Wanessa Trindade Clemente

Tuberculosis in liver transplant recipients: a single Brazilian center experience.

Background. Tuberculosis (TB) is an important opportunistic infection in transplant recipients worldwide. The frequency of Mycobacterium tuberculosis disease varies among different regions, but the incidence of TB in adult liver transplant (LT) recipients is largely unknown. The estimated frequency ranges from 0.7% to 2.3%, with mortality rate up to 30%. However, these data are based on individual case reports or series with small samples. In LT recipients, therapy is generally associated with significant hepatotoxicity and interactions with immunosuppressive drugs. Methods. This retrospective analysis included 319 patients who underwent LT at University Hospital, Federal University of Minas Gerais, Brazil, between September 1994 and July 2007 and survived more than 1 month. Among these, TB was diagnosed in five patients. No patients received chemoprophylaxis before or after LT. Results. All five patients were women, mean age 39.6±16.5 years. Two patients had disseminated TB, two pulmonary involvement, and one extrapulmonary disease. Cultures were positive in four patients. Overall, four patients received isoniazid, rifampin, and pyrazinamide for 6 to 12 months, with good tolerance, but one patient presented recurrence. Another patient presented raised hepatic enzymes levels after initiating therapy. All patients are alive and well. Conclusions. In this series, the TB frequency after liver transplantation was 1.57%, with no confirmed hepatotoxicity with conventional treatment and an excellent survival rate (100%).

Visceral leishmaniasis in liver transplant recipients from an endemic area.

Visceral leishmaniasis (VL) is a parasitic infection generally caused by the Leishmania donovani complex, and in Brazil by Leishmania chagasi. Every year, half a million new cases are diagnosed worldwide, and five countries— Nepal, Bangladesh, Brazil, India, and Sudan—account for up to 90% of cases (1, 2). Although considered a rare disease among transplant recipients, the number of reported cases has increased over the last two decades (3). VL diagnosis should also be considered in transplant recipients from nonendemic areas, in view of increasing migration and the globalized world. We report three cases of VL in liver transplantation (LT) recipients in a single center from Brazil. Hospital records of 595 patients who underwent LT from September 1994 to December 2009 at the Federal University Hospital of Minas Gerais, Brazil, were reviewed. Three of the 595 liver transplanted patients were diagnosed with VL. Their detailed clinical characteristics are shown in Table 1. A case is defined as the presence of Leishmania amastigotes in bone marrow aspirate or specimens of other reticuloendothelial system organs in patients with symptoms consistent with VL. The typical clinical picture is characterized by fever, splenomegaly, weight loss, blood cytopenia, and hypergammaglobulinemia (2, 4). All patients presented with fatigue, pancytopenia, and hypergammaglobulinemia, and two patients had fever and splenomegaly. Diagnosis was established by the presence of Leishmania amastigotes in bone marrow aspirate (Fig. 1) in all cases. Initial therapy was amphotericin B deoxycholate, which caused nephrotoxicity in all three patients and was replaced by liposomal amphotericin B. Immunosuppression was reduced once the VL diagnosis was established, and maintained at the lowest possible level for a few months. Two patients are alive and free of disease. The other patient is alive but experienced a VL relapse; he was retreated with liposomal amphotericin B and has continued on monthly secondary prophylaxis (3 mg/kg/monthly). VL infection in transplant recipients may occur in four ways: (1) the recipient may be infected by the graft; (2) by transfusion; (3) a previously infected recipient may reactivate a latent infection; and (4) immunosuppressed patients may develop de novo infections (3, 5). Because specific antibody responses are not protective (6), suppression of the T-cell host response after organ transplantation may reactivate a latent VL infection. In the present series, it was not possible to identify the way of transmission. The rising number of transplants, including in VL-endemic regions, justifies the increasing interest in such a neglected disease. Timely diagnosis followed by prompt treatment can have an impact on the high lethality rates (3). Until now, only 10 cases of VL in LT recipients have been described, one of them by our group (7–14). Cases are probably underestimated by misdiagnosis. Given that the liver is a reticuloendothelial organ preferentially affected by the protozoan, the risk of transmission through the graft may be greater than in other transplants. Transplanted patients should benefit from lipid formulations as of the beginning of treatment, because immunosuppressive drugs are also nephrotoxic and renal dysfunction is frequent. Cure is generally defined by clinical and hematological criteria (resolution of fever, hepatosplenomegaly, and pancitopenia). Follow-up is recommended for 6 months after treatment (15, 16). Although some authors also consider negative bone marrow biopsies or aspirate cultures after treatment (17), these are invasive procedures and absence of parasites does not define resolution or exclude relapse (18). VL cure rates after amphotericin treatment in transplanted patients are approximately 80%. However, relapse may occur in up to 35% of the cases, associated to poor prognosis (13). One described patient, despite adequate treatment, presented a relapse 5 months after amphotericin discontinuation. He was then retreated and remains on secondary prophylaxis with monthly liposomal amphotericin. Some studies have shown that secondary prophylaxis may prevent a VL relapse, but they were carried out in HIV patients (18, 19). The evidence of this recommendation in transplanted patients is not yet established, but it should be considered in those who relapse. Asymptomatic infection (from donors or recipients) in the pretransplant phase could facilitate the suspicion of VL after LT in the presence of certain symptoms (19). We do not perform VL serology routinely for screening liver donors and recipients before transplant, but this is the matter of an ongoing research project. At present, if recipients or donors have a positive result, we perform a stricter follow-up with a lower threshold of suspicion for VL. In conclusion, VL is a potential infectious complication in liver transplanted patients, mainly in endemic areas, and probably remains underestimated and underdiagnosed in these patients. Prompt diagnosis and treatment are essential to reduce lethality.

