Síndrome de Evans asociada a infección por citomegalovirus en una niña de 13 meses / Evans Syndrome Associated With Cytomegalovirus Infection In A 13-Month-Old Girl

Introducción: El síndrome de Evans es un desorden autoinmune poco frecuente, caracterizado por el descenso de al menos dos líneas celulares hemáticas. Las publicaciones del síndrome de Evans e infección por citomegalovirus resultan escasas. Objetivo: Examinar el caso de una niña con síndrome de Evans e infección activa por citomegalovirus que respondió favorablemente a la terapia antiviral. Presentación del caso: Niña de 13 meses con antecedentes de prematuridad y bajo peso al nacer, que acudió a consulta por presentar palidez y equimosis en tórax, abdomen y extremidades. En los exámenes de laboratorio se encontró trombocitopenia y anemia severa con prueba de Coombs directo positiva. Recibió pulsos de metilprednisolona con respuesta desfavorable. La carga viral resultó positiva para citomegalovirus (4019 copias de ADN) y recibió valganciclovir con evolución favorable en el seguimiento. Conclusiones: El síndrome de Evans asociado a infección por CMV es infrecuente. El tratamiento con valganciclovir podría ser beneficioso para cierto grupo de pacientes; sin embargo, hacen falta más estudios que demuestren la eficacia y seguridad de este tratamiento en este síndrome; más aún si está asociado a una elevada carga viral(AU)

Introduction: Evans syndrome is a rare autoimmune disorder, characterized by the descent of at least two blood cell lines. Publications of Evans syndrome and cytomegalovirus infection are scarce. Objective: To examine the case of a girl with Evans syndrome and active cytomegalovirus infection who responded favorably to antiviral therapy. Case presentation: A 13-month-old girl with a history of prematurity and low birth weight, who attended the consultation for presenting pallor and ecchymosis in the thorax, abdomen and extremities. Laboratory tests found thrombocytopenia and severe anemia after a positive direct Coombs test. She received pulses of methylprednisolone with unfavorable response. The viral load was positive for cytomegalovirus (4019 copies of DNA) and received valganciclovir with favorable evolution at follow-up. Conclusions: Evans syndrome associated with CMV infection is uncommon. Treatment with valganciclovir may be beneficial for a certain group of patients. However, more studies are needed to demonstrate the efficacy and safety of this treatment in this syndrome; even more so if it is associated with a high viral load(AU)

Evaluación neurológica durante el primer año en niños muy bajo peso al nacer con infección por citomegalovirus / Neurological evaluation during the first year in very low birth weight children with cytomegalovirus infection

Introducción: La infección congénita por citomegalovirus es causa de pérdida auditiva y alteraciones cognitivas. La infección perinatal por este virus es más frecuente en neonatos< 1500 g y produce menos secuelas neurológicas. Objetivo: Describir la evaluación neurológica en el primer año de vida en niños muy bajo peso al nacer con infección por citomegalovirus. Métodos: Estudio descriptivo y longitudinal en el que se incuyeron 14 neonatos< 1500 g, con diagnóstico de infección congénita o perinatal por citomegalovirus; a los cuales se les realizó evaluación del neurodesarrollo, ultrasonido craneal, potenciales evocados auditivos de tallo cerebral y potenciales visuales a las 40 semanas, a los seis meses y al año de edad gestacional corregida. En la primera evaluación se realizó además, electroencefalograma. Resultados: El 43 por ciento tuvo infección congénita y 57 por ciento infección perinatal. A las 40 semanas se evaluaron completamente 79 % de los casos, a los seis meses 64 por ciento y al año 36 por ciento. No se observaron anormalidades en el ultrasonido craneal, ni en el electroencefalograma. Al año de edad corregida, se detectaron alteraciones ligeras del neurodesarrolo en 33,3 por ciento del total de casos (2/6) y con igual porcentaje en los niños con infección congénita (1/3) y perinatal (1/3). En ningún paciente evaluado se detectó sordera neurosensorial, ni daño del nervio visual. Conclusiones: Las alteraciones del neurodesarrollo encontradas al año de edad corregida pueden estar relacionadas con la prematuridad o la infección por citomegalovirus. El seguimiento a mediano y largo plazo es necesario para detectar otras secuelas neurológicas de debut tardío(AU)

