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ABSTRACT From October 1994 to September 1996, in the municipality of Mangaratiba, Rio de Janeiro State, phlebotomines were captured on the walls of the houses by means of a manual suction tube and light traps, in the household, the peridomicile and in the forest. As it is an area undergoing a real expansion and an increment in the local tourism, with the purpose of assessing changes in the phlebotomine fauna caused by environmental changes in the region, new captures were made in the same location from October 2015 to September 2016, this time using only light traps. In the two phases of the study, a total of 6,681 phlebotomines were captured. The results indicated that Ny. intermedia and Mg. migonei are fully adapted to this anthropic environment, while Pi. fischeri was more abundant and eclectic, and was probably attracted to exercise hematophagy. Nyssomyia intermedia can be suggested as the main vector of the etiological agent of the American Tegumentary Leishmaniasis in the studied areas. Pintomyia fischeri can also transmit Leishmania braziliensis, both in the environment altered by human action, and in the wild environment. Phlebotomines were captured in greater numbers between 6 and 8 pm in the peridomicile and between 9 and 11 pm in the household. The highest densities of phlebotomines were recorded in December, January and February. Despite almost 20 years between the two studies in the municipality of Mangaratiba, there was no change in the profile of the phlebotomine fauna in general; however, there was a greater density of species of medical importance in areas that suffered environmental impacts.

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ABSTRACT Subsistence hunting is the main source of protein for forest reserve dwellers, contributing to the development of spurious infections by Calodium hepaticum, frequently associated with the consumption of the liver from wild mammals. The prevalence of infections by soil-transmitted helminths (STHs) and intestinal protozoa is considered an indicator of the social vulnerability of a country, besides providing information on habits, customs and quality of life of a given population. Intestinal parasites mostly affect poor rural communities with limited access to clean water and adequate sanitation. This study reports the results of a parasitological survey carried out in 2017 and 2019, in two municipalities (Xapuri and Sena Madureira) in Acre State. Stool samples were collected from 276 inhabitants. Upon receipt, each sample was divided into two aliquots. Fresh samples without preservative were processed and examined by the Kato-Katz technique. Samples fixed in 10% formalin were processed by the spontaneous sedimentation and the centrifugal sedimentation techniques. Calodium hepaticum eggs were found in three stool samples. The overall STH prevalence was 44.9%. The hookworm prevalence (19.2%) was higher than that of Ascaris lumbricoides (2.5%) and Trichuris trichiura (0.7%), an unexpected finding for municipalities belonging to the Western Brazilian Amazon. When considering parasites transmitted via the fecal-oral route, Endolimax nana and Entamoeba coli showed the highest positivity rates, of 13% and 10.9%, respectively. This study is the first report of spurious infection by C. hepaticum among forest reserve dwellers that consume undercooked liver of lowland pacas. Additionally, this is the first report of Blastocystis sp. in Acre State.

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ABSTRACT Chagas disease is among the 21 neglected diseases according to the World Health Organization. This study aimed to investigate the morbidity and mortality distribution of Chagas disease for identifying areas with greater prevalences and deaths of the disease in Northeast Brazil. A population-based ecological study was performed from 2016 to 2018 using data on acute Chagas disease patients from the Disease Notification Information System, chronic cases from the Chagas Disease and the referral Heart Failure Outpatient Clinic in Pernambuco, and Chagas disease-related mortality from the Mortality Information System. The unit of analysis were Pernambuco State mesoregions. The indicators were spatialized into thematic maps on the occurrence and mortality of the disease per 100,000 inhabitants. No cases of acute disease were reported in the period analyzed. Data on 801 chronic Chagas disease patients were analyzed. The population showed an average age of 62 years, with female predominance. The most prevalent comorbidity was systemic arterial hypertension and cardiologic involvement without ventricular dysfunction. The average chronic disease occurrence rate was 3.2/ 100,000 people/ year. As for deaths in the mortality system; in total, 350 deaths were recorded, showing male predominance, age ≥ 60 years, and chronic disease with cardiac involvement as the main mortality cause. The annual average mortality proportion was 1.6/100,000 people. The chronic case distribution showed spatial heterogeneity, with the highest rates of chronic disease and deaths observed in two mesoregions, with the main cause of death being heart-related. This highlights the need for more specialized services in areas with higher burden of the disease to avoid delay in the patients’ care.

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ABSTRACT Some studies have shown that secondary infections during the COVID-19 pandemic may have contributed to the high mortality. Our objective was to identify the frequency, types and etiology of bacterial infections in patients with COVID-19 admitted to an intensive care unit (ICU) and to evaluate the results of ICU stay, duration of mechanical ventilation (MV) and in-hospital mortality. It was a single-center study with a retrospective cohort of patients admitted consecutively to the ICU for more than 48 h between March and May 2020. Comparisons of groups with and without ICU- acquired infection were performed. A total of 191 patients with laboratory-confirmed COVID-19 were included and 57 patients had 97 secondary infectious events. The most frequent agents were Acinetobacter baumannii (28.9%), Pseudomonas aeruginosa (22.7%) and Klebsiella pneumoniae (14.4%); multi-drug resistance was present in 96% of A. baumannii and in 57% of K. pneumoniae. The most prevalent infection was ventilator-associated pneumonia in 57.9% of patients with bacterial infections, or 17.3% of all COVID-19 patients admitted to the ICU, followed by tracheobronchitis (26.3%). Patients with secondary infections had a longer ICU stay (40.0 vs. 17 days; p < 0.001), as well as a longer duration of MV (24.0 vs 9.0 days; p= 0.003). There were 68 (35.6%) deaths overall, of which 27 (39.7%) patients had bacterial infections. Among the 123 survivors, 30 (24.4%) had a secondary infections (OR 2.041; 95% CI 1.080 - 3.859). A high incidence of secondary infections, mainly caused by gram-negative bacteria has been observed. Secondary infections were associated with longer ICU stay, MV use and higher mortality.

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ABSTRACT The Western-blotting technique was applied to identify antigenic fractions of excretory-secretory Toxocara canis antigen recognized by IgG antibodies throughout an experimental infection in mice challenged by different inocula. Mice were inoculated with 5, 50 and 500 embryonated eggs and serum samples were collected 15, 30, 60, 90 and 120 days post-infection. Serum samples were analyzed using an excretory-secretory Toxocara antigen. Antibodies recognized antigenic fractions from 30 to 90 kDa. The protein fraction of 30-35 kDa was the most frequently recognized regardless of the size of inoculum and the stage of infection represented by the different collection times, but the antigenic recognition was more evident in groups infected with 50 and 500 eggs. This study presents an antigenic panel of the excretory-secretory antigen of T. canis and suggests that the 30-35 kDa antigenic fraction is a promising marker of the infection and should be further explored in future studies on experimental toxocariasis.

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ABSTRACT Hand-foot-and-mouth disease (HFMD) is a highly contagious viral disease commonly associated to Enteroviruses (EV). During 2018, Brazil faced massive HFMD outbreaks spread across the country. This study aimed to characterize the EV responsible for the HFMD outbreak that occurred in Paraiba State, Brazilian Northeastern region, in 2018, followed by a phylogenetic analysis to detail information on its genetic diversity. A total of 49 serum samples (one from each patient) collected from children ≤ 15 years old, clinically diagnosed with HFMD were tested for EV using conventional RT-PCR and RT-qPCR. EV infection was confirmed in 71.4% (35/49) of samples. The mean and median ages were 1.83 years and one year old, respectively. Twenty-two EV-positive samples were successfully sequenced and classified as EV-A species; 13 samples were also identified with the CV-A6 genotype. The phylogenetic analysis (VP1 region) of three samples revealed that the detected CV-A6 strains belonged to sub-lineage D3. The CV-A6 strains detected here clustered with strains from South America, Europe and West Asia strains that were also involved in HFMD cases during the 2017-2018 seasons, in addition to the previously detected Brazilian CV-A6 strains from 2012 to 2017, suggesting a global co-circulation of a set of different CV-A6 strains introduced in the country at different times. The growing circulation of the emerging CV-A6 associated with HFMD, together with the detection of more severe cases worldwide, suggests the need for a more intense surveillance system of HFMD in Brazil. In addition, this investigation was performed exclusively on serum samples, and the analysis of whole blood samples should be considered and could have shown advantages when employed in the diagnosis of enteroviral HFMD outbreaks.

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ABSTRACT Malaria is the most important vector-borne disease in the world and a challenge for control programs. In Brazil, 99% of cases occur in the Amazon region. In the extra-Amazonian region, a non-endemic area, epidemiological surveillance focuses on imported malaria and on autochthonous outbreaks, including cases with mild symptoms and low parasitemia acquired in the Atlantic Forest biome. In this scenario, cases are likely to be underreported, since submicroscopic parasitemias are not detected by thick blood smear, considered the reference test. Molecular tests are more sensitive, detecting asymptomatic individuals and mixed infections. The aim of this study was to propose a more efficient alternative to detect asymptomatic individuals living in areas of low malaria endemicity, as they are reservoirs of Plasmodium that maintain transmission locally. In total, 955 blood samples from residents of 16 municipalities with autochthonous malaria outbreaks in the Sao Paulo State were analyzed; 371 samples were collected in EDTA tubes and 584 in filter paper. All samples were initially screened by a genus-specific qPCR targeting ssrRNA genes (limit of detection of 1 parasite/µL). Then, positive samples were subjected to a nested PCR targeting ssrRNA and dihydrofolate reductase-thymidylate synthase genes (limit of detection of 10 parasites/µL) to determine Plasmodium species. The results showed a statistically significant difference (K = 0.049; p < 0.0001) between microscopy positivity (6.9%) and qPCR (22.9%) for EDTA-blood samples. Conversely, for samples collected in filter paper, no statistical difference was observed, with 2.6% positivity by thick blood smear and 3.1% for qPCR (K = 0.036; p = 0.7). Samples positive by qPCR were assayed by a species-specific nested PCR that was in turn positive in 26% of samples (16 P. vivax and 4 P. malariae ). The results showed that molecular protocols applied to blood samples from residents in areas with autochthonous transmission of malaria were useful to detect asymptomatic patients who act as a source of transmission. The results showed that the genus-specific qPCR was useful for screening positives, with the subsequent identification of species by nested PCR. Additional improvements, such as standardization of blood plotting on filter paper and a more sensitive protocol for species determination, are essential. The qPCR-based algorithm for screening positives followed by nested PCR will contribute to more efficient control of malaria transmission, offering faster and more sensitive tools to detect asymptomatic Plasmodium reservoirs.

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ABSTRACT Vaccination is a fundamental tool to prevent SARS-CoV-2 infection and to limit the COVID-19 pandemic. The emergence of SARS-CoV-2 variants with multiple mutations has raised serious concerns about the ability of neutralizing antibody responses elicited by prior vaccination to effectively combat these variants. The neutralizing capacity against the Gamma, Delta and Omicron variants of sera from individuals immunized with the CoronaVac vaccine remains incompletely determined. The present study evaluated 41 health care workers at the Faculdade de Medicina of the Universidade de Sao Paulo, in Sao Paulo, Brazil, naive to previous SARS- CoV-2 infection, who were vaccinated with two doses of the CoronaVac SARS-CoV-2 vaccine 28 days apart. Neutralizing antibody levels against the Gamma, Delta, and Omicron variants were measured at 32 and 186 days after the second vaccination. We also measured neutralizing antibodies against Omicron in 34 of these individuals following a subsequent booster immunization with the Pfizer vaccine. Quantification of neutralizing antibodies was performed using the Cytopathic Effect-based Virus Neutralization test. Neutralization antibody activity against the Gamma, Delta and Omicron variants was observed in 78.0%, 65.9% and 58.5% of serum samples, respectively, obtained at a mean of 32 days after the second immunization. This decreased to 17.1%, 24.4% and 2.4% of sera having activity against Delta, Gamma and Omicron, respectively, at 186 days post-vaccination. The median neutralizing antibody titers at 32 days were 1:40, 1:20 and 1:20 against Gamma, Delta and Omicron, respectively, and decreased to an undetectable median level against all variants at the later time. A booster immunization with the Pfizer vaccine elicited neutralizing antibodies against Omicron in 85% of subjects tested 60 days after vaccination. We conclude that two doses of the CoronaVac vaccine results in limited protection of short duration against the Gamma, Delta and Omicron SARS-CoV-2 variants. A booster dose with the Pfizer vaccine induced antibody neutralizing activity against Omicron in most patients which was measurable 60 days after the booster.

