Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The most common viruses involved in acute respiratory diseases among young children are the respiratory syncytial virus (RSV), influenzavirus (FLU), parainfluenzavirus (PIV), adenovirus (AdV) and human rhinovirus (HRV). The purpose of the present study was to identify the main respiratory viruses that affected children younger than five years old in Uberlândia, in Midwestern Brazil. Nasopharyngeal aspirates from 379 children attended at Hospital de Clínicas (HC/UFU), from 2001 to 2004, with acute respiratory disease, were collected and tested by either immunofluorescence assay (IFA) or reverse transcription polymerase chain reaction (RT-PCR). RSV was detected in 26.4% (100/379) of samples, FLU A and B in 9.5% (36/379), PIV 1, 2 and 3 in 6.3% (24/379) and AdV in 3.7% (14/379). Negative and indeterminate samples (205) by IFA were tested by RT-PCR for detection of HRV, and 29.6% (112/379) was positive. RSV, particularly among children in their first 6 months of life, and HRV cases showed highest incidence. For both virus, bronchiolitis and pneumonia/bronchopneumonia were the main nosological presentation among children less than 6 months, were RSV responded for 40,3% and 34,6% of the cases, respectively, and the HRV were detected in 25,0% of bronchiolitis cases and 15,4% of pneumonia/bronchopneumonia cases at the same referred age group. Negative samples by both IFA and RT-PCR might be indicative that other pathogens, such as coronavirus, human metapneumovirus and bacteria, could be the causative agent in these infections. Laboratorial diagnosis constituted an essential instrument to determine the incidence of the most common viruses in respiratory infections among young children in this region. / Os vírus mais comumente envolvidos em doenças respiratórias agudas em crianças são os vírus respiratório sincicial (VRS), influenzavírus tipos A e B (FLU A e B), parainfluenzavírus tipos 1, 2 e 3 (PIV-1, -2 e -3), adenovírus (AdV) e os rinovírus (HRV). O objetivo geral do presente estudo foi identificar os principais vírus respiratórios envolvidos em doenças respiratórias aguda (DRA) em crianças de até cinco anos de idade no período de 2001 a 2004. Aspirados de nasofaringe de 379 crianças atendidas no Hospital de Clínicas da Universidade Federal de Uberlândia (HC/UFU) com doença respiratória aguda foram coletadas e testadas pelas reações de imunofluorescência indireta (IFI) ou transcrição reversa da reação em cadeia da polimerase (RT-PCR). O VRS foi detectado em 26,4% (100/379) dessas amostras, FLU tipos A e B em 9,5% (36/379), PIV 1, 2 e 3 em 6,3% (24/379) e AdV em 3,7% (14/379). As amostras negativas e inconclusivas pela IFI (205) foram testadas por RT-PCR para detecção dos HRV, sendo que 26,9% (112/379) foram positivas. Neste estudo, os vírus mais comumente detectados em quadros clínicos de bronquiolite e pneumonia/broncopneumonia em crianças menores de seis meses de idade foram o VRS, respondendo por 40,3% e 34,6% do total de casos, respectivamente, e o HRV, identificado em 25,0% dos casos de bronquiolite e em 15,4% dos casos de pneumonia/broncopneumonia na mesma faixa etária. Relacionado à sazonalidade, a circulação dos vírus identificados predominou nos meses de temperaturas mais baixas. Esse padrão foi evidente para o VRS, que apresentou um pico de ocorrência em abril e maio, enquanto que o pico do FLU e HRV ocorreu em julho. Amostras negativas tanto pela IFI quanto pela RT-PCR indicam que outros patógenos, incluindo coronavírus, metapneumovirus humano além de bactérias, podem ter sido os responsáveis pelas infecções. Finalizando, este estudo foi essencial para um diagnóstico conclusivo de DRAs causadas por vírus, bem como para determinar quais agentes virais circularam nesta região. / Mestre em Imunologia e Parasitologia Aplicadas

