Publications by authors named "Sonia Mara Raboni"

56 Publications

Care management in coping with COVID-19 at a teaching hospital.

Rev Bras Enferm 2021 11;74(suppl 1):e20200970. Epub 2021 Jun 11.

Universidade Federal do Paraná. Curitiba, Paraná, Brazil.

Objective: to report the experience of implementing care management strategies in coping with the COVID-19 pandemic in a teaching hospital.

Method: this is an experience report of the managers who work at the largest public hospital in Paraná with functions as Head of the Care Management Division, Head of the Care Lines Management Sector, Head of the Infectiology Unit and support team.

Results: care management strategies were structured based on the service dynamics; physical structure; human Resources; professional and user safety.

Final Considerations: preparing for a pandemic involves measures that include modifying infrastructure and processes, managing employees and users, infection prevention strategies, and clinical recommendations. These measures are necessary to optimize the quality of care provided to users with COVID-19 and to reduce the risk of viral transmission to other users or health professionals.
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http://dx.doi.org/10.1590/0034-7167-2020-0970DOI Listing
June 2021

Association Between COVID-19 Pregnant Women Symptoms Severity and Placental Morphologic Features.

Front Immunol 2021 26;12:685919. Epub 2021 May 26.

Postgraduate Program of Health Sciences, School of Medicine, Pontifícia Universidade Católica do Paraná-PUCPR, Curitiba, Brazil.

Since the beginning of the pandemic, few papers describe the placenta's morphological and morphometrical features in SARS-CoV-2-positive pregnant women. Alterations, such as low placental weight, accelerated villous maturation, decidual vasculopathy, infarcts, thrombosis of fetal placental vessels, and chronic histiocytic intervillositis (CHI), have been described.

Objective: To analyze clinical data and the placental morphological and morphometric changes of pregnant women infected with SARS-CoV-2 (COVID-19 group) in comparison with the placentas of non-infected pregnant women, matched for maternal age and comorbidities, besides gestational age of delivery (Control group).

Method: The patients in the COVID-19 and the Control group were matched for maternal age, gestational age, and comorbidities. The morphological analysis of placentas was performed using Amsterdam Placental Workshop Group Consensus Statement. The quantitative morphometric evaluation included perimeter diameter and number of tertiary villi, number of sprouts and knots, evaluation of deposition of villous fibrin, and deposition of intra-villous collagen I and III by Sirius Red. Additionally, Hofbauer cells (HC) were counted within villi by immunohistochemistry with CD68 marker.

Results: Compared to controls, symptomatic women in the COVID-19 group were more likely to have at least one comorbidity, to evolve to preterm labor and infant death, and to have positive SARS-CoV-2 RNA testing in their concepts. Compared to controls, placentas in the COVID-19 group were more likely to show features of maternal and fetal vascular malperfusion. In the COVID-19 group, placentas of symptomatic women were more likely to show CHI. No significant results were found after morphometric analysis.

Conclusion: Pregnant women with symptomatic SARS-CoV-2 infection, particularly with the severe course, are more likely to exhibit an adverse fetal outcome, with slightly more frequent histopathologic findings of maternal and fetal vascular malperfusion, and CHI. The morphometric changes found in the placentas of the COVID-19 group do not seem to be different from those observed in the Control group, as far as maternal age, gestational age, and comorbidities are paired. Only the deposition of villous fibrin could be more accentuated in the COVID-19 group (p = 0.08 borderline). The number of HC/villous evaluated with CD68 immunohistochemistry did not show a difference between both groups.
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http://dx.doi.org/10.3389/fimmu.2021.685919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8187864PMC
July 2021

SARS-CoV-2 in asymptomatic pregnant women in South Brazil: RT-PCR and serological detection.

J Perinat Med 2021 Jul 10;49(6):717-722. Epub 2021 Jun 10.

Department of Obstetrics and Gynecology, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil.

Objectives: This study aims to detect the SARS-CoV-2 infection prevalence in asymptomatic pregnant women.

Methods: A group of 195 asymptomatic pregnant women who attended the prenatal care outclinic and to the obstetric emergency department was tested concomitantly for SARS-CoV-2 by RT-PCR and serological tests.

Results: The virus was detected by RT-PCR in two (1.02%) cases and 17 (8.71%) patients had antibodies detected by immunochromatographic tests.

Conclusions: Due to the high risk of this emerging infection in the health of pregnant women, fetuses and newborns, we suggest the universal screening of all pregnant women admitted to hospital through the combined method RT-PCR and serological.
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http://dx.doi.org/10.1515/jpm-2021-0173DOI Listing
July 2021

Simultaneous enterovirus EV-D68 and CVA6 infections causing acute respiratory distress syndrome and hand, foot and mouth disease.

Virol J 2021 Apr 30;18(1):88. Epub 2021 Apr 30.

Laboratório de Enterovírus, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.

Background: Although most enterovirus (EV) infections can be asymptomatic, these viral agents can cause serious conditions associated with central nervous system, respiratory disease and uncommon manifestations of hand, foot and mouth disease (HFMD). EV-coinfections have been rarely reported with development of complications and severe clinical outcome. An atypical case of a child presenting HFMD and severe acute respiratory syndrome, co-infected with EV-D68 and CVA6, is reported herein.

Case Presentation: A 3-year-old boy was admitted in the emergency department unit showing fever, abdominal pain and tachycardia. Twenty-four hours after hospitalization the child developed severe clinical symptoms associated with HFMD and was discharged after recovery. Two days later, the child was readmitted with fever, cough and respiratory distress. RT-PCR and Sanger sequencing confirmed positivity for EV-D68 and CVA6 in oro and nasopharynges swabs and vesicles fluid, respectively. Phylogenetic analysis based on VP1 gene sequences suggested that CVA6 was closely related with HFMD viruses circulating in Turkey, while EV-D68 was genetically related to a Chinese strain.

Conclusions: To the best of our knowledge, this case is the first report of a double infection caused by CVA6 and EV-D68, which shed light on the pathogenesis of enterovirus infections. Further studies must be conducted to ascertain the role and clinical significance of EV co-infections, as well as a potential synergistic pathway between these viruses.
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http://dx.doi.org/10.1186/s12985-021-01560-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085469PMC
April 2021

Creating a platform to enable collaborative learning in One Health: The Joint Initiative for Teaching and Learning on Global Health Challenges and One Health experience.

