Generation and Characterization of ALX-0171, a Potent Novel Therapeutic Nanobody for the Treatment of Respiratory Syncytial Virus Infection

Respiratory Syncytial Virus (RSV) is an important causative agent of lower respiratory tract infections in infants and elderly. Its fusion (F) protein is critical for virus infection. It is targeted by several investigational antivirals and by palivizumab, a humanised monoclonal antibody used prophylactically in infants considered at high risk of severe RSV disease. ALX-0171 is a trimeric Nanobody that binds the antigenic site II of RSV F-protein with subnanomolar affinity. ALX-0171 demonstrated superior in vitro neutralisation compared to palivizumab against prototypic RSV A and B strains. Moreover, ALX-0171 completely blocked replication below limit of detection in 87% of the viruses tested versus 18% for palivizumab at a fixed concentration. Importantly, ALX-0171 was highly effective in reducing both nasal and lung RSV titers when delivered prophylactically or therapeutically directly to the lungs of cotton rats. ALX-0171 represents a potent novel antiviral compound with significant potential to treat RSV-mediated disease.

Mycobacterium tuberculosis aortic graft infection with recurrent hemoptysis: a case report.

INTRODUCTION: Mycobacterium tuberculosis may cause a large variety of clinical presentations due to its ability to disseminate by contiguity or hematogenously. Tuberculosis may remain undiagnosed for years due to the chronic course of the disease, with potentially life-threatening long-term complications. CASE PRESENTATION: In this case report, we describe a tuberculous aortic graft infection in a 72-year-old man documented by polymerase chain reaction and cultures. The patient presented with three episodes of hemoptysis following a remote history of miliary tuberculosis. The infection was treated by graft replacement and prolonged antimycobacterial therapy. CONCLUSION: Tuberculous infection of a vascular graft is an uncommon complication, but should be considered in patients with an intravascular device and a history of previous tuberculosis, especially when hematogenous spread may have occurred a few months after surgery, or when an active mycobacterial infection is present in close proximity to the graft.

Étude des facteurs influençant la susceptibilité à l'infection au VIH chez des femmes africaines

Chez la femme, la majorité des cas d’infection au VIH sont acquis lors de relations hétérosexuelles. Cependant, très peu d’informations sont disponibles concernant l’immunité locale naturelle du tractus génital féminin, les facteurs influençant la susceptibilité à l’infection au VIH dans ce compartiment, ainsi que la réponse immunitaire de la muqueuse enclenchée après l’infection. Le but de notre projet est donc d’étudier certains facteurs pouvant être impliqués dans la susceptibilité à l’infection au VIH, afin de mieux comprendre l’immunité du tractus génital féminin. Nous avons, dans un premier temps, analysé le rôle du polymorphisme des gènes HLA-G et HLA-E sur la susceptibilité au VIH dans une population de femmes zimbabwéennes. La présence de l’allèle HLA-G*0105N, en combinaison avec le génotype HLA-EG/HLA-EG, était associée avec une diminution du risque d’infection. Puis, dans une étude cas-contrôle de travailleuses du sexe (TS) du Bénin, nous avons mesuré l’expression de HLA-G soluble au niveau du plasma. Nous avons observé une différence significative dans l’expression de HLA-G soluble, celle-ci étant plus faible dans le groupe des TS VIH positives comparé aux groupes de TS VIH négatives et de femmes VIH négatives de la population générale. Nous avons aussi analysé l’expression de cytokines et chimiokines dans le sérum et le tractus génital des participantes de l’étude du Bénin. Nous avons constaté que chez les TS VIH positives il y avait une expression plus élevée des chimiokines MPC-3, IP-10 et MIG dans le tractus génital et le sérum comparativement aux deux autres groupes. Les patrons d’expression des cytokines variaient selon les compartiments : le niveau de TNF-α et IFN-γ était plus élevé dans le tractus génital des TS VIH positives, alors que le niveau d’IL-2, d’IL-10 et de TNF-α était plus faible dans le sang des TS VIH positives, comparativement aux deux autres groupes. Ainsi, au niveau du tractus génital des femmes VIH positives, il semble y avoir une activation chronique du système immunitaire dans le but de favoriser la dissémination/perpétuation du virus. Les patrons d’expression différents entre le milieu systémique et génital nous montrent que l’immunité présente dans un compartiment n’est pas nécessairement le reflet de l’autre. Nous avons aussi observé une augmentation significative des niveaux d’IL-4, de MIP-1α, de MIP-1β et de MCP-1 dans le sérum des TS VIH négatives. Ces personnes, hautement exposées mais non infectées, semblent démontrer une plus grande capacité à enclencher une réponse immunitaire précoce pour empêcher la dissémination du virus. Notre étude a donc permis d’acquérir de nouvelles connaissances sur l’immunité du tractus génital féminin en relation avec l’infection au VIH.

