Neumonía lipoidea exógena crónica y sobreinfección por Mycobacterium tuberculosis / Chronic Exogenous Lipoid Pneumonia and Superinfection by Mycobacterium Tuberculosis

Introducción: la neumonía lipoidea exógena es una enfermedad pulmonar inflamatoria poco común, desencadenada por la inhalación o aspiración de material graso de origen animal, vegetal o mineral. El diagnóstico se establece a través de confirmación histo-patológica, por la presencia de macrófagos cargados de lípidos en muestras respirato-rias, asociado a las características clínicas específicas al momento de su presentación.Requiere de un alto nivel de sospecha y una adecuada anamnesis de los antecedentes exposicionales del paciente debido a que muchos casos son subdiagnosticados y trat-ados como neumonía adquirida en la comunidad, lo que retrasa su diagnóstico y mane-jo, sumado a la ausencia de guías disponibles para su tratamiento.Se han reportado pocos casos de sobreinfección por tuberculosis en pacientes con neu-monía lipoidea exógena crónica. Caso clínico: femenino 33 años, con antecedentes de exposición crónica a sustancias desinfectantes de características aceitosas sin protección de vía aérea, con cuadro de tos y dolor torácico. Conclusión: el diagnóstico temprano, asociado a tratamiento de soporte, general-mente conservador, favorece la mejoría clínica y radiológica, y de esta manera dis-minuye la morbimortalidad. (AU)

Introduction: exogenous lipoid pneumonia is a rare inflammatory lung disease, trigge-red by inhalation or aspiration of fatty material of animal, vegetable or mineral origin. The diagnosis is established through histological confirmation by the presence of lipid-laden macrophages in respiratory samples, associated with the specific clinical charac-teristics at the time of presentation. It requires a high level of suspicion and an adequate anamnesis of the patient's expo-sure history, since many cases are underdiagnosed and treated as community-acquired pneumonia, what delays its diagnosis and management, added to the absence of avai-lable guidelines for its treatment. Few cases of tuberculosis superinfection have been reported in patients with exoge-nous lipoid pneumonia.Clinical case: 33-year-old female, with a history of chronic exposure to oily disinfectant substances without airway protection, with symptoms of cough and chest pain.Conclusion: early diagnosis, associated with supportive treatment, generally conser-vative, favors clinical and radiological improvement, thus reducing morbidity and mor-tality. (AU)

Prolonged jaundice attributed to super infection of hepatitis E virus in a case of resolving leptospirosis.

India is endemic for both Leptospira and hepatitis E virus (HEV). The clinical presentations of these diseases have overlapping features. We report a case of superinfection of HEV in a patient with resolving leptospirosis with underlying Hodgkin lymphoma. The diagnosis of HEV in our case was established by HEV-RNA PCR as our patient was immunosuppressed. The present study highlights the need for molecular diagnosis in the case of HEV infection with strong clinical suspicion and negative serological results.

Infección por Strongyloides stercoralis: estudio epidemiológico, clínico, diagnóstico y terapéutico en 30 pacientes / Infection due to Strongyloides stercoralis: epidemiological, clinical, diagnosis findings and outcome in 30 patients

Background: Strongyloides stercoralis is a nematode parasite, which is endemic in tropical and subtropical regions. Infection usually remains asymptomatic, but in immunocompromised hosts severe and life-threatening manifestations such as hyperinfection syndrome and disseminated disease might occur. Methods: We retrospectively analyzed the epidemiological and clinical characteristics, including HIV co-infection, microbiological findings, and outcome in 30 patients with strongyloidiasis, who attended in the Infectious Diseases F. J. Muñiz Hospital in Buenos Aires from January 2004 to December 2008. Results: The study included 20 men and 10 women with an average age of 33 years. HIV co-infection was present in 21 patients (70 percent) with a median CD4 T cell count of 50 cells/mm³ (range 7-355) (average 56 cells/mm³). Among HIV negative patients the following comorbidities were detected: tuberculosis (n = 3) and chronic alcoholism, leprosy treated with corticosteroids, immunosuppressive treatment for psoriasis, and diabetes mellitus (each in one patient). Two patients did not have any predisposing diseases or immunosuppressive treatments. Seventeen patients presented with diarrhea and were classified as chronic intestinal strongyloidiasis (57 percent), asymptomatic infection with peripheral eosinophilia was diagnosed in 7 (23 percent), and 6 patients (20 percent) developed hyperinfection syndrome. Seventeen patients (57 percent) presented peripheral eosinophilia. Diagnosis was achieved by direct visualization of larvae in feces by Baermann technique (n = 20), by multiple stool smears examinations (n = 2), by combination of both (n = 1), by visualization of the filariform larvae in duodenal fluid and stool (n = 1), and in fecal and bronchoalveolar lavage specimens (n = 6). Overall mortality in this series was 20 percent (6/30). There was no significant correlation between age and mortality. A significant inverse correlation between the survival rate and CD4 T-cell count as well as eosinophilia was observed. There was also a significant correlation between HIV co-infection and mortality. Twenty-two patients responded favorably to treatment with ivermectin.