One Health 2021 Jun 31;12:100245. Epub 2021 Mar 31.

Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany.

The "Joint Initiative for Teaching and Learning on Global Health Challenges and One Health" targets education and training in Global Health Challenges and One Health, focusing on surpassing issues that affect One Health training programs. The present work describes the planning, implementation, and challenges to develop an international educational initiative among six partner institutions from four different countries, to build a collaborative teaching and learning environment. The course applies collaborative online international learning principles and is addressed to graduate students of universities from Brazil, Germany, Mozambique, and Kosovo. A pilot curriculum was developed with modules on intercultural competence, interprofessional and collaborative practice in One Health; One Health; healthcare, surveillance, and One Health; bioethics in One Health and careers in Global Health. The course combines synchronous and asynchronous activities developed in groups by mixing students from different institutions and countries. Forty-four experts from 22 institutions of the Americas, Africa, Europe, and Asia collaborated with the course content. Some challenges to implementing the course were the different criteria to assign credits across institutions, the lack of bibliographic material across all partners, limited overlap hours and periods for synchronous activities, and short semester overlap across institutions. Despite the challenges for implementation, the entire process of planning and delivering the course involves intense international collaboration, contributing to the curriculum internationalization, benefiting all institutions involved, promoting exchange even in the challenging scenario of the pandemic of coronavirus disease 2019 (COVID-19).
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http://dx.doi.org/10.1016/j.onehlt.2021.100245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048024PMC
June 2021

Rapid Serological Tests for Sars-Cov-2: Diagnostic Performance of Four Commercial Assays.

Med Princ Pract 2021 Apr 22. Epub 2021 Apr 22.

To assess the diagnostic performance of lateral flow immunochromatographic assays (LFA) of four different manufacturers to identify SARS-CoV-2 antibodies (IgM, IgG or total), comparing them with the nucleic acid amplification test (NAAT) or clinical defined (definite or probable SARS-CoV-2 infection respectively).

Methods: 119 serum samples were randomly selected by convenience and distributed in the groups: (1) Group with SARS-CoV-2 infection [n=82; RT-qPCR positive (definite, n=70), and probable (n=12)]; (2) other diseases [n= 27; other viruses identified (n=8), SARS of other etiologies (n=19)]; (3) healthy control group (n=10). LFA essays of four manufacturers were compared: MedTest Coronavírus (COVID-19) IgG/IgM (MedLevensohn, Brazil); COVID-19 IgG/IgM ECO Test (Ecodiagnóstica, Brazil); Camtech COVID-19 IgM/IgG Rapid Test Kit (Camtech Diagnostics Pte Ltd, Singapore); and one Step COVID-19 Test for total antibodies (Guangzhou Wondfo Biotech Co, China).

Results: The four tests studied showed high diagnostic performance characteristics for the diagnoses of definite or probable SARS-CoV-2 infection. The best measures were for the Wondfo test: sensitivity (86.59%; 95%CI, 77.26-93.11%); specificity (100%; 90.51-100%); DOR (257; 60-1008); LR+ (33.43; 4.82-231.85); LR- (0.13; 0.08 - 0.23); accuracy (90.76%; 84.06- 95.29%); Matthews Correlation coefficient (MCC) 0.82. Although considering only the probable SARS-CoV-2 infection (PCR-) cases, all the kits studied showed limited values.

Conclusion: Our data demonstrate the excellent performance of LFA for the diagnoses of definite or probable SARS-CoV-2 infection. There was substantial heterogeneity in sensitivities of IgM and IgG antibodies among the manufacturers. LFA tests cannot replace molecular diagnostics, but should be used as additional screening tool.
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http://dx.doi.org/10.1159/000516776DOI Listing
April 2021

Lung Neutrophilic Recruitment and IL-8/IL-17A Tissue Expression in COVID-19.

Front Immunol 2021 30;12:656350. Epub 2021 Mar 30.

Laboratory of Experimental Pathology, Postgraduate Program of Health Sciences, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil.

The new SARS-CoV-2 virus differs from the pandemic Influenza A virus H1N1 subtype (H1N1pmd09) how it induces a pro-inflammatory response in infected patients. This study aims to evaluate the involvement of SNPs and tissue expression of IL-17A and the neutrophils recruitment in lung samples from patients who died of severe forms of COVID-19 comparing to those who died by H1N1pdm09. Twenty lung samples from patients SARS-CoV-2 infected (COVID-19 group) and 10 lung samples from adults who died from a severe respiratory H1N1pdm09 infection (H1N1 group) were tested. The tissue expression of IL-8/IL-17A was identified by immunohistochemistry, and hematoxylin and eosin (H&E) stain slides were used for neutrophil scoring. DNA was extracted from paraffin blocks, and genotyping was done in real time-PCR for two target polymorphisms. Tissue expression increasing of IL-8/IL-17A and a higher number of neutrophils were identified in samples from the H1N1 group compared to the COVID-19 group. The distribution of genotype frequencies in the gene was not statistically significant between groups. However, the G allele (GG and GA) of rs3819025 was correlated with higher tissue expression of IL-17A in the COVID-19 group. SARS-CoV-2 virus evokes an exacerbated response of the host's immune system but differs from that observed in the H1N1pdm09 infection since the IL-8/IL-17A tissue expression, and lung neutrophilic recruitment may be decreased. In SNP rs3819025 (G/A), the G allele may be considered a risk allele in the patients who died for COVID-19.
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http://dx.doi.org/10.3389/fimmu.2021.656350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044579PMC
May 2021

The Xpert® MTB/RIF diagnostic test for pulmonary and extrapulmonary tuberculosis in immunocompetent and immunocompromised patients: Benefits and experiences over 2 years in different clinical contexts.

PLoS One 2021 3;16(3):e0247185. Epub 2021 Mar 3.

Programa de Pós graduação em Biotecnologia Aplicada à Saúde da Criança e do Adolescente da Faculdades Pequeno Príncipe (FPP), Instituto de Pesquisa Pelé Pequeno Príncipe (IPPPP), Curitiba, Paraná, Brasil.

