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------=_NextPart_01C3204F.FB67E0A0 Content-Location: file:///C:/1748D573/CITOMEGALOVIROSIS_archivos/master05.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C3204F.FB67E0A0 Content-Location: file:///C:/1748D573/CITOMEGALOVIROSIS_archivos/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C3204F.FB67E0A0 Content-Location: file:///C:/1748D573/CITOMEGALOVIROSIS_archivos/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" CITOMEGALOVIROSIS
CITOMEGALOVIROSIS
Prof. Dra. Adelina Braselli
Marzo 2003
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CITOMEGALOVIRUS (CMV)
nPertenece a la familia de Her= pesviridae
nComparte con los otros virus de la familia el hecho de ser un virus persistente = ;
nEs bastante termolábil y su vida media a 37ºC es de 45 minutos &#= 13;
nEl hombre es infectado solo por la cepa de CMV humano
nHay otras cepas animales que son especie-específicas
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INTRODUCCION
nINFECCION HABITUALMENTE BENIGNA Y AUTOLIMITADA EN EL HUESPED INMUNOCOMPETENTE
nPUEDE CAUSAR COMPROMISOS VISCERALES GRAVES EN:
ü<= /span>INMUNODEPRIMIDO (enfermo de sida, r= eceptor de transplante y neoplásico) 
ü<= /span>FETO Y RECIEN NACIDO infectado por vía transplacentaria (enfermedad congénita)
------=_NextPart_01C3204F.FB67E0A0 Content-Location: file:///C:/1748D573/CITOMEGALOVIROSIS_archivos/slide0002.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" CITOMEGALOVIROSIS
EPIDEMIOLOGIA
nINF= ECCION ENDEMICA DE CUALQUIER EPOCA DEL AÑO
nMUN= DIALMENTE FRECUENTE.  Prevalencia de anticuerpos en adu= ltos: 40 a 100 %, dependiendo de condiciones socioeconómicas del área
nRES= ERVORIO EXCLUSIVAMENTE HUMANO
nVIA= S DE TRANSMISION: oral, aérea-faríngea, sexual, transfusional, transplante de médula ósea u órgano sólido, transplacentaria, perinatal
nPARA CONTRAERLA SE NECESITA CONTACTO ESTRECHO O INTIMO
nMAY= OR TASA DE INFECCION: per&iacu= te;odos perinatal y comienzo de actividad sexual
nDES= PUES DE LA INFECCION AGUDA EL VIRUS PERMANECE LATENTE EN EL HUESPED. Está presente en leucocito= s de sangre circulante, saliva, secreciones cérvico-vaginales, esperma, orina, lágrimas, leche materna
nLOS NIÑOS INFECTADOS TRANSPORTAN VIRUS EN SUS VIAS RESPIRATORIAS Y ORIN= A, DURANTE LARGOS PERIODOS
nLA INFECCION PUEDE REACTIVARSE CUANDO SE DETERIORA LA INMUNIDAD CELULAR Y TAM= BIEN EN FORMA IMPREVISTA
n<= span style=3D'font-size:44%;mso-special-format:lastCR;display:none'>
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PATOGENESIS
nLa infecci&oacu= te;n por CMV está especialmente controlada por el aparato inmune celular
nAunque los anticuerpos específicos no parecen ofrecer una completa protección contra esta infección, a menudo reducen la seve= ridad de la enfermedad. La pre-existenci= a de dichos anticuerpos resulta útil en el receptor de aloingerto, la embarazada y el transfundido
nMientras en el inmunocompetente CMV causa una infección  benigna, en el inmunodeprimido pu= ede ocasionar una enfermedad oportunista grave
nCMV produce enfermedad a través de:
&Osl= ash;Da&= ntilde;o directo de los tejidos
&Osl= ash;Mec= anismo inmunológico
n
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INFECCION ADQUIRIDA - NIÑO Y ADULTO = INMUNOCOMPETENTE= S
nCLINICA DE LA PRIMOINFECCION <= /div>
n
nLA INFECCION POR CMV ES FRECUENTE, PERO LA ENFERMEDAD ES POCO COMUN
n
nCUANDO LA INFECCION ES SINTOMATICA habitualmente se manifiesta con un SIN= DROME MONONUCLEOTICO: fiebre prolongada, artralgias, erupción, diarrea, esplenomegalia, hiperlinfocitosis, linfocitos atípicos, aumento de transaminasas, trombocitopenia.  Usualmente = en el adulto faltan la faringitis y las adenomegalias. Se acompaña de numerosas anomalías inmunológicas. Raramente hay compromiso org&aacu= te;nico, salvo hepatitis química
