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1.  Mucosal Immunity in the Female Genital Tract, HIV/AIDS 
BioMed Research International  2014;2014:350195.
Mucosal immunity consists of innate and adaptive immune responses which can be influenced by systemic immunity. Despite having been the subject of intensive studies, it is not fully elucidated what exactly occurs after HIV contact with the female genital tract mucosa. The sexual route is the main route of HIV transmission, with an increased risk of infection in women compared to men. Several characteristics of the female genital tract make it suitable for inoculation, establishment of infection, and systemic spread of the virus, which causes local changes that may favor the development of infections by other pathogens, often called sexually transmitted diseases (STDs). The relationship of these STDs with HIV infection has been widely studied. Here we review the characteristics of mucosal immunity of the female genital tract, its alterations due to HIV/AIDS, and the characteristics of coinfections between HIV/AIDS and the most prevalent STDs.
doi:10.1155/2014/350195
PMCID: PMC4181941  PMID: 25313360
2.  Prognostic Factors and Scoring System for Death from Visceral Leishmaniasis: An Historical Cohort Study in Brazil 
Background
In Brazil, case-fatality rates attributable to visceral leishmaniasis (VL) are high and knowledge of the risk factors associated with death may help reduce mortality. The aim of this study was to construct and validate a scoring system for prognosis of death from VL by using all cases reported in Brazil from 2007 to 2011.
Methodology
In this historical cohort study, 18,501 VL cases were analyzed; of these, 17,345 cases were cured and 1,156 cases caused death. The database was divided into two series: primary (two-thirds of cases), to develop the model score, and secondary (one-third of cases), to validate the scoring system. Multivariate logistic regression models were performed to identify factors associated with death from VL, and these were included in the scoring system.
Principal Findings
The factors associated with death from VL were: bleeding (score 3); splenomegaly (score 1); edema (score 1); weakness (score 1); jaundice (score 1); Leishmania–HIV co-infection (score 1); bacterial infection (score 1); and age (≤0.5 years [score 5]; >0.5 and ≤1 [score 2]; >19 and ≤50 [score 2]; >50 and <65 [score 3]; ≥65 [score 5]). It was observed that patients with a score of 4 had a probability of death of approximately 4.5% and had a worse prognosis. The sensitivity, specificity, and accuracy of this score were 89.4, 51.2, and 53.5, respectively.
Conclusions/Significance
The scoring system based on risk factors for death showed good performance in identifying patients with signs of severity at the time of clinical suspicion of VL and can contribute to improving the surveillance system for reducing case fatalities. The classification of patients according to their prognosis for death may assist decision-making regarding the transfer of the patients to hospitals more capable of handling their condition, admission to the intensive care unit, and adequate support and specific treatment.
Author Summary
Visceral leishmaniasis (VL) is a fatal disease if not diagnosed and treated appropriately. In the present study, we investigated the risk factors associated with death caused by VL identifiable at the time of clinical suspicion. This study was conducted using all VL cases registered in Brazil during 2007 to 2011. The prognostic factors associated with death caused by VL were bleeding, age (1 year or younger and older than 19 years), Leishmania–human immunodeficiency virus (HIV) co-infection, bacterial infection, splenomegaly, edema, weakness, and jaundice. A prognostic scoring system for death caused by VL ranging from 0 to 14 was developed and validated using these risk factors. Patients with scores of 4 or more presented with a worsening prognosis. The scoring system showed good performance in identifying the severe cases. Classification of patients according to their prognosis for death can contribute to improving the clinical management of severe cases and reducing case-fatality rates associated with VL.
doi:10.1371/journal.pntd.0003374
PMCID: PMC4263605  PMID: 25503575
3.  Influence of Household Rat Infestation on Leptospira Transmission in the Urban Slum Environment 
Background
The Norway rat (Rattus norvegicus) is the principal reservoir for leptospirosis in many urban settings. Few studies have identified markers for rat infestation in slum environments while none have evaluated the association between household rat infestation and Leptospira infection in humans or the use of infestation markers as a predictive model to stratify risk for leptospirosis.
Methodology/Principal Findings
We enrolled a cohort of 2,003 urban slum residents from Salvador, Brazil in 2004, and followed the cohort during four annual serosurveys to identify serologic evidence for Leptospira infection. In 2007, we performed rodent infestation and environmental surveys of 80 case households, in which resided at least one individual with Leptospira infection, and 109 control households. In the case-control study, signs of rodent infestation were identified in 78% and 42% of the households, respectively. Regression modeling identified the presence of R. norvegicus feces (OR, 4.95; 95% CI, 2.13–11.47), rodent burrows (2.80; 1.06–7.36), access to water (2.79; 1.28–6.09), and un-plastered walls (2.71; 1.21–6.04) as independent risk factors associated with Leptospira infection in a household. We developed a predictive model for infection, based on assigning scores to each of the rodent infestation risk factors. Receiver operating characteristic curve analysis found that the prediction score produced a good/excellent fit based on an area under the curve of 0.78 (0.71–0.84).
