44 research outputs found
Leukoerythroblastosis in a Young Child with Severe Malaria and Superimposed Gram Negative Infection
Background: Leukoerythroblastosis, a non-specific and often
short-lasting response of the bone marrow to different diseases
such as malignancies or infections, is characterized by the
presence in the peripheral blood of immature red and white
cells. Methods: We present a case of leukoerythoblastosis
occurring in a 24 months old Mozambican girl, in the context of
a severe malaria episode and an associated urinary tract
infection. Peripheral blood smear was used for diagnosis of
malaria and leukoerythroblastosis. Enterobacter cloacae
isolation and antibiotic susceptibility testing were performed
by conventional microbiology. Results: Peripheral blood smear
was positive for Plasmodium falciparum and showed a
leukoerythroblastosis with red cell anisopoikilocytosis and left
shifted neutrophils. Urine culture confirmed the presence of a
multi-resistant E. cloacae. Treatment of underlying conditions
resolved the leukoerythroblastic reaction. Conclusions:
Leukoerythroblastosis may be related to different infectious
diseases and may also appear in the context of severe malaria.
Bacterial superinfection needs to be investigated
Improving stool sample processing and pyrosequencing for quantifying benzimidazole resistance alleles in Trichuris trichiura and Necator americanus pooled eggs
Background: There is an urgent need for an extensive evaluation of benzimidazole efcacy in humans. In veterinary science, benzimidazole resistance has been mainly associated with three single-nucleotide polymorphisms (SNPs) in the isotype-1 β-tubulin gene. In this study, we optimized the stool sample processing methodology and resistance allele frequency assessment in Trichuris trichiura and Necator americanus anthelmintic-related SNPs by pyrosequenc‑ ing, and standardized it for large-scale benzimidazole efcacy screening use. Methods: Three diferent protocols for stool sample processing were compared in 19 T. trichiura-positive samples: fresh stool, egg concentration using metallic sieves with decreasing pore size, and egg concentration followed by fotation with saturated salt solution. Yield of each protocol was assessed by estimating the load of parasite DNA by real-time PCR. Then, we sequenced a DNA fragment of the β-tubulin gene containing the putative benzimidazole resistance SNPs in T. trichiura and N. americanus. Afterwards, resistant and susceptible-type plasmids were produced and mixed at diferent proportions, simulating diferent resistance levels. These mixtures were used to compare previ‑ ously described pyrosequencing assays with processes newly designed by our own group. Once the stool sample processing and the pyrosequencing methodology was defned, the utility of the protocols was assessed by measur‑ ing the frequencies of putative resistance SNPs in 15 T. trichiura- and 15 N. americanus-positive stool samples. Results: The highest DNA load was provided by egg concentration using metallic sieves with decreasing pore size. Sequencing information of the β-tubulin gene in Mozambican specimens was highly similar to the sequences previ‑ ously reported, for T. trichiura and N. americanus, despite the origin of the sample. When we compared pyrosequenc‑ ing assays using plasmids constructs, primers designed in this study provided the most accurate SNP frequencies. When pooled egg samples were analysed, none of resistant SNPs were observed in T. trichiura, whereas 17% of the resistant SNPs at codon 198 were found in one N. americanus sample
Towards soil-transmitted helminths transmission interruption: The impact of diagnostic tools on infection prediction in a low intensity setting in Southern Mozambique