In Brazil, the few studies conducted have used viral etiology, in general, traditional methods (imunofluorescense techniques and and viral cultures) in hospitalized children. The purpose of the present study was to investigate the presence of respiratory viruses using indirect immunofluorescence techniques and the reverse transcription followed by polymerase chain reaction in nasopharyngeal aspirates of children with acute respiratory disease attendet in public institutions of primary and secondary care in the city of Uberlândia. Between february, 2008 to may, 2010 were obtained a convenience sample, nasopharyngeal aspirates from children under five years old with symptoms of acute respiratory disease, attended at Unidade Básica de Saúde da Família - Granada 1, Unidade de Atendimento Integrado-Pampulha and in Clinica Infantil Don Bosco in Uberlândia. Acute respiratory disease was defined by the presence of coryza, coughing, breathing difficulties and/or sibilance, with or without fever. The indirect immunofluorescence techniques and the reverse transcription followed by polymerase chain reaction were used to test for the presence of respiratory viruses. A total of 43 children (53,5% male and 46,5% female) between two and 60 months of age (average: 18,3 months; median 15 months; DP±16). The clinical diagnosis for admission was common cold for 23 children (53,4%), tracheobronchitis in four (9,3%); pneumonia in 12 (28%) and bronchiolitis in four (9,3%). At least one respiratory virus was detected in 22 (51,1%) of the samples. A total of 26 viruses were identified. Ten (38,4%) samples were positive for the respiratory syncytial virus; ten (38,4%) for rhinovirus, three (11,5%) for parainfluenzavirus; two (7,7%) for adenovirus and one (3,8%) for influenzavirus. Co-infection occurred in three of the samples. The indirect immunofluorescence techniques identified nine (21,0%) and the reverse transcription followed by polymerase chain reaction 19 (44,1%) of the respiratory viruses. The rhinovirus and respiratory syncytial virus were the respiratory virus most prevalent in children with acute respiratory disease in public institutions of primary and secondary care. The use of molecular method permitted a two fold increase in the capacity for detection of the viral agent collected from the nasopharyngeal aspirates. / No Brasil, os poucos estudos conduzidos com o objetivo de verificar a etiologia viral das doenças respiratórias agudas utilizaram, em geral, métodos tradicionais (imunofluorescência e cultura viral) em crianças hospitalizadas. O objetivo geral do presente estudo foi investigar a presença de vírus respiratórios por meio das técnicas de imunofluorescência indireta e da transcrição reversa seguida da reação em cadeia da polimerase em aspirados de nasofaringe de crianças com doença respiratória aguda atendidas em serviços públicos de atenção primária e secundária na cidade de Uberlândia, MG. Entre fevereiro de 2008 a maio de 2010 foram obtidos, por meio de uma amostra de conveniência, aspirados de nasofaringe de crianças menores de cinco anos com sintomas de doença respiratória aguda, atendidas na Unidade Básica de Saúde da Família - Granada 1, Unidade de Atendimento Integrado-Pampulha e Clínica Infantil Dom Bosco Uberlândia. Doença respiratória aguda foi definida pela presença de coriza, tosse, dificuldade para respirar ou sibilância, com ou sem febre. A imunofluorescência e a transcrição reversa seguida da reação em cadeia da polimerase foram utilizadas para testar a presença de vírus respiratórios. Partiparam do estudo 43 crianças (53,5% do gênero masculino e 46,5% gênero feminino) com idade entre dois a 60 meses (média = 18,3 meses; mediana = 15 meses; DP=±16). O diagnóstico clínico à admissão foi de resfriado comum em 23 crianças (53,4%), traqueobronquite, em quatro (9,3%), pneumonia, em doze (28%) e bronquiolite, em quatro (9,3%). Pelo menos um vírus respiratório foi detectado em 22 (51,1%) amostras, sendo que 26 vírus foram identificados. Dez (38,4%) amostras foram positivas para o vírus respiratório sincicial, dez (38,4%) para o rinivirus, três (11,5%) para o parainfluenzavírus; duas (7,7%) para adenovírus e uma (3,8%), para o influenzavírus. A presença de co-infecção ocorreu em três amostras. A imunofluorescência identificou nove (21%) e a transcrição reversa seguida da reação em cadeia da polimerase dezenove (44,1%) vírus respiratórios. O rinovírus e o vírus respiratório sincicial foram os vírus mais prevalentes em crianças com doença respiratória aguda em serviços de atenção primária e secundária. A utilização de método molecular permitiu dobrar a capacidade de detecção de agente viral nos aspirados de nasofaringe. / Mestre em Ciências da Saúde