Phenotypic and genotypic characterization of drug-resistant Mycobacterium tuberculosis strains.

Of 142 pulmonary tuberculosis patients, 76 were considered high risk for the development of resistance, and 24 were confirmed as resistant strain carriers. Resistant isoniazid strains presented a high frequency of katG and ahpC mutations (90%) correlated with an MIC >4 microg/mL (94%). inhA mutations were not seen. rpoB mutations were identified in 78.6% of rifampicin-resistant strains, usually in codon 531 (72.7%), and 75% had an MIC >16 microg/mL. katG and rpoB mutations recognized 88.2% of multidrug-resistant strains and proved more efficient than the katG and rpoB mutations alone. Seventy percent of resistant pyrazinamide strains had pncA mutations between genes 136 and 188, 62.5% of them with an MIC >900 microg/mL. Pyrazinamidase inactivity was not an efficient resistance marker because 60% of pncA-mutated strains maintained enzymatic activity despite displaying good correlation with high resistance levels. Resistant ethambutol strains had embB mutations in codon 306, with MIC >16 microg/mL.

Evolution of patients undergoing liver transplantation due to viral hepatitiss

Objectives: to describe the evolution of patients with a diagnosis of viral hepatitis B or C undergoing liver transplantation at a reference hospital. Methods: this was a cross-sectional study conducted in the Organ Transplantation Service of the Alfa Institute of Gastroenterology, General Hospital, Federal University of Minas Gerais, from 2005 to 2007. Data were collected from medical records and service databases. Results: out of 173 patients undergoing liver transplantation, 61 had hepatitis C, nine had hepatitis B, and one developed fulminant hepatitis A. Among patients with hepatitis C, 31 were treated before the transplantation (seven with sustained virological response). Only two patients with hepatitis B were pretreated. After liver transplantation, the recurrence of hepatitis occurred in 21 patients with hepatitis C, and in none with hepatitis B. The drug treatment after liver transplant was performed in 13 out of 21 patients with recurrent hepatitis C. Discussion: in cases of cirrhosis caused by the hepatitis C virus, recurrence of infection is common after liver transplantation and indicates the need for an effective treatment. Post-transplant survival in patients infected with hepatitis B virus depends on prevention using combined prophylaxis. Conclusion: viral hepatitis accounts for a significant proportion of indications for a liver transplant. Recurrence of hepatitis C persists as a major problem in transplanted patients due to viral hepatitis. Prophylaxis of hepatitis B post-transplant recurrence is mandatory with immunoglobulin and nucleoside analogs.

Primary care follow-up of recent mothers submitted to cesarean section and their newborns in reference service

Objective: To investigate the following up of parturients undergoing cesarean delivery and their newborns (RN), emphasizing the achievement of health care actions in primary health care. Methods: follow-up observational study on recent mothers and their RNs after cesarean delivery at the General Hospital at the Federal University of Minas Gerais, performed from March of 2010 to March of 2011. The information was obtained through telephone contact with the recent mothers and analyzed in the Statistical Package for Social Sciences software. The study was approved by the Research Ethics Committee of the Institution. Results: 500 (65.6%) out of 762 women undergoing Cesarean delivery were contacted, 126 (25.2%) were assisted in Basic Health Units (UBS) until 30 days postpartum and 34 (6.8%) had notified surgical wound infection. Post-discharge follow-up information was obtained for 456 RNs, excluding 21 deaths or stillbirths and 23 children who remained hospitalized. The recent mothers reported the following health actions for their children: 327 (71.7%) with consultation until 30 days postpartum, 439 (96.3%) with anti-hepatitis B vaccination, 428 (93.9%) with BCG vaccination, 450 (98.7%) with “foot test”, and 147 (32.2%) with hearing screening. There was no statistical difference in maternal and child health assistance when the post-cesarean surgical wound infection was considered. Conclusions: a low percentage of women was assisted in the UBSs; the majority of RNs had access to health actions and less adherence to the hearing screening.

Care of patients with suspected or confirmed Influenza A subtype H1N1 virus infection in 2009: experience of a university hospital

The present report addresses the planning and actions taken by the Hospital of the Federal University of Minas Gerais to confront and control the Influenza A virus subtype H1N1 pandemia, which occurred between the months of March and April 2009. We describe patient triage, the precautions established in the care of suspected or confirmed cases, the evolution of these patients, the associated mortality and the destination of the waste generated in care.

Current approaches to pelvic inflammatory disease

Pelvic inflammatory disease (PID) is an inflammatory process of infectious nature that can affect structures and organs of the upper genital tract. Considering this disease’s epidemiological relevance and severe complications, this article provides an update and proposes a systematic approach to PID. The main etiological agents are Neisseria gonorrhoeae, Chlamydia trachomatis and other etiological agents of urethritis, cervicitis, vulvovaginitis and vaginoses. These are generally of polymicrobial origin, which determines the treatment basis for pelvic inflammatory diseases. Women must be checked for PID when experiencing abdominal discomfort, backache, dyspareunia, or presenting with stains during gynecological examination and prior to transcervical procedures. The clinical and laparoscopic classification of PID can be divided into: a) stage I (endometritis/salpingitis without peritonitis), stage II (acute salpingitis with peritonitis), stage III (acute salpingitis with tubal occlusion or tube-ovarian abscess), and stage IV (tubeovarian abscess rupture). Defining the stage guides procedures and treatment, given that in mild forms (stage I) the treatment and follow-up can be performed in the ambulatory environment while moderate to severe cases require hospitalization so that intravenous treatment and treatment outcome monitoring can be started. Supportive treatment, removal of intrauterine device (IUD), sexual abstinence and rest are also indicated, as well as counseling on the implications of the disease and partner approach.