Copyright: © 2021 Grau-Pujol et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.[EN] World Health Organization goals against soil-transmitted helminthiases (STH) are pointing towards seeking their elimination as a public health problem: reducing to less than 2% the proportion of moderate and heavy infections. Some regions are reaching WHO goals, but transmission could rebound if strategies are discontinued without an epidemiological evalu-ation. For that, sensitive diagnostic methods to detect low intensity infections and localiza-tion of ongoing transmission are crucial. In this work, we estimated and compared the STH infection as obtained by different diagnostic methods in a low intensity setting. We conducted a cross-sectional study enrolling 792 participants from a district in Mozambique. Two stool samples from two consecutive days were collected from each participant. Samples were analysed by Telemann, Kato-Katz and qPCR for STH detection. We evaluated diagnostic sensitivity using a composite reference standard. By geostatistical methods, we estimated neighbourhood prevalence of at least one STH infection for each diagnostic method. We used environmental, demographical and socioeconomical indicators to account for any existing spatial heterogeneity in infection. qPCR was the most sensitive technique compared to composite reference standard: 92% (CI: 83%– 97%) for A. lumbricoides, 95% (CI: 88%– 98%) for T. trichiura and 95% (CI: 91%– 97%) for hookworm. qPCR also estimated the highest neighbourhood prevalences for at least one STH infection in a low intensity set-ting. While 10% of the neighbourhoods showed a prevalence above 20% when estimating with single Kato-Katz from one stool and Telemann from one stool, 86% of the neighbour-hoods had a prevalence above 20% when estimating with qPCR. In low intensity settings, STH estimated prevalence of infection may be underestimated if based on Kato-Katz. qPCR diagnosis outperformed the microscopy methods. Thus, implementation of qPCR based predictive maps at STH control and elimination programmes would disclose hidden transmission and facilitate targeted interventions for transmission interruption.SIBGP and JM received financial support for this study from Mundo Sano Foundation (www. mundosano.org). JG was personally supported at the beginning of the work by the Ramo´n Areces Foundation and is now funded by the Spanish ‘Juan de la Cierva’ Programme, Ministry of Economy and Competitiveness (FJC-2018-38305). MMV is personally supported by the Spanish ‘Ramo´n y Cajal’ Programme, Ministry of Economy and Competitiveness (RYC-2015-18368). MCP is personally supported by Junta de Castilla y Leo´n and Fondo Social Europeo (LE-135-19). ISGlobal is a member of the CERCA Programme, Generalitat de Catalunya. CISM is supported by the Government of Mozambique and the Spanish Agency for International Development (AECID). Prof. Dr. P.C. Flu Foundation also founded this project. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript
Characterization of Vaginal Escherichia coli Isolated from Pregnant Women in Two Different African Sites
The relevance of vaginal colonization of pregnant women by
Escherichia coli is poorly understood, despite these strains
sharing a similar virulence profile with other extraintestinal
pathogenic E. coli producing severe obstetric and neonatal
infections. We characterized the epidemiology, antimicrobial
susceptibility and virulence profiles of 84 vaginal E. coli
isolates from pregnant women from Rabat (Morocco) and Manhica
(Mozambique), two very distinct epidemiological settings. Low
levels of antimicrobial resistance were observed to all drugs
tested, except for trimethoprim-sulfamethoxazole in Manhica,
where this drug is extensively used as prophylaxis for
opportunistic HIV infections. The most prevalent virulence
factors were related to iron acquisition systems. Phylogroup A
was the most common in Rabat, while phylogroups E and
non-typeable were the most frequent in Manhica. Regardless of
the apparently "low virulence" of these isolates, the frequency
of infections is higher and the outcomes more devastating in
constrained-resources conditions, especially among pregnant
women and newborns
Impact of rotavirus vaccination on diarrheal hospitalizations in children younger than 5 years of age in a rural southern Mozambique
