Nonmicrocephalic Infants with Congenital Zika Syndrome Suspected Only after Neuroimaging Evaluation Compared with Those with Microcephaly at Birth and Postnatally: How Large Is the Zika Virus “Iceberg”?

BACKGROUND AND PURPOSE:Although microcephaly is the most prominent feature of congenital Zika syndrome, a spectrum with less severe cases is starting to be recognized. Our aim was to review neuroimaging of infants to detect cases without microcephaly and compare them with those with microcephaly.MATERIALS AND METHODS:We retrospectively evaluated all neuroimaging (MR imaging/CT) of infants 1 year of age or younger. Patients with congenital Zika syndrome were divided into those with microcephaly at birth, postnatal microcephaly, and without microcephaly. Neuroimaging was compared among groups.RESULTS:Among 77 infants, 24.6% had congenital Zika syndrome (11.7% microcephaly at birth, 9.1% postnatal microcephaly, 3.9% without microcephaly). The postnatal microcephaly and without microcephaly groups showed statistically similar imaging findings. The microcephaly at birth compared with the group without microcephaly showed statistically significant differences for the following: reduced brain volume, calcifications outside the cortico-subcortical junctions, corpus callosum abnormalities, moderate-to-severe ventriculomegaly, an enlarged extra-axial space, an enlarged cisterna magna (all absent in those without microcephaly), and polymicrogyria (the only malformation present without microcephaly). There was a trend toward pachygyria (absent in groups without microcephaly). The group with microcephaly at birth compared with the group with postnatal microcephaly showed significant differences for simplified gyral pattern, calcifications outside the cortico-subcortical junctions, corpus callosum abnormalities, moderate-to-severe ventriculomegaly, and an enlarged extra-axial space.CONCLUSIONS:In microcephaly at birth, except for polymicrogyria, all patients showed abnormalities described in the literature. In postnatal microcephaly, the only abnormalities not seen were a simplified gyral pattern and calcifications outside the cortico-subcortical junction. Infants with normocephaly presented with asymmetric frontal polymicrogyria, calcifications in the cortico-subcortical junction, mild ventriculomegaly, and delayed myelination.

The Zika virus (ZIKV) is an arboviral disease with its main vector being Aedes aegypti.¹ There are also reports of sexual transmission and viral detection in urine² and tears.³ The first epidemic of ZIKV occurred in 2007 in the Yap Islands, Micronesia⁴; the second occurred in 2013, in French Polynesia⁵; and the third began in Bahia, Northeast Brazil, in March 2015.⁶ In August 2015, in Pernambuco, Northeast Brazil, a significant increase in the number of congenital microcephaly cases was reported to the health authorities. Currently, the relationship between the ZIKV and microcephaly is well-established.⁷The most characteristic findings of congenital Zika syndrome (CZS) include microcephaly, arthrogryposis, and ophthalmologic and hearing abnormalities.^8–12 The major neuroimaging abnormalities reported by initial case series^8,13,14 were calcifications in the cortico-subcortical white matter junction and malformations of cortical development, associated with other brain abnormalities.^8,13,14These imaging features were reported on the basis of severe cases of microcephaly identified at birth.^8,13–15 However, some of these patients⁸ did not have microcephaly at birth and were detected because in the beginning, microcephaly was defined as a head circumference of ≤33 cm, a cutoff that decreased 2 times before the establishment of the current criteria based on the Intergrowth-21st.¹⁶ Therefore, there is probably a disease spectrum that has only recently been recognized, with some patients presenting with less severe brain damage and even without microcephaly.We reviewed the brain CT and MR imaging scans of infants 1 year of age or younger, to find cases of CZS without microcephaly and to compare them with infants with microcephaly. We hypothesized that these mild cases of CZS without microcephaly, not suspected before neuroimaging evaluation, have a milder degree of brain damage.     

Right-hemisphere language dominance in temporal lobe epilepsy: clinical and neuropsychological correlates

Prior to and following temporal lobe surgery, patients with right-hemisphere language dominance and focal left temporal lobe epilepsy (RHLD-LTLSz) were compared to right-handed patients with left-hemisphere language dominance and either left temporal lobe epilepsy (LHLD-LTLSz) or right temporal lobe epilepsy (LHLD-RTLSz). The group of RHLD-LTLSz patients had a more consistent history of brain involvement before the age of 5 years and had a higher seizure frequency rating than did either LHLD patient group. Cognitively, RHLD-LTLSz patients did not show significant deficits in psychometric intellectural scores. In addition, they did not demonstrate comparable degrees of verbal memory loss as found either pre- or postoperatively in LHLD-LTLSz patients. The right-handed RHLD-LTLSz and the right-handed LHLD-LTLSz groups both appeared to exhibit bilaterally depressed fine-motor coordination. The left-handed RHLD-LTLSz patients did not show the same motor deficiencies. These latter findings suggest that hemispheric dominance for bilateral motor control may exist independent of language dominance, but not independent of handedness.     

