DI - Doenças Infecciosas
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- Meningites - estudo descritivo de uma população pediátrica do norte e centro de PortugalPublication . Almeida, R.; Oliveira, A.; Cleto, E.; Cardoso, L.; Vieira, L.; Morais, L.; Ferreira, N.Objectivos: Caracterizar os casos de meningite quanto à sua etiologia, tratamento e evolução. Doentes e Métodos: Estudo multicêntrico, descritivo, retrospectivo (1 de Janeiro de 2000 a 28 de Fevereiro de 2003) e prospectivo (1 de Março a 31 de Julho de 2003) dos casos de meningite ocorridos em crianças com idades compreendidas entre 1 mês e 10 anos, inclusive. Resultados: Participaram neste estudo 17 hospitais das zonas norte e centro de Portugal. Foram incluídos 876 casos (802 do ramo retrospectivo). Registaram-se 110 casos de meningite bacteriana e 111 de meningite vírica (sendo as restantes assépticas ou decapitadas). O agente mais frequente de meningite bacteriana foi o meningococo seguido pelo pneumococo. A generalidade dos casos foi medicada com uma cefalosporina de 3ª geração isoladamente, verificando-se um elevado nº de crianças tratadas com dexametasona (62%) e restrição hídrica (36%). Registaram- se 18 casos de complicações agudas, 2 óbitos e sequelas permanentes em 8 crianças. Em todos as meningites víricas foi identificado um enterovírus. Foram detectadas diferenças estatisticamente significativas (p<0,05) entre estes dois grupos (víricas vs bacterianas) em relação à idade (<5 e ≥5 anos) à febre (< 39,5 e ≥ 39,5ºC) e aos parâmetros laboratoriais (contagem de leucócitos e neutrófilos no sangue, PCR, contagem de leucócitos e neutrófilos no LCR e proteinorráquia). Conclusões: A epidemiologia dos casos esteve de acordo com o esperado, bem como a escolha da terapêutica empírica e a evolução. Em relação à terapêutica adjuvante, a utilização de dexametasona e o recurso à restrição hídrica deverão ser repensadas.
- Sepsis por Clostridium Septicum em Criança com Neutropenia Auto-imunePublication . Castillo, M.; Marques, L.; Mesquita, A.; Morais, L.; Senra, V.RESUMO Os autores apresentam o caso clínico de uma criança de sete anos de idade com neutropenia autoimune severa e crónica, refractária à terapêutica, que deu entrada em choque séptico associado a lesões inflamatórias flictenulares perianais. Foi instituída terapêutica antibiótica de largo espectro com cobertura para anaeróbios associada a Imunoglobulina endovenosa em doses elevadas e Filgastrim. A criança manteve instabilidade hemodinamica nas primeiras 72 horas, com evolução favorável posterior. As lesões perianais evoluíram com mionecrose e formação de escaras necessitando de limpeza cirúrgica repetida, enxerto cutâneo e colostomia de protecção. Nas hemoculturas foi isolado Clostridium Septicum. A evolução subsequente foi favorável. Efectuada reconstituição do trânsito com recuperação da continência anal. Actualmente a criança tem dez anos de idade, mantém valores normais de neutrófilos sob terapêutica com Filgastrim e não voltou a ter intercorrências infecciosas. A infecção por Clostridium Septicum é muito rara na criança e ocorre caracteristicamente associada a neutropenia cíclica ou induzida pela quimioterapia, não tendo sido encontrada descrição no contexto de uma neutropenia autoimune na literatura consultada. A taxa de mortalidade é elevada (80%) e a sobrevivência depende da precocidade do diagnóstico e duma terapêutica médica e cirúrgica adequada. ABSTRACT The authors present the clinical case of a seven years old boy suffering a severe and chronic autoimmune neutropenia, resistant to therapy, who was admitted with a septic shock associated to perianal inflammatory lesions. Broad spectrum antibiotherapy associated to high dose of intravenous Immunoglobulin and Filgastrim ware instituted. The child was hemodinamically unstable for the first 72 hours, with subsequent favourable clinical evolution. The perianal lesions evolved to myonecrosis needing repeated surgical intervention to remove necrotic tissues, skin graft and protection colostomy. Clostridium Septicum was isolated from blood cultures. Subsequent evolution was favourable. The colostomy was closed and anal continence was recovered. For the last three years the child maintained normal neutrophil level under filgastrim therapy and had no further infections. Clostridium Septicum infection is rare in children. Neutropenic patients are at a particular high risk for this infection. The authors did not find reports of Clostridium Septicum infection in association with autoimmune neutropenia in the literature reviewed. It is described in patients with cyclic neutropenia or with chemotherapy-induced neutropenia. The mortality rate is high (80%) and survival depends on early diagnosis and appropriate surgical and medical treatment.