Conclusions/Significance
Our study found that a high proportion of slum households were infested with R. norvegicus and that rat infestation was significantly associated with the risk of Leptospira infection, indicating that high level transmission occurs among slum households. We developed an easily applicable prediction score based on rat infestation markers, which identified households with highest infection risk. The use of the prediction score in community-based screening may therefore be an effective risk stratification strategy for targeting control measures in slum settings of high leptospirosis transmission.
Author Summary
The Norway rat is an important reservoir for urban leptospirosis, a life-threatening zoonotic disease. In urban settings, leptospirosis transmission occurs primarily in the peri-domiciliary environment of the slums. Rodent control is one of the most frequent strategies to prevent leptospirosis, but the identification of domiciles at higher risk of transmission is challenging. We compared households where an individual with evidence of recent leptospirosis infection resided and households where none of the residents had evidence for infection. Houses with evidence of leptospirosis transmission had higher levels of rodent infestation and environmental conditions related to rodents. We propose a new methodology to easily characterize slum households, based on environmental characteristics, at different levels of risk for leptospirosis transmission. The findings of this study indicate that evaluation for rodent infestation intensity and environmental features may be a feasible strategy for targeting augmented control measures for leptospirosis.
doi:10.1371/journal.pntd.0003338
PMCID: PMC4256176  PMID: 25474580
4.  The TcI and TcII Trypanosoma cruzi experimental infections induce distinct immune responses and cardiac fibrosis in dogs 
Memórias do Instituto Oswaldo Cruz  2014;109(8):1005-1013.
Trypanosoma cruzi infection may be caused by different strains with distinct discrete typing units (DTUs) that can result in variable clinical forms of chronic Chagas disease. The present study evaluates the immune response and cardiac lesions in dogs experimentally infected with different T. cruzi strains with distinct DTUs, namely, the Colombian (Col) and Y strains of TcI and TcII DTU, respectively. During infection with the Col strain, increased levels of alanine aminotransferase, erythrocytes, haematocrit and haemoglobin were observed. In addition, CD8+ T-lymphocytes isolated from the peripheral blood produced higher levels of interleukin (IL)-4. The latter suggests that during the acute phase, infection with the Col strain may remain unnoticed by circulating mononuclear cells. In the chronic phase, a significant increase in the number of inflammatory cells was detected in the right atrium. Conversely, infection with the Y strain led to leucopoenia, thrombopoenia, inversion of the ratio of CD4+/CD8+ T-lymphocytes and alterations in monocyte number. The Y strain stimulated the production of interferon-γ by CD4+ and CD8+ T-lymphocytes and IL-4 by CD8+ T-cells. In the chronic phase, significant heart inflammation and fibrosis were observed, demonstrating that strains of different DTUs interact differently with the host.
doi:10.1590/0074-02760140208
PMCID: PMC4325618  PMID: 25591108
Trypanosoma cruzi; strain; dog; immune response; cardiac inflammation
5.  Nutritional Recovery Promotes Hypothalamic Inflammation in Rats during Adulthood 
Mediators of Inflammation  2014;2014:736506.
We evaluated whether protein restriction in fetal life alters food intake and glucose homeostasis in adulthood by interfering with insulin signal transduction through proinflammatory mechanisms in the hypothalamus and peripheral tissues. Rats were divided into the following: a control group (C); a recovered group (R); and a low protein (LP) group. Relative food intake was greater and serum leptin was diminished in LP and R compared to C rats. Proinflammatory genes and POMC mRNA were upregulated in the hypothalamus of R group. Hypothalamic NPY mRNA expression was greater but AKT phosphorylation was diminished in the LP than in the C rats. In muscle, AKT phosphorylation was higher in restricted than in control animals. The HOMA-IR was decreased in R and C compared to the LP group. In contrast, the Kitt in R was similar to that in C and both were lower than LP rats. Thus, nutritional recovery did not alter glucose homeostasis but produced middle hyperphagia, possibly due to increased anorexigenic neuropeptide expression that counteracted the hypothalamic inflammatory process. In long term protein deprived rats, hyperphagia most likely resulted from increased orexigenic neuropeptide expression, and glucose homeostasis was maintained, at least in part, at the expense of increased muscle insulin sensitivity.
doi:10.1155/2014/736506
PMCID: PMC4166447  PMID: 25258479
6.  Immediate effect of intravitreal injection of bevacizumab on intraocular pressure 
Purpose
To investigate the immediate effect of intravitreal injection of bevacizumab on intraocular pressure (IOP).
Methods
This was a prospective and nonrandomized study. A total of 291 eyes with macular edema or active choroidal neovascularization were submitted to a single 1.25 mg (0.05 mL) bevacizumab intravitreal injection. Intraocular pressure was measured with an Icare® tonometer immediately before and after injection in a seated position. The presence of subconjunctival reflux was recorded. The fellow eye served as the control.
Results
Mean preoperative IOP was 18.0±5.9 mmHg in the treated eye versus 16.9±6.0 mmHg in the fellow eye. Mean postoperative IOP was 42.1±14.5 mmHg in the treated eye versus 17.5±6.0 mmHg in the fellow eye. The IOP variation was statistically significant in both cases and controls (P<0.001 and P=0.003, respectively), and this increase was higher in cases than in controls (P<0.001). Postoperative IOPs higher than 50 mmHg were achieved in 32.0% of the eyes. Subconjunctival reflux was present in 21.3% and determined a lower IOP rise (P<0.001). Tested variables (glaucoma, phakic status, and sex) did not have a statistically significant effect on IOP rise or subconjunctival reflux.
