Regional moderate hyperthermia for mild-to-moderate COVID-19 (TherMoCoV study): a randomized controlled trial

Background

To prevent COVID-19 progression, low-cost alternatives that are available to all patients are needed. Diverse forms of thermotherapy have been proposed to prevent progression to severe/critical COVID-19.

Objective

The aim of this study is to evaluate the efficacy and safety of local thermotherapy to prevent disease progression in hospitalized adult patients with mild-to-moderate COVID-19.

Methods

A multicenter, open-label, parallel-group, randomized, adaptive trial is used to evaluate the efficacy and safety of local thermotherapy to prevent disease progression in hospitalized adult patients with mild-to-moderate COVID-19. Eligible hospitalized adult patients with symptoms of COVID-19 with ≤5 days from symptom onset, meeting criteria for mild or moderate COVID-19, were randomly assigned to the intervention consisting of local thermotherapy via an electric heat pad in the thorax (target temperature range 39.5–42°C) continuously for 90 min, twice daily, for 5 days, or standard care. The main outcome was the proportion of patients who progressed to severe-to-critical COVID-19 or death. Patients were randomized in a 1:1 ratio through a centralized computer-generated sequence of minimization with a random component of 20%. Participants and medical staff were not blinded to the intervention.

Results

One-hundred and five participants (thermotherapy n = 54, control n = 51) with a median age of 53 (IQR: 41–64) years were included for analysis after the early cessation of recruitment due to the closure of all temporal COVID-19 units (target sample size = 274). The primary outcome of disease progression occurred in 31.4% (16/51) of patients in the control group vs. 25.9% (14/54) of those receiving thermotherapy (risk difference = 5.5%; 95%CI: −11.8–22.7, p = 0.54). Thermotherapy was well tolerated with a median total duration of thermotherapy of 900 (IQR: 877.5–900) min. Seven (13.7%) patients in the control group and seven (12.9%) in the thermotherapy group had at least one AE (p = 0.9), none of which were causally attributed to the intervention. No statistically significant differences in serum cytokines (IL-1β, IL-6, IL-8, IL-10, IL-17, and IFN-γ) were observed between day 5 and baseline among groups.

Conclusion

Local thermotherapy was safe and well-tolerated. A non-statistically significant lower proportion of patients who experienced disease progression was found in the thermotherapy group compared to standard care. Local thermotherapy could be further studied as a strategy to prevent disease progression in ambulatory settings.

Clinical Trial registration: www.clinicaltrials.gov, identifier: NCT04363541.

Assessment of lamivudine, zidovudine, lopinavir, and ritonavir plasma levels in HIV-positive pregnant women: Drug monitoring application to improve patient safety

Simultaneous therapeutic drug monitoring (TDM) of combination antiretroviral therapy (cART) is critical during pregnancy in order to improve clinical follow-up, monitor viral load, and patient adherence to treatment.A modified simple and fast ultra-high performance liquid chromatography coupled with tandem mass spectrometry and electrospray ionization (UPLC-ESI-MS/MS) method was developed and validated according to national and international guidelines for the simultaneous determination of lamivudine (LMV), zidovudine (ZDV), lopinavir (LPV), and ritonavir (RTV) concentrations in 100-μL plasma sample of Human Immunodeficiency Virus (HIV)-positive pregnant women. Protein precipitation using 0.1% formic acid in cold acetonitrile was used for sample preparation. The chromatographic separation was achieved with a run-time of 3.0 minutes and 3-μL injection on an ethylene bridged hybrid C18 column (2.1 μm × 50 mm, 1.7 μm), under gradient conditions using acetonitrile and formic acid (0.1%).The chromatographic method was used to analyze 10 plasma samples from 8 HIV pregnant women as a clinical patient routinely follow-up by applying TDM criteria.The protonated precursor/product ion transitions for LMV (230.18/112.08), ZDV (268.22/127.10), LPV (629.55/447.35), and RTV (721.50/296.20) were recorded in multiple-reaction-monitoring (MRM) mode. The calibration curve was linear in the range of 50-3,000, 75-4,500, 250-15,000, and 25-1,500-ng/mL for LMV, ZDV, LPV, and RTV, respectively. The range of accuracy was 97.2% to 100.1% and precision 3.4% to 12.7%. The method showed specificity and matrix effect values of < 15%. Minimum absolute recovery percentages (%CV) were 90.5 (5.4), 90.8 (5.0), 95.4 (3.5), and 93.7 (6.9), for LMV, ZDV, LPV, and RTV, respectively. Drug concentrations in patient samples had high inter-individual variability with %CV of 91.98%, 77.54%, 53.80%, and 92.16% for ZDV, LMV, LPV, and RTV, respectively. Two of the 8 patients showed no adherence due to the absence of Protease Inhibitors (PIs) levels in plasma.This technique demonstrated to be effective in therapeutic drug monitoring and is intended to be used in population pharmacokinetics specifically for HIV-positive pregnant women.