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ABSTRACT COVID-19 is a disease whose knowledge is still under construction, high transmissibility, with no consensual treatment available to everyone. Therefore, the identification of patients at higher risk of evolving to the critical form of the disease is fundamental. The study aimed to determine risk factors associated with the severity of COVID-19 in adults patients. This is an observational, retrospective study from a cohort of adult patients with COVID-19 admitted to a public hospital from March to August 2020, whose medical records were evaluated. For the association of possible severity predictors, a Poisson regression was used. The primary outcome was the critical form of the disease (need for admission to the Intensive Care Unit and/or invasive mechanical ventilation). We included 565 patients: mostly men; 55.5% of those who progressed to the critical form of the disease were over sixty years old. Hypertension, diabetes mellitus and obesity were the most frequent comorbidities. There were 39.8% of patients who progressed to the critical form of the disease. The hospital mortality rate was 22.1%, and that of critical patients was 46.7%. The independent factors associated with the severity of the disease were obesity [RR = 1.33 (95% CI 1.07 to 1.66; p = 0.011)], SpO2/FiO2 ratio ≤ 315 [RR = 2.20 (95% CI 1.79 to 2.71; p = 0.000)], C-reactive protein > 100 mg/L [RR = 1.65 (95% CI 1.33 to 2.06; p = 0.000)], and lymphocytes < 1,000/µL [RR = 1.44 (95% CI 1.18 to 1.75; p = 0.000)]. Advanced age and comorbidities were dependent factors strongly associated with the critical form of the disease.

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ABSTRACT Spotted fever (SF) is a tick-borne zoonosis caused by bacteria of the genus Rickettsia . The disease varies in severity from mild clinical forms to severe cases. In Brazil, Rickettsia rickettsii SF is the most serious rickettsiosis and can result in death if not diagnosed and treated at the onset of symptoms. The SF mild form is caused by Rickettsia parkeri strain Atlantic Rainforest, and this etiological agent has been reported in the South, Southeast and Northeast regions of the country, in areas of preserved or little antropized Atlantic Rainforest. Amblyomma ovale is the proven vector and dogs are the hosts associated with the bioagent cycle. During a SF case investigation in Paraty municipality, Rio de Janeiro State, an Atlantic Rainforest biome area in Southeastern Brazil, the human pathogen R. parkeri strain Atlantic Rainforest was detected by PCR in a sample of human skin inoculation eschar and in a female A. ovale tick collected from a dog. These results expand the known area of occurrence of this mild form rickettsiosis in Brazil. In addition, the results of the present study indicate the importance of implementing programs to control canine ectoparasites and to raise awareness of the risks of infection, signs and symptoms of SF caused by R. parkeri strain Atlantic Rainforest.

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ABSTRACT This study represents the first overview of the epidemiological dynamics of SARS-CoV-2 in Espirito Santo (ES) State, Brazil, filling in knowledge on this topic, observing data collected in the State, and aiming at understanding the epidemiological dynamics of the virus in ES, as well as its possible routes of transmission and dissemination. . Our results highlight that, so far, nine lineages have been identified with ES State. The B.1.1.33 lineage was the first with the highest occurrence in ES, remaining predominant until September 2020. The second predominant lineage was Gamma, representing 45% of the samples. The Delta lineage appears on the State scene, proving to be the next dominant lineage. This research allowed us to understand how the lineages advanced and were distributed in the State, which is important for future work, also making it possible to guide sanitary control measures. Data analyses were made through the GISAID database for ES State showed that the pandemic in the State has been evolving dynamically with lineage replacements over the months since the first notification.

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ABSTRACT The prevalence of immunity to Chikungunya virus (CHIKV) in pregnant women and newborns in the Western Brazilian Amazon was assessed at a time when previous studies did not report chikungunya fever in the area. In 435 asymptomatic pregnant women and 642 healthy unrelated newborns, the presence of IgM and IgG antibodies to CHIKV were determined by a commercial ELISA. All participants were negative to IgM anti-CHIKV. Anti-CHIKV IgG was identified in 41 (9.4%) pregnant women and 66 (10.3%) newborns. The presence of anti-CHIKV IgG was positively associated with the lowest socioeconomic status in pregnant women (OR 2.54, 95% CI 1.15-5.62, p=0.021) and in the newborns’ mothers (OR 5.10, 95% CI 2.15-12.09, p< 0.001). Anti-CHIKV IgG was also associated with maternal age in both, the pregnant women (OR 1.06, 95% CI 1.00-1.11, p=0.037) and the newborns’mothers (OR 1.08, 95% CI 1.03-1.12, p=0.001). Pregnancy outcomes in which the mother or the newborn was anti-CHIKV IgG positive proceeded normally. Negative CHIKV serology was associated with being positive for DENV antibodies and having had malaria during pregnancy. These findings showed that there was already a silent circulation of CHIKV in this Amazon region before the first outbreak of chikungunya fever. Furthermore, seropositivity for CHIKV was surprisingly frequent (10%) in both, pregnant women and newborns, affecting mainly low-income women.

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ABSTRACT This study investigated the potential use of the String Test (ST) for the diagnosis of pulmonary tuberculosis (PTB) in children and adolescents. This is a case series of patients aged 4-15 years presenting with clinically presumed PTB and submitted to ST in three pediatric TB referral centers in Brazil, between November 2017 and July 2020. The ST was performed in the morning, after 4-12 h of fasting, followed by ingestion of the capsule by the patient, which was attached to the patient’s malar region. The material was collected for simultaneous smear microscopy (acid-fast bacilli - AFB), culture and the molecular investigation by the GeneXpert MTB/RIF®. Thirty-three patients with presumed PTB were included and ST was performed in 26 (78.8%) of them and 7 (21.2%) patients could not swallow the cord. The diagnosis of PTB was established in 11 (42.3%) of the 26 patients who underwent the ST. The diagnosis of PTB was confirmed (by culture or GeneXpert MTB/RIF®) in 5 patients, 4 of whom were also positive by the ST. Two of them showed positivity by the GeneXpert MTB/RIF® only in the ST sample. Two other patients had a positive ST following the induced sputum test (AFB, GeneXpert MTB/RIF®, and positive culture in both specimens). Thus, ST was positive in 36.4% of the patients in whom PTB was diagnosed. ST could be a useful test for diagnosing PTB in children and adolescents.

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ABSTRACT In the present study, the importance of laboratory parameters and CT findings in the early diagnosis of COVID-19 was investigated. To this end, 245 patients admitted between April 1st, and May 30th, 2020 with suspected COVID-19 were enrolled. The patients were divided into three groups according to chest CT findings and RT-PCR results. The non-COVID-19 group consisted of 71 patients with negative RT-PCR results and no chest CT findings. Ninety-five patients with positive RT-PCR results and negativechest CT findings were included in the COVID-19 group; 79 patients with positive RT-PCR results and chest CT findings consistent with COVID-19 manifestations were included in COVID-19 pneumonia group. Chest CT findings were positive in 45% of all COVID-19 patients. Patients with positive chest CT findings had mild (n=30), moderate (n=21) andor severe (n=28) lung involvement. In the COVID-19 group, CRP levels and the percentage of monocytes increased significantly. As disease progressed from mild to severe, CRP, LDH and ferritin levels gradually increased. In the ROC analysis, the area under the curve corresponding to the percentage value of monocytes (AUC=0.887) had a very good accuracy in predicting COVID-19 cases. The multinomial logistic regression analysis showed that CRP, LYM and % MONO were independent factors for COVID-19. Furthermore, the chest CT evaluation is a relevant tool in patients with clinical suspicion of COVID-19 pneumonia and negative RT-PCR results. In addition to decreased lymphocyte count, the increased percentage of monocytes may also guide the diagnosis.

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ABSTRACT Understanding local epidemiology is essential to reduce the burden of malaria in complex contexts, such as Brazilian municipalities that share borders with endemic countries. A descriptive study of malaria in the period 2003 to 2020 was conducted using data from the Malaria Epidemiological Surveillance Information System related to a remote municipality with an extensive border with Peru to understand the disease transmission, focusing on the obstacles to its elimination. The transmission increases at the end of the rainy season. During the period of 18 years, 53,575 malaria cases were reported (Mean of API 224.7 cases/1,000), of which 11% were imported from Peru. Thirteen outbreaks of malaria were observed during the studied period, the last one in 2018. The highest burden of cases was caused by P. vivax (73.2%), but P. falciparum was also prevalent at the beginning of the study period (50% in 2006). Several changes in the epidemiological risk were observed: (1) the proportion of international imported cases of malaria changed from 30.7% in 2003 to 3.5% in 2020 (p<0.05); (2) indigenous people affected increased from 24.3% in 2003 to 89.5% in 2020 (p<0.0001); (3) infected children and adolescents < 15 years old increased from 50.2% in 2003 to 67.4% in 2020 (p<0.01); (4) the proportion of men decreased from 56.7% in 2003 to 50.4% in 2020 (p<0.01); (5) the likelihood of P. falciparum malaria has significantly declined (p<0.01). The number of cases and the incidence of malaria in 2019 and 2020 were the lowest in the period of 18 years. The burden of malaria in indigenous areas and its determinants, seasonality, geographical access and the long international border are obstacles for the elimination of malaria that must be overcome.

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ABSTRACT Since the reintroduction of dengue viruses in 1987, Sao Paulo State (SP), Brazil, has experienced recurrent epidemics in a growing number of municipalities, each time with more cases and deaths. In the present study, we investigated the spatio-temporal dynamics of dengue-related deaths and associated factors in SP. This was an ecological study with spatial and temporal components, based on notified dengue-related deaths in the municipalities of SP between 2007 and 2017. A latent Gaussian Bayesian model with Poisson probability distribution was used to estimate the standardized mortality ratios (SMR) for dengue and relative risks (RR) for the socioeconomic, demographic, healthcare-related, and epidemiological factors considered. Epidemiological factors included the annual information on the number of circulating serotypes. A total of 1,019 dengue-related deaths (0.22 per 100,000 inhabitant-years) between 2007 and 2017 were confirmed in SP by laboratory testing. Mortality increased with age, peaking at 70 years or older (1.41 deaths per 100,000 inhabitant-years). Mortality was highest in 2015, and the highest SMR values were found in the North, Northwest, West, and coastal regions of SP. An increase of one circulating serotype, one standard deviation in the number of years with cases, and one standard deviation in the degree of urbanization were associated with increases of 75, 35, and 45% in the risk of death from dengue, respectively. The risk of death from dengue increased with age, and the distribution of deaths was heterogeneous in space and time. The positive relationship found between the number of dengue serotypes circulating and years with cases at the municipality/micro-region level indicates that this information can be used to identify risk areas, intensify surveillance and control measures, and organize healthcare to better respond to this disease.

