Prognóstico de pacientes infectados pelo HIV internados na Unidade de Terapia Intensiva: um estudo multicêntrico brasileiro

Made available in DSpace on 2018-03-19T16:39:47Z (GMT). No. of bitstreams: 2 license.txt: 1748 bytes, checksum: 8a4605be74aa9ea9d79846c1fba20a33 (MD5) hugo_andrade_ini_mest_2016.pdf: 9527935 bytes, checksum: b1c6c657301c83cc2f44efd738c6a4c0 (MD5)Fundação Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Rio de Janeiro, RJ, Brasil.A terapia antirretroviral combinada (cART) revolucionou o tratamento do HIV/Aids, com significativo impacto na sobrevida e na qualidade de vida. No entanto, a mortalidade de pacientes HIV que evoluem com gravidade e são internados em unidades de terapia intensiva (UTI) continua elevada. Conhecer os fatores prognósticos e prever o desfecho dos pacientes críticos com HIV são importantes para a adoção de medidas preventivas e tratamento mais adequado. Foi realizada, na primeira parte da dissertação, uma revisão sistemática da literatura sobre fatores prognósticos de curto prazo (mortalidade na UTI e hospitalar) de pacientes críticos portadores do HIV que concluiu que fatores associados com a gravidade da doença aguda, como escores prognósticos, albumina e falências orgânicas (choque e insuficiência respiratória), parecem ter maior importância como determinantes da mortalidade de curto prazo do que os associados ao HIV, mas uso de cART durante a internação na UTI pode ser benéfico conforme metanálise dos dados, apresentada na segunda parte da dissertação como um artigo científico original em inglês. Para comprovar os dados da revisão relativos à mortalidade na UTI, na terceira parte da dissertação apresenta-se um estudo observacional prospectivo multicêntrico, com três unidades de terapia intensiva brasileiras, que concluiu que choque à admissão, coma, hipoalbuminemia grave e infecção bacteriana adquirida na UTI são fatores independentemente associados com a mortalidade na unidade de terapia intensiva; enquanto fatores associados à infecção pelo HIV não apresentaram associação com a mortalidade na UTI.Combination antiretroviral therapy (cART) has revolutionized the treatment of HIV/AIDS, with a significant impact on survival and quality of life. However, the mortality of HIV patients who develop critical illness and are admitted to intensive care units (ICU) remains high. Knowing the prognostic factors and predicting the outcome of critically ill HIV patients are important for the adoption of preventive measures and appropriate treatment. A systematic review of the literature on short-term prognostic factors (ICU and hospital mortality) for critically ill HIV patients was performed and it concluded that factors associated with severity of acute illness, such as prognostic scores, albumin and organic failure (shock and respiratory failure), seem to have greater importance as determinants of short-term mortality than those associated with HIV. However, the use of cART during ICU stay can be beneficial as demonstrated by meta-analysis of revision data. To corroborate the systematic review\2019s conclusions on ICU mortality, we conducted a multicenter prospective observational study with three Brazilian intensive care units that showed that shock on admission, coma, severe hypoalbuminemia and bacterial infection acquired in the ICU are factors independently associated with mortality in the intensive care unit; while factors associated with HIV infection were not associated with mortality in the IC

