Etiología, clínica y evolución de infecciones fúngicas invasoras en pacientes con neoplasias hematológicas en un hospital universitario de Argentina

Introducción: Las infecciones fúngicas invasoras (IFI) en pacientes con neoplasias hematológicas (NH) representan un desafío diagnóstico y terapéutico. Objetivos: Describir la etiología, características clínicas, diagnóstico y evolución de los episodios de IFI probadas y probables en pacientes con NH y trasplante de progenitores hematopoyéticos (TPH). Pacientes y Métodos: Estudio descriptivo, retrospectivo y de cohorte que incluyó IFI probadas y probables en pacientes adultos con NH y TPH. Se realizó seguimiento hasta el día 90. Resultados: Se incluyeron 80 episodios de IFI: 49% probadas y 51% probables, 67,5% por hongos filamentosos (HF), 30% por hongos levaduriformes (HL) y 2,5% por hongos dimorfos. Los tipos de IFI más frecuentes fueron aspergilosis invasoras pulmonares (AP) y candidiasis invasoras (CI), en su mayoría por Candida spp. no albicans. Todos los casos de AP se diagnosticaron por detección de galactomanano en sangre y/o lavado broncoalveolar, y solamente 22,2% presentaban nódulos con halo en la tomografía computada (TC) de tórax, siendo los infiltrados inespecíficos los hallazgos más frecuentes. Tuvieron coinfección bacteriana y viral el 30 y 17,5%, respectivamente. El 50% fueron IFI de brecha, y la mortalidad global y mortalidad relacionada a la IFI fue 51 y 24%, respectivamente. Conclusión: Los HF fueron la principal causa de IFI, con una gran proporción de IFI de brecha, y presentaron elevada mortalidad. Para el diagnóstico, resulta importante la utilización de biomarcadores y jerarquizar cualquier imagen patológica en la TC.

Background: Invasive fungal infections (IFI) in patients with hematological malignancies (HM) represent a diagnostic and therapeutic challenge. Aim: To describe the etiology, clinical characteristics, diagnosis and evolution of proven and probable IFI episodes in patients with HM and hematopoietic stem cell transplantation (HSCT). Methods: Retrospective, descriptive, cohort study performed in adult patients with HM and HSCT, who developed proven and probable IFI. Follow-up was carried out until day 90. Results: A total of 80 IFI episodes were included: 49% proven and 51% probable, 67,5% due to mold (M), 30% to yeast-like fungi (Y) and 2,5% to dimorphic fungi. The most frequent causes were probable pulmonary aspergillosis (PA) and invasive candidiasis (IC), mainly due to non-albicans Candida species. PA were all diagnosed by detection of galactomannan (GM) in blood and bronchoalveolar lavage, and only 22,2% presented halo sign on chest CT. Bacterial and viral coinfections were reported in 30% and 17,5% respectively. Breakthrough IFI occurred in 50%, and global and IFI-related mortality were 51% and 24% respectively. Conclusion: Mold was the main cause of IFI, with a large proportion of breakthrough IFI, presenting high mortality. The use of biomarkers and the classification of any pathological image on CT contribute to the diagnosis.

Antibacterial and antifungal activity of curcumin and methylene blue associated with laser on bacterial and fungal strains

Objective:To analyze the effect of methylene blue and 10% curcumin in fungi and bacteria through an in vitrostudy using photodynamic therapy (PDT). Methods:Curcumin and methylene blue were photosensitized by a Photon Lase III laser applied for 90 s in a dark environment within a laminar flow chamber. Enterococcus faecalisand Candida albicans strains were cultured and standardized.Then, a minimum inhibitoryconcentration (MIC) assay was conducted for these photosensitizers, with concentration variations and incubation to evaluate their antimicrobial activity. Results:With PDT, Curcumin had significant antibacterial activity against E. faecalis (MIC = 250 µg/mL).In contrast, methylene blue had antibacterial activity against E. faecalis (MIC < 12.5 µg/mL with PDT) and antifungal activity against C. albicans (MIC <12.5 µg/mL with or without PDT).Both agents showed greater efficacy in the presence of the laser.The results suggest that curcumin and methylene blue associated with laser may effectively treat microbial infections. Conclusion:Further research is needed to evaluate the efficacy and safety of using these agents in animal and human models and theireffectiveness against different bacterial and fungal strains.

Comparative evaluation of histopathological analysis, KOH wet mount and fungal culture to diagnose fungal infections in post-COVID patients

Context and Aim: There is increasing prevalence of post-COVID fungal infection of rhinoorbitocerebral region especially mucormycosis and aspergillosis in India.[1] Early diagnosis of these fungal infections are of utmost importance, since it may improve outcome and survival.[2],[3],[4],[5],[6],[7],[8] The objective of this study was to evaluate and compare routine laboratory diagnostic methods, that is, histopathological examination, KOH wet mount and fungal culture in the diagnosis of post-COVID fungal infections. Materials and Methods: A total of 106 specimens of clinically suspected patients of post-COVID fungal infection of rhinoorbitocerebral region received in histopathology department were included in this study. The data of KOH wet mount and culture were acquired from the microbiology department after histopathological examination. Result: Approximately 88.68% of patients were diagnosed having fungal infections by one of the laboratory methods. The sensitivity of histopathological examination was highest (79.78%), followed by KOH wet mount (58.51%) and fungal culture (35.10%). Rhizopus species of zygomycetes group were the most common isolate (24.24%) on SDA culture. Overall 76% concordance was found between histopathological examination and fungal culture report for morphological identification of fungi. Conclusion: For the diagnosis of post-COVID fungal infection of Rhino-orbito-cerebral region, histopathological examination is was found to be more sensitive and rapid method to detect fungal hyphae. It leads to early treatment, prevents morbidity and mortality.

