AIDS-related progressive multifocal leukoencephalopathy

Abstract INTRODUCTION: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by reactivation of JC virus (JCV). METHODS: We described the profile of laboratory-confirmed PML cases among AIDS patients. RESULTS: A total of 43 HIV patients with clinical conditions compatible with PML were obtained; 5 cases were confirmed by JCV testing. The main clinical finding was mental confusion. Median CD4 count was 54 cells/mm³. CONCLUSIONS: Three of the five confirmed PML cases died; the time between diagnosis and death was 2, 5, and 6 months. It is important to consider JCV infection as a differential diagnosis.

YOKENELLA REGENSBURGEI osteoarticular infection: a case report

okenella regensburgei belongs to the family Enterobacteriaceae and is an opportunistic agent rarely associated with infections in humans. We report a case of osteoarticular knee infection caused by Y. regensburgei in a patient under treatment for rheumatoid arthritis, using corticosteroids, with complication in primary total arthroplasty of the knee. Y. regensburgei was identified using the VITEK2 system. Antimicrobial susceptibility testing was performed using the disk-diffusion method, according to the guidelines from the Clinical and Laboratory Standards Institute. The patient presented favorable clinical evolution after the second debridement, with complete removal of the prosthesis and antibiotic therapy with sulfamethoxazole/trimethoprim. This is the first case of Y. regensburgei infection described d in Brazil.

Meningoencephalitis and optical neuritis caused by CRYPTOCOCCUS GATTII in an immunocompetent patient

The following case is of a 59-year-old man, undergoing no medication, with no pathological history or others risk factors, who presented dizziness, fever and asthenia twenty days before admission. The patient was admitted for investigation when the asthenia intensified, followed by seizures. On admission, blood count, biochemical tests and chest computed tomography were normal, a serological test for anti-HIV proved negative, while the magnetic resonance of the brain showed signs suggestive of meningoencephalitis. Cerebrospinal fluid (CSF) analysis suggested bacterial meningitis due to increased leukocytes with a predominance of polymorphonuclear cells, reduced glucose and increased proteins as well as positive Gram cocci in pairs by Gram and negative fungi by India ink test. Treatment with ceftriaxone was started. Since there was no significant improvement, CSF analysis was repeated on the seventh day of treatment. Intracranial pressure was measured by manometry (29 mmHg) and CSF analysis showed the presence of encapsulated yeasts similar to Cryptococcus neoformans by the India ink test. The treatment was modified to liposomal amphotericin B and flucytosine; the intracranial hypertension was controlled by repeated CSF punctures. After fourteen days of antifungal treatment, the patient presented visual turbidity and bilateral papillar edema, so corticosteroid therapy was prescribed. The evolution was favorable, with progressive resolution of symptoms, improvement of CSF parameters and visual acuity. The patient was discharged eight weeks after admission, with outpatient guidance. Corticosteroid therapy associated with antifungal therapy proved to be beneficial in this case, since following the introduction of corticosteroids there was progressive visual improvement.

Isoniazid-resistant tuberculous spondylodiscitis associated with scrofuloderma

The extrapulmonary forms of tuberculosis are responsible for about 20% of cases. Scrofuloderma is the cutaneous manifestation secondary to infection in some subcutaneous foci. A 33-year-old patient was admitted to the Clinical Hospital with exudative skin lesions on the back and thorax, initiated 10 months previously, associated with daily fever, and constipation. Spine resonance showed a paravertebral pseudotumoral lesion with T4 and T9 invasion, including vertebral canal and sub-ligament extension. The lesions presented fistulas for paravertebral muscles, lung and skin. Polimerase chain reaction (PCR) proved positive for Mycobacterium tubeculosis in the thorax wound secretion, caracterizing tuberculous spondilodiscitis with scrofuloderma. Treatment was initiated with rifampicin, isoniazid, pyrazinamide and ethambutol with important clinical improvement after the first week. The febrile peaks came to an end and there was improvement in the pattern of the cutaneous lesions. The susceptibility test showed resistance to isoniazid

Infecção urinária multirresistente na gravidez / Multiresistant urinary infection in pregnancy

