Phenolic chalcones as agents against Trichomonas vaginalis

Trichomonas vaginalis, a flagellated and anaerobic protozoan, is a causative agent of trichomoniasis. This disease is among the world's most common non-viral sexually transmitted infection. A single class drug, nitroimidazoles, is currently available for the trichomoniasis treatment. However, resistant isolates have been identified from unsuccessfully treated patients. Thus, there is a great challenge for a discovery of innovative anti-T. vaginalis agents. As part of our ongoing search for antiprotozoal chalcones, we designed and synthesized a series of 21 phenolic chalcones, which were evaluated against T. vaginalis trophozoites. Structure-activity relationship indicated hydroxyl group plays a role key in antiprotozoal activity. 4'-Hydroxychalcone (4HC) was the most active compound (IC50 = 27.5 µM) and selected for detailed bioassays. In vitro and in vivo evaluations demonstrated 4HC was not toxic against human erythrocytes and Galleria mellonella larvae. Trophozoites of T. vaginalis were treated with 4HC and did not present significant reactive oxygen species (ROS) accumulation. However, compound 4HC was able to increase ROS accumulation in neutrophils coincubated with T. vaginalis. qRT-PCR Experiments indicated that 4HC did not affect the expression of pyruvate:ferredoxin oxidoreductase (PFOR) and β-tubulin genes. In silico simulations, using purine nucleoside phosphorylase of T. vaginalis (TvPNP), corroborated 4HC as a promising ligand. Compound 4HC was able to establish interactions with residues D21, G20, M180, R28, R87 and T90 through hydrophobic interactions, π-donor hydrogen bond and hydrogen bonds. Altogether, these results open new avenues for phenolic chalcones to combat trichomoniasis, a parasitic neglected infection.

Antimicrobial and Antibiofilm Activities of Copper(II)-1,10-phenanthroline-5,6-pione Against Commensal Bacteria and Fungi Responsible for Vaginal Microbiota Dysbiosis

The disbalance of vaginal eubiotic microbiota can lead to overgrowth of Candida species and bacteria responsible for aerobic vaginitis, activating inflammatory pathways. The presence of Trichomonas vaginalis, a sexually transmitted protozoan pathogen, can be a predisposing factor for disordering the growth of bacterial/fungal pathogenic species due to the increase in pH and reduction of eubiotic microbiota. Herein, we evaluated the effects of the potent trichomonacidal compound, copper(II)-1,10-phenanthroline-5,6-dione (Cu-phendione), against pathogens responsible for candidiasis and aerobic vaginitis. Cu-phendione showed antimicrobial activity against Candida albicans, non-albicans Candida species (C. glabrata, C. krusei, C. parapsilosis, and C. tropicalis) and Gram-negative (Escherichia coli) and Gram-positive (Staphylococcus aureus, Enterococcus faecalis, and Streptococcus agalactiae) bacteria. Moreover, Cu-phendione was able to interfere with the fungal biofilm formation. These results highlight the antimicrobial potential of Cu-phendione against bacterial and fungal strains of vaginitis-causing infectious agents.

Development of Echinocandin Resistance in Candida haemulonii: An Emergent, Widespread, and Opportunistic Fungal Pathogen

Echinocandins, used for the prevention and treatment of invasive fungal infections, have led to a rise in breakthrough infections caused by resistant Candida species. Among these species, those belonging to the Candida haemulonii complex are rare multidrug-resistant (MDR) yeasts that are frequently misidentified but have emerged as significant healthcare-associated pathogens causing invasive infections. The objectives of this study were to investigate the evolutionary pathways of echinocandin resistance in C. haemulonii by identifying mutations in the FKS1 gene and evaluating the impact of resistance on fitness. After subjecting a MDR clinical isolate of C. haemulonii (named Ch4) to direct selection using increasing caspofungin concentrations, we successfully obtained an isolate (designated Ch4'r) that exhibited a high level of resistance, with MIC values exceeding 16 mg/L for all tested echinocandin drugs (caspofungin, micafungin, and anidulafungin). Sequence analysis revealed a specific mutation in the resistant Ch4'r strain, leading to an arginine-histidine amino acid substitution (R1354H), occurring at the G4061A position of the HS2 region of the FKS1 gene. Compared to the wild-type strain, Ch4'r exhibited significantly reduced growth proliferation, biofilm formation capability, and phagocytosis ratio, indicating a decrease in fitness. Transmission electron microscopy analysis revealed alterations in cell wall components, with a notable increase in cell wall thickness. The resistant strain also exhibited higher amounts (2.5-fold) of chitin, a cell wall-located molecule, compared to the wild-type strain. Furthermore, the resistant strain demonstrated attenuated virulence in the Galleria mellonella larval model. The evolved strain Ch4'r maintained its resistance profile in vivo since the treatment with either caspofungin or micafungin did not improve larval survival or reduce the fungal load. Taken together, our findings suggest that the acquisition of pan-echinocandin resistance occurred rapidly after drug exposure and was associated with a significant fitness cost in C. haemulonii. This is particularly concerning as echinocandins are often the first-line treatment option for MDR Candida species.

