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.

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.

Pulmonary aspergilloma: A case report

@#Chronic pulmonary aspergillosis (CPA) is a rare disease. It is usually diagnosed in immunocompromised patients with other chronic respiratory disorders. Diagnosis can be challenging due to non-specific symptoms. It is based on clinical, radiological, and microbiological criteria and excludes other causes of the symptoms. The outcomes of antifungal treatment may be unpredictable as optimal treatment duration has not yet been standardized. This is the case of a 74-year-old male who presented via teleconsultation with hemoptysis. GeneXpert for pulmonary tuberculosis was negative. Chest radiograph showed a cavitary lesion with an aspergilloma within. This led to a longstanding treatment effort with voriconazole, as he was a poor candidate for surgical resection due to the risk of post-operative complications. Three months into the treatment, the patient unexpectedly suffered from a severe episode of dyspnea, culminating in cardiac arrest. While the patient has been resuscitated with no residuals, it is only one of the many steps on his road to recovery and his second lease on life, this time coming to terms with his own preferences and values regarding his medical care. The patient showed clinical improvement and the promise of a cure in his fifth month of treatment. Learning points include the role of family physicians in a patient’s well-being even in specialized cases, the value of individualized care and the application of technology in hybrid consultation and monitoring.

A case of pulmonary aspergillus infection in underground coal mine workers / 中华劳动卫生职业病杂志

The underground environment is dark and humid, and it is easy to breed pathogenic microorganisms. A lump in the right lung of a coal mine underground transport worker was found druing occupational health examination. CT examination showed that the lump was located in the posterior segment of the upper lobe of the right lung, with point strip calcification, liquefaction necrosis, and proximal bronchial stenosis and occlusion. MRI examination FS-T(2)WI and DWI showed "target sign", annular low signal around the central high signal, and low mixed signal around the periphery, and annular high signal in the isosignal lesions on T(1)WI. Then the pulmonary aspergillus infection was confirmed by pathology.

Aspectos clínicos asociados al diagnóstico y tratamiento de la aspergilosis laríngea en pacientes inmunocompetentes / Clinical aspects associated with the diagnosis and treatment of laryngeal aspergillosis in immunocompetent patients

INTRODUCCIÓN. La aspergilosis laríngea en individuos inmunocompetentes, aunque rara, se reporta cada vez con más frecuencia; por lo cual, es necesario comprender mejor los aspectos clínicos y terapéuticos más adecuados para abordar su atención. OBJETIVO. Documentar los aspectos clínicos asociados al diagnóstico y el tratamiento de la aspergilosis laríngea en sujetos inmunocompetentes. METODOLOGÍA. Se realizó un estudio Bibliográfico Narrativo de carácter retrospectivo, donde se evaluaron los casos clínicos reportados de personas inmunocompetentes con aspergilosis laríngea desde el año 1983 hasta el 2022. Se hizo una revisión bibliográfica en las bases de datos PubMed/Medline y ScienceDirect, y se incluyeron todos los casos reportados en sujetos inmunocompetentes. RESULTADOS. Se identificaron 30 casos clínicos que cumplieron con los criterios de inclusión dentro de un grupo de 586 artículos revisados. El patógeno más reportado fue Aspergillus fumigatus y la evaluación histopatológica la principal herramienta para diagnosticar la aspergilosis. Se reportaron más casos en mujeres con un 58%. La mayor incidencia se observó en sujetos entre 20 y 49 años de edad. Los síntomas más comunes fueron disfonía, disnea y tos. El tratamiento farmacológico empleado actualmente es el Itraconazol seguido por el Voriconazol. CONCLUSIONES. La evidencia reportada mostró que la aspergilosis laríngea en pacientes inmunocompetentes podría estar dejando de ser un evento "poco común" por lo que debe prestarse más atención a su diagnóstico y tratamiento.

INTRODUCTION. Laryngeal aspergillosis in immunocompetent individuals, although rare, is reported with increasing frequency; therefore, it is necessary to better understand the most appropriate clinical and therapeutic aspects to address its care. OBJECTIVE. To document the clinical aspects associated with the diagnosis and treatment of laryngeal aspergillosis in immunocompetent subjects. METHODOLOGY. A retrospective Narrative Bibliographic study was performed, where clinical case reports of immunocompetent subjects with laryngeal aspergillosis from 1983 to 2022 were evaluated. A literature review was performed in PubMed/Medline and ScienceDirect databases, and all reported cases in immunocompetent subjects were included. RESULTS. Thirty clinical cases that met the inclusion criteria were identified from a pool of 586 articles reviewed. The most reported pathogen was Aspergillus fumigatus and histopathologic evaluation the main tool for diagnosing aspergillosis. More cases were reported in women with 58%. The highest incidence was observed in subjects between 20 and 49 years of age. The most common symptoms were dysphonia, dyspnea and cough. The pharmacological treatment currently used is Itraconazole followed by Voriconazole. CONCLUSIONS. The evidence reported showed that laryngeal aspergillosis in immunocompetent patients may no longer be a "rare" event and more attention should be paid to its diagnosis and treatment.

