Doctors' awareness concerning primary immunodeficiencies in Brazil.

BACKGROUND: PIDs are a heterogeneous group of genetic illnesses, and delay in their diagnosis is thought to be caused by a lack of awareness among physicians concerning PIDs. The latter is what we aimed to evaluate in Brazil. METHODS: Physicians working at general hospitals all over the country were asked to complete a 14-item questionnaire. One of the questions described 25 clinical situations that could be associated with PIDs and a score was created based on percentages of appropriate answers. RESULTS: A total of 4026 physicians participated in the study: 1628 paediatricians (40.4%), 1436 clinicians (35.7%), and 962 surgeons (23.9%). About 67% of the physicians had learned about PIDs in medical school or residency training, 84.6% evaluated patients who frequently took antibiotics, but only 40.3% of them participated in the immunological evaluation of these patients. Seventy-seven percent of the participating physicians were not familiar with the warning signs for PIDs. The mean score of correct answers for the 25 clinical situations was 48.08% (±16.06). Only 18.3% of the paediatricians, 7.4% of the clinicians, and 5.8% of the surgeons answered at least 2/3 of these situations appropriately. CONCLUSIONS: There is a lack of medical awareness concerning PIDs, even among paediatricians, who have been targeted with PID educational programmes in recent years in Brazil. An increase in awareness with regard to these disorders within the medical community is an important step towards improving recognition and treatment of PIDs.

Severe combined immunodeficiency in Brazil: management, prognosis, and BCG-associated complications.

BACKGROUND: Severe combined immunodeficiency (SCID) is one of the most severe forms of primary immunodeficiency. The objectives of this study were to analyze the diagnosis, treatment, and prognosis of SCID in Brazil and to document the impact of BCG vaccine. METHODS: We actively searched for cases by contacting all Brazilian referral centers. RESULTS: We contacted 23 centers and 70 patients from 65 families. Patients were born between 1996 and 2011, and 49 (70%) were male. More than half (39) of the diagnoses were made after 2006. Mean age at diagnosis declined from 9.7 to 6.1 months (P = .058) before and after 2000, respectively, and mean delay in diagnosis decreased from 7.9 to 4.2 months (P = .009). Most patients (60/70) were vaccinated with BCG before the diagnosis, 39 of 60 (65%) had complications related to BCG vaccine, and the complication was disseminated in 29 of 39 (74.3%). Less than half of the patients (30, 42.9%) underwent hematopoietic stem cell transplantation (HSCT). Half of the patients died (35, 50%), and 23 of these patients had not undergone HSCT. Disseminated BCG was the cause of death, either alone or in association with other causes, in 9 of 31 cases (29%, no data for 4 cases). CONCLUSIONS: In Brazil, diagnosis of SCID has improved over the last decade, both in terms of the number of cases and age at diagnosis, although a much higher number of cases had been expected. Mortality is higher than in developed countries. Complications of BCG vaccine are an important warning sign for the presence of SCID and account for significant morbidity during disease progression.

Nutritional supplementation assessment with whey proteins and TGF-ß in patients with Crohn's disease.

UNLABELLED: Crohn's disease (CD) is a chronic inflammatory disorder that primarily affects the intestines, resulting in breakage of the intestinal barrier, pathological inflammation and nutritional disorders that encompass from trace elements deficiency to severe malnutrition. Nutritional interventions either alone or associated to drug therapy may be effective to achieve and maintain inflammation remission. OBJECTIVE: To evaluate usual food intake as quantitative and qualitatively, in CD patients; and describe the effect of a supplement containing whey proteins and TGF- on their body composition. PATIENTS AND METHODS: Dietary intake was assessed considering 42 consecutive patients, followed in a tertiary center, and by using the 3-day food recall and food intake frequency questionnaire. Body composition was assessed previously and 8 weeks after supplementation with a diet containing whey proteins and TGF-ß (N = 22). RESULTS AND DISCUSSION: Considering carbohydrates and lipids, most patients had adequate dietary intake according recommendations. Protein, saturated fat, B12 vitamin and zinc intakes were higher than the recommended values. The dietary fiber, A, D, C and E vitamins, calcium, iron, folate, potassium and sodium intakes did not reach the recommended requirements in most patients. Patients supplemented with the whey protein and TGF-ß dietary presented a positive increment in their lean body mass, when compared to non-supplemented group. CONCLUSION: CD patients require nutritional orientation. Whey protein intake resulted in significant differences, such as improvement in Lean Body Mass and reduction in Fat percentage.