Funding Information: We thank the participants in this study and their parents for allowing the collection of samples and data. The authors would also like to thank all Centro de Investigação em Saúde de Manhiça (CISM) staff particularly those supporting Diarrheal Disease Research Area and Manhiça District Hospital. Core funding for CISM is provided by the Spanish Agency for International Cooperation and Development (AECID). ISGlobal receives support from the Spanish Ministry of Science and Innovation through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018-000806-S), and support from the Generalitat de Catalunya through the CERCA Program. The GEMS study was supported by the Bill & Melinda Gates Foundation (Project OPP 38874). The impact of rotavirus study was supported by GAVI funds through Centers for Disease Control and Prevention Foundation (CDCF), Atlanta & World Health Organization, Regional Offices for Africa (WHO AFRO). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The findings and conclusions of this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention and World Health Organization. The authors declare no conflict of interest. Funding Information: We thank the participants in this study and their parents for allowing the collection of samples and data. The authors would also like to thank all Centro de Investigação em Saúde de Manhiça (CISM) staff particularly those supporting Diarrheal Disease Research Area and Manhiça District Hospital. Core funding for CISM is provided by the Spanish Agency for International Cooperation and Development (AECID). ISGlobal receives support from the Spanish Ministry of Science and Innovation through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018-000806-S), and support from the Generalitat de Catalunya through the CERCA Program. The GEMS study was supported by the Bill & Melinda Gates Foundation (Project OPP 38874). The impact of rotavirus study was supported by GAVI funds through Centers for Disease Control and Prevention Foundation (CDCF), Atlanta & World Health Organization, Regional Offices for Africa (WHO AFRO). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Publisher Copyright: © 2022Background: Rotavirus vaccine (Rotarix®) was introduced in Mozambique through its Expanded Program of Immunization in September 2015. We assessed the impact of rotavirus vaccination on childhood gastroenteritis-associated hospitalizations post-vaccine introduction in a high HIV prevalence rural setting of southern Mozambique. Methods: We reviewed and compared the trend of hospitalizations (prevalence) and incidence rates of acute gastroenteritis (AGE), and rotavirus associated-diarrhea (laboratory confirmed rotavirus) in pre- (January 2008–August 2015) and post-rotavirus vaccine introduction periods (September 2015–December 2020), among children <5 years of age admitted to Manhiça District Hospital. Results: From January 2008 to December 2020, rotavirus vaccination was found to contribute to the decline of the prevalence of AGE from 19% (95% CI: 18.14–20.44) prior to the vaccine introduction to 10% (95% CI: 8.89–11.48) in the post-introduction period, preventing 40% (95 % IE: 38–42) and 84% (95 % IE: 80–87) of the expected AGE and laboratory confirmed rotavirus cases, respectively, among infants. Similarly, the overall incidence of rotavirus was 11.8-fold lower in the post-vaccine introduction period (0.4/1000 child-years-at-risk [CYAR]; 95% CI: 0.3–0.6) compared with the pre-vaccination period (4.7/1000 CYAR; 95% CI: 4.2–5.1) with the highest reduction being observed among infants (16.8-fold lower from the 15.1/1000 CYAR in the pre-vaccine to 0.9/1000 CYAR in the post-vaccine eras). Conclusions: We documented a significant reduction in all-cause diarrhea hospitalizations and rotavirus positivity after vaccine introduction demonstrating the beneficial impact of rotavirus vaccination in a highly vulnerable population.publishersversionpublishe
Maternal Carriage of Group B Streptococcus and Escherichia coli in a District Hospital in Mozambique.