ENCEFALITE POR ENTEROVÍRUS EM UMA PACIENTE ADULTA IMUNOCOMPETENTE

Mulher, 45 anos, previamente hígida, foi internada por quadro de confusão mental, agitação psicomotora e crises epilépticas iniciado 3 dias após receber vacina tríplice viral. Hipótese diagnóstica inicial foi de encefalite pós-vacinal, ácido valproico 1500 mg/dia foi introduzido para controle das crises. Devido a possibilidade de encefalite herpética, fez uso de aciclovir venoso. Durante a internação realizou ressonância magnética (RM) de crânio que evidenciou lesões hiperintensas em FLAIR nos centros semiovais e lobo temporal direito. Líquor com 01 célula (100% mono), glicose (78mg/dl), proteínas (38mg/dl), teste de reação em cadeia da polimerase (PCR) para HSV1, HSV2, VZV, EBV, CMV, HH6, HH8 e sarampo negativos; PCR para enterovírus (EV) detectável, confirmando diagnóstico de encefalite por EV. Após melhora do quadro neurológico e sem novos episódios de crises epilépticas, recebeu alta hospitalar para seguimento pela neurologia. Durante acompanhamento precisou da conciliação das doses das drogas anticrise (DAC) sendo o último esquema em uso composto por ácido valproico 1500mg/dia e fenitoína 300mg/dia. Após três anos de acompanhamento ambulatorial, foi diagnosticada com tuberculose ganglionar confirmada por GeneXpert MTB-RIF detectável, sensível à rifampicina em material de biópsia de linfonodo. Nova sorologia para HIV não reagente. Iniciou RHZE, foi realizada troca de fenitoína por levetiracetam por interação medicamentosa com isoniazida. Um mês após o início do RHZE, reinternou por novo quadro de crise epiléptica, após ampla investigação, excluído nova infecção e aventada hipótese de crise epiléptica secundaria a uso de isoniazida, não sendo necessário sua interrupção, apenas ajuste das DAC, para melhora do quadro. A incidência de encefalite em adultos varia de 0,7-12,6/100.000 habitantes, sendo maior em crianças menores de um ano. A encefalite viral é a causa mais comum de encefalite e as etiologias mais comuns em todo o mundo são: herpes vírus (HSV-1/HSV-2), arbovírus e enterovírus não poliomielite. Os enterovírus (EV) possuem mais de 70 sorotipos; o sorotipo EV-71 tem sido associado a uma taxa mais alta de encefalite. O diagnóstico é realizado por identificação do EV por PCR. A RM cerebral pode evidenciar lesões hiperintensas de T2WI e FLAIR no mesencéfalo, ponte e medula. Cerca de 20% dos pacientes recuperados apresentam sequelas neurológicas. A isoniazida raramente (0,01%) pode causar sintomas neurológicos como crises epilépticas

Paracoccidioidomycosis due to Paracoccidioides brasiliensis S1 plus HIV co-infection

<div><p> BACKGROUND Paracoccidioidomycosis (PCM) is one of the most important systemic mycoses in Latin America and the leading fungal cause of mortality in non-immunosuppressed individuals in Brazil. However, HIV/PCM co-infection can increase the clinical severity in these co-infected patients. This co-infection is rarely reported in the literature mainly because of the different epidemiological profiles of these infections. Furthermore, PCM is a neglected and non-notifiable disease, which may underestimate the real importance of this disease. The advent of molecular studies on the species of the genus Paracoccidioides has expanded the knowledge regarding the severity and the clinical spectrum in PCM. In this context, the development of studies to describe the association of the Paracoccidioides phylogenetic cryptic species in vulnerable populations, such as HIV-infected patients, appears relevant. OBJECTIVE To describe the clinical, epidemiological, therapeutic and prognostic aspects in HIV/PCM co-infected patients, along with the molecular identification of the Paracoccidioides species involved in these cases. METHODS The investigators performed a molecular and clinical retrospective study involving HIV/PCM co-infected patients, from a reference centre for PCM care in the endemic area of Rio de Janeiro, Brazil, from 1998 to 2015. Molecular identification of the fungal strains was done by amplification of partial sequences of arf and gp43 genes. FINDINGS Of 89 patients diagnosed with PCM by fungal isolation in the culture, a viable isolate was recovered for molecular analysis from 44 patients. Of these 44 patients, 28 (63.6%) had their serum samples submitted for enzyme immunoassay tests for screening of HIV antibodies, and 5 (17.9%) had a positive result. All cases were considered severe, with a variable clinical presentation, including mixed, acute/subacute clinical forms and a high rate of complications, requiring combination therapy. Paracoccidioides brasiliensis S1 was the species identified in all cases. CONCLUSIONS HIV/PCM co-infection can change the natural history of this fungal disease. The authors reinforce the need to include HIV screening diagnostic tests routinely for patients with PCM.</p></div

Highly active antiretroviral therapy for critically ill HIV patients: A systematic review and meta-analysis