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ABSTRACT The B.1.617.2 (Delta) variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has contributed to a new increment in cases across the globe. We conducted a prospective follow-up of COVID-19 cases to explore the recurrence and potential propagation risk of the Delta variant and discuss potential explanations for the infection recurrence. A prospective, non-interventional follow-up of discharged patients who had SARS-CoV-2 infections by the Delta variant in Guangdong, China, from May 2021 to June 2021 was conducted. The subjects were asked to complete a physical health examination and undergo nucleic acid testing and antibody detection for the laboratory diagnosis of COVID-19. In total, 20.33% (25/123) of patients exhibited recurrent positive results after discharge. All patients with infection recurrence were asymptomatic and showed no abnormalities in the pulmonary computed tomography. The time from discharge to the recurrent positive testing was usually between 1-33 days, with a mean time of 9.36 days. The cycle threshold from the real-time polymerase chain reaction assay that detected the recurrence of positivity ranged from 27.48 to 39.00, with an average of 35.30. The proportion of vaccination in the non-recurrent group was higher than that in the recurrently positive group (26% vs. 4%; χ2 = 7.902; P < 0.05). Two months after discharge, the most common symptom was hair loss and 59.6% of patients had no long-term symptoms at all. It is possible for the Delta variant SARS-CoV-2 patients after discharge to show recurrent positive results of nucleic acid detection; however, there is a low risk of continuous community transmission. Both, the physical and mental quality of life of discharged patients were significantly affected. Our results suggest that it makes sense to implement mass vaccination against the Delta variant of SARS-CoV-2.

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ABSTRACT Leishmaniasis is a serious public health concern in the Northeastern region of Brazil, where the sand fly fauna is well studied, although few species have been identified as competent vectors. The detection of Leishmania spp. parasites in wild-caught sand flies could help sanitary authorities draw strategies to avoid the transmission of the parasites and, therefore, the incidence of leishmaniases. We detected Leishmania DNA in wild-caught sand flies and correlated that data with aspects of sand fly ecology in the Caxias municipality, Maranhao State, Brazil. The sand flies were sampled in the peridomicile (open areas in the vicinity of human residences) and intradomicile (inside the residences) from July/2019 to March/2020. Leishmania DNA was detected in females, targeting a fragment of the Internal Transcribed Spacer (ITS1) from ribosomal DNA. Among the fourteen species of sand flies identified, five (Lutzomyia longipalpis, Nyssomyia whitmani, Evandromyia evandroi, Micropygomyia trinidadensis, and Micropygomyia quinquefer) harbored DNA of Leishmania (Leishmania) amazonensis. The most abundant species in rural (Ny. whitmani: 35.2% and Ev. evandroi: 32.4%) and urban areas (Lu. longipalpis: 89.8%) are the permissive vectors of L. (L.) amazonensis, especially Ny. whitmani, a known vector of causative agents of cutaneous leishmaniasis. Although Lu. longipalpis is the vector of L. (L.) infantum, which was not detected in this study, its permissiveness for the transmission of L. (L.) amazonensis has been reported. We suspect that visceral leishmaniasis and cutaneous leishmaniasis are caused by L. (L.) amazonensis, and the transmission may be occurring through Lu. longipalpis, at least in the urban area.

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ABSTRACT Localized cutaneous leishmaniasis (LCL) is an endemic disease in several Mexican States with the main endemic areas located in the South-Southeast region of the country, where 90% of Leishmania (Leishmania) mexicana cases are registered. The Southeast region is located in the Yucatan Peninsula, including Campeche, Quintana Roo and Yucatan States. Campeche and Quintana Roo register more than 60% of the cases in the country each year, while in Yucatan the reports are of imported cases due to residents traveling to endemic areas. However, since 2015, autochthonous cases have been diagnosed by health authorities in municipalities with no previous transmission records. We aimed to identify Leishmania parasite species involved in autochthonous cases by means of the PCR technique. The present study included 13 autochthonous cases of LCL with clinical and parasitological diagnoses during 2018 and 2019 by health authorities, without specific identification of the causal agent. Tissue samples were taken by scraping the margins of active lesions and then they were spotted onto an FTATM Elute Microcard. Next, DNA was eluted and used for PCR amplification of specific Leishmania genus and L. (L.) mexicana species-specific fragments. Molecular analysis showed evidence that L. (L.) mexicana was the causal agent of LCL in 12 of the 13 patients; in one patient, PCR was not performed due to the patient’s refusal to participate in the study. Identifying Leishmania species that cause LCL is necessary to define efficient treatment schemes and control strategies for the disease in vulnerable and susceptible areas of the Yucatan State’s municipalities.

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ABSTRACT This cross-sectional population-based study compared clinical features of leprosy and American tegumentary leishmaniasis (ATL) in patients diagnosed with both diseases (n=414) and in those diagnosed with only leprosy (n=27,790) or only ATL (n=24,357) in Mato Grosso State, which is a hyperendemic area for both diseases in Midwest Brazil. All new cases of leprosy and ATL reported in the area from 2008 to 2017 were included. Patients diagnosed with both diseases were identified by a probabilistic linkage procedure applied to leprosy and ATL databases of the national reporting system. The distribution of the frequency of clinical features between groups was compared by the chi-square test, followed by a multivariate logistic regression. Patients diagnosed with both leprosy and ATL presented higher odds of having nerve damage (OR: 1.34; 95% CI: 1.09–1.66) and leprosy reactions (OR: 1.35; 95% CI: 1.04–1.76) compared to patients diagnosed only with leprosy. Mucocutaneous leishmaniasis (OR: 2.29; 95% CI: 1.74–3.00) was more frequent among patients with both diagnoses when compared to patients who only had ATL. In conclusion, patients diagnosed with both leprosy and ATL present more severe clinical features of such diseases. Our data can be useful for designing health policies aimed at timely and integrated management of leprosy and ATL in co-endemic areas.

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ABSTRACT Brucellosis is one of the most important and widespread bacterial zoonotic diseases worldwide, and it is transmitted to humans from various sources, including direct contact with infected animals and the ingestion of contaminated products, including unpasteurized milk. There are only a few epidemiological studies on said disease in humans in Western Santa Catarina, a region instantiated by agriculture. Thus, the objective of this study was to characterize the epidemiological aspects of human brucellosis reported in Western Santa Catarina from 2013 to 2018. The data were provided by the Epidemiological Surveillance Board (Diretoria de Vigilancia Epidemiologica). The frequency of the disease in humans and the epidemiological profile of confirmed human cases were evaluated. Cases that were screened positive and those that were confirmed and submitted to the therapeutic protocol were analyzed. During the study period, 3,671 people were tested, of which 12.34% were screened positive (453/ 3,671) and 3.40% were confirmed (125/3,671). The year with the highest number of people testing positive was 2015 (123 cases), and 2018 was the year with the highest number of confirmed cases (39 cases). Confirmed cases predominated in males (48.8%), self-declared white (22.4%), aged 20-59 years old (60%), with incomplete primary education (22.4%), of rural origin (59.2%), with occupational contact with cattle (64.8%), engaged in professions directly linked to agricultural and livestock activities (55.5%), and who reported consumption of unpasteurized dairy products (59.2%). No seasonal variation was observed in case numbers. The results demonstrated that brucellosis is an endemic disease in Western Santa Catarina.

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ABSTRACT This prospective cohort study aims to analyze the surveillance of COVID-19 at a single hematopoietic stem cell transplantation (HSCT) center in Brazil, in 29 patients undergoing allogeneic HSCT and 57 healthcare workers (nurses and dentists), through viral shedding of SARS-CoV-2 in saliva and plasma and seroprevalence of anti-SARS-CoV-2 IgG. In addition, we report two cases with prolonged persistent detection of SARS-CoV-2 without seroconversion. The sample collection was performed seven times for patients and five times for healthcare workers. Only two patients tested positive for SARS-CoV-2 in their saliva and plasma samples (6.9%) without seroconversion. All healthcare workers were asymptomatic and none tested positive. Two patients (6.9%) and four nurses (8%) had positive serology. No dentists had positive viral detection or positive serology. Our results reflect a low prevalence of positive RT-PCR and seroprevalence of SARS-CoV-2 in patients and healthcare workers at a single HSCT center. Results have also corroborated how the rigorous protocols adopted in transplant centers were even more strengthened in this pandemic scenario.

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ABSTRACT Blastocystis sp. is a common intestinal microorganism. The α-L-fucosidase (ALFuc) is an enzyme long associated with the colonization of the gut microbiota. However, this enzyme has not been experimentally identified in Blastocystis cultures. The objective of the present study was to identify ALFuc in supernatants of axenic cultures of Blastocystis subtype (ST)1 ATCC-50177 and ATCC-50610 and to compare predicted ALFuc proteins of alfuc genes in sequenced STs1–3 isolates in human Blastocystis carriers. Excretion/secretion (Es/p) and cell lysate proteins were obtained by processing Blastocystis ATCC cultures and submitting them to SDS–PAGE and immunoblotting. In addition, 18 fecal samples from symptomatic Blastocystis human carriers were analyzed by sequencing of amplification products for subtyping. A complete identification of the alfuc gene and phylogenetic analysis were performed. Immunoblotting showed that the amplified band corresponding to ALFuc (~51 kDa) was recognized only in the ES/p. Furthermore, prediction analysis of ALFuc 3D structures revealed that the domain α-L-fucosidase and the GH29 family's catalytic sites were conserved; interestingly, the galactose-binding domain was recognized only in ST1 and ST2. The phylogenetic inferences of ALFuc showed that STs1–3 were clearly identifiable and grouped into specific clusters. Our results show, for the first time through experimental data that ALFuc is a secretion product of Blastocystis sp., which could have a relevant role during intestinal colonization; however, further studies are required to clarify this condition. Furthermore, the alfuc gene is a promising candidate for a phylogenetic marker, as it shows a conserved classification with the SSU-rDNA gene.

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ABSTRACT Intestinal parasitic infections (IPIs) are neglected diseases caused by helminths and protozoa, with the relationships between parasite, host and environment having the potential to produce high morbidity and incapacity to work and mortality in vulnerable areas. This study assessed the prevalence of IPIs concerning socio-environmental conditions and analyzed the knowledge, attitudes and practices related to these diseases among men living in the slums of Rio de Janeiro city, Rio de Janeiro State, Brazil. A cross-sectional study was conducted in an agglomeration of urban slums between 2018 and 2019, with men aged between 20 and 59 years. A socioeconomic status questionnaire and an IPIs knowledge, attitudes and practices questionnaire (KAPQ) were applied. Coproparasitological diagnoses (n=454) were performed using four methods and samples of water for household consumption (n=392) were subjected to microbiological and physicochemical analysis. A total of 624 participants were enrolled. About 40% of the households had “water unsuitable for consumption”. Only one Major Area, MA 3 was not statistically significant for IPIs (AOR=0.75; 95% CI: 0.30-1.88; p=0.55). The overall prevalence of IPIs was 23.8%. Endolimax nana (n=65, 14.3%) and hookworm (n=8, 1.7%) were the most frequently identified parasites. The analysis of the frequency of responses to the KAPQ has shown that men reported to seeking medical care if they were suspicious of IPIs, and around 35% would self-medicate. The results have shown the need to adopt integrated health education practices targeting male residents in urban slums to qualify the care with water for human consumption and promote self-care about IPIs. The household can be considered strategic for Primary Health Care activities for men.

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ABSTRACT Monkeypox virus (MPXV), a zoonotic virus endemic to the African continent, has been reported in 33 non-endemic countries since May 2022. We report an almost complete genome of the first confirmed case of MPXV in Brazil. Shotgun metagenomic sequencing was completed in 18 hours, from DNA extraction to consensus sequence generation.