Introduction: Congenital cytomegalovirus infection is a cause of hearing loss and cognitive impairments. Perinatal infection by this virus is more frequent in neonates< 1500 g and produces fewer neurological sequelae. Objective: To describe neurological evaluation in the first year of life in very low birth weight children with cytomegalovirus infection. Methods: A descriptive and longitudinal study involving 14 neonates< 1500 g, with a diagnosis of congenital or perinatal cytomegalovirus infection; to which neurodevelopmental evaluation, cranial ultrasound, auditory brain stem evoked potentials and visual potentials were performed at 40 weeks, six months and one year of corrected gestational age. In the first evaluation, electroencephalogram was also performed. Results: 43 percent had congenital infection and 57 percent perinatal infection. At 40 weeks, 79 percent of cases were fully evaluated, at six months 64 percent and at one year 36 percent. No abnormalities were observed on the cranial ultrasound or electroencephalogram. At one year of corrected age, slight alterations in neurodevelopment were detected in 33.3 percent of all cases (2/6) and with the same percentage in children with congenital (1/3) and perinatal (1/3) infection. In no patient evaluated, sensorineural deafness or visual nerve damage was detected. Conclusions: The neurodevelopmental alterations found at one year of corrected age may be related to prematurity or cytomegalovirus infection. Medium- and long-term follow-up is necessary to detect other late-onset neurological sequelae(AU)

Enfermedad por citomegalovirus en pacientes receptores de trasplante de corazón en un centro de referencia nacional / Cytomegalovirus disease in post-heart-transplant patients at a national reference center

Introduction: Heart transplantation remains as the treatment of choice when the heart failure is refractory to the medical or surgical therapy. Therefore, cytomegalovirus disease is an important post-heart-transplant infectious complication. Aims: To describe the prevalence and clinical characteristics of the cytomegalovirus disease after heart transplant surgery. Materials and Methods: A retrospective, descriptive study was conducted. It enrolled 35 heart-transplant patients attended in the Cardiovascular National Institute (INCOR), between 2010 and 2015. The information was obtained through the review of medical records. The demographic and relevant clinical variables were analyzed for the cytomegalovirus disease cases. Results: The population mean age was 39.49 ± 15.07 years and most of them were male patients (63%). The prevalence of the cytomegalovirus disease was 5.7% (two patients), both were seronegative for cytomegalovirus before transplantation. One of the patients had the disease before finishing the valganciclovir prophylaxis and the other after the end of it. Conclusion: The prevalence of the cytomegalovirus disease is slightly lower than in other studies. Moreover, the cytomegalovirus disease can remit with a prompt diagnosis and the proper medical treatment.

Introducción: El trasplante cardiaco es el tratamiento de elección ante la falla cardiaca refractaria a la terapia médica o quirúrgica. En base a ello, la enfermedad por citomegalovirus (CMV) es una importante complicación infecciosa post-trasplante de corazón. Objetivos: Describir la prevalencia y las características clínicas de los pacientes que desarrollaron enfermedad por CMV posttrasplante de corazón. Materiales y Métodos: Se realizó un estudio retrospectivo y descriptivo, donde se incluyó a los 35 pacientes que recibieron trasplante de corazón en el Instituto Nacional Cardiovascular entre el período 2010-2015. La información se obtuvo mediante la revisión de historias clínicas. Se analizaron las variables demográficas y clínicas relevantes de los casos con enfermedad por CMV. Resultados: La edad media de la población fue de 39,49 ± 15,07 años, siendo la mayoría de sexo masculino (63%). La prevalencia de la enfermedad por CMV fue de 5,7%, -dos pacientes-, ambos con serología negativa para CMV previa al trasplante. Uno de ellos presentó la enfermedad antes de terminar la profilaxis con valganciclovir y el otro luego del cese de la misma. Conclusión: La prevalencia de la enfermedad por CMV es ligeramente menor que en otros estudios. Asimismo, ésta puede remitir con un pronto diagnóstico y el adecuado tratamiento médico.