Conclusion
IOP increases with intravitreal bevacizumab injection, reaching 50 mmHg or more in about one third of patients. A higher IOP is expected if no subconjunctival reflux occurs. The baseline IOP does not influence the incidence of subconjunctival reflux. The clinical relevance of these facts has yet to be clarified.
doi:10.2147/OPTH.S64721
PMCID: PMC4114901  PMID: 25092962
bevacizumab; intraocular pressure; intravitreal injection; Icare®
7.  Immunopathological Aspects of Experimental Trypanosoma cruzi Reinfections 
BioMed Research International  2014;2014:648715.
Chagas disease is caused by Trypanosoma cruzi infection. Besides the host-related factors, such as immune response and genetic background, the parasite, strain, and occurrences of reinfection episodes, may influence disease outcome. Our results demonstrate that both the primary infection and the reinfection with the Colombiana strain are connected with lower survival rate of the mice. After reinfection, parasitaemia is approximately ten times lower than in primary infected animals. Only Colombiana, Colombiana/Colombiana, and Y/Colombiana groups presented amastigote nests in cardiac tissue. Moreover, the mice infected and/or reinfected with the Colombiana strain had more T. cruzi nests, more intense inflammatory infiltrate, and higher in situ expression of TNF-α and IFN-γ than Y strain. Antigen-stimulated spleen cells from infected and/or reinfected animals produced higher levels of TNF-α, IFN-γ, and IL-10. Our results reinforce the idea that Chagas disease outcome is influenced by the strain of the infective parasite, being differentially modulated during reinfection episodes. It highlights the need of control strategies involving parasite strain characterization in endemic areas for Chagas disease.
doi:10.1155/2014/648715
PMCID: PMC4094717  PMID: 25050370
8.  Prospective Study of Leptospirosis Transmission in an Urban Slum Community: Role of Poor Environment in Repeated Exposures to the Leptospira Agent 
Background
Leptospirosis has emerged as an urban health problem as slum settlements have rapidly spread worldwide and created conditions for rat-borne transmission. Prospective studies have not been performed to determine the disease burden, identify risk factors for infection and provide information needed to guide interventions in these marginalized communities.
Methodology/Principal Findings
We enrolled and followed a cohort of 2,003 residents from a slum community in the city of Salvador, Brazil. Baseline and one-year serosurveys were performed to identify primary and secondary Leptospira infections, defined as respectively, seroconversion and four-fold rise in microscopic agglutination titers. We used multinomial logistic regression models to evaluate risk exposures for acquiring primary and secondary infection. A total of 51 Leptospira infections were identified among 1,585 (79%) participants who completed the one-year follow-up protocol. The crude infection rate was 37.8 per 1,000 person-years. The secondary infection rate was 2.3 times higher than that of primary infection rate (71.7 and 31.1 infections per 1,000 person-years, respectively). Male gender (OR 2.88; 95% CI 1.40–5.91) and lower per capita household income (OR 0.54; 95% CI, 0.30–0.98 for an increase of $1 per person per day) were independent risk factors for primary infection. In contrast, the 15–34 year age group (OR 10.82, 95% CI 1.38–85.08), and proximity of residence to an open sewer (OR 0.95; 0.91–0.99 for an increase of 1 m distance) were significant risk factors for secondary infection.
Conclusions/Significance
This study found that slum residents had high risk (>3% per year) for acquiring a Leptospira infection. Re-infection is a frequent event and occurs in regions of slum settlements that are in proximity to open sewers. Effective prevention of leptospirosis will therefore require interventions that address the infrastructure deficiencies that contribute to repeated exposures among slum inhabitants.
Author Summary
Leptospirosis is a disease that is transmitted by human contact with an environment contaminated with urine from animals, such as rodents, infected by the Leptospira bacteria. Human illness due to these bacteria can be mild, or can have very severe complications. Residents of urban slum settlements are at high risk for this disease, but the specific risk factors for transmission in these settlements are not understood because of the lack of prospective studies in this epidemiological setting. We performed a prospective study in a Brazilian slum community to measure the risk of infection, identify the environmental and social factors that place slum residents at risk for infection, and determine whether some individuals are at risk of repeated infections. We identified a burden of infection with leptospirosis among slum residents, and found that male gender and low income both increase the risk for infection. In addition, a significant proportion of slum residents had a second exposure to leptospirosis and re-infection occurred most frequently among young adults and the poorest members of the slum community who reside in proximity of open sewers. These risk factors are amenable to interventions aimed to reduce the burden that leptospirosis imparts in this high-risk setting.
doi:10.1371/journal.pntd.0002927
PMCID: PMC4038618  PMID: 24875389
9.  Distribution of superantigens in group A streptococcal isolates from Salvador, Brazil 
BMC Infectious Diseases  2014;14:294.