The extremophile Anoxybacillus sp. PC2 isolated from Brazilian semiarid region (Caatinga) produces a thermostable keratinase

The aim of this study was to select and identify thermophilic bacteria from Caatinga biome (Brazil) able to produce thermoactive keratinases and characterize the keratinase produced by the selected isolate. After enrichment in keratin culture media, an Anoxybacillus caldiproteolyticus PC2 was isolated. This thermotolerant isolate presents a remarkable feature producing a thermostable keratinase at 60°C. The partially purified keratinase, identified as a thermolysin-like peptidase, was active at a pH range of 5.0-10.0 with maximal activity at a temperature range of 50-80°C. The optimal activity was observed at pH 7.0 and 50-60°C. These characteristics are potentially useful for biotechnological purposes such as processing and bioconversion of keratin.

Surface, adhesiveness and virulence aspects of Candida haemulonii species complex

The emerging opportunistic pathogens comprising the Candida haemulonii complex (C. haemulonii [Ch], C. duobushaemulonii [Cd] and C. haemulonii var. vulnera[Chv]) are notable for their intrinsic antifungal resistance. Different clinical manifestations are associated with these fungal infections; however, little is known about their biology and potential virulence attributes. Herein, we evaluated some surface properties of 12 clinical isolates of Ch (n = 5), Cd (n = 4) and Chv (n = 3) as well as their virulence on murine macrophages and Galleria mellonella larvae. Scanning electron microscopy demonstrated the presence of homogeneous populations among the species of the C. haemulonii complex, represented by oval yeasts with surface irregularities able to form aggregates. Cell surface hydrophobicity was isolate-specific, exhibiting high (16.7%), moderate (25.0%) and low (58.3%) hydrophobicity. The isolates had negative surface charge, except for one. Mannose/glucose- and N-acetylglucosamine-containing glycoconjugates were evidenced in considerable amounts in all isolates; however, the surface expression of sialic acid was poorly detected. Cd isolates presented significantly higher amounts of chitin than Ch and Chv. Membrane sterol and lipid bodies, containing neutral lipids, were quite similar among all fungi studied. All isolates adhered to inert surfaces in the order: polystyrene > poly-L-lysine-coated glass > glass. Likewise, they interacted with murine macrophages in a quite similar way. Regarding in vivo virulence, the C. haemulonii species complex were able to kill at least 80% of the larvae after 120 hours. Our results evidenced the ability of C. haemulonii complex to produce potential surface-related virulence attributes, key components that actively participate in the infection process described in Candida spp.

Virulence of Candida haemulonii complex in Galleria mellonella and efficacy of classical antifungal drugs: a comparative study with other clinically relevant non-albicans Candida species

Candida haemulonii complex has emerged as notorious yeasts causing invasive infections with high rates of treatment failures. Since there is a particular interest in the development of non-mammalian host models to study microbial virulence, with the aim to evade the ethical impact of animal tests, herein we compared the virulence of C. haemulonii, C. duobushaemulonii and C. haemulonii var. vulnera with non-albicans Candida species (C. tropicalis, C. krusei and C. lusitaniae) on Galleria mellonella and the efficacy of antifungal drugs. All these fungi induced a dose-dependent effect on larvae killing, a decrease in hemocyte density and fungi were phagocytozed by hemocytes in equal proportions. Fungal inoculation caused early larvae melanization after some minutes of injection, followed by an augmented pigmentation after 24 h. Differences among species virulence can be explained, in part, by differences in growth rate and production of hydrolytic enzymes. First-line antifungals were tested with equivalent therapeutic doses and MIC profile in vitro was correlated with in vivo antifungal efficacy. Additionally, fungal burden increased in infected larvae along time and only caspofungin reduced the number of CFUs of C. haemulonii species complex. So, G. mellonella offers a simple and feasible model to study C. haemulonii complex virulence and drug efficacy.

