ABSTRACT The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.

Abstract Infection by hepatitis B virus (HBV) is a worldwide public health problem. Chronic HBV infection with high viral replication may lead to cirrhosis and/or hepatocellular carcinoma. Mutant HBV strains, such as the HBV A1762T/G1764A double mutant, have been associated with poor prognosis and higher risk of the patient for developing cirrhosis and/or hepatocellular carcinoma. This study analyzed the presence of the HBV A1762T/G1764A double mutant in patients with chronic HBV and its association with clinical parameters such as viral load, aminotransferases, and HBV antigens. A total of 49 patients with chronic hepatitis B were included in the study, and the HBV A1762T/G1764A double mutant strain was detected in four samples (8.16%) by polymerase chain reaction followed by restriction fragment length analysis (PCR-RFLP). The viral load was not significantly different between patients with or without the double mutant strain (p = 0.43). On the other hand, carriers of the HBV A1762T/G1764A double mutant had higher levels of ALT (p = 0.0028), while AST levels did not differ between groups (p = 0.051). In this study, 75% of the samples with the HBV A1762T/G1764A double mutation were HBeAg negative and anti-HBe positive, reflecting seroconversion even though they still displayed high viral loads. Our study has shown that the HBV A1762T/G1764A double mutant strain circulates in Brazilian patients, and is associated with elevated levels of ALT and HBeAg seroconversion.

ABSTRACT INTRODUCTION: Validation of food frequency questionnaires (FFQs) is recommended for accurate measurement of habitual food consumption. We assessed the relative validity of a FFQ in patients coinfected with hepatitis C virus and human immunodeficiency virus. METHODS: Each patient responded to a FFQ and three 24-hour food recalls. Pearson’s correlation and weighted Kappa index analyses were performed to identify the FFQ relative validity and concordance. RESULTS: De-attenuated correlation coefficients ranged from 0.35 (vitamin B1) to 0.81 (selenium). The concordance index ranged from 0.07 (vitamin C) to 0.51 (calcium). CONCLUSIONS: The FFQ showed satisfactory relative validity for most nutrients.

RESUMO Contexto Em virtude da elevada prevalência da coinfecção pelos vírus da hepatite C (HCV) e da imunodeficiência humana (HIV) e às inúmeras complicações que esses vírus acarretam, é fundamental o maior entendimento do comportamento biológico dos mesmos. O polimorfismo de nucleotídeo único rs1045642 C3435T do gene de resistência a múltiplas drogas MDR1, no qual ocorre modificação do códon ATC para ATT, parece estar relacionado à resposta virológica sustentada ao tratamento do HCV em coinfectados HCV-HIV. Objetivo Mapear o polimorfismo C3435T do gene MDR1 em pacientes coinfectados HCV-HIV e correlacionar com dados clínicos e laboratoriais. Métodos Foram analisados 99 pacientes coinfectados HCV-HIV. A identificação molecular do polimorfismo de nucleotídeo único rs1045642 do gene MDR1 foi realizada pela técnica de PCR em tempo real (qPCR) alelo-específico com primers e sondas específicos para a identificação desse polimorfismo. Fatores de risco para a aquisição do HCV e a resposta virológica sustentada ao tratamento do HCV com interferon-alfa peguilado e ribavirina foram analisados. Resultados Dentre os pacientes avaliados, 54 (54,5%) eram do gênero masculino e 45 (45,5%) do gênero feminino. A média de idade foi de 46,1 anos (±9,8). As frequências dos genótipos CC, CT e TT foram 28,3%, 47,5% e 24,2% respectivamente, e as frequências alélicas foram 52% para alelo C e 48% para alelo T. Não houve associação entre o gene MDR1 e a resposta virológica sustentada (P=0,308). Conclusão Neste estudo, o polimorfismo C3435T no gene MDR1 não apresentou associação com a resposta virológica sustentada ao tratamento em indivíduos coinfectados HCV-HIV.