Les virus sont des parasites biologiques de taille nanométrique. Détournant la machinerie cellulaire de la cellule infectée, ils mettent en place une stratégie de réplication permettant la production de nouveaux virus. Un virus est constitué d’une capside protéique protégeant le génome viral, long polymère d’ADN ou ARN, et possède dans certains cas une enveloppe lipidique. Des travaux récents suggèrent que les propriétés physiques des virus sont importantes pour comprendre certaines étapes du cycle viral. Dans le but de relier le comportement biologique des virus à leurs propriétés physiques, nous avons utilisé une approche combinant l’imagerie AFM et des mesures mécaniques à l’échelle nanométrique, en lien avec la modélisation physique des capsides virales. Nous avons développé des outils d’analyse automatisée des images et courbes de forces obtenues pour quantifier les propriétés physiques de capsides virales et l’effet du microenvironnement. Nous avons étudié deux virus très différents : le rétrovirus VIH-1, responsable du SIDA et le vecteur AAV, utilisé en thérapie génique. Ce travail a permis la caractérisation des propriétés morphologiques et mécaniques de pseudo-particules virales et de cores du VIH-1, à l’échelle du virus unique et sur des populations de centaines de virus. En nous intéressant à l’effet de la nature de l’ARN encapsidé dans les particules virales in cellulo, nous avons montré un rôle structurant pour l’ARN viral du VIH-1 et en particulier son signal d’encapsidation psi. Enfin, nous avons initié l’étude de l’effet de la retro-transcription (conversion du génome viral ARN en ADN) au sein du core VIH-1 sur la stabilité de celui-ci. L’étude du parvovirus AAV existant sous forme de plusieurs variants naturels (sérotypes) nous a permis de comparer les propriétés physiques des capsides à l’équilibre thermodynamique et hors d’équilibre. En faisant varier le microenvironnement (température et pH), nous avons sondé son influence sur la stabilité des capsides AAV. Nous avons pu montrer en particulier que la capside AAV8 est plus rigide que AAV9 alors que sa stabilité thermique est réduite, en relation avec des propriétés biologiques différentes pour ces deux sérotypes. En outre, la rigidité des capsides AAV8 diminue dans un environnement acide imitant l’endosome tardif, et ceci se traduit par une plus grande stabilité thermique. Enfin, nous avons quantifié l’effet de la longueur et de la nature du génome sur la stabilité des capsides AAV. / Viruses are nanometer size biological parasite, which highjack the cellular machinery of the infected cells to replicate and thereby produce new viruses. A virus consists of a protein capsid, protecting the viral genome, a long polymer of DNA or RNA, and in some cases is surrounded by a lipid envelope. Recent work suggests that the physical properties of viruses are important in order to understand the viral cycle. In order to link the biological behavior of the virus to their physical properties, we used an approach combining AFM imaging and mechanical measurements at the nanometer scale, in connection with the physical modeling of viral capsids. We have developed automated image and force curves analysis tools to quantify the physical properties of viral capsids and the effect of the microenvironment. We have focused on two very different viruses: the HIV-1 retrovirus, responsible for AIDS and the AAV vector used in gene therapy. This work has led to the characterization of the morphological and mechanical properties of virus-like particles and cores of HIV-1 at the single virus level and on populations of hundreds of viruses. Focusing on the effect of the nature of the RNA encapsidated inside the viral particles in cellulo, we have highlighted the structural control of the viral RNA, and more precisely the psi packaging signal, on both HIV-1 VLPs and cores. Finally, we have initiated the study of the effect of reverse transcription (conversion of viral genomic RNA into DNA) within the cores HIV-1 on its stability. The study of parvovirus AAV existing form of several natural variants (serotypes) allowed us to compare the capsid physical properties at thermodynamic equilibrium and out of equilibrium. By varying the microenvironment (temperature and pH), we probed its influence on the stability of the AAV capsid. We have shown in particular that the AAV8 virus is stiffer than AAV9 while thermal stability is reduced, in relation to different biological properties for these two serotypes. In addition, the rigidity of AAV8 capsids decreases in an acidic environment mimicking the late endosome transport, and this results in a higher thermal stability. Finally, we quantified the effect of the length and nature of the confined genome on the thermal stability of AAV capsids.