Mucormycosis an Emerging Fungal Infection Associated with COVID-19- A Case Report

Introduction: Mucormycosis is an exceptional but rising fungal infection correlated with the COVID-19 disease. COVID-19 positive patients exhibiting severe symptoms admitted in the ICU have an increased susceptibility to develop bacterial and fungal infection. We hereby report a case of oral mucormycosis that is seen in a patient in post COVID-19 infection. Case Presentation: A 65-year-old woman presented to our institution, with the chief complaint of ulceration in her right palate region for the past 7 days along with pyrexia and generalised malaise. The patient reported to have recovered from COVID-19 infection recently. She presented with medical history of diabetes and hypertension for past 8 years. Post recovery from COVID-19 infection the patient developed an ulcer in the hard palate. Treatment: Surgery was done under General anesthesia. Maxillectomy was done with aggressive debridement of necrotic tissue. Bilaterally periosteal flap was approximated and suture was placed. Conclusion: The extensive use of steroids and broad-spectrum antibiotics in COVID-19 treatment may raise the risk of fungal infections. Medical practitioners should be aware of the possibility of invasive secondary fungal infections in patients with COVID-19 infection.

Antifungal drugs prescription pattern in a tertiary care teaching hospital in South India

Background: Fungal infections are a major threat to human health. Immunocompromised patients are more susceptible to fungal infections which may be from superficial to systemic fungal infections. Proper diagnosis and appropriate prescription is essential for management of these fungal infections. Inappropriate use of antifungal agents can lead to antifungal resistance and adverse effects caused by them. Therefore, this study was carried out to understand the prescription pattern of antifungal drugs among patients from various departments such as general medicine, dermatology, obstetrics, and gynaecology at a tertiary care hospital in South India. Aims and Objectives: The objectives of the study are as follows: (i) To understand the Antifungal prescription practices in our hospital and (ii) to improve the rational use of antifungal drugs. Materials and Methods: This was an observational and cross-sectional study. Inpatients and outpatients of age above 18 years attending Government Omandurar Medical College, Chennai, during the study period of 2 months who were prescribed antifungal drugs were included in this study. The prescriptions of 342 patients were collected and data including age, gender, diagnosis, name of the antifungal drugs, route of administration, dosage form, and duration of treatment were reviewed. Out of 342 prescriptions, 92 contained more than one antifungal drugs in their prescriptions. The data collected were analyzed for frequency of antifungal drugs prescription and percentage values calculated. Results: In our study, females (n = 198; 57.95%) were prescribed antifungal drugs more than males. Most of them are out patients from the age group of 31–50 years (n = 159; 46.49%). Dermatology (n = 272; 79.53%) department had the most number of antifungal prescriptions. Tinea corporis (n = 138; 40.35%) was the most common fungal infection to be prescribed. Clotrimazole (n = 115; 27.89%) was the most commonly prescribed antifungal drug followed by Fluconazole (n = 105; 24.19%). Topical route (n = 268; 61.75%) was the most common route of administration of antifungal drugs followed by oral and parental routes, respectively. Conclusion: This study report helped us to analyze the prescribing pattern of antifungal drugs in our tertiary care hospital. This gave an idea to create guidelines for the rational use of antifungal drugs in our institution.

Entomoftoromicosis por Conidiobolus coronatus en un paciente joven proveniente de área rural

La conidiobolomicosis es una micosis subcutánea causada por un hongo saprofito, Conidiobulus spp. perteneciente a la clase Zigomicetos, orden Entomoftorales, que habita en regiones tropicales. La manifestación clínica clásica es la deformidad progresiva de estructuras faciales y su diagnóstico se basa en cultivos de la zona afectada y el estudio histopatológico, siendo el "fenómeno de Splendore-Hoeppli" el hallazgo más característico. Dada su baja frecuencia de presentación, no existe consenso sobre la mejor opción y tiempo de tratamiento. Aquí presentamos un caso de entomoftoromicosis rinofacial causada por Conidiobolus coronatus en un paciente inmunocompetente de la región sur de Colombia.

Conidiobolomycosis is a subcutaneous mycosis caused by a saprophytic fungus, Conidiobulus, belonging to the class of Zygomycetes, an order of Entomophtorales that inhabits tropical regions. Its most frequent clinical manifestation is the progressive deformity of facial midline structures, and the diagnosis is based on cultures taken from the affected area and the histopathological study, being the "Splendore-Hoeppli phenomenon" the most characteristic finding. Due to its low frequency of presentation, there is no consensus about the best option and treatment time. We present a case of rhinofacial entomophthoromycosis caused by Conidiobolus coronatus in an immunocompetent patient from the southern region of Colombia.

Infección por Aspergillus flavus y Rhizopus oryzae complex en paciente con diabetes mellitus / Infection due to Aspergillus flavus and Rhizopus oryzae complex in a patient with diabetes mellitus

La sinusitis micótica es una condición patológica que puede presentarse en pacientes con diabetes mellitus y estar asociada a una crisis hiperglucémica. Es una entidad agresiva con complicaciones locales que incluyen afectación de la órbita y el sistema nervioso central, y compromiso vascular. A pesar del tratamiento quirúrgico y antimicótico, la mortalidad es de hasta el 75 %. Se describe el caso de una paciente con diagnóstico de cetoacidosis diabética y signos de oftalmoplejía unilateral que llevaron al estudio con resonancia magnética del sistema nervioso central; se encontraron signos de sinusitis, meningitis y cerebritis. Los estudios microbiológicos iniciales fueron negativos, y los biomarcadores galactomanano sérico y el antígeno de Cryptococcus también fueron negativos. Tras el manejo quirúrgico, se llegó a la identificación de Aspergillus flavus y Rhizopus spp. en el tejido de los senos paranasales. La paciente recibió tratamiento con posaconazol y, tras dos meses de seguimiento, había presentado mejoría clínica. La infección fúngica dual y la infección por A. flavus son entidades poco frecuentes y de relevancia clínica, sin casos presentados previamente en nuestro país por lo que este corresponde a un caso de interés clínico.