Adevonin, a novel synthetic antimicrobial peptide designed from the Adenanthera pavonina trypsin inhibitor (ApTI) sequence

The biological activities and the structural arrangement of adevonin, a novel antimicrobial peptide, were investigated. The trypsin inhibitor ApTI, isolated from Adenanthera pavonina seeds, was used as a template for screening 18-amino acid peptides with predicted antimicrobial activity. Adevonin presented antimicrobial activity and minimum inhibitory concentrations (MIC) ranging from 1.86 to 7.35 µM against both Gram-positive and - negative bacterial strains. Moreover, adevonin exerted time-kill effects within 10 min and both susceptible and drug-resistant bacterial strains were affected by the peptide. In vitro and in vivo assays showed that, at MIC concentration, adevonin did not affect human fibroblasts (MRC-5) viability or Galleria mellonella survival, respectively. Hemolytic activity was observed only at high peptide concentrations. Additionally, nucleic acid efflux assays, gentian violet uptake and time-kill kinetics indicate that the antimicrobial activity of adevonin may be mediated by bacterial membrane damage. Furthermore, molecular dynamic simulation in the presence of SDS micelles and anionic membrane bilayers showed that adevonin acquired a stable α-helix secondary structure. Further studies are encouraged to better understand the mechanism of action of adevonin, as well as to investigate the anti-infective activity of this peptide.

Evaluation of antibiotics as a methodological procedure to inhibit free-living and biofilm bacteria in marine zooplankton culture

There is a problem with keeping culture medium completely or partially free from bacteria. The use of prokaryotic metabolic inhibitors, such as antibiotics, is suggested as an alternative solution, although such substances should not harm non-target organisms. Thus, the aim of this study was to assess the effectiveness of antibiotic treatments in inhibiting free-living and biofilm bacteria and their half-life in artificial marine environment using the copepod Acartia tonsa as bioindicador of non-harmful antibiotic combinations. Regarding to results, the application of 0.025 g L-1 penicillin G potassium + 0.08 g L-1 streptomycin sulphate + 0.04 g L-1 neomycin sulphate showed great potential for use in marine cultures and scientific experiments without lethal effects to non-target organisms. The effect of this combination starts within the first six hours of exposure and reduces up to 93 % the bacterial density, but the half-life is short, requiring replacement. No adverse changes in water quality were observed within 168 hours of exposure. As a conclusion, we can infer that this treatment was an effective procedure for zooplankton cultures and scientific experiments with the aim of measuring the role of free-living and biofilm in the marine community.

Distinct composition signatures of archaeal and bacterial phylotypes in the Wanda Glacier forefield, Antarctic Peninsula

Several studies have shown that microbial communities in Antarctic environments are highly diverse. However, considering that the Antarctic Peninsula is among the regions with the fastest warming rates, and that regional climate change has been linked to an increase in the mean rate of glacier retreat, the microbial diversity in Antarctic soil is still poorly understood. In this study, we analysed more than 40 000 sequences of the V5-V6 hypervariable region of the 16S rRNA gene obtained by 454 pyrosequencing from four soil samples from the Wanda Glacier forefield, King George Island, Antarctic Peninsula. Phylotype diversity and richness were surprisingly high, and taxonomic assignment of sequences revealed that communities are dominated by Proteobacteria, Bacteroidetes and Euryarchaeota, with a high frequency of archaeal and bacterial phylotypes unclassified at the genus level and without cultured representative strains, representing a distinct microbial community signature. Several phylotypes were related to marine microorganisms, indicating the importance of the marine environment as a source of colonizers for this recently deglaciated environment. Finally, dominant phylotypes were related to different microorganisms possessing a large array of metabolic strategies, indicating that early successional communities in Antarctic glacier forefield can be also functionally diverse.

Tannins possessing bacteriostatic effect impair Pseudomonas aeruginosa adhesion and biofilm formation

Plants produce many compounds that are biologically active, either as part of their normal program of growth and development or in response to pathogen attack or stress. Traditionally, Anadenanthera colubrina, Commiphora leptophloeos and Myracrodruon urundeuva have been used by communities in the Brazilian Caatinga to treat several infectious diseases. The ability to impair bacterial adhesion represents an ideal strategy to combat bacterial pathogenesis, because of its importance in the early stages of the infectious process; thus, the search for anti-adherent compounds in plants is a very promising alternative. This study investigated the ability of stem-bark extracts from these three species to control the growth and prevent biofilm formation of Pseudomonas aeruginosa, an important opportunistic pathogen that adheres to surfaces and forms protective biofilms. A kinetic study (0–72 h) demonstrated that the growth of extract-treated bacteria was inhibited up to 9 h after incubation, suggesting a bacteriostatic activity. Transmission electron microscopy and fluorescence microscopy showed both viable and nonviable cells, indicating bacterial membrane damage; crystal violet assay and scanning electron microscopy demonstrated that treatment strongly inhibited biofilm formation during 6 and 24 h and that matrix production remained impaired even after growth was restored, at 24 and 48 h of incubation. Herein, we propose that the identified (condensed and hydrolyzable) tannins are able to inhibit biofilm formation via bacteriostatic properties, damaging the bacterial membrane and hindering matrix production. Our findings demonstrate the importance of this abundant class of Natural Products in higher plants against one of the most challenging issues in the hospital setting: biofilm resilience.