n
nINFECCION PERINATAL: habitualmente asintomática
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COMPLICACIONES
nRARAS = EN INMUNOCOMPETENTE: miocarditis, pericarditis, neumonitis y meningoencefalitis
n
nA TRAV= ES DE MECANISMO AUTOINMUNE:
nAnemia hemolítica
nPúrpura tromocitopénico
nEpidermolisis
nSindrome de Guillain-Barré
nEnfermedad de injerto contra huésped siguiendo al TMO
nPUEDEN DETECTARSE VARIOS TIPOS DE AUTOANTICUERPOS Y AUMENTO DE GAMMA-GLOBULINA. C= on frecuencia se encuentran anticuerpos antinucleares y anti-músculo l= iso, elevación de crioaglutininas,  crioglobulinemia, factor reumatoide, test de Coombs positivo. Anticuerpos anti-eritrocitos son más raros.
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TRANSMISION VERTICAL – INFECCION CONGENITA
nResulta del pasaje transplacentario del virus durante la vire= mia materna, que habit= ualmente tiene lugar en el curso de la primoinfección
nPor eso el riesgo fetal depende del tipo de infeccion materna: primaria o secundar= ia (reactivación)
n= En la primoinfección materna el riesgo de infección fetal es 35 a = 50%, mientras que en la reactivación desciende a 5%
nSólo 10 % de los fetos infectados tienen síntomas al nacer
nEl riesgo de infección fetal es mayor si la primoinfección mate= rna ocurre al final del embarazo. Pero durante la primera mitad de la gestación las consecuencia para el feto son mayores
n
n
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INFECCION MATERNA EN EL EMBARAZO
– RIESGO DE INFECCION FETAL -
ANTES DEL EMBARAZO <= /b>
Ac. Anti-CMV
-        = ;             +
PRIMOINFECCION
REINFECCION
RIESGO FETAL
de infección = ;
 35-50%
RIESGO FETAL
de infección =
5%
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= 3DOrganigrama
CONSECUENCIAS DE INFECCION FETAL
- ENFERMEDAD CONGENITA -
INFECCION FETAL
SINTOMATICA
85-90%
ASINTOMATICA
10-15%
SECUELAS =
 NEURO-
SENSORIALES
5-15%
DESARROLLO
NORMAL
10%
MUERTE
 DEL
RECIEN NACIDO
30%
SECUELAS =
NEURO-
SENSORIALES
60%
DESARROLLO
NORMAL
85-95%
     EN EL CURSO DE  2 PRIMEROS = AÑOS
AL NACIMIENTO=   è
ç     = 3;
Datos de: Mazero= n M.C. Cytomégalovirus.  La Revue du Prat= icien. 1999:49:2224
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INFECCION PERINATAL
nPOR VI= RUS PRESENTES EN:
nSECRECIONES CERVICO-VAGINALES, CUANDO EL FETO PASA A TRAVES DEL CANAL DEL PARTO
nLECHE MATERNA
nEXCRECIONES DEL AMBIENTE
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INFECCION POR CMV EN INMUNODEPRIMIDOS
nLA INFECCION ACTIVA POR HERPESVIRUS ES UNA CAUSA FRECUENTE DE MORBILIDAD Y MU= ERTE EN INMUNODEPRIMIDOS POR SIDA Y RECEPTORES DE TRANSPLANTE DE ORGANO SOLIDO O MEDULA OSEA
n
nCMV ES LA INFECCION VIRAL MAS IMPORTANTE EN ESTA POBLACION
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ENFERMEDAD OPORTUNISTA POR CMV = EN SIDA
nESTA OCASIONADA POR LA REACTIVACION ENDOGENA DE UNA INFECCION LATENTE O POR INFECCION O REINFECCION EXOGENA CON UNA CEPA DIFERENTE <= /div>
nSE OBSERVA CUANDO LA INMUNODEPRESION ES SEVERA: LCD4 < 50-100/mm3
nSU PREVALENCIA HA DISMINUIDO DESPUES DE TARAA
nMANIFESTACIONES:
ücoriorretinitis= : Es la más frecuente. Constituye el 85 % de las manifestaciones
&u= uml;úlceras digestivas
&uu= ml;compromisos neurológicos: encefalitis, neuropatías
ü<= /span>neumonitis: muy raras Aunque CMV se= aisla con frecuencia del pulmón, su rol no es aun conocido
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RETINITIS EN SIDA
nEs la localización mas frecuente de la infección por CMV. En la mi= tad de los casos es inicialmente asintomática