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. .

Comparación de las técnicas de reacción de polimerasa en cadena en tiempo real y antigenemia para la detección de citomegalovirus en sangre de niños sometidos a trasplantes / Comparison of real-time polymerase chain reaction and antigenemia assay to detect cytomegalovirus in pediatric transplants

Background: Cytomegalovirus (CMV) infections are an important cause of morbidity and mortality in transplant recipient. To date, the antigenemia assay is the most used technique for diagnostic and management of CM V infections. However, quantification of CMV viral load by real time polymerase chain reaction (RT-PCR) has becoming the method of choice to detect CMV in a rapid, sensitive and specific manner. Objective: To compare antigenemia and RT-PCR assays in the detection of CMV in blood sample from solid organ and bone marrow transplant (BMT) in children attended at the Dr. Luis Calvo Mackenna Hospital. Methods: In a prospective study, we detect the presence of CMV in blood sample by RT-PCR and antigenemia assays. Results: We analyzed 219 blood samples from 68 children subjected to kidney, liver and BMT. Out of 219 samples analyzed, 147 were negative and 33 were positive for CMV by both techniques. Thirty-seven samples were positive only by RT-PCR and 2 by antigenemia. Considering the antigenemia as a reference, RT-PCR shows 94 percent, 80 percent, 34 percent and 99 percent sensitivity, specificity, positive and negative predictive values, respectively. The kappa coefficient between both techniques was 0.528. Conclusion: Quantitative determination of CMV viral load by RT-PCR is a sensitive technique with excellent negative predictive valué compared to antigenemia. Our results support the use of RT-PCR as a technique that might facilítate the diagnostic and treatment of active CMV infection in pediatric transplants.

Antecedentes: Las infecciones por citomegalovirus (CMV) corresponden a una importante causa de morbilidad y mortalidad en pacientes sometidos a trasplantes. Hasta la fecha, la detección de CMV en células infectadas en sangre periférica mediante la técnica de inmunofluorescencia (antigenemia) es la más utilizada para el diagnóstico y monitorización de la infección por este agente. Sin embargo, en el último tiempo la cuantificación de la carga de ácido nucleico (ADN) de CMV en sangre mediante la técnica de reacción de polimerasa en cadena en tiempo real (RPC-TR) ha permitido la detección de CMV de forma más rápida, sensible y específica. Objetivos: Comparar las técnicas de antigenemia y RPC-TR para la detección de CMV en sangre en niños sometidos a trasplante de órganos sólidos y trasplante de precursores hematopoyéticos (TPH) en el Hospital Dr. Luis Calvo Mackenna. Metodología: En un estudio prospectivo de seguimiento preventivo de reactivación se detectó la presencia de CMV en muestras de sangre utilizando las técnicas de RPC-TR y antigenemia. Resultados: Se analizaron 219 muestras de sangre, correspondiente a 68 niños sometidos a trasplante de hígado, riñon y TPH. De las muestras analizadas, 147 fueron negativas y 33 positivas para CMV utilizando ambas técnicas. Treinta y siete muestras resultaron ser positivas sólo por RPC-TR y dos sólo por antigenemia. Tomando en cuenta la antigenemia como referencia, la RPC-TR mostró una sensibilidad, especificidad, valor predictor positivo y negativo de 94 por ciento, 80 por ciento, 34 por ciento y 99 por ciento, respectivamente. El índice de concordancia entre ambas técnicas tuvo un valor de kappa = 0,528. Conclusión: La determinación cuantitativa de ADN de CMV por RPC-TR es una técnica sensible, con un gran valor predictor negativo comparada con la antigenemia. Los resultados obtenidos en este trabajo apoyan el uso de RPC-TR para el diagnóstico y tratamiento oportuno de las infecciones activas por CMV en niños sometidos a trasplantes.

