Ocular Toxoplasmosis Reactivation During Pregnancy – A Case Report

Introduction: Toxoplasmosis is caused by Toxoplasma gondii and may be acquired from food or water contaminated with cat feces or by vertical transmission. Severe fetal complications can overcome during pregnancy. There are also rare case-reports of congenital toxoplasmosis from previously immunized pregnant women; usually these women being had prior retinal toxoplasmic lesions. Immunosuppresion is one of the risk factors which accounts for some of these cases. Case report: 30 year-old pregnant woman, OI 2002, brazilian, previously healthy, admitted in Ophtalmology Department because of sudden left eye amaurosis in June, 2010. The fundoscopy revealed retinal scars suggesting previous infections; she was treated with corticoids and spiramycin for ocular toxoplasmosis reactivation. Previous serum analysis (2008) showed immunity to T. Gondii, but in July the IgM was negative and high levels of specific IgG were found (1227UI/mL). The serologic findings were later confirmed by a more accurate laboratory technique which found the IgM to be also positive. An amniocentesis was performed and it was negative for fetal transmission. Clinical and ultrasound follow-up throughout the rest of the gestational period was normal; daily spiramycin intake was maintained. An uneventful term delivery was performed. Neither the newborn’s serum analysis nor the histopathological study of the placenta were positive for congenital infection. Conclusion: Toxoplasmosis reactivation in pregnant women without immunosuppression is rare but is more likely to occur if previous post-infectious retinal scars are present. T. gondii infection is endemic in Brazil, so the geographical origin is important. If risk factors are present, fundoscopy should be performed every three months during pregnancy and one should always be aware of any visual symptoms. If you suspect reactivation, start medical prophylaxis for fetal transmission, perform amniocentesis and regular ultrasound follow-up.

Estudo da Distribuição de Factores de Risco para o Desenvolvimento de Doença Ocular Aguda em Portadores de Lentes de Contacto

Objectivo: Estudar os factores de risco (FR) associados a complicações clínicas agudas (CCA) numa amostra de portadores de lentes de contacto (LC). Doentes e Métodos: Análise de todos os doentes com CCA associadas ao uso de LC, que, no período de um ano, recorreram ao SU do Centro Hospitalar de Lisboa Central. O estudo focou-se na análise do perfil demográfico e de risco destes doentes. Resultados: Dos 103 doentes referenciados pelo SU foram estudados os que compareceram para seguimento no Departamento de Contactologia (84). A maioria era do sexo feminino, caucasiana e de educação diferenciada. A mediana das idades foi de 29 anos. 15% dos doentes cumpria as horas de uso diário recomendadas e 5% cumpria todas as regras de higiene; 26% dos doentes apresentavam FR oftalmológicos e 58% FR sistémicos. O prescritor das LC foi o médico em 36% e 26% mantinha vigilância médica oftalmológica regular. Comentários: A maioria dos doentes não cumpria as regras de segurança e de higiene do uso de LC, sendo o desconhecimento destas regras elevado. O papel muito reduzido dos médicos oftalmologistas na prescrição de LC e na vigilância dos portadores pode estar na origem do desconhecimento e incumprimento das regras de utilização das LC por parte de alguns doentes.

Consulta de Diabetes Ocular. Primeiros Resultados do Rastreio da Retinopatia Diabética por Câmara Não Midriática

Introdução: a retinopatia diabética (RD) é, nos países industrializados, uma das principais causas de cegueira. A perda de visão na RD diminui com o diagnóstico precoce e instituição terapêutica2 adequada possibilitados por programas de rastreio sistemático. O rastreio efectuado por fotografias do polo posterior com câmara não midriática é simples e apresenta boa sensibilidade e especificidade3. Material e Métodos: estudo prospectivo, observacional, dos doentes diabéticos sem seguimento oftalmológico regular, seguidos na consulta de Medicina do Centro Hospitalar de Lisboa Central desde Setembro de 2008 a Julho de 2009. Incluíram-se 86 doentes. Um ortoptista fez a aquisição de imagens do polo posterior com uma câmara não midriática e a impressão de fotografias compostas, coloridas, que foram posteriormente analisadas por um oftalmologista da consulta de Diabetes Ocular. Resultados: foram excluídos 7 olhos (4,2%) por não existir qualidade de imagem. Identificou-se a existência de RD em 26% dos 165 olhos incluídos ( 28% dos doentes), apresentando 21% RD não proliferativa e 5% proliferativa. Apurou-se uma relação estatisticamente significativa entre a existência de RD, a idade (p= 0,253 x 10-1) e a duração da diabetes (p= 7,16 x 10-5). Relativamente ao encaminhamento, 57,8% foram referenciados para rastreio anual e 42,2% para a Consulta Geral de Oftalmologia. Todos os excluídos foram igualmente encaminhados para a Consulta Geral de Oftalmologia. Conclusões: a percentagem de doentes rastreados que apresentou RD foi elevada (28%). O rastreio sistemático da população diabética com câmara não midriática pareceu-nos ser um método simples e eficaz no despiste da RD.

