Strategies to reduce mortality and morbidity due to AIDS-related cryptococcal meningitis in Latin America

Latin America is the region with the third most AIDS-related cryptococcal meningitis infections globally. Highly active antiretroviral therapy (HAART) has reduced the number of infections; however, the number of deaths and the case-fatality rate continues to be unacceptable. In this review, we focus on the burden of AIDS-related cryptococcosis in Latin America and discuss potential strategies to reduce early mortality from Cryptococcus. In this review, we highlight the importance of: (1) earlier HIV diagnosis and HAART initiation with retention-in-care to avoid AIDS; (2) pre-HAART cryptococcal antigen (CRAG) screening with preemptive fluconazole treatment; (3) better diagnostics (e.g. CRAG testing); and (4) optimal treatment with aggressive management of intracranial pressure and induction therapy with antifungal combination. Implementation of these strategies can reduce cryptococcal-related deaths, improve care, and reduce healthcare costs.

Ring enhancing intracranial lesion responding to antituberculous treatment in an HIV-infected patient / Lesão intracraniana que respondeu ao tratamento anti-tuberculoso em paciente infectado pelo HIV

Cerebral tuberculomas constitute a major differential diagnosis of cerebral toxoplasmosis in human immunodeficiency virus (HIV)-infected patients in developing countries. We report the case of a 34-year old woman co-infected with HIV and possible disseminated tuberculosis (hepatitis, lymphadenopathy, and pleural effusion) who presented a large and solitary intracranial mass lesion. Despite extensive diagnostic efforts, including brain, ganglionar, and liver biopsies, no definitive diagnosis was reached. However, a trial with first-line antituberculous drugs led to a significant clinical and radiological improvement. Atypical presentations of cerebral tuberculomas should always be considered in the differential diagnosis of intracranial mass lesions in HIV-infected patients and a trial with antituberculous drugs is a valuable strategy to infer the diagnosis in a subset of patients.

Os tuberculomas cerebrais constituem diagnóstico diferencial importante da toxoplasmose cerebral em pacientes infectados pelo vírus da imunodeficiência humana (HIV) de países em desenvolvimento. Os autores relatam o caso de uma mulher HIV positiva de 34 anos de idade, que apresentou provável tuberculose disseminada (hepatite, adenomegalia, e derrame pleural) associada à lesão expansiva cerebral única e gigante. Apesar dos esforços diagnósticos realizados, incluindo biópsia cerebral, ganglionar e hepática, o diagnóstico etiológico não foi confirmado. Porém, a resposta clínico-radiológica ao tratamento tuberculostático permitiu definir o diagnóstico de tuberculoma cerebral e a paciente teve alta hospitalar. Apresentações atípicas de tuberculomas cerebrais devem ser sempre consideradas no diagnóstico diferencial das lesões expansivas cerebrais em pacientes infectados pelo HIV e o uso do tratamento tuberculostático constitui ferramenta útil na definição diagnóstica em um sub-grupo de pacientes.

Comparative performance of imagicides on Anopheles stephensi, main malaria vector in a malarious area, southern Iran.

BACKGROUND & OBJECTIVES: Jiroft district has subtropical climate and prone to seasonal malaria transmission with annual parasite index (API) 4.2 per 1000 in 2006. Anopheles stephensi Liston is a dominant malaria vector. The monitoring of insecticide susceptibility and irritability was conducted using discriminative dose as described by WHO. METHODS: The IV instar larvae were collected from different larval breeding places and transported to the temporary insectary, fed with Bemax and then 2-3 days-old emerged and sugar-fed adults were used for susceptibility and irritability tests employing WHO methods and kits to organochlorine (OC) and pyrethroid (PY) insecticides. RESULTS: Mortality rates of field strain of An. stephensi were 91.3 +/- 0.14 and 90 +/- 0.47% to DDT and dieldrin, respectively at one hour exposure time but was susceptible to all pyrethroids tested. The average number of take-offs per min per adult was 2.09 +/- 0.13 for DDT, 0.581 +/- 0.05 for dieldrin, 1.85 +/- 0.08 for permethrin, 1.87 +/- 0.21 for lambda-cyhalothrin, 1.53 +/- 0.13 for cyfluthrin, and 1.23 +/- 0.1 for deltamethrin. INTERPRETATION & CONCLUSION: Currently, deltamethrin is being used for indoor residual spraying against malaria vectors in the endemic areas of Iran. The findings revealed that the main malaria species is susceptible to all pyrethroids including deltamethrin, permethrin, cyfluthrin and lambda-cyhalothrin but was tolerant to DDT and dieldrin. This report and the finding are coincided with results of previous studies carried out during 1957-61 in the same area. Irritability tests to OC and PY insecticides revealed the moderate level of irritability to DDT compared to pyrethroids and dieldrin. Monitoring for possible cross-resistance between OC and PY insecticides should come into consideration for malaria control programme.