Infección y enfermedad por citomegalovirus en niños sometidos a trasplante de órgano sólido: experiencia en un centro de referencia chileno / Cytomegalovirus infection and disease in pediatric solid organ transplarntation: experience in a Chilean multiorganic transplantation center

Cytomegalovirus (CMV) infection and disease in transplant (Tx) recipients may severely complícate the patients outcome. Aim: To determine the incidence, clinical characteristics and risk factors for CMV infection and disease in liver and kidney transplant recipients in a tertiary care children's hospital. Method: A clinical and laboratory evaluation was prospectively performed in 44 and 20 children receiving a renal and liver Tx respectively in the Hospital Luis Calvo Mackenna between 2004 and 2006. Results: At the time of the organ Tx 20.3 percent (13/64) children were seronegative for CMV. Thirty six per cent (23/64) patients were infected with CMV, of whom 32 percent (14/44) received kidney Tx and 9/20 (45 percent) received liver Tx. CMV disease occurred in 52 percent (12/23) of infected patients. CMV disease was characterized by fever (100 percent), anemia (50 percent), leucopenia (16.6 percent) and specific organ involvement (renal graft 60 percent liver graft 57.1 percent, lung 25 percent, intestine 16.6 percent). Variables significantly associated with infection were a CMV seronegative status (p = 0.035) and lower age 5.5 + 3.7 years oíd vs 8.3 + 4.4 years oíd (p = 0.01). Conclusions: Incidence of CMV infection was high in children receiving a solid organ transplant in our institution and near half of infected children developed CMV-associated disease.

La infección y enfermedad por citomegalovirus (CMV) en pacientes sometidos a trasplantes (Tx) es una complicación que condiciona la evolución del injerto y la sobrevida del paciente. Objetivos: Determinar la incidencia de infección y enfermedad por CMV durante los primeros seis meses de efectuados Tx hepático y renal. Caracterizar la enfermedad, e identificar factores de riesgo asociados a infección. Metodología: Análisis prospectivo en 64 pacientes pediátricos sometidos a Tx renal (n: 44) o hepático (n: 20) en el Hospital Luis Calvo Mackenna entre 2004 y 2006. Resultados: Al trasplante, 23,1 por ciento (13/64) eran receptores IgG CMV (-). Cumplieron criterio de infección 36 por cientoo (23/64) de los pacientes, con Tx renal 32 por ciento (14/44) y con Tx hepático 45 por ciento (9/20). Desarrolló enfermedad el 52 por ciento) (12/23) la que se caracterizó porfiebre (100 por cientoo), anemia (50 por cientoo), leucopenia (16,6 por cientoo), disfunción del órgano trasplantado 60 por cientoo en Tx renal, hepático 57, l por cientoo, compromiso pulmonar en 25 por cientoo e intestinal en 16,6 por cientoo del total de pacientes. Variables asociadas a infección fueron: ser receptor IgG CMV (-)pre-Tx (p=0,035) y una menor edad del paciente 5,5 +3,7 vs 8,3 + 4,4 (p= 0,01). Conclusiones: Hay una elevada tasa de infección por CMV en la población de pacientes con Tx renal y hepática en nuestro medio, la mitad de ellos desarrolló enfermedad amenazando la función del injerto.