Abnormalities in body composition and nutritional status in HIV-infected children and adolescents on antiretroviral therapy.

This cross-sectional study aimed to compare growth, nutritional status and body composition outcomes between a group of 94 HIV-infected children and adolescents on antiretroviral therapy (ART) and 364 healthy controls, and to evaluate their association with clinical and lifestyle variables within the HIV-infected group. When compared with the control group, HIV patients had higher risk of stunting (odds ratio [OR] 5.33, 95% confidence interval [CI]: 2.83-10.04) and thinness (OR 4.7, 95% CI: 2.44-9.06), higher waist-to-hip ratios (medians 0.89 versus 0.82 for boys and 0.90 versus 0.77 for girls, P < 0.001), and lower prevalence of overweight or obesity (OR 0.33, 95% CI: 0.14-0.78). Protease inhibitor usage was associated with thinness (OR 3.51, 95% CI 1.07-11.44) and lipoatrophy (OR 3.5, 95% CI 1.37-8.95). HIV-infected children on ART showed significant nutritional status and body composition abnormalities, consistent with the severity of vertical HIV infection and the consequences of prolonged ART.

Mutations of Bruton's tyrosine kinase gene in Brazilian patients with X-linked agammaglobulinemia

Mutations in Bruton's tyrosine kinase (BTK) gene are responsible for X-linked agammaglobulinemia (XLA), which is characterized by recurrent bacterial infections, profound hypogammaglobulinemia, and decreased numbers of mature B cells in peripheral blood. We evaluated 5 male Brazilian patients, ranging from 3 to 10 years of age, from unrelated families, whose diagnosis was based on recurrent infections, markedly reduced levels of IgM, IgG and IgA, and circulating B cell numbers <2 percent. BTK gene analysis was carried out using PCR-SSCP followed by sequencing. We detected three novel (Ala347fsX55, I355T, and Thr324fsX24) and two previously reported mutations (Q196X and E441X). Flow cytometry revealed a reduced expression of BTK protein in patients and a mosaic pattern of BTK expression was obtained from mothers, indicating that they were XLA carriers.

Mutations of Bruton's tyrosine kinase gene in Brazilian patients with X-linked agammaglobulinemia.

Mutations in Bruton's tyrosine kinase (BTK) gene are responsible for X-linked agammaglobulinemia (XLA), which is characterized by recurrent bacterial infections, profound hypogammaglobulinemia, and decreased numbers of mature B cells in peripheral blood. We evaluated 5 male Brazilian patients, ranging from 3 to 10 years of age, from unrelated families, whose diagnosis was based on recurrent infections, markedly reduced levels of IgM, IgG and IgA, and circulating B cell numbers <2%. BTK gene analysis was carried out using PCR-SSCP followed by sequencing. We detected three novel (Ala347fsX55, I355T, and Thr324fsX24) and two previously reported mutations (Q196X and E441X). Flow cytometry revealed a reduced expression of BTK protein in patients and a mosaic pattern of BTK expression was obtained from mothers, indicating that they were XLA carriers.

Immunogenicity and safety of combined intradermal recombinant Hepatitis B with BCG vaccines at birth.

This randomized, prospective, non-inferiority study aimed to quantify anti-HBs titers induced by recombinant Hepatitis B vaccine from healthy infants vaccinated with combined Hepatitis B and Bacillus Calmette-Guérin (BCG) vaccines (HbsAg 10 microg plus BCG suspension 0.1mg) and compare them to titers obtained with separated vaccines. Infants were immunized at birth either with combined intradermal (ID) BCG and Hepatitis B or ID BCG alone and intramuscular (IM) Hepatitis B. Both groups received IM Hepatitis B at 1 and 6 months of age. After the third dose anti-HBs titers > or =10 IU/mL were observed in 99% of vaccinees and > or =1000 IU/mL in 71%. There were no adverse events in both groups. Combination of HbsAg with BCG as first dose did not modify the profile of the humoral immune response for Hepatitis B indicating safety and immunogenicity of this vaccine in newborn.