Background
Group A streptococcus (GAS) causes invasive disease, superficial disease, and can asymptomatically colonize humans. Superantigens are one virulence factor found in GAS. Previous studies found associations between the genes that encode superantigens and emm type of GAS. It is unknown if these associations are due to underlying biological factors that limit the distribution of superantigens or, alternatively, if these associations are due to the expansion of local GAS linages where these studies took place. To further address this question we screened GAS isolates collected from Salvador, Brazil for 11 known superantigen genes.
Methods
Seventy-seven GAS isolates were screened by PCR for superantigen genes. These superantigen genes were speA, speC, speG, speH, speI, speJ, speK, speL, speM, ssa, and smeZ. We used Fisher’s two-sided exact test to identify associations between superantigens and GAS emm type. We then compared our results to previous reports of superantigen prevalence and superantigen association with emm type.
Results
In our collection we found several emm type and superantigen genotype combinations that have previously been reported in isolates from Europe and Australia. We also found that speA was significantly associated with emm type 1, and that speC was significantly associated with emm type 12.
Conclusions
Our study reports superantigen genotypes of GAS from a region of the world that is lacking this information. We found evidence of common GAS superantigen genotypes that are spread worldwide as well as novel superantigen genotypes that, so far, are unique to Brazil.
doi:10.1186/1471-2334-14-294
PMCID: PMC4045995  PMID: 24885209
Streptococcus pyogenes; Streptococcal superantigens; Group A streptococcus; Emm types
10.  Longitudinal surveillance for meningitis by Acinetobacter in a large urban setting in Brazil 
The study aim was to describe the emergency of carbapenem resistance and clonal complexes (CC), defined by multilocus sequence typing (MLST), in Acinetobacter baumannii in a surveillance system for meningitis. Starting in 1996 at an urban setting of Brazil, surveillance detected meningitis by Acinetobacter sp for the first time in 2002. Until 2008, 35 isolates were saved. Carbapenem resistance emerged in 2006, reaching 70% of A. baumannii isolates in 2008, including one colistin-resistant. A. baumannii belonged to CC113/79 (University of Oxford/ Institute Pasteur schemes), CC235/162 and CC103/15. Dissemination of infections resistant to all antimicrobial agents may occur in the future.
doi:10.1111/1469-0691.12145
PMCID: PMC3625502  PMID: 23398654
Acinetobacter baumannii; bacterial meningitis; carbapenem-resistance; multilocus sequence typing; clonal complexes
11.  Impact of CPAP on physical exercise tolerance and sympathetic-vagal balance in patients with chronic heart failure 
Background:
Chronic heart failure (CHF) leads to exercise intolerance. However, non-invasive ventilation is able to improve functional capacity of patients with CHF.
Objectives:
The aim of this study was to evaluate the effectiveness of continuous positive airway pressure (CPAP) on physical exercise tolerance and heart rate variability (HRV) in patients with CHF.
Method
: Seven men with CHF (62±8 years) and left ventricle ejection fraction of 41±8% were submitted to an incremental symptom-limited exercise test (IT) on the cicloergometer. On separate days, patients were randomized to perform four constant work rate exercise tests to maximal tolerance with and without CPAP (5 cmH2O) in the following conditions: i) at 50% of peak work rate of IT; and ii) at 75% of peak work rate of IT. At rest and during these conditions, instantaneous heart rate (HR) was recorded using a cardiofrequencimeter and HRV was analyzed in time domain (SDNN and RMSSD indexes). For statistical procedures, Wilcoxon test or Kruskall-Wallis test with Dunn's post-hoc were used accordingly. In addition, categorical variables were analysed through Fischer's test (p<0.05).
Results:
There were significant improvements in exercise tolerance at 75% of peak work rate of IT with CPAP (405±52 vs. 438±58 s). RMSSD indexes were lower during exercise tests compared to CPAP at rest and with 50% of peak work rate of IT.
Conclusion:
These data suggest that CPAP appears to be a useful strategy to improve functional capacity in patients with CHF. However, the positive impact of CPAP did not generate significant changes in the HRV during physical exercises.
doi:10.1590/bjpt-rbf.2014.0037
PMCID: PMC4183494  PMID: 25003274
non-invasive ventilation; heart rate variability; chronic heart failure; exercise tolerance; continuous positive airway pressure; physical therapy
12.  Renal Biopsy: Use of Biomarkers as a Tool for the Diagnosis of Focal Segmental Glomerulosclerosis 
Disease Markers  2014;2014:192836.
Focal segmental glomerulosclerosis (FSGS) is a glomerulopathy associated with nephrotic syndrome and podocyte injury. FSGS occurs both in children and adults and it is considered the main idiopathic nephrotic syndrome nowadays. It is extremely difficult to establish a morphological diagnosis, since some biopsies lack a considerable quantifiable number of sclerotic glomeruli, given their focal aspect and the fact that FSGS occurs in less than half of the glomeruli. Therefore, many biological molecules have been evaluated as potential markers that would enhance the diagnosis of FSGS. Some of these molecules and receptors are associated with the pathogenesis of FSGS and have potential use in diagnosis.