Calcium-binding proteins in skeletal muscles of the mdx mice: potential role in the pathogenesis of Duchenne muscular dystrophy

Duchenne muscular dystrophy is one of the most common hereditary diseases. Abnormal ion handling renders dystrophic muscle fibers more susceptible to necrosis and a rise in intracellular calcium is an important initiating event in dystrophic muscle pathogenesis. In the mdx mice, muscles are affected with different intensities and some muscles are spared. We investigated the levels of the calcium-binding proteins calsequestrin and calmodulin in the non-spared axial (sternomastoid and diaphragm), limb (tibialis anterior and soleus), cardiac and in the spared extraocular muscles (EOM) of control and mdx mice. Immunoblotting analysis showed a significant increase of the proteins in the spared mdx EOM and a significant decrease in the most affected diaphragm. Both proteins were comparable to the cardiac muscle controls. In limb and sternomastoid muscles, calmodulin and calsequestrin were affected differently. These results suggest that differential levels of the calcium-handling proteins may be involved in the pathogenesis of myonecrosis in mdx muscles. Understanding the signaling mechanisms involving Ca²⁺-calmodulin activation and calsequestrin expression may be a valuable way to develop new therapeutic approaches to the dystrophinopaties.     

Depression and conservative surgery for breast cancer

BACKGROUND:

Depression is prevalent among women and associated with reduced quality of life, and therefore it is important to determine its incidence in adult women, especially in those with breast cancer.

OBJECTIVE:

To determine the occurrence of depression in women who underwent conservative surgery for breast cancer with or without breast reconstruction.

METHODS:

Seventy‐five women aged between 18 and 65 years were enrolled. Patients had undergone conservative surgery for breast cancer with immediate breast reconstruction (n = 25) or without breast reconstruction (n = 25) at least one year before the study. The control group consisted of 25 women without cancer, but of similar age and educational level distribution as the other two groups. The Beck Depression Inventory was used to measure depression. The collected data were assessed using analysis of variance and the χ² test.

RESULTS:

There were no significant differences between groups in age (p = 0.72) or educational level (p = 0.20). A smaller number of patients had undergone the menopause (p = 0.02) in the control group than in other groups. There were no significant differences in occurrence of depression between groups (χ² = 9.97; p = 0.126).

CONCLUSION:

Conservative surgery for breast cancer did not affect the occurrence of depression in women, regardless of whether breast reconstruction was performed.     

Performance characteristics of a rapid new immunochromatographic test for detection of antibodies to human immunodeficiency virus

A new immunochromatographic rapid test (Rapid Check HIV 1 and 2; Núcleo de Doen?as Infecciosas) for the detection of antibodies to human immunodeficiency virus type 1 and type 2 in human samples (whole blood, serum, and plasma) was evaluated and compared to the commercially available Determine (Abbott Laboratories). When whole-blood samples were evaluated, the specificity and sensitivity of both tests were 100%. However, when plasma samples were used, sensitivity for the Rapid Check HIV 1&2 and the Determine tests were 100 and 98.58%, respectively. The observed specificity for plasma samples was 98.94% for the Rapid Check HIV 1&2 and 96.97% for the Determine test. The results presented here are encouraging and support the adoption of both tests as an alternative to enzyme-lined immunosorbent assay and/or Western blots in regions where laboratorial infrastructure is not available or for use in the management of occupational accidents for healthcare workers.     

Score for atrial fibrillation detection in acute stroke and transient ischemic attack patients in a Brazilian population: The acute stroke atrial fibrillation scoring system

OBJECTIVE:

Atrial fibrillation is a common arrhythmia that increases the risk of stroke by four- to five-fold. We aimed to establish a profile of patients with atrial fibrillation from a population of patients admitted with acute ischemic stroke or transient ischemic attack using clinical and echocardiographic findings.

METHODS:

We evaluated patients consecutively admitted to a tertiary hospital with acute ischemic stroke or transient ischemic attack. Subjects were divided into an original set (admissions from May 2009 to October 2010) and a validation set (admissions from November 2010 to April 2013). The study was designed as a cohort, with clinical and echocardiographic findings compared between patients with and without atrial fibrillation. A multivariable model was built, and independent predictive factors were used to produce a predictive grading score for atrial fibrillation (Acute Stroke AF Score-ASAS).

RESULTS:

A total of 257 patients were evaluated from May 2009 to October 2010 and included in the original set. Atrial fibrillation was diagnosed in 17.5% of these patients. Significant predictors of atrial fibrillation in the multivariate analysis included age, National Institutes of Health Stroke Scores, and the presence of left atrial enlargement. These predictors were used in the final logistic model. For this model, the area under the receiver operating characteristic curve was 0.79. The score derived from the logistic regression analysis was The model developed from the original data set was then applied to the validation data set, showing the preserved discriminatory ability of the model (c statistic = 0.76).

CONCLUSIONS:

Our risk score suggests that the individual risk for atrial fibrillation in patients with acute ischemic stroke can be assessed using simple data, including age, National Institutes of Health Stroke Scores at admission, and the presence of left atrial enlargement.     

Pectus deformities: tomographic analysis and clinical correlation

Objective  

To assess, with computed tomography (CT) studies, features of anterior chest wall development that can be related to different types of pectus deformities.     

Juvenile paracoccidioidomycosis in urban area: report of two cases

We present two cases of juvenile form of paracoccidioidomycosis (PCM), a systemic mycosis frequently found in rural areas, whose prognosis is poor in children and young adults. They are a 14-year-old boy and a 25-year-old woman, both residents in an urban area in São Paulo – Brazil, without any history of travelling to an endemic area. They have been admitted to the hospital due to fever, weight loss and lymphadenopathy. The diagnosis was confirmed by serologic and histopathologic study. Patients have recovered after therapy with oral itraconazole and were discharged from hospital, maintaining outpatient visits. In this article, the authors discuss the unusual presentation of PCM in an urban area.