Du fait de sa haute conservation et de ses fonctions clés dans le virus VIH-1, la protéine de la nucléocapside NC est une cible de choix pour développer de nouveaux anti-viraux. Bien que la compréhension mécanistique des propriétés chaperonnes de NC vis-à-vis des acides nucléiques ait connu d’importants progrès, les aspects dynamiques de ces propriétés restent mal comprises, faute notamment d’outils appropriés pour les suivre au niveau moléculaire. L’objectif de ce travail de thèse a été de caractériser au niveau moléculaire la dynamique des interactions de NC avec les acides nucléiques, à l’aide d’outils fluorescents développés au laboratoire ou en collaboration. En utilisant des peptides NC et des oligonucléotides marqués en différentes positions par des analogues fluorescents d’acides aminés et de nucléosides, respectivement, nous avons pu donner une image complète du processus dynamique sous-tendant le mécanisme chaperon de NC dans le second transfert de brins de la transcription inverse du cycle du VIH-1. Cette compréhension est fondamentale pour concevoir des stratégies rationnelles afin de cibler le rôle spécifique de NC dans ses interactions avec ses cibles nucléiques. / Due to its high conservation and key functions in the HIV-1 virus, the nucleocapsid protein NC is a potential target for the development of new anti-viral drugs. Although the mechanistic understanding of the NC nucleic acid chaperone properties has achieved a significant progress, the dynamic aspects of these properties remain poorly understood, mainly due to the lack of the appropriate tools to monitor them at the molecular level. The objective of this thesis was to characterize the dynamic interactions of NC with nucleic acids at the molecular level using new fluorescent tools developed in the laboratory or in collaboration. Using NC peptides and its target oligonucleotides labeled in different positions by fluorescent amino acid and nucleoside analogs, respectively, we were able to give a complete picture of the dynamic processes underlying the chaperone activity of NC in the second strand transfer of HIV-1 reverse transcription. This understanding is fundamental to design rational strategies in order to target the specific role of NC in interaction with its nucleic acid targets.

La protéine de nucléocapside du VIH-1 (NCp7) joue un rôle important dans plusieurs étapes du cycle viral. Ses interactions dans l’environnement intracellulaire dans les conditions proches d’une vraie infection sont peu décrites. L’objectif de ce projet de thèse a été de développer des approches d’imagerie permettant de suivre la NCp7 au cours des étapes précoces du cycle viral directement dans les cellules infectées. En analysant l’intensité des pseudovirus fluorescents nous avons montré un effet de « dequenching » de fluorescence témoignant d’une diminution de la concentration en NCp7 au sein des particules virales, résultant très probablement du relargage des molécules de nucléocapside à partir des complexes viraux. Ces résultats montrent pour la première fois la libération de la NCp7 dans le cytoplasme lors de la transcription inverse. Les pseudovirus NCp7-TC ont ensuite été imagés en haute résolution par microscopie PALM. Les images de distribution de la NCp7 marquée ont révélé la présence de la NCp7-TC à l'intérieur du noyau. Nous avons mis en evidence par microscopie électronique la presence de la NCp7-TC à proximité de pores nucléaires. / The nucleocapsid protein of HIV-1 (NCp7) plays an important role in several stages of the viral cycle. Its interactions in the intracellular environment under conditions close to true infection are not well described. The objective of this thesis project was to develop imaging approaches to monitor NCp7 during the early stages of the viral cycle directly in infected cells. By analyzing the intensity of the fluorescent pseudoviruses, we showed a fluorescence "dequenching" effect indicating a decrease in the NCp7 concentration within the virus particles, most likely resulting from the release of the nucleocapsid molecules from the viral complexes. These results show for the first time the release of NCp7 into the cytoplasm during reverse transcription. The pseudoviruses NCp7-TC were then imaged in high resolution by PALM microscopy. The distribution images of labeled NCp7 revealed the presence of NCp7-TC within the nucleus. We have demonstrated the presence of NCp7-TC in the vicinity of nuclear pores by electron microscopy.