Congenital Zika Syndrome and Extra-Central Nervous System Detection of Zika Virus in a Pre-term Newborn in Mexico

BACKGROUND

During pregnancy, the Zika virus (ZIKV) replicates in the placenta and central nervous system (CNS) of infected fetuses; nevertheless, the ability of ZIKV to replicate in other fetal tissues has not been extensively characterized.

METHODS

We researched whether dissemination of congenitally-acquired ZIKV outside the CNS exists by searching for the accumulation of the viral envelope protein, ZIKV ribonucleic acid (RNA), and infectious viral particles in different organs of a deceased newborn with Congenital Zika Syndrome. A real-time qualitative polymerase chain reaction (qPCR) was used to detect ZIKV RNA in the brain, thymus, lungs, kidneys, adrenal glands, spleen, liver, and small intestine. The same tissues were analyzed by indirect immunofluorescence and immunoperoxidase assays using the monoclonal antibody 4G2 to detect ZIKV envelope antigens. Isolation of infectious ZIKV in a cell culture was carried out using brain and kidney samples.

RESULTS

A postmortem, virological analysis of multiple organs, such as the kidneys (epithelial cells in the renal tubules), lungs (bronchial epithelia), thymus (epithelial cells inside the Hassall's corpuscles), and brain (neurons, ependymal cells, and macrophages) revealed the presence of ZIKV RNA and envelope antigens. Other tissues of the deceased newborn tested positive by qPCR for Epstein-Barr virus and human herpesvirus 6, including the brain cortex (Epstein-Barr) and the thymus, kidneys, and adrenal glands (human herpesvirus 6). The kidneys were identified as a significant niche for viral replication, given that infectious particles were successfully isolated from renal tissues.

CONCLUSIONS

Our findings demonstrate the ability of congenitally-acquired ZIKV to produce disseminated infections and the viral tropism towards epithelial cells.

A Proinflammatory Immune Response Might Determine Toxoplasma gondii Vertical Transmission and Severity of Clinical Features in Congenitally Infected Newborns

Toxoplasma gondii is the etiological agent of toxoplasmosis. Mother-to-child transmission of this parasite can occur during pregnancy. Newborns with congenital toxoplasmosis may develop central nervous system impairment, with severity ranging from subclinical manifestations to death. A proinflammatory/regulated specific immune profile is crucial in the defense against the parasite; nevertheless, its role in the infected pregnant women and the congenitally infected offspring has been poorly explored, and there is still no consensus about its relation to parasite vertical transmission or to severity and dissemination in the congenitally infected newborns. This work aimed to characterize these relations by means of principal component and principal factor analyses. For this purpose, we determined the specific production of the four immunoglobulin G antibody subclasses, cytokines, and lymphocyte proliferation in the T. gondii–infected pregnant women−10 who transmitted the infection to their offspring and seven who did not—as well as in 11 newborns congenitally infected and grouped according to disease severity (five mild and six moderate/severe) and dissemination (four local and seven disseminated). We found that the immune response of nontransmitter women differed from that of the transmitters, the latter having a stronger proinflammatory response, supporting a previous report. We also found that newborns who developed moderate/severe disease presented higher levels of lymphocyte proliferation, particularly of CD8⁺ and CD19⁺ cells, a high proportion of tumor necrosis factor α producers, and reduced expression of the immune modulator transforming growth factor β, as opposed to children who developed mild clinical complications. Our results suggest that a distinctive, not regulated, proinflammatory immune response might favor T. gondii vertical transmission and the development of severe clinical manifestations in congenitally infected newborns.

Maternal Immune Response During Pregnancy and Vertical Transmission in Human Toxoplasmosis