Étude de la régulation du facteur de transcription NF-kB dans l'infection par le RSV

L’infection par le Virus Respiratoire Syncytial cause des affections pulmonaires aiguës en pédiatrie caractérisée par une réponse inflammatoire excessive médiée par la production de cytokines par les cellules épithéliales des voies aériennes. Les gènes codant pour ces cytokines sont régulés par le facteur de transcription NF-κB (p50/p65) dont l’activation est classiquement induite par la phosphorylation de son inhibiteur IκBα, ce qui permet l’accumulation de l’hétérodimère au noyau. Par contre, nous avons récemment identifié la phosphorylation en sérine 536 de la sous-unité p65 comme une autre étape essentielle à son activation lors de l’infection des AEC par RSV. Le travail présenté dans ce mémoire a permis de démontrer que l’inhibition de l’expression de RIG-I, de Cardif ou de TRAF6, 3 protéines impliquées dans la reconnaissance cellulaire des virus, conduit à l’inhibition de cette phosphorylation en réponse à RSV. Nous avons également établi à l’aide d’inhibiteurs pharmacologiques et d’ARNi que, parmi les diverses kinases connues pour phosphoryler p65 en réponse à divers stimulus, IKKα/β sont essentielles à cette phosphorylation lors d’une stimulation par RSV. Puisque TRAF6 est bien connu dans la littérature pour activer le complexe IKK, nous proposons que TRAF6, après reconnaissance de l’ARN viral de RSV par RIG-I, active le complexe IKK qui induit la phosphorylation de la sousunité p65 de NF-κB, permettant l’expression de gènes cibles. D’autre part, nous avions précédemment démontré que Nox2, un isoforme de NADPH oxydase, contrôle l’activation de NF-κB en régulant les phosphorylations de IκBα et p65. Nous montrons ici que l’inhibition de Nox2 réduit fortement l’activité du complexe kinase IKK. De plus, la présence au niveau basal de Nox2 est critique pour le niveau d’ARN messager de Cardif. Nous proposons donc que la régulation de la phosphorylation de p65 en ser536 par Nox2 soit via son effet sur Cardif en permettant la fonctionnalité de la voie RIG-I.

Identification of a new cell line permissive to porcine reproductive and respiratory syndrome virus infection and replication which is phenotypically distinct from MARC-145 cell line

Background Airborne transmitted pathogens, such as porcine reproductive and respiratory syndrome virus (PRRSV), need to interact with host cells of the respiratory tract in order to be able to enter and disseminate in the host organism. Pulmonary alveolar macrophages (PAM) and MA104 derived monkey kidney MARC-145 cells are known to be permissive to PRRSV infection and replication and are the most studied cells in the literature. More recently, new cell lines developed to study PRRSV have been genetically modified to make them permissive to the virus. The SJPL cell line origin was initially reported to be epithelial cells of the respiratory tract of swine. Thus, the goal of this study was to determine if SJPL cells could support PRRSV infection and replication in vitro. Results The SJPL cell growth was significantly slower than MARC-145 cell growth. The SJPL cells were found to express the CD151 protein but not the CD163 and neither the sialoadhesin PRRSV receptors. During the course of the present study, the SJPL cells have been reported to be of monkey origin. Nevertheless, SJPL cells were found to be permissive to PRRSV infection and replication even if the development of the cytopathic effect was delayed compared to PRRSV-infected MARC-145 cells. Following PRRSV replication, the amount of infectious viral particles produced in SJPL and MARC-145 infected cells was similar. The SJPL cells allowed the replication of several PRRSV North American strains and were almost efficient as MARC-145 cells for virus isolation. Interestingly, PRRSV is 8 to 16 times more sensitive to IFNα antiviral effect in SJPL cell in comparison to that in MARC-145 cells. PRRSV induced an increase in IFNβ mRNA and no up regulation of IFNα mRNA in both infected cell types. In addition, PRRSV induced an up regulation of IFNγ and TNF-α mRNAs only in infected MARC-145 cells. Conclusions In conclusion, the SJPL cells are permissive to PRRSV. In addition, they are phenotypically different from MARC-145 cells and are an additional tool that could be used to study PRRSV pathogenesis mechanisms in vitro.