Fungal sinusitis is a pathology that can occur in patients with diabetes mellitus and be associated with a hyperglycemic crisis. It is an aggressive entity with local complications that include involvement of the orbit or the central nervous system, and vascular involvement. Despite surgical and antifungal treatment, mortality raises up to 75%. We report the case of a female patient with a diagnosis of diabetic ketoacidosis and signs of unilateral ophthalmoplegia, which led to the study with magnetic resonance imaging of the central nervous system, finding signs of sinusitis, meningitis, and cerebritis. Initial microbiological studies were negative, and biomarkers such as serum galactomannan and Cryptococcus antigen were also negative. After surgical management and the identification of Aspergillus flavus and Rhizopus spp. in sinus tissue, the patient received treatment with posaconazole and after two months of follow-up she presented clinical improvement. Dual fungal infection and infection by A. flavus are uncommon and clinically relevant entities, with no cases previously reported in our country, therefore this corresponds to a case of clinical interest.

Efficacy analysis of subcutaneous injection of granulocyte-macrophage colony-stimulating factor for prevention of invasive fungal disease in patients with multiple myeloma / 白血病·淋巴瘤

Objective:To explore the efficacy of subcutaneous injection of granulocyte-macrophage colony-stimulating factor (GM-CSF) in preventing invasive fungal disease (IFD) in patients with multiple myeloma (MM).Methods:The clinical data of 222 patients who were admitted to the Second Hospital of Harbin Medical University from January 2015 to June 2021 were retrospectively analyzed. The patients was given GM-CSF (3-5 μg·kg -1·d -1, GM-CSF group) or granulocyte colony-stimulating factor (G-CSF, 2-5 μg·kg -1·d -1, G-CSF group) when neutrophils (ANC) ≤1.5×10 9/L after induction chemotherapy. Patients were discontinued when white blood cell count (WBC) ≥10.0×10 9/L. The incidence of IFD (including confirmed, clinical and proposed diagnosis) and breakthrough invasive fungal infections was compared between the two groups. Results:The incidence of IFD was 8.1% (18/222) in all patients. The incidence of IFD was 3.5% (3/85) and 10.9% (15/137) in the GM-CSF and G-CSF groups, respectively, and the difference between the two groups was statistically significant ( χ2 = 3.88, P = 0.049). In 9 patients of GM-CSF group receiving fungal infection prophylaxis and in 15 patients of G-CSF group receiving fungal infection prophylaxis, the incidence of breakthrough invasive fungal infections was 0 and 7 cases, respectively, and the difference between the two groups was statistically significant ( P = 0.022). Conclusions:GM-CSF application in MM patients can reduce the incidence of IFD and breakthrough invasive fungal infections.

"Star of Bethlehem sign" in the analysis of the evolution of brain lesions during and after treatment for neuroparacoccidioidomycosis / "Sinal da Estrela de Belém" na análise evolutiva das lesões durante e após o tratamento em pacientes com neuroparacoccidioidomicose

Abstract Objective: To describe the clinical and radiological evolution of lesions during and after treatment in patients diagnosed with neuroparacoccidioidomycosis (NPCM). Materials and Methods: This was a retrospective study of the medical records, computed tomography scans, and magnetic resonance imaging (MRI) scans of patients with NPCM treated between September 2013 and January 2022. Results: Of 36 cases of NPCM, eight were included in the study. One patient presented only with pachymeningeal and skull involvement, and seven presented with pseudotumors in the brain. Collectively, the eight patients presented with 52 lesions, of which 46 (88.5%) were supratentorial. There were 32 lesions with a diameter ≤ 1.2 cm, of which 27 (84.4%) disappeared during the treatment. In three cases, there were lesions > 1.2 cm that showed a characteristic pattern of evolution on MRI: an eccentric gadolinium contrast-enhanced nodule, with a subsequent decreased in the size and degree of contrast enhancement of the lesions. Conclusion: In NPCM, supratentorial lesions seem to predominate. Lesions ≤ 1.2 cm tend to disappear completely during treatment. Lesions > 1.2 cm tend to present with a similar pattern, designated the "Star of Bethlehem sign", throughout treatment.

Resumo Objetivo: Descrever a evolução clínica e radiológica das lesões durante e após o tratamento de pacientes diagnosticados com neuroparacoccidioidomicose (NPCM). Materiais e Métodos: Revisamos os prontuários médicos, estudos de tomografia computadorizada e ressonância magnética (RM) de pacientes com NPCM de nossa instituição, no período de setembro de 2013 a janeiro de 2022. Resultados: Dos 36 casos de NPCM, oito foram incluídos no presente estudo. Um caso apresentava apenas envolvimento paquimeníngeo e ósseo craniano e sete casos apresentavam lesões encefálicas pseudotumorais, totalizando 52 lesões, sendo 46 (88,5%) supratentoriais. Dentre 32 lesões com diâmetro ≤ 1,2 cm, 27 (84,4%) apresentaram resolução completa durante o tratamento. Três casos apresentaram padrão semelhante de evolução da lesão na RM em lesões > 1,2 cm, caracterizado pelo aparecimento de nódulo excêntrico com impregnação pelo gadolínio, seguido de redução das dimensões e do realce nodular pelo contraste nos estudos subsequentes. Conclusão: A NPCM apresenta-se predominantemente com lesões supratentoriais. Lesões ≤ 1,2 cm tendem a desaparecer completamente durante o tratamento. Lesões > 1,2 cm tendem a apresentar um padrão de imagem de RM característico ao longo do tratamento, descrito como o "sinal da Estrela de Belém".