Evaluación de la prueba Aspergillus Galactomannan Ag VircliaR Monotest como alternativa a kit Platelia ™ Aspergillus EIA / Evaluation of the Aspergillus Galactomannan ag VircliaR Monotest test as an alternative to Platelia™ Aspergillus EIA kit

INTRODUCCIÓN: La prueba Aspergillus galactomannan Ag Virclia® (GM-VClia) es una técnica de galactomanano monotest, auto-matizada, basada en inmunoensayo quimioluminiscente (CLIA). OBJETIVO: Evaluar el desempeño del test de GM-VClia en muestras de suero y lavado bronquioalveolar (LBA) procesadas previamente con el kit Platelia™ Aspergillus EIA (GM-Plat). MATERIALES Y MÉTODOS: Se estudiaron 56 muestras de suero y 40 de LBA, correspondientes a un total de 59 pacientes (algunos con determinación de galactomamano en ambas muestras) con enfermedades pulmonares, hematológicas, LES, Covid-19 y tumores, entre otros. Trece pacientes tuvieron aspergilosis invasora (1 probada y 12 probables). RESULTADOS: La correlación entre ambos métodos para suero y LBA fue r = 0,8861 p < 0,0001 y r = 0,6368 p < 0,001, respectivamente. Hubo una concordancia global de 67,7% (65/96), siendo de 85,7% (48/56) en sueros y 42,5,0% (14/49) en LBA. Al subir el punto de corte en LBA por GM-VClia la concordancia aumentó a 85,7%. CONCLUSIONES: Se observó una mayor correlación y concordancia en sueros que en LBA. El kit GM-VClia presentó una mayor sensibilidad y valor predictor negativo (VPN), que el kit GM-Plat. Las desventajas de GM-VClia, la constituyen la categoría "dudoso", que dificulta la interpretación y que, con los puntos de corte actuales en LBA, la correlación con GM-Plat es menor. Las ventajas son su mayor sensibilidad, facilidad de procesamiento y una mayor rapidez en los resultados.

BACKGROUND: The Aspergillus Galactomannan Ag Virclia® (GMVClia) test is a monotest and automated galactomannan technique based on chemiluminescent immunoassay (CLIA). AIM: To evaluate the performance of the GM-VClia test in serum and bronchioalveolar lavage (BAL) samples previously processed with the Platelia ™ Aspergillus EIA kit (GM-Plat). METHODS: 56 samples of serum 40 from BAL (some of them with galactomaman determination in both samples), from patients with pulmonary diseases, hematological diseases, SLE, Covid-19 and tumors, among others, were studied. Thirteen patients had invasive aspergillosis (1 proven and 12 probable). RESULTS: The correlation between both methods for serum and BAL was r = 0.8861 p < 0.0001 and r = 0.6368 p < 0.001, respectively. There was a global concordance of 67.7% (65/96), being 85.7% (48/56) in sera and 42.5.0% (14/49) in BAL. By raising the cut-off point in LBA by GM-VClia, the agreement increased to 85.7%. CONCLUSION: A greater correlation and concordance was observed in sera than in BAL. The GM-VClia kit had a higher sensitivity and NPV than the GM-Plat kit. The disadvantages of GM-VClia are the "doubtful" category, which makes interpretation difficult and that with the current cut-off points in LBA the correlation with GM-Plat is lower. The advantages are its greater sensitivity, ease of processing and faster results.

Multiparametric assay of screening for the diagnosis of mycoses of interest in Public Health: standardization of methodology / Ensaio multiparamétrico de triagem para diagnóstico de micoses de interesse em Saúde Pública: padronização da metodologia

The standardization and validation of a multiplex assay requires the combination of important parameters such as sensitivity and specificity, acceptable levels of performance, robustness, and reproducibility. We standardized a multiparametric Dot-blot aimed at the serological screening of paracoccidioidomycosis, histoplasmosis, and aspergillosis. A total of 148 serum were evaluated: 10 from healthy subjects, 36 from patients with paracoccidioidomycosis, 62 from patients with histoplasmosis, and 40 from patients with aspergillosis. It was found that the multiparametric Dot-blot showed a high percentage of cross-reactivity. However, when evaluated individually, in the serological screening of histoplasmosis, a good performance was observed when compared to the double immunodiffusion assay, considered the gold standard test, with 100% co-positivity and 83.3% co-negativity. The performance of serological screening for aspergillosis was not satisfactory when compared to double immunodiffusion, showing 71.4% co-positivity and 100% co-negativity. The evaluation of the stability of nitrocellulose membranes showed that membranes sensitized with H. capsulatum antigen remained stable for 90 days and those sensitized with A. fumigatus antigen for 30 days. We conclude that the use of crude antigens was not suitable for the standardization of the multiparametric Dot-blot assay, due to the high cross-reactivity, and that further tests should be performed with purified proteins (AU).