ABSTRACT Background Due to the high prevalence of co-infection by hepatitis C virus (HCV) and human immunodeficiency virus (HIV) and the severity of these infections, the understanding of the biological mechanisms involved in these processes, including viral behavior and host genetic profile, is of great importance for patient treatment and for public health policies.Some single nucleotide polymorphisms (SNPs) in the human genome, such as the SNP rs1045642 (C3435T) in the MDR1 gene, have been reported to be associated to the sustained virological response (SVR) to HCV treatment in HCV-HIV co-infected patients. Objective The present study analyzes the MDR1 gene C3435T polymorphism in HCV-HIV co-infected patients. Methods A total of 99 HCV-HIV patients were included in the study. The DNA was extracted from blood samples, and the SNP rs1045642 was assessed by Real Time PCR (qPCR). Risk factors for acquiring the virus and the SVR after HCV treatment with pegylated interferon-alpha and ribavirin were also analyzed. Results Among the patients, 54 (54.5%) were male and 45 (45.5%) were female. The average age was 46.1±9.8 years. The SVR after HCV treatment was 40%. The frequencies of MDR1 genotypes CC, CT and TT were 28.3%, 47.5% and 24.2%, respectively. Allele frequencies were 52% for the C allele and 48% for the T allele. No association was found for SNP rs1045642 (C3435T) regarding response to treatment (P=0.308). Conclusion - In this study, the C3435T polymorphism in the MDR1 gene appears not to be associated with SVR in HCV-HIV co-infected individuals.

OBJECTIVE: To evaluate the influence of hepatitis C virus on immunological and virological responses after highly active antiretroviral therapy initiation in human immunodeficiency virus/hepatitis C virus coinfected patients compared to monoinfected human immunodeficiency virus-infected patients. METHODS: The study enrolled 65 human immunodeficiency virus-1-infected subjects who initiated highly active antiretroviral therapy and attended follow-up visits over 48 weeks from 2008 to 2010. They were grouped based on hepatitis C virus-RNA results. Virological and immunological responses were monitored at baseline and at the end of weeks 12, 24, 36, and 48. RESULTS: There were 35 human immunodeficiency virus monoinfected and 30 human immunodeficiency virus/hepatitis C virus coinfected patients. In the present study human immunodeficiency virus/hepatitis C virus coinfection did not seem to influence CD4 Tlymphocytes recovery. There was no difference between the curves of CD4 T-lymphocytes raise of coinfected and monoinfected groups. CONCLUSION: This prospective study confirms that hepatitis C virus infection does not seem to be associated with impaired CD4 T-lymphocytes recovery after HAART.

Cromoblastomicose é uma infecção fúngica crônica do tecido subcutâneo causada pela inoculação traumática de um grupo específico de fungos através da pele, encontrados eventualmente em trabalhadores do campo descalços em países de clima tropical e subtropical. Relatamos aqui o caso de um paciente do sexo masculino com uma lesão dermatológica de crescimento lento e pruriginosa nos membros inferiores por 20 anos, diagnosticada e tratada com sucesso para cromoblastomicose. Apesar da prevalência desta doença em nossa região, o tratamento ainda é um desafio.

Chromoblastomycosis is a chronic human melanized fungi infection of the subcutaneous tissue caused by traumatic inoculation of a specific group of dematiaceous fungi through the skin, often found in barefooted agricultural workers, in tropical and subtropical climate countries. We report the case of a male patient presenting a slow-growing pruriginous lesion on the limbs for 20 years, mistreated over that time, which was diagnosed and successfully treated as chromoblastomycosis. Besides the prevalence of this disease, treatment is still a clinical challenge.

INTRODUÇÃO: O impacto da terapia antirretroviral altamente ativa na progressão da fibrose hepática em pacientes co-infectados com HIV e hepatite C não está totalmente esclarecido. Marcadores não-invasivos de fibrose hepática podem ser considerados promissores no estadiamento e na monitorização da sua evolução. MÉTODOS: Um total de 24 pacientes, divididos em dois grupos: 12 monoinfectados por HIV e 12 co-infectados com HIV e HCV foram acompanhados de julho de 2008 a agosto de 2009, desde o início de HAART, a cada três meses, com avaliação de dados clínicos, epidemiológicos e laboratoriais, assim como o cálculo do índice da relação aspartato aminotransferase sobre plaquetas. O objetivo deste estudo foi comparar a progressão de APRI, marcador não-invasivo de fibrose hepática, entre populações portadoras do vírus do HIV e co-infectados com HIV e HCV. RESULTADOS: Os grupos estudados não mostraram diferenças quando avaliados idade, sexo, medida de CD4 e carga viral para HIV em todas visitas, tipo de HAART e APRI antes do início de HAART. O grupo de pacientes co-infectados com HIV e HCV apresentava APRI significativamente maior que o grupo de monoinfectados por HIV no terceiro (0,57 + 0,31 x 0,27 + 0,05, p = 0,02) e sexto mês (0,93 + 0,79 x 0,28 + 0,11, p = 0,04). CONCLUSÕES: Neste estudo, HAART foi associado com aumento de APRI no terceiro e sexto mês de seguimento nos pacientes co-infectados, sugerindo que nestes pode estar ocorrendo hepatotoxicidade cumulativa e síndrome inflamatória da reconstituição imune após início dos antirretrovirais.