BACKGROUND: In low-income countries, data on prevalence and effects of group B Streptococcus (GBS) and Escherichia coli (E. coli) colonization among pregnant women are scarce, but necessary to formulate prevention strategies. We assessed prevalence of GBS and E. coli colonization and factors associated among pregnant women, its effect in newborns and acceptability regarding the utilized sampling methods in a semirural Mozambican hospital. METHODS: Pregnant women were recruited from June 2014 to January 2015, during routine antenatal clinics at gestational age ≥ 34 weeks (n = 200); or upon delivery (n = 120). Maternal risk factors were collected. Vaginal and vagino-rectal samples for GBS and E. coli determination were obtained and characterized in terms of antimicrobial resistance and serotype. Anti-GBS antibodies were also determined. Neonatal follow-up was performed in the first 3 months after birth. Semistructured interviews were performed to investigate acceptability of sample collection methods. RESULTS: In total, 21.3% of women recruited were GBS carriers, while 16.3% were positive for E. coli. Prevalence of HIV was 36.6%. No association was found between being colonized by GBS and E. coli and maternal risk factors. GBS isolates were fully susceptible to penicillin and ampicillin. Serotypes V (32.4%), Ia (14.7%) and III (10.3%) were the most commonly found and 69.2% of the women tested had immunoglobuline G antibodies against GBS. E. coli isolates showed resistance to ampicillin in 28.9% and trimethoprim/sulfamethoxazole in 61.3% of the cases. CONCLUSION: Prevalence of GBS and/or E. coli colonization among pregnant women is high in this semirural community and comparable with those reported in similar settings. Four serotypes accounted for nearly 70% of all isolates of GBS. Population-based data on infant GBS infections would enable the design of prevention strategies for GBS disease in Mozambique
Unmasking the hidden tuberculosis mortality burden in a large postmortem study in Maputo Central Hospital, Mozambique
Sensitive tools are
needed to accurately establish the diagnosis of tuberculosis
(TB) at death, especially in low-income countries. The objective
of this study was to evaluate the burden of TB in a series of
patients who died in a tertiary referral hospital in sub-Saharan
Africa using an in-house real time PCR (TB-PCR) and the Xpert
MTB/RIF Ultra (Xpert Ultra) assay.Complete diagnostic autopsies
were performed in a series of 223 deaths (56.5% being
HIV-positive), including 54 children, 57 maternal deaths and 112
other adults occurring at the Maputo Central Hospital,
Mozambique. TB-PCR was performed in all lung, cerebrospinal
fluid and central nervous system samples in HIV-positive
patients. All samples positive for TB-PCR or showing
histological findings suggestive of TB were analysed with the
Xpert Ultra assay.TB was identified as the cause of death in 31
patients: 3/54 (6%) children, 5/57 (9%) maternal deaths and
23/112 (21%) other adults. The sensitivity of the main clinical
diagnosis to detect TB as the cause of death was 19.4% (95% CI:
7.5-37.5) and the specificity was 97.4% (94.0-99.1) compared to
autopsy findings. Concomitant TB (TB disease in a patient dying
of other causes) was found in 31 additional cases. Xpert Ultra
helped to identify 15 cases of concomitant TB. In 18 patients, "
- " DNA was identified by TB-PCR and Xpert Ultra in the absence
of histological TB lesions. Overall, 62 cases (27.8%) had TB
disease at death and 80 (35.9%) had TB findings.The use of
highly sensitive, easy to perform molecular tests in complete
diagnostic autopsies may contribute to identifying TB cases at
death that would have otherwise been missed. Routine use of
these tools in certain diagnostic algorithms for hospitalised
patients needs to be considered. Clinical diagnosis showed poor
sensitivity for the diagnosis of TB at death
High within-host diversity found from direct genotyping on post-mortem tuberculosis specimens in a high-burden setting
Objectives: To characterize the clonal complexity in Mycobacterium tuberculosis (MTB) infections considering factors that help maximize the detection of coexisting strains/variants. Methods: Genotypic analysis by Mycobacterial Interspersed Repetitive-Unit-Variable-Number Tandem-Repeats (MIRU-VNTR) was performed directly on 70 biopsy specimens from two or more different tissues involving 28 tuberculosis cases diagnosed post-mortem in Mozambique, a country with a high tuberculosis burden. Results: Genotypic data from isolates collected from two or more tissues were obtained for 23 of the 28 cases (82.1%), allowing the analysis of within-patient diversity. MIRU-VNTR analysis revealed clonal diversity in ten cases (35.7%). Five cases showed allelic differences in three or more loci, suggesting mixed infection with two different strains. In half of the cases showing within-host diversity, one of the specimens associated with clonal heterogeneity was brain tissue. Conclusions: Direct MTB genotyping from post-mortem tissue samples revealed a frequent within-host Mycobacterium tuberculosis diversity, including mixed and polyclonal infections. Most of this diversity would have been overlooked if only standard analysis of respiratory specimens had been performed
Validity of a minimally invasive autopsy for cause of death determination in maternal deaths in Mozambique: An observational study
BACKGROUND: Despite global health efforts to reduce maternal
mortality, rates continue to be unacceptably high in large parts
of the world. Feasible, acceptable, and accurate postmortem
sampling methods could provide the necessary evidence to improve
the understanding of the real causes of maternal mortality,
guiding the design of interventions to reduce this burden.