Prevalence of anti-CMV antibodies in blood donors in Urmia

Infection with cytomegalovirus [CMV] is very common. Contamiated persons can transmit the virus to normal recipients through blood donation. While infection with CMV in normal immunocompetent persons usually has no adverse outcomes, transmission of the virus to immunocompromised patients can lead to serious morbidity and mortality. So we designed a study to determine the prevalence rate of anti-CMV antibodies among the blood donors of Urmia Blood Transfusion Center. In this cross-sectional descriptive study, the prevalence rate of anti-CMV antibodies [IgM, IgG] was estimated by ELISA method in serum samples obtained from 180 healthy blood donors in various age and sex groups of Urmia. According to the findings, all [100%] of the sera studied were positive for IgG irrespective of the age and sex of donors while only five persons [2.8%] had anti-CMV IgM at detectable levels. There were four males and one female, all living at urban regions with the age range of 20 to 50 years. The high rate of positive test results among blood donors indicated that nearly all of donated blood units have an infectious nature at least for immunocompromised patients. The findings of this study clearly show that it is time for all blood donations to be screened for CMV infectivity at least for immunocompromised group of recipients such as the patients with malignant diseases receiving chemotherapy and recipients of allograft organs. This group of patients should at least benefit from protective measures in blood transfusion including the use of leukocyte filters which is at the time being limited to thalassemic patients in our country

Cytomegalovirus infection in neonates following exchange transfusion.

OBJECTIVES: This study was undertaken to ascertain the acquisition of cytomegalovirus infection following exchange transfusion and factors affecting such transmission in newborn infants at a tertiary care hospital in India. METHODS: Neonates undergoing double volume exchange transfusion (for any indication) with whole blood in the Neonatal Intensive Care Unit were enrolled over a 8 month period. Serum samples from the infant were collected for CMV serology before exchange transfusion, and at 6 and 12 weeks following the exchange. CMV serology was also conducted on samples obtained from the respective maternal and donor blood. RESULTS: Of 47 neonates who received exchange transfusion during the study period; only 26 (55.3%) neonates were finally followed up till 12 weeks of age. Only 3 (11.5%) children demonstrated CMV seroconversion during follow-up; all were low birth weight and small for gestational age. None of them demonstrated any clinical, hematological, biochemical, or radiological signs suggestive of perinatal CMV infection either at birth or during the course of follow-up. CONCLUSION: Exchange transfusion in neonates can result in perinatal transmission of CMV infection in low birth weight neonates. Such transmission does not result in any immediate manifestations. Data are not sufficient to warrant routine CMV screening of donor blood for exchange transfusion in our setting.

Detection of serologic prevalence of anti-CMV antibodies in thalassemia major patients and blood donors

Cytomegalovirus [CMV] infection has been recognized as a complication of blood transfusion. Transfusion-related CMV infection produces dramatic problems in immunocompromised patients including organ transplantation recipients, AIDS patients under immunosuppressive therapy, thalassemia major patients, and premature neonates. Regarding the importance of this infection in multitransfused patients and differences in prevalence of transfusion - related CMV infection in various reports, especially in thalassemia major patients, we decided to detect and compare the prevalence of CMV antibodies in thalassemia patients and blood donors. In this study we detected anti-CMV antibodies [IgGJgM] by Elisa technique. We tested these antibodies in 55 thalassemia major patients [45 non-splenectomized and 10 splenectomized] and 1040 healthy donors. Our results showed that anti-CMV IgG antibody was positive in 89.6% of control group and 100% of thalassamic group, thus indicating of no significant difference in these two groups. Anti-CMV IgM antibody was positive in 0.04% of control group and in 9.1% of thalassemic group showing a significant difference. The prevalence of this antibody was respectively 30% and 4.5% in splenectomized and non-splenectomized groups of patients Absence of significant difference of anti-CMV IgM antibody in patient and control group reflected high frequency of this infection in our population and also the importance of the use of leukocyte free products for high risk blood recipients. Moreover, the significant difference in anti-CMV IgM antibody in splenectomized and non-splenectomized patient groups is related to the role of spleen in clearance of infectious agents and production of IgM antibody in this organ

A pilot study on the role of cytomegalovirus & human herpesvirus-6 infections in Indian bone marrow transplant recipients.