INTRODUCTION: The impact of highly active antiretroviral therapy (HAART) on hepatic fibrosis progression in HIV and hepatitis C virus coinfected patients is not completely understood. Noninvasive hepatic fibrosis markers show great promise in determining liver fibrosis staging and monitoring disease progression. METHODS: Twenty-four patients divided equally into two groups: 12 HIV-monoinfected and 12 with HIV/HCV coinfected patients, were followed from July 2008 to August 2009, after initiating HAART, with clinical, epidemiological and laboratorial assessments every 3 months and calculation of the aspartate aminotransferase to platelet ratio index (APRI). This study aimed to compare the progression of APRI, a noninvasive hepatic fibrosis marker, among populations with HIV and HIV/HCV coinfection. RESULTS: No differences were observed between the groups regarding age, sex, measurement of CD4 and HIV viral load in all consultations, type of HAART and APRI before initiating HAART. Coinfected patients showed a significantly higher APRI than the monoinfected group in month 3 (0.57 ± 0.31 x 0.27 ± 0.105, p = 0.02) and 6 (0.93 ± 0.79 x 0.28 ± 0.11, p = 0.04). CONCLUSIONS: In the present study, HAART was associated with APRI increases over six months follow-up in HIV/HCV coinfected patients, suggesting that these may be experiencing cumulative hepatotoxicity and immune reconstitution inflammatory syndrome after initiating antiretroviral drugs.

Embora Candida albicans seja a principal causa de esofagite fúngica, outras espécies como C. tropicalis, C. krusei e C. stellatoidea também têm sido implicadas. O objetivo desse estudo foi descrever espécies causadoras de esofagite fúngica em nosso centro durante um período de 18 meses, além de comparar condições predisponentes para candidose esofágica causadas por diferentes espécies de Candida. De janeiro de 2005 a julho de 2006, 21.248 endoscopias digestivas altas foram realizadas no Complexo Hospitalar Santa Casa (Porto Alegre, Brasil). A prevalência de esofagite por Candida foi de 0,74% (n = 158). C. albicans foi a causadora da maioria das infecções (96,2%), seguida por C. tropicalis (2,5%), C. lusitaniae (0,6%) e C. glabrata (0,6%). Candidose oral concomitante foi documentada em 10,8% (n = 17). Cerca de 21% dos pacientes não teve qualquer fator de risco identificável para candidose esofágica. Em função do pequeno número de pacientes infectados por espécies não-Candida albicans, não foi possível determinarmos fatores de risco para estas infecções.

Although Candida albicans is the main cause of fungal esophagitis, other species such as C. tropicalis, C. krusei and C. stellatoidea have also been implicated. Several studies have identified risk factors for C. albicans esophagitis. However, data for non-C. albicans species is still sparse. The aim of this study was to determine the etiology of Candida esophagitis in our medical centre over an 18-month period. Additionally, we aimed to investigate predisposing conditions for esophageal candidosis caused by different Candida species. A total of 21,248 upper gastroscopies were performed in Santa Casa Complexo Hospitalar between January 2005 and July 2006. The prevalence of Candida esophagitis was 0.74% (n = 158). C. albicans caused the vast majority of infections (96.2%), followed by C. tropicalis (2.5%), C. lusitaniae (0.6%) and C. glabrata (0.6%). There were 81 women (51.3%) and 77 men (48.7%). No case of mixed infection occurred. Concomitant oral candidosis was documented for 10.8% (n = 17). Most of cases (55.1%) involved outpatients. Around one fifth of patients in our cohort had no identifiable risk factors for esophageal candidosis (20.8%). Since nearly all infections were caused by C. albicans we were not able to determine risk factors for esophagitis caused by other Candida species.