Impacto do Diâmetro do Nervo Óptico na Amplitude de Pulso Ocular no Glaucoma Primário de Ângulo Aberto

Introdução: A pressão intra-craniana (PIC) tem sido descrita como estando envolvida no glaucoma primário de ângulo aberto (GPAA). A sua avaliação está contudo limitada pela necessidade de métodos invasivos, como a punção lombar. A ecografia ocular permite uma avaliação indirecta da PIC através da medição do diâmetro da bainha do nervo óptico (NO). Desconhece-se se esta nova variável tem capacidade de modular factores de risco normalmente investigados em doentes com GPAA. Objectivo: Avaliar o impacto do diâmetro da bainha do NO na pressão intra-ocular (PIO) e na amplitude de pulso ocular (OPA) de doentes com GPAA. Métodos: Quinze doentes com GPAA foram submetidos a medição da PIO por tonometria de contorno dinâmico, avaliação topográfica do disco óptico e ecografia ocular modo B com sonda doppler. Apenas o olho com maior dano glaucomatoso foi seleccionado por doente. Resultados: A média do diâmetro da bainha do NO foi de 5,6±0,67mm, a PIO média de 17,8±2,2mmHg e a OPA de 3,1±1,7mmHg. O diâmetro da bainha do NO correlacionou-se negativamente a OPA (r=-0.54, p=0.05), não tendo influenciado a PIO (r=-0,25, p=0,41). Da avaliação hemodinâmica, apenas o índice de resistência da artéria central da retina (CRA) foi influenciado pelo diâmetro da bainha do NO (r=-0.52, p=0.04). Conclusão: O diâmetro da bainha do NO correlaciona-se negativamente com a OPA. Este efeito poderá ser explicado pela alteração da resistência vascular da artéria que atravessa este espaço subaracnoideu, a CRA. O estudo da região retrobulbar e do balanço entre as pressões aí exercidas é assim um campo cuja importância será crescente na avaliação do doente com GPAA.

Treatment of Hepatitis C Virus Infection in Kidney Transplant Recipients: Case Report

Chronic hepatitis C virus (HCV) infection exists in a large proportion of patients undergoing renal transplantation. Nowadays it is not considered to be an absolute contraindication to transplantation; however, it is associated with an increased risk for the patient and accounts for a shorter half-life of the renal allograft. We present three transplant recipients who displayed serious hepatic dysfunction after renal transplantation due to an HCV infection. In two of these cases, the liver biopsies established the diagnosis of FCH. In the third case, the liver biopsy was compatible with the early stages of FCH. All patients were started on peg-interferon alfa 2-b and ribavirin with subsequent normalization of hepatic function and early complete viral responses.

Burkitt’s Lymphoma Related to Epstein–Barr Virus Infection During Pregnancy

Setting: Burkitt’s lymphoma is a rare form of cancer and is an extremely rare diagnosis during pregnancy. This form of lymphoma is a very fast growing B cell neoplasm and chemotherapy is the treatment of choice for the disease in all its stages. Case report: The authors describe the case of a Caucasian 40-year-old nulliparous woman, with previous known Epstein–Barr virus infection, that presents at 28 weeks gestation with supraclavicular adenopathy and multiple bilateral breast nodules, in which biopsy showed non-Hodgkin lymphoma, Burkitt’s type. Discussion: There are few described cases of Burkitt’s lymphoma during pregnancy and in general the outcomes have been poor. In most of the cases, the patients were not treated by current standards or instead had a late diagnosis. This neoplasia is the most rapidly progressive human tumor, and any delay in initiating therapy can adversely aVect patient’s prognosis. The authors discuss treatment options in pregnancy and its perinatal implications.