Expression of Fc gamma and complement receptors in monocytes of X-linked agammaglobulinaemia and common variable immunodeficiency patients.

Recently we reported that monocyte phagocytosis and chemotaxis are impaired in X-linked agammaglobulinaemia (XLA) and common variable immunodeficiency (CVI) patients. Few data exist on the in vivo expression of receptors for the constant region of immunoglobulin (IgG) (Fc gammaR) and complement receptors (CR) in these patients. The objective of this study was to investigate the expression of Fc gammaR and CR on monocytes from XLA and CVI patients and compare it to that of healthy controls. Whole blood samples were obtained from 10 patients with XLA, 12 with CVI and 18 healthy controls. Monocyte phenotype was determined by flow cytometry with gating on CD14+ cells. Surface expression of Fc gammaRI (CD64), Fc gammaRII (CD32) and Fc gammaRIII (CD16), CR1 (CD35) and CR3 (CD11b and CD18) was measured by determination of the proportion of CD14+ cells positive for each receptor and by receptor density. Compared to controls, a significantly higher percentage of CD16 and CD35+ monocytes from XLA (P = 0.002 and P = 0.007, respectively) were observed. The relative fluorescence intensity (RFI) expression of Fc gammaRII (CD32) and Fc gammaRIII (CD16) were significantly lower on CVI monocytes compared to controls (P = 0.001 and P = 0.035, respectively). XLA patients, who have a reduction of Bruton's tyrosine kinase (Btk), showed normal or increased percentages of monocytes expressing Fc gamma and complement receptors. CVI patients, who have normal expression of Btk, showed reduced expression of CD16 and CD32 on monocytes. Inefficient chemotaxis and phagocytosis, reported previously in XLA patients, could be due to defects of cytoplasmatic transduction mechanisms.

Robust gammadelta+ T cell expansion in infants immunized at birth with BCG vaccine.

Cell-mediated immune responses to BCG vaccine were evaluated in 7-month-old infants vaccinated with intradermal combined BCG and Hepatitis B or intradermal BCG and intramuscular Hepatitis B at birth. Peripheral blood mononuclear cell cultures from both groups showed CD4(+), CD8(+) and remarkable gammadelta(+) T cell BCG-specific proliferation, without significant differences. Also, IL-10, IL-12, IFN-gamma and TNF-alpha concentrations in culture supernatants, measured by ELISA, were similar. The results suggested that the combined BCG and Hepatitis B vaccine was as immunogenic as BCG separated from Hepatitis B vaccine.

Lung disease features in Brazilian children with HIV infection before HAART era.

Lower respiratory tract diseases are major causes of morbidity and mortality in HIV infected children. We studied the lung disease features associated with AIDS in children and adolescents, in an era of ineffective antiretroviral therapy, between January 1996 and October 1998. This prospective, descriptive, longitudinal and historical medical chart review included 48 vertically HIV infected patients, receiving mono or double antiretroviral therapy, who had developed pulmonary disease. Those who presented acute pneumonia were classified into group 1; radiological changes for >or=3 months into group 2; those from group 1 and 2 who underwent lung biopsy into group 3. A rapidly progressive clinical course was found in 70.7% of the children and 37.5% younger than 6 months old. Bacterial pneumonia was diagnosed in all patients. High resolution chest computer tomographic scans (HRCT) from 27 patients showed a reticulonodular pattern in 8, ground-glass in 3, reticular in 3, nodular in 3, airspace consolidation in 3, mediastinal adenopathy in 3, pulmonary air cystic in 2 and air-trapping in 1. In five patients the HRCT were normal. Histopathology revealed: lymphoid interstitial pneumonitis in 5 patients, pulmonary lymphoid hyperplasia in 9, tuberculosis in 1, interstitial pneumonia in 1, diffuse alveolar damage in 1. Two patients had Cryptococcus neoformans and Mycobacterium tuberculosis. We conclude that lung diseases were the major risk factor for high morbidity, and an invasive diagnostic procedure may clarify the main cause for similar radiologic images of infectious and non-infectious processes.