Xpert® MTB/RIF has been widely used for tuberculosis (TB) diagnosis in Brazil, since 2014. This prospective observational study aimed to evaluate the performance of Xpert in different contexts during a two-year period: (i) laboratory and clinical/epidemiological diagnosis; (ii) HIV-positive and -negative populations; (iii) type of specimens: pulmonary and extrapulmonary. Overall, 924 specimens from 743 patients were evaluated. The performance of the assays was evaluated considering culture (Lowenstein Jensen or LJ medium) results and composite reference standard (CRS) classification as gold standard. According to CRS evaluation, 219 cases (29.5%) were classified as positive cases, 157 (21.1%) as 'possible TB', and 367 (49.3%) as 'not TB'. Based on culture, Xpert and AFB smear achieved a sensitivity of 96% and 62%, respectively, while based on CRS, the sensitivities of Xpert, AFB smear, and culture were 40.7%, 20%, and 25%, respectively. The pooled sensitivity and specificity of Xpert were 96% and 94%, respectively. Metric evaluations were similar between pulmonary and extrapulmonary samples against culture, whereas compared to CRS, the sensitivities were 44.6% and 29.3% for the pulmonary and extrapulmonary cases, respectively. The Xpert detected 42/69 (60.9%) patients with confirmed TB and negative culture on LJ medium, and 52/69 (75.4%) patients with negative AFB smear results. There was no significant difference in the diagnostic accuracy based on the types of specimens and population (positive- and negative-HIV). Molecular testing detected 13 cases of TB in culture-negative patients with severe immunosuppression. Resistance to rifampicin was detected in seven samples. Herein, Xpert showed improved detection of pulmonary and extrapulmonary TB cases, both among HIV-positive and -negative patients, even in cases with advanced immunosuppression, thereby performing better than multiple other diagnostic parameters.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0247185PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928506PMC
March 2021

Mortality among pediatric hematopoietic stem cell transplantation patients: Report from a single center in southern Brazil.

Pediatr Transplant 2021 Aug 29;25(5):e13944. Epub 2021 Jan 29.

Postgraduate Program in Internal Medicine and Health Science, Federal University of Paraná, Curitiba, Brazil.

Introduction: HSCT has grown in number in recent years. This treatment in children has its particularities and has been characterized in previous studies only on a limited basis. There are important causes of morbidity and mortality in this group of patients, including evolution of primary disease, graft failure, infectious diseases, and GVHD. The aim of this study was to report case series of TRM within 100 days after transplantation and associated factors.

Methods: Retrospective cohort. All children transplanted between January 1, 2010 and December 31, 2017 were included and those who underwent the first HSCT in another center were excluded.

Results: Data from 292 children were analyzed. TRM in 100 days was 5.8%, being significantly higher in patients with umbilical cord blood as the cell source. Infectious complications were frequent in this sample (bacterial infections in 27%, viral infections in 75.3%, and fungal infections in 12%) and both the presence of fungal disease and more than one infection during the follow-up (viral and bacterial, viral and fungal or bacterial and fungal) had statistically significant association with the outcome.

Conclusions: The prognosis in allogeneic HSCT is influenced by the origin of the stem cells, the presence of acute GVHD and the occurrence of infectious diseases. Studies that evaluate pediatric individuals undergoing HSCT and analyze their mortality profile, can improve the management of these patients, possibly leading to a reduction in TRM.
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http://dx.doi.org/10.1111/petr.13944DOI Listing
August 2021

Vaccination coverage and adherence to a dengue vaccination program in the state of Paraná, Brazil.

Vaccine 2021 01 29;39(4):711-719. Epub 2020 Dec 29.

Universidade Federal do Paraná (UFPR), Postgraduate Program in Public Health - Curitiba, Rua Padre Camargo, 280 - Alto da Glória, Curitiba, PR 80060-240, Brazil.

The success of vaccination programs depends on the level of acceptance of the vaccine to achieve high vaccine coverage rates (VCR). Vaccine hesitancy is a challenge, especially concerning new vaccines. Dengue vaccine, Dengvaxia®, was licensed in Brazil in 2015 and implemented, in a pioneering publicly-funded initiative in the state of Paraná, between 2016 and 2018. The vaccination program took place in five phases in the 30 municipalities most affected by dengue in the state, targeting individuals from nine to 44 years-old in two cities and from 15 to 27 years-old in the other 28 municipalities, totaling a target population of 500,000 individuals. A cross-sectional descriptive study was carried out to assess VCR and adherence to the dengue vaccine in this program. VCR, dropout ratio (DR), and compliance with the vaccination schedule (CVS) were analyzed by sex, age group, and municipality size. A total of 302,603 individuals (60.5%) received ≥ 1 dose, 44.2% received ≥ 2 doses, and 28.6% 3 doses. The DR was 52.8%. Among individuals who started vaccination, 40.6% achieved CVS. The highest VCR, highest CVS, and lowest DR occurred in the age group from 9 to 14 years old and from 28 to 44 years old and in smaller municipalities. A greater proportion of men started vaccination (male 64.0%; female 57.1%) however, the DR was higher in men (male 55.4%; female 49.9%), and a higher percentage of women completed the vaccination schedule according to the recommendations (CVS male 37.8%; female 43.6%). Differences were noted in the CVS according to the initial phase of the program (first phase 50.8%; second phase 18.8%). The heterogeneity in vaccine uptake and compliance according to sex, age, and municipality size suggests the need for differentiated strategies to address challenges with new and multiple-dose vaccines.
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http://dx.doi.org/10.1016/j.vaccine.2020.12.030DOI Listing
January 2021

The role of the lectin pathway of the complement system in SARS-CoV-2 lung injury.

Transl Res 2021 05 20;231:55-63. Epub 2020 Nov 20.

Laboratory of Experimental Pathology, School of Medicine, Pontifícia Universidade Católica do Paraná - PUCPR, Curitiba, PR, Brazil.