Toxoplasmosis is a parasitic zoonosis distributed worldwide, caused by the ingestion of contaminated water/food with the parasite Toxoplasma gondii. If a pregnant woman is infected with this parasite, it may be transmitted to the fetus and produce ocular, neurological, or systemic damage with variable severity. The strength and profile of mother's immune response have been suggested as important factors involved in vertical transmission rate and severity of clinical outcome in the congenitally infected fetus. The aim of this work was to evaluate a possible relation between the mother's immune response during pregnancy and congenital transmission to the fetus. We obtained peripheral blood from T. gondii infected pregnant woman and tested it for anti T. gondii (IgG1, IgG2, IgG3, IgG4, and IgA) in serum. Peripheral blood mononuclear cells (PBMCs) were isolated to analyze the in vitro effect of soluble T. gondii antigens on proliferation and production of cytokines. We found that IgG2-4 and IgA antibodies and lymphocytes proliferation, especially CD4⁺, CD8⁺, and CD19⁺ were positive in a higher proportion of cases in transmitter than in non-transmitter women. Furthermore, IgG2-3 and IgA anti-Toxoplasma antibody levels were higher in those mothers who transmitted the infection than in those who did not. Interestingly, a higher proportion of positive cases to IFN-γ and negatives to the immunoregulatory cytokine TGF-β, were related to T. gondii vertical transmission. Our descriptive results are consistent with the paradoxical previous observations in murine models of congenital toxoplasmosis, which suggest that an increased immune response that protects the mothers from a disseminated or severe disease, and should protect the fetus from infection, is positively related to parasite transmission.

High heterogeneity, mixed infections and new genotypes in human congenital toxoplasmosis cases in the mega-metropolis of Central Mexico

Mexico presents high prevalence of Toxoplasma gondii infection, including the congenital form, but there are few data about the genetic diversity of the parasite, so we attempted parasite isolation and genotyping in nine mother/children pairs with congenital toxoplasmosis (CT), living in the Valley of Mexico, who were part of a 30 cases cohort that started 12 years ago. They were recruited through research projects which included pre- and postnatal screening of congenital infections or directly CT, and cases referred to INP for management because they had clinical abnormalities. Genotyping was performed by PCR-RFLP of SAG1, SAG2, SAG3, BTUB GRA6, c22-8, c29-2, L358, PK1 and Apico markers, followed by sequencing. Sixty seven percent of samples were typed for the SAG3 locus, 39% for Apico and 33% for BTUB, while Alt. SAG2, GRA6 and c29-2 types could be labelled in less cases. Type I alleles predominated, followed by II and III. We isolated the first strain obtained from humans in Mexico and found three genotypes not previously found in the world. The presence of ToxoDB#10 clonal type was documented in one pair, as well as mixed infections in five mothers. No relation of genotype or parasite load with clinical signs was found. In conclusion, we encountered great genetic diversity and mixed T. gondii infections among mother/children pairs with congenital toxoplasmosis in the mega-metropolis of the Valley of Mexico.

Simultaneous quantification of four antiretroviral drugs in breast milk samples from HIV-positive women by an ultra-high performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) method

The primary strategy to avoid mother-to-child transmission of human immunodeficiency virus (HIV) through breastfeeding is administration of highly active antiretroviral therapy (HAART) to HIV-positive pregnant women. Because significant changes in the pharmacokinetics of antiretroviral (ARV) drugs occur during pregnancy, quantifying HAART and the viral load in breast milk in this population is essential. Here, we developed an analytical assay for the simultaneous quantification of four ARV drugs in breast milk using ultra-performance liquid chromatography coupled to tandem mass spectrometry. We validated this method following Mexican and international guidelines. ARV drugs. We extracted the ARV drugs from 200 μL samples of breast milk and detected these drugs in a triple quadrupole mass spectrometer with positive electrospray ionization. The validated concentration ranges (ng/mL) for zidovudine, lamivudine, lopinavir, and ritonavir were 12.5–750, 50–2500, 100–5000 and 5 to 250, respectively. Additionally, the absolute recovery percentages (and matrix effects) were 91.4 (8.39), 88.78 (28.75), 91.38 (11.77) and 89.78 (12.37), respectively. We determined that ARV drugs are stable for 24 h at 8°C and 24°C for 15 days at –80°C. This methodology had the capacity for simultaneous detection; separation; and accurate, precise quantification of ARV drugs in human breast milk samples according to Mexican standard laws and United States Food and Drug Administration guidelines.

Percepción cultural respecto al embarazo no planeado de mujeres gestantes viviendo con VIH

Objetivo: En el presente trabajo se exploraron percepciones culturales de mujeres gestantes viviendo con VIH que cursaron un embarazo no planeado, con la finalidad de comprender su toma de decisiones en lo relativo a la vida reproductiva. Material y métodos: Todas las mujeres fueron atendidas en el Instituto Nacional de Perinatología, México. El estudio tuvo un enfoque sociocultural con una base metodológica cualitativa, y se realizó análisis del discurso. Previo consentimiento informado, a cada mujer se le aplicó una entrevista semiestructurada. Se estudiaron 15 gestantes con VIH que no planearon su embarazo. Los temas principales que se exploraron en la entrevista fueron: 1) significado del embarazo; 2) percepción de la infección por el VIH; 3) motivos para continuar el embarazo no planeado; y 4) preocupaciones de la tríada mujer-maternidad-VIH. Resultados: La razón más frecuente para continuar el embarazo no planeado fue la percepción sociocultural del aborto como crimen. Los familiares y el personal de salud fueron las personas que con mayor frecuencia sugirieron continuar el embarazo. Conclusiones: El contexto social y cultural que determina las creencias y significados sobre la infección por el VIH y la reproducción, tiene un papel fundamental para comprender el comportamiento de las embarazadas gestantes viviendo con VIH. A estas mujeres se les debe proporcionar la atención sin prejuicios y sugerirles las opciones de manejo solicitándoles su opinión.