A Rat Model of Diabetic Wound Infection for the Evaluation of Topical Antimicrobial Therapies

Diabetes mellitus is an epidemic multisystemic chronic disease that frequently is complicated by complex wound infections. Innovative topical antimicrobial therapy agents are potentially useful for multimodal treatment of these infections. However, an appropriately standardized in vivo model is currently not available to facilitate the screening of these emerging products and their effect on wound healing. To develop such a model, we analyzed, tested, and modified published models of wound healing. We optimized various aspects of the model, including animal species, diabetes induction method, hair removal technique, splint and dressing methods, the control of unintentional bacterial infection, sampling methods for the evaluation of bacterial burden, and aspects of the microscopic and macroscopic assessment of wound healing, all while taking into consideration animal welfare and the '3Rs' principle. We thus developed a new wound infection model in rats that is optimized for testing topical antimicrobial therapy agents. This model accurately reproduces the pathophysiology of infected diabetic wound healing and includes the current standard treatment (that is, debridement). The numerous benefits of this model include the ready availability of necessary materials, simple techniques, high reproducibility, and practicality for experiments with large sample sizes. Furthermore, given its similarities to infected-wound healing and treatment in humans, our new model can serve as a valid alternative for applied research.

Perinatal Bacterial Infection: Screenning of Vertical Transmitted Infections

Perinatal bacterial infection may be caused by any microorganism colonizing the vaginal tract. Neonatologists and paediatricians are especially concerned about group B Stretpococcus (GBS). However, Enterobactereacea, mainly E.coli and Proteus, are also responsible for infection. GBS screening may be accomplished in over 90% of pregnant women. In our maternity in 2007-2008, 85% of the mothers had been screened. Screening and prophylaxis were responsible for a decreasing incidence of neonatal infection - from 0.6/1000 to 0.15/1000 live births in Portugal, from 2002 to 2007. However there are some difficulties related to screening. In the second Portuguese study 16/57 NB with early-onset infection (28%) were born to “negative” mothers. Several factors illustrate how difficult is to draw national screening policies: a wide range of carrier’s state rate throughout a country - in Portugal from 12% to 30%. The success of any screening policy may also be affected by additional technical and organizational problems. In countries where home delivery is a tradition or a trend intrapartum GBS prophylaxis requires a very well organized assistance.. Moreover factors usually accepted as protective are not so effective. In the Portuguese study 24/57 infected newborns (42%) were delivery by caesarean section. Another subject deals with the workload in the postnatal ward generated by deficient compliance to the guidelines a problem not confirm by a study of our group. Decreasing the importance of GBS, highlight the importance of E. coli in perinatal infection. From the 16 340 registrations of the National Registry 1676 were newborns with mother-related infection. Applying the same reasoning to E.coli as to GBS and Listeria monocytogenes – that is considering all of them are of maternal origin - 6.7% of these infections were due to E. coli, 4.6% to SGB and 0.5% to Listeria monocytogenes. In conclusion screening and prophylaxis may be not the best way to prevent all GBS neonatal infections but by now it is the only available procedure. The other bacteria continue to demand a high suspicion level and immediate intervention.

The 2009 Pandemic Influenza A (H1N1) Infection: Renal Histopathology Findings in Two Infected Patients

Background: Acute kidney injury in the pandemic swine origin influenza A virus (H1N1) infection has been reported as coursing with severe illness, although renal pathogenic mechanisms and histologic features are still being characterised. Case Report: We present two patients admitted with H1N1 pneumonia, sepsis, acute respiratory distress syndrome and need for invasive mechanical ventilation who developed acute kidney injury and became dialysis-dependent. In both cases a kidney biopsy was performed to establish a definitive diagnosis. Severe acute tubular necrosis was identified, with no further abnormalities. Conclusion: This report seems to confirm that the acute kidney injury in H1N1 infection is focused on the tubular cells. Our cases corroborate the renal histopathologic findings of other studies, highlighting the central role of the tubular cell. We bring new evidence of the histopathology of AKI in H1N1 infection since our data were collected in living patients and not via post-mortem studies.