Although some evidence showed the activation of complement systems in COVID-19 patients, proinflammatory status and lectin pathway remain unclear. Thus, the present study aimed to demonstrate the role of MBL and ficolin-3 in the complement system activation and compared to pandemic Influenza A virus H1N1 subtype infection (H1N1pdm09) and control patients. A total of 27 lungs formalin-fixed paraffin-embedded samples (10 from H1N1 group, 6 from the COVID-19 group, and 11 from the control group) were analyzed by immunohistochemistry using anti-IL-6, TNF-alfa, CD163, MBL e FCN3 antibodies. Genotyping of target polymorphisms in the MBL2 gene was performed by real-time PCR. Proinflammatory cytokines such as IL-6 and TNF-alpha presented higher tissue expression in the COVID-19 group compared to H1N1 and control groups. The same results were observed for ICAM-1 tissue expression. Increased expression of the FCN3 was observed in the COVID-19 group and H1N1 group compared to the control group. The MBL tissue expression was higher in the COVID-19 group compared to H1N1 and control groups. The genotypes AA for rs180040 (G/A), GG for rs1800451 (G/A) and CC for rs5030737 (T/C) showed a higher prevalence in the COVID-19 group. The intense activation of the lectin pathway, with particular emphasis on the MBL pathway, together with endothelial dysfunction and a massive proinflammatory cytokines production, possibly lead to a worse outcome in patients infected with SARS-Cov-2. Moreover, 3 SNPs of our study presented genotypes that might be correlated with high MBL tissue expression in the COVID-19 pulmonary samples.
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http://dx.doi.org/10.1016/j.trsl.2020.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677075PMC
May 2021

Intrauterine Transmission of SARS-CoV-2.

Emerg Infect Dis 2021 Feb 13;27(2):638-641. Epub 2020 Nov 13.

We documented fetal death associated with intrauterine transmission of severe acute respiratory syndrome coronavirus 2. We found chronic histiocytic intervillositis, maternal and fetal vascular malperfusion, microglial hyperplasia, and lymphocytic infiltrate in muscle in the placenta and fetal tissue. Placenta and umbilical cord blood tested positive for the virus by PCR, confirming transplacental transmission.
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http://dx.doi.org/10.3201/eid2702.203824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853547PMC
February 2021

Invasive aspergillosis complication in yellow fever vaccine induced viscerotropic disease.

Med Mycol Case Rep 2020 Dec 17;30:12-14. Epub 2020 Sep 17.

Complexo Hospital de Clínicas, Universidade Federal Do Paraná, 180 General Carneiro Street, Curitiba, 80060-900, Brazil.

Invasive aspergillosis (IA) usually occurs in immunocompromised hosts, but in the last decade IA has emerged in critically ill non-neutropenic patients, as those with severe Influenza and Chronic Obstructive Pulmonary Disease (COPD). We report an unusual fatal case of disseminated IA in a non-immunocompromised patient following yellow fever vaccine-associated viscerotropic disease.
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http://dx.doi.org/10.1016/j.mmcr.2020.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522283PMC
December 2020

Acute Childhood Viral Encephalitis in Southern Brazil.

Pediatr Infect Dis J 2020 10;39(10):894-898

From the Division of Pediatric Neurology.

Background: Viral meningoencephalitis is highly heterogeneous, varying by geographic location. The aim of this study was to characterize the etiology and reporting the clinical findings and outcome of viral encephalitis in children in southern Brazil.

Methods: A cross-Sectional study was conducted at Hospital Pequeno Príncipe, Curitiba, Brazil, between January 2013 and December 2017. It included patients younger than 18 years, who fulfilled the criteria: altered mental status as a major criteria and 2 or more minor criteria (1) fever, (2) seizures, (3) focal neurologic findings, (4) central system fluid white cell count of ≥5 cells/mm, (5) abnormal brain imaging, and/or (6) electroencephalogram abnormalities.

Results: Viral meningoencephalitis was diagnosed in 270 children, with median age of 2 years (interquartile range: 0-4), The etiology of viral meningoencephalitis was confirmed in 47% of patients. Enterovirus (18%) was the major cause of encephalitis in Southern Brazilian children, and a high prevalence of Epstein-Barr virus (6%) was demonstrated. Most patients presented with fever (81%), followed by vomiting (50%), focal neurologic findings (46%), seizures (31%) and headache (30%). Few abnormalities were detected on electroencephalograms and brain magnetic resonance images. On discharge from hospital, symptoms resolved completely in 87% of children. Sequelae were mainly observed in patients with focal neurologic symptoms (P<0.001), presence of seizures (P<0.001) and electroencephalogram abnormalities (P=0.024).

Conclusions: Enterovirus was the major cause of encephalitis. Etiologic agent of encephalitis seems to be influenced by the local virologic pattern. A poor outcome was identified in patients with seizures, focal neurologic findings and electroencephalogram abnormalities.
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http://dx.doi.org/10.1097/INF.0000000000002709DOI Listing
October 2020

The role of IL-17A/IL-17RA and lung injuries in children with lethal non-pandemic acute viral pneumonia.

Immunobiology 2020 07 6;225(4):151981. Epub 2020 Jul 6.

Laboratory of Experimental Pathology, School of Medicine, Pontifical Catholic University of Parana - PUCPR, R. Imaculada Conceição, 1155 - Prado Velho, Curitiba, PR, Brazil; Department of Medical Pathology, Federal University of Parana - UFPR, R. Padre Camargo, 280 - Alto da Glória, Curitiba, PR, Brazil. Electronic address:

This study aimed to evaluate IL-17A (interleukin 17A) and IL-17RA (IL-17A receptor) in a pediatric population that died with non-pandemic acute viral pneumonia compared to the non-viral pneumonia group. Necropsy lung samples (n = 193) from children that died after severe acute infection pneumonia were selected and processed for viral antigen detection by immunohistochemistry. After this, they were separated into two groups: virus-positive (n = 68) and virus-negative lung samples (n = 125). Immunohistochemistry was performed to assess the presence of IL-17A and IL-17RA in the lung tissue. The virus-positive group showed stronger immunolabeling for IL-17A and IL-17RA (p = 0.020 and p < 0.001, respectively). The result of this study may suggest that IL-17A and IL-17RA plays an essential role in the maintenance of viral infection and lung injuries. These aspects may increase the severity of the inflammatory response leading to lethal lung injuries in these patients. Children with community-acquired non-pandemic pneumonia that requiring hospitalization could benefit from using IL-17RA/IL-17A monoclonal antibodies to block their injurious effects.
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http://dx.doi.org/10.1016/j.imbio.2020.151981DOI Listing
July 2020

Multicenter study of the epidemiology of Clostridioides difficile infection and recurrence in southern Brazil.