A padronização e validação de um ensaio multiplex requer a combinação de parâmetros importantes, como sensibilidade e especificidade, níveis aceitáveis de desempenho, robustez e reprodutibilidade. Este trabalho padronizou um Dot-blot multiparamétrico visando a triagem sorológica da paracoccidioidomicose, histoplasmose e aspergilose. Foram avaliadas 148 amostras de soro: 10 de indivíduos saudáveis, 36 de pacientes com paracoccidioidomicose, 62 de pacientes com histoplasmose e 40 de pacientes com aspergilose. Verificou-se que o Dot-blot multiparamétrico apresentou elevado percentual de reatividade cruzada. Entretanto, quando avaliado individualmente, na triagem sorológica da histoplasmose observou-se bom desempenho quando comparado ao ensaio de imunodifusão dupla, considerado o teste padrão ouro, com 100% de co-positividade e 83,3% de co-negatividade. O desempenho da triagem sorológica da aspergilose não foi satisfatório quando comparado a imunodifusão dupla, apresentando 71,4% de co-positividade e 100% de co-negatividade. A avaliação da estabilidade das membranas de nitrocelulose mostrou que membranas sensibilizadas com antígeno de H. capsulatum permaneceram estáveis por 90 dias e as sensibilizadas com antígeno de A. fumigatus, por 30 dias. Concluímos que o uso de antígenos brutos não foi adequado para a padronização do ensaio de Dot-blot multiparamétrico, devido ao alto índice de reatividade cruzada, e que novos testes devem ser realizados com proteínas purificadas (AU).

Evaluación de la dosificación de voriconazol intravenoso tres veces al día vs dos veces al día para el tratamiento de aspergilosis invasora en niños inmunocomprometidos: monitorización terapéutica y seguridad / Evaluation dosing intravenous voriconazole three times a day vs twice daily for the treatment of invasive aspergillosis in immunocompromised children: therapeutic drugs monitoring and safety

INTRODUCCIÓN: Voriconazol es el antifúngico de elección para el tratamiento de la aspergilosis invasora (AI). Concentraciones plasmáticas (CPs) > 1 μg/mL se han asociado a mejores resultados terapéuticos, las que no siempre se alcanzan durante el tratamiento en niños inmunocomprometidos. Dada la necesidad de iniciar una terapia precoz y efectiva de la infección, es relevante establecer el régimen de administración de voriconazol que se asocie con CPs óptimas en esta población. OBJETIVO: Comparar las CPs y seguridad de voriconazol intravenoso (IV), dosificado BID y TID en niños inmunocomprometidos con indicación de tratamiento antifúngico. MÉTODO: Estudio observacional retrospectivo de enero de 2015 a julio de 2018 en un hospital pediátrico de alta complejidad de Santiago de Chile, en pacientes de 0 a 17 años que recibieron tratamiento con voriconazol IV. Se excluyeron aquellos con terapia de reemplazo renal, falla hepática y/o falla renal. Se compararon las CPs valles entre un grupo con régimen de dosificación BID y otro grupo con administración TID. Se evaluaron las reacciones adversas en ambos grupos. RESULTADOS: Se obtuvieron 137 CPs valles en 76 niños, con una mediana de edad de 9 años (0-17 años) en el grupo BID y 9 años (0-16 años) en el grupo TID, con una mediana de peso de 27 kg (6-83 kg) y 28 kg (9,3-60 kg), respectivamente. Resultados: Pacientes 1 gg/mL en comparación con la administración BID (p = 0,001). Se reportaron ocho reacciones adversas, principalmente fotofobia, sin encontrarse diferencias significativas entre grupo BID y TID. CONCLUSIÓN: Dosificaciones TID están asociadas a una mayor probabilidad de obtener una adecuada exposición a voriconazol en pacientes < 12 años en comparación a dosificaciones BID, con baja frecuencia de reacciones adversas.

BACKGROUND: Voriconazole is the antifungal of choice for the treatment of invasive aspergillosis (IA). Plasma concentrations (PCs) > 1 μg / mL llave been associated with better therapeutic results which have not always been achieved during treatment in immunocompromised children. In the necessity to initiate early and effective therapy for the infection, it is relevant to establish the voriconazole administration regimen that is associated with optimal PCs in this population. AIM: To compare the PC and safety of intravenous (IV) voriconazole, dosed BID and TID in immunocompromised children with indication of antifungal treatment. METHOD: Retrospective observational study since January 2015 until July 2018 in a highly complex pediatric hospital in Santiago of Chile, in patients aged 0 to 17 years who received treatment with IV voriconazole. Those with renal replacement therapy, liver failure and / or renal failure were excluded. Trough PCs were compared between a group with BID dosing regimen versus another group with TID administration. Adverse reactions were evaluated in both groups. RESULTS: 137 trough PCs were obtained in 76 children, with a median age of 9 years (0-17 years) in the BID group and 9 years (0-16) in the TID group with a median weight of 27 kg (6-83 kg) and 28 kg (9.3-60 kg), respectively. Patients 1 gg/mL compared to BID administration (p = 0.001). Eight adverse reactions were reported, mainly photophobia, with no significant difference found between the BID and TID groups. CONCLUSION: TID dosages are associated with a greater probability of obtaining adequate exposure to voriconazole in patients < 12 years old compared to BID dosages, with a low frequency of adverse reactions.