Paraccoicidiomicosis, reflexión de una micosis diseminada: reporte de caso

Introducción: La paracoccidioidomicosis, es una micosis endémica en diferentes países de latinoamérica, incluyendo zonas de Colombia, con manifestación clínica muy variada ya que es considerada una enfermedad que puede ser crónica y sistémica. Objetivos: Exponer la importancia del examen clínico-estomatológico en la detección de diferentes entidades en sistema estomatognático, y el manejo multidisciplinario de paracoccidioidomicosis oral y sistémica. Caso clínico: paciente masculino en sexta década de vida, el cual presenta glosalgia y dolor de región ocular. Clínicamente presenta lesión de tipo granulomatoso en bordes laterales de lengua con evolución de hace 1 año aproximadamente, el resultado de la biopsia es paracoccidioidomicosis, se inicia manejo multidisciplinario con medicamentos intravenosos y orales, luego de 10 meses presenta resolución de este. Conclusiones: un buen interrogatorio, análisis de cuadro clínico y exámenes complementarios, son claves para un diagnóstico temprano y tratamiento oportuno, preservando la vida del paciente, especialmente en infecciones oportunistas como la paracoccidioidomicosis.

Introdução: A paracoccidioidomicose é uma micose endêmica em diferentes países da América Latina, incluindo áreas da Colômbia, com manifestação clínica muito variada por ser considerada uma doença que pode ser crônica e sistêmica. Objetivos: Expor a importância do exame clínico-estomatológico na detecção de diferentes entidades do sistema estomatognático e no manejo multidisciplinar da paracoccidioidomicose oral e sistêmica. Caso clínico: paciente do sexo masculino na sexta década de vida, que apresentava glossalgia e dor na região ocular. Clinicamente apresenta lesão tipo granulomatosa nas bordas laterais da língua com evolução de aproximadamente 1 ano, resultado da biópsia é paracoccidioidomicose, inicia-se manejo multidisciplinar com medicações endovenosas e orais, após 10 meses resolve. Conclusões: um bom questionamento, análise do quadro clínico e exames complementares são fundamentais para o diagnóstico precoce e tratamento oportuno, preservando a vida do paciente, principalmente nas infecções oportunistas como a paracoccidioidomicose.

Introduction: Paracoccidioidomycosis is an endemic mycosis in different Latin American countries, including areas of Colombia, with a very varied clinical manifestation since it is considered a disease that can be chronic and systemic. Objectives: To expose the importance of the clinical-stomatological examination in the detection of different entities in the stomatognathic system, and the multidisciplinary management of oral and systemic paracoccidioidomycosis. Clinical case: male patient in the sixth decade of life, who presented glossalgia and pain in the ocular region. Clinically, it presents a granulomatous-type lesion on the lateral edges of the tongue with evolution of approximately 1 year ago, the result of the biopsy is paracoccidioidomycosis, multidisciplinary management is started with intravenous and oral medications, after 10 months it resolves. Conclusions: a good questioning, analysis of the clinical picture and complementary tests are key to early diagnosis and timely treatment, preserving the patient's life, especially in opportunistic infections such as paracoccidioidomycosis.

Reporte de dos casos de neuro-paracoccidiomicosis / Report of two cases of neuro-paracoccidiomycosis

La paracoccidiodomicosis es la micosis sistémica más frecuente en América Latina. La afectación del sistema nervioso central (SNC) está descrita en un 10-27%. El objetivo es presentar dos pacientes del sexo masculino con neuroparacoccidiodomicosis internados en el Departamento de Medicina Interna del Hospital Nacional, uno en el año 2017 y el otro en el 2021. Ambos pacientes presentaron síntomas neurológicos con mejoría de las lesiones con anfotericina B. Los granulomas cerebrales de PCM pueden tener comportamiento pseudotumoral. La regresión de las lesiones fue completa con anfotericina B y trimetoprin sulfametoxasol en el primer caso y anfotericina B e itraconazol en el segundo caso.

Paracoccidioidomycosis is the most common systemic mycosis in Latin America. Central nervous system (CNS) involvement is described in 10-27%. The objective is to present two male patients with neuroparacoccidioidomycosis admitted to the Department of Internal Medicine of the National Hospital, one in 2017 and the other in 2021. Both patients presented neurological symptoms with improvement of the lesions with amphotericin B. The granulomas brain cells of PCM may have pseudotumor behavior. Regression of the lesions was complete with amphotericin B and trimethoprim sulfamethoxazole in the first case and amphotericin B and itraconazole in the second case.