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ABSTRACT The increase of H. pylori resistance to clarithromycin is a concern. This study evaluated the prevalence of H. pylori’s primary resistance to clarithromycin and its association with virulence factors in adult dyspeptic patients and asymptomatic children. The gastric mucosa from patients (153 gastritis, 24 gastric cancer, 21 peptic ulcer) and gastric juice obtained by string test from 24 H. pylori and 23S rRNA positive asymptomatic children were included. The clarithromycin resistance was assessed by TaqMan RT-PCR 23S rRNA point mutations, A2142G and/or A2143G, and H. pylori virulence markers by PCR. Overall, the clarithromycin resistance was 14.4% (32/222), 14.2% in adults, and 12% in children, whereas origin, gender, and disease were not distinctive factors. The most prevalent point mutation was A2143G (62.5%). The point mutation was significantly less frequent in cagA-positive (11.4%) than in cagA-negative (23.6%) strains (p=0.03 OR = 0.4 95%CI = 0.19 - 0.91) as well as in cagE-positive (10.2%), cagE-negative (21.2%) (p=0.03 OR: 0.4 I.C:0.20-0.91). No difference was found in iceA or vacA alleles genotypes. Primary resistance to clarithromycin was lower than that reported in Southeast Brazil. The cagA and cagE positive H. pylori samples have few point mutations suggesting that individuals infected with virulent strains may be more susceptible to anti-H. pylori treatment.

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ABSTRACT This study assessed the technical performance of a rapid lateral flow immunochromatographic assay (LFIA) for the detection of anti-SARS-CoV-2 IgG and compared LFIA results with chemiluminescent immunoassay (CLIA) results and an in-house enzyme immunoassay (EIA). To this end, a total of 216 whole blood or serum samples from three groups were analyzed: the first group was composed of 68 true negative cases corresponding to blood bank donors, healthy young volunteers, and eight pediatric patients diagnosed with other coronavirus infections. The serum samples from these participants were obtained and stored in a pre-COVID-19 period, thus they were not expected to have COVID-19. In the second group of true positive cases, we chose to replace natural cases of COVID-19 by 96 participants who were expected to have produced anti-SARS-CoV-2 IgG antibodies 30-60 days after the vaccine booster dose. The serum samples were collected on the same day that LFIA were tested either by EIA or CLIA. The third study group was composed of 52 participants (12 adults and 40 children) who did or did not have anti-SARS-CoV-2 IgG antibodies due to specific clinical scenarios. The 12 adults had been vaccinated more than seven months before LFIA testing, and the 40 children had non-severe COVID-19 diagnosed using RT-PCR during the acute phase of infection. They were referred for outpatient follow-up and during this period the serum samples were collected and tested by CLIA and LFIA. All tests were performed by the same healthcare operator and there was no variation of LFIA results when tests were performed on finger prick whole blood or serum samples, so that results were grouped for analysis. LFIA’s sensitivity in detecting anti-SARS-CoV-2 IgG antibodies was 90%, specificity 97.6%, efficiency 93%, PPV 98.3%, NPV 86.6%, and likelihood ratio for a positive or a negative result were 37.5 and 0.01 respectively. There was a good agreement (Kappa index of 0.677) between LFIA results and serological (EIA or CLIA) results. In conclusion, LFIA analyzed in this study showed a good technical performance and agreement with reference serological assays (EIA or CLIA), therefore it can be recommended for use in the outpatient follow-up of non-severe cases of COVID-19 and to assess anti-SARS-CoV-2 IgG antibody production induced by vaccination and the antibodies decrease over time. However, LFIAs should be confirmed by using reference serological assays whenever possible.

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ABSTRACT Despite the high sustained virologic response (SVR) rates of direct-acting antiviral (DAAs) therapy, a small number of patients does not eradicate the virus, and these patients represent a challenge. This study aims to compare the outcomes of three second-line regimens for DAAs-experienced patients with chronic hepatitis C (CHC). This prospective observational study was conducted at the Damanhur Viral Hepatitis Center from January 2017 to February 2020. We included patients with CHC who did not achieve SVR after the complete course of Sofosbuvir/Daclatasvir±Ribavirin (SOF/DAC±RBV). The primary endpoint was SVR-12 after re-treatment. This study included 360 patients (with a mean age of 51.53±11.38 years). Approximately 51.1% of the patients were males, and 65.5% had liver cirrhosis. All patients of group 1 (45 patients) received SOF/VEL/VOX over 12-weeks; SVR-12 was achieved in 44 patients (97.8%). Group 2 (28 patients) received SOF/DAC/RBV over 24-weeks; (one patient was lost during follow-ups and one patient discontinued treatment due to hepatic decompensation). SVR-12 was achieved in 25 patients (96.2%). Group 3 (287 patients) received SOF/Ombitasvir/Paritaprevir/Ritonavir/RBV) over 12-weeks. Eight patients were lost during follow-ups, and one patient discontinued treatment due to grade 4 adverse events. SVR-12 was achieved in 276 patients (99.3%). There was no difference between the groups regarding their age, gender distribution, baseline viral load or comorbidities. Adverse events (thrombocytopenia, anemia, hyperbilirubinaemia and prolonged INR) were significantly higher in group 3, while group 1 did not experience any. The three studied retreatment regimens can be used for DAAs treatment-experienced patients considering availability. The SOF/VEL/VOX combination had the least adverse events.

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ABSTRACT Human Visceral Leishmaniasis (HVL) presents a subacute clinical evolution with systemic involvement, which can result in high case fatality, especially among untreated individuals or those with low socioeconomic status. This study aimed to identify epidemiological and clinical factors associated with HVL case fatality in the Ceara State, from 2007 to 2018. This is an analytical cross-sectional study. The bivariate analysis was performed by Stata 15.1 using Pearson’s Chi-square or Fisher’s exact test; and Poisson regression for age-controlled multivariate analysis. From 2007 to 2018, there were 4,863 new confirmed cases and 343 deaths from HVL (case fatality rate=7.05%). The risk factors associated with case fatalities were: age group (RR=8.69; 95%CI:3.56-21.20); black population (RR=2.21; 95%CI:1.45-3.35); jaundice symptoms (RR=1.72; 95%CI:1.38-2.14); edema (RR=2.62; 95%CI:2.10-3.26) and hemorrhagic phenomena (RR=1.63; 95%CI:1.26-2.10); and no prescription drug intake (RR=4.03; 95%CI:2.98-5.46). Treatment with pentavalent antimonial was a protective factor (RR=0.35; 95%CI:0.27-0.45). The number of deaths increased among the elderly, illiterate, urban residents, and black skin color individuals. The drugs pentavalent antimonial and amphotericin B showed an association with death, but were not considered causal factors. Treatment failure led to a high risk of death. In multivariate analysis, the risk factors for fatal cases were age group, black skin, symptoms of jaundice, edema and hemorrhagic phenomena; and failure to take the prescription drugs. Treatment with pentavalent antimonial was shown to be a protective factor. Knowing the factors associated with the fatality of VL-HIV cases may help to improve public policies, in order to refine the epidemiological surveillance program and, consequently, prevent deaths related to the disease in Ceara.

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ABSTRACT Schistosomiasis is considered one of the Neglected Tropical Diseases (NTDs), which affects around 240 million people worldwide. In Brazil, Schistosomiasis mansoni has been registered in 19 states, predominantly in rural areas. This study aimed to analyze the spatial distribution of Schistosomiasis mansoni cases in the Maranhao State from 2007 to 2016, as well as the temporal trend over this period. The data were obtained from secondary sources: Schistosomiasis Control Program of Maranhao (PCE-MA) and Information System for Notifiable Diseases (SINAN). The State Health Regions (HRs) were considered analysis units. Maranhao had a positivity rate of 3.8 for the period. The Regions that presented the highest percentages of positivity in the state were Pinheiro (7.92), Ze Doca (3.30), and Viana (3.10). Municipalities such as Bacuri, Serrano do Maranhao, and Bequimao, located in the Pinheiro HR, showed positivity rates of 16.56, 13.31, and 11.01 respectively. The spatial analysis of schistosomiasis cases showed that Maranhao has two main centers for the spread of the disease, both located in the northern portion of the state, namely the Baixada Maranhense and the east coast. This study concluded that the positivity of Schistosomiasis mansoni in Maranhao was stable over the analyzed period. The state still maintains the Baixada Maranhense micro-region as an important area for the spread of the disease reaching socially vulnerable population groups.

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ABSTRACT Healthcare workers, the elderly and other vulnerable populations were the first to receive COVID-19 vaccines in public health programs. There were few vaccine safety data available on the elderly. This observational study aimed to evaluate the inactivated vaccine (CoronaVac) safety in the elderly, at the beginning of the vaccination program, in Sao Paulo city, Brazil. The elderly people that received CoronaVac at the Reference Center for Special Immunobiologicals (CRIE) or at home, administered by the Interdisciplinary Home Care Team (NADI) of the Hospital das Clinicas were invited to participate in this phase 4 observational study. The vaccination schedule included two CoronaVac doses 28 days apart. The information on solicited and unsolicited adverse events following immunization were collected by phone calls on days 4 and 8 after each vaccine dose. We enrolled 158 adults aged 65 to 101 years (mean of 84.1 years); 63.9% were females and 95.6% had chronic conditions, 21.5% had moderate or severe impairment in daily living activities; 34.2% were pre-frail and 19.6% were frail. We were able to contact 95.6% and 91.6% of the vaccinated people, after the first and second doses, respectively; 31.8% and 23.4% of the contacted participants reported some adverse events (AE) following the first and second doses, respectively. Pain at the injection site, fatigue, myalgia and headaches were the most frequent solicited AE. Most AE were mild to moderate. There were eight severe adverse events, but none of them were considered related to the vaccine. The CoronaVac was safe and well tolerated by these adults of advanced age with frailty and comorbidities.

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ABSTRACT Although tuberculosis (TB) is a serious public health concern, we still don’t understand why only 10% of people infected will develop the disease. Apoptosis plays a role in the interaction of Mycobacterium tuberculosis (Mtb) with the human host and it may be modified by subtle alterations in the B-cell lymphoma 2 (BCL2) gene, an anti-apoptotic regulatory element. Therefore, we investigated whether there is an association between BCL2 polymorphisms and susceptibility to TB by analyzing 130 TB cases, 108 subjects with latent TB infection (LTBI), and 163 healthy controls (HC). Logistic regression was used to calculate odds ratios (ORs) and 95% confidential intervals (95% CIs) for possible associations between single nucleotide polymorphisms (SNPs) in BCL2 and the risk of tuberculosis. We found that the G allele of rs80030866 (OR=0.62, 95%CI:0.42-0.91, P=0.015), and also the G allele of rs9955190 (OR=0.58, 95%CI:0.38-0.88, P=0.011) were less frequent in the TB group compared with the LTBI group. In addition, individuals with rs2551402 CC genotype were more likely to have LTBI than those with AA genotype (OR=2.166, 95%CI:1.046-4.484, P=0.037). Our study suggests that BCL2 gene polymorphisms may be correlated with susceptibility to both TB and LTBI.

