Histoplasmosis diseminada en una paciente pediátrica inmunocompetente / Disseminated histoplasmosis in an immunocompetent pediatric patient

La histoplasmosis es una micosis endémica producida por el hongo Histoplasma capsulatum. La forma diseminada en pediatría conlleva alta morbimortalidad. Reportamos el caso de una niña inmunocompetente con diagnóstico de histoplasmosis diseminada. Paciente de 3 años de edad con cuadro clínico de síndrome febril prolongado acompañado de hepatoesplenomegalia confirmada por ecografía. Laboratorio con anemia normocítica, normocrómica y leucopenia. Se arribó al diagnóstico por biopsia de ganglio periportal y periesplénico. El cultivo fue positivo para Histoplasma capsulatum y en estudios histopatológicos se observó linfadenitis granulomatosa con elementos levaduriformes intracelulares. Realizó tratamiento con anfotericina B 1 mg/kg/día durante 6 semanas con favorable resolución clínica. Se debe considerar histoplasmosis diseminada en aquellos pacientes provenientes de zonas endémicas que presentan la tríada de fiebre, hepatoesplenomegalia y citopenias, para poder brindar un tratamiento oportuno, mejorar el pronóstico y disminuir la mortalidad de la enfermedad.

Histoplasmosis is an endemic fungal infection caused by the fungus Histoplasma capsulatum. The disseminated form is associated with a high morbidity and mortality in pediatrics. Here we report the case of an immunocompetent female patient diagnosed with disseminated histoplasmosis. She was 3 years old and presented with protracted febrile syndrome and hepatosplenomegaly confirmed by ultrasound. Lab tests showed normocytic anemia and leukopenia. Diagnosis was made by periportal and perisplenic lymph node biopsy. The culture was positive for Histoplasma capsulatum and histopathological studies showed granulomatous lymphadenitis with intracellular yeast-like elements. Amphotericin B was administered at 1 mg/kg/day for 6 weeks, with a favorable clinical course. Disseminated histoplasmosis should be considered in patients from endemic areas who present the triad of fever, hepatosplenomegaly, and cytopenias so as to provide a timely treatment, improve prognosis, and reduce the mortality from this disease.

Nocardiosis pulmonar y del sistema nervioso central: el alcoholismo como factor de inmunocompromiso / Pulmonary and central nervous system nocardiosis: Alcoholism as an immunocompromising factor

La nocardiosis es una enfermedad de distribución mundial; de forma habitual se encuentra en zonas tropicales y afecta principalmente a pacientes inmunocomprometidos, sin embargo, también existen casos reportados de infección en personas inmunocompetentes. Esta infección es causada por actinomicetos del género Nocardia spp. que son bacterias Gram positivas, saprófitos ambientales. Aunque la exposición a Nocardia spp. es casi universal, solo una pequeña fracción de las personas expuestas desarrollan la enfermedad. Se presenta el caso de un hombre de 47 años, sin dato de inmunosupresión, procedente de un área rural de Boyacá, que consultó por un cuadro clínico de cefalea intensa e intermitente, con parestesias y, finalmente, alteración del estado de conciencia. Se practicó una resonancia magnética cerebral, en la que se evidenció una lesión que ocupaba espacio de localización córtico-subcortical en la región fronto-témporo-parietal izquierda, con efecto compresivo y desplazamiento de las cavidades del sistema ventricular. Se sospechó, inicialmente, una lesión neoplásica o un absceso cerebral. El paciente fue sometido a una resección quirúrgica, y el cultivo de la lesión documentó Nocardia africana/nova; en estudios posteriores, se evidenció un posible foco pulmonar primario. Como único factor de riesgo en el paciente, se documentó alcoholismo. Completó seis semanas de tratamiento antibiótico intrahospitalario con evolución clínica y radiológica, y egresó con plan de un año de terapia antibiótica ambulatoria. Aunque la enfermedad por Nocardia spp. afecta principalmente a pacientes inmunocomprometidos, la "evidencia" clínica demuestra que este microorganismo también puede ser una amenaza para individuos sin los factores de riesgo tradicionales para inmunosupresión.