Corticosteroid therapy associated with COVID-19: an ally or a risk factor for the establishment of secondary fungal co-infections?

Corticosteroid therapy to combat inflammation caused by SARS-CoV-2 seems to be a risk factor for developing secondary fungal co-infections. PubMed and ScienceDirect databases were searched, with the following word groups: [(aspergillosis OR mucormycosis OR candidiasis) AND (coronavirus disease) AND (corticoids). The selected articles present the main risk factors related to the establishment of secondary fungal co-infections in COVID-19 patients. Corticosteroid therapy used to combat inflammation caused by SARS-CoV-2 has been shown to be strongly associated with the establishment of mucormycosis and aspergillosis. Mucormycosis has been the main fungal co-infection related to corticosteroid therapy, causing a high number of deaths in COVID-19 patients. Diabetes mellitus was the most prevalent comorbidity, especially for the establishment of mucormycosis. Dexamethasone use seems to be associated with mucormycosis emergence and death. However, aspergillosis showed a greater relationship with patient recovery. Thus, risk factors such as diabetes mellitus, combined with corticosteroid use, have shown a relationship to the establishment of mucormycosis. The corticosteroids used in COVID-19 patients should be individually analyzed, considering the patient's medical history and the risk/benefit ratio of the use of these drugs.

Monitoreo ambiental de sistemas de aclimatización en edificios residenciales y su relación en las micosis respiratorias / Environmental monitoring of air conditioning systems in residential buildings and their relationship with respiratory mycoses

En todo el mundo, los cambios climáticos y estilo de vida han resultado en un cambio de ambientes de aire libre a ambientes herméticos y energéticamente eficientes en el hogar y en los lugares de trabajo, donde las personas pasan parte sustancial de su tiempo. En esos entornos, el mantenimiento inadecuado de los aparatos de aire acondicionado, el diseño deficiente de edificio o de los hogares, y las actividades de sus ocupantes pueden dar lugar a condiciones de salud precaria, que pueden incluir enfermedades respiratorias. Bajo un estudio descriptivo, de cohorte transversal, se evaluaron 104 residencias familiares tipo apartamento con sistemas de aclimatización tipo Split en las habitaciones de descanso. Se obtuvieron resultados positivos para dermatofitos en 34 de las 104 muestras (33,65%), mientras que los hongos filamentosos y levaduras fueron 27 casos (25,96%). La concentración osciló entre 17 y 227 UFC/m3 y de 9 a 46 UFC/m3 para dermatofitos y para filamentosos y levaduras, respectivamente. Las especies de hongos dermatofitos aislados en el aire fueron Trichophyton rubrum y Trichophyton mentagrophytes, siendo el más frecuente fue el Trichophyton rubrum que apareció en el 73,52% de las muestras positivas, representamdo una frecuencia de ocurrencia de 24,04%; en ninguna de las muestras se observaron colonias mixtas con ambas especies a la vez. En el grupo de los no dermatofitos, el Penicillium spp. se presento en 10,58% de las muestras evaluadas, siendo el hongo mas prevalente de este grupo, con contajes que alcanzaron hasta 46 UFC/m3. Este grupo en los 27 positivos, se evidencio al menos dos especies de hongos y adicionalmente en 14 casos una levadura. Este estudio demostró que el no aplicar las medidas correctivas y sistema de limpieza de los aires acondiconados puede comprometer la salud de sus habitantes, especialmente por problemas respiratorios, por la presencia de hongos(AU)

Throughout the world, climate and lifestyle changes have resulted in a shift from outdoor environments to airtight and energy-efficient environments at home and in workplaces, where people spend a substantial part of their time. In these environments, inadequate maintenance of air conditioners, poor building or home design, and the activities of its occupants can lead to poor health conditions, which may include respiratory diseases. Under a descriptive, cross-sectional cohort study, 104 apartment-type family residences with acclimatization systems in Split-type rest rooms were evaluated. Positive results for dermatophytes were obtained in 34 of the 104 samples (33.65%), while filamentous fungi and yeasts were 27 cases (25.96%). The concentration ranged between 17 and 227 CFU/m3 and from 9 to 46 CFU/m3 for dermatophytes and for filamentous and yeasts, respectively. The species of dermatophyte fungi isolated in the air were Trichophyton rubrum and Trichophyton mentagrophytes, the most frequent being Trichophyton rubrum, which appeared in 73.52% of the positive samples, representing a frequency of occurrence of 24.04%; mixed colonies with both species at the same time were not observed in any of the samples. In the group of non-dermatophytes, Penicillium spp. it was present in 10.58% of the evaluated samples, being the most prevalent fungus of this group, with counts that reached up to 46 CFU/m3. This group in the 27 positives, evidenced at least two species of fungi and additionally in 14 cases a yeast. This study showed that not applying corrective measures and the air conditioning cleaning system can compromise the health of its inhabitants, especially due to respiratory problems, due to the presence of fungi

Gamma-glutamyl transpeptidase-platelet ratio, systemic immune inflammation index, and system inflammation response index in invasive Aspergillosis