Infecciones fúngicas invasivas en niños hospitalizados en un centro de referencia de Uruguay / Invasive fungal infections in children hospitalized at a pediatric reference hospital in Uruguay / Infecções fúngicas invasivas em crianças internadas em um centro hospitalar de referência no Uruguai

Introducción: las infecciones fúngicas invasivas (IFI) son un problema de salud en creciente aumento. Objetivo: describir las características epidemiológicas, microbiológicas y clínicas de los menores de 15 años con IFI hospitalizados en el Hospital Pediátrico, Centro Hospitalario Pereira Rossell entre 2010- 2019. Metodología: estudio retrospectivo, mediante revisión de historias clínicas. Variables: edad, sexo, comorbilidades, factores de riesgo, clínica, patógenos, tratamiento y evolución. Resultados: se registraron 26 casos de IFI en 23 niños. La mediana de edad fue 8 años, de sexo femenino 17, con comorbilidades 17: infección por VIH 5, enfermedad hematooncológica 4. Todos presentaban factores de riesgo para IFI. Las manifestaciones clínicas de sospecha fueron: fiebre en 19, síntomas neurológicos 11, respiratorios 9, gastrointestinales 6, urinarios 2, sepsis/shock en 3. Los agentes identificados fueron: Candida spp en 14, Cryptococcus neoformans complex 8 y Aspergillus fumigatus complex 4. Tratamiento: se indicó fluconazol en 15, asociado a anfotericina B 11. Todas las infecciones por candida fueron sensibles a los azoles. Fallecieron 7 niños, la mediana de edad fue 1 año. En 4 se identificó Candida spp, Aspergillus fumigatus complex 2 y Cryptococcus neoformans complex 1. Conclusiones: las IFI son poco frecuentes, afectan en su mayoría a niños inmunocomprometidos asociando elevada mortalidad. El diagnóstico requiere alto índice de sospecha. Candida spp y Cryptococcus spp fueron los agentes más involucrados. El inicio precoz del tratamiento acorde a la susceptibilidad disponible se asocia a menor mortalidad.

Summary: Introduction: invasive fungal infections (IFI) are an increasing health problem. Objective: describe the epidemiological, microbiological and clinical characteristics of children under 15 years of age with IFI hospitalized at the Pereira Rossell Hospital Center between 2010-2019. Methodology: retrospective study, review of medical records. Variables: age, sex, comorbidities, risk factors, symptoms, pathogens, treatment and evolution. Results: 26 cases of IFI were recorded involving 23 children. Median age 8 years, female 17, comorbidities 17, HIV infection 5, hematological-oncological disease 4. All with risk factors. Suspicion symptoms: fever 19, neurological symptoms 11, respiratory 9, gastrointestinal 6, urinary 2, sepsis / shock 3. Identified agents: Candida spp 14, Cryptococcus neoformans complex 8 and Aspergillus fumigatus complex 4. Treatment: fluconazole 15, associated with amphotericin B 11. All candida infections were sensitive to azoles. 7 died, median age 1 year. In 4, Candida spp was isolated, Aspergillus fumigatus complex in 2 and Cryptococcus neoformans complex in 1. Conclusions: IFI are rare, mostly affecting immunocompromised children, associated with high mortality. The diagnosis requires a high index of suspicion. Candida spp and Cryptococcus spp were the most involved agents. Early treatment according to available susceptibility is associated with lower mortality.

Introdução: as infecções fúngicas invasivas (IFI) são um problema de saúde crescente. Objetivo: descrever as características epidemiológicas, microbiológicas e clínicas de crianças menores de 15 anos com IFI internadas no Centro Hospitalar Pereira Rossell entre 2010 e 2019. Metodologia: estudo retrospectivo, revisão de prontuários. Variáveis: idade, sexo, comorbidades, fatores de risco, sintomas, patógenos, tratamento e evolução. Resultados: foram registrados 26 casos de IFI em 23 crianças. Idade mediana 8 anos, sexo feminino 17, comorbidades 17, infecção por HIV 5, doença hemato-oncológica 4. Todos com fatores de risco. Suspeita clínica: febre 19, sintomas neurológicos 11, respiratórios 9, gastrointestinais 6, urinários 2, sepse/choque 3. Agentes identificados: Candida spp 14, Cryptococcus neoformans complexo 8 e Aspergillus fumigatus complexo 4. Tratamento: fluconazol 15, associado à anfotericina B 11. Todas as infecções por cândida foram sensíveis aos azóis. 7 morreram, idade média de 1 ano. Em 4 das crianças Cândida spp foi isolada, Aspergillus fumigatus complexo em 2 e Cryptococcus neoformans complexo em 1. Conclusões: IFIs são raras, afetando principalmente crianças imunocomprometidas, associadas a alta mortalidade. O diagnóstico requer alto índice de suspeita. Cândida spp e Cryptococcus spp são os agentes mais envolvidos. O tratamento precoce de acordo com a suscetibilidade disponível está associado a menor mortalidade.

Mucurmicosis rinocerebral en un paciente con diabetes descompensada

La mucormicosis es una infección con una alta mortalidad, el pronóstico está en relación con el diagnóstico precoz, el tratamiento quirúrgico y antimicótico. Se presenta un varón de 65 años de edad, hipertenso conocido, tratado con losartan, ingresa con una historia de 15 días de evolución con astenia, anorexia, pérdida de peso y cefalea holocraneana, y ptosis palpebral de una semana de evolución. Al examen físico se constata una protrusión ocular y parálisis del tercer par del ojo derecho. Presentó hiperglicemia que fue revertida con insulina. La resonancia magnética de órbita y senos paranasales mostró un engrosamiento del nervio óptico derecho, ocupación de los senos paranasales. El paciente fue sometido a un tratamiento quirúrgico de la lesión retrocular, la biopsia de la lesión mostró al examen directo hifas hialinas compatible con mucorales. Se inició tratamiento con amfotericina B.