Nocardiosis is a disease with worldwide distribution. It is usually found in tropical areas and mainly affects immunocompromised patients, however, there are also cases where its infection has been reported in immunocompetent patients. This pathology is caused by bacteria known as Nocardia spp., which are gram-positive microorganisms and environmental saprophytes, and although exposure to Nocardia spp. is almost universal, only a small fraction of exposed people develops the disease. We present the case of a 47-year-old man, with no evidence of immunosuppression, from a rural area of Boyacá, who was admitted due to intense and intermittent headache accompanied by paresthesia and, finally, a decrease in consciousness. A brain magnetic resonance was performed and evidenced a fronto-temporo- occipital space-occupying lesion in the cortico-subcortical region with a compressive effect and displacement of the ventricular system cavities. It was suspected at first a neoplastic lesion or a brain abscess. The lesion was surgically resected, and its culture showed Nocardia africana/nova. In later studies a possible primary pulmonary focus was evidenced. Alcoholism was the only risk factor documented. The patient completed 6 weeks of hospital antibiotic treatment with favorable clinical and radiological evolution and was discharged with a 1-year plan of outpatient antibiotic therapy. Although Nocardia spp. mainly affects immunocompromised patients, evidence shows that this microorganism can also be a threat to individuals without traditional immunosuppression risk factors.

Shock séptico de foco respiratorio por Pasteurella multocida en un paciente inmunocompetente. Caso Clínico / Septic shock originating from a pulmonary focus caused by Pasteurella multocida. Report of one case

Pasteurella multocida is a gram-negative coccobacillus bacterium found as a commensal in the oropharynx of domestic animals such as cats and dogs and some farm animals. Soft tissue infections and occasionally bacteremia in immunocompromised patients with direct contact with animals are described. We report a 61 year old male with a history of scratches and close contact with domestic cats, with a septic shock originating from a pulmonary focus, requiring mechanical ventilation and vasopressors. Blood cultures disclosed the presence of Pasteurella multocida. He responded successfully to antimicrobials.

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.

Características radiográficas de la neumonía adquirida en la comunidad en el adulto inmunocompetente hospitalizado según el agente causal / Radiographic characteristics of community-acquired pneumonia in the immunocompetent adult hospitalized according to the etiologic agent

Resumen En la práctica clínica, la radiografía de tórax permite confirmar el diagnóstico y la extensión de la neumonía adquirida en la comunidad (NAC). Objetivos: Examinar las características radiográficas de la NAC según el agente causal y el grado de concordancia interobservador (CI) en la descripción de los hallazgos radiográficos. Métodos: Se evaluaron las radiografías de tórax de 300 pacientes adultos inmunocompetentes hospitalizados por NAC, tres residentes de radiología consignaron el patrón de los infiltrados pulmonares, su localización anatómica y extensión, la presencia de derrame pleural y otros hallazgos radiográficos. Se realizaron cultivos de esputo, hemocultivos, pruebas serológicas y técnicas de biología molecular de hisopado nasofaríngeo para identificar los principales patógenos respiratorios. Resultados: Las manifestaciones clínicas y los hallazgos de la radiografía de tórax fueron similares en las neumonías causadas por diferentes patógenos respiratorios: bacterias clásicas, virus respiratorios y microorganismos atípicos. En las neumonías bacterianas predominó el patrón de relleno alveolar de distribución lobar, en las neumonías vírales y atípicas predominó el patrón intersticial o mixto alvéolo-intersticial con opacidades en vidrio esmerilado. La CI fue satisfactoria (kappa > 0,6) para determinar el patrón principal de los infiltrados pulmonares, su localización anatómica y la presencia de derrame pleural, su localización y extensión. La CI fue moderada (kappa 0,4-0,6) para definir la extensión de la neumonía y detectar signos radiológicos asociados a congestión pulmonar. Conclusión: Los hallazgos de la radiografía de tórax no permitieron identificar con precisión el agente causal de la neumonía, siendo útil en la caracterización de los infiltrados pulmonares y para detectar complicaciones como el derrame paraneumónico.