SUMMARY OBJECTIVE: Gamma-glutamyl transpeptidase-platelet ratio, system inflammation response index, and systemic immune inflammation index are three systemic immune and inflammation indexes that were investigated for their diagnostic and prognostic proficiencies in cardiovascular diseases and cancers. However, their predictive values for invasive aspergillosis have not yet been studied. The aim of this study was to evaluate Gamma-glutamyl transpeptidase-platelet ratio, system inflammation response index, and systemic immune inflammation index levels and their diagnostic values in invasive aspergillosis. METHODS: A total of 23 patients with invasive aspergillosis and 23 sex- and age-matched healthy participants were included in this study. Complete blood count parameters and liver function tests were studied. Gamma-glutamyl transpeptidase-platelet ratio, system inflammation response index, and systemic immune inflammation index were calculated. RESULTS: Leukocyte, neutrophil, lymphocyte, and monocyte levels were statistically significantly higher in IA group (p=0.031, p=0.027, p=0.033, and p=0.001, respectively). In invasive aspergillosis group, platelets were numerically lower; Aspartate transaminase, alanine aminotransferase, and lactic dehydrogenase levels were numerically higher than those in control group but differences between levels were not statistically significant (p>0.05). The γ-glutamyl transpeptidase levels of patients were statistically significantly higher (p=0.007), and in addition, statistically significant differences were found between groups in terms of gamma-glutamyl transpeptidase-platelet ratio, system inflammation response index, and systemic immune inflammation index (p<0.001, p=0.037, p=0.001, respectively). Receiver operating characteristic analysis was performed, and areas under the curves were evaluated. gamma-glutamyl transpeptidase-platelet ratio had the higher area under the curve than systemic immune inflammation index and system inflammation response index (AUC 0.849, 0.798, 0.693, respectively). The results from receiver operating characteristic analysis of the data suggested that the use of a cutoff value of 0.15 for gamma-glutamyl transpeptidase-platelet ratio would be optimum for clinical use to confirm independent predictors of patients with invasive aspergillosis. CONCLUSIONS: Gamma-glutamyl transpeptidase-platelet ratio is an independent, a useful predictor, and is superior to other evaluated markers in the diagnosis of inflammation in invasive aspergillosis. Gamma-glutamyl transpeptidase-platelet ratio may also be a helpful biomarker for clinicians to follow-up the inflammatory process of these patients.

Enfoque del paciente con cavitación pulmonar / Approach to the patient with lung cavitation / Enfoque do paciente com cavitação pulmonar

Cavitation is a common finding in lung images, secondary to infectious, inflammatory, tumor, and autoimmune conditions, the former being the most common cause in all levels of care and geography. The diagnostic approach must be judicious, integrating the image, with the patient's medical history, personal history, and exposures, as well as the time of evolution of the symptoms; which are key elements for the approach. It is always essential to integrate the clinical findings with the laboratory and the pathology in order to reach an accurate diagnosis and timely treatment, since the isolated image is not enough, given the multiple etiologies described and variety of presentation that make this radiological sign only a premise to the confirmation of an underlying disease.

Una cavitación es un hallazgo común en imágenes pulmonares, secundaria a condiciones infecciosas, inflamatorias, tumorales y autoinmunes, siendo las primeras la causa más común en todos los niveles de atención y geográficos. El abordaje diagnóstico debe ser riguroso, integrando la imagen con la historia clínica del paciente, sus antecedentes personales y exposiciones, así como el tiempo de evolución de los síntomas; estos son elementos clave para el enfoque. Siempre es fundamental integrar los hallazgos clínicos con el laboratorio y la patología para llegar a un diagnóstico preciso y a un tratamiento oportuno, pues la imagen aislada no es suficiente, dadas las múltiples etiologías descritas y la variedad de presentación que hacen de este signo radiológico solo una premisa a la confirmación de una enfermedad subyacente.

Uma cavitação é uma descoberta comum em imagens pulmonares, secundária a condições infecciosas, inflamatórias, tumorais e autoimunes, sendo as primeiras a causa mais comum em todos os níveis de atenção e geográficos. A abordagem diagnóstica deve ser rigorosa, integrando a imagem com a história clínica do paciente, seus antecedentes pessoais e exposições, assim como o tempo de evolução dos sintomas; estes são elementos chave para o enfoque. Sempre é fundamental integrar as descobertas clínicas com o laboratório e a patologia para chegar a um diagnóstico preciso e a um tratamento oportuno, pois a imagem isolada não é suficiente, dadas as múltiplas etiologias descritas e a variedade de apresentação que fazem deste signo radiológico só uma premissa à confirmação de uma doença subjacente.

Traqueobronquitis necrotizante secundaria a aspergilosis invasiva en paciente inmunocompetente / Necrotizing tracheobronchitis due to invasive aspergillosis in an immunocompetent patient

Resumen La traqueobronquitis aspergilar es una forma poco frecuente de aspergilosis invasiva reportada excepcionalmente en el paciente inmunocompetente. Su diagnóstico es difícil, y los tratamientos propuestos hasta ahora son de escasa efectividad, todo lo cual constituye un verdadero problema para el equipo de salud. Presentamos el caso de una paciente de 28 años, inmunocompetente y sin antecedentes epidemiológicos, que desarrolló traqueobronquitis necrotizante por aspergilosis invasiva y recibió tratamiento con voriconazol con instilación local por broncoscopia con buena respuesta.