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ABSTRACT This study was conducted to characterize the transmission cycle of the tegumentary leishmaniasis (TL) in an old colonization area at Pernambuco State, Brazil. The aims were to identify autochthonous cases, sandflies fauna, domestic animals as possible reservoir hosts and the Leishmania species involved in this endemic area. A total of 168 suspected human cases of TL and 272 domestic animals (canine, feline, equine, goat, and sheep) were included. The sandflies were captured and identified by species. Patients were predominantly male and the average age was 37+18.1 years old. Of 85 patients who had skin lesions, 25.6% of them had direct positive smears for TL and 34 isolates were identified as Leishmania (Viannia) braziliensis. The confirmation for TL diagnosed by molecular detection (PCR) was almost three times more sensitive than the direct test [p < 0.001; PR = 2.72] associated with clinical examination. The Kappa test on PCR between two different specimens, biopsy, and skin lesion swab was 60.8% (p < 0.001). More than 200 specimens of sandflies (80 males and 159 females) were captured and identified as Lutzomyia whitmani (99.6%) and Lu. evandroi (0.4%). The detection of L. (V.) braziliensis by Real-Time PCR in the blood of a captured fed female was positive in 59.3% of Lu. whitmani. Of the 272 domestic animals included, 61.76% were male (n = 168). Thirty-six animals (13.2%) had lesions compatible with TL (34 dogs, 1 cat and 1 sheep) and 3 of them, all dogs, had lesions on the snout, showing destruction of cartilage and mucosa. The study suggests the participation of domestic animals as possible reservoirs. However, further studies are necessary to better understand the transmission cycle and take recommended measures in order to control the disease.

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ABSTRACT The Hepatitis C virus (HCV) infection is a public health problem. The high level of HCV replication and its lack of post-transcriptional correction mechanisms results in the emergence of viral variants and the difficulty in determining polymorphisms and variants that contain the substitutions associated with resistance towards new antivirals. The main focus of this study was to map the NS5A and NS5B polymorphisms and resistance mutations to new antiviral drugs in HCV strains genotype 1 from patients with chronic hepatitis C infection. Serum samples were collected from patients who underwent routine viral load tests at the Instituto Adolfo Lutz, Sao Paulo city, Brazil. A total of 698 and 853 samples were used for the characterization of NS5A and NS5B regions, respectively, which comprise the HCV genotypes 1a and 1b. The prevalence of resistance mutations found in the NS5A region was 6.4%, with Y93H, L31M, Q30R, and Y93N as the main resistance-associated substitutions (RAS). No NS5B-associated RAS was observed for any of the analyzed drugs. These findings support that the RAS test should be offered to individuals with poor response to double combination regimens prior to treatment initiation, thereby assisting strain vigilance and selection of effective treatment or retreatment options using DAA regimens.

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ABSTRACT COVID-19 disease is spread worldwide and diagnostic techniques have been studied in order to contain the pandemic. Immunochromatographic (IC) assays are feasible and a low-cost alternative especially in low and middle-income countries, which lack structure to perform certain diagnostic techniques. Here we evaluate the sensitivity and specificity of eleven different IC tests in 145 serum samples from confirmed cases of COVID-19 using RT-PCR and 100 negative serum samples from blood donors collected in February 2019. We also evaluated the cross-reactivity with dengue using 20 serum samples from patients with confirmed diagnosis for dengue collected in early 2019 through four different tests. We found high sensitivity (92%), specificity (100%) and an almost perfect agreement (Kappa 0.92) of IC assay, especially when we evaluated IgG and IgM combined after 10 days from the onset of symptoms with RT-PCR. However, we detected cross-reactivity between dengue and COVID-19 mainly with IgM antibodies (5 to 20% of cross-reaction) and demonstrated the need for better studies about diagnostic techniques for these diseases.

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ABSTRACT Salmonellosis ranks among the most frequently reported zoonosis worldwide and is often associated with foodborne outbreaks. Since the 1950s, the distribution of Salmonella serotypes in Sao Paulo State, Brazil, has been documented and periodically reported. In this study, we updated the data on the distribution of Salmonella serotypes received in our reference laboratory, isolated from human infections and nonhuman sources, from 2004 to 2020. In that period, a total of 9,014 Salmonella isolates were analyzed, of which 3,553 (39.4%) were recovered from human samples, mainly of stool (65%) and blood (25.6%), and 5,461 (60.6%) were isolated from nonhuman origins, such as animals (47.2%), food (27.7%) and animal environments (18.6%). In human isolates, a total of 104 serotypes were identified and the most frequent ones were Enteritidis, Typhimurium, S . I. 4,[5],12:i:-, Dublin and Typhi. A consistent reduction of the Enteritidis proportion was observed over the years. Among the 156 serotypes identified in isolates with nonhuman origins, Enteritidis, Mbandaka, Typhimurium, Agona and Anatum were ranked as the top five Salmonella serotypes; in more recent years, S . Heidelberg has increased in frequency. Although with different proportions, the top 10 prevalent serotypes were identified in both human and nonhuman origins, underscoring the role of animals, food products and environment as reservoirs of Salmonella with potential to cause human salmonellosis.

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ABSTRACT Human Adenovirus 36 (HAdV-36) has been related to diverse effects on metabolism and may attenuate the lipid accumulation in kidneys with increased adiposity. Some of these effects would be related to viral persistence. However, until now, a model of persistent in vitro infection by HAdV-36 is unknown. In this study, we examined the cells of the Vero lineage to explore their permissiveness to long-term HAdV-36 infection. HAdV-36 was productively replicated in Vero cells and maintained long-term infection for up to 35 cell passages. A subculture was obtained from the cells that survived the primary infection at a low MOI (0.5). The production of the extracellular infectious virus with titers ranging from 104 to 106 TCID50/mL and DNA-bearing cells was detected. In long-term infected cells, the intracellular distribution of viral antigen was demonstrated by performing immunolocalization (IFI) and expression of cell-viral antigen in 50% of cells by flow cytometry, using anti-HAdV-36 hyperimmune rabbit serum. Furthermore, E1a and E4orf1 genes in long-term infected passages showed a decreasing trend. Our preliminary results reveal that renal epithelial monkey cells are permissive for the productive infection of HAdV-36. Vero cell culture long-term infection might be a promising model for addressing the fundamental aspects of the HAdV-36 biology that cannot reveal broadly-used cultures, which do not maintain long-term infection in primary or transformed cells.

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ABSTRACT This cross-sectional observational study that describes the epidemiological data of the first year of the COVID-19 pandemic in the Mato Grosso do Sul State, aimed to demonstrate the differences between indigenous and non-indigenous populations, characterize confirmed cases of COVID-19 according to risk factors related to ethnicity, comorbidities and their evolution and to verify the challenges in facing the disease in Brazil. SIVEP-Gripe and E-SUS-VE, a nationwide surveillance database in Brazil, from March 2020 to March 2021 in Mato Grosso do Sul state, were used to compare survivors and non-survivors from indigenous and non-indigenous populations and the epidemiological incidence curves of these populations. A total of 176,478, including 5,299 indigenous people, were confirmed. Among the indigenous population, 52.5% (confidence interval [CI] 51.2-53.9) were women, 38% (CI 36.7-39.4) were 20-39 years old, 56.7% were diagnosed by rapid antibody tests, 12.3% (CI 95%:11.5-13.2) had at least one comorbidity, and 5.3% (CI 95%:4.7–5.9) were hospitalized. In the non-indigenous patients, 56.8% were confirmed using RT-PCR, 4.4% (CI 95%:4.3-4.5) had at least one comorbidity, and 8.0% (CI 95%:7.9-8.2) were hospitalized. The majority of non-survivors were ≥60 years old (65.1% indigenous vs. 74.1% non-indigenous). The mortality in indigenous people was more than three times higher (11% vs. 2.9%). Indigenous people had a lower proportion of RT-PCR diagnoses; deaths were more frequent in younger patients and were less likely to be admitted to hospital. Mass vaccination may have controlled the incidence and mortality associated with COVID-19 in this population during the period of increased viral circulation.

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ABSTRACT Paracoccidioidomycosis (PCM) may present as an acute/subacute clinical form, characterized by a progressive disease arising from the airborne initial infection, or, most often, as an asymptomatic or subclinical infection that may manifest later during an individual’s life, the chronic form. Epidemiological studies show the existence of a strong association between smoking and the development of the chronic form. Current evidence demonstrates that cigarette smoke (CS) has immunosuppressive properties that could be implicated in the increasing susceptibility to the chronic form of PCM. To address this issue, we developed a murine model of a non-progressive pulmonary form of PCM that was exposed to CS at a magnitude that mimicked a moderate smoker. The chronic CS exposure started after 2 weeks and lasted up until 20 weeks post-infection, with the aim of mimicking human natural history, since it is estimated that individuals from endemic areas are infected early in life. The control group consisted of infected but not CS-exposed mice. We assessed the lung fungal burden (colony forming units [CFU]) and the area affected by the granulomatous inflammatory response, fungal dissemination to spleen and liver, and, by immunohistochemistry, the presence of CD4 and CD8 lymphocytes, CD68 and MAC-2 macrophages, and IFN-γ, IL-10 and TNF expressing cells within the granulomatous response. We detected a CS effect as early as 2 weeks after exposure (four weeks post-infection) when the lung CFU of exposed animals was significantly higher than in their non-exposed counterparts. At 12 weeks, the CS-exposed animals presented a more severe disease, as witnessed by the persistent higher lung fungal load (although it did not reach statistical significance [ p = 0.054]), greater dissemination to other organs, greater affected area of the lung, decreased IFN-γ/IL-10 ratio, and higher TNF expression within the granulomas, compared with CS-non-exposed mice. The number of CD4 and CD8 lymphocytes infiltrating the granulomas was similar between both mice groups, but there was a decrease in the number of MAC-2+ macrophages. No difference was noted in the CD68+ macrophage number. However, the follow-up in week 20 showed that the immunological effects of exposure to CS ceased, with both CS and NCS mice showing the same infectious features, i.e., a trend for resolution of the infection. In conclusion, we show that chronic CS-exposure alters the course of the disease in an experimental model of subclinical pulmonary PCM, confirming the epidemiological link between CS-exposure and the chronic form of PCM. However, we also show that this effect is transitory, being detected between 4- and 12-weeks post-infection but not thereafter. The possible immune mechanisms that mediate this effect and the reasons for its transitory effect are discussed.

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ABSTRACT The World Health Organization recommends conducting prevalence surveys to validate the elimination of trachoma as a public health problem by the year 2030. The recommendation specifies that the surveys should be directed to previous endemic poor rural areas. Brazil is an endemic country for trachoma and has experienced a large internal migration from the rural areas to the outskirts of the major cities. This study aimed to determine the prevalence of trachoma in children aged 1 to 9 years old in two of the poorest municipalities on the outskirts of Sao Paulo to test the hypothesis of whether internal migration brought trachoma with it. A household survey was conducted between 2013 and 2014. The field teams went door-to-door to collect data on households with children of the selected age group and their members. The trachoma prevalence in this group was 1.5% (79/5,393). In the 10 to 19 years old group, the trachoma prevalence was significantly higher among girls 3.2% (47/1,448) than among boys 1.5% (20/1,361). This result adds evidence to the elimination of trachoma as a public health problem and will be included in the supporting material to validate its elimination in Brazil.