Features of whey protein concentrate supplementation in children with rapidly progressive HIV infection.

HIV infection is associated with subnormal GSH levels. An increase in glutathione levels has been observed in HIV-infected adults under oral whey protein supplementation. We studied the features associated with a whey protein concentrate supplementation in children with rapidly progressive AIDS. A prospective double-blind clinical trial was carried out for 4 months with 18 vertically HIV-infected children (1.98-6.37 years), under antiretroviral therapy, who had received whey protein, maltodextrin (placebo) or none. Erythrocyte glutathione concentration, T lymphocyte counts (CD4+ and CD8+) and occurrence of associated co-infections were evaluated. Wilcoxon's and Fischer's Exact tests were used to assess differences between whey protein-supplemented and control (placebo and non-supplemented) groups. A significant median increase of 16.14 mg/dl (p = 0.018) in erythrocyte glutathione levels was observed in the whey protein-supplemented group; the TCD4/CD8 lymphocyte ratio showed a non significant increase and lower occurrence of associated co-infections was also observed. In conclusion, whey protein concentrate supplementation can stimulate glutathione synthesis and, possibly, decrease the occurrence of associated co-infections.

Bone marrow features in children with HIV infection and peripheral blood cytopenias.

HIV infection is associated with numerous abnormalities affecting both the myeloid and lymphoid lineages. We studied the features associated with peripheral cytopenias as the first sign of HIV infection in children. Peripheral blood (PB) counts, PB and bone marrow (BM) lymphocyte subsets, as well as viral load and serum levels of ferritin, vitamin B12, and folic acid were determined. Five children were naive of treatment (Group 1) and three were under HAART (Group 2). In Group 1 all patients had anemia of chronic disease. One had a bone marrow culture positive for Mycobacterium avium intracellulare and pancytopenia. Besides this, neutropenia and thrombocytopenia were seen in one patient each. In Group 2 anemia was found in all, neutropenia in one, and thrombocytopenia in two patients. Peripheral blood cytopenias were due to HAART toxicity in one patient. In the other two they were due to iron or folate deficiency. Bone marrow cytology showed cell abnormalities mainly in granulocytic precursors and megakaryocytes. All except two (taking HAART) patients had a high viral load. There was a straight correlation between viral load in PB and bone marrow. Viral load was correlated with peripheral CD4 but not with CD8 lymphocytes. A decrease in bone marrow B lymphocytes was seen in all patients. The introduction of HAART improved peripheral cytopenias. Bone marrow examination was useful for determining the etiology of the cytopenias and for detection of opportunistic infection. Hemopoietic cell abnormalities were similar to those seen in adults and indicative of HIV infection.

Early diagnosis of HIV-1: infected infants in Brazil using nested-PCR.

The polymerase chain reaction (PCR) has been the most promising test for HIV-1 early diagnosis in infants suspected of perinatal transmission. The first and second reactions of the amplification in 41 infants (under 18 months old) suspected of HIV-1 perinatal infection, were standardized and carried out in the present study. The first and the second PCR were carried out with the sets of primers JA4-JA7, JA9-JA12, JA13-JA16, and JA17-JA20 for the first reaction of amplification (outer primers) and JA5-JA6, JA10-JA11, JA14-JA15, and JA18-JA19 for the second reaction of amplification (inner primers), resulting in amplification of 131, 341, 172, and 129 pb, respectively. From 41 patients analysed, 12 patients presented positive to HIV-1 infection by PCR. The gag, env (region 1), and pol regions presented a greater sensitivity. The first and the second reactions of the amplification were performed with the same concentration of MgCl2 for all sets of primers. The results agree with several studies that affirm that the PCR is the indicated method for HIV-1 early diagnosis in infants suspected of perinatal infection.