Pregnant women infected with pandemic H1N1pdm2009 influenza virus displayed overproduction of peripheral blood CD69+ lymphocytes and increased levels of serum cytokines

The first pandemic of the 21^st century occurred in 2009 and was caused by the H1N1pdm influenza A virus. Severe cases of H1N1pdm infection in adults are characterized by sustained immune activation, whereas pregnant women are prone to more severe forms of influenza, with increased morbi-mortality. During the H1N1pdm09 pandemic, few studies assessed the immune status of infected pregnant women. The objective of this study was to evaluate the behavior of several immune markers in 13 H1N1pdm2009 virus-infected pregnant (PH1N1) women, in comparison to pregnant women with an influenza-like illness (ILI), healthy pregnant women (HP) and healthy non-pregnant women (HW). The blood leukocyte phenotypes and the serological cytokine and chemokine concentrations of the blood leukocytes, as measured by flow cytometry, showed that the CD69+ cell counts in the T and B-lymphocytes were significantly higher in the PH1N1 group. We found that pro-inflammatory (TNF-α, IL-1β, IL-6) and anti-inflammatory (IL-10) cytokines and some chemokines (CXCL8, CXCL10), which are typically at lower levels during pregnancy, were substantially increased in the women in the ILI group. Our findings suggest that CD69 overexpression in blood lymphocytes and elevated levels of serum cytokines might be potential markers for the discrimination of H1N1 disease from other influenza-like illnesses in pregnant women.

Toxoplasmosis in pregnancy: determination of IgM, IgG and avidity in filter paper-embedded blood

OBJECTIVE

To detect immunoglobulin M (IgM) anti-Toxoplasma gondii antibodies and determine immunoglobulin G (IgG) titer and avidity in filter paper-embedded blood (FPEB) samples of pregnant women.

STUDY DESIGN

A total of 100 FPEB samples of pregnant women (30 positive and 70 negative) were analyzed for anti-T. gondii-specific IgM antibodies. Eleven and nine pairs of serum and FPEB samples were used to standardize IgG titration and avidity, respectively. Then, the correlation of avidity results was determined with 23 serum/FPEB pairs from IgG-positive cases.

RESULT

IgM detection in FPEB was 92% sensitive and 100% specific. The titration of IgG antibodies in FPEB correlated with that of serum (r >or=0.9). Significant difference in avidity between the acute and the undetermined/chronic cases was observed in both samples. As expected, no correlation was found between IgM levels and avidity.

CONCLUSION

The FPEB is useful to infer infection phase, and thus to speed clinical decisions in congenital toxoplasmosis management.

Comparison of short-term treatment regimen of ciprofloxacin versus long-term treatment regimens of trimethoprim/sulfamethoxazole or norfloxacin for uncomplicated lower urinary tract infections: a randomized, multicentre, open-label, prospective study

OBJECTIVE

To compare the bacteriological and clinical efficacy of three treatments for uncomplicated cystitis in ambulatory pre-menopausal women: ciprofloxacin 250 mg orally twice daily for 3 days, trimethoprim/sulfamethoxazole 160/800 mg orally twice daily for 7 days, and norfloxacin 400 mg orally twice daily for 7 days.

MATERIALS AND METHODS

A total of 455 women were randomly assigned to three treatment groups: 151 received ciprofloxacin, 150 received trimethoprim/sulfamethoxazole, and 154 received norfloxacin. Bacteriological cure and clinical resolution were evaluated 5-9 days and 4-6 weeks after completion of treatment.

RESULTS

There was no significant difference among the three treatment groups: overall efficacy ranged from 78.5% for the trimethoprim/sulfamethoxazole group, to 84.5% for the ciprofloxacin group. The highest overall incidence of drug-related adverse effects occurred in the trimethoprim/sulfamethoxazole patients.

CONCLUSIONS

These data indicate that a 3 day treatment with ciprofloxacin is at least as clinically and bacteriologically effective as 7 day treatments with trimethoprim/sulfamethoxazole and norfloxacin for uncomplicated lower urinary tract infections.