Abstract Aspergillus tracheobronchitis is a rare form of invasive aspergillosis reported exceptionally in the immunocompetent patient. Its diagnosis is difficult, and the treatments proposed so far are of little effectiveness, all of which constitute a real problem for the health team. We present the case of an immunocompetent 28 yearsold woman, with no epidemiological background, who developed necrotizing tracheobronchitis due to invasive aspergillosis and received voriconazole with local instillation by bronchoscopy with a good response.

Outbreak of avian aspergillosis in colonial-bred chicks (Isa Brown) in southern Rio Grande do Sul - case report / [Surto de aspergilose aviária em pintainhas (Isa Brown) de criação colonial na região sul do Rio Grande do Sul - relato de caso]

In this study we describe the epidemiology, clinical signs, and pathology of an outbreak of avian aspergillosis in alternative breeding in the southern region of Rio Grande do Sul, Brazil. Between the fifth and tenth day of life, 360 chicks from a flock of 4000 developed unspecific clinical signs and died. The birds were housed in a reused aviary litter, without previous treatment. In 11 six-day-old female ISA Brown chicks (Gallus gallus domesticus), necropsy revealed firm, yellowish-white, multinodular lesions extending from the pleura to the lung parenchyma. Histologically, a granulomatous, multifocal to coalescent pneumonia was observed. Granulomas were characterized by central necrosis, with heterophil and epithelioid macrophage infiltration and presence of countless Y-shaped intralesional septate hyphae morphologically compatible with Aspergillus spp. The diagnosis through isolation confirmed Aspergillus fumigatus. We highlight the importance of aspergillosis as a primary cause of diseases in the respiratory tract of young birds in alternative breeding. Measures to prevent aspergillosis mainly regarding the reuse of aviary litter are essential in poultry husbandry to prevent economic losses, reduce environmental contamination and mitigate the potential risk to public health.(AU)

Descrevem-se os aspectos epidemiológicos e patológicos de um surto de aspergilose aviária em criação alternativa na região sul do Rio Grande do Sul, Brasil. De um lote de 4000 pintainhas, entre o quinto e o 10º dia de vida, 360 aves apresentaram sinais clínicos inespecíficos e morreram. As aves foram alojadas em cama reutilizada do aviário, sem tratamento prévio. Na necropsia de 11 pintainhas (Gallus gallus domesticus), fêmeas, seis dias de idade da linhagem Isa Brown, foram observadas no pulmão lesões multinodulares, branco-amareladas e firmes, que se estendiam da pleura ao parênquima. Histologicamente foi observada pneumonia granulomatosa, multifocal a coalescente. Os granulomas eram caracterizados por necrose central, com infiltrado inflamatório de heterófilos, macrófagos, células epitelioides com presença de inúmeras hifas septadas intralesionais, semelhantes à letra "Y", morfologicamente compatíveis com Aspergillus spp. O diagnóstico foi confirmado pelo isolamento de Aspergillus fumigatus. Alerta-se para a importância da aspergilose como causa primária de afecções no trato respiratório de aves jovens em criações alternativas. Medidas preventivas relacionadas ao manejo dessas aves são indispensáveis principalmente quanto à reutilização da cama dos aviários, a fim de evitar perdas econômicas, reduzir a contaminação ambiental e o potencial risco à saúde pública.(AU)

Antifungal susceptibility profile of Aspergillus fumigatus isolates from avian lungs / Perfil de suscetibilidade antifúngica de isolados de Aspergillus fumigatus provenientes de pulmões de aves

Susceptibility testing is essential to inform the correct management of Aspergillus infections. In this study we present antifungal susceptibility profile of A. fumigatus isolates recovered from lungs of birds with and without aspergillosis. Fifty three isolates were tested for their antifungal susceptibility to voriconazole (VRC), itraconazole (ITZ), amphotericin (AMB) and caspofungin (CSP) using the M38-A2 broth microdilution reference method. Five isolates were resistant to more than one antifungal drug (CSP + AMB, VRC + ITZ and AMB + ITZ). Fifteen (28%) isolates with susceptible increased exposure (I) to ITZ were sensible to VRC. Resistance to AMB (>2µg/mL) was observed in only four isolates. Eleven (21%) A. fumigatus present resistance to ITZ (13%) and VRC (8%). Fungal isolation from respiratory samples has been regarded as being of limited usefulness in the ante mortem diagnosis of aspergillosis in birds. However, the results suggest that the detection and antifungal susceptibility profile may be helpful for monitoring of therapy for avian species and where antifungal resistance might be emerging and what conditions are associated to the event.(AU)