The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial

Objective: Evaluation of selective decontamination of the digestive tract (SDD) on late mortality in ventilated trauma patients in an intensive care unit (ICU). Methods: A multicenter, randomized controlled trial was undertaken in 401 trauma patients with Hospital Trauma Index-Injury Severity Score of 16 or higher. Patients were randomized to control (n = 200) or SDD (n = 201), using polymyxin E, tobramycin, and amphotericin B in throat and gut throughout ICU treatment combined with cefotaxime for 4 days. Primary endpoint was late mortality excluding early death from hemorrhage or craniocerebral injury. Secondary endpoints were infection and organ dysfunction. Results: Mortality was 20.9% with SDD and 22.0% in controls. Overall late mortality was 15.3% (57/372) as 29 patients died from cerebral injury, 16 SDD and 13 control. The odds ratio (95% confidence intervals) of late mortality for SDD relative to control was 0.75 (0.40-1.37), corresponding to estimates of 13.4% SDD and 17.2% control. The overall infection rate was reduced in the test group (48.8% vs. 61.0%). SDD reduced lower airway infections (30.9% vs. 50.0%) and bloodstream infections due to aerobic Gram-negative bacilli (2.5% vs. 7.5%). No difference in organ dysfunction was found. Concluson: This study demonstrates that SDD significantly reduces infection in multiple trauma, although this RCT in 401 patients was underpowered to detect a mortality benefit.

Infection of gnotobiotic calves with Escherichia coli O157 : H7 strain A84

Six colostrum-deprived, hysterotomy-derived calves were maintained under sterile conditions and fed a milk replacer diet. At five days of age, five of the calves were dosed orally with 10(9)cfu of Escherichia coli O157: H7 strain A84. They were killed after, one, two, six, 12 and 24 days, and samples were taken for bacteriological and pathological examination. The sixth uninfected control calf was killed at seven days of age and matched samples were taken for pathological comparison. The animals remained normal throughout the observation period. Bacteriological data indicated a heavy bacterial load of strain A84 throughout the gastrointestinal tract but the bacterium was not found in liver, kidney or muscle. No evidence of attaching and effacing' lesions in the small or large intestine was found although there was a mild inflammatory response in the intestinal tract, consisting mainly of infiltrating eosinophils.

Lack of flagella disadvantages Salmonella enterica serovar Enteritidis during the early stages of infection in the rat

The roles of flagella and five fimbriae (SEF14, SEF17, SEF21, pef, lpf) in the early stages (up to 3 days) of Salmonella enterica serovar Enteritidis (S. Enteritidis) infection have been investigated in the rat. Wild-type strains LA5 and S1400 (fim+/fla+) and insertionally inactivated mutants unable to express the five fimbriae (fim-/fla+), flagella (fim+/fla-) or fimbriae and flagella (fim-/fla-) were used. All wild-type and mutant strains were able to colonize the gut and spread to the mesenteric lymph nodes, liver and spleen. There appeared to be little or no difference between the fim-/fla+ and wild-type (fim+/fla+) strains. In contrast, the numbers of aflagellate (fim+/fla- or fim-/fla-) salmonella in the liver and spleen were transiently reduced. In addition, fim+/fla- or fim-/fla-strains were less able to persist in the upper gastrointestinal tract and the inflammatory responses they elicited in the gut were less severe. Thus, expression of SEF14, SEF17, SEF21, pef and lpf did not appear to be a prerequisite for induction of S. Enteritidis infection in the rat. Deletion of flagella did, however, disadvantage the bacterium. This may be due to the inability to produce or release the potent immunomodulating protein flagellin.

EspJ is a prophage-carried type III effector protein of attaching and effacing pathogens that modulates infection dynamics

Enterohemorrhagic Escherichia coli, enteropathogenic E. coli, and Citrobacter rodentium are highly adapted enteropathogens that successfully colonize their host's gastrointestinal tract via the formation of attaching and effacing (A/E) lesions. These pathogens utilize a type III secretion system (TTSS) apparatus, encoded by the locus of enterocyte effacement, to translocate bacterial effector proteins into epithelial cells. Here, we report the identification of EspJ (E. coli-secreted protein J), a translocated TTSS effector that is carried on the 5' end of the cryptic prophage CP-933U. Infection of epithelial cells in culture revealed that EspJ is not required for A/E lesion activity in vivo and ex vivo. However, in vivo studies performed with mice demonstrated that EspJ possesses properties that influence the dynamics of clearance of the pathogen from the host's intestinal tract, suggesting a role in host survival and pathogen transmission.