Effects of prenatal exposure to Zidovudine and Lamivudine on brainstem auditory evoked potentials in infants from HIV-infected women

Long-term in utero adverse effects of infants exposed perinatally to antiretroviral drugs are still unknown. The purpose of this study was to determine whether there were differences in Brainstem Auditory Evoked Potential (BAEP) waves and interval interwaves in a group of Zidovudine (AZT) alone or AZT plus Lamivudine (3TC) prenatally exposed infants as the result of a mother with Human Immunodeficiency Virus (HIV) infection; compared with a group of infants not exposed to antiretroviral drugs. Results couls provide an index of neurotoxicity in newborns. Pregnant women were recruited at the first trimester of pregnancy, when they were diagnosed with HIV syndrome. Infants were included in the study if they were exposed prenatally to AZT alone or AZT plus 3TC. BAEP recordings were blinded from each investigator and results compared with a cephalic perimeter-matched control group of non-exposed infants. Comparison of wave latencies showed significant delay of wave I and I-III interwave interval in the AZT-3TC-treated group. The present findings suggest that prenatal exposure to the antiretroviral drugs AZT and/or 3TC is related to increased latencies in wave I and I-III interwave interval. This finding may provide an index of toxicity in lower regions of the brainstem in exposed infants.

[Bacteriological study of surgical infected wounds in elective surgery. Bacteriology of surgical wound infection]

OBJECTIVE

To identify the frequency and type of microorganisms isolated from infected surgical wounds at the Instituto Nacional de Perinatología, and identify the association among the microorganisms isolated and the outcome of the infected patients.

METHODOLOGY

Observational, descriptive and cross-sectional study carried out between January 1999 and January 2001. Postoperative patients of an obstetric or gynecologic procedure, complicated with a surgical wound infection and with a culture and smear of the wound, were included.

RESULTS

During the study period 41 surgical wound infections were identified. The general incidence of surgical infections was 3.9 infections per 1,000 surgical procedures. The incidence of infections after abdominal hysterectomy was 12.4 per 1,000, after vaginal hysterectomy 6.5 per 1,000, postcesarean section 5.3 per 1,000 and after episiotomy 1 per 1,000 procedures. The comparison among bacterial isolates in 1988 with 1999-2000 period showed a high frequency of gram negative bacteria isolation in the second period.

CONCLUSIONS

In this study the incidence of surgical infections was less than the incidence reported in the medical literature, but the type of bacteria isolated was similar to other studies.

[Clinical and demographic profile of patients with gyneco-obstetric disease colonized by Streptococcus agalactiae]

OBJECTIVE

To describe demographics and clinical features in women with vaginal colonization with Streptococcus agalactiae attended in a gyneco-obstetric hospital.

METHODS

Descriptive study of 118 women with isolation of Streptococcus agalactiae in cervical swab during January 1992 to December 1998. Major patient features were obtained in retrospective revising their chart and were classified in demographic, gyneco-obstetrical and clinical characteristics. Statistical analyses were performed with descriptive statistics using central tendency measurements and dispersion, frequencies, rates and proportions with all different variables.

RESULTS

Mean age was 31 +/- 11 years; 44 (37.3%) received attention because of sterility, 37 (31.4%) were pregnant, 26 (22%) had any other gynecological disease and, 11 (9.3%) were in a group of high pregestational risk. One hundred eleven (94.1%) were sexually active, starting at a mean age of 20.9 +/- 4.3. GBS was the only microorganism isolated in 70 patients (59.3%). A concomitant cervicovaginal infection was identified in 22 (18.6%) patients. A sexual transmitted disease was present in 25 (21.2%) patients, with isolation of human papilomavirus (HPV), M. hominis, C. trachomatis y T. vaginalis. Fifty-five patients had a concomitant illness: 24 with endocrine disease, 12 cardiovascular pathology and 10 with oncologic disease.

CONCLUSIONS

Vaginal colonization of mexican women by GBS is low. However, clinical and demographics characteristics are required to identify these women easily, because of the importance of maternal and infant infection by this organism.

[Factors associated with acceptance of postpartum tubal ligation among HIV-infected women]

OBJECTIVE

To identify the factors associated with the acceptance of tubal ligation after childbirth among HIV-infected patients.

MATERIAL AND METHODS

A case-control study was conducted from March 1988 to February 1999, at Mexico's National Institute of Perinatology (INPer), in 72 HIV-positive pregnant women. Cases were 49 women who accepted postpartum tubal ligation after childbirth, and controls were 23 women who refused this birth control method. Data collected for each patient were demographic characteristics, sexual and reproductive history, and HIV status. Statistical analysis consisted of descriptive measures, Chi 2 or Fisher's exact test for categorical variables, and Student's t test for continuous variables. Odds ratios (OR) with 95% CI were used to compare groups and potential confounders were assessed by stratified analysis with the Mantel-Haenszel method.