Os testes de suscetibilidade são essenciais para informar o correto manejo das infecções por Aspergillus. Neste estudo apresentamos o perfil antifúngico de isolados de A. fumigatus provenientes de pulmões de aves com e sem aspergilose. Cinqüenta e três isolados foram testados quanto à susceptibilidade antifúngica ao voriconazol (VRC), itraconazol (ITZ), anfotericina B (AMB) e caspofungina (CSP) pelo método de referência de microdiluição do caldo M38-A2. Cinco isolados foram resistentes a mais de um antifúngico (CSP + AMB, VRC + ITZ e AMB + ITZ). Quinze (28%) isolados suscetíveis - com exposição aumentada (I) ao ITZ foram sensíveis ao VRC. A resistência ao AMB (>2µg/mL) foi observada em apenas quatro isolados. Onze (21%) A. fumigatus apresentaram resistência a ITZ (13%) e VRC (8%). O isolamento de fungos de amostras respiratórias tem sido considerado de utilidade limitada no diagnóstico ante mortem de aspergilose em aves. No entanto, os resultados sugerem que a detecção e o perfil de suscetibilidade a antifúngicos podem ser úteis para o monitoramento da terapia de espécies aviárias, assim como a emergência da resistência antifúngica e quais condições podem estar associadas ao evento.(AU)

Aspergilose sistêmica em um cavalo - relato de caso / Systemic aspergilosis in a horse - case report

O presente trabalho relata o caso de aspergilose sistêmica em um cavalo da raça Quarto de Milha. O animal apresentava quadro de emagrecimento progressivo e alopecia. Os parâmetros avaliados durante o exame clínico encontravam-se de acordo com os valores normais para a espécie. No hemograma verificou-se leucocitose por neutrofilia, sem desvio à esquerda, proteínas plasmáticas totais elevadas e aumento do fibrinogênio, indicando um processo inflamatório acompanhado de desidratação. Os exames bioquímicos séricos demonstraram aumento no valor da ureia. Apesar dos exames realizados e da terapia instituída com antibióticos de amplo espectro e suporte nutricional, após 51 dias de internamento o quadro clínico evoluiu para caquexia e decúbito permanente do paciente, o qual foi submetido à eutanásia seguida de necropsia. Com base nos achados nos exames necroscópico e histopatológico, diagnosticou-se infecção sistêmica por Aspergillus sp., acometendo pulmões, fígado, rins, peritônio parietal e encéfalo. Dentre os fatores predisponentes à relatada infecção fúngica sistêmica, destaca-se o status imunológico debilitado do paciente, possivelmente proporcionado por tratamentos prolongados com antibióticos e anti-inflamatórios esteroidais. O presente trabalho relata o primeiro caso descrito de arpergilose sistêmica no Brasil. O diagnóstico definitivo só foi possível após necropsia e histopatologia, visto que os sinais clínicos inespecíficos não foram determinantes para o diagnóstico em vida.(AU)

This paper reports the case of systemic aspergillosis on a Quarter Horse. The animal had progressive weight loss and alopecia. The parameters evaluated during the clinical examination were in agreement with the normal values for the species. The hemogram showed neutrophilic leukocytosis, without left-sided, elevated total plasma proteins and an increase in fibrinogen, indicating an inflammatory process accompanied by dehydration. Serum biochemical tests showed an increase in the value of urea. Despite the performed tests and established therapy with broad spectrum antibiotics and nutritional support, after 51 days of hospitalization the clinical condition evolved into cachexia and permanent decubitus of the patient which underwent to euthanasia and necropsy. From the findings of necropsy and histopathology, systemic infection was diagnosed by Aspergillus sp., affecting the lungs, liver, kidneys, parietal peritoneum and encephalon. Among the factors predisposing to the reported systemic fungal infection, the patient's weakened immune status is highlighted, possibly due to prolonged antibiotic and steroidal anti-inflammatory treatments. This paper reports the first case described of systemic aspergillosis in Brazil. Definitive diagnosis was only possible after necropsy and histopathology, since nonspecific clinical signs were not determinant for the diagnosis in life.(AU)

MR Findings of Fungus Ball: Significance of High Signal Intensity on T1-Weighted Images

Epidemiología de la enfermedad fúngica invasora por hongos filamentosos en el período 2005 a 2015, en un hospital universitario en Santiago, Chile / Epidemiology of invasive fungal disease by filamentous fungi in the period 2005 to 2015, in a university hospital in Santiago, Chile