Egg wax from the cattle tick Rhipicephalus (Boophilus) microplus inhibits Pseudomonas aeruginosa biofilm

Rhipicephalus (Boophilus) microplus is constantly challenged during its life cycle by microorganisms present in their hosts or in the environment. Tick eggs may be especially vulnerable to environmental conditions because they are exposed to a rich and diverse microflora in the soil. Despite being oviposited in such hostile sites, tick eggs remain viable, suggesting that the egg surface has defense mechanisms against opportunistic and/or pathogenic organisms. R. microplus engorged females deposit a superficial wax layer onto their eggs during oviposition. This egg wax is essential for preventing desiccation as well as acting as a barrier against attack by microorganisms. In this study, we report the detection of anti-biofilm activity of R. microplus egg wax against Pseudomonas aeruginosa PA14. Genes involved in the functions of production and maintenance of the biofilm extracellular matrix, pelA and cdrA, respectively, were markedly downregulated by a tick egg-wax extract. Moreover, this extract strongly inhibited fliC gene expression. Instead of a compact extracellular matrix, P. aeruginosa PA14 treated with egg-wax extract produces a fragile one. Also, the colony morphology of cells treated with egg-wax extract appears much paler and brownish, instead of the bright purple characteristic of normal colonies. Swarming motility was also inhibited by treatment with the egg-wax extract. The inhibition of P. aeruginosa biofilm does not seem to depend on inhibition of the quorum sensing system since mRNA levels of the 3 regulators of this system were not inhibited by egg-wax extract.

A steroidal molecule present in the egg wax of the tick Rhipicephalus (Boophilus) microplus inhibits bacterial biofilms

The cattle tick Rhipicephalus (Boophilus) microplus lays eggs in the soil near the roots of grass, or in similar highly moist environments that are prone to biofilm formation. Tick eggs have a protective wax coating that may be a source of nutrients for microorganisms. However, as the eggs remain viable and show no visible signs of microbial colonization, we hypothesized that the coating might have anti-biofilm properties. We show here that the coating inhibits biofilm formation by both Gram-negative and Gram-positive bacteria, though by different mechanisms. We have identified the anti-biofilm molecule as N-(3-sulfooxy-25-cholest-5-en-26-oyl)-L-isoleucine (boophiline), and we show that it inhibits the expression of fliC (flagellin) and cdrA (biofilm scaffold), whose products are necessary for biofilm formation in Pseudomonas aeruginosa. Boophiline is a novel biofilm inhibitor being also effective against Staphylococcus epidermidis biofilm. In our study we show evidences of the boophiline mode of action in the protection of arthropod eggs against biofilm colonization.

Antibiofilm activity of Cobetia marina filtrate upon Staphylococcus epidermidis catheter-related isolates

We report the antibiofilm activity by the sponge-associated bacterium Cobetia marina upon Staphylococcus epidermidis clinical isolates obtained from central venous catheters. Antibiofilm activity/antimicrobial susceptibility correlation might predict the action of the metabolite(s) upon Staphylococcus epidermidis in the clinic, making it a possible adjuvant in therapies against biofilm-associated infections.

Phylogeny by a polyphasic approach of the order Caulobacterales, proposal of Caulobacter mirabilis sp. nov., Phenylobacterium haematophilum sp. nov. and Phenylobacterium conjunctum sp. nov., and emendation of the genus Phenylobacterium

Three strains of Gram-negative, rod-shaped, non-spore-forming bacteria were isolated from fresh water and human blood. As determined by analyses of 16S rRNA gene sequences, the prosthecate strain FWC 38T was affiliated to the alphaproteobacterial genus Caulobacter, with Caulobacter henricii (96.8 %) and Caulobacter fusiformis (96.8 %) as its closest relatives. The non-prosthecate strain LMG 11050T and the prosthecate strain FWC 21T both belonged to the genus Phenylobacterium with Phenylobacterium koreense (96.9 %) and Phenylobacterium immobile (96.3 %) as the closest relatives. This affiliation was supported by chemotaxonomic data (polar lipids and cellular fatty acids). Physiological and biochemical tests allowed genotypic and phenotypic differentiation of the novel strains from all hitherto recognized species of the genera Caulobacter and Phenylobacterium. The strains therefore represent novel species, for which the names Caulobacter mirabilis sp. nov. (type strain FWC 38T=LMG 24261T=CCUG 55073T), Phenylobacterium conjunctum (type strain FWC 21T=LMG 24262T=CCUG 55074T), the first described prosthecate Phenylobacterium species, and Phenylobacterium haematophilum sp. nov. (type strain LMG 11050T=CCUG 26751T) are proposed. Marker nucleotides within the 16S rRNA genes were determined for the genera Asticcacaulis, Brevundimonas, Caulobacter and Phenylobacterium and the description of the genus Phenylobacterium is emended.