RESULTS

The patients' mean age was 25.5 +/- 5.5 years. The median gestation period was 27 weeks (range 7 to 40 weeks); 16 women (22.2%) had no prenatal care visits at INPer. The median time of HIV positivist awareness was 9 months (range 1 to 108). Variables associated with acceptance of tubal ligation were: having a prior childbirth (OR 11.1, 95% CI 3.4 to 36), pregnancy care from 1995 onward (OR 4.7, 95% CI 1.7 to 13.3), and having given birth to an HIV-infected child (OR 4.6, 95% CI 1.05 to 23.1). Stratified analysis showed no modification of the strength of association of these variables with acceptance of tubal ligation.

CONCLUSIONS

A prior childbirth was the most important predictor of tubal ligation acceptance. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

[Clinical manifestations and lethality of descending necrotizing mediastinitis]

OBJECTIVE

To describe the clinical manifestations, treatment and lethality of a series of patients with descending necrotizing mediastinitis (DNM).

DESIGN

Retrospective study of a series of cases. SITE OF STUDY: The Infectious Diseases Hospital (IDH) of the Mexican Social Security Institute, Mexico City; a national reference hospital.

PATIENTS AND METHODS

From January 1996 through December 1998, 18 consecutive patients with diagnostic criteria for DNM were treated in the IDH. Demographic variables, precedents, clinical manifestations, characteristics of paraclinical studies, and treatment results were recollected from the chart of each patient. We made a comparison between patients who survived and the patients who died.

RESULTS

The mean age of the patients was 48.8 +/- 19.1 years; 13 (72.5%) were men. Nine (50%) had an underlying disease, being diabetes mellitus the most frequent one. In 13 (72.5%) cases an odontogenic abscess was the original infection; three (16.6%) patients had retropharyngeal abscesses. The mean time between the beginning of symptoms and admission to the hospital was 10.6 +/- 6.7 days. The most frequent symptoms were fever, dyspnea, dysphagia, and hypotension. The treatment was medical and surgical in all cases, with antibiotics, thoracotomy, drainage and debridement. The most frequent complications were septic shock, nosocomial pneumonia and ARDS. Nine patients died, the lethality rate was 50%. Patients who died had, at admission lower leukocytes and platelets counts; higher glycemia, and developed more frequently cardiovascular complications and septic shock.

CONCLUSIONS

Odontogenic abscesses are the most frequent primary infections in patients with DNM. This is an infectious problem with high lethality. Septic shock is the principal cause of death.

Neonatal outcome of children born to women with tuberculosis

BACKGROUND

As the incidence of tuberculosis (TB) has increased worldwide, it is expected that pregnant women will acquire this infection more frequently. Mycobacterium tuberculosis infection during pregnancy may represent a risk for maternal and neonatal complications.

METHODS

We studied the perinatal events of 35 consecutive pregnancies complicated by TB from March 1990 to June 1998; 105 apparently healthy pregnant women were included as controls, matched in age, gestational age upon arrival at the Institute, and socioeconomic status. Frequency and type of neonatal complications were recorded. Relative risk (RR) with 95% confidence interval (CI) was calculated. To control potentially confounding variables, a stratified analysis was performed.

RESULTS

Seventeen (48.5%) tuberculous mothers had a pulmonary infection and 18 (51.5%), an extrapulmonar localization of the TB. The neonatal morbidity rate in children born to women with TB was 23% against 3.8% of the children of the control cohort (p <0.05). Average weight of newborn infants of tuberculous mothers was 2,859 +/- 78.5 g, while average weight at birth of control neonates was 3,099 +/- 484 g (p = 0.03). Newborns of women with TB had a higher risk of prematurity (RR 2.1; 95% CI 1-4.3), perinatal death (RR 3.1; 95% CI 1.6-6), and weight at birth less than 2,500 g (RR 2.2; 95% CI 1.1-4.9). Pulmonary localization of the TB and late start of the treatment in the mothers increase the risk of perinatal death and neonatal morbidity.

CONCLUSIONS

Children born to women with TB have an increased risk of morbidity and mortality in the neonatal period.

[Pregnancy outcome in women infected with the human immunodeficiency virus]

OBJECTIVE

To identify the medical complications in a cohort of HIV-infected, pregnant women and to determine the risk of having the virus in the development of these complications.

MATERIAL AND METHODS

A cohort study of 44 HIV-infected and 88 seronegative pregnant women was performed. Pregnancy was followed and perinatal results were compared. HIV-infected women were asymptomatic with CD4 count > 200 mm3. Patients were matched for age and socioeconomic status.