Resumen Introducción: La enfermedad fúngica invasora (EFI) por hongos filamentosos es cada vez más frecuente. Objetivo: Estudiar la epidemiología de la EFI en adultos hospitalizados en nuestro centro. Metodología: Estudio retrospectivo de pacientes adultos de un hospital universitario en Santiago, Chile, con EFI por hongos filamentosos entre enero de 2005 y diciembre de 2015. Resultados: Se identificaron 125 episodios, siendo 48% categoria probada, 40% probable y 11% posible según criterios EORTC/MSG, incidencia global 0,47 x 1.000 egresos, 57% pacientes masculinos y edad de 50 ± 16 años. El 66,4% tenía patología hematológica, 11,2% trasplante de órgano sólido, 11,2% enfermedad reumatológica, 11,2% otra condición. Los factores de riesgo fueron neutropenia 44%, corticoterapia 21%, inmunosupresores 13%. Los hongos más frecuentemente identificados fueron Aspergillus spp (53,6%), Mucorales (16%), Fusarium spp (8,8%), Alternaria spp (5,6%), otros filamentosos (3,2%). Todos recibieron antifúngicos, 82% monoterapia, 18% terapia combinada, hubo defocación quirúrgica en 90% de mucormicosis. La mortalidad global fue 42%. Al comparar 2005-2009 vs 2010-2015, hubo un aumento significativo de la incidencia y una tendencia a menor mortalidad en el segundo período. Conclusiones: Durante un período de 10 años, observamos un aumento de la incidencia de EFI por filamentosos, aspergilosis fue la etiología más frecuente y la mortalidad global fue 42%.

Background: Invasive fungal disease (IFD) due to filamentous fungi is increasingly common. Aim: To study the epidemiology of EFI in hospitalized adults in our center. Methods: Retrospective study of adult patients of a university hospital in Santiago, Chile, with EFI due to filamentous fungi between January 2005 and December 2015. Results: 125 episodes were identified, being 48% proven, 40% probable and 11% possible according to EORTC/MSG criteria, overall incidence was 0.47/1,000 admissions, 57% male patients and age 50 ± 16 years. 66.4% had hematological pathology, 11.2% solid organ transplant, 11.2% rheumatology diseases, 11.2% other conditions. The risk factors were neutropenia 44%, corticosteroid therapy 21%, immunosuppressants 13%. The most frequent mould identified were Aspergillus spp (53.6%), Mucorales (16%), Fusarium spp (8.8%), Alternaria spp (5.6%) and other filamentous (3.2%). All received antifungals, 82% monotherapy, 18% combined therapy, there was surgical defocation in 90% of mucormycosis. The overall mortality was 42%. When comparing 2005-2009 vs 2010-2015, there was a significant increase in incidence and a tendency to lower mortality in the second period. Conclusions: Over a period of 10 years, we observed an increase in the incidence of EFI by filamentous, aspergillosis was the most frequent etiology and the overall mortality was 42%.

Caracterización clínico epidemilógica de la aspergilosis / Clinical Epidemiological Characterization of Aspergillosis

La aspergilosis es una infección o respuesta alérgica debida al hongo Aspergillus spp. El hongo comúnmente crece en hojas muertas, granos almacenados, pilas de estiércol o abono u otra vegetación en descomposición. Implica un amplio espectro de entidades que requieren de alto grado de sospecha por mantener altas tasas de mortalidad, especialmente en el paciente inmunosupreso, estas pueden ser modificadas con el tratamiento temprano. Objetivo: actualizar las características clínicas y epidemiológicas de la aspergilosis incluyendo el diagnóstico y manejo, así como los factores presentes en general y en particular en los inmunosupresos. Material y Métodos: se realiza selección bibliográfica de revisiones y guías de manejo en las bases de datos bibliográficas PUBMED (últimos 5 años), SciELO y Revistas Hondureñas (BVS); se incluyen 21 referencias sobre diferentes aspectos de diagnóstico, manejo y tratamiento de aspergilosis. Conclusión: la sospecha de aspergilosis en cualquier cuadro respiratorio atípico con manifestaciones similares a tuberculosis o asma, debe ser mandatorio en los protocolos hospitalarios de manejo, especialmente en individuos con factores de riesgo conocidos, que implican riesgo ocupacional de contacto con conidias de Aspergillus spp...(AU)

Rhino-maxillary aspergillosis in an immunocompetent patient: case report

Introduction: Aspergillosis is the second most frequent opportunistic fungal infection of the pa-ranasal sinuses. It primarily affects the maxillary sinus and occurs mainly in immunocompromi-sed individuals. Infection is caused by inhalation of spores or by an oro-sinusal communication. Aspergillosis is classified into an invasive and non-invasive form or Aspergilloma, which usually affects immunocompetent patients. Violaceous lesions, ulcers, necrosis and tissue destruction can be manifested clinically. Patients may experience pain, paresthesias, increases in the vo-lume of purulent or bloody nasal discharge and congestion. Case report: A 62-year-old female patient, immunocompetent, with a condition evolving for about six years. Condition began after a dental extraction, and consisted of absence of scarring and recurrent episodes of symptoma-tology suggestive of maxillary sinusitis with poor response to antibiotics. The patient was referred to the maxillofacial care unit, presenting an increase of volume in the right genial region, pain and paraesthesia of infraorbital region. The CT scan showed the presence of a radiopaque foreign body in the right maxillary sinus. A surgical procedure was carried out using the Caldwe-ll-Luc technique and biopsy; the case was diagnosed with Aspergillosis. The patient was treated without antifungal therapy because she had a good immune status. Conclusion: Aspergilloma is the most common form of Aspergillosis in immunocompetent individuals. It is usually diagnosed late, as its clinical picture is similar to bacterial sinusitis. In most cases, patients respond well to surgical treatment, and systemic antifungal therapy is not necessary.