In a clinical setting the chest radiograph is the reference standard in establishing the diagnosis of community-acquired pneumonia (CAP). Objectives: This study aimed to assess interobserver reliability (IR) of radiographic findings and the relationship to different respiratory pathogens in CAP. Methods: Chest radiographs of 300 immunocompetent adult patients hospitalized with pneumonia, obtained from a database, were reviewed by three residents of radiology without specific clinical information. Main pattern of pulmonary infiltrates, topographic localization, extent of pneumonia, presence of pleural fluid, thickened bronchial walls, lymphadenopathy and air bronchogram were scored. Sputum and blood cultures, serological tests and nasopharyngeal swab for respiratory virus detection by molecular diagnostic techniques were performed to identify the causative pathogen. Results: Clinical manifestations and chest X-ray findings were similar in pneumonias caused by different respiratory pathogens: classic bacteria, respiratory viruses and atypical microorganisms. The alveolar pattern of lobar distribution predominated in bacterial pneumonia; meanwhile, interstitial or mixed alveolar-interstitial pattern with ground glass opacities predominated in viral and atypical pneumonias. IR was fair to good (kappa > 0.6) for determining the main pattern of infiltrates, anatomical location and the presence of pleural effusion, their anatomical location and extension. IR was moderate (kappa 0.4-0.6) for determining the extent of pneumonia and signs of congestive heart failure. Conclusion: Simple features such as main pattern description, anatomical location, identifying the involved lobes and pleural fluid recognition showed fair to excellent interobserver reliability. Chest radiographs was of limited value in predicting the causative pathogen but were of beneficial use to characterize pulmonary infiltrates and to detect complications such as parapneumonic effusion.

Forma aguda de histoplasmose em paciente imunocompetente: relato de caso / Acute form of histoplasmosis in immunocompetent patient: case report

A histoplasmose é uma doença granulomatosa infecciosa sistêmica cuja transmissão é aerógena e a contaminação se dá pelo contato com fezes de aves e morcegos, depende da exposição e da imunidade do paciente. Trata-se de uma doença com difícil diagnóstico, dada a semelhança dos sintomas com os de outras doenças granulomatosas infecciosas, principalmente em pacientes imunocompetentes, visto que a regressão é geralmente espontânea. Um homem de 34 anos, branco, natural e procedente de Atibaia, previamente hígido, iniciou quadro de dor e edema no tornozelo esquerdo, e evoluiu com dispneia progressiva, com piora ao decúbito, acompanhada de sudorese noturna, tosse seca e febre baixa. Foi realizado o exame de tomografia computadorizada (TC) de tórax sem contraste, que evidenciou espessamento difuso das paredes brônquicas, de aspecto inflamatório, micronódulos esparsos bilateralmente. Paciente apresentou PCR elevado, COVID, sorologias, BAAR e hemoculturas negativas, punção articular e ecocardiograma sem alterações. Optado por COXCIP 4, sulfametoxazol-trimetoprim e anfotericina B de forma empírica. Pesquisa de fungos em escarro positivo; leveduras e lavado brônquico sugestivos de histoplasmose. Evoluiu com insuficiência respiratória necessitando de intubação orotraqueal, posteriormente, traqueostomia e apesar do tratamento antifúngico, evoluiu com óbito após 21 dias. A histoplasmose é uma doença grave, com diversas formas clínicas e prognóstico normalmente autolimitado, mas que pode ser fatal, mesmo em pacientes previamente imunocompetentes.

Histoplasmosis is a systemic infectious granulomatous disease whose transmission is airborne, and contamination occurs through contact with bird and bat feces, depending on the exposure and immunity of the patient. It is a disease with difficult diagnosis, given the similarity of symptoms with those of other infectious granulomatous diseases, especially in immunocompetent patients since regression is usually spontaneous. A 34-year-old Caucasian man from Atibaia, previously healthy, developed pain and swelling in his left ankle, progressing to progressive dyspnea, worsening in recumbency, accompanied by night sweats, dry cough and low-grade fever. A non-contrast-enhanced computed tomography (CT) scan of the chest was performed, which showed diffuse thickening of the bronchial walls, with an inflammatory appearance, and bilaterally sparse micronodules. Patient had high C-reactive protein, COVID, serology, BAAR and negative blood cultures, joint puncture, and echocardiogram without changes. Empirically opted for COXCIP 4, trimethoprim-sulfamethoxazole and amphotericin B. Search for fungi in positive sputum, yeasts, and bronchial lavage suggestive of histoplasmosis. He envolved with respiratory failure requiring orotracheal intubation, later tracheostomy and despite antifungal treatment, he died after 21 days. Histoplasmosis is a serious disease, with several clinical forms and a prognosis that is usually self-limiting, but it can be fatal, even in previously immunocompetent patients