Aim: To develop an immunomagnetic assay for the isolation of circulating tumor cells (CTCs) followed by the analysis of a multimarker panel, which will enable the characterization of these malignant cells with high accuracy. Patients and Methods: Peripheral blood (PB) was collected from 32 metastatic breast cancer patients and 42 negative controls. The antibodies BM7 and VU1D9 were used for immunomagnetic tumor cell enrichment. A real-time reverse transcription-polymerase chain reaction (RT-PCR) approach for the markers KRT19, SCGB2A2, MUC1, EPCAM, BIRC5 and ERBB2 was used for CTC detection and characterization. Results: The positivity rates for each marker were as follows: 46.9% for KRT19, 25.0% for SCGB2A2, 28.1% for MUC1, 28.1% for EPCAM, 21.9% for BIRC5, and 15.6% for ERBB2. After the creation of individualized cutoffs, the sensitivity and specificity of the combined marker gene panel increased to 56.3% and 100%, respectively. Interestingly, 27.0% of the HER2-negative tumor patients showed ERBB2 mRNA-positive CTCs. Conclusions: The described technique can be used to measure CTCs with great accuracy. The use of a multimarker panel for the characterization of CTCs may provide real-time information and be of great value in therapy monitoring. / Ziel: Entwicklung eines immunomagnetischen Verfahrens zur Isolierung zirkulierender Tumorzellen (CTCs) in Kombination mit einer molekularen Multimarkeranalyse für die hochspezifische Identifizierung maligner Zellen. Patientinnen und Methoden: Peripheres Blut (PB) von 32 Patientinnen mit metastasiertem Mammakarzinom und von 42 gesunden Kontrollen wurde für die immunomagnetische Tumorzellanreicherung mit den Antikörpern BM7 und VU1D9 genutzt. Eine Real-Time Reverse Transkription Polymerase-Kettenreaktion (RT-PCR)-Methodik mit den Markern KRT19, SCGB2A2, MUC1, EPCAM, BIRC5 und ERBB2 wurde für den CTC-Nachweis und die Tumorzellcharakterisierung entwickelt. Ergebnisse: Für die einzelnen Marker wurden die folgenden Positivitätsraten ermittelt: 46,9% für KRT19, 25,0% für SCGB2A2, 28,1% für MUC1, 28,1% für EPCAM, 21,9% für BIRC5 und 15,6% für ERBB2. Nach der Bestimmung individualisierter Cut-off-Werte ergab sich für den kombinierten Multimarkernachweis eine Sensitivität und Spezifität von 56,3% bzw. 100%. Bemerkenswert war der Befund, dass 27,0% der HER2-tumornegativen Patientinnen ERBB2-mRNA-positive CTCs aufwiesen. Schlussfolgerung: Die hier beschriebene Methodik bestimmt CTCs mit hoher Spezifität. Die molekulare Multimarkeranalyse liefert wertvolle Real-Time-Informationen für personalisierte Behandlungsmodalitäten. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

INTRODUÇÃO: A endomiocardiofibrose (EMF) é uma miocardiopatia de padrão restritivo de etiologia desconhecida, prevalente em regiões tropicais. Caracteriza-se por espessamento fibroso do endocárdio e miocárdio subjacente, comprometendo ponta e via de entrada de um ou de ambos os ventrículos. Sua etiopatogenia é pouco conhecida e muitos autores a associam à doença infecciosa cardíaca ou sistêmica, à eosinofilia prévia e/ou à carência nutricional. O prognóstico em geral é grave e a ressecção cirúrgica da lesão é indicada aos pacientes com insuficiência cardíaca refratária a tratamento clínico, em classe funcional III ou IV (NYHA). Os estudos anatomopatológicos até o momento foram realizados em material de autópsia ou de biópsia endomiocárdica. OBJETIVOS: Este estudo retrospectivo se propõe a (1) descrever os três aspectos morfológicos da lesão endocárdica (fibrose, infiltrado inflamatório e vasos) utilizando microscopia óptica comum e técnicas imunoistoquímicas, assim como correlacioná-los aos dados clínicos, laboratoriais e de imagem dos pacientes (2) comparar os aspectos morfológicos de espécimes de ressecção cirúrgica com os de autópsia a fim de verificar se os primeiros podem ser empregados para diagnóstico histológico da doença; e (3) discutir a patogenia da EMF e realizar pesquisa de agentes infecciosos cardiotrópicos em amostra endomiocárdica incluída em parafina por técnica de biologia molecular. MÉTODOS: Foram utilizadas amostras de ressecção cirúrgica endocárdica incluídas em parafina provenientes de 31 pacientes com diagnóstico clínico e cineangiocardiográfico de EMF, operados no InCor entre 1991 e 2005. As amostras foram coradas por técnicas convencionais (HE, tricômico de Masson, Verhoeff e reticulina) e submetidas a reações imunoistoquímicas para fibras colágenas tipo I, III e IV, para células inflamatórias (CD3, CD20, CD68) e para endotélio de linfáticos (D2-40). Amostras de nove corações de autópsia de pacientes com o mesmo diagnóstico serviram de controle positivo da doença. A pesquisa de agentes infecciosos foi feita por reação de cadeia de polimerase e reação de transcrição reversa de cadeia de polimerase (PCR e RT-PCR) em amostras endomiocárdicas incluídas em parafina, para T. gondii e para vírus cardiotrópicos (enterovirus, adenovirus, influenza A e B, citomegalovirus, parvovirus B19 e herpes simples). Para identificar alterações vasculares intramiocárdicas, procedeu-se à revisão de prontuários clínicos dos pacientes e de 16 cineangiocoronariografias. RESULTADOS: Foi observado intenso espessamento endocárdico ventricular à custa de fibrose hialina superficial escassamente celular, com fibras colágenas tipos I e III, predominando o tipo I sobre o III. O colágeno tipo IV foi identificado na membrana basal de vasos. Na porção profunda da lesão endocárdica observou-se escasso infiltrado inflamatório crônico