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ABSTRACT Leukocyte biomarkers, including the neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte-(MLR), platelet-to-lymphocyte (PLR) ratios and systemic immune-inflammation index (SII) have been associated with severity and mortality of patients with COVID-19. The purpose of this study was to evaluate the association of baseline leukocyte biomarkers calculated in the emergency department (ED) with the disease severity and mortality. This was a retrospective cohort study that evaluated 1,535 (mean age 57+18 years) patients with SARS-CoV-2 infection in the ED of a single reference center. Outcomes were severity, defined as intensive care unit (ICU) admission requirement, and in-hospital mortality. All leukocyte biomarkers were calculated in the ED before the hospital admission. Their ability to predict the severity and mortality was measured using receiver operating characteristic (ROC) curves. Severity and mortality were observed in 30.9% and 12.6% of the patients, respectively, and were significantly correlated with NLR, MLR, PLR and SII, but only NLR was independently associated with both outcomes on multivariate analysis. Analysis of ROC curves revealed that NLR (0.78 for severity and 0.80 for mortality) and SII (0.77 for severity and 0.75 for mortality) had the best ability to predict mortality, when compared to other ratios. The highest AUC was observed for NLR, employing cut-off points of 5.4 for severity and 5.5 for mortality. Leukocyte biomarkers, particularly NLR, are capable of predicting the severity and mortality of patients with SARS-CoV-2 infection and could be important adjunct tools to identify patients in the ED that are more prone to develop adverse outcomes.

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ABSTRACT Given the magnitude of COVID-19 and the increase in hospitalization cases for severe acute respiratory syndrome (SARS), especially among patients with diabetes mellitus, it is essential to understand the epidemiological aspects inherent to the disease and the worsening of cases. Thus, this study aimed to analyze the survival of patients with diabetes mellitus hospitalized for SARS due to COVID-19 in different regions of Brazil. This is a longitudinal study, carried out based on data reported in the Influenza Epidemiological Surveillance Information System during the year 2020. The number of patients with diabetes mellitus among the hospitalized cases of SARS due to COVID-19 in the different regions of Brazil and the lethality rate among them were identified. A comparison of patient profiles of those who survived or did not survive and the Cox regression analysis were performed to evaluate the factors associated with shorter survival of patients. It was found that 51.4% of patients hospitalized with SARS due to COVID-19 had diabetes, and the case lethality rate among them was 45.0%. The Northeastern and Northern regions presented a higher proportion of patients with diabetes mellitus (56.5% and 54.3%, respectively) and a higher lethality rate (53.8% and 59.9%, respectively). The mean survival time of cases with diabetes mellitus hospitalized for SARS due to COVID-19 was estimated to be 35.7 days (0.5 days). A lower survival rate was observed among residents of the Northeastern and Northern regions with skin color reported as non-white, who required admission to Intensive Care Units and invasive mechanical ventilation, and presented respiratory symptoms such as dyspnea, respiratory distress and an oxygen saturation lower than 95%. It is concluded that diabetes mellitus was responsible for the high occurrence and lethality, mainly in the Northeastern and Northern regions, among non-white patients and those with greater clinical severity, which reinforces the importance of taking measures aimed at supporting this population.

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ABSTRACT Syphilis is caused by the bacterium Treponema pallidum. The diagnosis is based on clinical data and serological analysis; however, the sensitivity and specificity of such tests may vary depending on the type of test and stage of the infection. In order to overcome this premise, this study utilized the polymerase chain reaction (PCR) for the detection of T. pallidum DNA in whole blood samples of patients with syphilis. The blood samples from patients with or without symptoms of syphilis, but with positive results in enzyme-linked immunosorbent assay (ELISA), were included in this study. A venereal disease research laboratory (VDRL) test was performed for all collected sera samples. For PCR, the T. pallidum DNA was extracted from the collected blood samples and a specific primer set was designed to amplify 131 nucleotides of polA (Tp0105). The specificity of the primers was evaluated with the DNA of 17 different pathogens. From a total of 314 blood samples reactive in ELISA, 58.2% (183/314) of the samples were reactive in the VDRL test. In the PCR, 54% (168/314) of the ELISA-reactive samples were positive. In both tests (VDRL and PCR) 104 samples were positive. Of 104 positive samples for both tests, 71 were at the latent stage. Based on these results, it can be concluded that PCR with the designed set of primers can be utilized as a diagnostic method for T. pallidum detection in blood samples of patients with syphilis, especially those with latent infection. In addition, it can be utilized as a supplement for serological methods to improve the diagnosis of syphilis.

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ABSTRACT This systematic review aimed to identify the pathogens causing or associated with congenital microcephaly in Brazil in the last 20 years due to the lack of official information by the Health Authorities and, as a consequence the uncertainty on the real infectious etiology of congenital microcephaly. A review protocol was prepared according to the PRISMA recommendation, using the PubMed, SciELO and LILACS databases to search for references presenting original data on microcephaly caused by or associated with congenital infectious in Brazil, using the descriptors “MICROCEPHALY AND INFECTION”. The search ended on 30/Jun/2020. All selected titles were read in full and analyzed independently by the three reviewers. After searching the databases, 2,389 articles were selected for title review. Of these, 109 were excluded due to duplicates and 2,236 according to the criteria defined in the review. Only 44 met the eligibility criteria and were therefore read in full. Data extraction was performed on 10 articles, all published after 2015. Seven studies were literature reviews or case series, only two were case-control, and one was a cross-sectional study. As the studies focused on the period of the ZIKV epidemic in Brazil, the cases of congenital microcephaly between 2015 and 2017 were attributed to maternal infection by this virus when it was not possible to prove the presence of other etiological agents. Among the TORCH agents, a predominance of syphilis was observed. The analyzed studies did not add consistent information about the infectious causes or association of microcephaly in Brazil outside the period of ZIKV epidemic, revealing the need for more studies on the subject.

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ABSTRACT Despite the many efforts of researchers around the world, there is currently no effective vaccine for malaria. Numerous studies have been developed to find vaccine antigens that are immunogenic and safe. Among antigen candidates, Plasmodium falciparum merozoite surface protein 3 (MSP3) has stood out in a number of these studies for its ability to induce a consistent and protective immune response, also being safe for use in humans. This review presents the main studies that explored MSP3 as a vaccine candidate over the last few decades. MSP3 formulations were tested in animals and humans and the most advanced candidate formulations are MSP3-LSP, a combination of MSP3 and LSP1, and GMZ2 (a vaccine based on the recombinant protein fusion GLURP and MSP3) which is currently being tested in phase II clinical studies. This brief review highlights the history and the main formulations of MSP3-based vaccines approaches against P. falciparum .

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ABSTRACT Chronic Chagas Cardiomyopathy (CCC) is the most prevalent type of myocarditis and the main clinical form of the Chagas disease, which has peculiarities such as focal inflammation, structural derangement, hypertrophy, dilation, and intense reparative fibrosis. Many cellular compounds contribute to CCC development. Galectin-3 is a partaker in inflammation and contributes to myocardial fibrosis formation. Some studies showed the connection between Galectin-3 and fibrosis in Chagas disease but are still inconclusive on the guidance for the early implementation of pharmacological therapy. This systematic review evaluated Galectin-3 as a biomarker for fibrosis intensity in CCC. Two independent reviewers have searched five databases (PubMed, EMBASE, Cochrane Library, Scopus, and Lilacs), using the following search terms: galectin-3, biomarkers, fibrosis, Chagas cardiomyopathy, and Chagas disease. Overall, seven studies met the inclusion criteria and made up this review. There were four trials conducted through animal model experiments and three trials with humans. Experimental data in mice indicate an association between Galectin-3 expression and fibrosis in CCC (75% of studies). Data from human studies showed no direct connection between myocardial fibrosis and Galectin-3 expression (80% of studies). Thus, human findings do not provide significant evidence indicating that Galectin-3 is related to fibrosis formation in Chagas disease. Based on the analyzed studies, it is suggested that Galectin-3 might not be a good fibrosis marker in CCC.

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ABSTRACT People who interact with leprosy patients in their environment, neighborhood, family, or social relationships are at risk to develop the disease. This systematic review investigated the risk and protective factors associated with the development of leprosy in Brazilian contacts. The studies were found in Cochrane Library, PubMed (MEDLINE), Embase, Virtual Health Library, grey literature and hand search until July 2021. The study selection, data extraction and quality assessment were independently performed by two investigators. The quality assessment was performed using the Newcastle-Ottawa Scale (NOS). This review was registered in PROSPERO (CRD42020160680). Seventeen articles fulfilled the inclusion criteria (n=544). The immunological and molecular factors, such as Anti-phenolic Glycolipid Antibodies (Anti-PGL-1) seropositivity, negative Mitsuda test, absence of Bacillus Calmette-Guérin (BCG) scar, positive Polymerase Chain Reaction (PCR) in blood; age and race; conviviality, education, contact time and type of contact, as well as elements related to the index case (bacilloscopic index; genetic conditions, family relationships), and some combined factors were shown to be relevant risk factors associated with the development of the disease in Brazilian leprosy contacts. The protective factors reported were the presence of one or more BCG scars, positive Mitsuda test, and education level. All selected studies were considered of high quality according to NOS. The knowledge of disease-related risk and protective factors provides the scientific basis for decision-making in the management of the disease in leprosy contacts.

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ABSTRACT Interferon-gamma (IFN-γ) plays a crucial role in viral infections by preventing viral replication and in the promotion of innate and adaptive immune responses. However, IFN-gamma can exert distinct effects in different persistent viral infections. The long-term overproduction of IFN-γ in retroviral infections, such as the human immunodeficiency virus (HIV), human T-lymphotropic virus type 1 (HTLV-1), and human endogenous retroviruses (HERVs), resulting in inflammation, may cause neuronal damage. This review is provocative about the role of IFN-γ during persistent retroviral infections and its relationship with the causation of some neurological disorders that are important for public health.

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ABSTRACT Cryptosporidiosis is a disease caused by the Cryptosporidium spp parasite. As some species of Cryptosporidium have a wide host spectrum, the characterization of the pathogen at the species or genotype level is of great importance to define the sources of infection for humans and the potential for public health. This study investigated the diversity of the genus Cryptosporidium spp. in humans from all over the American continent and observed whether the method used to search for the parasite influenced the prevalence found in the Americas. This systematic review was carried out using the Pubmed, Science direct, Lilacs, Scielo, and Scopus databases with publications from January 1, 2010, to December 31, 2020. For data synthesis, the PRISMA flowchart was used and for the meta-analysis we used the MetaXL program. Of the selected publications, 57, 9 and 16 belonged to the region of South, Central and North America, respectively. The prevalence found for South, Central, and North America was 7%, 7%, and 8%, respectively, when analyzing publications that used only the microscopy method. When we analyzed the publications that used immunological and molecular methods, we found prevalences of 10%, 9%, and 21% for South, Central, and North America, respectively. The C. hominis subtype IbA10G2 was the most reported in the American continent, followed by subtype IeA11G3T3 and, for C. parvum, subtype IIaA15G2RI was the most reported. In conclusion, Cryptosporidium spp. is present throughout the American continent and its prevalence is higher when immunological and/or molecular methods are used, in addition to direct microscopic examination.

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ABSTRACT Tenofovir Disoproxil Fumarate (TDF) is one of the drugs in the initial first-line antiretroviral regimen for the treatment of hepatitis B and HIV infections. Despite its effectiveness and few adverse effects, it is related to renal and bone toxicity. We described two cases of HIV-positive middle-aged women who had been using TDF for two and four years (cases 1 and 2, respectively) and were admitted to the emergency room. Case 1 presented with metabolic ileum and diffuse bone pain while case 2 presented with bilateral coxo-femoral pain after a fall from standing height. Both cases had similar laboratory tests: hyperchloremic metabolic acidosis, hypophosphatemia, hypokalemia, hypouricemia and elevated plasma creatinine. In urinary exams, there was evidence of renal loss of electrolytes, justifying the serum alterations, in addition to glucosuria and proteinuria. The bone pain investigation identified bone fractures and reduced bone mineral density, together with increased levels of parathyroid hormone, alkaline phosphatase and vitamin D deficiency. These two cases illustrate the spectrum of adverse renal and bone effects associated with TDF use. TDF was discontinued and treatment was focused on correcting the electrolyte disturbances and acidosis, in addition to controlling the bone disease through vitamin D and calcium supplementation. The renal changes found in both cases characterized the Fanconi’s syndrome, and occurred due to TDF toxicity to proximal tubule cells mitochondria. Bone toxicity occurred due to direct interference of TDF in bone homeostasis, in addition to vitamin D deficiency and phosphaturia resulting from tubulopathy. During the follow-up, both cases evolved with chronic kidney disease and in one of them, the Fanconi’s syndrome did not revert. We emphasize the need to monitor markers of bone metabolism and glomerular and tubular functions in patients using TDF.