Loss of an eye to mucormycosis following corticosteroid therapy for COVID-19

Mucormycosis is a rare, sometimes severe fungal infection that has emerged as a possible complication of COVID-19. We report a case of a non-diabetic, apparently immunocompetent patient diagnosed with rhino-orbital-cerebral mucormycosis shortly after COVID-19 treatment with dexamethasone. The patient received optimized systemic antifungal therapy and extensive surgical treatment. So far, four months after the last hospital discharge, the patient has been in good general condition. This case is a dramatic reminder that beneficial corticosteroid therapy in general inevitably carries a risk of opportunistic infection, and corticosteroid therapy for COVID-19 risks orbital-rhinocerebral mucormycosis that clinicians should watch for with vigilance.

La ecografía del timo en la niñez: una herramienta útil para evaluar la respuesta inmune en el crecimiento y desarrollo infantil / Echography of thymus in childhood: a useful tool to evaluate the immune response in childhood growth and development

Se presenta conceptos de la inmunocompetencia y su relación con la nutrición en niños, que describen aspectos fisiológicos integrales. También se describen los aspectos inmunológicos, que permiten interpretar los mecanismos de la respuesta inmune, destacándose conceptos y criterios fisiológicos. Un niño malnutrido presenta alteraciones inmunológicas, y las mismas se las puede identificar como deficiencias a predominio celular, y a predominio humoral. Se destaca la importancia del eje Neuroinmunoendocrinológico como integrador de respuestas fisiológicas. El propósito del presente trabajo, esta dirigido a identificar las herramientas que permiten el estudio del sistema inmune en nuestro contexto, haciendo especial hincapié en la ecografía del timo, por ser una herramienta útil para evaluar al sistema inmune en niños con estado nutricional alterado en forma leve o moderada.

Concepts of immunocompetence and its relationship with nutrition in children are presented, describing comprehensive physiological aspects. Immunological aspects are also described, which allow to interpret the mechanisms of the immune response, highlighting physiological concepts and criteria. A malnourished child presents immunological alterations, and these can be identified as deficiencies with a cellular predominance, and with a humoral predominance. The importance of the Neuro-immunoendocrinological axis as an integrator of physiological responses is highlighted. The purpose of this work is aimed at identifying the tools that allow the study of the immune system in our context, with special emphasis on ultrasound of the thymus, as it is a useful tool to evaluate the immune system in children with altered nutritional status, mild or moderate.

Failure of immunological competence: when to suspect?

Abstract Objectives: To draw physicians' attention to the different warning signs of diseases of inborn errors of immunity. Data sources: A non-systematic review of the literature was carried out in the PubMed, LILACS, and SciELO databases, in addition to consultation of reference textbooks. Summary of the findings: It is known that the lack of immunological competence observed in patients with inborn errors of immunity diseases causes particularly serious and/or recurrent infections. However, manifestations related to autoimmunity, inflammation, allergies, and malignancy can also occur. Aiming at the early identification of these patients, a list of warning signs for inborn errors of immunity was created, in which the need for intravenous antibiotics or prolonged antibiotics use to control infection, failure to thrive, and positive family history for this group of diseases are considered the most sensitive. Regarding non-infectious manifestations, early onset, difficulty in controlling with the usual treatments, atypical presentations or association with other warning signs are noteworthy, and investigation for inborn errors of immunity in these situations is recommended. Conclusions: This article highlights the importance of considering this group of diseases even in the face of patients with non-infectious manifestations. Disclosure of inborn errors of immunity diseases, especially to non-specialists, is essential for early diagnosis and, consequently, for the reduction of these patients' morbidity and mortality.

Immune system: development and acquisition of immunological competence

Abstract Objectives: To describe the ontogeny of the immune system and the adaptive mechanisms of the immune system in the neonatal period, with an emphasis on transplacental antibody transport and breastfeeding. Source of data: Non-systematic literature review in the PubMed database. Summary of the findings: The last two decades have witnessed a great advance in the knowledge of the immune system since conception. Several investigation tools have provided insight on phenomena that were previously inadequately understood. Still expanding, the functional and molecular investigation of various aspects of the immune system will make it possible to understand how intra-uterus maternal-fetal exchanges, the maternal microbiota interacting with the fetus and newborn, and the acquisition of immunological competence occur in healthy and disease scenarios. Conclusions: In-depth knowledge of the development of the immune system and of the adaptive mechanisms that allow a safer transition to the extrauterine environment are fundamental components of optimizing maternal and young infant vaccination, as well as the strategies associated with full postnatal development, and the early diagnosis and treatment of innate errors of immunity.