doi:10.1155/2014/192836
PMCID: PMC3955602  PMID: 24719498
13.  Knowledge, Attitudes, and Practices Related to Leptospirosis among Urban Slum Residents in Brazil 
Leptospirosis disproportionately affects residents of urban slums. To understand the knowledge, attitudes, and practices regarding leptospirosis, we conducted a cross-sectional study among residents of an urban slum community in Salvador, Brazil. Of the 257 residents who were interviewed, 225 (90%) were aware of leptospirosis and more than two-thirds of respondents correctly identified the modes of disease transmission and ways to reduce exposure. However, study participants who performed risk activities such as cleaning open sewers had limited access to protective clothing such as boots (33%) or gloves (35%). Almost all respondents performed at least one activity to prevent household rat infestation, which often included use of an illegal poison. Our findings support the need for interventions targeted at the individual and household levels to reduce risk of leptospirosis until large-scale structural interventions are available to residents of urban slum communities.
doi:10.4269/ajtmh.2012.12-0245
PMCID: PMC3583330  PMID: 23269657
14.  Fetal Wound Healing Biomarkers 
Disease Markers  2013;35(6):939-944.
Fetal skin has the intrinsic capacity for wound healing, which is not correlated with the intrauterine environment. This intrinsic ability requires biochemical signals, which start at the cellular level and lead to secretion of transforming factors and expression of receptors, and specific markers that promote wound healing without scar formation. The mechanisms and molecular pathways of wound healing still need to be elucidated to achieve a complete understanding of this remodeling system. The aim of this paper is to discuss the main biomarkers involved in fetal skin wound healing as well as their respective mechanisms of action.
doi:10.1155/2013/567353
PMCID: PMC3886274  PMID: 24427782
15.  Clinical Forms of Canine Visceral Leishmaniasis in Naturally Leishmania infantum–Infected Dogs and Related Myelogram and Hemogram Changes 
PLoS ONE  2013;8(12):e82947.
Hematological analysis has limited applications for disease diagnosis in Leishmania infantum–infected dogs, but it can be very important in evaluating the clinical forms of the disease and in understanding the evolution of canine visceral leishmaniasis (CVL) pathogenesis. Recently, we demonstrated that alterations in leucopoiesis and erythropoiesis are related to clinical status and bone marrow parasite density in dogs naturally infected by L. infantum. To further characterize these alterations, we evaluated the association between the hematological parameters in bone marrow and peripheral blood alterations in groups of L. infantum–infected dogs: asymptomatic I (AD-I: serum negative/PCR+), asymptomatic II (AD-II: serum positive), oligosymptomatic (OD), and symptomatic (SD). Results were compared with those from noninfected dogs (NID). The SD group was found to present a decrease in erythropoietic lineage with concomitant reductions in erythrocytes, hemoglobin, and hematocrit parameters, resulting in anemia. The SD group also had increased neutrophils and precursors and decreased band eosinophils and eosinophils, leading to peripheral blood leucopenia. In the AD-II group, lymphocytosis occurred in both the peripheral blood and the bone marrow compartments. The SD group exhibited lymphocytosis in the bone marrow, with lymphopenia in the peripheral blood. In contrast, the AD-I group, showed no significant changes suggestive of CVL, presenting normal counts in bone marrow and peripheral blood. Our results showed for the first time that important changes in hematopoiesis and hematological parameters occur during ongoing CVL in naturally infected dogs, mainly in symptomatic disease. Taken together, our results based on myelogram and hemogram parameters enable better understanding of the pathogenesis of the anemia, lymphocytosis, and lymphopenia, as well as the leucopenia (eosinopenia and monocytopenia), that contribute to CVL prognosis.
doi:10.1371/journal.pone.0082947
PMCID: PMC3871677  PMID: 24376612
16.  Characteristics of the Human Host Have Little Influence on Which Local Schistosoma mansoni Populations Are Acquired 
Background
Brazil remains the country in the Americas with the highest prevalence of schistosomiasis. A combination of control efforts and development, however, has sharply reduced its intensity and distribution. The acquisition of specific schistosome populations may be dependent on host characteristics such as sex, age, geography, work, habits and culture. How these and other host characteristics align with parasite subpopulations may guide approaches to improve control.
Methodology
A cohort of more than 90% of the residents in two rural communities in Brazil participated in an epidemiologic survey of demographic, socio-economic and behavioral characteristics. The variables sex, age, intensity of infection, socio-economic index, % lifetime spent on site, previous infection, and trips outside the district were used to group parasites infecting individuals. Schistosoma mansoni infection status was determined by examination of stools submitted on 3 different days. The aggregate of eggs collected from the whole stool was used to determine degree of population differentiation from allele frequencies for 15 microsatellites.
Conclusions/Significance
Infection prevalence was 41% for these communities, and the epidemiologic characteristics were similar to many of the endemic areas of Brazil and the world. Parasite population structuring was observed between the two communities (Jost's D 0.046, CI95% 0.042–0.051), although separated by only 8 km and connected by a highway. No structuring was observed when infected individuals were stratified by host's biologic, demographic or epidemiologic characteristics. Those most heavily infected best reflected the communities' overall parasite diversity. The lack of differentiation within villages suggests that individuals are likely to get infected at the same sites or that the same parasite multilocus genotypes can be found at most sites. The geographic structuring between villages and the lack of structuring by age of the host further supports the impression of a population little affected by migration or drift.
