Predictive Factors for Fatal Tick-Borne Spotted Fever in Brazil.

In Brazil, two pathogenic Rickettsia species have been identified causing tick-borne spotted fever (SF). The aetiological agent Rickettsia rickettsii causes serious illness, particularly in the south-eastern region of the country. Moreover, the Rickettsia sp. strain Atlantic Rainforest cause milder clinical manifestations in south-eastern, south and north-east regions. This study has sought to analyse predictive factors for fatal SF. A case-control study was performed using disease notification records in Brazil. The cases included were individuals with laboratory confirmation and fatal progression of SF, while the controls included individuals with SF who were cured. A total of 386 cases and 415 controls were identified (1 : 1.1), and the cases and controls were similar in age. The factors identified as being protective against death were reported presence of ticks (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.41-0.88), residing in urban areas (OR, 0.47, 95% CI, 0.31-0.74) and presenting lymphadenopathy (OR, 0.43; 95% CI, 0.23-0.82). Males exhibited a greater chance of death (OR, 1.57; 95% CI, 1.13-2.18), as did patients who were hospitalized (OR, 10.82; 95% CI, 6.38-18.35) and who presented hypotension or shock (OR, 10.80; 95% CI, 7.33-15.93), seizures (OR, 11.24; 95% CI, 6.49-19.45) and coma (OR of 15.16; 95% CI, 8.51-27.02). The study demonstrates the severity profile of the SF cases, defined either as the frequency of hospitalization (even in cases that were cured) or as the increased frequency of the clinical complications typically found in critical patients. Opportune clinical diagnosis, a careful evaluation of the epidemiological aspects of the disease and adequate care for patients are determining factors for reducing SF fatality rates.

Survival benefits of interferon-based therapy in patients with recurrent hepatitis C after orthotopic liver transplantation.

Recurrent hepatitis C after orthotopic liver transplantation (OLT) is universal and can lead to graft failure and, consequently, reduced survival. Hepatitis C treatment can be used to prevent these detrimental outcomes. The aim of this study was to describe rates of hepatitis C recurrence and sustained virological response (SVR) to interferon-based treatment after OLT and its relationship to survival and progression of liver disease through retrospective analysis of medical records of 127 patients who underwent OLT due to cirrhosis or hepatocellular carcinoma secondary to chronic hepatitis C between January 2002 and December 2013. Fifty-six patients were diagnosed with recurrent disease, 42 started interferon-based therapy and 37 completed treatment. Demographic, treatment- and outcome-related variables were compared between SVR and non-responders (non-SVR). There was an overall 54.1% SVR rate with interferon-based therapies. SVR was associated with longer follow-up after treatment (median 66.5 vs 37 months for non-SVR, P=0.03) and after OLT (median 105 vs 72 months, P=0.074), and lower rates of disease progression (15 vs 64.7%, P=0.0028) and death (5 vs 35.3%, P=0.033). Regardless of the result of therapy (SVR or non-SVR), there was a significant difference between treated and untreated patients regarding the occurrence of death (P<0.001) and months of survival (P<0.001). Even with suboptimal interferon-based therapies (compared to the new direct-acting antivirals) there is a 54.1% SVR rate to treatment. SVR is associated with improved survival and reduced risks of clinical decompensation, loss of the liver graft and death.

Evaluation of PCR in the diagnosis of canine leishmaniasis in two different epidemiological regions: Campinas (SP) and Teresina (PI), Brazil.

SUMMARY Using the polymerase chain reaction (PCR) test for diagnosis of canine leishmaniasis has greater sensitivity and specificity than culture and visualization of the parasite. This study compares PCR for the diagnosis of the genus and species of Leishmania with serological techniques used for the control of canine visceral leishmaniasis (CVL) in Brazil, considering two regions. We analysed peripheral blood samples collected from 195 dogs in the Campinas (SP) and Teresina (PI) regions. ELISA was performed as a serological method and PCR was performed using specific primers for the genus Leishmania spp. and the species Leishmania chagasi. In Campinas, a greater sensitivity of PCR (88.24%) (P = 0.0455) compared to Teresina (14.71%) (P < 0.0001) was observed, and an agreement was observed for Cohen's kappa index (0.9096). Both PCR and ELISA showed discordance for sensitivity (Campinas 100%, Teresina 21.74%), specificity (Campinas 30.77%, Teresina 100%), positive predictive value (Campinas 68.97%, Teresina 100%), negative predictive value (Campinas 100%, Teresina 37.94%) and Cohen's kappa index (0.1238). This study confirms the importance of PCR in analysis of the canine reservoir, and as an effective method for the detection of active and recent infection.