nLos síntomas son inespecíficos: visión borrosa, disminución de agudeza visual, escotoma
nBilateral desde su comienzo (20%) o se hace bilateral en su evolución (50%)&#= 13;
n= El diagnóstico es clínico y se hace con el fondo de ojo
nSi no se trata conduce a la ceguera
nDiagnóstico diferencial: coriorretinitis toxoplásmica, retinitis necrotizante p= or VHS o VVZ, retinitis sifilítica y otras
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INFECCIONES DIGESTIVAS EN SIDA
nESOFAGITIS: disfagia, dolor retroesternal, epigastralgia, náuseas, vómit= os. Fibroscopía: 1 o más úlceras bien delimitadas. Biopsia visualiza inclusiones virales a CMV
nGASTRITIS: náuseas, vómitos, epigastralgia. Endoscopía: inflamación y úlceras gigantes. Biopsia
nCOLITIS: diarrea y dolor abdominal, hemorragia y perforación. Endoscop&iacut= e;a y biopsia
nANITIS Y RECTITIS
nHEPATITIS
nCOLANGITIS
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COMPROMISO NEUROLOGICO EN SIDA
nENCEFALITIS:
&uu= ml;Forma subaguda: sindrome demencial&= #13;
ü<= /span>Forma aguda: fiebre, síndrome deficitario, especialmente de tronco, convulsiones, alteración de conciencia
nMIELORADICULITIS: parestesias, paraparesia, alteraciones esfinterianas
nPOLINEUROPATIA PERIFERICA
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NEUMONITIS EN SIDA
nMUY POCO FRECUENTE
nMANIFESTACIONES INESPECIFICAS: fiebre, tos, disnea. Patrón radiológico intersticial o intersticio-nodular
nDIFICIL DE DIAGNOSTICAR. La presencia de CMV en el fluido del LBA no indica enferm= edad respiratoria. Para de afirmar el diagnóstico es necesario descartar otras causas de neumonitis intersticial y demostrar el efecto citopático del virus
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CITOMEGALOVIROSIS EN RECEPTOR D= E TRANSPLANTE DE M= EDULA OSEA (1)
nEs el resultado de la infección o reinfección a partir del donante seropositivo o de la reactivación de una infección latente e= n el receptor
nLos síntomas sobrevienen 4 a 6 semanas después del transplante&#= 13;
n= La manifestación más frecuente y temida en esta població= n es la neumonitis intersticial, que ocurre en 10 a 20 % de los sometidos a transplante alogénico= 3;
nCon frecuencia se observan: esofagitis, gastritis y colitis
nLa infección por CMV se asocia a supresión medular y a enfermed= ad crónica de injerto contra huésped
n
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CITOMEGALOVIROSIS EN RECEPTOR D= E TRANSPLANTE DE M= EDULA OSEA (2)
nSe asocia a una mortalidad de 15 a 30% después del transplante alogénico de médula ósea
nLa incidencia de la infección aumenta con la intensidad y duraci&oacut= e;n de la inmunodepresión y se aproxima a 70% en receptores de transpla= nte alogénico de MO que son seropositivos o el donante es seropositivo = para CMV
nLa incidencia de infección y enfermedad por CMV es mucho menor cuando = el transplante de MO es autólogo
n
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CITOMEGALOVIROSIS EN RECEPTOR D= E TRANSPLANTE DE O= RGANO SOLIDO (1)
nLa citomegalovirosis es una causa frecuente de morbilidad en esta población
nSu incidencia es de 30 a 50% dependiendo del estado serológico del don= ante y del receptor antes del transplante, el tipo de transplante y la intensid= ad de la terapia inmunosupresora
nSe manifiesta predominantemente durante los 4 meses siguientes al transplante
nLa severidad de la infección es variable, desde asintomática a letal
nEl órgano aloinjertado es particularmente susceptible  a la infección por CMV = ;
n
n
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CITOMEGALOVIROSIS EN RECEPTOR D= E TRANSPLANTE DE O= RGANO SOLIDO (2)
nEn los transplantados de hígado, corazón y riñón, la neumonitis intersticial por CMV es menos común que en el receptor de médula ósea, pero igualmente grave