Author Summary
Schistosomiasis is one of the world's most important parasitic infections. Its elimination has proved difficult even in countries such as Brazil where access to treatment is readily available. Infection is the result of human contact with surface water where there are infected snails, so that human biology and habits may bring different individuals in contact with different groups of parasites. Identification of schistosome subpopulations may assist understanding transmission patterns and guide control efforts. We compared microsatellite allele frequencies from all of the infections in 2 small villages and determined that the movement of parasites between them was limited. Individual infections were distinct composites of parasites, but if infected humans were grouped by demographic and epidemiologic characteristics, there was no evidence that specific parasite subpopulations were being selected in these types of hosts. Infections were also not differentiated when stratified by host's age indicating that the populations were stable over time. Since the infection cycle requires human fecal contamination of water, local human behavior can to some degree be inferred from the patterns of schistosome subpopulation distribution.
doi:10.1371/journal.pntd.0002572
PMCID: PMC3854954  PMID: 24340115
17.  Genetic Population Structure of Cercariae from an Urban Foci of Schistosoma mansoni, Brazil 
Rapid urbanization in Brazil has meant that many persons from rural areas where Schistosoma mansoni is endemic have migrated to cities. Discovery of a focus of active transmission in the city of Salvador prompted a citywide survey for active and potential transmission sites. Cercariae shed from infected snails collected from four locations were used to determine how these samples were related and if they were representative of the parasite population infecting humans. Each cercarial collection was greatly differentiated from the others, and diversity was significantly lower when compared with eggs from natural human infections in one site. Egg samples collected 7 years apart in one neighborhood showed little differentiation (Jost's D = 0.01–0.03). Given the clonal nature of parasite reproduction in the snail host and the short-term acquisition of parasites, cercariae from collections at one time point are unlikely to be representative of the diversity in the human population.
doi:10.4269/ajtmh.2012.11-0641
PMCID: PMC3516259  PMID: 22949518
18.  Bullous pemphigoid in a 3-month-old infant: case report and literature review of this dermatosis in childhood*  
Anais Brasileiros de Dermatologia  2013;88(6):961-965.
Bullous pemphigoid is an autoimmune subepidermal blistering dermatosis that is uncommon in childhood. We report a case of a female infant, 3 months old, which presented clinical and laboratory data for the confirmatory diagnosis of bullous pemphigoid. The authors used immunohistochemical staining for collagen type IV that allowed the differentiation of bullous pemphigoid from other subepidermal bullous diseases. Opportunely we review the clinical, immunological, therapeutic and prognostic features of this pathology in children.
doi:10.1590/abd1806-4841.20132378
PMCID: PMC3900348  PMID: 24474106
Child; Collagen type IV; Pemphigoid, bullous; Skin diseases, vesiculobullous
19.  Cytokine Response Signatures in Disease Progression and Development of Severe Clinical Outcomes for Leptospirosis 
Background
The role of the immune response in influencing leptospirosis clinical outcomes is not yet well understood. We hypothesized that acute-phase serum cytokine responses may play a role in disease progression, risk for death, and severe pulmonary hemorrhage syndrome (SPHS).
Methodology/Principal Findings
We performed a case-control study design to compare cytokine profiles in patients with mild and severe forms of leptospirosis. Among patients hospitalized with severe disease, we compared those with fatal and nonfatal outcomes. During active outpatient and hospital-based surveillance we prospectively enrolled 172 patients, 23 with mild disease (outpatient) and 149 with severe leptospirosis (hospitalized). Circulating concentrations of pro- and anti-inflammatory cytokines at the time of patient presentation were measured using a multiplex bead array assay. Concentrations of IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-17A, and TNF-α were significantly higher (P<0.05) in severe disease compared to mild disease. Among severe patients, levels of IL-6 (P<0.001), IL-8 (P = 0.0049) and IL-10 (P<0.001), were higher in fatal compared to non-fatal cases. High levels of IL-6 and IL-10 were independently associated (P<0.05) with case fatality after adjustment for age and days of symptoms. IL-6 levels were higher (P = 0.0519) among fatal cases who developed SPHS than among who did not.
Conclusion/Significance
This study shows that severe cases of leptospirosis are differentiated from mild disease by a “cytokine storm” process, and that IL-6 and IL-10 may play an immunopathogenic role in the development of life-threatening outcomes in human leptospirosis.
