uninfected. Haematological toxicity in newborns was common: anaemia in 27; neutropenia in five (two severe); platelets counts <100 000 in two. All values recovered on study completion. Conclusions: Fixed dose AZT/3TC is well accepted, gives improvements in CD4 and viral load; no infants were HIV infected. Haematological toxicity in infants needs careful monitoring.

Paracoccidioidomycosis and tuberculosis in AIDS patients: Report of two cases in Brazil☆

AIDS is spreading rapidly in Brazil. Caused by the dimorphic fungus Paracoccidioides brasiliensis paracoccidioidomycosis (PBM) is one of the systemic mycoses most frequently diagnosed among immunocompetent individuals in Latin America. The condition is most commonly diagnosed among agricultural workers living in humid tropical and subtropical rural regions. According to Marques et al. the estimated incidence of PBM among Brazilian AIDS patients in 1992 was 0.09% and among the 26 reported cases there was a 29.4% mortality rate. Given the current increase in the heterosexual transmission of HIV and the simultaneous spread of HIV to more rural areas of Latin America there will probably be an increase in the number of people infected concurrently with HIV and P. brasiliensis who present with PBM as the first manifestation of AIDS. 2 cases are described in which PBM was found together with tuberculosis as the first manifestation of AIDS. Both patients were living in urban areas of Brazil at the time of diagnosis. One case was a 48 year old male painter complaining of persistent fever without chills for 1 month a rapidly growing cervical mass and a 7 kg weight loss over 45 days. The second case was a 28 year old man admitted for the evaluation and treatment of a draining cervical lymph node and skin lesions. He related that his disease began 5 months earlier presenting with fever and cervical lymphadenopathy.