<div><p>Introduction</p><p>It is unclear whether the treatment of an HIV infection with highly active antiretroviral therapy (HAART) affects intensive care unit (ICU) outcomes. In this paper, we report the results of a systematic review and meta-analysis performed to summarize the effects of HAART on the prognosis of critically ill HIV positive patients.</p><p>Materials and methods</p><p>A bibliographic search was performed in 3 databases (PubMed, Web of Science and Scopus) to identify articles that investigated the use of HAART during ICU admissions for short- and long-term mortality or survival. Eligible articles were selected in a staged process and were independently assessed by two investigators. The methodological quality of the selected articles was evaluated using the <i>Methodological Index for Non-Randomized Studies</i> (MINORS) tool.</p><p>Results</p><p>Twelve articles met the systematic review inclusion criteria and examined short-term mortality. Six of them also examined long-term mortality (≥90 days) after ICU discharge. The short-term mortality meta-analysis showed a significant beneficial effect of initiating or maintaining HAART during the ICU stay (random effects odds ratio 0.53, p = 0.02). The data analysis of long-term outcomes also suggested a reduced mortality when HAART was used, but the effect of HAART on long-term mortality of HIV positive critically ill patients remains uncertain.</p><p>Conclusions</p><p>This meta-analysis suggests improved survival rates for HIV positive patients who were treated with HAART during their ICU admission.</p></div

Highly active antiretroviral therapy systematic review and meta-analysis flowchart.

<p>HAART systematic review flowchart, which shows the procedure used for the selection of the articles for the qualitative and quantitative synthesis. <i>HAART</i> highly active antiretroviral therapy; <i>ICU</i> intensive care unit. PRISMA Model Flow Diagram [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0186968#pone.0186968.ref024" target="_blank">24</a>].</p

Forest plot of the effects of highly active antiretroviral therapy (HAART) on <i>short-term</i> mortality–random effects odds ratio.

<p>Forest plot of the effects of highly active antiretroviral therapy (HAART) on <i>short-term</i> mortality–random effects odds ratio.</p

Funnel plot of the effects of highly active antiretroviral therapy (HAART) on <i>short-term</i> mortality–random effects odds ratio.

<p>Funnel plot of the effects of highly active antiretroviral therapy (HAART) on <i>short-term</i> mortality–random effects odds ratio.</p

General characteristics of the studies.

<p>General characteristics of the studies.</p

In-hospital mortality and severe outcomes after hospital discharge due to COVID-19: A prospective multicenter study from Brazil.

BackgroundWe evaluated in-hospital mortality and outcomes incidence after hospital discharge due to COVID-19 in a Brazilian multicenter cohort.MethodsThis prospective multicenter study (RECOVER-SUS, NCT04807699) included COVID-19 patients hospitalized in public tertiary hospitals in Brazil from June 2020 to March 2021. Clinical assessment and blood samples were performed at hospital admission, with post-hospital discharge remote visits. Hospitalized participants were followed-up until March 31, 2021. The outcomes were in-hospital mortality and incidence of rehospitalization or death after hospital discharge. Kaplan-Meier curves and Cox proportional-hazard models were performed.Findings1589 participants [54.5% male, age=62 (IQR 50-70) years; BMI=28.4 (IQR,24.9-32.9) Kg/m² and 51.9% with diabetes] were included. A total of 429 individuals [27.0% (95%CI,24.8-29.2)] died during hospitalization (median time 14 (IQR,9-24) days). Older age [vs&lt;40 years; age=60-69 years-aHR=1.89 (95%CI,1.08-3.32); age=70-79 years-aHR=2.52 (95%CI,1.42-4.45); age≥80-aHR=2.90 (95%CI 1.54-5.47)]; noninvasive or mechanical ventilation at admission [vs facial-mask or none; aHR=1.69 (95%CI 1.30-2.19)]; SAPS-III score≥57 [vs&lt;57; aHR=1.47 (95%CI 1.13-1.92)] and SOFA score≥10 [vs &lt;10; aHR=1.51 (95%CI 1.08-2.10)] were independently associated with in-hospital mortality. A total of 65 individuals [6.7% (95%CI 5.3-8.4)] had a rehospitalization or death [rate=323 (95%CI 250-417) per 1000 person-years] in a median time of 52 (range 1-280) days post-hospital discharge. Age ≥ 60 years [vs &lt;60, aHR=2.13 (95%CI 1.15-3.94)] and SAPS-III ≥57 at admission [vs &lt;57, aHR=2.37 (95%CI 1.22-4.59)] were independently associated with rehospitalization or death after hospital discharge.InterpretationHigh in-hospital mortality rates due to COVID-19 were observed and elderly people remained at high risk of rehospitalization and death after hospital discharge.FundingFundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Programa INOVA-FIOCRUZ