Os micro-organismos que apresentam mecanismos de resistência aos antimicrobianos, como produção de ß-lactamase de espectro estendido (ESBL), resultam em uma maior dificuldade no tratamento e exigem a utilização de antibióticos de largo espectro com frequência crescente. Assim, este estudo busca revisar a literatura sobre as infecções causadas por micro-organismos multirresistentes na gravidez. Foi realizada uma busca de artigos no PubMed, MedLine e Lilacs usando-se unitermos, incluindo-se os estudos publicados de 2000 a 2016, de línguas portuguesa e inglesa, envolvendo apenas seres humanos. Foram selecionados 59 artigos com força de evidência A e B. Os critérios para inclusão no estudo são: estarem grávidas e terem diagnóstico de infecção do trato urinário. Serão critérios de exclusão: uso de antimicrobiano a menos de duas semanas antes da coleta da amostra e portadoras de doença imunossupressora. A verdadeira prevalência de ITU em gestantes por bactérias multirresistentes é desconhecida. As ITUs por bactérias produtoras de ESBL variam entre 1% e 40%. O tratamento mais aceito para os casos mais graves (pielonefrite ou bacteremia) é com carbapenêmicos. A nitrofurantoína e a fosfomicina têm sido utilizadas para tratar a cistite com patógenos produtores de ESBL com sucesso.(AU)

Microorganisms that have resistance mechanisms to antimicrobial agents, such as production of ß-lactamase extended spectrum (ESBL), result in greater difficulty in treatment and require the use of broad spectrum antibiotics with increasing frequency. This study aims to review the literature on infections caused by multiresistant microorganisms in pregnancy. A search for articles was conducted in PubMed, MedLine and Lilacs are using key words, including published studies from 2000 to 2016, Portuguese and English, involving only human. 59 articles were selected on strength of evidence A and B. The criteria for inclusion was pregnant and having diagnosed of urinary tract infection. The criteria for exclusion was: use of antimicrobial less than two weeks before sample collection and suffering from immunosuppressive disease. The true prevalence of UTI in pregnant women by multiresistant bacteria is unknown. UTIs for ESBL-producing bacteria, ranging from 1% to 40%. The treatment more acceptable for the most serious cases (pyelonephritis or bacteremia) is with carbapenems. Nitrofurantoin and fosfomycin has been used to treat successfully with cystitis ESBL producers pathogens.(AU)

Neurological manifestations of dengue in Central Brazil

Abstract INTRODUCTION: The incidence of dengue has increased throughout the 2000s with a consequent global increase in atypical clinical forms. METHODS: This study reports a series of cases of neurological dengue out of 498 confirmed cases of laboratory dengue in Goiânia, Brazil. Cases were confirmed based on viral RNA detection via polymerase chain reaction or IgM antibody capture. RESULTS: Neurological symptoms occurred in 5.6% of cases, including paresthesia (3.8%), encephalitis (2%), encephalopathy (1%), seizure (0.8%), meningoencephalitis (0.4%), and paresis (0.4%). DENV-3 was the predominant circulating serotype (93%). CONCLUSIONS: We reported dengue cases with neurological manifestations in endemic area.

Staphylococcus aureus bacteremia in a Brazilian Midwest teaching hospital

Staphylococcus aureus bacteremia is a frequent and potentially fatal condition. Resistance to methicillin is considered to be a predictive factor for mortality. The purpose of this study was to evaluate the epidemiological behaviour of S. aureus bacteremia in a teaching hospital. The incidence was 5.1 cases per 1,000 admissions. There was a significant improvement in the susceptibility of S. aureus; the incidence of methicillin-resistant S. aureus (MRSA) was 31.3% (95% confidence interval (CI) 24.5-39.1); whereas MRSA bacteremia a decade before had accounted for 55.0% (95% CI 45.2-64.3) of the cases. Overall mortality due to S. aureus bacteremia was 29.3%. MRSA bacteremia was not a risk factor for death

Healthcare-associated Staphylococcus aureus bloodstream infection: length of stay, attributable mortality, and additional direct costs