Mucormycosis is an infection with high mortality, the prognosis is related to early diagnosis, surgical and antifungal treatment. We present a 65-year-old male, known hypertensive, under treatment with losartan, admitted with a 15-day history of asthenia, anorexia, weight loss and holocranial headache, and palpebral ptosis of one week's evolution. Physical examination revealed ocular protrusion and paralysis of the third pair of the right eye. The patient presented hyperglycemia that was reversed with insulin. Magnetic resonance imaging of the orbit and paranasal sinuses showed thickening of the right optic nerve, occupation of the paranasal sinuses. The patient underwent surgical treatment of the retrocular lesion, biopsy of the lesion showed hyaline hyphae compatible with mucorales on direct examination. Treatment with amphotericin B was started.

Una experiencia de siete años en el laboratorio de Micología del Hospital de Pediatría Juan P. Garrahan / A seven-year experience in the Mycology Laboratory of Hospital de Pediatría Juan P. Garrahan

En noviembre del año 2015 nos incorporamos al Laboratorio de Micología del Servicio de Microbiología del Hospital Garrahan. En este breve resumen queremos compartir los avances logrados a través de nuestra experiencia durante siete años de trabajo profesional. Debido a los diagnósticos realizados y su complejidad, consideramos que el Hospital Garrahan, sus pacientes y la comunidad toda necesitan contar con un laboratorio de Micología que responda a sus necesidades. Creemos haber iniciado un camino que esperamos continúe y culmine con la creación de la Unidad de Micología (AU)

In November 2015 we joined the Mycology Laboratory of the Microbiology Service of the Hospital Garrahan. In this brief summary we want to share the advances achieved through our experience during seven years of professional work. Due to the diagnosis made and their complexity, we believe that the Hospital Garrahan, its patients and the entire community, need to have a Mycology laboratory that responds to their requirements. We believe we have started a path that we hope will continue and culminate with the creation of the Mycology Unit (AU)

Características de la infección fúngica invasiva en los pacientes críticos de la altitud con shock séptico

Introducción: En UCI, 19% tienen hongos, 23% desarrollan shock séptico. Cándida albicans el más frecuente. Antimicótico más utilizado es fluconazol. Objetivos: En residentes de la altitud con shock séptico (SS) describiremos: Características, evolución y sensibilidad de la infección fúngica invasiva (IFI) y los contrastaremos con los publicados a nivel del mar. El estudio: Retrospectivo y transversal. Analizamos hemocultivos de adultos con SS y IFIs en una UCI a 3,250 metros de altitud, durante 7 años. Hallazgos: 123 muestras. Las IFIs aumentaron 3.6 para candida albicans. Mujeres con 74 años fue frecuente. BGN representaron 52.88%, BGP 37.9% y hongos 9.22%. Cándida albicans 79.67% con sensibilidad mayor al 90% para Voriconazol, Anfotericina B y Fluconazol. Conclusiones: IFIs con SS fueron causadas por cándida albicans, IFIs aumentaron, existe adecuada sensibilidad a los antimicóticos En la altitud existe mayor frecuencia del sexo femenino, mayor promedio de edad y una buena sensibilidad al fluconazol.

Introduction: In the ICU, 19% have fungi, 23% develop septic shock. Candida albicans the most frequent. The most commonly used antifungal is fluconazole. Objectives: In high altitude residents with septic shock (SS) we will describe: Characteristics, evolution and sensitivity of invasive fungal infection (IFI) and we will contrast them with those published at sea level. The study: Retrospective and transversal. We analyzed blood cultures of adults with SS and IFIs in an ICU at 3,250 meters of altitude, for 7 years. Findings: 123 samples. The IFIs increased 3.6 for candida albicans. Women with 74 years was frequent. BGN represented 52.88%, BGP 37.9% and fungi 9.22%. Candida albicans 79.67% with sensitivity greater than 90% for Voriconazole, Amphotericin B and Fluconazole. Conclusions: IFIs with SS were caused by candida albicans, IFIs increased, there is adequate sensitivity to antifungals. At high altitudes there is a higher frequency of females, higher average age, and good sensitivity to fluconazole.

Afectación esofágica y pulmonar por paracoccidioidomicosis en paciente inmunocompetente: reporte de caso / Esophageal and Pulmonary Involvement Caused by Paracoccidioidomycosis in Immunocompromised Patient: Case Report

Resumen La paracoccidioidomicosis es una infección fúngica endémica de América del Sur, que afecta predominantemente a los hombres y, según su campo laboral, granjeros y agricultores. Es ocasionada por la aspiración del hongo en su forma micelar y debuta en tres formas de presentación: aguda, subaguda y crónica; esta última es más frecuente en adultos, cuyo tratamiento dependerá de los azoles, anfotericina B y sulfonamidas. El presente caso trata de un hombre de 57 años, colombiano, agricultor, sin antecedentes patológicos, quien presentaba dos meses de disfagia para sólidos que progresó a líquidos, sialorrea y pérdida de peso, a quien se le realizó endoscopia de vías digestivas altas y se observaron lesiones blanquecinas, por lo cual se realizó una biopsia que evidenció levaduras en múltiple gemación compatibles con paracoccidioidomicosis; a su vez, se observó en una tomografía de tórax compromiso parenquimatoso intersticial generalizado; posteriormente, recibió tratamiento con itraconazol, con el que mostró mejoría y resolución del cuadro clínico. En vista de que América del Sur es endémica de la patología descrita y puede presentarse de forma diseminada en inmunocompetentes, se debe tener en cuenta en aquellos pacientes que poseen factores de riesgo, sintomatología y hallazgos en estudios de extensión sugestivos de dicha enfermedad, dado el gran espectro de presentación de la infección, para así dar tratamiento oportuno y dirigido.