Summer Vacations not Only a Memory for Life, but Also a Rare Infection

Introduction: Rhinoscleroma is a rare, chronic, granulomatous disease that most frequently affects the upper respiratory tract, especially the nasal cavity and sometimes extends through the lower respiratory tract. Is associated with Klebsiella rhinoscleromatis, which is endemic in certain geographic regions namely Central America. The pathogenesis and risk factors remain unclear. Clinical case: We report a five years Old Portuguese boy, previously healthy, brought to the Emergency Department with epistaxis, without other accompanying signs or symptoms. The Otorhinolaryngologist (ORL) performed rhinoscopy and identified an intranasal bleeding mass. The MRI revealed an intranasal mass with extension to the ethmoid bone sinus, and performed biopsy. The histopathology was vital, making the diagnosis of Rhinoscleroma. The child had traveled abroad for the first time on vacations a year before to Dominican Republic. The bacteriologic exam identified a Klebsiella spp. sensible to the association of amoxicillin and clavulanic acid. Blood test performed excluded association of immunodeficiency. Since it’s a rare disease genetic study are under course. Monthly evaluation by ORL and pediatrician was performed which documented progressive reduction until total disappearing of the macro and microscopic lesion, and negative bacteriologic exam. Six months of antibiotic therapy were completed without any known secondary effects. The child remained asymptomatic up to the last visit, 3 months following treatment and has shown no evidence of recurrence. Conclusion: Globalization and free transit of people to areas far from origin countries here some rare diseases are endemic brings a new challenge to modern medicine. Sometimes vacations bring more than memories.

Induced Labor– Is There an Increased Risk of Perinatal Infection?

Objectives: To assess induced labor-associated perinatal infection risk at Hospital D.Estefânia from January to June of 2010 at Hospital de D. Estefânia’s delivery rooms, reviewing the indications for inducing labor as well as the techniques used. Material and Methods: Performing an historical prospective study searching the clinical processes as well as the mother and newborn’s computer database from January to June of 2010. An exposed and an unexposed group were created; the first group comprises pregnant women and their newborns whose labor was induced. The unexposed group is constituted by newborns and pregnant women whose labor was spontaneous. Labor induction was performed using intra-vaginal prostaglandins in women who didn’t start it spontaneously; perinatal infection was defined either clinically or using blood tests. The gestational age was ≥ 37 weeks for both groups. 19 variables were studied for both groups. Results: A total of 190 mother-newborn pairs were included: 55 in the exposed group and 135 in the unexposed group. 3 cases of perinatal infection were reported, two in the exposed group and one in the unexposed group. Preliminary data resulted in a perinatal infection rate of 3.6% in the exposed group and 0.7% in the unexposed group; preliminary data suggest that the risk of perinatal infection may be increased in up to 5-fold when labor is inducted. Conclusions: A larger series of patients and a multivariable analysis using logistic regression are both necessary in order to perform a more thorough assessment of labor induction’s role in perinatal infection risk. One must also try to distinguish labor inducing- and clinical practicesrelated factors.

Perspectivas do Estudo da Diabetes Ocular numa Consulta Pediátrica

A duração da diabetes mellitus é um factor de risco no aparecimento de complicações oculares. A prevalência da retinopatia diabética é praticamente nula antes dos 10 anos de idade, independentemente da duração da doença, atingindo 95% após 20-30 anos de evolução. Na Consulta de Oftalmologia Pediátrica do Hospital D. Estefânia avaliámos retrospectivamente 62 crianças com diagnóstico de diabetes meliitus tipo I, no intervalo d etempo compreendido entre 1 de Janeiro de 1999 e 31 de Junho de 2000. As idades oscilavam entre os 3 e os 17 anos(média 11,8 anos), tendo sido 29 casos do sexo feminino e 33 do sexo masculino. O período de evolução da doença variava entre 6 meses e 16 anos (média 6,2 anos). Na população estudada constatámos uma incidência de 6,4% de lesões oculares. Vericámos 1 caso (1,6%) de retinopatia de fundo, numa adolescente de 17 anos de idade e 11 anos de evoluão da doença, e 3 casos (4,8%) de catarata bilateral. Na diabetes juvenil a probabilidade de ocorrência de lesões oculares precoces é baixa. Exceptuando a catarata que pode ocorrer com alguma precocidade, a retinopatia clínica é raramente demosntrável antes do inicio da puberdade.