Proteção ineficaz em pacientes submetidos ao transplante de células-tronco hematopoiéticas: análise de conceito / Ineffective protection in patients undergoing hematopoietic stem cell transplantation: concept analysis

Objetivou-se analisar o conceito de "Proteção" em pacientes submetidos ao transplante de células tronco hematopoiéticas e cor-relacionar com os elementos do diagnóstico de enfermagem "Proteção Ineficaz" proposto pela NANDA-I.Revisão integrativa da literatura, fundamentada no modelo de Análise de Conceito proposto por Walker e Avant. Realizada na Biblioteca Virtual em Saúde e as seguintes bases de dados: CINAHL, SCOPUS, PUBMED/MEDLINE, LILACS e Web of Science com recorte temporal de cinco anos. A amostra final foi composta por 16 artigos e pela identificação de três atributos definidores, 15 antecedentes e 11 consequentes.Conclusão:a análise de conceito pode contribuir para o refinamento e o aprimoramento do diagnóstico de en-fermagem "Proteção Ineficaz". Foi possível identificar uma outra definição, 10 antecedentes e 10 consequentes que não constam na NANDA-I, bem como a necessidade de revisar a definição e demais componentes do diagnóstico propostos pela taxonomia.

The objective was to analyze the "Protection" concept in patients undergoing hematopoietic stem cell transplantation and correlate it with elements of the "Ineffective Protection" nursing diagnosis proposed by NANDA-I. Integrative literature review based on the Concept Analysis model proposed by Walker and Avant and performed at the Virtual Health Library and CINAHL, SCOPUS, PUBMED/MEDLINE, LILACS and Web of Science databases within a five-year time frame . The final sample consisted of 16 articles and the identification of three defining attributes, 15 antecedents and 11 consequences. Conclusion: concept analysis can contribute to refine and improve the nursing diagnosis "Ineffective Protection". It was possible to identify another definition, 10 antecedents and 10 consequences that are not included in NANDA-I, as well as the need to revise the definition and other components of the diagnosis proposed by the taxonomy.

Esporotricose pulmonar em paciente imunocompetente: relato de caso / Pulmonary sporotrichosis in immunocompetent patient: case report

A forma extracutânea pulmonar da esporotricose, uma infecção causada por espécies geneticamente distintas de um fungo dimórfico do gênero Sporothrix, é rara, com poucos casos relatados na literatura. Trata-se de um caso de uma mulher de 55 anos, residente da região do Barreiro de Belo Horizonte/Minas Gerais, que buscou o serviço de infectologia de um hospital público de Belo Horizonte com história de emagrecimento, dispneia aos pequenos esforços, tosse crônica e calafrios vespertinos de três anos de evolução. Foi tratada para pneumonia bacteriana, em cinco ocasiões, sem melhora clínica. Apresentou tomografia computadorizada de tórax com cavitação residual e lesões escavadas pulmonares. A paciente foi internada com quadro de dispneia aos pequenos esforços, tosse e expectoração purulenta, sendo sua cultura de escarro positiva para Sporothrix spp. Foi instituído o tratamento padrão ouro para esporotricose pulmonar, inicialmente, com itraconazol, 200 mg, duas vezes ao dia, entretanto, após 10 meses, a melhora clínica e radiológica não foi satisfatória e optou-se pela internação a administração de anfotericina B complexo lipídico endovenosa 4 mg/kg/dia. Em menos de 1 mês a paciente apresentou piora do quadro e evoluiu a óbito, apesar de ter recebido 2g de dose acumulada de anfotericina

The pulmonary extracutaneous form of sporotrichosis, an infection caused by genetically distinct species of a dimorphic fungus of the genus Sporothrix, is rare, with few cases reported in the literature. This is a case of a 55-year-old woman, resident of the Barreiro region in Belo Horizonte/ Minas Gerais, who sought the infectious disease service of a public hospital in Belo Horizonte with a history of weight loss, dyspnea at small efforts, chronic cough and three-year-old vespertinus chills. She was treated for bacterial pneumonia on five occasions without clinical improvement. He presented computed tomography of the chest with residual cavitation and excavated pulmonary lesions. The patient was hospitalized with dyspnea on small efforts, cough and purulent sputum, and her sputum culture was positive for Sporothrix spp. The gold standard treatment for pulmonary sporotrichosis was instituted, initially with itraconazole, 200 mg twice a day, however, after 10 months, the clinical and radiological improvement was not satisfactory and the administration of intravenous amphotericin B lipid complex 4 mg/kg/day was chosen. In less than 1 month the patient presented worsening of the condition and died, despite receiving 2g of accumulated dose of amphotericin B lipid complex.