This study aimed to determine the excess length of stay, extra expenditures, and attributable mortality to healthcare-associated S. aureus bloodstream infection (BSI) at a teaching hospital in central Brazil. The study design was a matched (1:1) case-control. Cases were defined as patients > 13 years old, with a healthcare-associated S. aureus BSI. Controls included patients without an S. aureus BSI, who were matched to cases by gender, age (± 7 years), morbidity, and underlying disease. Data were collected from medical records and from the Brazilian National Hospital Information System (Sistema de Informações Hospitalares do Sistema Único de Saúde - SIH/SUS). A Wilcoxon rank sum test was performed to compare length of stay and costs between cases and controls. Differences in mortality between cases and controls were compared using McNemar's tests. The Mantel-Haenzel stratified analysis was performed to compare invasive device utilization. Data analyses were conducted using Epi Info 6.0 and Statistical Package for Social Sciences (SPSS 13.0). 84 case-control pairs matched by gender, age, admission period, morbidity, and underlying disease were analyzed. The mean lengths of hospital stay were 48.3 and 16.2 days for cases and controls, respectively (p < 0.01), yielding an excess hospital stay among cases of 32.1 days. the excess mortality among cases compared to controls that was attributable to s. aureus bloodstream infection was 45.2%. Cases had a higher risk of dying compared to controls (OR 7.3, 95% CI 3.1-21.1). Overall costs of hospitalization (SIH/SUS) reached US$ 123,065 for cases versus US$ 40,247 for controls (p < 0.01). the cost of antimicrobial therapy was 6.7 fold higher for cases compared to controls. healthcare-associated s. aureus BSI was associated with statistically significant increases in length of hospitalization, attributable mortality, and economic burden. Implementation of measures to minimize the risk of healthcare-associated bacterial infections is essential.

Enterococo resistente à vancomicina em um Hospital Universitário no Centro-oeste do Brasil / Vancomycin-resistant enterococcus in an university hospital in center-west of Brazil

O enterococo resistente à vancomicina (VRE) atualmente constitui uma preocupação para os profissionais da área da saúde em razão de sua crescente incidência nos serviços de assistência à saúde. No presente estudo, descreve-se o primeiro caso de VRE identificado na cidade de Goiânia,Região Centro-Oeste do Brasil, isolado de paciente masculino, 70 anos, admitido no hospital com diagnóstico de aneurisma de aorta abdominal infrarrenal. Diversos procedimentos cirúrgicos foram realizados com o uso de múltiplos antimicrobianos, mas após 61 dias a doença levou o paciente aóbito. Dentre as possíveis causas da morte, aponta-se a sepse indicada pela cultura de secreção de ferida operatória com isolamento e identificação de VRE.

Acidentes com material biológico entre profissionais de Hospital Universitário em Goiânia / Accidents with biological material among professionals working in an university Hospital in Goiania, Brazil

Os profissionais da área da saúde vivem sob isco de exposição a material biológico em seu ambiente de trabalho e uma das mais temidas consequências é a transmissão de doenças infecciosas. A principal forma de evitar os acidentes profissionais é precaver-se durante o contato com o paciente. Neste estudo descritivo, pretendeu-se avaliar os acidentes profissionais com material biológico ocorridos entre profissionais do Hospital das Clínicas da Universidade Federal de Goiás (HC/UFG), na cidade de Goiânia, durante o período de janeiro de 2006 a maio de 2007. O acidente foi caracterizado e definiu-se o status sorológico do profissional para hepatite B, hepatite C, sífilis e HIV. No período do estudo, foram acompanhados 46 profissionais no ambulatório de Infectologia do HC/UFG. Os acidentes ocorreram principalmente entre os técnicos de enfermagem (50por cento) e, em sua maioria (87por cento), durante o manuseio de agulhas e processamento de materiais. Não foi observada soroconversão para nenhuma das infecções monitoradas durante o período de seguimento. Quase 30por cento dos acidentados não haviam sido vacinados contra hepatite B, o que evidencia a necessidade de reforçar/oferecer a vacinação para todos os profissionais de saúde da instituição. Ressalta-se também a necessidade de educação continuada para a adoção de medidas preventivas que favoreçam a redução da frequência de acidentes profissionais.