METHODS AND FINDINGS: The validity of a minimally invasive
autopsy (MIA) method in determining the cause of death was
assessed in an observational study in 57 maternal deaths by
comparing the results of the MIA with those of the gold standard
(complete diagnostic autopsy [CDA], which includes any available
clinical information). Concordance between the MIA and the gold
standard diagnostic categories was assessed by the kappa
statistic, and the sensitivity, specificity, positive and
negative predictive values and their 95% confidence intervals
(95% CI) to identify the categories of diagnoses were estimated.
The main limitation of the study is that both the MIA and the
CDA include some degree of subjective interpretation in the
attribution of cause of death. A cause of death was identified
in the CDA in 98% (56/57) of cases, with indirect obstetric
conditions accounting for 32 (56%) deaths and direct obstetric
complications for 24 (42%) deaths. Nonobstetric infectious
diseases (22/32, 69%) and obstetric hemorrhage (13/24, 54%) were
the most common causes of death among indirect and direct
obstetric conditions, respectively. Thirty-six (63%) women were
HIV positive, and HIV-related conditions accounted for 16 (28%)
of all deaths. Cerebral malaria caused 4 (7%) deaths. The MIA
identified a cause of death in 86% of women. The overall
concordance of the MIA with the CDA was moderate (kappa = 0.48,
95% CI: 0.31-0.66). Both methods agreed in 68% of the diagnostic
categories and the agreement was higher for indirect (91%) than
for direct obstetric causes (38%). All HIV infections and
cerebral malaria cases were identified in the MIA. The main
limitation of the technique is its relatively low performance
for identifying obstetric causes of death in the absence of
clinical information. CONCLUSIONS: The MIA procedure could be a
valuable tool to determine the causes of maternal death,
especially for indirect obstetric conditions, most of which are
infectious diseases. The information provided by the MIA could
help to prioritize interventions to reduce maternal mortality
and to monitor progress towards achieving global health targets
Contribution of the clinical information to the accuracy of the minimally invasive and the complete diagnostic autopsy
Although autopsy diagnosis includes routinely, a thorough
evaluation of all available pathological results and also of any
available clinical data, the contribution of this clinical
information to the diagnostic yield of the autopsy has not been
analyzed. We aimed to determine to which degree the use of
clinical data improves the diagnostic accuracy of the complete
diagnostic autopsy (CDA) and the minimally invasive autopsy
(MIA), a simplified pathological postmortem procedure designed
for low-income sites. 264 coupled MIA and CDA procedures (112
adults, 57 maternal deaths, 54 children and 41 neonates) were
performed at the Maputo hospital, Mozambique. We compared the
diagnoses obtained by the MIA blind to clinical data (MIAb), the
MIA adding the clinical information (MIAc), and the CDA blind to
clinical information (CDAb), with the results of the gold
standard, the CDA with clinical data, by comparing the ICD-10
codes and the main diagnostic classes obtained with each
evaluation strategy (MIAb, MIAc, CDAb, CDAc). The clinical data
increased diagnostic coincidence to the MIAb with the gold
standard in 30/264 (11%) cases and modified the CDAb diagnosis
in 20/264 (8%) cases. The increase in concordance between MIAb
and MIAc with the gold standard was significant in neonatal
deaths (kappa increasing from 0.404 to 0.618, P=.0271), adult
deaths (kappa increasing from 0.732 to 0.813, P=.0221) and
maternal deaths (kappa increasing from 0.485 to 0.836,
P<.0001). In conclusion, the use of clinical information
increases the precision of MIA and CDA and may strengthen the
performance of the MIA in resource-limited settings