Abstract Paracoccidioidomycosis (PCM) is a fungal infection endemic to South America. It predominantly affects men, depending on their work field: farmers and agriculturists. Paracoccidioidomycosis is caused by the aspiration of the fungus in its micellar form and manifests in three conditions: acute, subacute, and chronic; the latter is more frequent in adults, whose treatment will depend on azoles, amphotericin B, and sulfonamides. This case concerns a 57-year-old Colombian man, a farmer with no pathological history who showed dysphagia for solids that progressed to liquids, sialorrhea, and weight loss for two months. He underwent upper GI endoscopy, and whitish lesions were observed; thus, he was biopsied, displaying yeasts in multiple gemmations compatible with paracoccidioidomycosis. In turn, a chest CT scan showed generalized interstitial parenchymal involvement. Subsequently, he was treated with itraconazole, showing improvement and resolution in his clinical picture. Since the pathology described is endemic in South America and can be disseminated in immunocompromised patients. Given the broad infection spectrum, consideration should be given to patients with risk factors, symptomatology, and findings in extension studies suggesting this disease to provide timely and specific treatment.

Infección fúngica invasiva por Saprochaete capitata en un niño con aplasia medular / Invasive fungal infection by Saprochaete capitata in a child with bone marrow aplasia

RESUMEN Saprochaete capitata es una causa rara de infección fúngica invasiva en pacientes inmunocomprometidos con alta mortalidad y resistencia antifúngica. Presentamos el caso de un niño de cinco años con diagnóstico de aplasia medular, sometido a trasplante de progenitores hematopoyéticos (TPH), que cursó con neutropenia febril persistente, dolor abdominal intenso, aparición de lesiones maculopapulares en piel y deterioro de la función renal. Se identificó la presencia de S. capitata, en hemocultivos transcatéter venoso central. Esta infección fúngica invasiva resulta ser rara, pero emergente y potencialmente mortal, en pacientes con neutropenia febril persistente y uso prolongado de dispositivos invasivos intravasculares como catéter venoso central.

ABSTRACT Saprochaete capitata is a rare cause of invasive fungal infection in immunocompromised patients with high mortality and antifungal resistance. We present the case of a 5-year-old boy with bone marrow aplasia, who underwent hematopoietic stem cell transplantation (HSCT) and presented persistent febrile neutropenia, abdominal pain, appearance of maculopapular lesions on the skin, and impaired renal function. The presence of S. capitata was identified by blood culture from a central venous catheter. This invasive fungal infection is rare but emergent and life-threatening, especially in immunocompromised patients with persistent febrile neutropenia and prolonged use of invasive devices such as central venous catheters.

Mucormicosis asociada a COVID-19: revisión de la literatura para odontólogos / COVID-19 associated mucormycosis: a literature review for dentists

La mucormicosis es una infección fúngica rara, con alta morbilidad y mortalidad. Se presenta principalmente en pa- cientes con diabetes mellitus no controlada, inmunocompro- metidos, con tratamiento crónicos con esteroides, entre otros. Actualmente, se cree que la pandemia de COVID-19 y los tratamientos con corticosteroides podrían estar implicados en el aumento de casos de esta micosis. Este hongo invade el sistema vascular, ocluyendo el flujo sanguíneo arterial y generando una rápida trombosis e isque- mia, lo que provoca la necrosis de los tejidos duros y blandos, con invasión rápida a los tejidos circundantes. Hay varias formas clínicas. En la cavidad bucal se presenta la variante rino-orbito-cerebral, que afecta el paladar en forma de lesión eritematosa o grisácea que puede progresar hacia la formación de una masa necrótica o ulceración con muy escaso sangrado de mucosa. Se manifiesta con síntomas típicos de una rinosinusitis con fiebre y dolor en las piezas dentarias superiores. El tratamiento consta de tres pilares fundamentales: el diagnóstico, un manejo adecuado de las comorbilidades y la combinación de las terapias antifúngica y quirúrgica. Desde el año 2020, la mucormicosis asociada a COVID-19 pasó a ser un evento de notificación obligatoria inmediata al Sistema Nacional de Vigilancia de la Salud (SNVS2.0) me- diante el Sistema Integrado de Información Sanitaria Argen- tina (SISA). Es importante destacar que se han reportado casos de mu- cormicosis luego de extracciones dentales; lo que impulsa a afianzar los conocimientos sobre esta enfermedad, extremar las medidas preventivas e incentivar el diagnóstico precoz en la atención odontológica, debido a la rapidez en la evolución de la patología (AU))

Mucormycosis is a rare fungal infection, with high mor- bidity and mortality. It occurs mainly in patients with uncon- trolled diabetes mellitus, immunocompromised, on chronic treatment with steroids, among others. Currently, it is believed that the COVID-19 pandemic and the corticosteroid treatments could be one of the causes of increased cases. This fungus invades the vascular system, occluding arteri- al blood flow and generating rapid thrombosis and ischemia, which causes necrosis of hard and soft tissues, with rapid in- vasion to the surrounding tissues. There are several clinical forms. In the oral cavity, the rhino-orbito-cerebral variant presents itself affecting the pal- ate in the form of an erythematous or grayish lesion that can progress towards the formation of a necrotic mass or ulcera- tion with very little mucosal bleeding. It manifests itself with typical symptoms of rhinosinusitis, with fever and pain in the upper teeth. The treatment consists of three fundamental pillars: diag- nosis, proper management of comorbidities and the combina- tion of antifungal and surgical therapies. Since 2020, COVID-19 associated mucormycosis became an event of mandatory immediate notification to the National Health Surveillance System (SNVS2.0,) through the Argentina Integrated Health Information System (SISA). It is important to emphasize that mucormycosis cases had been reported following tooth extractions, which drives to strengthen knowledge about this disease, extreme preventive measures and encourage early diagnosis in dental care, due to the speed of the evolution of the pathology (AU))

