Usefulness of aqueous and vitreous humor analysis in infectious uveitis

OBJECTIVE: To evaluate the role of intraocular fluid analysis as a diagnostic aid for uveitis. METHODS: Twenty-eight samples (27 patients including 3 HIV-infected patients) with active (n=24) or non-active (n=4) uveitis were submitted to aqueous (AH; n=12) or vitreous humor (VH) analysis (n=16). All samples were analyzed by quantitative PCR for herpes simplex virus (HSV), varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV) and Toxoplasma gondii. RESULTS: The positivity of the PCR in AH was 41.7% (5/12), with 50% (2/4) in immunocompetent and 67% (2/3) in HIV+ patients. The positivity of the PCR in VH was 31.2% (5/16), with 13% (1/8) in immunocompetent and 50% (4/8) in immunosuppressed HIV negative patients. The analysis was a determinant in the diagnostic definition in 58% of HA and 50% of VH. CONCLUSION: Even in posterior uveitis, initial AH analysis may be helpful. A careful formulation of possible clinical diagnosis seems to increase the chance of intraocular sample analysis being meaningful.

Rabdomiólisis grave secundaria a deshidratación hipernatrémica / Severe rhabdomyolysis secondary to severe hypernatraemic dehydration

Introducción: La rabdomiólisis es una enfermedad poco frecuente en pediatría. El objetivo es presentar un paciente en el que se desarrolló secundario a una deshidratación hipernatrémica grave tras una diarrea aguda. Caso clínico: Lactante de 11 meses que consultó por fiebre, vómitos, diarrea y anuria. Presentó convulsión tónico-clónica autolimitada. Ingresó en mal estado general, severamente deshidratado, con escasa reactividad. En las pruebas complementarias destacó acidosis metabólica grave, hipernatremia e insuficiencia renal prerrenal. Al tercer día apreció leve hipotonía axial y elevación de creatín fosfokinasa 75.076 UI/l, interpretado como rabdomiólisis. Se inició hiperhidratación y alcalinización sistémica, con buena respuesta clínica y bioquímica, siendo dado de alta sin secuelas motoras. Conclusiones: La hipernatremia grave está descrita como causa rara de rabdomiólisis e insuficiencia renal. En pacientes críticos es importante un alto índice de sospecha de rabdomiólisis y determinación seriada de la creatín fosfokinasa para su detección y tratamiento precoz.

Introduction: Rhabdomyolysis is a rare paediatric condition. The case is presented of a patient in whom this developed secondary to severe hypernatraemic dehydration following acute diarrhoea. Case report: Infant 11 months of age who presented with vomiting, fever, diarrhoea and anuria for 15 hours. Parents reported adequate preparation of artificial formula and oral rehydration solution. He was admitted with malaise, severe dehydration signs and symptoms, cyanosis, and low reactivity. The laboratory tests highlighted severe metabolic acidosis, hypernatraemia and pre-renal kidney failure (Sodium [Na] plasma 181 mEq/L, urine density> 1030). He was managed in Intensive Care Unit with gradual clinical and renal function improvement. On the third day, slight axial hypotonia and elevated cell lysis enzymes (creatine phosphokinase 75,076 IU/L) were observed, interpreted as rhabdomyolysis. He was treated with intravenous rehydration up to 1.5 times the basal requirements, and he showed a good clinical and biochemical response, being discharged 12 days after admission without motor sequelae. Conclusions: Severe hypernatraemia is described as a rare cause of rhabdomyolysis and renal failure. In critically ill patients, it is important to have a high index of suspicion for rhabdomyolysis and performing serial determinations of creatine phosphokinase for early detection and treatment.

Real-time PCR in infectious uveitis as an alternative diagnosis / PCR em tempo real em uveites infecciosas como um diagnóstico alternativo

PURPOSE: Uveitis is a major visual impairment disease affecting parts or the entire uveal tract and occasionally the sclera, the cornea or the optic nerve. The disease is a major cause of ocular morbidity and blindness in immunocompetent and immunocompromised patients. In this work we analyzed the sensitivity and specificity of real-time PCR to detect the etiological agent from blood, plasma, vitreous and aqueous humor and compared with the diagnostic hypothesis. METHODS: Twenty-seven patients (13 male) were studied and Real-time PCR method was used for the detection of herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), varicella zoster virus (VZV), cytomegalovirus (CMV), Mycobacterium tuberculosis (TB) and Toxoplasma gondii (Toxo) in the aqueous humor as well as in the vitreous, blood and plasma. RESULTS: Our results showed the presence of Toxo, CMV, VZV or HSV-2 in 19.2 percent of aqueous humor samples, and in 30 percent of vitreous humor samples. In plasma and blood samples, only CMV was detected (11.1 percent and 3.7 percent, respectively). CONCLUSION: Real-time PCR was able to detect and to confirm diagnostic hypothesis in uveitis. Our data also confirms that vitreous humor is the best source for molecular diagnosis of infectious uveitis but indicates aqueous humor samples that are easier to obtain may also be appropriate to be tested by Real-time PCR.