- Quisto Porencefálico após Hemorragia Intracraniana: Evolução Imagiológica pré e pós-natalPublication . Cunha, A.; Mendes, M.; Ramos, C.; Nogueira, R.; Martins, M.; Veloso, P.; Mendes, R.RESUMO A infecção por Citomegalovírus (CMV) é a infecçâo congénita mais frequente. As manifestações clínicas são variáveis e multisistémicas. Do envolvimento do sistema nervoso central (SNC) podem resultar microcefalia, calcificações e, mais raramente, hidranencefalia e porencefalia por destruição do tecido cerebral. Estes achados são geralmente de diagnóstico tardio em Diagnóstico Pré Natal (DPN) com manifestações ecográficas muitas vezes inespecíficas. Os autores descrevem os aspectos imagiológicos ultrasonográficos no período fetal, neonatal, e tomográfico pósnatal num caso de hemorragia parenquimatosa cerebral com evolução para quisto porencefálico por provável infecção por citomegalovirus. Este caso mostra que achados ecográficos inespecíficos pré-natais numa paciente de alto risco têm um valor preditivo alto para infecção fetal por citomegalovirus e também podem ter significado prognóstico. ABSTRACT CMV is the most common congenital infection. Clinical manifestations can be multiple and affect different organs. Microcephaly, intracranial calcifications and less frequently hydranencephaly and porencephaly can be a consequence of cerebral involvement. These anomalies are generally diagnosed late in pregnancy after prenatal sonographic signs of little sensitivity. In this report, we describe the prenatal and neonatal images of cerebral hemorrhage and porencephaly, presumed secondary to intrauterine cytomegalovirus infection.This case shows that subtle ultrasound findings in a high risk pregnant woman may be predictive of sequelae in infected fetuses.
- Estudo Viriato: Actualização de dados de susceptibilidade aos antimicrobianos de bactérias responsáveis por infecções respiratórias adquiridas na comunidade em Portugal em 2003 e 2004Publication . Melo-Cristino, J.; Santos, L.; Ramirez, M.; Grupo de Estudo Português de Bactérias Patogénicas RespiratóriasO Estudo Viriato é um estudo nacional, prospectivo e multicêntrico, de vigilância da susceptibilidade aos antimicrobianos de bactérias frequentemente responsáveis por infecções do aparelho respiratório adquiridas na comunidade.Nos anos de 2003 e 2004 participaram 29 laboratórios de todo o país. Isolaram-se 2945 microrganismos que foram estudados num laboratório coordenador. Das 513 estirpes de Streptococcus pyogenes de doentes com amigdalo-faringite aguda, todas eram susceptíveis à penicilina e outros antibióticos beta-lactâmicos, mas 18,9% eram resistentes à eritromicina, claritromicina e azitromicina. Nas estirpes resistentes foi mais frequente o fenótipo M (67,0%) que confere resistência à eritromicina (CIM90=16 mg/L), claritromicina e azitromicina, mas susceptibilidade à clindamicina (CIM90=0,094 mg/L). De doentes com infecção do aparelho respiratório inferior estudaram-se 1300 estirpes de Streptococcus pneumoniae (pneumococos), 829 de Haemophilus influenzae e 303 de Moraxella catarrhalis. Em S. pneumoniae, 18,4% das estirpes eram resistentes à penicilina (3,5% com resistência elevada), 7,1% à cefuroxima, 0,5% à amoxicilina, 0,5% à amoxicilina/clavulanato, 18,8% à eritromicina, claritromicina e azitromicina, 14,5 % à tetraciclina, 16,5% ao cotrimoxazol e 0,4% à levofloxacina. Nas estirpes resistentes aos macrólidos, dominou o fenótipo MLSB (83,7%), caracterizado por resistência elevada (CIM90>256 mg/L) à eritromicina, claritromicina, azitromicina e clindamicina. Produziam beta- -lactamase 10,0% de H. influenzae e 96,4% de M. catarrhalis. Em H. influenzae demonstrou-se 5,5% de resistência à claritromicina e 13,4% ao cotrimoxazol. A quase totalidade das estirpes era susceptível à amoxicilina / clavulanato, cefuroxima, azitromicina, tetraciclina e ciprofloxacina. Em M. catarrhalis a resistência ao co-trimoxazol foi de 27,1% e à tetraciclina de 1,0%. Todas as estirpes eram susceptíveis à amoxicilina / clavulanato, cefuroxima, claritromicina, azitromicina e ciprofloxacina. De entre o conjunto de antibióticos ensaiado, a penicilina continua a ser o mais activocontra S. pyogenes e a amoxicilina / clavulanato e as quinolonas os mais activos simultaneamente contra S. pneumoniae, H. influenzae e M. catarrhalis.
- HIV indeterminate serology in a Portuguese blood donor population ‐ Review of seven yearsPublication . LEITE, F.; DIAS, F.; FERREIRA, C.; MARQUES, A.; OLIVEIRA, F.; MOTA, A.HIV indeterminate serology in a Portuguese blood donor population – review of seven years Fernanda Leite,1 Francisco Dias,1 Carla Ferreira,1 Adelina Marques,1 Fátima Oliveira,1 and Ana Mota1 1Clinical Haematology, Hospital Santo António, Porto, Portugal Corresponding author. Fernanda Leite: fernandajtleite@hotmail.com Supplement 2006 International Meeting of The Institute of Human Virology http://www.biomedcentral.com/content/pdf/1742-4690-3-S1-info.pdf Conference 2006 International Meeting of The Institute of Human Virology 17–21 November 2006 Baltimore, USA Other Sections▼ Background Results Conclusion Background To study the meaning of HIV indeterminate serology (HIVi), evaluating the deferral criteria of HIV screening test, we looked for donors (D) whose blood donations (BD) were discarded for HIVi from 1/1/1999 till 31/12/2005. The test system of blood donations is Prism Abbott Anti-HIV 1/2; HIV supplemental test was New Lav-Blot I/II-Bio-Rad till 2002 and Inno-Lia™ HIV I/II-Innogenetics afterwards. We perform a NAT test in all single donation since 2000, detecting HIV-1 and HCV RNA; since 2/2004 we perform Procleix® Ultrio™ Assay. Grey zone (GZ) for HIV screening test means 20% inferior to the cutoff (ICO). D that have been deferred for HIV serology but didn't obey to these criteria were excluded. Results In seven years, we find in a body of 25 024 D, 145 with HIVi; 8 were excluded and 18 had no follow-up. 64 D showed a confirmed result and 55 D didn't confirm. 77 cases had the supplemental test negative, 52 showed an indeterminate pattern and one a positive pattern. This case became negative after 1 year of follow-up. None of D seroconverted. 50 cases of the indeterminate supplemental test have occurred before 2002. None of BD or D had a reactive NAT test. The ICO value showed a direct relation with the confirmation rate. Conclusion We found 0,58% indeterminate HIV donors, 41,6% in GZ ICO and 54% didin't confirm. ICO hadn't shown predictive value for HIV infection. A positive supplemental test in a low prevalence population may not correspond to HIV infection. Inno-Lia™ HIV I/II showed a specificity of 92,9% compared to 47,4% of New Lav-Blot I/II. GZ in anti-HIV test hasn't brought more security. There isn't HIV-1 infection without a NAT test reactive and we save 23,8% of HIVi donors. -------------------------------------------------------------------------------- Articles from Retrovirology are provided here courtesy of BioMed Central