com macrófagos, linfócitos T e B em menor número. O infiltrado estava distribuído ao redor de vasos proliferados com intensas alterações estruturais na parede e com participação de linfáticos. No miocárdio superficial identificou-se miocardite \"borderline\" (critério de \"Dallas\"). Foram obtidos ácidos nucléicos em quantidade suficiente para a reação de PCR/RT-PCR em 12/36 (33%) amostras. Genomas de agentes infecciosos foram identificados em 6/12 (50%) pacientes. Dois casos foram positivos para enterovirus (EV), dois para citomegalovirus (CMV), um para ambos (CMV e EV) e um para T. gondii. Não foram observadas diferenças histopatológicas entre as amostras cirúrgicas e as de autópsia. Foram detectadas alterações vasculares à cineangiocoronariografia em 9/16 (56%) pacientes. Não houve correlação anatomoclínica definida entre os múltiplos dados comparados. CONCLUSÕES: Os resultados indicam que na EMF ocorre processo inflamatório crônico mantido por rede vascular anômala rica em linfáticos localizada na profundidade da lesão endocárdica. A rede vascular provavelmente contribui para a manutenção da placa fibrótica e deve ser considerada como fator importante na patogenia da doença. O diagnóstico anatomopatológico pode ser feito com segurança em material de ressecção cirúrgica. A análise molecular do endomiocárdio possibilitou a detecção de alta incidência de genomas de agentes infecciosos cardiotrópicos. Seu significado, contudo, permanece controverso. / BACKGROUND: Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy of unknown etiology prevalent in tropical regions. The disease involves the inflow tract and apex of either one or both ventricles and is characterized by a fibrous thickening of the endocardium and the underlying myocardium. Although its etiology remains unknown, most authors believe it could be related to systemic or heart infection/parasitism, previous blood eosinophilia or malnutrition. Surgical resection of the thickened endocardium is recommended to patients with advanced heart failure of functional class III or IV, New York Heart Association (NYHA). The gross and histological features of the heart have been comprehensively studied in autopsies and endomyocardial biopsies. Studies in surgical samples, however, are still lacking. AIMS: This study was conducted to evaluated: (1) the histomorphological changes of EMF as seen in surgical specimens by means of routine histological and immunohistochemical methods in an attempt to correlate them with clinical symptoms and coronary angiographic features; (2) to compare histological data between surgical and autopsy samples, and (3) to discuss probable pathogenetic mechanisms of the disease, as well as to investigate cardiotropic infective agents by means of molecular analysis of endomyocardial surgical samples. METHODS: We collected all available clinical records and endomyocardial surgical samples from 31 patients with EMF who had been submitted to surgery between 1991 and 2005 at InCor. The diagnosis was based on clinical, hemodynamic and angiocardiographic findings. The surgical samples were fixed in 10% formalin, submitted to standard processing, and stained with H&E, Masson\'s trichrome, reticulin and elastic stains. Immunohistochemical methods were employed to detect collagen fibers type I, III, and IV, inflammatory cells (CD3, CD20, CD68) and lymphatic vessels\' endothelium (D2-40). Nine samples from autopsied hearts of EMF patients were used as a positive control group. Polymerase chain reaction (PCR) and reverse transcription-PCR were used retrospectively to search for genomes of T. gondii and cardiotropic viruses (enterovirus, adenovirus, influenza A e B, cytomegalovirus, parvovirus B19 and herpes simplex) in the surgical material. All clinical and surgical reports were reviewed, including follow-ups and 16 coronary cineangiocardiographies. RESULTS: Ventricular endocardium was thickened by superficial acellular hyaline collagen fibers type I and III. Type-IV collagen fibers were seen only around vessels. Focal chronic inflammatory infiltrate with T-lymphocytes, macrophages and a few B-lymphocytes was seen around blood vessels with a peculiar pattern of vascular changes and numerous lymphatics within the endocardium. The superficial myocardium showed borderline myocarditis (Dallas criteria). RNA and DNA were successfully extracted from 12/36 samples. Infective agents were detected in 6/12 (50%) patients; two of them were positive for cytomegalovirus (CMV), two for enterovirus (EV), one for both (CMV and EV) and one for T. gondii. No histopathological differences between surgical samples and autopsy fragments were observed. Vascular blush or neovascularity was detected in 9 of the 16 coronary cineangiocardiographies reviewed. Clinicopathologic characteristics are associated neither with infective genomes in the endocardium nor with vascular blush. CONCLUSIONS: Results indicate that there is an non especific chronic inflammatory process maintained by an anomalous vascular net rich in lymphatics situated deep within the endocardium. This angiolymphatic web probably contributes to the maintenance of the fibrotic plaque and might be considered an important pathological finding concerning in the pathogenesis of EMF. Histopathological changes as seen in surgical material are diagnostic of EMF. Molecular analysis of the endomyocardium revealed high incidence of cardiotropic infective agents, but their role in the pathogenesis of the disease is still controversial.