Micosis sistémicas en pacientes con Sida: descripción y relación del diagnóstico clínico con estudios complementarios

Las micosis profundas sistémicas (MPS) en los pacientes con Síndrome de Inmunodeficiencia Adquirida (Sida) pueden manifestarse de forma severa y fatal, y se requiere de una alta precisión diagnóstica, para mejorar su sobrevida y pronóstico. Objetivo: Describir y analizar la relación entre el diagnóstico clínico de las MPS con los resultados de biopsias y de los estudios micológicos en los pacientes con Sida del Servicio de Infectología del Hospital Universitario de Caracas, entre 2010 al 2015. Métodos: Se diseñó un estudio de casos, analítico, retrospectivo, descriptivo, no experimental. Se revisaron 195 historias clínicas y los resultados de biopsias, cultivos, inmunofluorescencia directa (IFD), criptolátex (CL)/Tinta china (TC). El análisis estadístico se realizó con medidas de tendencia central. Resultados: La edad media fue de 36,2 años; 65,2 % tenían menos de 5 años de diagnóstico de la infección por el virus de inmunodeficiencia humana (VIH); 68,2 % no tenían tratamiento antirretroviral de gran actividad (TARGA); los niveles de linfocitos TCD4 (LTCD4) estaban por debajo de 200 células (cels)/mm3 (49,2 %) y sus cargas virales mayores de 50 000 copias/mL (33,3 %). Las formas de presentación clínica más frecuentes fueron respiratorio febril con hepatomegalia (64,6 %), los diagnósticos clínicos predominantes fueron neumocistosis (34,9 %), neumocistosis/histoplasmosis (30,8 %) e histoplasmosis (16,4 %), no pudo establecerse la relación entre los diagnósticos clínicos y los resultados de cultivos/PCR ­ IFD, CL/TC y de biopsias por no disponer de resultados. Conclusión: El diagnóstico clínico más frecuente fue neumocistosis y las comparaciones no se pudieron realizarse por fallas en los reportes de paraclínicos imprescindibles.

Systemic deep mycoses (PSM) in patients with Acquired Immunodeficiency Syndrome (AIDS) can manifest severely and fatally, and high diagnostic accuracy is required to improve survival and prognosis. Objective: To describe and analyze the relationship between the clinical diagnosis of MPS with the results of biopsies and mycological studies in AIDS patients of the Infectology Service of the University Hospital of Caracas, between 2010 and 2015. Methods: A study was designed of cases, analytical, retrospective, descriptive, non-experimental. 195 medical records and the results of biopsies, cultures, direct immunofluorescence (DIF), cryptolatex (CL)/Indian ink (CT) were reviewed. Statistical analysis was performed with measures of central tendency. Results: The mean age was 36.2 years; 65.2 % had been diagnosed with human immunodeficiency virus (HIV) infection less than 5 years ago; 68.2 % had not received highly active antiretroviral treatment (HAART); the levels of TCD4 lymphocytes (LTCD4) were below 200 cells (cels)/mm3 (49.2 %) and their viral loads were greater than 50 000 copies/mL (33.3 %). The most frequent forms of clinical presentation were febrile respiratory with hepatomegaly (64.6 %), the predominant clinical diagnoses were pneumocystosis (34.9 %), pneumocystosis/histoplasmosis (30.8 %) and histoplasmosis (16.4 %), The relationship between the clinical diagnoses and the results of cultures/PCR ­ IFD, LC/CT and biopsies could not be established due to the lack of results. Conclusions: The most frequent clinical diagnosis was pneumocystosis and the comparisons could not be made due to failures in the essential paraclinical reports.

Refractory rhino-orbito-cerebral mucormycosis treated with intraconal amphotericin B / Mucormicose rino-orbito-cerebral refratária tratada com anfotericina B intraconal

ABSTRACT We report the case of a 46-year-old diabetic man receiving treatment for rhino-orbital-cerebral mucormycosis with liposomal amphotericin B and surgical debridement. The patient's condition worsened clinically, accompanied by the loss of ocular motility and a visual acuity of absence of light perception. Radiological extension of the infection was evidenced, with invasion of the cavernous sinus. Based on ophthalmological findings, exenteration (a potentially disfiguring procedure) was indicated, but we opted for wide surgical debridement and administration of amphotericin B via intraconal catheter. Clinical improvement and resolution of inflammation occurred after 2 weeks of treatment. Thus, rhino-orbital-cerebral mucormycosis was effectively controlled through intraconal administration of amphotericin B, while avoiding exenteration. The intervention should be considered as an adjuvant treatment in selected rhino-orbital-cerebral mucormycosis cases before attempting exenteration.

RESUMO Os autores relatam o caso de um homem diabético de 46 anos de idade em tratamento para mucormicose rino-orbital-cerebral com anfotericina B lipossomal e desbridamento cirúrgico. Piora clínica foi observada, com acometimento de motilidade ocular e acuidade visual de ausência de percepção luminosa, sendo evidenciada extensão radiológica da infecção, com invasão do seio cavernoso. Com base nos achados oftalmológicos, uma exenteração, procedimento potencialmente desfigurante, foi indicada, mas optamos por realizar amplo desbridamento cirúrgico e administração intraconal de anfotericina B por cateter. Melhora clínica e resolução da inflamação ocorreram após duas semanas de tratamento. Dessa forma, a mucormicose rino-orbital-cerebral foi efetivamente controlada com a administração intraconal de anfotericina B, evitando a exenteração. A intervenção deve ser considerada como um tratamento adjuvante em casos selecionados de mucormicose rino-orbital-cerebral antes que a exenteração seja realizada.