Defective Fc-, CR1- and CR3-mediated monocyte phagocytosis and chemotaxis in common variable immunodeficiency and X-linked agammaglobulinemia patients.

Blood monocyte phagocytic functions were evaluated by chemotaxis, phagocytosis, and superoxide anion production in nine patients with common variable immunodeficiency (CVI), eight patients with X-linked agammaglobulinemia (XLA), and in 17 normal subjects. Further laboratory diagnosis included the determination of the Bruton's tyrosine kinase (Btk) protein expression in monocytes using flow cytometry. The analysis of monocyte phagocytic function demonstrated that CR3-, CR1-, and Fc-mediated phagocytosis (p = 0.0001) were significantly decreased in CVI and XLA patients, and chemotaxis of monocytes (p = 0.0082) was reduced in XLA patients. Superoxide anion production, however, did not differ between the CVI, XLA, and the control groups. The cytoplasmic expression of Btk protein in monocytes was normal in CVI patients and decreased or not detected in XLA patients. It is proposed that impaired chemotaxis and phagocytosis by monocytes may be a characteristic of the innate immune system in CVI and XLA patients, providing a new direction for the physiopathology of these immunodeficiencies.

Pathogenicity and virulence of Candida dubliniensis: comparison with C. albicans.

Candida dubliniensis is a newly described fungus that is frequently isolated from the oral cavities of HIV-positive patients. Although extensive studies have been performed on the phylogeny of C. dubliniensis, little is known about the pathogenic ecology of this yeast. Here we examined aspects related to C. dubliniensis in comparison with those of C. albicans. When injected intravenously into mice, C. dubliniensis had a higher survival rate than C. albicans. Histopathological analysis disclosed that C. dubliniensis remained mostly in the yeast form in the infected organs, whereas C. albicans changed into the mycelial form. The host inflammatory reaction was aggressive with C. dubliniensis infection and mild with C. albicans infection. Co-culture of the yeasts with human polymorphonuclear leukocytes disclosed that C. dubliniensis is more vulnerable to the fungicidal activity of leukocytes than C. albicans. C. dubliniensis was also more susceptible to the toxic effect of hydrogen peroxide. When cultured in vitro, C. dubliniensis grew more slowly than C. albicans, but the formation of germ tubes was faster. When the fungi were cultured in RPMI 1640, a fetal bovine serum supplement suppressed the growth of C. dubliniensis but enhanced that of C. albicans. These results clearly indicated that C. dubliniensis is less virulence than C. albicans.

External PIGE-PIXE measurements at the São Paulo 8UD tandem accelerator / Medidas externas do PIGE-PIXE em São Paulo 8UD acelerador tandem

An external PIGE-PIXE setup was installed on a beam line of the 8 MV tandem Pelletron accelerator of the Open Nuclear Physics Laboratory (LAFN). Proton beam energy was chosen in the 8-12 MeV range, sufficient to get an acceptable gamma ray yield but not so high as to prevent us from measuring X-rays. This also allowed the use of a thick aluminum exit window (0.5 mm) instead of the usual thin and sometimes fragile plastic windows. This external PIXE-PIGE system was used to analyze trace element concentrations in the enamel of human and animal teeth. The main interest was to find compatible human teeth substitutes for dentistry laboratory practice and chemical tests. In spite of their morpho-histological similarity, trace element concentrations in human and animal teeth have not yet been compared. Teeth from humans, cattle and swine collected primary at São Paulo region were analyzed. The elements Cu, K, Zn, Fe, Ti, Sr, V, Mn and Zr were detected by high energy external beam PIXE technique. Though preliminary, the results showed that the trace element concentrations observed in the enamel of human and swine are more similar to each other than to cattle teeth

[Serum immunoglobulins in children perinatally exposed to human immunodeficiency virus] / Imunoglobulinas séricas em crianças com exposição perinatal ao vírus da imunodeficiência humana.