INTRODUÇÃO: A endomiocardiofibrose (EMF) é uma miocardiopatia de padrão restritivo de etiologia desconhecida, prevalente em regiões tropicais. Caracteriza-se por espessamento fibroso do endocárdio e miocárdio subjacente, comprometendo ponta e via de entrada de um ou de ambos os ventrículos. Sua etiopatogenia é pouco conhecida e muitos autores a associam à doença infecciosa cardíaca ou sistêmica, à eosinofilia prévia e/ou à carência nutricional. O prognóstico em geral é grave e a ressecção cirúrgica da lesão é indicada aos pacientes com insuficiência cardíaca refratária a tratamento clínico, em classe funcional III ou IV (NYHA). Os estudos anatomopatológicos até o momento foram realizados em material de autópsia ou de biópsia endomiocárdica. OBJETIVOS: Este estudo retrospectivo se propõe a (1) descrever os três aspectos morfológicos da lesão endocárdica (fibrose, infiltrado inflamatório e vasos) utilizando microscopia óptica comum e técnicas imunoistoquímicas, assim como correlacioná-los aos dados clínicos, laboratoriais e de imagem dos pacientes (2) comparar os aspectos morfológicos de espécimes de ressecção cirúrgica com os de autópsia a fim de verificar se os primeiros podem ser empregados para diagnóstico histológico da doença; e (3) discutir a patogenia da EMF e realizar pesquisa de agentes infecciosos cardiotrópicos em amostra endomiocárdica incluída em parafina por técnica de biologia molecular. MÉTODOS: Foram utilizadas amostras de ressecção cirúrgica endocárdica incluídas em parafina provenientes de 31 pacientes com diagnóstico clínico e cineangiocardiográfico de EMF, operados no InCor entre 1991 e 2005. As amostras foram coradas por técnicas convencionais (HE, tricômico de Masson, Verhoeff e reticulina) e submetidas a reações imunoistoquímicas para fibras colágenas tipo I, III e IV, para células inflamatórias (CD3, CD20, CD68) e para endotélio de linfáticos (D2-40). Amostras de nove corações de autópsia de pacientes com o mesmo diagnóstico serviram de controle positivo da doença. A pesquisa de agentes infecciosos foi feita por reação de cadeia de polimerase e reação de transcrição reversa de cadeia de polimerase (PCR e RT-PCR) em amostras endomiocárdicas incluídas em parafina, para T. gondii e para vírus cardiotrópicos (enterovirus, adenovirus, influenza A e B, citomegalovirus, parvovirus B19 e herpes simples). Para identificar alterações vasculares intramiocárdicas, procedeu-se à revisão de prontuários clínicos dos pacientes e de 16 cineangiocoronariografias. RESULTADOS: Foi observado intenso espessamento endocárdico ventricular à custa de fibrose hialina superficial escassamente celular, com fibras colágenas tipos I e III, predominando o tipo I sobre o III. O colágeno tipo IV foi identificado na membrana basal de vasos. Na porção profunda da lesão endocárdica observou-se escasso infiltrado inflamatório crônico com macrófagos, linfócitos T e B em menor número. O infiltrado estava distribuído ao redor de vasos proliferados com intensas alterações estruturais na parede e com participação de linfáticos. No miocárdio superficial identificou-se miocardite \"borderline\" (critério de \"Dallas\"). Foram obtidos ácidos nucléicos em quantidade suficiente para a reação de PCR/RT-PCR em 12/36 (33%) amostras. Genomas de agentes infecciosos foram identificados em 6/12 (50%) pacientes. Dois casos foram positivos para enterovirus (EV), dois para citomegalovirus (CMV), um para ambos (CMV e EV) e um para T. gondii. Não foram observadas diferenças histopatológicas entre as amostras cirúrgicas e as de autópsia. Foram detectadas alterações vasculares à cineangiocoronariografia em 9/16 (56%) pacientes. Não houve correlação anatomoclínica definida entre os múltiplos dados comparados. CONCLUSÕES: Os resultados indicam que na EMF ocorre processo inflamatório crônico mantido por rede vascular anômala rica em linfáticos localizada na profundidade da lesão endocárdica. A rede vascular provavelmente contribui para a manutenção da placa fibrótica e deve ser considerada como fator importante na patogenia da doença. O diagnóstico anatomopatológico pode ser feito com segurança em material de ressecção cirúrgica. A análise molecular do endomiocárdio