Influence of colostrum deprivation and concurrent Cryptosporidium parvum infection on the colonization and persistence of Escherichia coli O157:H7 in young lambs

Escherichia coli O157: H7 and Cryptosporidium parvum infections of man have been associated with direct contact with small ruminants. Colostrum protects neonates against gastrointestinal pathogens, and orphan lambs, which are common on petting farms, may be deprived of this protection. In a recent study, it was demonstrated that high shedding of E coli O157 : H7 by an 8-week-old goat kid was associated with coincidental C. parvum infection. Furthermore, both pathogens were co-located in the distal gastrointestinal tract. It was hypothesized that colostrum deprivation and pre-infection with C. parvum predisposed young ruminants to colonization and increased shedding of E coli O157: H7. To test this, 21 lambs 5 weeks of age were divided into four groups as follows: (A) colostrum-deprived and inoculated with E coli O157: H7, (B) colostrum-deprived and inoculated with C. parvum and then E coli O157: H7, (C) conventionally reared and inoculated with E coli O157: H7, (D) conventionally reared and inoculated with C. parvum and then E coli O15 7: H7. C. parvum was detected between 8 and 12 days post-inoculation in most of the infected lambs. At 24 h post-inoculation with E coli O157: H7, all lambs were shedding between 5 x 10(4) and 5 x 10(7) c.f.u. E coli O157: H7 per gram of faeces. E coli O157: H7 was shed in higher numbers in the groups pre-inoculated with C. parvum, whether conventionally reared or colostrum-deprived. Interestingly, for the colostrum-deprived lambs on day 3, a significant difference in shedding of E coli O157: H7 was observed (P= 0-038), with the lambs inoculated with E coli alone yielding higher counts than those pre-inoculated with C. parvum. From day 15 onwards, shedding of E coli O157: H7 was highest from the colostrum-deprived C. parvum-infected lambs, then (in descending order of shedding) the colostrum-deprived lambs, the conventionally reared lambs infected with C. parvum, and the conventionally reared animals. In total, four animals were euthanized, two at 24 h and two at 96 h post inoculation with E coli 0 157: H7 (two conventionally reared and two colostrum-deprived). All animals euthanized were from groups pre-inoculated with C. parvum prior to challenge with E coli O157 : H7. On examination of tissues, in three of the four animals examined, multifocal attaching and effacing lesions were observed in the caecum, colon, rectum and at the recto-anal junction, and were confirmed by immunolhistochemistry to be associated with E coli O157: H7.

Sole infection by human metapneumovirus among children with radiographically diagnosed community-acquired pneumonia in a tropical region

Background Limited information is available on the role of human metapneumovirus (HMPV) as the unique pathogen among children hospitalized for community-acquired pneumonia (CAP) in a tropical region. Objective We aimed to describe HMPV infection among children with CAP investigating bacterial and viral co-infections. Patients and methods A prospective study was carried out in Salvador, North-East Brazil. Overall, 268 children aged <5 years hospitalized for CAP were enrolled. Human metapneumovirus RNA was detected in nasopharyngeal aspirates (NPA) by reverse transcription polymerase chain reaction. Sixteen other bacterial and viral pathogens were investigated by an expanded panel of laboratory methods. Chest X-ray taken on admission was read by an independent paediatric radiologist unaware of clinical information or the established aetiology. Results Human metapneumovirus RNA was detected in NPAs of 11 (4.1%) children, of which 4 (36%) had sole HMPV infection. The disease was significantly shorter among patients with sole HMPV infection in comparison with patients with mixed infection (4 +/- 1 versus 7 +/- 2 days, P = 0.03). Three of those four patients had alveolar infiltrates. Conclusion Sole HMPV infection was detected in children with CAP in Salvador, North-East Brazil. HMPV may play a role in the childhood CAP burden.

Multilevel analysis of hepatitis A infection in children and adolescents: a household survey in the Northeast and Central-west regions of Brazil