Anaerobe 2020 Aug 24;64:102238. Epub 2020 Jul 24.

Laboratory of Bacteriology, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Rua Padre Camargo, 280 - Alto da Glória, CEP: 80.062-240, Curitiba, Paraná, Brazil; Basic Pathology Department, Universidade Federal do Paraná, Avenida Coronel Francisco H. dos Santos, 100 - Jardim das Américas, CEP: 81531-980, Curitiba, Paraná, Brazil. Electronic address:

Clostridioides (Clostridium) difficile is the main etiology underlying antibiotic-associated diarrhea (AAD). Still, few Brazilian data are available on this infection. The aims of this multicenter study were to identify the prevalence, clinical characteristics, and outcomes of C. difficile infection (CDI) in patients with antibiotic associated diarrhea at eight hospitals in Curitiba, southern Brazil, during the years 2017-2019. Stool samples were tested using enzyme immunoassay for glutamate dehydrogenase antigen (GDH) and A/B toxins. Positive GDH samples were further evaluated by real-time polymerase chain reaction (PCR) for the presence of genes encoding toxin B (tcdB), binary toxin (cdt), and marker of hypervirulent C. difficile strain (tcdC deletion). The prevalence of CDI in 351 patients with AAD included in the study was 17.7% (n = 62). Among the CDI cases, tcdB was positive in all 62 stool samples, while cdt was positive in 10 samples, and tcdC deletion was positive in only two. Carriage of carbapenem-resistant Gram-negative bacilli, previous hospitalization, and use of broad-spectrum cephalosporin and carbapenem were associated with CDI. Among patients with CDI, 64.5% presented with severe diarrhea, and 8% (5/62) progressed with colitis and required intensive care. The 30-day mortality was 24% (15/62), and the CDI-associated mortality was 4.8% (3/62). Overall, 83.8% (52/62) of the patients achieved primary cure, and 20.8% of the evaluated patients (10/48) presented CDI recurrence. The treatment administered was not significantly associated with the 60-day recurrence or mortality. In conclusion, we reported in this study data of prevalence and recurrence rates of CDI in patients with AAD and evaluated the number of severe cases and infection-related mortality, which were up to now unknown in Southern Brazilian hospitals.
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http://dx.doi.org/10.1016/j.anaerobe.2020.102238DOI Listing
August 2020

Infectious complications in pediatric allogeneic hematopoietic stem cell transplantation recipients-A retrospective clinical and epidemiological cohort study.

Transpl Infect Dis 2020 Oct 29;22(5):e13369. Epub 2020 Jun 29.

Postgraduate Program in Internal Medicine and Health Science, Federal University of Paraná, Curitiba, Brazil.

Background: Hematopoietic stem cell transplantation (HSCT) is an important therapeutic strategy for several hematologic diseases. In the absence of a matched related donor, allogeneic HSCT has been associated with increased risk of infectious complications. Here, we present the clinical and epidemiological characteristics of early infectious complications in children undergoing HSCT from Southern Brazil.

Methods: This is a retrospective unicentric cohort study of infections in all children receiving their first HSCT during the period between 2010 and 2017.

Results: Data from 292 patients were analyzed; bone marrow failures (52.7%) comprised most of the baseline diagnosis. Bone marrow (BM) was the stem cell source in 254 (87%), followed by cord blood (CB) in 34 (11.6%) children. The use of alternative donors (77.8%) and presence of acute graft-vs-host disease (GVHD) (23.6%) were associated with an increased risk of viral and fungal infection. Bacterial infection was observed in 79 patients (27%); 220 patients (75.3%) were diagnosed with viral infection, and 35 patients (12%) developed fungal infection. The presence of fungal disease together with the presence of multiple infections during follow-up was associated with an increased risk of death (P < .001).

Conclusions: The clinical profile of HSCT-related infections in this cohort suggests that prognosis in allogeneic HSCT is influenced by the source of stem cells (CB having worse prognosis), presence of acute GVHD and complications arising from fungal infections. The appropriate management of these factors has the potential to improve the overall prognosis rates in pediatric allogeneic HSCT recipients.
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http://dx.doi.org/10.1111/tid.13369DOI Listing
October 2020

Inactivated rabies vaccines: Standardization of an in vitro assay for residual viable virus detection.

PLoS Negl Trop Dis 2020 03 25;14(3):e0008142. Epub 2020 Mar 25.

Virology Laboratory, Hospital de Clínicas, Universidade Federal do Parana, Curitiba, Parana, Brazil.

Human rabies, a neglected viral zoonosis, is preventable through domestic animals vaccination and post-exposure prophylaxis using inactivated rabies vaccines. During vaccine production, several mandatory in vivo quality control trials, such as potency, live virus, and safety, are responsible for the use of large numbers of laboratory animals. Over the years, global organizations encouraged the development of alternative methods to reduce, replace and refine the use of animals in the pharmaceutical industry. In this study we standardized an in vitro assay for determination of residual live virus combining viral isolation techniques with direct immunofluorescence detection and viral quantification by a molecular method. Standardization of viral recovery steps and quantification by RT-qPCR were performed and the combined method was shown to be 3 fold more sensitive than the in vivo assay. It was possible to identify viral suspensions cultures, which still had residual viable rabies virus particles, evidencing the importance to implement this method in quality control schemes of rabies vaccine production. In addition, this developed assay is more practical, inexpensive and less time consuming, producing results in just 4 days, which may allow greater agility in the internal quality control of the vaccine. The in vitro method may reduce 2/3rd of laboratory animals numbers used for this purpose, since it can be applied in the intermediate quality control of inactivated rabies vaccine production.
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http://dx.doi.org/10.1371/journal.pntd.0008142DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7135352PMC
March 2020

Influenza Sentinel Surveillance and Severe Acute Respiratory Infection in a Reference Hospital in Southern Brazil.

Rev Soc Bras Med Trop 2019 20;53:e20170498. Epub 2019 Dec 20.

Universidade Federal do Paraná, Serviço de Doenças Infecciosas, Curitiba, PR, Brasil.