Author Summary
Leptospirosis is a tropical bacterial disease that is transmitted to humans from infected animals. Leptospirosis symptoms can range from mild fever to fatal disease forms, such as massive bleeding into the lungs, called Severe Pulmonary Hemorrhage Syndrome (SPHS). It is not known what determines the severity of leptospirosis, but we hypothesized that it may be influenced by differences in the type and concentration of signaling proteins called cytokines that are produced by the immune system in response to infection. We collected blood from patients with mild and severe leptospirosis, and compared the concentration of eight different cytokines circulating in the blood. We found that patients with severe leptospirosis had higher levels of most cytokines. Among patients who had severe forms, higher levels of specific cytokines called IL-6 and IL-8 were predictive of death even after statistical adjustment for age and number of days of symptoms prior to hospitalization. IL-6 was higher in patients who died from SPHS compared to those who died of other leptospirosis complications. This knowledge suggests that severe forms of leptospirosis may be due to a specific kind of immune response, which may lead to targeted therapies to reduce the impact of this disease.
doi:10.1371/journal.pntd.0002457
PMCID: PMC3777885  PMID: 24069500
20.  The Importance of C4d in Biopsies of Kidney Transplant Recipients 
Antibody-mediated rejection (AMR) is highly detrimental to the prolonged survival of transplanted kidneys. C4d has been regarded as a footprint of AMR tissue damage, and the introduction of C4d staining in daily clinical practice aroused an ever-increasing interest in the role of antibody-mediated mechanisms in allograft rejection. Despite the general acceptance of the usefulness of C4d in the identification of acute AMR, the data for C4d staining in chronic AMR is variable. The presence of C4d in the majority of the biopsies with features of chronic antibody-mediated rejection is reported, but this rejection without C4d staining is observed as well, suggesting that C4d is specific but not sensitive. Further studies on AMR with positive C4d staining in biopsy specimens are really important, as well as the study of novel routine markers that may participate in the pathogenesis of this process.
doi:10.1155/2013/678180
PMCID: PMC3722852  PMID: 23935649
21.  Study of dermatoses in kidney transplant patients*  
Anais Brasileiros de Dermatologia  2013;88(3):361-367.
BACKGROUND
The increasing in the number of kidney transplant recipients has favored, more frequently than before, the emergence of dermatoses and warranted their study through subsequent publications.
OBJECTIVES
to evaluate the frequency of dermatoses in kidney transplant recipients.
METHODS
kidney transplant recipients with suspected dermatoses between March 1st 2009 and June 30th 2010.
RESULTS
53 patients (28 males and 25 females), aged between 22 and 69 (mean age = 45 years) were evaluated. Most of them came from the cities of Ceilândia, Samambaia and São Sebastião/DF, and had already been transplanted for 5 to 10 years before (37.7%); 62.3% were recipients of living donors and 83% were prednisone-treated. The most prevalent dermatoses were of fungal (45.3%) and viral (39.6%) etiologies. Among the non-melanoma malignant neoplasms, the basal cell carcinoma prevailed (six cases), in spite of the low incidence. Concerning fungal dermatoses, 12 cases of onychomycosis, five of pityriasis versicolor and four of pityrosporum folliculitis were reported. For diagnosis, in most cases (64.2%), laboratory examinations (mycological and histopathological) were performed.
CONCLUSION
cutaneous manifestations in kidney transplant recipients are generally secondary to immunosuppression. The infectious dermatoses, especially those of fungal origin, are frequently found in kidney transplant recipients and their occurrence increases progressively according to the time elapsed from the transplantation, which makes follow-up important.
doi:10.1590/abd1806-4841.20131859
PMCID: PMC3754366  PMID: 23793196
Immunosuppression; Kidney transplantation; Onychomycosis; Prednisone
22.  Mapping and signaling of neural pathways involved in the regulation of hydromineral homeostasis 
Several forebrain and brainstem neurochemical circuitries interact with peripheral neural and humoral signals to collaboratively maintain both the volume and osmolality of extracellular fluids. Although much progress has been made over the past decades in the understanding of complex mechanisms underlying neuroendocrine control of hydromineral homeostasis, several issues still remain to be clarified. The use of techniques such as molecular biology, neuronal tracing, electrophysiology, immunohistochemistry, and microinfusions has significantly improved our ability to identify neuronal phenotypes and their signals, including those related to neuron-glia interactions. Accordingly, neurons have been shown to produce and release a large number of chemical mediators (neurotransmitters, neurohormones and neuromodulators) into the interstitial space, which include not only classic neurotransmitters, such as acetylcholine, amines (noradrenaline, serotonin) and amino acids (glutamate, GABA), but also gaseous (nitric oxide, carbon monoxide and hydrogen sulfide) and lipid-derived (endocannabinoids) mediators. This efferent response, initiated within the neuronal environment, recruits several peripheral effectors, such as hormones (glucocorticoids, angiotensin II, estrogen), which in turn modulate central nervous system responsiveness to systemic challenges. Therefore, in this review, we shall evaluate in an integrated manner the physiological control of body fluid homeostasis from the molecular aspects to the systemic and integrated responses.
doi:10.1590/1414-431X20132788
PMCID: PMC3854407  PMID: 23579631
Hypothalamus; Gaseous neuromodulators; Neuropeptides; Endocannabinoids; Glial cells; Neurotransmitters
23.  Accuracy of real-time PCR, Gram stain and culture for Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae meningitis diagnosis 
Background
Although cerebrospinal fluid (CSF) culture is the diagnostic reference standard for bacterial meningitis, its sensitivity is limited, particularly when antibiotics were previously administered. CSF Gram staining and real-time PCR are theoretically less affected by antibiotics; however, it is difficult to evaluate these tests with an imperfect reference standard.