Antecedentes: Strongyloides stercoralis, parásito endémico de áreas tropicales y subtropicales del planeta, en sujetos inmunodeprimidos puede cursar con formas graves y aun mortales como el síndrome de hiperinfestación y la enfermedad diseminada. Métodos: Análisis retrospectivo de las características epidemiológicas, manifestaciones clínicas, co-infección por virus de inmunodeficiencia humana (VIH), hallazgos microbiológicos y evolución de 30 pacientes con estrongiloidiasis, atendidos en el Hospital de Enfermedades Infecciosas F. J. Muñiz de Buenos Aires, entre enero 2004 y diciembre 2008. Resultados: Se incluyeron en la evaluación 20 hombres y 10 mujeres con una mediana de edad de 33 años. Co-infección por VIH hubo en 21 pacientes (70 por ciento); la mediana de linfocitos T CD4+ en ellos al momento del diagnóstico de la parasitosis fue de 50 céls/mm³ (rango 7 a 355), (media de 56 céls/mm³). En los pacientes seronegativos para VIH, se comprobaron las siguientes co-morbilidades: tuberculosis (n: 3) y un caso de cada una de las siguientes afecciones: alcoholismo crónico, diabetes mellitus, reacción lepromatosa bajo corticotera-pia, y psoriasis en tratamiento inmunosupresor. Hubo dos pacientes sin aparentes enfermedades de base. Diecisiete pacientes presentaron enfermedad intestinal crónica con diarrea (57 por ciento), era asintomática y fue sospechada por la eosinofilia periférica (n: 7, 23 por ciento) y se clasificó como síndrome de hiperinfestación (n: 6, 20 por ciento) diagnosticado por la identificación de larvas en la materia fecal y secreciones broncopulmonares. Diecisiete pacientes (57 por ciento) presentaron eosinofilia periférica. El diagnóstico se efectuó por la visualización directa de las larvas en muestras de heces en fresco mediante la técnica de concentración de Baer-man (n: 20); por el examen copro-parasitológico seriado (n: 2) y por ambos métodos (n: 1); en líquido duodenal y materia fecal (n: 1) y por la identificación de larvas en materia fecal y secreciones respiratorias (n: 6). Letalidad global: 20 por ciento (6/30). Los pacientes con eosinofilia tuvieron una menor letalidad que aquellos sin esta respuesta (p < 0,001). No hubo correlación estadística entre la edad y la supervivencia. Sí fue significativa la correlación entre el recuento de CD4 y la letalidad, incluyendo 18 de los 21 pacientes seropositivos para VIH (p: 0,03). Finalmente, la correlación seropositividad para VIH y letalidad también fue significativa. Veintidós pacientes respondieron a la terapia antiparasitaria con ivermectina y evolucionaron favorablemente.

Fatal Strongyloides stercoralis hyper-infection in a patient with multiple myeloma

Strongyloides stercoralis (S.S.) is a human intestinal parasite, which may lead to complicated strongyloidiasis. We report a case of disseminated strongyloidiasis following the treatment of myeloma. The patient developed skin lesions, respiratory distress, aseptic meningitis and bacterial and fungal sepsis. The diagnosis of strongyloidiasis was established through endotracheal tube secretions. Despite the treatment with Ivermectin and Albendazole, the outcome was fatal. The value of screening for strongyloidiasis is unclear but may be of benefit in patients with hematological malignancies from high endemic areas.

Staphylococcus warneri meningitis in a patient with Strongyloides stercoralis hyperinfection and lymphoma: first report of a case / Staphylococcus warneri meningite em paciente com hiperinfecção com Strongyloides stercoralis e linfoma: primeiro relato de caso

A case of meningitis due to Staphylococcus warneri in a patient with a hyperinfection with Strongyloides stercoralis possibly associated with rituximab treatment for mantel cell lymphoma is reported for the first time in the literature. The patient was a 59-year-old woman, with a 3-year history of an apparently well controlled lymphoma after treatment with chemotherapy-immunotherapy and then immunotherapy alone, and diagnosis of strongyloidiasis. Meningitis was diagnosed by cerebrospinal fluid culture and tested with an automated plate system. The patient was successfully treated with vancomycin; although fever and productive cough persisted. Severe gastrointestinal symptoms and pneumonia developed three weeks later. Hyperinfection syndrome by S. stercoralis was diagnosed, with abundant larvae in feces and expectoration.