Background The objectives were to estimate the prevalence of hepatitis A among children and adolescents from the Northeast and Midwest regions and the Federal District of Brazil and to identify individual-, household- and area-levels factors associated with hepatitis A infection. Methods This population-based survey was conducted in 20042005 and covered individuals aged between 5 and 19 years. A stratified multistage cluster sampling technique with probability proportional to size was used to select 1937 individuals aged between 5 and 19 years living in the Federal capital and in the State capitals of 12 states in the study regions. The sample was stratified according to age (59 and 10- to 19-years-old) and capital within each region. Individual- and household-level data were collected by interview at the home of the individual. Variables related to the area were retrieved from census tract data. The outcome was total antibodies to hepatitis A virus detected using commercial EIA. The age distribution of the susceptible population was estimated using a simple catalytic model. The associations between HAV infection and independent variables were assessed using the odds ratio and corrected for the random design effect and sampling weight. Multilevel analysis was performed by GLLAMM using Stata 9.2. Results The prevalence of hepatitis A infection in the 59 and 1019 age-group was 41.5 and 57.4, respectively for the Northeast, 32.3 and 56.0, respectively for the Midwest and 33.8 and 65.1 for the Federal District. A trend for the prevalence of HAV infection to increase according to age was detected in all sites. By the age of 5, 31.5 of the children had already been infected with HAV in the Northeast region compared with 20.0 in the other sites. By the age of 19 years, seropositivity was 70 in all areas. The curves of susceptible populations differed from one area to another. Multilevel modeling showed that variables relating to different levels of education were associated with HAV infection in all sites. Conclusion The study sites were classified as areas with intermediate endemicity area for hepatitis A infection. Differences in age trends of infection were detected among settings. This multilevel model allowed for quantification of contextual predictors of hepatitis A infection in urban areas.

Adherence and invasion of Bacteroidales isolated from the human intestinal tract

Members of the genera Bacteroides and Parabacteroides are important constituents of both human and animal intestinal microbiota, and are significant facultative pathogens. In this study, the ability of Bacteroides spp. and Parabacteroides distasonis isolated from both diarrhoeal and normal stools (n = 114) to adhere to and invade HEp-2 cells was evaluated. The presence of putative virulence factors such as capsule and fimbriae was also investigated. Adherence to HEp-2 cells was observed in 75.4% of the strains, which displayed non-localized clusters. Invasion was observed in 37.5% and 26% of the strains isolated from diarrhoeal and non-diarrhoeal stools, respectively. All strains displayed a capsule, whereas none of them showed fimbriae-like structures. This is the first report of the ability of Bacteroides spp. and P. distasonis to adhere to and invade cultured HEp-2 epithelial cells.

The development of a Defense System against Coxsackievirus B5 Infection in Suckling Mice

There are many viruses that are able to infect the alimentary tract of man. Little is known, however, about the mechanism of infection itself or the pathophysiology of the gut during infection. 'The research reported here is concerned with the differences in susceptibility among suckling mice of various ages inoculated by the intraperitoneal and intragastric routes. Since the normal mode of entry of many viruses to the gut is via the oral route, Coxsackievirus B5, a human enterovirus which does attack this way, was utilized. It is a non-tumor producing RNA virus that has been shown to act similarly in the mouse and human. The virus was pooled in HeLa cell cultures and titered by a plaquing assay in the same cell cultures. CD-l mice, 10, 14, 18, and 22 days old , were infected either orally or intraperitoneally with 5.0 x 10^10 (10 day old animals) and 1.0 x10^9 plaque forming units per animal. Dissections were done at 1 and 3 days post infection with samples of the blood, heart, liver, and gut being taken from each animal. Each sample was titered individually and the data presented as an average of six samples. As a result of previous work, it is known that the gut of a newborn mouse isn't able to decrease the concentration of the infecting dose and therefore provides no defense against an enteric infection with Coxsackievirus B5. In contrat, mature mice are able to reduce the amount of viral dissemination across the gut as well as inhibit replication after absorption has occurred. The results of this study indicate that there is a double barrier system developing in suckling mice that is involved with and directly related to the gastrointestinal tract The first part of this defense is the inhibition of penetration of virus across the gut when the primary site of' infection is the intestinal mucosa. This mechanism develops sometime around 20 to 22 days after birth. At about 16-18 days of age, suckling mice that were challenged intragastrically are able to stop active replication and initiate clearance of virus from the systemic circulation. There are many factors that might contribute to the marked decrease in susceptibility with age of suckling mice. Some of these or possibly a combination of these factors might explain the defense mechanisms described above, but to date, the chemistry or mechanical functioning of the gastrointestinal barrier to enteric viral infection is unknown.

Incidência de infecção por Legionella pneumophila em pacientes que internaram no HCPA com pneumonia adquirida na comunidade