Sepsis Mortality Prediction Based on Predisposition, Infection and Response

OBJECTIVE: To empirically test, based on a large multicenter, multinational database, whether a modified PIRO (predisposition, insult, response, and organ dysfunction) concept could be applied to predict mortality in patients with infection and sepsis. DESIGN: Substudy of a multicenter multinational cohort study (SAPS 3). PATIENTS: A total of 2,628 patients with signs of infection or sepsis who stayed in the ICU for >48 h. Three boxes of variables were defined, according to the PIRO concept. Box 1 (Predisposition) contained information about the patient's condition before ICU admission. Box 2 (Injury) contained information about the infection at ICU admission. Box 3 (Response) was defined as the response to the infection, expressed as a Sequential Organ Failure Assessment score after 48 h. INTERVENTIONS: None. MAIN MEASUREMENTS AND RESULTS: Most of the infections were community acquired (59.6%); 32.5% were hospital acquired. The median age of the patients was 65 (50-75) years, and 41.1% were female. About 22% (n=576) of the patients presented with infection only, 36.3% (n=953) with signs of sepsis, 23.6% (n=619) with severe sepsis, and 18.3% (n=480) with septic shock. Hospital mortality was 40.6% overall, greater in those with septic shock (52.5%) than in those with infection (34.7%). Several factors related to predisposition, infection and response were associated with hospital mortality. CONCLUSION: The proposed three-level system, by using objectively defined criteria for risk of mortality in sepsis, could be used by physicians to stratify patients at ICU admission or shortly thereafter, contributing to a better selection of management according to the risk of death.

Community-Associated Methicillin-Resistant Staphylococcus Aureus Lacking PVL, as a Cause of Severe Invasive Infection Treated with Linezolid

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is an emerging public health problem worldwide. Severe invasive infections have been described, mostly associated with the presence of Panton-Valentine leukocidin (PVL). In Portugal limited information exists regarding CA-MRSA infections. In this study we describe the case of a previously healthy 12-year-old female, sport athlete, who presented to the hospital with acetabulofemoral septic arthritis, myositis, fasciitis, acetabulum osteomyelitis, and pneumonia.The MRSA isolated from blood and synovial fluid was PVL negative and staphylococcal enterotoxin type P (SEP) and type L (SEL) positive, with a vancomycin MIC of 1.0mg/L and resistant to clindamycin and ciprofloxacin. The patient was submitted to multiple surgical drainages and started on vancomycin, rifampicin, and gentamycin. Due to persistence of fever and no microbiological clearance, linezolid was started with improvement. This is one of the few reported cases of severe invasive infection caused by CA-MRSA in Portugal,which was successfully treated with linezolid. In spite of the severity of infection, the MRSA isolate did not produce PVL.

HCV Infection in Patients with Hereditary Bleeding Disorders

Introduction: Hepatitis C virus (HCV) infection in patients with hereditary bleeding disorders (HBDs), as a consequence of treatment with transfusion of human bloodderived components between the late 1970s and 1980s, represents a major health concern. Objectives: Assessment and evaluation of the burden of HCV infection, its complications, and treatment in a population of patients with HBDs. Methods: Analysis of a series of 161 patients with HBDs treated in the Immunohemotherapy Service of the Centro Hospitalar de Lisboa Central (Lisboa, Portugal), consultation and systematic review of the patients clinical processes, elaboration of a database comprising the information gathered; and statistical study of its variables: age, gender, degree of severity of the bleeding disorder, treatment modality, and major and minor complications of HCV infection. Results: Sixty-five (40%) of the 161 patients have HCV infection. Among the patients with hemophilia A, 36% are severe and 62% of those have HCV infection; 9% moderate with 57%; 25% mild with 20%. In the hemophilia B group, 8% are severe with 23% infected and 6% moderate or mild with 10%. Concerning the patients with von Willebrand disease, 12% have type 2 with 16% infected and 4% have type 3 with 86%. Conclusions: HCV infection represents a very significant complication of the treatment employed in the past in the studied population. Considering that most of these patients were infected in the late 1970s and early 1980s, and the natural evolution of HCV infection in patients without bleeding disorders, it is expected that the prevalence of major complications will rise significantly in the coming years. Prophylactic measures should be implemented to enhance the follow-up protocols and prevent further development of liver damage in these patients.