nTambién se observan: esofagitis, gastritis, colitis y hepatitis =
nEn transplantados renales con frecuencia se observa un sindrome febril asocia= do a leucopenia, linfocitosis relativa, linfocitos atípicos, hepatoesplenomegalia y aumento de enzimas hepáticas, con comprobación de infección activa por CMV <= /div>
nPuede desencadenar o acelerar el rechazo o la reacción de injerto contra huésped
nAdemás agrava la inmunodepresión lo que favorece sobreinfecciones por bacterias, virus y hongos
n
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CITOMEGALOVIROSIS EN INMUNODEPRIMIDO NEOPLASICO
nLa infección activa por CMV en pacientes neoplásicos es menos frecuente que en receptores de transplante porque:
n
ü<= /span>La quimioterapia inmunosupresora no= suele ser tan intensa y prolongada
ü
ü<= /span>La neutropenia tampoco es factor de= riesgo para reactivar CMV
ü
ü<= /span>Salvo que el paciente haya recibido= varias transfusiones, la fuente externa de virus es menos importante
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DIAGNOSTICO
= nPUEDE HACERSE POR DIFERENTES MÉTODOS:
= n
nExamen directo d= e las muestras demostrando:
ncorpúsculos de inclusi&oacut= e;n viral
nantígeno <= /div>
nDNA viral
naislamiento de CMV en cultivos celulares
= n
= nEstudio serológico demostran= do:
nseroconversión (cuadruplicación de títulos de IgG)
npresencia de IgM
n<= span style=3D'font-size:75%;mso-special-format:lastCR;display:none'>
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DIAGNOSTICO DE LA INFECCION POR CMV
nEL = METODO DIAGNOSTICO A UTILIZAR DEPENDE DE LO QUE SE QUIERA DEMOSTRAR:
n= SEROCONVERSIÓN: confirma primoinfección= 3;
n= IgG  ESPECIFICA : es índice de infección crónica latente
n= IgM ESPECIFICA: es pos= itiva en la primoinfección, después de la cual puede persistir varios meses. También puede detectarse en reactivaciones. Puede faltar en = el inmunodeprimido
n= INDICE DE AVIDEZ DE IgG: = menos de 50% en primoinfección reciente, 60 a 100% en infección antig= ua y reactivación
n= ANTIGENEMIA pp65: reemplaza a = la viremia. Util para el diagnóstico de infección activa y diseminación sanguínea
n= ADN VIRAL: por t&eacut= e;cnica de PCR: en muestras de LCR, líquido amniótico, tejidos <= /span>
n= BIOPSIAS VISCERALES: partículas de inclusión, DNA por PCR
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DIAGNOSTICO DE LA INFECCION ADQUIRIDA
nSEROLOG&Iacut= e;A:
n= Viraje serológico: cuadruplicación o más del título de IgG en muestras pareadas sacadas con 15 días de intervalo
n= Presencia de IgM: puede demo= rar en aparecer 2 a 3 semanas y persiste más de 3 meses =
n<= span style=3D'font-size:75%;mso-special-format:lastCR;display:none'>
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DIAGNOSTICO EN EL INMUNOCOMPROMETIDO
n= Demostración, directa o indirecta, de la presencia del virus en el órgano comprometido. Much= as veces no es posible obtener biopsia
nUna alternativa es demostrar viremia o antigenemia (hay buena correlación entre viremia o antigenemia y enfermedad invasiva por CMV
nPresencia de IgM no siempre indica infección primaria. En el inmunodeprimido = son frecuentes las reactivaciones, muchas veces asintomáticas, con reaparición de IgM
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DIAGNOSTICO EN LA EMBARAZADA
- SITUACION SEROLOGICA PREVIA -
nSEROLOGIA POSITIVA PARA CMV ANTES DE LA CONCEPCION:= Test serológicos no necesarios. La inmunidad materna protege al fe= to. En caso de sufrir una reactivación endógena o una reinfección exógena, el riesgo de transmisión fetal es bajo y las consecuencias menores por la presencia de inmunidad espec&iacut= e;fica.