Introdução: O diagnóstico microbiológico da infecção por Legionella é complexo, pois a bactéria não é visualizada à coloração de Gram no escarro, e sua cultura não é realizada na maioria dos laboratórios clínicos. A imunofluorescência direta nas secreções respiratórias tem baixa sensibilidade, em torno de 40% e a técnica da “PCR” não é ainda recomendada para o diagnóstico clínico (CDC, 1997). A detecção de anticorpos no soro é a técnica mais utilizada, e o critério definitivo é a soroconversão para no mínimo 1:128, cuja sensibilidade é de 70 a 80% (Edelstein, 1993). Como critérios diagnósticos de possível pneumonia por Legionella, eram utilizados: título único de anticorpos a L pneumophila positivo na diluição 1:256, em paciente com quadro clínico compatível (CDC, 1990) e o achado de antígeno a Legionella na urina (WHO, 1990). Nos últimos anos, porém, com o uso crescente do teste de antigenúria, foram detectados casos de pneumonia por Legionella, que não eram diagnosticados por cultura ou sorologia, tornando-o método diagnóstico de certeza para o diagnóstico de pneumonia por Legionella (CDC, 1997). Por sua fácil execução, resultado imediato, e alta sensibilidade - de 86% a 98% (Kashuba & Ballow, 1986; Harrison & Doshi, 2001), tem sido recomendado para o diagnóstico das PAC que necessitam internação hospitalar (Mulazimoglu & Yu, 2001; Gupta et al., 2001; Marrie, 2001), especialmente em UTI (ATS, 2001). Vários estudos documentaram baixo valor preditivo positivo do título único positivo de 1:256, tornando-o sem valor para o diagnóstico da pneumonia por Legionella, exceto, talvez, em surtos (Plouffe et al., 1995). Outros detectaram alta prevalência de anticorpos positivos na diluição 1:256 na população, em pessoas normais (Wilkinson et al., 1983; Nichol et al., 1991). A partir de 1996, o CDC de Atlanta recomendou que não seja mais utilizado o critério de caso provável de infecção por Legionella pneumophila por título único de fase convalescente ≥1:256, por falta de especificidade(CDC, 1997). A pneumonia por Legionella é raramente diagnosticada, e sua incidência é subestimada. Em estudos de PAC, a incidência da pneumonia por Legionella nos EUA, Europa, Israel e Austrália, foi estimada entre 1% a 16% (Muder & Yu, 2000). Nos EUA, foi estimado que cerca de 8 000 a 23 000 casos de PAC por Legionella ocorrem anualmente, em pacientes que requerem hospitalização (Marston et al., 1994 e 1977). No Brasil, a incidência de PAC causadas por Legionella em pacientes hospitalizados é tema de investigação pertinente, ainda não relatado na literatura. Objetivo: detectar a incidência de pneumonias causadas por Legionella pneumophila sorogrupos 1 a 6, em pacientes que internaram no Hospital de Clínicas de Porto Alegre por PAC, por um ano. Material e Métodos: o delineamento escolhido foi um estudo de coorte (de incidência), constituída por casos consecutivos de pneumonia adquirida na comunidade que internaram no HCPA de 19 de julho de 2000 a 18 de julho de 2001. Para a identificação dos casos, foram examinados diariamente o registro computadorizado das internações hospitalares, exceto as internações da pediatria e da obstetrícia, sendo selecionados todos os pacientes internados com o diagnóstico de pneumonia e de insuficiência respiratória aguda. Foram excluídos aqueles com menos de 18 anos ou mais de 80 anos; os procedentes de instituições, HIV-positivos, gestantes, pacientes restritos ao leito; e portadores de doença estrutural pulmonar ou traqueostomias. Foram excluídos os pacientes que tivessem tido alta hospitalar nos últimos 15 dias, e aqueles já incluídos no decorrer do estudo. Os pacientes selecionados foram examinados por um pesquisador, e incluídos para estudo se apresentassem infiltrado ao RX de tórax compatível com pneumonia, associado a pelo menos um dos sintomas respiratórios maiores (temperatura axilar > 37,8ºC, tosse ou escarro; ou dois sintomas menores (pleurisia, dispnéia, alteração do estado mental, sinais de consolidação à ausculta pulmonar, mais de 12 000 leucócitos/mm3). O estudo foi previamente aprovado pela Comissão de Ética em Pesquisa do HCPA. Os pacientes eram entrevistados por um pesquisador, dando seu consentimento por escrito, e então seus dados clínicos e laboratoriais eram registrados em protocolo individual. Não houve interferência do pesquisador, durante a internação, exceto pela coleta de urina e de sangue para exame laboratoriais específicos da pesquisa. Os pacientes eram agendados, no ambulatório