BACKGROUND & OBJECTIVES: Studies from Western transplant centers have shown the importance of cytomegalovirus (CMV) in infections among immunosuppressed post-transplant patients (both solid and bone marrow transplant recipients). Human herpesvirus-6 (HHV-6) infection is also important. Since such data are lacking from India, we carried out a pilot study to investigate the role of these two viruses in infections among Indian allogeneic bone marrow transplant (BMT) recipients. METHODS: A total of 21 BMT patients who developed acute graft versus host disease (GVHD), two patients who developed chronic GVHD, and eight recipients who did not develop GVHD but had skin rash/elevated liver enzymes, persistent cytopaenia or interstitial pneumonitis with a high clinical suspicion of possible CMV association were studied for markers of CMV and HHV-6 infections. RESULTS: CMV DNAemia was documented in 9 (42.8%) and CMV IgM in 4(19%) of the 21 patients with acute GVHD. HHV-6 DNAemia was not seen in any patient with acute GVHD but 2 (9.5%) had HHV-6 IgM. Of the 2 patients with chronic GVHD, 1 was positive for CMV DNA and IgM, and both were negative for HHV-6 markers. The lower incidence of CMV DNAemia in our recipients may be attributable to the presence of neutralizing antibody (anti gB/AD-1) among the 17 CMV and HHV-6 DNAemia negative recipients, 4(23.5%) had neutralizing antibodies (S/N ratio > or = 5). Of the 13 CMV DNAemia positive recipients, only one (7.7%) was positive for neutralizing antibodies. Among the 5 neutralizing antibody (S/N ratio > or = 5) positive recipients, 4 (80%) were negative for CMV DNAemia. The one nPCR positive was revealed only at high DNA (> 0.1 microgram) input indicating low CMV signal strength. INTERPRETATION & CONCLUSION: The present study shows the use of DNAemia in detecting CMV infections among BMT recipients. All recipients had high avidity CMV IgG (AI > 50%) confirming CMV reactivation or reinfection in these patients. There was evidence from this study suggesting that neutralizing antibodies may play a role in controlling CMV reactivation. We found no significant HHV-6 association with GVHD in Indian allogeneic BMT recipients.

Blood support for pediatric surgery.

Increasingly complicated surgeries are being performed on neonatal and pediatric patients. Provision of a safe and adequate blood supply is essential for the success of many of these surgeries. Depending on the clinical situation, autologous and/or allogeneic blood may be used. However, in all cases, every attempt should be made to minimize the number of donor exposures to reduce the risk of transfusion transmitted infections. Transfusion of neonatal and pediatric patients requires additional considerations too, such as the risk of graft vs host disease, cytomegalovirus infection, the effects of various preservative anticoagulant solutions, electrolyte levels during blood storage, and wheather or not leukoreduced components are indicated.

Citomegalovirus en el transplante cardíaco: seguridad y eficacia de los distintos esquemas de profilaxis / Cytomegalovirus in heart transplantation: safety and efficacy of prophylactic plans

La introducción de nuevos fármacos inmunosupresores en el área de la trasplantología, logró solucionar uno de los problemas fundamentales del transplante; el rechazo, permaneciendo el inconveniente de la infección por citomegalovirus (CMV). Los virus herpéticos se encuentran ampliamente diseminados ente los huéspedes inmunocompetentes y en ellos la infección suele ser asintomática y a veces, son capaces de producir infecciones graves en los huéspedes inmunodeprimidos, en particular receptores de transplante. En los receptores de trasplantes renales, cardíacos o de médula ósea, el riesgo global de infección por CMV, durante el primer año, oscila entre 50 y 70 por ciento. La primoinfección, sobreinfección por cepas nuevas o la reactivación del CMV constituye un problema importante en el transplante cardíaco, elevando la morbimortalidad en forma significativa. En la actualidad no existe consenso acerca de los esquemas, tanto de profilaxis como de tratamiento de las infecciones por CMV. Cuando se analiza el match entre donante y receptor en relación al CMV se puede determinar distintos grupos de riesgo para desarrollar infección y enfermedad con significancia clínica y pronóstica. Según este análisis, nosotros creemos que el grupo que más riesgo de desarrollar enfermedades por CMV es el de los receptores negativos que reciben órganos de donantes positivos los cuales presentan una incidencia de enfermedad por CMV mayor de 50 por ciento. Esta incidencia disminuye a 14 por ciento, en aquellos pacientes que son tratados profilácticamente con gammaglobulina hiperinmune