Methods and findings
CSF from patients with suspected meningitis from Salvador, Brazil were tested with culture, Gram stain, and real-time PCR using S. pneumoniae, N. meningitidis, and H. influenzae specific primers and probes. An antibiotic detection disk bioassay was used to test for the presence of antibiotic activity in CSF. The diagnostic accuracy of tests were evaluated using multiple methods, including direct evaluation of Gram stain and real-time PCR against CSF culture, evaluation of real-time PCR against a composite reference standard, and latent class analysis modeling to evaluate all three tests simultaneously.
Results
Among 451 CSF specimens, 80 (17.7%) had culture isolation of one of the three pathogens (40 S. pneumoniae, 36 N. meningitidis, and 4 H. influenzae), and 113 (25.1%) were real-time PCR positive (51 S. pneumoniae, 57 N. meningitidis, and 5 H. influenzae). Compared to culture, real-time PCR sensitivity and specificity were 95.0% and 90.0%, respectively. In a latent class analysis model, the sensitivity and specificity estimates were: culture, 81.3% and 99.7%; Gram stain, 98.2% and 98.7%; and real-time PCR, 95.7% and 94.3%, respectively. Gram stain and real-time PCR sensitivity did not change significantly when there was antibiotic activity in the CSF.
Conclusion
Real-time PCR and Gram stain were highly accurate in diagnosing meningitis caused by S. pneumoniae, N. meningitidis, and H. influenzae, though there were few cases of H. influenzae. Furthermore, real-time PCR and Gram staining were less affected by antibiotic presence and might be useful when antibiotics were previously administered. Gram staining, which is inexpensive and commonly available, should be encouraged in all clinical settings.
doi:10.1186/1471-2334-13-26
PMCID: PMC3558362  PMID: 23339355
Bacterial meningitis; Diagnostic test evaluation; Real-time PCR; Streptococcus pneumoniae; Neisseria meningitidis; Haemophilus influenzae
24.  Pulmonary Innate Immune Response and Melatonin Receptors in the Perinatal Stress 
Objective. To analyze the cytokines of the innate immune pulmonary response and the capacity for local response to melatonin according to the perinatal stress. Methods. 49 cases of pediatric autopsies were evaluated, divided according to cause of death, perinatal stress, gestational age, and birth weight. The percentages of IL-6, C-reactive protein (CRP), IL-1β, TNF-α, and melatonin receptor were evaluated by immunohistochemistry. Results. The IL-6 expression was higher in the children showing chronic stress, anoxia, and infection. The IL-6 expression showed a progressive increase according to the relation between weight and GA. There was no significant difference in the expression of IL-1β and TNF-α. The CRP expression was higher in the cases showing chronic stress and premature cases. The expression of melatonin receptors was significantly higher in the cases showing chronic stress, being more evident in the cases showing infection. Conclusion. The cause of death and the type of stress influence the expression in situ of melatonin and cytokines of the innate immune pulmonary response. The evaluation of IL-6 and CRP may contribute to the understanding of the evolution of neonates with chronic stress. The greater sensitivity of the lung to melatonin in these cases may indicate an attempt at controlling the immunological response, in an attempt to diminish the harmful effects of stress.
doi:10.1155/2013/340959
PMCID: PMC3562617  PMID: 23401697
25.  Protective effects of aerobic exercise on acute lung injury induced by LPS in mice 
Critical Care  2012;16(5):R199.
Introduction
The regular practice of physical exercise has been associated with beneficial effects on various pulmonary conditions. We investigated the mechanisms involved in the protective effect of exercise in a model of lipopolysaccharide (LPS)-induced acute lung injury (ALI).
Methods
Mice were divided into four groups: Control (CTR), Exercise (Exe), LPS, and Exercise + LPS (Exe + LPS). Exercised mice were trained using low intensity daily exercise for five weeks. LPS and Exe + LPS mice received 200 µg of LPS intratracheally 48 hours after the last physical test. We measured exhaled nitric oxide (eNO); respiratory mechanics; neutrophil density in lung tissue; protein leakage; bronchoalveolar lavage fluid (BALF) cell counts; cytokine levels in BALF, plasma and lung tissue; antioxidant activity in lung tissue; and tissue expression of glucocorticoid receptors (Gre).
Results
LPS instillation resulted in increased eNO, neutrophils in BALF and tissue, pulmonary resistance and elastance, protein leakage, TNF-alpha in lung tissue, plasma levels of IL-6 and IL-10, and IL-1beta, IL-6 and KC levels in BALF compared to CTR (P ≤0.02). Aerobic exercise resulted in decreases in eNO levels, neutrophil density and TNF-alpha expression in lung tissue, pulmonary resistance and elastance, and increased the levels of IL-6, IL-10, superoxide dismutase (SOD-2) and Gre in lung tissue and IL-1beta in BALF compared to the LPS group (P ≤0.04).
Conclusions
Aerobic exercise plays important roles in protecting the lungs from the inflammatory effects of LPS-induced ALI. The effects of exercise are mainly mediated by the expression of anti-inflammatory cytokines and antioxidants, suggesting that exercise can modulate the inflammatory-anti-inflammatory and the oxidative-antioxidative balance in the early phase of ALI.
doi:10.1186/cc11807
PMCID: PMC3682301  PMID: 23078757

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