OBJETIVO: Uveíte é a maior causa de doença ocular que afeta o trato uveal, e ocasionalmente a esclera, cornea e o nervo óptico. Esta doença é a maior causa de morbidade ocular e cegueira em pacientes imunocompetentes e imunossuprimidos. Neste trabalho nós analisamos a sensiblidade e especificidade do PCR em tempo real para detectar agentes etiológicos no sangue, plasma, humor vítreo e aquoso, e comparamos com a hipótese diagnóstica. MÉTODOS: Vinte e sete pacientes (13 homens) foram estudados e o método de PCR em tempo real foi usado para detectar o vírus da herpes simples 1 (HSV-1), vírus da herpes simples 2 (HSV-2), vírus varicella zoster (VZV), citomegalovírus (CMV), Mycobacterium tuberculosis (TB) e Toxoplama gondii (Toxo) no humor aquoso e vítreo, além do sangue e plasma. RESULTADOS: Nossos resultados mostraram a presença de Toxo, CMV, VZV ou HSV-2 em 19,2 por cento das amostras de humor aquoso, e em 30 por cento das amostras de humor vítreo. Nas amostras de plasma e sangue somente CMV foi detectado (11,1 por cento e 3,7 por cento, respectivamente). CONCLUSÃO: PCR em tempo real foi capaz de detectar e confirmar a hipótese diagnóstica em uveíte. Nossos dados confirmam que o humor vítreo é a melhor fonte para diagnóstico molecular de uveíte infecciosa, porém o humor aquoso também foi uma fonte importante de detecção, além de ser mais fácil de se obter.

Correlation between clinical diagnosis and PCR analysis of serum, aqueous, and vitreous samples in patients with inflammatory eye disease

PURPOSE: To study the applicability (sensitivity, specificity) of polymerase chain reaction (PCR) tests in the detection of cytomegalovirus (CMV), herpes virus (HSV) and varicella zoster (VZV), Epstein-Barr virus (EBV), Mycobacterium sp and Toxoplasma gondii in the diagnosis of patients with or without AIDS, with presumably infectious uveitis, using serum, aqueous humor and vitreous humor samples. METHODS: Twenty individuals with uveitis of presumed infectious origin were evaluated. Sixteen of them had AIDS, four were immunocompetent individuals. We also evaluated 4 normal controls who underwent vitrectomy surgery. Clinical evaluation of the patients was performed together by three clinicians. PCR evaluations of the serum, aqueous, and vitreous humor were performed in a masked fashion by the laboratory staff. RESULTS: Twelve patients had a clinical diagnosis of CMV retinitis. Of these 6 (50 percent) had a positive PCR for CMV in the vitreous, three (25 percent) had a positive PCR for CMV in the serum, and none were positive in the aqueous. Five patients had a clinical diagnosis of acute retinal necrosis (ARN). Three (60 percent) of these had positive PCR for HSV/VZV in the vitreous. One of these patients had a positive PCR reaction for both EBV and HSV/VZV in the vitreous samples. One patient with cutaneous herpes zoster had a positive PCR reaction for HSV/VZV in the serum. Four patients had a presumed diagnosis of ocular toxoplasmosis, one patient (25 percent) had a positive PCR for Toxoplasma gondii in the serum, 3 (75 percent) had positive results in the aqueous, and 2 (50 percent) had positive results in the vitreous. One patient with presumed ocular tuberculosis had a positive PCR reaction both in the serum and in the vitreous samples. Finally, none of the four control individuals revealed any positive PCR reaction. CONCLUSION: PCR is an auxiliary diagnostic procedure that should be evaluated together with ophthalmological aspects...

OBJETIVOS: Avaliar a aplicabilidade (especificidade, sensibilidade) do teste da reação da cadeia de polimerase (PCR) na detecção de citomegalovírus (CMV), herpes vírus e varicela zoster (HSV, VZV), Epstein-Barr vírus (EBV), Mycobacterium sp e Toxoplasma gondii no diagnóstico de pacientes com ou sem AIDS, com uveíte infecciosa presumível, utilizando amostras de humor aquoso, humor vítreo e soro. MÉTODOS: Vinte pacientes com uveíte infecciosa presumível foram estudados. Dezesseis destes apresentavam AIDS e quatro eram imunocompetentes. Foram utilizados quatro pacientes como grupo controle que se submeteram a vitrectomia. A avaliação clínica foi feita conjuntamente com três oftalmologistas. O exame do PCR do soro, aquoso e vítreo foi feito sem o conhecimento da hipótese diagnóstica pela equipe do laboratório. RESULTADOS: Doze pacientes tinham o diagnóstico clínico de retinite por CMV. Deste subgrupo 6 (50 por cento) eram PCR positivo para CMV no vítreo, 3 (25 por cento) eram PCR positivos para CMV no soro e nenhum destes foi positivo no aquoso. Cinco pacientes tinham o diagnóstico clínico de necrose aguda de retina (ARN). Três (60 por cento) destes eram PCR positivos para HSV/VZV no vítreo. Um destes pacientes era PCR positivo tanto para EBV e HSV/VZV na amostra do vítreo. Um destes pacientes com herpes zoster cutâneo era PCR positivo para HSV/VZV no soro. Quatro pacientes tinham o diagnóstico de toxoplasmose ocular presumida, um paciente (25 por cento) era PCR positivo para Toxoplasma gondii no soro, 3 (75 por cento) eram positivos no aquoso e 2 (50 por cento) eram positivo no vítreo. Um paciente com tuberculose ocular presumível era PCR positivo tanto no soro quanto no vítreo. Nenhum dos pacientes do grupo controle era PCR positivo em qualquer amostra. CONCLUSÃO: O exame do PCR é procedimento diagnóstico auxiliar que deve ser utilizado conjuntamente com os aspectos clínicos.