Insuficiencia respiratoria hipoxémica grave por Pneumocystis jirovecii después de trasplante renal / Severe hypoxemic respiratory failure caused by Pneumocystis jirovecii in a late kidney transplant recipient

Resumen La neumonitis por Pneumocystis jirovecii es una infección infrecuente en pacientes con trasplante de riñón, que se presenta de forma aguda y puede progresar rápidamente hasta la insuficiencia respiratoria y la muerte. El período de mayor riesgo es el de los primeros seis meses después del trasplante, y se asocia con las altas dosis de medicamentos inmunosupresores que reciben los pacientes. La condición también puede presentarse de manera tardía, asociada con la suspensión de la profilaxis con trimetoprim-sulfametoxazol. Se reportan dos casos de pacientes con trasplante renal que presentaron insuficiencia respiratoria hipoxémica grave por P. jirovecii pasados seis años del trasplante, y que fueron tratados con trimetoprim-sulfametoxazol y esteroides. Uno de los pacientes murió y el otro se recuperó sin que hubiera efectos en la función del injerto renal.

Abstract Pneumonia caused by Pneumocystis jirovecii is an uncommon infection in kidney transplant patients that can have an acute and rapid progression to respiratory failure and death. The period of greatest risk occurs in the first six months after the transplant, and it relates to the high doses of immunosuppression drugs required by patients. However, it may occur late, associated with the suspension of prophylaxis with trimethoprim-sulfamethoxazole. We present two cases of renal transplant patients who had severe hypoxemic respiratory failure due to P. jirovecii six years after transplantation. In addition to steroids, they received treatment with trimethoprim-sulfamethoxazole. One patient died, while the other had clinical recovery, with preservation of the renal graft function.

Toxoplasmosis diseminada en un paciente con trasplante de corazón a pesar de la profilaxis con trimetoprim-sulfametoxazol / Disseminated toxoplasmosis in a heart transplant patient despite cotrimoxazole prophylaxis: A case report

Resumen Se reporta el caso de un paciente de sexo masculino, de 61 años de edad, quien ocho meses después de someterse a un trasplante de corazón presentó una enfermedad sistémica con compromiso del sistema nervioso central y del sistema inmunológico, así como de pulmón, riñón, colon y piel, y a quien finalmente se le diagnosticó toxoplasmosis diseminada, a pesar de haber recibido profilaxis con trimetoprim-sulfametoxazol, debido a que el órgano provenía de un donante positivo para toxoplasmosis siendo él un receptor negativo. Se discuten las opciones de profilaxis en nuestro medio.

Abstract We report the case of a 61 year-old male who underwent heart transplantation eight months before developing a systemic condition with central nervous system, lung, kidney, colonic, cutaneous, and hematologic involvement, found to be secondary to a systemic toxoplasmosis despite co-trimoxazole prophylaxis in a previous-to-transplant seronegative patient receiving a heart from a seropositive donor. A review of prophylactic options in our environment is discussed.

Administração de medicamentos para crianças nascidas expostas ao vírus da imunodeficiência humana / Administration of medications for children born exposed to human immune deficiency virus

OBJETIVO: Avaliar a capacidade de mães com HIV/Aids de administrar a zidovudina e a profilaxia com sulfametoxazol-trimetoprima aos filhos nascidos expostos ao HIV. MÉTODOS: Estudo transversal e quantitativo, realizado em hospital de referência no atendimento a casos de HIV/Aids em Fortaleza (CE), Brasil. Utilizou-se a Escala de Avaliação da Capacidade para Cuidar de Crianças Expostas ao HIV, que foi respondida por 60 mães. RESULTADOS: O nível de capacidade de administrar a zidovudina variou de moderado a alto, sem diferenças significantes em relação às variáveis maternas (p>0,05). Em relação à administração do sulfametoxazol-trimetoprima, o nível de capacidade variou entre baixo, moderado e alto. A variável materna "paridade" apresentou relação com o nível de cuidado alto (p=0,051). CONCLUSÃO: O nível de capacidade das mães para administrar o AZT xarope (Fator I) variou de moderado a alto e para administrar e SMZ-TMP (Fator IV), o nível de capacidade de administração distribuiu-se sem diferença entre baixo, moderado e alto.