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ABSTRACT The effect of antiretroviral therapy (ART) on CD4+/CD25hi/CD127low T lymphocyte changes in people living with HIV/AIDS (PLWHA) is still a matter of debate. From October 2015 to December 2019, peripheral blood from 70 cases of PLWHA were collected for the detection of CD4+/CD25hi/CD127low T lymphocytes by flow cytometry. Statistical analysis was performed to detect changes of CD4+/CD25hi/CD127low T lymphocytes in patients with different duration of ART and different treatment effects. We found that the number of CD4+/CD25hi/CD127low T lymphocytes in ART-naive PLWHA were lower than those in healthy volunteers (10.3±٦.٠ cells/uL vs 31.7±8.0 cells/uL, P < 0.05). CD4+/CD25hi/CD127low T lymphocyte counts increased to 17.8±٤.٠ cells/uL 6 months post-ART and 25.0±١١.٩ cells/uL 9 months post-ART, respectively (P < 0.05). There was no significant difference in CD4+/CD25hi/CD127low T lymphocyte counts between PLWHA who reached a complete immune reconstruction after ART and healthy volunteers. The growth of CD4+/CD25hi/CD127low T lymphocyte counts in patients who had baseline CD4 > 200 cells/uL was greater than those who had baseline CD4 ≤ 200 cells/uL (12.6±٤.٦ cells/uL vs 5.6±٥.٠ cells/uL, P = 0.027). CD4+/CD25hi/CD127low T lymphocyte counts were positively correlated with CD4+ T lymphocyte counts (r = 0.923, P < 0.001) and CD4+/CD8+ ratio (r = 0.741, P < 0.001), but were negatively correlated with HIV-VL (r = −0.648, P = 0.000). In conclusion, the results of the present study showed that changes in CD4+/CD25hi/CD127low T lymphocyte counts can be used to assess the effect of ART in PLWHA.

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ABSTRACT Clinical similarities among viral diseases become even more relevant considering the current scenario, especially in Brazil, where there is a high incidence of these diseases and overlapping seasonality. We report the case of a patient with acute clinical manifestations composed of predominant respiratory symptoms and alveolar hemorrhage in which three etiologies (dengue, influenza and COVID-19) were investigated concomitantly. Only the diagnosis of dengue was confirmed. Then, the patient’s immunological profile in response to stimulation of mononuclear cells with dengue virus antigen was analyzed in an attempt to identify specific characteristics that could be associated with the clinical manifestation.

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ABSTRACT The global pandemic of COVID-19 is caused by the novel coronavirus SARS-CoV-2, which often causes flu-like symptoms and can progress to severe respiratory illness. Thus, as the disease spreads, COVID-19 cases have multiplied across the world, and manifestations involving multiple systems have been described. We report a case of COVID-19-associated meningoencephalitis in a Brazilian male patient who presented with seizures and altered mental status. To the best of our knowledge, this is the first reported case of COVID-19-associated meningoencephalitis in Brazil. COVID-19-associated meningoencephalitis is a rare manifestation of this viral infection and clinicians should be aware of this possible complication.

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ABSTRACT We report the case of a 6-year-old boy that presented with enlarged lymph nodes on his neck. He complained of tiredness and discouragement, which worsened during feverish periods. There were no relevant laboratory test abnormalities and serological tests were not reactive. Bartonella henselae DNA was detected by species-specific nested polymerase chain reaction. After treatment, the patient progressed with no fever or lymphadenopathy. Bartonellosis is a group of infectious diseases caused by bacteria of the genus Bartonella. This case report is a useful reminder to clinicians that long-term fever of unknown origin can be related to B. henselae infection, even if the specific serology is not reactive.

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ABSTRACT As leprosy and leprosy reactions are the most prevalent infectious cause of physical disability, it is important to commit efforts to better understand these chronic reactions. Infections, even when asymptomatic, can trigger leprosy reactions and Bartonella spp. in turn, can cause chronic infections. We presented a case of a 51-year-old man who was admitted presenting with chronic type 2 leprosy reactions. He had a lepromatous form of leprosy that was histologically diagnosed six months after the onset of signs and symptoms compatible with a chronic type 2 reaction. He reported a history of a previous hepatitis B diagnosis. During a 24-month multidrug therapy (MDT), chronic reactions were partially controlled with prednisone and thalidomide. Thirty-three months following the leprosy treatment, he still experienced chronic reactions, and whole bacilli as well as globi were found on a new skin biopsy. Since coinfections can trigger type 2 reactions and the patient had close contact with animals and ticks, we investigated the presence of a Bartonella sp. infection. Bartonella henselae DNA was detected in a skin fragment obtained before the beginning of the leprosy retreatment. However, even after six months of a second leprosy MDT, he continued to experience type 2 chronic reactions. He was admitted to the hospital to undergo an intravenous antibiotic therapy for 14 days and then complete the treatment per os for ten more weeks. Leprosy reactions improved following the treatment for B. henselae. After completing the MDT treatment, he has been accompanied for sixty months with no signs of leprosy or leprosy reactions. The asymptomatic infection by B. henselaein this patient was considered the putative trigger of chronic leprosy reactions and leprosy relapse.

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ABSTRACT Visceral leishmaniasis (VL) is an opportunistic disease in immunosuppressed individuals, who may present severe clinical conditions, such as the ones described in this patient. She lived in an endemic region for VL, and was possibly infected with L. (L.) infantum chagasi through the bite of a contaminated sand fly. This initial infection has triggered a pemphigus vulgaris condition by immunogenic proteins present in the mosquito's saliva. The immunosuppression caused by the use of high doses of corticosteroids to control the disease promoted a severe VL condition, with hepatosplenomegaly, thrombocytopenia and hemorrhages, requiring hospitalization and the onset of a subsequent SARS-CoV-2 infection. Due to the intensity of clinical manifestations related to VL, aggravated by COVID-19, she died two days after admission to the Clinical Hospital of Marilia Medical School (HC–Famema).

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ABSTRACT This study aimed to report the first case of a patient with hepatosplenic schistosomiasis mansoni, refractory ascites and portal vein thrombosis treated with a transjugular intrahepatic portosystemic shunt (TIPS), at the Instituto de Radiologia, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil. After the procedure, the patient recovered favorably and progressed with portal pressure reduction and no deterioration of the liver function. Endovascular shunt modification is a conservative medical approach that often helps in reducing symptoms significantly, making it a less invasive and a safer alternative to liver transplantation for the treatment of schistosomiasis with portal hypertension.

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ABSTRACT Capnocytophaga canimorsus is a gram-negative rod that is part of the commensal microbiota of dogs’ and cats’ mouths. In this case, we report an 85-year-old man with COVID-19 who had his right arm bitten by a dog. His symptoms were impaired consciousness, agitation and aggressive behavior. Physical examination revealed neck stiffness and Brudzinski’s sign. The cerebrospinal fluid culture was compatible with Capnocytophaga canimorsus. He required intensive care and received a 14-day prescription of meropenem. After 40 days of hospitalization, the patient was fully recovered and was discharged. This case highlights the importance of physician and microbiologist be awareness of this disease, mainly in patients with neurological symptoms after a dog or cat bite.

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ABSTRACT Burkholderia cepacia complex (BCC) is group of widespread gram-negative bacillus organized in over 20 phylogenetically distinct bacterial species. According to previous studies, BCC species pathogens are widely reported in patients with cystic fibrosis (CF), but not in individuals with diabetes mellitus (DM). In this case report, a 42-year-old male patient with DM and a foot infection caused by BCC is presented. The patient was hospitalized after antibiotic treatment failure and improved after two surgical debridement procedures and a high-dose extended infusion (EI) of meropenem. The team of vascular surgeons and the infectious disease specialists worked fervently to solve the case. Finally, a scoping review was conducted to map BCC infections in patients with DM.

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ABSTRACT Visceral leishmaniasis (VL) is mainly caused by Leishmania (Leishmania) donovani and Leishmania (L.) infantum; however, other Leishmania species have been associated with VL. We report a case of a patient simultaneously diagnosed with VL caused by Leishmania (L.) amazonensis and Hodgkin’s lymphoma. After treatment with liposomal amphotericin B and chemotherapy, the patient presented a clinical cure. This case report reinforces the hypothesis that other Leishmania species can cause visceral lesions mainly related to immunosuppression.

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ABSTRACT In 2022, an outbreak of monkeypox is being reported in non-endemic areas, with unusual clinical manifestations. The detailed clinical description of the first patient that received the diagnosis of monkeypox in Brazil is reported here, whose clinical manifestations can easily lead to misdiagnosis of sexually transmitted infections. A 41 years old male presented to an emergency room with a vesicular rash with eight days of evolution. He had traveled to Portugal and Spain and reported non-penetrative sexual involvement with three different male individuals. On the third day of symptoms, he sought medical care and received empirical treatment directed to sexually transmitted infections. As the symptoms did not improve, he sought medical attention at an infectious disease referral center presenting, on admission, an ulcerated penile lesion with central necrotic crusts, a disseminated pleomorphic skin rash and an oropharyngeal ulcer. The monkeypox diagnosis was suspected due to the characteristics of the lesions and the history of intimate contact with casual partners, and it was later confirmed by sequencing the almost complete monkeypox genome. The patient was hospitalized for pain control, which required opiate administration. He developed a secondary bacterial infection on the penile lesions, which were treated with oral antibiotics. He was discharged after 14 days, with lesions in process of re-epithelialization. Given the current outbreak, we must consider the possibility of monkeypox in patients with suggestive lesions, anywhere on the body (including the genitals), added to an epidemiological link or history of intimate contact with strangers or casual partners.

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ABSTRACT Leukocytoclastic vasculitis (LCV) is a small vessel vasculitis characterized by an inflammatory infiltrate composed of neutrophils with fibrinoid necrosis and “leukocytoclasia”, a term that refers to nuclei disintegration into fragments. LCV is related to multiple conditions including ANCA-associated vasculitis, cryoglobulinemia, IgA vasculitis, infectious and systemic diseases such as rheumatoid arthritis and systemic erythematous lupus (SLE) as well as infections and malignancy. We describe the clinical case of severe systemic vasculitis in a young male patient with secondary syphilis and HIV coinfection manifested by cutaneous and neurological involvement, as well as peripheral necrosis that requires bilateral lower limb amputation. The skin biopsy revealed histopathological changes compatible with endarteritis obliterans and LCV related to treponemal infection. This case highlights the plethora of clinical manifestations of treponemal infection and the diagnostic challenge this poses in current clinical practice.

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ABSTRACT A 35-year-old immunocompetent woman from southern China went to the hand surgery clinic with a six-month history of progressive swelling in her right index finger. She had been pinched by a lobster and had received several treatments without any improvement. Pus specimens were taken from the swollen parts of her finger, and the pathology showed granulomatous inflammation. Ziehl–Neelsen staining revealed positive bacillus in the pus specimens. The bacteria grew well on Columbia blood agar. However, the MALDI-TOF MS and 16S rRNA gene sequencing were not able to distinguish between Mycobacterium marinum and Mycobacterium ulcerans because of their close genetic relationship. Photochromogenicity testing can help differentiate between these species based on the alteration in colony color after light exposure. For our patient, the colonies turned yellow after 18h of incubation in the sun, identifying the species as M. marinum. Besides surgical drainage, the patient received rifampicin and clarithromycin for three months, and her symptoms resolved without relapse after six months of follow-up.