de pesquisa, num prazo de 4 a 12 semanas após sua inclusão no estudo, quando realizavam nova coleta de sangue, RX de tórax de controle, e outros exames que se fizessem necessários para esclarecimento diagnóstico.Todos os pacientes foram acompanhados por 1 ano, após sua inclusão no estudo.Foram utilizadas a técnica de imunofluorescência indireta para detecção de anticorpos das classes IgG, IgM e IgA a Legionella pneumophila sorogrupos 1 a 6 no soro, em duas amostras, colhidas, respectivamente, na 1ª semana de internação e depois de 4 a 12 semanas; e a técnica imunológica por teste ELISA para a detecção do antígeno de Legionella pneumophila sorogrupo 1 na urina, colhida na primeira semana de internação. As urinas eram armazenadas, imediatamente após sua coleta, em freezer a –70ºC, e depois descongeladas e processadas em grupos de cerca de 20 amostras. A imunofluorescência foi feita no laboratório de doenças Infecciosas da Universidade de Louisville (KY, EUA), em amostras de soro da fase aguda e convalescente, a partir da diluição 1:8; e a detecção do antígeno de Legionella pneumophila sorogrupo 1, nas amostras de urina, foi realizada no laboratório de pesquisa do HCPA, pelos investigadores, utilizando um kit comercial de teste ELISA fabricado por Binax (Binax Legionella Urinary Enzyme Assay, Raritan, EUA). As urinas positivas eram recongeladas novamente, para serem enviadas para confirmação no mesmo laboratório americano, ao fim do estudo. Foram adotados como critérios definitivos de infecção por Legionella pneumophila sorogrupos 1 a 6, a soroconversão (elevação de 4 vezes no título de anticorpos séricos entre o soro da fase aguda e da fase convalescente para no mínimo 1:128); ou o achado de antígeno de L pneumophila sorogrupo 1 na urina não concentrada, numa razão superior a 3, conforme instruções do fabricante e da literatura.Os pacientes foram classificados, de acordo com suas características clínicas, em 1º) portadores de doenças crônicas (doenças pulmonares, cardíacas, diabete mellitus, hepatopatias e insuficiência renal); 2º) portadores de doenças subjacentes com imunossupressão; 3º) pacientes hígidos ou com outras doenças que não determinassem insuficiência orgânica. Imunossupressão foi definida como esplenectomia, ser portador de neoplasia hematológica, portador de doença auto-imune, ou de transplante; ou uso de medicação imunossupressora nas 4 semanas anteriores ao diagnóstico (Yu et al., 2002b); ou uso de prednisolona 10 mg/dia ou equivalente nos últimos 3 meses (Lim et al., 2001). As características clínicas e laboratoriais dos pacientes que evoluíram ao óbito por pneumonia foram comparados àquelas dos pacientes que obtiveram cura. Para a análise das variáveis categóricas, utilizou-se o teste qui-quadrado de Pearson ou teste exato de Fisher. Para as variáveis numéricas contínuas, utilizou-se o teste “t“ de Student. Um valor de p< 0,05 foi considerado como resultado estatisticamente significativo (programas SPSS, versão 10). Foi calculada a freqüência de mortes por pneumonia na população estudada, adotando-se a alta hospitalar como critério de cura. Foi calculada a incidência cumulativa para pneumonia por Legionella pneumophila sorogrupos 1 a 6, em um hospital geral, no período de 1 ano. Resultados: durante um ano de estudo foram examinados 645 registros de internação, nos quais constavam, como motivo de baixa hospitalar, o diagnóstico de pneumonia ou de insuficiência respiratória aguda; a maioria desses diagnósticos iniciais não foram confirmados. Desses 645 pacientes, foram incluídos no estudo 82 pacientes, nos quais os critérios clínicos ou radiológicos de pneumonia foram confirmados pelos pesquisadores. Durante o acompanhamento desses pacientes, porém, foram excluídos 23 pacientes por apresentarem outras patologias que mimetizavam pneumonia: DPOC agudizado (5), insuficiência cardíaca (3), tuberculose pulmonar (2), colagenose (1), fibrose pulmonar idiopática (1), edema pulmonar em paciente com cirrose (1), somente infecçâo respiratória em paciente com sequelas pulmonares (4); ou por apresentarem critérios de exclusão: bronquiectasias (4), HIV positivo (1), pneumatocele prévia (1). Ao final, foram estudados 59 pacientes com pneumonia adquirida na comunidade, sendo 20 do sexo feminino e 39 do sexo masculino, com idade entre 24 e 80 anos (média de 57,6 anos e desvio padrão de ±10,6). Tivemos 36 pacientes com doenças subjacentes classificadas como “doenças crônicas”, dos quais 18 pacientes apresentavam