OBJECTIVE: To evaluate HIV-positive mothers' ability to administer zidovudine and trimethoprim-sulfamethoxazole (SMZ/TMP) prophylaxis for HIV-exposed infants. METHODS: This cross-sectional and quantitative study was carried out at a reference hospital for HIV/AIDS patients in Fortaleza (CE), Brazil. A total of 60 mothers responded to the ability assessment scale for the care of HIV-exposed children. RESULTS: The level of ability to administer zidovudine varied from moderate to high. Maternal variables did not show significant differences (p>0.05). TMP/SMZ administration varied from low, moderate, and high. The variable "parity" was related to a high level of care (p=0.051). CONCLUSION: The level of ability of mothers to administer AZT syrup (factor I) varied from moderate to high; with SMZ-TMP administration (factor IV), no difference among low, moderate, and high was seen.

Falla de la profilaxis con cotrimoxazol para la neumonía por Pneumocystis jiroveci con el uso concomitante de leucovorina: Reporte de un caso / Failure of cotrimoxazole prophylaxis for Pneumocystis jiroveci pneumonia with concomitant use of leucovorin: Case report

The concomitant use of leucovorin and cotrimoxazole in PCP can lead to therapeutic failure and increased risk of death due to antagonism. It is important to keep this possible antagonistic interaction in mind even during prophylaxis. This paper presents a case with this failure outcome.

Profilaxis de neumonía por Pneumocystis jiroveci en niños y adultos sometidos a trasplante de órganos sólidos y de precursores hematopoyéticos / Prophylaxis against Pneumocystis pneumonia in pediatric and adult patients undergoing solid organ or hematopoietic stem cells transplantation

Pneumocystis jiroveci is an important pathogen in patients undergoing SOT and HSCT. Universal prophylaxis is recommended for all adults and children with SOT and HSCT, considering that its use significantly reduces the occurrence and mortality associated with pneumonia by this agent. The drug of choice is cotrimoxazole (A1) three times a week, low-dose scheme, that has proved equally effective and better tolerated than the daily regimen and/or at high doses. Prophylaxis starts 7 to 14 days post transplant in SOT recipients and post-implant in HSCT, with an average duration of 6 months except in liver and lung transplant as in HSCT with significant degree of immunosuppression, that lasts for 1 year. Alternatives for prophylaxis are dapsone (B2), aerosolized pentamidine (B2) and atovaquone (C2).

Pneumocystis jiroveci es un patógeno importante en pacientes sometidos a TOS y TPH. Se recomienda proilaxis universal a todos los pacientes adultos y niños sometidos a TOS o TPH porque su uso reduce signiicati-vamente la ocurrencia y mortalidad asociada a neumonía por este agente. El medicamento de elección es cotrimoxa-zol (A1) tres veces por semana, en dosis bajas, esquema que ha demostrado igual eicacia y mejor tolerancia que el esquema diario y/o con dosis altas. La proilaxis se inicia 7 a 14 días post trasplante en TOS y posterior al implante en TPH, con una duración promedio de 6 meses salvo en trasplante de hígado y pulmón en que se prolonga por 1 año, al igual que en TPH con grado importante de inmunosupresión. Son alternativas de profilaxis dapsona (B2), pentamidina aerosolizada (B2) y atavacuona (C2).

Concurrent mycetoma and chromomycosis.

Chromoblastomycosis and Madura foot are chronic localised mycotic infection of the skin and subcutaneous tissue that follows the implantation of the fungi through minor trauma, mainly found in persons working outdoors on bare foot. In cases where both Madura and chromoblastomycosis are present, the treatment becomes difficult with low cure rates and frequent relapses. Here, we present such a very rare case of a 38-year-old cattle farmer who presented with verrucose nodules, tumefaction and multiple discharging nodules on the left lower 1/3 rd leg and foot since last 9 years. Direct KOH mount of the verrucose tissue showed Fonsecaea pedrosoi sclerotic muriform bodies and a biopsy of one granule discharging nodule demonstrated fungal mycetoma. He was put on tab. Itraconazole 200 mg o.d. and cotrimoxazole bid for 6 months with very little improvement. The rarity of this combination is most probably due to different geographical distribution.

Nocardiosis linfocutánea por Nocardia brasiliensis / Lymphocutaneous nocardiosis due to Nocardia brasiliensis

La nocardiosis linfocutánea es una de las formas clínicas de nocardiosis cutánea, producida en la mayoría de los casos por Nocardia brasiliensis. Puede ser difícil de diagnosticar sin una alta sospecha clínica, debido a su semejanza con otras enfermedades que pueden presentarse con patrones linfocutáneos. Los pacientes con nocardiosis cutánea tienen a menudo una historia previa de traumatismo cutáneo, ya sea herida punzante, picadura de insecto o abrasiones contaminadas. Se comunica un caso de nocardiosis linfocutánea primaria en una paciente inmunocompetente, de 33años.