Introduction: We report the results of the active surveillance of influenza infections in hospitalized patients and the evaluation of the seasonality and correlation with temperature and rainfall data.

Methods: During the 2-year study period, 775 patients were tested for 15 respiratory viruses (RVs).

Results: Most of the 57% of (n=444) virus-positive samples were human rhinovirus and respiratory syncytial virus. However, 10.4% (n=46) were influenza virus (80% FluA; 20% FluB). Age and SARI were significantly associated with influenza. FluB circulation was higher is 2013.

Conclusions: In the post-epidemic period, influenza remains an important cause of hospitalization in SARI patients.
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http://dx.doi.org/10.1590/0037-8682-0498-2017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083379PMC
February 2020

Detection and quantification of human immunodeficiency virus and hepatitis C virus in cadaveric tissue donors using different molecular tests.

J Clin Virol 2019 12 4;121:104203. Epub 2019 Nov 4.

Laboratory of Emerging Infectious Diseases, School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, 80215-901, Brazil. Electronic address:

Background: Tissues from cadaveric donors are used in several clinical circumstances, and the transmission of infectious diseases has been reported. Cadaveric donor (CD) blood sample analysis is challenging due to its poor quality. However, studies have demonstrated the usefulness of molecular based methods, and the lack of studies using available commercial molecular tests was reported.

Objective: The aim of this study was to evaluate the performance, specificity, sensitivity, and accuracy of different commercial molecular tests for HIV and HCV detection and quantification in CD through spiked samples.

Study Design: 20 CD and 20 blood donor samples were tested using 1,000 copies/mL and 1,000 IU/mL of lyophilized standards of HIV and HCV, respectively. Samples were analyzed by different molecular kits: XPERT HCV Viral Load and HIV-1 (Cepheid), COBAS® TaqMan® HIV-1 and COBAS® TaqMan® HCV Test, v2.0 (Roche), and artus® HI Virus-1 QS-RGQ and artus® HCV RG RT-PCR Kit (Qiagen).

Results: HIV and HCV in CD were detected by RT-PCR-based quantitative kits. The tests performed by the Cepheid and the Roche kits showed the most accurate, sensitive and specific results, however, a wide variability between the assays and kits was observed. The Qiagen kits did not demonstrate satisfactory results.

Conclusions: CD evaluation showed great variability. The Cepheid and Roche kits were more sensitive for detecting HIV on CD and Cepheid was the most efficient kit for HCV quantification in CD. The Roche and Cepheid kits can be used to screen tissue donors for HIV and HCV.
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http://dx.doi.org/10.1016/j.jcv.2019.104203DOI Listing
December 2019

Standardization of Antigenemia and qPCR Cut-off Values in Whole Blood for the Detection of Cytomegalovirus Disease in HIV Patients.

Rev Soc Bras Med Trop 2019 Jun 27;52:e20180457. Epub 2019 Jun 27.

Divisão de Doenças Infecciosas, Universidade Federal do Paraná, Curitiba, PR, Brasil.

Introduction: We defined the cut-off values of the antigenemia and cytomegalovirus (CMV) DNA tests in HIV/AIDS patients to identify CMV disease.

Methods: A total of 97 samples from 68 patients with and without CMV disease were analyzed by viral DNA detection and antigenemia assay.

Results: Qualitative and quantitative results significantly differed between assays. The cut-off values for the antigenemia and qPCR assays were 1.5 positive cells/200,000 leukocytes and 3.715 log/mL, respectively.

Conclusions: Antigenemia and qPCR are suitable for monitoring CMV disease in HIV patients, however, the threshold values should be determined within the centers where the patients are monitored.
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http://dx.doi.org/10.1590/0037-8682-0457-2018DOI Listing
June 2019

Human adenovirus meningoencephalitis: a 3-years' overview.

J Neurovirol 2019 08 17;25(4):589-596. Epub 2019 May 17.

Virology Laboratory, Clinical Pathology Laboratory - Hospital de Clínicas, Universidade Federal do Paraná, Rua Padre Camargo, n. 280, Setor de Ciências da Saúde, Bairro Alto da Glória, Curitiba, Parana, 80060240, Brazil.

Human adenovirus (HAdV) has been recognized as a significant viral pathogen implicated in neurological diseases, particularly in immunocompromised patients. However, its involvement in meningoencephalitis remains unclear. The aim of this study was to investigate HAdV and other viral co-infections in the cerebrospinal fluid (CSF) of patients suspected of having either meningoencephalitis or encephalitis. A total of 373 CSF samples from patients under clinical suspicion of neurological viral infection were included in this study. HAdV was investigated by conventional or multiplex real-time PCR, for different time periods. The frequency of HAdV central nervous system (CNS) infection was 1.08%, predominating in female patients with a predisposing condition, and presented with HAdV encephalitis. HAdV CNS infection was found to occur during the months of autumn and winter. The frequency of HAdV detected in CSF positive samples increased after the change in the diagnostic method from conventional to multiplex real-time PCR. There were no specific NMRI or EEG characteristics and two CSF samples with HAdV encephalitis had normal CSF WBC count. There were two cases of co-infection with HIV; no other co-infections with enterovirus or herpes family viruses were detected. All patients had good outcome. Although HAdV is rarely observable in CNS infectious syndromes, it must be investigated particularly in immunocompromised patients.
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http://dx.doi.org/10.1007/s13365-019-00758-7DOI Listing
August 2019

Development and validation of a real-time RT-PCR assay for the quantification of rabies virus as quality control of inactivated rabies vaccines.

J Virol Methods 2019 08 3;270:46-51. Epub 2019 May 3.