OBJECTIVE: Hypergammaglobulinemia is an early manifestation of perinatal HIV infection. Our objective was to analyze the differences in serum immunoglobulin levels between infected and seroreverter children and their association with clinical outcome. METHODS: We carried out a historical prospective study with 107 infected and 90 seroreverter children. We compared the IgA, IgG, and IgM levels between infected and seroreverters in the first 18 months of life; IgA, IgG, and IgM as surrogate markers of infection; and IgA, IgG, and IgM levels in the first 5 years in infected children, according to clinical outcome. The Mann-Whitney test was used for comparison between groups. Surrogate markers were assessed according to sensitivity, specificity, positive and negative predictive values, and J index. RESULTS: Infected children, when compared to seroreverters, showed significantly higher levels of: IgM from the 1st to the 5th trimester; IgA and IgG from the 2nd to the 6th trimester (P /= 90 mg/dl in the 2nd trimester and IgG >/= 1,700 mg/ dl or 1,200 mg/dl in the 2nd and 3rd trimesters were associated with HIV infection with J indexes of 0.97, 0.92, and 0.93, respectively. Infected children in the B and C categories, compared to those in the N and A, showed higher levels of IgM from the 2nd to the 4th year, and IgA from the 3rd to the 5th year (P

[Clinical aspects and complete blood counts in children exposed to HIV-1: comparison between infected patients and seroreverters] / Aspectos clínicos e o hemograma em crianças expostas ao HIV-1: comparação entre pacientes infectados e soro-reversores.

OBJECTIVE: To analyze the evolution of clinical and hematological aspects of children exposed to the vertical transmission of HIV-1, comparing infected patients with uninfected ones or seroreverters. METHODS: Prospective, descriptive, longitudinal study. We analyzed 79 children born from HIV-1 infected mothers, under clinical follow up from March, 1996 until November, 1997, at the Immunodeficiency division of the Hospital de Clínicas da Unicamp (State University Hospital of Campinas). RESULTS: Failure to thrive was observed in both groups, but was greater among seroreverters. Among the infected children, 23 mothers did not use AZT during pregnancy, 16 of them (61.5%) had been breastfed, four were classified into clinical category N, seven into A and fifteen into B. Clinical manifestations in patients younger than one year were seen in 18 infected children (69.2%). Anemia was observed in 73.1% of the infected group and in 41.5% of the seroreverters (P<0.008). The comparison between the groups showed that the most common hematologic alterations in the infected children was microcytosis and hypochromia (P<0.05), lymphopenia between 15 and 18 months (P<0.05), monocytosis between 9 and 12 months (P<0.05) and a tendency towards high ferritin levels, with no statistical significance. CONCLUSIONS: Microcytic and hypochromic anemia were observed in both groups: iron deficiency in the uninfected children, and chronic disease anemia in the infected ones. The infected children presented with monocytosis and lymphopenia at an earlier stage.

Evolution of nutritional status of infants infected with the human immunodeficiency virus.

CONTEXT: There are today only a limited number of studies defining growth parameters and nutritional status for HIV children. OBJECTIVE: To study the nutritional status of infants infected with the human immunodeficiency virus. TYPE OF STUDY: Longitudinal study. SETTING: Department of Pediatrics, Faculty of Medical Sciences, UNICAMP, Campinas, Brazil. PARTICIPANTS: One hundred and twenty-four children born to HIV infected mothers were evaluated from birth until the age of two years. They were subdivided into two groups: 71 infected children and 53 non-infected children. MAIN MEASUREMENTS: Growth was evaluated in both groups by comparing Z-scores for weight/age (w/a), length/age (H/a) and weight/length (w/H) (using the NCHS curves as reference). RESULTS: The Z-score analyses showed that there was a significant difference between the two groups for all the variables studied, except for the H/a value at 3 months of age and the W/H value at 21 months of age, which showed P > 0.05. CONCLUSIONS: The growth of infected infants was observed to be severely affected in comparison with that of seroreversed infants in the same age groups. Although clinical manifestations may take time to appear, the onset of growth changes begin soon after birth.