Effect of washing on the bioefficacy of insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs) against main malaria vector Anopheles stephensi by three bioassay methods.

BACKGROUND & OBJECTIVES: The use of pyrethoid impregnated bednets is one of the main malaria vector control strategies worldwide. The objective of the present study was to evaluate the bioefficacy of bednets impregnated with various pyrethroids after repeated washings. METHODS: The effectiveness of bednets impregnated with permethrin, deltamethrin, bifenthrin, etofenprox and long-lasting bednets like OlysetNet and PermaNet which were provided by WHOPES was evaluated. The tests were carried out according to the WHO-recommended methods. Malaria vector, Anopheles stephensi was exposed to impregnated bednets for 3 min and the mortality was measured after 24 h recovery period. Knockdown was measured as well. RESULTS: Results of three methods of bioassay tests showed that between two LLINs, PermaNet was more efficient than OlysetNet. Results of ITNs exhibited that deltamethrin and permethrin were more effective than etofenprox and bifenthrin as impregnants. INTERPRETATION & CONCLUSION: Findings of this study will be useful for WHO, local authorities and people who wish to use different pyrethroid-impregnated bednets for malaria vector control.

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil

La aspergilosis cerebral es una causa rara de lesión expansiva cerebral en pacientes con SIDA. Presentamos el primer reporte de un absceso cerebral causado por Aspergillus fumigatus en un paciente brasileño con SIDA. El paciente, de 26 años de edad, presentaba antecedentes de infección por el virus de la inmunodeficiencia humana (VIH), tuberculosis pulmonar y toxoplasmosis cerebral. Manifestó fiebre, tos, disnea y dos episódios de convulsiones. La tomografía computadorizada (TC) demostró una lesión hipodensa parasagital y bi-parietal con realce periférico e importante efecto de masa. Se inició tratamiento anti-Toxoplasma. Tres semanas después, el paciente evidenció confusión mental y una nueva TC de cráneo mostró aumento de la lesión. Se realizó biopsia cerebral con drenaje de 10 mL de material purulento. El examen micológico directo reveló hifas hialinas septadas. Se inició anfotericina B deoxicolato. La cultura del material demostró presencia de Aspergillus fumigatus. En los siguientes dos meses el paciente fue sometido a otras tres cirugías, insertándose un catéter de drenaje y administrándose anfotericina B intralesional. Tres meses después de la admisión hospitalaria, la condición neurológica del paciente sufrió discretos cambios. Sin embargo, falleció debido a neumonia intrahospitalaria. Aunque muy raros, los abscesos cerebrales causados por Aspergillus fumigatus deben ser considerados en el diagnóstico diferencial de las lesiones expansivas cerebrales en pacientes con SIDA.

Cerebral mass lesion due to cytomegalovirus in a patient with AIDS: case report and literature review

Cytomegalovirus (CMV) disease in acquired immunodeficiency syndrome (AIDS) patients most commonly presents as chorioretinitis and gastro-intestinal infection. Neurological involvement due to CMV may cause several clinical presentations: polyradiculitis, myelitis, encephalitis, ventriculo-encephalitis, and mononeuritis multiplex. Rarely, cerebral mass lesion is described. We report a 39 year-old woman with AIDS and previous cerebral toxoplasmosis. She presented with fever, seizures, and vulval ulcers. Her chest X-ray showed multiple lung nodules, and a large frontal lobe lesion was seen in a brain computed tomography scan. She underwent a brain biopsy through a frontal craniotomy, but her condition deteriorated and she died in the first postoperative day. Histopathological studies and immunohistochemistry disclosed CMV disease, and there was no evidence of cerebral toxoplasmosis, bacterial, mycobacterial or fungal infection. CMV disease should be considered in the differential diagnosis of cerebral mass lesion in AIDS patients. High suspicion index, timely diagnostic procedures (surgical or minimally invasive), and proper utilization of prophylactic and therapeutic medication could improve outcome of these patients.