nSEROLOGIA NEGATIVA PARA CMV EN LOS 6 MESES PREVIOS = A LA CONCEPCION: est&aa= cute; a riesgo de la primoinfección. Educar en medid= as de higiene y realizar test serológicos en meses 2 y 4 <= /span>
nESTADO SEROLOGICO PREVIO AL EMBARAZO  DESCONOCIDO= : = realizar test serológicos
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TEST DIAGNOSTICOS EN LA EMBARAZADA
nLO IMP= ORTANTE ES CONFIRMAR O DESCARTAR LA PRIMOINFECCION POR CMV, CUANDO ESTA SE SOSPECHA  EN LAS PRIMERAS 16 SEMANAS DE AMENORREA
n
nLOS METODOS USADOS SON:
n= SEROLOGICOS:
üIgM<= span lang=3DES-TRAD style=3D'font-size:63%'>: por sí sola no es sin&oacu= te;nimo de infección aguda
üTest de avidez = de IgG: permite conocer mejor el tiempo q= ue lleva la infección. La avidez es baja si la infección es reciente (18-20 semanas) y alta si la infección es más antigua
n= VIRALES: antigenemia, DN= A por PCR
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DIAGNOSTICO PRENATAL
nLO PRIMERO A CONFIRMAR ES LA PRIMOINFECCION MATERNA
n
nPOSTERIORMENTE, EL DIAGNOSTICO DE INFECCION FETAL SE HACE POR AMNIOCENTESIS. EN EL LIQUIDO SE INVESTIGA (entre= semanas 21 y 23 de amenorrea) DNA/CMV POR TECNICA DE PCR<= span lang=3DES-TRAD style=3D'font-size:63%'>
n
n= ECOGRAFIA FETAL: DETECTA ANO= MALIAS MORFOLOGICAS
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DIAGNOSTICO DE INFECCION CONGENITA
nAis= lamiento del virus en muestra de orina, dentro de las 2 primeras semanas de vida (más tarde puede ser una infección perinatal)
nPCR= es una alternativa al aislamiento viral
nPer= sistencia o aumento de título de IgG en los meses sucesivos
nDet= ección de IgM (poco sensible = y falsos positivos)
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DIAGNOSTICO DE INFECCION PERINATAL
nAis= lamiento del virus en muestra de orina. Se confirma que la infección es perinatal si este estudio es negati= vo en las 2 primeras semanas y positivo a partir de la 4a semana de vida =
n
nIgM= negativo al nacimiento y posterior= mente positivo
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TRATAMIENTO – DROGAS DISPONIBLES (1)<= span style=3D'font-size:64%;font-weight:normal;mso-special-format:lastCR;displa= y: none'>
nGANCICLOVIR (GC= V):
nEs activo in vitro contra todos los herpesvirus, pero particularmente potente para inhibir la replicación de CMV.