Nocardiosis cutánea y sus formas clínicas / Cutaneous nocardiosis and its various presentations

La nocardiosis cutánea es una dermatosis infecciosa poco frecuente, que puede presentarse tanto en individuos inmunocompetentes como en inmunocomprometidos. A continuación se describen tres pacientes de sexo masculino inmunosuprimidos, en tratamiento con corticoesteroides, que presentaron diferentes formas clínicas de nocardiosis cutánea.

Cutaneous nocardiosis is a rare opportunistic infection found in bothimmunocompromised and immunocompetent patients. We describe three male immunocompromised patients who exhibited diff erent clinical forms of cutaneous nocardiosis. All of them were under corticosteroid regimen.

Infección por Staphylococcus aureus meticilino-resistente comunitario en un grupo familiar / Community meticiline resistant Staphylococcus aureus skin infection in a family setting

Staphylococcus aureus es un patógeno que causa infecciones de diversa gravedad en niños y adultos. Su frecuencia es alta (28,4 casos por cada 100.000 personas). En los últimos años reemerge como patógeno de infecciones severas de piel y partes blandas en pacientes de la comunidad, con características feno y genotípicas diferentes; se lo denomina Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMRAC). En nuestro país constituye un patógeno emergente subdiagnosticado. Se presenta una familia que durante 1 año consultó por múltiples episodios de infecciones cutáneas recidivantes, tratadas con esquemas antibióticos empíricos, sin aislamiento microbiológico y fracaso terapéutico. Se observaron nódulos eritematosos, algunos con centro necrótico y ulcerados, en diversas localizaciones. El cultivo de las lesiones de los 3 pacientes confirmó el diagnóstico de SAMRAC. Los hisopados nasales fueron negativos. Realizaron tratamiento con trimetoprima-sulfametoxazol 800/160 mg cada 12 hs y clindamicina 300 mg cada 6hs por 14 días, con curación total de las lesiones

Staphylococcus aureus is a pathogen responsible for infections of variableseverity both in children and adults. Its prevalence is high (about28.4 cases per 100.000 persons). Nowadays this pathogen cause severeskin and soft tissue infections in the community setting. Neverthelessits features are different and has been denominated communityacquired meticiline resistant S. aureus (CA-SAMR). In our countrythis pathogen is under diagnosed.We describe a family with multiple episodes of recidivate skin infectionswhich were treated empirically and without success. The clinical featurewas the presence of eritemathous nodules, some of them ulcerated andnecrotic, in diff erent sites. CA-SAMR was isolated in all patients. Nasalsamples were negative in all family members. They were treated with trimetoprimsulfamethoxazol 800/160 mg each 12 hours and clindamicine300 each 6 hours for 14 days with complete cure of the lesions. (DermatolArgent 2010;16(2):126-128).

A modified two-step treatment for actinomycetoma.

BACKGROUND: Combination antibiotic regimens are effective in the treatment of actinomycetoma but many treatment schedules require supervised parenteral therapy for prolonged periods. We describe a schedule that includes parenteral medication in an initial, short phase followed by a longer phase of oral medication. METHODS: Sixteen patients with clinically diagnosed mycetoma, who did not show any evidence of a fungal etiology, were treated presumptively for actinomycetoma. Evidence of actinomycotic infection was found on microscopy of granules / discharge and / or histopathological examination in eight (50%) patients. The treatment consisted of an intensive phase (Step 1) with gentamicin, 80 mg twice daily, intravenously and cotrimoxazole, 320/1600 mg twice daily orally for four weeks. This was followed by a maintenance phase with cotrimoxazole and doxycycline, 100 mg twice daily till all sinuses healed completely. The treatment was continued for 5-6 months. RESULTS: Treatment response was assessed monthly. At the end of the intensive phase, there was a significant improvement in all 16 patients. Nine patients who continued the maintenance phase of the regimen had complete healing of sinuses with marked reductions in swelling and induration in 2.4 +/- 1.7 months. Maintenance treatment was continued for a mean of 9.1 +/- 4.3 months in these patients. Six patients have remained free of disease activity during a follow-up period of 11.1 +/- 4.2 months after treatment was stopped. Two patients developed leucopenia and thrombocytopenia necessitating withdrawal of cotrimoxazole. CONCLUSION: This regimen was effective in treating actinomycetoma. The short duration of the phase requiring parenteral therapy makes it convenient to administer.