mais de uma co-morbidade, por ordem de prevalência: doenças pulmonares, cardíacas, diabete mellitus, hepatopatias e insuficiência renal; neoplasias ocorreram em 9 pacientes, sendo sólidas em 7 pacientes e hematológicas em 2. Dos 59 pacientes, 61% eram tabagistas e 16,9%, alcoolistas. Do total, 10 pacientes apresentavam imunossupressão. Dos demais 13 pacientes, somente um era previamente hígido, enquanto os outros apresentavam tabagismo, sinusite, anemia, HAS, gota, ou arterite de Takayasu. A apresentação radiológica inicial foi broncopneumonia em 59,3% dos casos; pneumonia alveolar ocorreu em 23,7% dos casos, enquanto ambos padrões ocorreram em 15,2% dos pacientes. Pneumonia intersticial ocorreu em somente um caso, enquanto broncopneumonia obstrutiva ocorreu em 5 pacientes (8,5%). Derrame pleural ocorreu em 22% dos casos, e em 21 pacientes (35%) houve comprometimento de mais de um lobo ao RX de tórax. Foram usados beta-lactâmicos para o tratamento da maioria dos pacientes (72,9%9). A segunda classe de antibióticos mais usados foi a das fluoroquinolonas respiratórias, que foram receitadas para 23 pacientes (39,0%), e em 3º lugar, os macrolídeos, usados por 11 pacientes (18,6%). Apenas 16 pacientes não usaram beta-lactâmicos, em sua maioria recebendo quinolonas ou macrolídeos. Dos 43 pacientes que usaram beta-lactâmicos, 25 não usaram nem macrolídeos, nem quinolonas. Em 13 pacientes as fluoroquinolonas respiratórias foram as únicas drogas usadas para o tratamento da pneumonia. Do total, 8 pacientes foram a óbito por pneumonia; em outros 3 pacientes, o óbito foi atribuído a neoplasia em estágio avançado. Dos 48 pacientes que obtiveram cura, 33 (68,7%) estavam vivos após 12 meses. Os resultados da comparação realizada evidenciaram tendência a maior mortalidade no sexo masculino e em pacientes com imunossupressão, porém essa associação não alcançou significância estatística. Os pacientes que usaram somente beta-lactâmicos não apresentaram maior mortalidade do que os pacientes que usaram beta-lactâmicos associados a outras classes de antibióticos ou somente outras classes de antibióticos. Examinando-se os pacientes que utiizaram macrolídeos ou quinolonas em seu regime de tratamento, isoladamente ou combinados a outros antibióticos, observou-se que também não houve diferença dos outros pacientes, quanto à mortalidade. Os pacientes com padrão radiológico de pneumonia alveolar tiveram maior mortalidade, e essa diferença apresentou uma significância limítrofe (p= 0,05). Nossa mortalidade (11,9%) foi similar à de Fang et al. (1990), em estudo clássico de 1991 (13,7%); foi também similar à média de mortalidade das PAC internadas não em UTI (12%), relatada pela ATS, no seu último consenso para o tratamento empírico das PAC (ATS, 2001). Foram detectados 3 pacientes com pneumonia por Legionella pneumophila sorogrupo 1 na população estudada: 2 foram diagnosticados por soroconversão e por antigenúria positiva, e o 3º foi diagnosticado somente pelo critério de antigenúria positiva, tendo sorologia negativa, como alguns autores (McWhinney et al., 2000). Dois pacientes com PAC por Legionella não responderam ao tratamento inicial com beta-lactâmicos, obtendo cura com levofloxacina; o 3º paciente foi tratado somente com betalactâmicos, obtendo cura. Conclusões: A incidência anual de PAC por Legionella pneumophila sorogrupos 1 a 6, no HCPA, foi de 5,1%, que representa a incidência anual de PAC por Legionella pneumophila sorogrupos 1 a 6 em um hospital geral universitário. Comentários e Perspectivas: Há necessidade de se empregar métodos diagnósticos específicos para o diagnóstico das pneumonias por Legionella em nosso meio, como a cultura, a sorologia com detecção de todas as classes de anticorpos, e a detecção do antígeno urinário, pois somente com o uso simultâneo de técnicas complementares pode-se detectar a incidência real de pneumonias causadas tanto por Legionella pneumophila, como por outras espécies. A detecção do antígeno de Legionella na urina é o teste diagnóstico de maior rendimento, sendo recomendado seu uso em todas as PAC que necessitarem internação hospitalar (Mulazimoglu & Yu, 2001; Gupta et al., 2001); em todos os pacientes com PAC que apresentarem fatores de risco potenciais para legionelose (Marrie, 2001); e para o diagnóstico etiológico das pneumonias graves (ATS, 2001). Seu uso é indicado, com unanimidade na literatura, para a pesquisa de legionelose nosocomial e de surtos de legionelose na comunidade.