- A case-control study on risk factors for early-onset respiratory tract infection in patients admitted in ICUPublication . Cardoso, T.; Lopes, M.; Carneiro, A.BACKGROUND: Respiratory tract infections are common in intensive care units (ICU), with incidences reported from 10 to 65%, and case fatality rates over 20% in pneumonia. This study was designed to identify risk factors for the development of an early onset respiratory tract infection (ERI) and to review the microbiological profile and the effectiveness of first intention antibiotic therapy. METHODS: Case-control, retrospective clinical study of the patients admitted to the Intensive Care Unit (ICU) of our hospital, a teaching and tertiary care facility, from January to September 2000 who had a respiratory tract infection diagnosed in the first 5 days of hospital stay. RESULTS: Of the 385 patients admitted to our unit: 129 (33,5%) had a diagnosis of ERI and 86 patients were admitted to the control group. Documented aspiration (adjusted OR = 5,265; 95% CI = 1,155 - 24,007) and fractured ribs (adjusted OR = 12,150; 95% CI = 1,571 - 93,941) were found to be independent risk factors for the development of ERI (multiple logistic regression model performed with the diagnostic group as dependent variable and adjusted for age, sex, SAPS II, documented aspiration, non-elective oro-tracheal intubation (OTI), fractured ribs, pneumothorax and pleural effusion).A total of 78 organisms were isolated in 61 patients (47%). The normal flora of the upper airway (Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenza and Moraxella catharralis) accounted for 72% of all isolations achieved, polimicrobian infections were responsible for 25% of all microbiological documented infections. First intention treatment was, in 62% of the patients, the association amoxacillin+clavulanate, being effective in 75% of the patients to whom it was administered. The patients with ERI needed more days of OTI (6 vs 2, p < 0,001) and mechanical ventilation (6 vs 2, p < 0,001) and had a longer ICU (7 vs 2, p < 0,001) and hospital length of stay (17 vs 11, p = 0,018), when compared with controls. CONCLUSION: In this study documented tracheobronchial aspiration and fractured ribs were identified as independent risk factors for ERI. Microbiological profile was dominated by sensitive micro-organisms. The choice amoxacilin+clavulanate revealed to be a good option with an effectiveness rate of 77% in the patients in whom it was used.
- HUMAN BLOOD T AND NK CELL IN VITRO STIMULATION REVEALS A SIMILAR ACTIVATION PHENOTYPE THAT RESEMBLES EARLY ACTIVATION STAGES DURING ACUTE VIRUS INFECTIONPublication . Moura, J.; Gonçalves, M:; Fonseca, S.; Santos, A.; Queirós, M.; Teixeira, M.; Lima, M.The complexity of T and NK-cell responses needs a great deal of control in the way these cells respond to stimulation. This is made by a precise regulation of gene expression leading to specific changes of membrane proteins, in order to acquire their full cytotoxic or immunological mediators secreting potential. The immunophenotypic changes occurring in-vivo on blood T and NK-cells in patients with acute and chronic infections have been previously characterized in detail, defining early and late activation related phenotypes, but in-vitro experiments are needed to define the earliest activation stages.