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ABSTRACT Brazilian spotted fever, a zoonotic disease transmitted by ticks, is caused by Rickettsia rickettsii. We report a fulminant case of this zoonosis in a healthy 46-year-old military man in the urban region of Rio de Janeiro city, in October, 2021. Ticks and capybaras (Amblyomma sculptum, Hydrochoerus hydrochaeris, respectively) were identified in the military fields, pointing to the participation of this large synanthropic rodent, recognized as an efficient amplifier host of Rickettsia rickettsii in Brazil. As the military population is considered a risk group for spotted fever, it is necessary to alert health professionals to the importance of the early detection of the disease and its adequate management, mainly in populations that are particularly at risk of exposure to ticks, in order to avoid fatal outcomes.

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ABSTRACT The COVID-19 pandemic in Brazil has been marked by high infection and death rates. The immune response generated by current vaccination might be influenced by previous natural infection, and baseline estimates may help in the evaluation of vaccine-induced serological response. We evaluated previous SARS-CoV-2 testing (RT-PCR), and performed rapid diagnostic tests (RDT) and high throughput electrochemiluminescence immunoassay (ECLIA) before vaccination among people living with HIV (PLWH), users of antiretroviral prophylaxis (PrEP/PEP), and healthcare professionals in an HIV outpatient clinic (HCP-HC). RDT was positive in 25.7% (95% CI: 19-33%) overall, 31.3% (95% CI : 18-45%) among PLWH, 23.7% (95% CI : 14-34%) in PrEP/PEP users and 21.4% (95% CI : 05-28%) in HCP-HC (p=0.548). Diagnostic RT-PCR testing was very limited, even for symptomatic individuals, and whereas all HCP-HC had one test perfomed, only 35% of the patients (PREP/PEP/PLWH) were tested (p<0.0001). Adequate monitoring of post-vaccination humoral response and breakthrough infections including those in asymptomatic cases are warranted, especially in immunologically compromised individuals.

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ABSTRACT The present study aimed to establish a population pharmacokinetic (PopPK) modeling of benznidazole (BZD) in Brazilian patients with chronic Chagas disease. This was part of a Brazilian prospective cohort study with eight patients diagnosed with Chagas disease during the beginning of BZD treatment up to the 60th day. On the 15th day of treatment, a blood sampling was collected and analyzed. A one-compartment PK model was developed using Pmetrics. Patients with an average age of 50.3 (SD: 6.2) years old, 6 female patients and 2 males, 70.2 kg (14.2), receiving a 5 mg/Kg/day dose were included. PK parameters estimated for CL, V and Ka were 6.27 L/h, 38.97 L and 1.66 h-1, respectively. This is the first study to establish a population pharmacokinetic modeling of BZD in Brazilian patients with chronic Chagas disease. Therefore, further studies are needed to obtain the complete characterization of BZD pharmacokinetics.

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ABSTRACT Worldwide, transplant programs have suffered a setback during the coronavirus disease 2019 (COVID-19) pandemic and most have temporarily suspended their transplant activities. . We identified 36 liver transplant patients who tested positive for COVID-19. The cases were confirmed by the nucleic acid test (RT-PCR). Epidemiological, demographic, clinical, laboratory, management and outcome data were obtained from the patients’ medical records. Fourteen patients (38.9%) required admission to the Intensive Care Unit and/or invasive ventilatory support (severe cases). The mean age of these severe cases was 63.8 years. Regarding the time since the transplant, 71.4% (10/14 patients) had undergone the procedure less than one year before. The immunosuppressive therapy was reduced in patients who required Intensive Care Unit. A total of 12 cases (12/14, 85.7%) required invasive ventilatory support. Eight cases (8/14, 57.1%) required renal replacement therapy. In this group of patients, nine died (64.3 %). In turn, 22 patients had mild to moderate symptoms of COVID-19, not requiring invasive ventilatory support or admission to the Intensive Care Unit. The mean age in these patients was 56.5 years and comorbidities were present in 15 (68.2%) of the cases. In this group, only five patients (5/22, 22.7%) required hospitalization due to complications and there were no deaths This report describes the results of COVID-19 infection in a very specific population, suggesting that liver transplant patients have a significant higher risk of progressing to severeCOVID-19 , with a mortality rate among critically-ill patients above that of the general population.

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ABSTRACT This prospective study describes the use of Gene-Xpert Ultra for the diagnosis of extrapulmonary tuberculosis (EPTB) in children and adolescents, in Rio de Janeiro, Brazil. Eighteen patients were studied; the final diagnosis of EPTB was established in 13 (72%). Gene-Xpert Ultra results showed detection in 10/13 (77%) of EPTB cases (7 of these 10 with trace-positive results). Gene-Xpert Ultra proved to be a promising method for the diagnosis of childhood EPTB.

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ABSTRACT This study aims to assess COVID-19 and other respiratory viruses in pediatric patients. Between April 17 and September 30, 2020, we collected 1,566 respiratory samples from 1,044 symptomatic patients who were younger than 18 years old to assess SARS-CoV-2 infection. Of these, 919 were analyzed for other respiratory pathogens (ORP). Patients with laboratory-confirmed COVID-19 or ORP were included. We evaluated 76 pediatric COVID-19 infections and 157 other respiratory virus infections. Rhinovirus occurred in 132/157 (84%). COVID-19 patients who were significantly older, had more fevers, headaches and pneumonia than those with ORP. The median white blood cell count was lower in patients with SARS-CoV-2 than in those with ORP (6,470 versus 8,170; p=0.02). COVID-19 patients had significantly worse symptoms than those with ORP.

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ABSTRACT Q fever is a major public health problem in French Guiana. In recent years, a considerable number of cases has been reported in French Guiana’s penitentiary center. The main objective of this study was to describe the epidemiology of these cases. A retrospective study was conducted at the prison to identify cases of acute Q fever in people incarcerated between 2010 and 2021. During the study period, 16 patients were diagnosed with acute Q fever. The positivity rate varied between 13 and 57%. The annual incidence rate in 2019, 2020 and 2021 was 269 (95% CI: 0-640) 1,120 (95% CI: 290-1950) and 1,931 (95% CI: 60-3810) per 100,000 person-years, respectively. While several vertebrate species have already been shown to play an important role in the transmission of Coxiella burnetii, the full epidemiology picture in the tropics is far from clear, and the prison context, with its controlled environment, could help provide answers.

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ABSTRACT SARS-Cov2 has already infected over 482 million people and caused more than 6.1 million deaths. The beginning of the pandemic has led the health authorities of several countries to adopt non-pharmacological preventive measures such as daycare closures. The reopening took place when the country had the highest rates of infection and mortality (mainly due to the gamma variant (P.1) outbreak) and the beginning of the vaccination program. Therefore, we aimed to investigate the prevalence of SARS-CoV2 in daycare after educational activities resumed. The study was conducted in seven childcare facilities. Swab samples from the nasopharynx were collected from children and staff members. The viral RNA was obtained through PureLink RNA extraction kit purification and SARS-CoV2 presence was detected using the All plex SARS-CoV2 kit. The study population included 201 participants, including daycare workers and children. The average age of the workers and children is 40 and 3 years old, respectively. Among the children, 47.5% are female and among the workers, 91.4%. One (0.5%) test came out positive for the presence of SARS-CoV-2, which was from a sample of an asymptomatic childcare worker, and no secondary infections were detected. Considering that the return to daycare activities occurred during a period with a high number of deaths and a lack of vaccines throughout the country, the small number of cases indicates the effectiveness of the several preventive measures used by daycare centers in preventing SARS-CoV2 transmission.

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ABSTRACT Loop-mediated isothermal amplification (LAMP) is a simple and efficient nucleic acid amplification method for the rapid diagnosis of infectious diseases. This study assessed the performance of an in-house LAMP for tuberculosis (TB) diagnosis at a remote reference laboratory in the endemic setting of Thailand. As part of the routine service, 1,882 sputum samples were processed for mycobacterial culture in Lowenstein-Jensen and MGIT media. The DNA was extracted from the remaining decontaminated samples after the culture procedure for real-time polymerase chain reaction (PCR) analysis using Anyplex plus MTB/NTM detection kit. 785 (40.28%) were positive by mycobacterial culture. Of these, 222 DNA remnants were available and subjected to LAMP analysis. Based on culture as reference (Mycobacterium tuberculosis; MTB= 209/ non-tuberculous mycobacteria; NTM= 13), the overall sensitivity of LAMP and Anyplex plus assays for MTB detection were 89.95% (188/209; 95% confidential interval [CI]: 85.05-93.67%) and 96.65% (202/209; 95% CI: 93.22-98.64%), and the accuracy values were 88.74% (197/222; 95% CI: 83.83-92.58) and 96.40% (214/222; 93.02-98.43%), respectively. The sensitivity and accuracy of the in-house LAMP and the Anyplex plus real-time PCR assay were high in comparison to culture results. The high sensitivity and accuracy suggested that this in-house LAMP was promising and might be useful for early TB diagnosis.

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ABSTRACT We described a MRSA bloodstream infection outbreak that was rapidly identified and controlled in a Neonatal Intensive Care Unit after implementation of a bundle of measures, including PCR-screening and HCW decolonization. We found 35% of healthcare workers(HCW) colonized with S. aureus by PCR, one of them that presented skin lesion positive for MSSA (same clone and spa type than two patients). Our findings raise the hypothesis that the outbreak could be related to HCW colonization.

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ABSTRACT This study aimed to evaluate the COVID-19 hospitalizations in a tertiary hospital by age group and month, considering the introduction and the advance of the vaccination against the disease. The laboratory-confirmed COVID-19-associated hospitalizations among people aged 20 years or older, that occurred between March 2020 and June 2021, were distributed by month of symptom onset and age group. The proportion of hospitalizations by age group was calculated for the year 2021. The proportions were compared using the chi-square test for trends. The marks of vaccination advances among different age groups were taken from the official website LocalizaSUS. In 2020, hospitalizations among people aged 60–80 years old were the most frequent (39.1%). From January–June 2021, when the vaccination commenced, while hospitalizations of patients aged 20 to < 40 and 40 to 60 years old showed an increasing trend, the older age groups and those with vaccination recommendations (from 60 to < 80 and from 80 or over) showed a downward trend. As of June 2021, with widespread vaccination, a drop in hospitalizations was observed in > 60 years old. At 20 to <40 and 40 to < 60, an increase in hospitalizations was observed. It demonstrates the important role of vaccination in combating the COVID-19 pandemic.

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ABSTRACT In this study, B. cereus was detected in dialysis fluids within international parameters (ultrapure – maximum limit of 0.1 CFU/mL for heterotrophic bacteria count) by analyzing the pellet obtained through the centrifugation method. We also investigated the ability of the B. cereus isolate to form a biofilm at different temperatures, the production of virulence factors, and the susceptibility to commercial antimicrobial agents. This study demonstrated a high ability of B. cereus to persist in the hemodialysis system, which can be explained by its broad ability to produce a biofilm at 25 °C, its relevant production of virulence factors, such as β-hemolysin, lecithinase and cereulide, and its important resistance pattern to antimicrobial drugs. In conclusion, these new findings expand the understanding that this microorganism should not be neglected and new methods for tracking it should be considered.