Avaliação da antibioticoprofilaxia cirúrgica em Hospital Universitário / Evaluation of prophylactic antibiotics for surgery in an university hospital

A prescrição inadvertida de antimicrobianos profiláticos favorece seleção de cepas bacterianas resistentes. Este estudo tem como objetivo caracterizar a prescrição inadvertida de antimicrobianos profiláticos em relação a indicação, espectro escolhido, dose e duração da profilaxia em um Hospital Universitário de Goiânia, além de subsidiar propostas de adequação nas prescrições de acordo com a literatura. Por meio de questionário estruturado foram identificados: especialidade na qual o antibiótico fora prescrito, tipo de cirurgia, indicação, espectro de ação, dose utilizada e duração prevista. Foram avaliados 203 procedimentos cirúrgicos (64 por cento cirurgias limpas, 30 por cento potencialmente contaminadas e 6 por cento contaminadas). O antibiótico mais empregado foi a cefazolina (92 por cento). Foi observada inadequação da prescrição em 75 por cento dos casos, entre os quais 77 por cento referiam-se à duração excessiva do uso do antimicrobiano. Em 18 por cento das cirurgias não havia indicação da profilaxia e em 9 por cento foram utilizadas subdoses de antimicrobiano. O custo adicional estimado das prescrições não indicadas e com duração excessiva seria equivalente a R$1.635,00 reais. Ressalta-se a necessidade de um trabalho conjunto entre equipe cirúrgica e comissão de controle de infecção hospitalar, de modo que seja possível maior adesão às rotinas de antibioticoprofilaxia, redução de custos e seleção de cepas bacterianas resistentes, entre outros efeitos.

Bacteremias em pacientes internados em hospital universitário / Bacteremias at a teaching hospital: etiology, antimicrobial susceptibiliy pattern and risk factors for mortality

OBJETIVO: Avaliar a incidência de bacteremias, seu perfil de suscetibilidade antimicrobiana, e fatores associados ao óbito, em hospital universitário, no período de 1° de janeiro de 2000 a 31 de dezembro de 2001. MÉTODOS: Coorte retrospectiva. Pacientes maiores de 1 ano de idade, com bacteremia laboratorialmente confirmada e clinicamente significativa foram incluídos no estudo. Realizada análise de sobrevida multivariada, seguindo o modelo de riscos proporcionais de Cox. RESULTADOS: Foram detectados 295 episódios de bacteremia. O patógeno mais freqüente foi o Staphylococcus aureus: 118 (40 por cento), com 55,9 por cento de MRSA. A letalidade pela bacteremia foi de 34,5 por cento. Os fatores de risco independentes para o óbito foram terapia inicial inadequada (HR ajustado 2,05 IC 95 por cento: 1,25-3,36) e gravidade da apresentação clínica (HR ajustado 5,52 IC 95 por cento: 3,15-9,69). CONCLUSÃO: Nosso estudo mostrou elevada letalidade associada a bacteremia, com alta freqüência de MRSA. A terapia inicial inadequada e a gravidade da apresentação clínica foram fatores de risco independentes para o óbito pela bacteremia.

OBJECTIVE: To evaluate the frequency and profile of bacteremia, its antimicrobial susceptibility and to analyze predictors of mortality in bloodstream infections (BSI) at this Teaching Hospital from January 1, 2000 to December 31, 2001. METHODS: Design: retrospective cohort. Patients over one year old with clinically significant episodes of BSI which were microbiologically documented were included in the study. The Cox proportional hazards risk model was applied to identify prognostic factors related to death by bacteremia. RESULTS: A total of 295 episodes of BSI were detected. The most common pathogen was S. aureus: 118 (40.0 percent), with 55.9 percent of MRSA. Mortality associated with bacteremia was 34.5 percent. Independent predictors of mortality were: inadequate initial therapy (HR adjusted 2.05 IC95 percent: 1.25-3.36) and severity of the clinical manifestations (HR adjusted 5.52 IC95 percent: 3.15-9.69). CONCLUSION: This study disclosed high mortality rates due to BSI and a high frequency of MRSA. Inadequate initial therapy and severity of clinical manifestations were significantly and independently associated with mortality.