- Reducing mortality in severe sepsis with the implementation of a core 6-hour bundle: results from the Portuguese community-acquired sepsis study (SACiUCI study)Publication . Cardoso, T.; Carneiro, A.; Ribeiro, O.; Teixeira-Pinto, A.; Costa-Pereira, A.Abstract INTRODUCTION: To evaluate the impact of compliance with a core version of the Surviving Sepsis Campaign 6-hour bundle on 28 days mortality. METHODS: Cohort, multi-centre, prospective study on community-acquired sepsis (CAS). RESULTS: Seventeen intensive care units (ICU) entered the study. Over a one year period, 4,142 patients were enrolled in the study. Of the 897 (24%) admitted with CAS, 778 (87%) had severe sepsis or septic shock on ICU admission. In the first six hours of hospital admission: (1) 62% had serum lactate measured; (2) 69% fluids administered; (3) 77% specimens collected for microbiology before antibiotic administration; (4) 48% blood cultures obtained; (5) 52% antibiotics administered within the first hour of the diagnosis; (6) vasopressors were given in 78%; (7) 56% had central venous measurement (CVP) measurement; (8) 17% had a central venous oxygen saturation (ScvO2) measurement; (9) dobutamine was administered in 52%. Compliance with all actions 1 to 6 (core bundle) was associated with an odds ratio (OR) of 0.44 [95% confidence interval (CI) = 0.24-0.80] in severe sepsis and 0.49 (95% CI = 0.25-0.95) in septic shock, for 28 days mortality. This corresponded to a number needed to treat of 6 patients to save one life. CONCLUSIONS: Compliance with this core bundle was associated with a significant reduction in the 28 days mortality. Urgent action should be taken in order to ensure that early sepsis diagnosis is followed by full completion of this "core bundle" followed by activation of expertise help in severe sepsis.
- Hepatite C em toxicodependentes: acompanhamento e acesso à terapêuticaPublication . Sarmento-Castro, R.; Valente, C.; Ramos, J.; Almeida, J.; Marinho, R.; Branco, T.; Andrade, S.; Macedo, A.A hepatite C constitui, actualmente, um grave problema de saúde pública. Estima-se que existam, em todo o mundo, 180 milhões de pessoas com infecção crónica por vírus da hepatite C (VHC) e que a sua prevalência na população portuguesa varie entre 1 e 1,5%. Em Portugal, não existem normas de orientação actualizadas de tratamento, nem recomendações para o diagnóstico e acompanhamento dos doentes com VHC e, em particular, para os UDEVs. O presente artigo reúne informação de consenso relativa à de prática clínica e propõe algumas orientações para o acompanhamento e acessibilidade ao tratamento dos doentes toxicodependentes com infecção crónica por VHC, em Portugal.
- From Clinical Presentation to the Outcome: the Natural History of PML in a Portuguese Population of HIV Infected PatientsPublication . Nery, F.; França, M.; Almeida, I.; Vasconcelos, c.Background Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system, associated with immunosuppression states. As there are only some non-published documents concerning PML in HIV infected patients in Portugal, we pretend to characterize natural history of PML infection in a population of HIV patients. Methods We retrospectively reviewed, from 1992 to 2009, PML cases in a population of 724 HIV infected patients followed in our institution. Clinical, biological, imagery features and outcomes were characterized. Results Twenty-five (3.45%) patients were identified as having PML. The mean time between HIV and PML diagnosis was 20.4 months. PML was the presentation of HIV infection in 40% of the patients, and 92% had CD4 T cell count lower than 200/mm3. Paresis was the most common clinical presentation. No specific characteristics were found in cerebrospinal fluid and JCV DNA was positive in 3 of 7 patients. MRI revealed characteristic findings. Combined antiretroviral therapy was started or changed in 96% of the patients. Neurological condition got worse in 12 patients. From the 14 deaths, 5 were directly attributed to PML progression. Follow-up was lost in 8 patients. Conclusions PML was the presentation of HIV infection in more than 1/3 of patients, frequently associated with advanced immunocompromise. MRI sensitivity to PML is high, and JCV DNA determination in CSF was not revealed to be sensible. PML diagnosis should be taken into account in HIV patients presenting any neurological symptoms, and HIV infection should be suspected when radiological findings suggest PML lesions even in previously healthy individuals.