nEn experimentación animal mostró ser teratogénico en con= ejos y mutagénico en diversos sistemas; tóxico sobre los sistemas reproductores, hematopoyético y gastrointestinal y potencialmente carcinogénico
nLos efectos adversos más frecuentemente observados en el hombre son: neutropenia y trombocitopenia. También se han descrito efectos secundarios sobre el SNC de diversa severidad. Otros efectos indeseables s= on: fiebre, erupción, anemia, náuseas, vómitos, alteracio= nes de la funcionalidad hepática, eosinofilia
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TRATAMIENTO – DROGAS DISPONIBLES (2)<= span style=3D'font-size:64%;font-weight:normal;mso-special-format:lastCR;displa= y: none'>
nFOSCARNET:
nEs una alternativa para cepas resistentes al GCV
nActivo in vitro contra la mayoría de herpesvirus, hepadnavirus y VIH <= /span>
nEs nefrotóxico. Otros efectos tóxicos son: anemia, alteraciones= en la función hepática, hiper o hipocalcemia =
nLos efectos secundarios más frecuentes son: máuseas, vómi= tos, cefalea, fatiga, temblor, irritabilidad
nCIDOFOVIR:
nEs nefrotóxico
n
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ACCION DE LAS DROGAS E INDICACIONES
nTodos los antivirales disponibles s= on virostáticos
nActúan inhibiendo la síntesis del DNA viral
nNo tienen acción sobre virus latentes
n= El potencial efecto tóxico de los mismos limita su uso al tratamiento y profilaxis de las infecciones graves en inmunodeprimidos
nDespués del tratamiento de inducción, de 2 a 3 semanas, se prosigue con la terapia supresiva o de mantenimiento, si persiste la inmunodepresión grave
n
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TRATAMIENTO – DOSIS, VIAS Y DURACION<= span style=3D'font-size:64%;font-weight:normal;mso-special-format:lastCR;displa= y: none'>
nGANCICLOVIR:=
ninducción: 5 mg/k c/12 h, i/= v, 2 a 3 semanas
nmantenimiento: 5 mg/k/d, 5-7 d/sema= na, en  coreorretinitis o hasta <= /span>el día 100-120 post-transpla= nte de MO. Alternativa: 1 g c/8 h v/o en coreorretinitis
n= 3;
nFOSCARNET:&#= 13;
ninducción: 90-100 mg/k c/12 = h, i/v, 2 a 3 semanas
nmantenimiento: 90-120 mg/k/d, 5-7 d/semana
n= 3;
nCIDOFOVIR: &= #13;
ninducción 5 mg/k/semanal, i/= v, 2 semanas
nmantenimiento; 5 mg/k, i/v, c/2 semanas
n<= span style=3D'font-size:56%;mso-special-format:lastCR;display:none'>
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TRATAMIENTO - CORIORRETINITIS
nOtras = opciones terapéuticas para la retinitis por CMV son:
n
nImplante intraocular de ganciclovir=
n
nInyección intravítreo= de
üganciclovir 400 µg 2 v/semana, luego semanal
üo foscarnet  2.400 µg 2 v/semana, luego semanal
üo cidofovir 20 µg c/5-6 días
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GAMAGLOBULINA HIPERINMUNE
nSe ha recomendado en asociación con ganciclovir para el tratamiento de enfermedades graves
n
nSu eficacia para prevenir la infección o enfermedad por CMV siguiendo = al transplante alogénico de médula ósea es controvertido=
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PROFILAXIS
n= MEDIDAS DE HIGIENE. Difíciles de aplicar dado lo expandida de la infección, el c= urso asintomático en la mayoría de los casos y el prolongado tiem= po de eliminación del virus, especialmente en niños =
n
n= LAS TRANSFUSIONES DE SANGRE DESLEUCOCITADA POR FILTRACION están indicadas en receptor= es seronegativos de aloinjerto de órgano o MO, embarazadas y reci&eacu= te;n nacidos
n
n= LA PROFILAXIS ANTIVIRAL CON ACICLOVIR, VALACICLOVIR Y GANCICLOVIR = mostró que reduce la infección y la enfermedad por CMV siguiendo al transplante de médula ósea y órganos sólidos
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parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } } function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) || (event && (event.keyCode=3D=3D32) ) ) parent.GoToNextSld(); } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"Fin de la presentación, haga clic para salir.", = SCREEN_MODE=3D"Frames", gIsEndShow=3D0, NUM_VIS_SLDS=3D38, SCRIPT_HREF=3D"s= cript.js", FULLSCR_HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0001.htm",1,-1,1),new hrefList(= "slide0041.htm",1,-1,1),new hrefList("slide0003.htm",1,-1,1),new hrefList("= slide0002.htm",1,-1,1),new hrefList("slide0018.htm",1,-1,1),new hrefList("s= lide0004.htm",1,-1,1),new hrefList("slide0019.htm",1,-1,1),new hrefList("sl= ide0005.