RESULTS

In 42 (95.4%) of HIV patients the disease had been transmitted sexually; 35 (79.5%) had been infected for less than one year and 15 (34%) received antiviral treatment during pregnancy. HIV-infected patients showed greater risk of infectious disorders (RR3.1, CI95% 1.9-52), cervical infections (RR 2.2, CI95% 1-48) and sexually transmitted diseases (RR 18, CI95% 2.3-137). Newborns showed low birth weight and were premature, and neonatal affections were similar in the two groups compared. Stratified analysis showed that no antiretroviral treatment and more than three sexual partners increase the risk of infections.

CONCLUSIONS

HIV-seropositive, asymptomatic, pregnant women with > 200/mm3 CD4 count did not show greater medical risk along pregnancy and birth, although higher incidence of infections was detected.

[The outcome of pregnancies complicated by rubella, 1990-1997]

OBJECTIVE

To describe the experience of management of pregnant women complicated with rubella and to evaluate the perinatal outcome.

MATERIAL AND METHODS

A total of 67 pregnant women with positive IgM test for rubella were studied in the period from January 1st, 1990 to October 31st, 1997. Sixty-six of these women were followed until the end of gestation, in 4 patients an elective abortion was performed and 1 patient had a molar pregnancy. The effects of rubella on gestation and on the product were evaluated in sixty-one of the patients. Anti-rubella IgM was determined at birth and positive infants were subjected to evaluation by echocardiogram, brainstem auditory evoked potentials (BAEP) and ophthalmological study.

RESULTS

Mean age of the patients was 24.7 +/- 5.5 years; 28 patients were primigravidae. Pregnancies were normal showing no complications due to the rubella episode. In 35 cases (52.2%), the viral infection occurred during the first trimester of pregnancy, in 23 cases (34.5%) during the second and in 9 (13.3%) during the third. Seventy-one percent of infants born to mothers infected during the first trimester of pregnancy were also infected, and 51.6% developed congenital rubella syndrome. The most frequent manifestations of CRS were: prematurity, low birth weight and alterations of the BAEP.

CONCLUSIONS

In Mexico, rubella is still a cause of fetal damage, which shows the need for preventive strategies, such as universal vaccination, to avoid rubella infection during pregnancy.

Amniotic fluid interleukin-6 and the risk of early-onset sepsis among preterm infants

BACKGROUND

High concentrations of interleukin-6 (IL-6) have been demonstrated in amniotic fluid (AF) from women with intra-amniotic infection. Recent studies have reported that IL-6 levels in AF were related to an increase in neonatal morbidity; moreover, higher IL-6 plasma levels have been observed in neonates with sepsis.

METHODS

A cohort study was carried out at the National Institute of Perinatology in Mexico City. Inclusion criteria were the following: 1) preterm singleton pregnancy; 2) intact membranes at time of enrollment, and 3) written informed consent. Women with other complications of pregnancy were excluded. Newborn sepsis during the first 72 h was defined as early-onset sepsis. Amniotic fluid was obtained at the moment of delivery. Amniotic fluid IL-6 (AF IL-6) was determined by enzyme-linked immunoassays.

RESULTS

Ninety-three women met the criteria for enrollment in the study and 31 (33%) of their newborns had early-onset neonatal sepsis. The mean AF IL-6 in mothers of septic newborns was 5779 +/- 2804 pg/ml compared to 729 +/- 382 pg/ml in mothers with non-infected neonates (p < 0.001). AF IL-6 concentrations higher than 1250 pg/ml were significantly associated with early-onset sepsis (OR 33.3; 95% CI 9.4-117.3) (p < 0.001). Gestational age under 32 weeks was also associated with neonatal sepsis (OR 2.56; 95% CI 1.2-9) (p = 0.002). Women whose infants developed neonatal sepsis had a higher frequency of clinical chorioamnionitis (p = 0.02).

CONCLUSIONS

IL-6 determination in AF may be a useful indicator to identify neonates with higher risk of in utero bacterial infection.

[Diagnostic tests for amniotic infection: review of the literature]

The diagnosis of intraamniotic infection (IAI) is not difficult when clinical manifestations are present, but there are patients with subclinical infections, in these cases the examination of the amniotic fluid is the most important diagnostic procedure. We made a critical review of the medical literature of diagnostic tests of IAI, according to the analysis criterion of the medical articles of the Department of Clinical Epidemiology of the McMaster University. The articles were identified looking for in the MEDLINE-CD ROOM and INDEX MEDICUS from 1991 to 1995. We identified 19 articles, none of them complied with all of the analysis criterion, none of the studies were blinded nor independently compared with a gold standard test and only five articles studied a full spectrum of patients. The articles with better methodologic design were those that studied the interleukin-6 role as diagnostic test for IAI; they showed a sensibility between 75 to 89% and a specificity of 97 to 100%; nevertheless it is still necessary to standardize the cut-off point of the interleukin-6 levels.