Caso de meningite por Staphylococcus warneri em paciente com hiperinfecção com Strongyloides stercoralis, possivelmente associada com tratamento de rituximab para linfoma de células do manto é relatada pela primeira vez na literatura. A paciente, mulher de 59 anos com história de três anos de linfoma aparentemente bem controlado com tratamento com quimioterapia-imunoterapia e, em seguida, somente imunoterapia e diagnóstico de estrongiloidíase. Meningite foi diagnosticada por cultura do líquido cefalorraquidiano e testada com sistema automatizado de placa. A paciente foi tratada com sucesso com vancomicina, embora a febre e a tosse produtiva não tenham desaparecido. Após graves sintomas gastrointestinais a paciente desenvolveu pneumonia três semanas mais tarde. Síndrome de hiperinfecção por S. stercoralis foi diagnosticada, com larvas abundantes nas fezes e expectoração.

Hepatitis E virus is responsible for decompensation of chronic liver disease in an endemic region.

BACKGROUND: Hepatitis A virus infection in patients with previously stable chronic liver disease is associated with liver decompensation. Whether infection with hepatitis E virus (HEV) also does so is not known. METHODS: We studied 32 patients with decompensated liver disease and definite evidence of underlying cirrhosis for evidence of recent HEV infection. RESULTS: Of 32 patients, 14 (44%) had detectable IgM anti-HEV in their serum. In comparison, only 3 of 48 (6%) patients with stable cirrhosis and no recent decompensation had such antibodies (p<0.0001). Of the 14 patients with evidence of recent HEV infection, 11 had history of prodrome. The etiology of cirrhosis in these patients was: hepatitis B 6, hepatitis C 2, both hepatitis B and C 2, Wilson's disease 1, autoimmune 1 and cryptogenic 2. Two of these 14 patients died. Twelve patients survived, as compared to 9 of 18 patients without evidence of recent HEV infection (p<0.01). CONCLUSION: HEV infection is a frequent cause of decompensation in patients with liver cirrhosis in HEV-endemic regions.

Ecological aspects of antimicrobial susceptibility of anaerobic bacteria in Nicaragua

El objetivo de este estudio fue conocer el perfil de sensibilidad de bacterias anaerobias aisladas de la microflora intestinal de niños sanos no tratados con antimicrobiana desde su nacimiento o al cumplir 1,3, 6, 12, y 24 meses de edad y de niños tratados conlos antimicrobianos comúnmente usados en Nicaragua yde las mismas edades. 947 cepas de Bacteroides y 745cepas de Clostridium fueron aisladas de 67 niños sanos y 94 niños tratados con antimicrobianas. Las concentraciones mínimas inhibitorias de ampicilina, cefoxitina, imipenem, clindamicina, metronidazol y cloranfenicol fueron determinadas por el método de dilución en agar. La producción de batalactamasas, se determinó mediante el análisis con nitrocefina. No se encontraron bacterias resistentes a imipenem, clindamicina, metronidazol y cloranfenicol. Las especies de bacteroides aisladas de los niños tratadas con antimicrobianos mostraron un progresivo descenso de la sensibilidad a ampicilina y cefoxitina valores del 88 porciento a 78 porciento y 94 porciento a 81 porciento desde el primer mes hasta los 24 meses de edad. Todas la cepas de bacteroides aísladas de los niños sanos<- doce meses de edad fueron 100 porciento sensibles a cefoxitina y 92 porciento sensibles en los mayores de edad. las sensibilidad de bacteroides para ampicilina fue desde el 91 porciento al mes de edad hasta el 86 porciento a los 24 meses de edad. Todas las cepas de clostridium fueron sensibles a cefoxitina y ampicilina. La producción de betalactamasas fue positiva solamente en cepas de bacteroides. Los resultados de este estudio indican que es necesario un uso racional de los antimicrobianos para evitar el desarrollo de resistencias en las bacterias anaerobías

Enlarging pulmonary histoplasmoma associated with pulmonary tuberculosis.

Histoplasmosis is not a frequently reported infection from India. Similarity of its clinical and radiological features with pulmonary tuberculosis, may cause a difficult diagnostic dilemma when the two occur together. We report a case who initially presented with cavitary lesions over right lung responding well to anti tuberculosis chemotherapy but subsequently a small opacity present over the left upper zone showed a relentless increase till it attained a massive size few years later. Operative removal and histopathological examination of the mass confirmed it to be histoplasmoma. She became sputum AFB smear positive and culture negative for a short while during this period and this is explained on the basis of previous reports.