Sphingobium aromaticiconvertens sp. nov., a xenobiotic-compound-degrading bacterium from polluted river sediment

A bacterial strain capable of degrading some monochlorinated dibenzofurans, designated RW16T, was isolated from aerobic River Elbe sediments. The strain was characterized based on 16S rRNA gene sequence analysis, DNA G+C content, physiological characteristics, polyamines, ubiquinone and polar lipid pattern and fatty acid composition. This analysis revealed that strain RW16T represents a novel species of the genus Sphingobium. The DNA G+C content of strain RW16T, 60.7 mol%, is the lowest yet reported for the genus. 16S rRNA gene sequence analysis placed strain RW16T as an outlier in the genus Sphingobium. The name Sphingobium aromaticiconvertens sp. nov. is proposed for this dibenzofuran-mineralizing organism, with type strain RW16T (=DSM 12677T=CIP 109198T).

Sphingomonas fennica sp. nov. and Sphingomonas haloaromaticamans sp. nov., outliers of the genus Sphingomonas

Bacterial isolates obtained from polychlorophenol-contaminated sites in Finland (strain K101T) and from a Dutch drinking water well (strain A175T) were characterized taxonomically. 16S rRNA gene sequence analysis, determination of DNA G+C content, physiological characterization, estimation of the ubiquinone and polar lipid patterns and fatty acid content revealed that strains K101T and A175T were similar to Sphingomonas wittichii RW1T but also showed pronounced differences. The DNA G+C contents of the two novel strains were 63.6 and 66.1 mol%, respectively. On the basis of these results, two novel species of the genus Sphingomonas are described, for which the names Sphingomonas haloaromaticamans sp. nov. [type strain A175T (=DSM 13477T=CCUG 53463T)] and Sphingomonas fennica sp. nov. [type strain K101T (=DSM 13665T=CCUG 53462T)] are proposed.

Widespread capacity to metabolize polychlorinated biphenyls by diverse microbial communities in soils with no significant exposure to PCB contamination

The purpose of this work was to determine the extent of microbial metabolic potential for polychlorinated biphenyls (PCBs) in soils that have had no previous exposure to this class of xenobiotic pollutants. Soil and sediment samples of distinct characteristics from six sites in Germany were used to inoculate PCB oil (Aroclor 1242) microdroplets. All samples yielded multispecies biofilms, as revealed by single-strand conformation polymorphism (SSCP) analyses of polymerase chain reaction (PCR) analysis of 16S rRNA genes, and sequence analysis of the main amplicons. Microbes representing 20 different operational taxonomic units (OTUs) were identified in the biofilms, but only a few were common to all biofilms, namely those closely related to Aquabacterium sp., Caulobacter sp., Imtechium assamiensis, Nevskia ramosa, Parvibaculum lavamentivorans and Burkholderia sp. The PCB biofilm communities were always distinct from control biofilms developing from the same samples in the absence of PCB. All PCB droplet-grown biofilms degraded multiple PCB congeners but differed in the congener spectra they degraded. These findings reveal that microbial potential to degrade PCBs is widespread in soils that have not been subjected to PCB contamination, and that this potential is characteristic of consortia of very diverse phylogenetic composition.

Novel keratinase from Bacillus subtilis S14 exhibiting remarkable dehairing capabilities

We report the isolation of a keratinolytic-producing Bacillus subtilis strain and the characterization of the exceptional dehairing properties of its subtilisin-like keratinase. This enzyme can be an alternative to sodium sulfide, the major pollutant from tanneries, and may completely replace it. Its unique nonactivity upon collagen enhances its industrial potential.