[Hemorrhagic cystitis in pregnancy: report of a case and analysis of its treatment]

Hemorrhagic cystitis is generally a benign self-limited disorder, however there are some severe cases which are associated to a significant blood loss. The etiology may be either bacterial, viral or chemical in origin; though the cause is not identified in most of the cases. Immunocompromised patients or patients who have undergone chemotherapy or radiation constitute the highest risk group. There are only a few articles about hemorrhagic cystitis in pregnancy, that is the reason why the therapy for this disorder is not uniform. Hemorrhagic cystitis in pregnant women frequently is associated with preterm labor. We describe one patient with a clinical status of hematuria, dysuria, frequency, urgency and premature labor. The cystoscopic study showed data that suggest hemorrhagic cystitis. The various treatment used in this disorder are reviewed here.

[Measles and pregnancy. Evolution and management]

Measles is a highly infectious disease. In Mexico, nevertheless the postvaccine era, continue being an endemic disease. It has been described that measles increase the maternal mortality, because pregnant women have a more severe clinical course of the disease; measles also has negative repercussion on pregnancy, increasing the frequency of premature labor. We report two pregnant women complicated with measles, both of them had a clinical course of the disease and they didn't have obstetric or neonatal complications.

[Prevalence of serologic markers of hepatitis A, B, C, and D viruses in pregnant women]

OBJECTIVE

To determine the seroprevalence of hepatitis A, B, C and D virus infection among pregnant women attending a perinatal care hospital.

MATERIAL AND METHODS

A prospective study was carried out to determine the seroprevalence of hepatitis A virus IgG antibodies (anti-HAV), hepatitis B virus markers (anti-HBcAg and HBsAg) and hepatitis C virus antibodies (anti-HCV) in pregnant women. In HBsAg positive cases. HBeAg and hepatitis D virus antibodies (anti-HDV) were investigated. All analyses were performed with the ELISA technique.

RESULTS

Of the 1500 pregnant women studied. 93.3% were positive for anti-HAV IgG. The HBsAg seroprevalence was 0.26% and anti-HCV seroprevalence was 0.53%. There were no patients with HBeAg or anti-HDV.

CONCLUSIONS

A higher seroprevalence of HBsAg was found in this study than in other studies of pregnant Mexican women. We propose that HBsAg screening become a routine prenatal test.

[Pre- and postgestational vaccination]

Vaccination is one of the most important methods to prevent infectious diseases, it consist of application of an inactive but immunogenic antigen, with the objective of simulating a natural infection and originate an immunological response. Important vaccines used in women's reproductive age are: 1) antirubella, if the woman has not serum antibodies against rubella virus; 2) tetanus toxoid is indicated in all pregnant women which had not been vaccinated against tetanus in the last ten years; 3) hepatitis B vaccine, to be applicated in newborns of women with positive serological indicators of chronic hepatitis B infection; 4) antirabies vaccine and gamaglobulin hiperimmune must be used in women with a recent exposure to rabies virus.

[Nosocomial infections of gynecologic-obstetrical origin at a perinatal care hospital]

Nosocomial infections (NI) are still a major cause of morbidity among gynecology & obstetrics patients (GOP). At the Instituto Nacional de Perinatología (INPer), during 1989, there was an overall NI rate of 2.37 per 100 GOP discharged, while specific NI rates for the subgroups of puerperal and gynecologic surgery patients were 2.11 and 6.3 respectively. Endometritis and infected surgical wounds were the most frequent type of NI, having a multimicrobial etiology. There was a significant increase in hospital days of stay for those patients who developed NI. It is clearly necessary to improve the surveillance of NI as well as the collaboration among different wards dealing with GOP, in order to find more effective and efficient ways to prevent the development of NI.

[Zygomycosis in childhood. A report of 2 cases]

Zygomycosis is a fungal infection which shows a definitive predisposition to attack the compromised host. It is usually associated with poorly controlled diabetes mellitus (DM). In the early infancy the cutaneous and gastrointestinal forms are the most frequent, in older children the most recognized form is that in which the primary impact of the infection is upon facial and intracranial structures. We report two cases of zygomycosis, the first patient was a 15 years old girl with a know systemic lupus erythematosus, and the second was a 14 years old boy with a insulin-dependent type I DM. Both were treated with anphotericin B and aggressive surgical intervention. The favorable outcome was attributed to a prompt diagnosis, early initiation of anphotericin B, surgical intervention and a control of the underlying illness.