Is isoniazid safe for liver transplant candidates with latent tuberculosis?

Isoniazid (INH) is recommended for tuberculosis prophylaxis in non-liver transplant recipients. However, there is a great reluctance to prescribe this agent for liver transplant candidates and recipients due to the risk of precipitating further hepatic decompensation. We analyzed the records of liver transplantation candidates undergoing a purified protein derivative (PPD) test (tuberculosis skin test) between 2008 and 2010. Patients with no respiratory symptoms, PPD test > 10 mm, and normal chest radiography were diagnosed as latent tuberculosis and prescribed INH (300 mg) per day for 6 months. The 191 patients submitted to a PPD test and those on tuberculosis prophylaxis underwent blood tests and clinical evaluations monthly to detect hepatotoxicity of patients The 33 subjects (17.2%) with a PPD test ≥ 10 mm displayed an average model for end-stage liver disease score of 20 (range: 9-29) and child-Pugh A/B score. The main causes for liver disease were chronic hepatitis C, hepatocellular carcinoma, and alcohol abuse. Among 27 patients who received INH, 18 (66.6%) completed 6 months of prophylaxis. Eight who had shorter treatment courses of 2 to 4 months had undergone transplantation. One patient had to stop treatment because of clinical decompensation due to spontaneous bacterial peritonitis without a transaminases elevation. Six patients did not receive INH: previous tuberculosis treatment, transplantation before initiating prophylaxis, or removal from the liver candidacy list. No patient showed clinical decompensation or laboratory abnormalities associated with use of INH. The average values of alanine aminotransferase pre- and posttreatment were similar (69 and 72 U/l respectively), demonstrating that tuberculosis prophylaxis with INH was safe for liver transplant candidates.

Intradermal hepatitis B vaccination in patients with advanced chronic renal failure: immunogenicity and follow-up.

BACKGROUND: Patients undergoing dialysis usually have a poor response to conventional hepatitis B vaccination. AIM: To observe the effects of intradermal hepatitis B (HB) vaccination in a 13-month prospective study of adult patients with end-stage renal failure. The patients were with or without previous hepatitis B vaccination, but all had antibody titres <10 mUI/mL. METHODS: Patients were allotted to two groups: previous hepatitis B virus vaccination and no previous hepatitis B virus vaccination or anti-HBs titres <10 mUI/mL. Patients in both groups received 16 i.d. injections of 0.1 mL of hepatitis B virus vaccine over an eight-week period. Patients had antibody titres assessed before vaccination, 1 month after and every 3 months for a year. Antibody titres >/=10 mUI/mL were considered protective. RESULTS: Seventy patients completed the protocol. Protective titres were elicited in 82% of each group. Age, time under dialysis, diabetes, smoking and body-mass index were not associated with seroconversion. Persistent protective titres >12 months occurred in 27 (58.7%). Adverse events were trivial. CONCLUSION: Intradermal hepatitis B virus vaccination is an alternative in end-stage renal failure.

Hepatitis C virus in monozygotic twins.

A case of a pregnant patient with chronic hepatitis C who gave birth to monozygotic twins that were infected with HCV is reported. One of the newborns was positive for HCV-RNA in blood sample collected 12 hours after delivery. The other newborn was negative for HCV-RNA at birth, but was detected HCV viremia at three months of age. The results have led to the conclusion that one of the twins was probably contaminated in the intrauterine period, while the other acquired the infection in the perinatal period. Both were negative for HCV-RNA and for anti-HCV in the serum samples collected at nine months of age. The report describes the changes in the laboratory tests conducted in mother and twins until 29 months after delivery.