Enfermedad pulmonar intersticial crónica en un lactante: caso clínico / Chronic interstitial pneumonia in an infant: clinical case

La enfermedad pulmonar interstical crónica es frecuente en lactantes y comprende un grupo heterogéno de enfermedades con patrón histológico semejante. Se presenta el caso de una lactante que inició su sintomatología en el período neonatal, con neumonías y atelectasias repetidas, asociadas a transtornos de la deglución con aspiración hacia la vía aérea. El estudio radiológico de tórax demostró infiltrados intersticiales bilaterales persistentes. La biopsia pulmonar fue compatible con una neumonía crónica interstical histiocitaria. Se trató con oxigenoterapia permanente, corticoides inhalatorios, broncodilatadores, kinesiterapia respiratoria, prednisona oral, que luego se cambió a cloroquina, la cual se mantiene hasta la fecha (tiempo de admini9stración 34 meses). La evolución clínica y radiológica ha sido favorable, lográndose la suspensión de la oxigenoterapia luego de un año de uso. Después del primer año de tratamiento no ha presentado neumonías y no han aparecido efectos secundarios por el uso prolongado de cloroquina. Su desarrollo pondoestatural no ha sido adecuado ya que es portadora de una genopatía aún no precisada, sin relación con la enfermedad pulmonar

El síndrome Torch

El síndrome de TORCH (Toxoplasmosis, otros como Sífilis, Rubéola, Citomegalovirus y Herpesvirus) reune el grupo de agentes más comunes en infección intrauterina crónica, causante de las más serias lesiones embrionarias. La infección por el virus de inclusión citomegálica es la más común, afecta del 0.5 al 2 por ciento de los nacidos vivos, la toxoplasmosis afecta cerca de uno a cuatro por mil nacidos vivos, la rubéola a uno por mil en épocas no epidémicas y la sífilis presenta una incidencia variable. Las manifestaciones clínicas y serológicas varian con cada entidad pero es importante conocer que en nuestro medio existe un grupo considerable de gestantes en los grupos de riesgo ante el síndrome TORCH; se debe considerar estos agentes en el control periódico de toda gestante, incluyendo necesariamente, estudios serológicos para buscar anticuerpos específicos y análisis de la inmunidad contra los mismos. Es importante detectar los recién nacidos asitimáticos ya que pueden beneficiarse del tratamiento temprano; dichos casos deben continuar en control al menos durante el primer año. El conocimiento adecuado de la epidemiología de una comunidad determinada permitirá ampliar de una forma adecuada el tamizaje a otros agentes.

Prevalência e aspectos clínicos da infecçäo congênita por citomegalovirus / Prevalence and clinical aspects of congenital cytomegalovirus infection