Virology Laboratory, Hospital de Clínicas, Universidade Federal do Paraná, Rua General Carneiro, nº 181, Alto da Glória, Curitiba, Paraná, Zip Code 80060-900, Brazil. Electronic address:

Rabies is an infectious viral disease, characterized as a neglected zoonosis, responsible for nearly 60,000 deaths annually. The virus is transmitted mainly by dogs in Africa and Asia, and wildlife in Europe and the Americas, to all mammals' species, causing severe encephalitis almost always fatal after the onset of neurological symptoms. Human rabies can be prevented through extensive vaccination of dogs and pre/post-prophylaxis treatments in humans with inactivated rabies vaccines. The vaccine manufacture involves a series of quality control assays using laboratory animals, which are mandatory to exclude the presence of viable residual virus. The quality controls must be carried out in various steps during the vaccine production, which demands the use of a large number of animals. In this study, we standardized a real-time quantitative RT-PCR duplex assay to be used during intermediate stages of the vaccine production. This assay was done for the quantification of vaccine strain rabies virus, targeting rabies nucleoprotein, and β-actin mRNA of BHK-21 cells as an internal endogenous control. The results showed specific amplification, with the analytical sensitivity ranged from 10 to 10 TCID/mL with high repeatability rate for the quantification of rabies virus in inactivated vaccine samples. Global organizations are engaged to develop new approaches to determine viable residual virus, and this assay can be applied in combination with traditional in vitro methods for the release of intermediate batches of vaccines during the production process, keeping the in vivo tests only for final release.
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http://dx.doi.org/10.1016/j.jviromet.2019.04.025DOI Listing
August 2019

Assessment of clinical and epidemiological characteristics of patients with and without sepsis in intensive care units of a tertiary hospital.

Einstein (Sao Paulo) 2019 15;17(2):eAO4476. Epub 2019 Apr 15.

Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.

Objective: To describe the clinical and epidemiological features of patients with and without sepsis at critical care units of a public hospital.

Methods: A cross-sectional study was carried out from May 2012 to April 2013. Clinical and laboratory data of patients with and without sepsis in the intensive care units were reviewed of medical records.

Results: We evaluated 466 patients, 58% were men, median age was 40 years, and 146 (31%) of them were diagnosed with sepsis. The overall mortality was 20% being significantly higher for patients with sepsis (39%). The factors associated with intensive care unit mortality were the presence of sepsis (OR: 6.1, 95%CI: 3.7-10.5), age (OR: 3.6, 95%CI: 1.4-7.2), and length of hospital stay (OR: 0.96, 95%CI: 0.94-0.98). Pulmonary (49%) and intra-abdominal (20%) infections were most commonly identified sites, and coagulase-negative staphylococci and enteric Gram negative bacilli the most frequent (66%) pathogens isolated.

Conclusion: Although the impact of sepsis on mortality is related to patients' clinical and epidemiological characteristics, a critical evaluation of these data is important since they will allow the direct implementation of local policies for managing this serious public health problem.
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http://dx.doi.org/10.31744/einstein_journal/2019AO4476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459321PMC
May 2019

Epidemiology of enteric viruses in children with gastroenteritis in Ogun State, Nigeria.

J Med Virol 2019 06 28;91(6):1022-1029. Epub 2019 Jan 28.

Virology Laboratory, Infectious Diseases Division, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil.

Acute gastroenteritis (AGE) remains a global public health concern and Nigeria is one of the two countries accounting for 42% of global under-5 deaths attributable to gastroenteritis. This study aimed to determine the prevalence, seasonality, and risk factors of enteric viruses (EVs) in children with AGE in Ogun State, Nigeria. Stool samples collected from children under-5 from three different hospitals between February 2015 and April 2017 were analyzed using molecular methods for the presence of four EVs (group A rotavirus [RVA], norovirus [NoV], human astrovirus [HAstV], and human adenovirus [HAdV]). Among the 175 samples analyzed, 63 (36%) were positive for at least one EV. The most prevalent was HAstV (19.4%), followed by RVA (16.6%), NoV (5.1%), and HAdV (5.1%). Mixed infections were found in 17 cases. No significant association was observed with age, sex, and risk factors. Though not significant, EV prevalence was higher in the dry season. Positive cases (asides HAdV) had no correlation with temperature and/or humidity. This study provides information on the prevalence and seasonal fluctuations of EVs, which will be of value in the effective management of patients and control strategies for viral gastroenteritis in the country.
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http://dx.doi.org/10.1002/jmv.25399DOI Listing
June 2019

High frequency of multiple HPV types detection in Fanconi anemia patients oral swabs.

Transpl Infect Dis 2019 Apr 14;21(2):e13030. Epub 2018 Dec 14.

Department of Stomatology, Federal University of Paraná, Curitiba, Brazil.

Background: Fanconi anemia (FA) is a rare genetic disease usually characterized by bone marrow failure and congenital malformations. The risk of development of malignancies in the oral cavity of FA patients, such as squamous cell carcinoma (SCC), increases significantly after a hematopoietic stem cells transplant (HSCT), and may also be linked with the presence of human papillomavirus (HPV) infections in the oral cavity. We investigated the prevalence and the HPV genotypes in oral mucosa of Brazilian FA patients.

Methods And Results: Oral swabs of 49 FA patients were collected. The median age of patients was 20 years (range 5-44) and 57% were over 18 years. Oral lesions were present in 20% of all patients, being 90% leukoplakia. HPV DNA was detected in 28% (14/49) of patients, and one of them also reported genital HPV lesions. Sixty-seven percent of all patients had undergone HSCT, including 12 patients (86%) of those with HPV results. Multiple HPV types were detected in 78% and 71% of HPV samples by Sanger sequencing and reverse hybridization methods, respectively. The most prevalent HPV types detected were 6, 11, 18, and 68.

Conclusions: HPV prevalence in the oral mucosa of the assessed FA patients was higher than reported in the general population. Additional studies with collection of sequential samples are needed to know the natural history of the presence of multiple HPV types in these individuals and its association with the development of tumors, to evaluate the implementation of preventive measures, such as vaccination, and to guide early treatment.
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http://dx.doi.org/10.1111/tid.13030DOI Listing
April 2019

Host Factor Predictors in Long-term Nonprogressors HIV-1 Infected with Distinct Viral Clades.

Curr HIV Res 2017 ;15(6):440-447

Postgraduate Program in Internal Medicine and Health Science, Universidade Federal do Parana, Parana, Brazil.

Background: HIV-1+ long-term nonprogressors (LTNPs) maintain natural control of viral infection. This study sought to identify and characterize HIV- LTNPs series case, regarding the presence of possible host factors that may be associated with this status.