[Cardiovascular morbidity in children with human immunodeficiency virus infection]

Abnormalities of cardiovascular structure and function have been described among children with human immunodeficiency virus (HIV). In order to evaluate their occurrence and clinical predictors, 32 children infected with HIV, aged three months to 13 years (mean age = 3.11 +/- 3.51 years) were studied. Perinatal transmission was identified in 90% of the children. Twenty-two patients (pts) (69%) had symptoms, nine being moderately symptomatic and eight severely symptomatic. Fourteen pts had immunological disturbances and eight of them were severely immunosuppressed. Twenty-eight pts (88%) had HIV-1 infection and 6 recent Ebstein-Barr virus coinfection. Nineteen were on zidovudine and 14 on intravenous immunoglobulin treatment. Nineteen cardiovascular abnormalities were found in 15 pts (47%): 11 cases of pulmonary hypertension by echocardiographic criteria (eight of them had interstitial lung infiltrates seen on chest X-ray) and four cases of left ventricular dysfunction requiring anticongestive therapy. Other abnormalities were: patent ductus arteriosus, septal hypertrophy, mitral valve prolapse and pericardial effusion (one case each). Surface ECG displayed right ventricular hypertrophy in four pts, left ventricular hypertrophy in one patient and unspecific ST-T wave changes in two pts. Fourteen pts (44%) had sinus tachycardia with mean heart rate above the 95th percentile on 24-hour Holter monitoring.

CONCLUSIONS

Cardiovascular abnormalities are frequent among children with HIV-1 infection in late stages; pulmonary hypertension is the most frequently found cardiovascular anomaly and seems to be related to either chronic or recurrent respiratory disease; cardiological follow-up is recommended for HIV-infected children.

[Prenatal cardiology. Suspicion to confirmation]

The mortality rate is high and prognosis is worse among new-borns with prenatal diagnosis of heart malformation, mainly due to factors such as its association with other malformations, and a range of more severe diseases probably resulting from the predominance of the obstetric use of the four chamber view. In this study we retrospectively assessed the range of cardiopathies diagnosed by foetal echocardiography and their evolution, compared with previous years. From January 1994 to December 1995, 1173 foetal echocardiograms were performed at a gestation age of 24 weeks. Sixty-one foetuses (5.2%) had cardiac anomalies, structural in 56 and arrhythmia in 5. The risks and indications were maternal in 37%, foetal in 31%, familial in 17% and environmental in 15%. Three were false negatives (VSD:2; truncus arteriosus: 1). Five died in utero, and 18 were assessed after birth with a mean gestational age of 37 weeks and birth weight of 3 Kg, a caesarean section was performed in 9. All but one were born in central hospitals. Six children were operated on. Two children died, one after surgery. Compared with the four previous years of activity, indication due to foetal risk rose from 6 to 31%, the number of cases diagnosed with heart disease increased from 14 to 30 per year, and the mortality decreased from 59 to 11%. Despite this, we still observe that the vast majority of new-borns who are hospitalised due to a severe heart disease had no prenatal diagnosis, indicating the need to continue our educational policy in this field.

The parachute-like asymmetric mitral valve and its two papillary muscles

OBJECTIVES

The morphologic features of parachute-like asymmetric mitral valves are described to discriminate this anomaly from parachute mitral valves.

BACKGROUND

Mitral valves with unifocal attachment of chords have been called "parachute valves," independent of the number of papillary muscles. Therefore the anomaly involving two papillary muscles has not received separate attention.

METHODS

The gross anatomy of 29 mitral valves with focalized attachment of chords was studied.

RESULTS

In 28 of the autopsy specimens asymmetric mitral valves with two papillary muscles were present, and one of the muscles was elongated, located higher in the left ventricle with its tip reaching to the anulus, and attached at both its base and lateral side to the left ventricular wall. The valve leaflets could be directly attached to this abnormal muscle that received few chords or, in three hearts, no chords at all, resulting in an oblique and eccentric orifice. Because of the focalized attachment of chords to one of the two papillary muscles, we call this malformation "parachute-like asymmetric mitral valve," We found only one "true parachute mitral valve," that is, one having a single papillary muscle that received all chords.

CONCLUSIONS

The morphologic features of asymmetric mitral valves are essentially different from those of true parachute valves. A distinction between these two anomalies will contribute to recognition by the pediatric cardiologist and surgeon.

Cardiac hydatid cyst in a child

Cardiac hydatid cyst is a rare disease, especially in children. An 11-year-old boy with a previous anaphylactic reaction and episodes of abdominal pain was admitted for workup of an acquired long systolic murmur. Echocardiographic investigation disclosed a tumor of the right ventricular anterior wall, with multiple loculations. Magnetic resonance imaging characterized it as a multilobular tumor with cyst formation and disclosed another cyst in the right pulmonary artery. With a positive ELISA reaction the child was admitted for surgery with the diagnosis of cardiac and pulmonary hydatid cysts. Cardiac surgery was performed with good results, followed by medical treatment with albendazole.

[A resurgence of rheumatic fever. New causes or old attitudes?]