possibilitou a detecção de alta incidência de genomas de agentes infecciosos cardiotrópicos. Seu significado, contudo, permanece controverso. / BACKGROUND: Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy of unknown etiology prevalent in tropical regions. The disease involves the inflow tract and apex of either one or both ventricles and is characterized by a fibrous thickening of the endocardium and the underlying myocardium. Although its etiology remains unknown, most authors believe it could be related to systemic or heart infection/parasitism, previous blood eosinophilia or malnutrition. Surgical resection of the thickened endocardium is recommended to patients with advanced heart failure of functional class III or IV, New York Heart Association (NYHA). The gross and histological features of the heart have been comprehensively studied in autopsies and endomyocardial biopsies. Studies in surgical samples, however, are still lacking. AIMS: This study was conducted to evaluated: (1) the histomorphological changes of EMF as seen in surgical specimens by means of routine histological and immunohistochemical methods in an attempt to correlate them with clinical symptoms and coronary angiographic features; (2) to compare histological data between surgical and autopsy samples, and (3) to discuss probable pathogenetic mechanisms of the disease, as well as to investigate cardiotropic infective agents by means of molecular analysis of endomyocardial surgical samples. METHODS: We collected all available clinical records and endomyocardial surgical samples from 31 patients with EMF who had been submitted to surgery between 1991 and 2005 at InCor. The diagnosis was based on clinical, hemodynamic and angiocardiographic findings. The surgical samples were fixed in 10% formalin, submitted to standard processing, and stained with H&E, Masson\'s trichrome, reticulin and elastic stains. Immunohistochemical methods were employed to detect collagen fibers type I, III, and IV, inflammatory cells (CD3, CD20, CD68) and lymphatic vessels\' endothelium (D2-40). Nine samples from autopsied hearts of EMF patients were used as a positive control group. Polymerase chain reaction (PCR) and reverse transcription-PCR were used retrospectively to search for genomes of T. gondii and cardiotropic viruses (enterovirus, adenovirus, influenza A e B, cytomegalovirus, parvovirus B19 and herpes simplex) in the surgical material. All clinical and surgical reports were reviewed, including follow-ups and 16 coronary cineangiocardiographies. RESULTS: Ventricular endocardium was thickened by superficial acellular hyaline collagen fibers type I and III. Type-IV collagen fibers were seen only around vessels. Focal chronic inflammatory infiltrate with T-lymphocytes, macrophages and a few B-lymphocytes was seen around blood vessels with a peculiar pattern of vascular changes and numerous lymphatics within the endocardium. The superficial myocardium showed borderline myocarditis (Dallas criteria). RNA and DNA were successfully extracted from 12/36 samples. Infective agents were detected in 6/12 (50%) patients; two of them were positive for cytomegalovirus (CMV), two for enterovirus (EV), one for both (CMV and EV) and one for T. gondii. No histopathological differences between surgical samples and autopsy fragments were observed. Vascular blush or neovascularity was detected in 9 of the 16 coronary cineangiocardiographies reviewed. Clinicopathologic characteristics are associated neither with infective genomes in the endocardium nor with vascular blush. CONCLUSIONS: Results indicate that there is an non especific chronic inflammatory process maintained by an anomalous vascular net rich in lymphatics situated deep within the endocardium. This angiolymphatic web probably contributes to the maintenance of the fibrotic plaque and might be considered an important pathological finding concerning in the pathogenesis of EMF. Histopathological changes as seen in surgical material are diagnostic of EMF. Molecular analysis of the endomyocardium revealed high incidence of cardiotropic infective agents, but their role in the pathogenesis of the disease is still controversial.