Methods: We evaluated the plasma levels of IP-10/IL-8 chemokines, HLA-B alleles, and IL28B rs12979860 polymorphism in 24 LTNPs who presented with infection by different clades of HIV-1.

Results: IL-8 chemokine was significantly higher in progressors than in LTNPs, but there was no difference between the LTNP subgroups. There was a negative correlation in CD4+ T cell (TC) count and IL-8 dosage, and a positive correlation with CD8+ TC. IP-10 chemokine levels were associated with viremia, and the elite controller (EC) subgroup showed nearly the same level than healthy individuals and progressors with viral load suppressed. Furthermore, the CD4+ TC count, percentage of CD4+ TC, and CD4/CD8 ratio were negatively correlated with IP-10. No association was found in plasma levels of IL-8 and IP-10 chemokines and HIV-1 clades. In the EC/viremic controller subgroup, 80% presented with at least one HLA-B allele previously considered as potentially protective for AIDS progression. No association was observed between the HLA-B alleles and HIV- 1 clades. The IL28B CC genotype was identified in 87.5% of LTNPs.

Conclusion: In this LTNP series case we observed different host factors that may be contributing to their nonprogressor status, and the association of these factors with the control of infection progression may be critically important for future therapeutic and prophylactic options in HIV-1 infection.
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http://dx.doi.org/10.2174/1570162X16666171206120024DOI Listing
April 2019

Biomarkers of neuronal injury and amyloid metabolism in the cerebrospinal fluid of patients infected with HIV-1 subtypes B and C.

J Neurovirol 2018 02 23;24(1):28-40. Epub 2017 Oct 23.

HNRC-University of California-San Diego, San Diego, CA, USA.

Based on prior reports that the HIV-1 Tat protein modulates amyloid-beta (Aβ) metabolism, this study aimed to compare CSF neural injury biomarkers between 27 patients with HIV subtype B, 26 patients with HIV subtype C, 18 healthy HIV-negative controls, and 24 patients with Alzheimer's disease (AD). Immunoassays were used to measure soluble amyloid precursor protein α and β (sAPPα, sAPPβ), Aβ oligomers 38, 40, 42, and Aβ-total; phosphorylated tau (P-tau), and total tau (T-tau). Comparisons between HIV(+) and HIV(-) (including AD) were adjusted by linear regression for gender and age; HIV subtype comparisons were adjusted for nadir CD4 and plasma viral load suppression. The p values were corrected for multiple testing with the Benjamini-Hochberg procedure. CSF Aβ-42 and Hulstaert (P-tau) index were lower in HIV1-C than B (p = 0.03, and 0.049 respectively); subtypes did not differ on other CSF biomarkers or ratios. Compared to AD, HIV(+) had lower CSF levels of T-tau, P-tau (p < 0.001), and sAPPα (p = 0.041); HIV(+) had higher CSF Aβ-42 (p = 0.002) and higher CSF indexes: [Aß-42/(240 + 1.18 T-tau)], P-tau/Aβ-42, T-tau/Aβ-42, P-tau/T-tau, sAPPα/β (all p ≤ 0.01) than AD. Compared to HIV(-), HIV(+) had lower CSF Aβ-42, and T-tau (all p ≤ 0.004). As conclusion, amyloid metabolism was influenced by HIV infection in a subtype-dependent manner. Aß-42 levels were lower in HIV1-C than B, suggesting that there may be greater deposition of Aß-42 in HIV1-C. These findings are supported by CSF Hulstaert (P-tau) index. Differences between HIV and AD in the patterns of Aß and Tau biomarkers suggest that CNS HIV infection and AD may not share some of same mechanisms of neuronal injury.
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http://dx.doi.org/10.1007/s13365-017-0591-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5792298PMC
February 2018

Profile of HIV subtypes in HIV/HBV- and HIV/HCV-coinfected patients in Southern Brazil.

Rev Soc Bras Med Trop 2017 Jul-Aug;50(4):470-477

Programa de Pós Graduação em Medicina Interna, Universidade Federal do Paraná, Curitiba, PR, Brasil.

Introduction: : HIV and viral hepatitis infections are major causes of chronic disease worldwide and have some similarities with regard to routes of transmission, epidemiology, front barriers faced during access of treatment, and strategies for a global public health response. The objective was to describe the HIV-1 subtypes, viral tropism and single-nucleotide polymorphisms (SNPs) of interleukin 28B (IL28B) from a case series of HIV/viral hepatitis coinfected patients from southern Brazil.

Methods:: Clinical and epidemiological data were evaluated by a review of medical records. Periodic blood draws were taken to determine the viral and host characteristics.

Results:: This study included 38 patients with HIV/HBV or HIV/HCV coinfection; the median age was 49 years. Thirty-seven (97.4%) were on antiretroviral therapy, 32 (84.2%) had an undetectable viral load, a median CD4+ T-cell count of 452 cells/mm3. HIV-1 subtyping showed 47.4 and 31.6% of patients with subtypes C and B, respectively. Analysis of viral co-receptor usage showed a predominance of the R5 variant (64.7%), with no significant difference between the subtypes. Twenty patients with HIV/HCV coinfection were eligible to receive HCV therapy with pegylated-interferon-alpha plus ribavirin, and 10/20 (50%) of them achieved sustained virological response. SNPs of IL28B were evaluated in 93.3% of patients with HIV/HCV coinfection, and 17 (60.7%) presented the CC genotype.

Conclusions:: In the present case series, a higher frequency of HIV subtype C was found in coinfected patients. However such findings need to be prospectively evaluated with the inclusion of data from regional multicenter analyses.
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http://dx.doi.org/10.1590/0037-8682-0450-2016DOI Listing
November 2017

Human parechovirus: sepsis-like illness with pulmonary infection.

Braz J Infect Dis 2017 Nov - Dec;21(6):675-677. Epub 2017 Jul 7.

Universidade Federal do Paraná, Hospital de Clínicas, Laboratório de Virologia, Curitiba, PR, Brazil; Universidade Federal do Paraná, Programa de Pós-graduação em Tocoginecologia, Curitiba, PR, Brazil; Universidade Federal do Paraná, Departamento de Análises Clínicas, Curitiba, PR, Brazil.

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http://dx.doi.org/10.1016/j.bjid.2017.06.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7129718PMC
November 2018
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