Bearing in mind that in the last years there has been an increase in rheumatic fever episodes, the authors evaluate the cases recently observed in the department. The data of 3 children born and living in Portugal, the first known outbreak of rheumatic fever observed between June 93 and March 94, were examined. One case presented polyarthritis, another polyarthritis and carditis and the third chorea and carditis. In just one case was the diagnosis of rheumatic fever considered in the beginning, and over-all, failures in the diagnosis and treatment of tonsillitis, and in echocardiographic diagnosis were detected. In view of these examples, the authors conclude that the increasing incidence and morbidity of rheumatic fever is more probably due to forgetfulness of old attitudes than to new causes. Delay in the diagnosis and errors in secondary prophylaxis may influence long term results.

[Acute myocardial infarct in infants]

A retrospective study was made of 6 children, with nonsurgical-related acute myocardial infarction (AMI), between January 1987 and December 1994. The ratio for gender was 1 and mean age at AMI was 49 days, 4 cases being associated with congenital heart disease (Fallot's tetralogy, truncus arteriosus and DiGeorge syndrome, one case each, and anomalous origin of left coronary artery, 2 cases). Kawasaki disease and coronary embolisation from thrombosis of the renal vein occurred in the other 2 cases respectively. All developed congestive cardiac failure and cardiomegaly. In the ECG pathologic q waves with more than 35 msec occurred in all, and QT prolongation occurred in 3. Five children (83%) all with AMI in the anterior and lateral wall of the left ventricle died, death being related with cardiac mechanical failure and not with arrhythmias.

[Prenatal diagnosis of congenital cardiomyopathies. Current reality in the south of the country]

In order to make an actual perspective about prenatal diagnosis of congenital heart disease in the area of influence of our department, a prospective study including 948 fetus and 185 newborn was done, 348 fetus and 20 newborn evaluated during 1993 (group I) and the remaining during 1994 (group II). In both groups indications for fetal echocardiography were mainly maternal (18%) and familiar (14%) factors, but occurrence of CHD were respectively 2% and 0% for them. Fetal factors for echocardiography account for 7%, namely arrhythmias (7%) and obstetric suspicion of CHD (6%), but occurrence of CHD was respectively 13% and 32% for group I and 36% and 48% for group II. In the newborn with serious CHD, risk factors could be identified in 30% in group I and 36% in group II, being respectively 15% and 7% referred for fetal echocardiography. It is concluded that although a rise in the number of fetus evaluated and a better obstetric accuracy have occurred, the rate of prenatal diagnosis of CHD is still very low, pointing to necessity of continuing our actual policy of teaching and spreading this area, specially in the primary health care units.

[Restrictive myocardiopathy in children]

Four children, three males and one female, aged 1.5 months to 11 years, with restrictive cardiomyopathy are described. One had patent ductus arteriosus in association. Hepatomegaly, abnormal second heart sound and signs of pulmonary venous congestion in chest X-ray were the most consistent clinical findings. Diagnosis was based on echocardiographic findings, cardiac catheterization data and results of pathology. The most frequent echocardiographic sign was the enlargement of both atria but with the ventricles within normal size and normal systolic function. Abnormalities in second phase of the ventricular filling were recorded in 2D-echo Doppler and cardiac catheterization, where a dip and plateau morphology of ventricular tracings was recorded. Metabolic studies performed in two children were normal, and any child had hypereosinophilia. Two children died, one was lost for follow-up and another is asymptomatic. Remarks on medical and surgical management are made.

[Fetal arrhythmia. A case load of 4 years and a half]

In a 4 1/2 year period fetal, echocardiographic studies were performed on 1600 fetuses. In 55 with arrhythmia, 44 had supraventricular ectopic beats, resolved in all, and none had heart disease. Sustained arrhythmias occurred in 11 fetuses. Atrial flutter was present in 3 all with heart disease (Ebstein disease, right atrial tumour and WPW diagnosed after birth). Another 3 fetuses had supraventricular tachycardia (SVT), all with a normal heart. In the bradycardia group, 2 had complete heart block (CHB) associated with AVSD; 2 sinus bradycardia and one had non conducted atrial ectopic beats. Digoxin was the first choice drug for tachyarrhythmia therapy; association with Verapamil, Flecainide, Quinidine and Procainamide was used in 4 of the 6. One fetus with CHB received Orciprenaline with no results. Atrial flutter resolved or improved; in SVT 2 fetuses converted to sinus rhythm and one died in utero. All fetuses with CHB died in cardiac failure. Mortality was 27% (3 cases) in utero and global 36%. In our experience most fetal arrhythmias (90%) were transitory ectopic beats or non lasting bradycardia in normal heart and did not trigger other kinds of arrhythmias. In sustained arrhythmias, heart failure and heart disease had a negative effect on prognosis.