Objetivos: Determinar a prevalência da infecçäo congênita por citomegalovirus (CMV), bem como avaliar o palel desse agente como causa de doença congênita r descrever as principais manifestaçöes clínicas dessa doença em crianças atendidas em hospital universitário de Ribeiräo Preto. Casuística e métodos: Para determinaçäo da prevalência da infecçäo congênita, foram estudados 189 recém-nascidos e suas mäes, constituindo um primeiro grupo de estudo. Para avaliaçäo da importância do CMV na etiologia da doença congênita e descriçäo das manifestaçöes clínicas da citomegalovirose congênita, foram incluídos outros 130 recém-nascidos e 74 lactentes com clínica sugestiva de infecçäo congênita, constituindo um segundo grupo. O diagnóstico laboratorial foi realizado pelo isolamento viral na urina em cultura de fibroblastos humanos, pela detecçäo do DNA viral na urina através da reaçäo de amplificaçäo gênica catalizada pela polimerase e pela reaçäo de imunofluorescência para pesquisa de IgM e IgG específicos anti-CMV. Resultados: A prelência da infecçäo congênita foi de 2,6 por cento e 95 por cento das mäes tinham IgG anti-CMV. Todas as crianças infectadas do primeiro grupo eram assintomáticas ao nascimento, porém em uma evidenciaram-se calcificaçöes intracranianas ao exame radiológico. No segundo grupo de estudo, CMV foi detectado na urina 12(5,9 por cento) das crianças com apresentaçäo clínica compatível com doença congênita. Destas, em 10 (83 por cento), o diagnóstico foi relaizado após o período neonatal. Os achados clínicos incluíram hepatoesplenomegalia (75 por cento), icterícia neonatal em hiperbilirrubinemia direta (42 por cento) e anormalidades neurológicas caracterizadas por microcefalia e calcificaçöes intracranianas (42 por cento). Conclusöes: Observou-se uma prevalência de infecçäo congênita por CMV similar à encontrada nos estudos realizados em populaçöes de soroprevalência elevada para CMV. Crianças com citomegalovirose assintomática podem ter acomentimento do SNC, clinicamente imperceptível ao nascimento, e crianças sintomáticas apresentam doença multissistêmica. O diagnóstico diferencial de qualquer recém-nascido com anormalidades, incluindo envolvimento hepático, hematopoético e neurológico, deve incluir pesquisa para citomegalovirose congênita. Os CMV mostraram ser agaentes importantes na etiologia dessas afecçöes, e a grande maioria das crianças sintomáticas foram identificadas após o período neonatal, dificultando um diagnóstico definitivo

Successful treatment with ganciclovir for cytomegalovirus duodenitis following allogenic bone marrow transplantation

Cytomegalovirus(CMV) disease is a major cause of morbidity and mortality in immunocompromised patients. CMV enteritis should be considered when nausea and vomiting continue 3 to 4 weeks after bone marrow transplantation(BMT). The treatment of CMV enteritis is not well established. We report a CMV duodenitis patient following allogenic bone marrow transplantation. The patient had prolonged nausea and vomiting for 5 weeks after bone marrow transplantation and CMV duodenitis was diagnosed by the gastroduodenoscopic mucosal biopsy which showed cytomegalic cells. Ganciclovir treatment for 3 weeks resulted in the resolution of symptoms and promoted healing of the lesion. The patient was free of CMV infection until 288 days after allogenic BMT without maintenance ganciclovir treatment.

Infecçäo pelo citomegalovírus em pacientes submetidos a transplante renal: estudo de 20 casos / Cytomegalovirus infection in patients submitted to kidney transplantation: study of 20 cases

Para comparar a eficácia do método "shell vial assay" (SVA) em relaçao à detecçao de anticorpos anti-citomegalovirus (ELISA) para o diagnóstico da infecçao ativa pelo citomegalovírus (CMV), conduzimos um estudo prospectivo acompanhando 20 receptores de transplante renal até o 6§ mês após o transplante, com coleta rotineira de sangue e urina, além de avaliaçao clínica periódica. Noventa por cento dos pacientes entre doadores e receptores apresentava anticorpos anti-CMV antes do transplante. Após a realizaçao do transplante, 18/20 (90 por cento) dos receptores apresentou infecçao ativa pelo CMV, sendo apenas 2 destes pacientes sintomáticos (10 por cento). Das 18 infecçoes ativas, 3 foram infecçoes primárias (2 sintomáticas), sendo o enxerto o provável veículo. A detecçao de anticorpos fez o diagnóstico em 88,9 por cento dos casos, sendo que IgM foi detectada em 4 pacientes. O SVA fez o diagnóstico em 83,3 por cento dos casos, todos eles através de detecçao de virúria, nao havendo detecçao de viremia. Em 13 casos onde houve concordância entre os dois métodos, a detecçao de anticorpos diagnosticou a infecçao ativa em média 28 dias mais precocemente (50,8 X 78,5 dias, p=0,02). Concluímos que a infecçao ativa pelo CMV após transplante renal é extremamente frequente em nosso meio e que o SVA nao é superior à detecçao de anticorpos (ELISA) neste diagnóstico.