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("sli= de0008.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("slid= e0009.htm",1,-1,1),new hrefList("slide0010.htm",1,-1,1),new hrefList("slide= 0012.htm",1,-1,1),new hrefList("slide0013.htm",1,-1,1),new hrefList("slide0= 014.htm",1,-1,1),new hrefList("slide0015.htm",1,-1,1),new hrefList("slide00= 21.htm",1,-1,1),new hrefList("slide0034.htm",1,-1,1),new hrefList("slide002= 0.htm",1,-1,1),new hrefList("slide0035.htm",1,-1,1),new hrefList("slide0022= .htm",1,-1,1),new hrefList("slide0036.htm",1,-1,1),new hrefList("slide0011.= htm",1,-1,1),new hrefList("slide0037.htm",1,-1,1),new hrefList("slide0040.h= tm",1,-1,1),new hrefList("slide0026.htm",1,-1,1),new hrefList("slide0028.ht= m",1,-1,1),new hrefList("slide0024.htm",1,-1,1),new hrefList("slide0039.htm= ",1,-1,1),new hrefList("slide0038.htm",1,-1,1),new hrefList("slide0023.htm"= ,1,-1,1),new hrefList("slide0029.htm",1,-1,1),new hrefList("slide0031.htm",= 1,-1,1),new hrefList("slide0030.htm",1,-1,1),new hrefList("slide0033.htm",1= ,-1,1),new hrefList("slide0032.htm",1,-1,1),new hrefList("slide0025.htm",1,= -1,1)); function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) { var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix(); function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') { href=3Dnew String(document.location.href) Start=3Dhref.indexOf('!')+1 End=3Dhref.lastIndexOf('/')+1 if (End < Start) return href.substring(0, Start) else return href.substring(0, End) } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ToggleOtlPane() { frmset=3Ddocument.all("PPTHorizAdjust") frm=3Ddocument.all("PPTOtl") if( gOtlOpen ) frmset.cols=3D"*,100%" else frmset.cols=3D"25%,*" gOtlOpen=3D!gOtlOpen frm.noResize=3D!frm.noResize UpdOtNavPane() } function ToggleNtsPane() { frmset=3Ddocument.all("PPTVertAdjust") frm=3Ddocument.all("PPTNts") if( gNtsOpen ) frmset.rows=3D"100%,*" else frmset.rows=3D"*,20%" gNtsOpen=3D!gNtsOpen UpdNtsPane() } function ClearMedia() { if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() { if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else return gCurSld } function GetNumSlds() { if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); function ImgBtn( oId,bId,w,action ) { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } function TxtBtn( oId,oeId,action,chkState ) { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new TxtBtn( "nb_nts","nb_ntsElem",parent.ToggleNtsPan= e,GetNtsState ) gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","nb_prevBorder",30,parent.GoToP= revSld ) gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","nb_nextBorder",30,parent.GoToN= extSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D new ImgBtn( "nb_voice","nb_voiceBorder",18,parent.= ToggleVNarration ) gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlTxt","nb_otlTxtBorder",23,parent= .ToggleOtlText ) gBtnArr["nb_nts"].m_flagId=3D "notes_flag" gBtnArr["nb_nts"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState var sNext=3D"Siguiente",sPrev=3D"Anterior",sEnd=3D"Fin de la presentaci&oac= ute;n",sFont=3D"Arial",sArrow=3D"Flecha",sFreeform=3D"Forma libre",sRect=3D= "Rectángulo",sOval=3D"Óvalo" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { history.back(); PPTSld.event.ca= ncelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; s.fontFamily=3DsFont s.fontSize=3D"9pt" s.paddingLeft=3D2 } function CreateSeparator( node ) { var sObj=3DCreateItem( node ) SetCMBorder(sObj,"menu","menu") var s=3DsObj.style s.borderTopColor=3D"threedshadow" s.borderBottomColor=3D"threedhighlight" s.height=3D1 s.fontSize=3D"0px" } function CreateItem( node ) { var elem=3DPPTSld.document.createElement("DIV") node.insertBefore( elem ) return elem } function SetCMBorder( o,ltClr,rbClr ) { var s=3Do.style s.backgroundColor=3D"menu" s.borderStyle=3D"solid" s.borderWidth=3D1 s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr } ------=_NextPart_01C3204F.FB67E0A0 Content-Location: file:///C:/1748D573/CITOMEGALOVIROSIS_archivos/fullscreen.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; 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