[Contribution to the prenatal diagnosis of congenital cardiopathies]

After concluding a local teaching program to obstetric echographists about prenatal diagnosis of congenital heart disease (CHD), we compared 2 periods of activity in fetal echocardiography, that before, lasting 3 and one half years (G.I) and the other 6 months after (G.II). During the second period 20 newborn consecutively admitted with CHD (G.III) were also studied. Teaching program protocol for the 10 district hospitals visited is described. The results show a rise from 25 to 58 foetus per month observed, comparing the two periods, being 4 and 7% respectively those referred with suspicion of CHD, and 54 and 33% the obstetric accuracy. Total incidence of CHD was 4,2%, 41 in G.I and 6 in G.II. Types of CHD, treatment and evolution are described, being the mortality 68 and 50% respectively. Of the 20 newborn from G.III, 90% had no prenatal diagnosis of CHD, being 30% high risk pregnancies. Mortality in this group was 20%, 50% in the newborn from high risk pregnancies; eight newborns were operated on without mortality, 5 to aortic coarctation and 2 with arterial switch for transposition. It is concluded the necessity of continuing teaching programs so that prenatal diagnosis of CHD may improve and the care of the newborn may so be anticipated and ameliorated.

[The echocardiogram in the first attack of rheumatic fever in childhood]

In order to evaluate the contribution of echocardiography (echo) in the first episode of rheumatic fever, 18 children (mean age: 8.5 +/- 2.9 years) observed between 1987 and 1992 have been retrospectively studied. In 11 of them the echo has been done in the first month after the initial episode. By M-Mode echo the most constant finding was a high left atrium: aorta ratio in all cases with clinical carditis. By 2D-echo, hyperechogenicity of mitral valve leaflets and subvalvular apparatus was a common finding, three patients having mitral valve prolapse, one with dilatation of the mitral ring and the other with leaflets not able to coapt. Doppler-echo displayed in 17 patients mitral valve regurgitation, and in three aortic regurgitation. In three children the diagnosis of carditis was made by echo in the absence of murmur. During follow-up mitral valve regurgitation disappeared in four children. The authors conclude that early echo is very important in all children suspected to have rheumatic fever, specially because mitral valve regurgitation can be demonstrated by color flow mapping even in the absence of cardiac murmur.

[Fetal cardiology. Bases for the prenatal diagnosis of congenital cardiopathies]

The bases for prenatal diagnosis of congenital heart disease are presented, in the line of a comprehensive program undertaken by paediatric cardiology and obstetrics. This program is designed to improve the screening of fetal heart diseases by obstetric echographists, particularly those working at peripheral high risk clinics. It includes the visit of paediatric cardiologists to district hospitals for joint meetings with local physicians, going over theoretical aspects, case presentation and four chamber view with outflow tract demonstrations using local ultrasound equipment. Referring protocols, handouts and support media exchange are contemplated. Support texts on the program divulged, on etiology of congenital heart disease, on abnormal fetal echocardiography and on fetal dysrhythmias are presented here in. The need for an organized national effort to increase the prenatal diagnosis of congenital heart disease is emphasized as well as the need to centralize some aspects related to diagnosis and treatment in order to improve the care of newborns with congenital heart disease.

[Fetal echocardiography. The results of a 3-year study]

During the last three years (July 89 to July 92), 875 fetal echocardiographic studies were performed, at a mean gestational age of 26 +/- 6.5 weeks (12 to 40 weeks), with the following main referral indications: family history of congenital heart disease 23%; advanced maternal age 13%; fetal arrhythmia 10%; amniotic fluid abnormalities 8%; fetal malformations 7%; diabetes 6%; four chamber view changes 4%. There were 15 twin pregnancies, two of them thoracopagus. The referral patterns with higher percentage of cardiac pathology were: abnormal four chamber view 56%; fetal chromosomal anomalies 50%; omphalocele 33%; twin pregnancy 33%; IUGR 29%; arrhythmias 20%. The referral patterns with lower percentage of cardiac pathology were: congenital heart disease in the family 0.2%; maternal risk 2%; amniotic fluid volume alterations 2%. The diagnosis of congenital heart disease was made in 37 fetus (4.2%), with the following most frequent: 9 cases with the atrioventricular septal defect, 5 cases with ventricular septal defect, 5 cases with hypoplastic left heart syndrome and 5 cases with tricuspid valve abnormalities. From a total of 78 referred fetal arrhythmias, 25 were confirmed, 20 being ectopic beats without structural heart disease, 3 with tachycardia, and 2 with bradycardia. One newborn with tachycardia and Ebstein's disease died, and the fetus with AV block and left atrial isomerism died in utero. The treatment and follow up of the remaining cases with heart disease are described. The whole mortality in the cases with heart pathology was 65%.(ABSTRACT TRUNCATED AT 250 WORDS)