Clinical guideline for diagnosis and management of melioidosis

Melioidose é uma infecção emergente no Brasil e em países vizinhos da América do Sul. O amplo espectro de apresentação clínica inclui pneumonia adquirida na comunidade, septicemia, infecção do sistema nervoso central e infecção de partes moles de menor severidade. O diagnóstico depende essencialmente da identificação microbiológica. Burkholderia pseudomallei, a causa bacteriana da melioidose, é facilmente cultivada em sangue, escarro e em outras amostras clínicas. Entretanto, B. pseudomallei pode ser difícil de identificar com segurança e também ser confundido com outras bactérias Gram negativas. Os exames sorológicos podem dar suporte a um diagnóstico de melioidose, mas não fornece um diagnóstico definitivo por si só. A realização de investigação laboratorial seqüenciada pode ajudar a reduzir o risco de não reconhecer isolados incomuns de B. pseudomallei. O tratamento antibiótico recomendado para infecção severa é Ceftazidima ou Meropenem endovenosos por várias semanas, seguido por um tratamento oral com uma combinação de Sulfametoxazol-Trimetopim e Doxiciclina por até 20 semanas. O uso consistente do diagnóstico microbiológico e o tratamento rigoroso da infecção severa com antibióticos adequados nas duas etapas, aguda e de erradicação, contribuirão para a redução da mortalidade por melioidose.

Antibiotics in older adults

Antibiotics are frequently prescribed in the older person, the dosification needs special care, since the pharmacokinetic parameters changes with aging and the side effects can be different in the older person. The creatinine clearance changes and we must modify the way we prescribe such antibiotics to the elderly, calculating. The variety of antibiotics now available led us to consider this paper in which we have presented the antimicrobial agents that can be considered in the treatment of the older person. We present several groups: the penicillins, cephalosporins, monobactams, carbapenems and betalactamase inhibitors or the great betalactam group. Other trimetroprin-sulfame-thoxazole, the newer macrolides (azithromycin and clarithromycin) as well as the aminoglycosides, vancomycin, clindamycin, metroridazole. The indications and contraindications are presented and reviewed.

Infecciones del tracto urinario: microbiología y resistencia antibiótica / Urinary tract infections: microbiology and antibiotic resistance

Las infecciones del tracto urinario son la principal causa de morbilidad actualmente, por lo cual a su vez implican el mayor gasto en salud en personas de todas las edades. Nuestro estudio comprendió urocultilvos realizados en la clínica de Atenas del 5-8-02 al 17-12-03, de los cuales; un 78.43 por ciento fueron positivos para E. coli relegando a los demás agentes a una minoría, además la mayoría de las cepas de E. coli son resistentes al Trimetoprim sulfametoxazole (TMP SMX) que es actualmente el medicamento más utilizado. Como segundo agente causal más frecuente encontramos a Kliebsiella sp.

A randomized, pilot trial comparing full versus escalating dose regimens for the desensitization of AIDS patients allergic to sulfonamides

Sulfonamides are drugs extensively used in the management of AIDS patients. However, the use of sulfonamides is often associated with the development of allergic reactions, provoking the substitution of the drug (by another that may be less effective); alternatively attempts are made to desensitize the patient. OBJECTIVE: Compare two drug regimens (full vs. escalating doses) for the oral desensitization of AIDS patients allergic to sulfonamides. MATERIAL AND METHODS: AIDS patients with previous allergic reactions to sulfonamides and requiring prophylaxis against Pneumocistis carinii, central nervous system toxoplasmosis and diarrhea caused by Isospora belli were randomly assigned to a group receiving a routine dose of cothrimoxazole, or another that received escalating doses of an oral suspension of the same drug, initiating with 75mg/day of sulfamethoxazole that was doubled every 48 hours till the full dose was reached, if no allergic reaction occurred. Patients were monitored for at least 6 months after enrollment in the trial. The major end-point was the ability to maintain prophylactic treatment after that period of time. Plasma viral load (PVL) and CD4/CD8 counts were measured at baseline. Liver enzymes and hematological parameters were measured at baseline and after 1, 3 and 6 months. RESULTS: Eighteen patients were enrolled in the study (15 men and 3 women), with ages ranging from 30 to 57 years (mean 39.9). The mean CD4 counts were slightly higher for patients receiving a full dose; there was also a trend towards higher baseline CD8 counts among patients developing new reactions. The mean PVL was similar among the patients in both desensitization groups. The incidence of new allergic reactions was identical (40 percent) in the two groups. All adverse reactions were mild and no significant increase in liver enzymes were observed. CONCLUSON: Dose regimen is not a predictor of the development of new allergic reactions amongst patients challenged with sulfonamides after an initial allergic reaction.