Achados Epidemiológicos de Neurocriptococose em Pacientes Imunocompetentes: Relato de Casos de um Hospital Público de Joinville, Brasil / Epidemiological Findings of Neurocriptococcosis in Immunocompetent Patients: Case Reports from a Public Hospital in Joinville, Brazil / Hallazgos epidemiológicos de la neurocriptococosis en pacientes inmunocompetentes: relato de casos de un hospital público en Joinville, Brasil

Justificativa e Objetivos: Neurocriptococose é uma doença fúngica que acomete principalmente pacientes imunocomprometidos. Casos em pacientes imunocompetentes têm sido descritos em alguns relatos de casos; no entanto, por não ser uma doença de notificação compulsória no Brasil até 2020, ainda pouco se sabe sobre sua epidemiologia no sul do país. O presente estudo teve como objetivo descrever aspectos epidemiológicos relacionados à doença em pacientes supostamente imunocompetentes. Métodos: Estudo retrospectivo, observacional, baseado em uma série de casos atendidos entre 2018 e 2019, em um hospital público de Joinville, Santa Catarina, Brasil. Pacientes com diagnóstico clínico confirmado pela presença do fungo do gênero Cryptococcus spp. no líquido cefalorraquidiano pelo método tinta da China foram avaliados quanto aos aspectos clínicos, tratamento e complicações durante o período de internação. Resultados: Houve dois pacientes em 2018 e seis pacientes em 2019 com diagnóstico confirmado. Todos sem fatores aparentes para imunocomprometimento e sem fator de risco ambiental evidente. A maioria eram homens com média de idade de 39 anos. Febre e confusão mental foram os achados mais comuns na apresentação. A variante C. neoformans foi encontrada em 75% dos casos. Todos receberam Anfotericina B, no mínimo, durante 13 dias, associado ou não a Fluconazol. Seis pacientes apresentaram nefrotoxicidade pela Anfotericina B, dois evoluíram para óbito intra-hospitalar e dois permaneceram com sequelas neurológicas. Conclusão: A mortalidade e as complicações relacionadas ao tratamento da neurocriptococose em pessoas imunocompetentes foram altas na amostra estudada. A recente inclusão da doença como uma patologia de notificação compulsória poderá aprimorar dados epidemiológicos para o melhor entendimento e a prevenção dessa doença.(AU)

Background and Objectives: Neurocryptococcosis is a fungal disease that affects mainly immunocompromised patients. Cases in immunocompetent patients have been described in some case reports. However, as its reporting was not mandatory in Brazil until 2020, little is known about its epidemiology in the South Region of the country. The present study had the objective of describing epidemiological aspects related to the disease in presumably immunocompetent patients. Methods: A retrospective and observational study was developed, based on cases of patients who received care in a public hospital in Joinville, Santa Catarina, Brazil, between 2018 and 2019. Patients with a clinical diagnosis confirmed by the presence of the fungus Cryptococcus spp. in cerebrospinal fluid by means of the Chinese ink staining were evaluated regarding clinical aspects, treatment, and complications during hospitalization. Results: The diagnosis of the disease was confirmed for two patients in 2018 and six patients in 2019. All of them showed no apparent factors for immunodeficiency and no evident environmental risk factors. Most were men with an average age of 39 years. Fever and mental confusion were the most common symptoms at admission. The variant C. neoformans was found in 75% of the cases. All patients received amphotericin B for at least 13 days with or without combined fluconazole. Six patients had nephrotoxicity due to amphotericin B, two evolved to in-hospital death, and two had neurological sequelae. Conclusion: Mortality and complications related to the treatment of neurocryptococcosis in immunocompetent people showed high rates in the studied sample. The recent inclusion of this disease as a mandatory reporting pathology can improve epidemiological data, which will be used to achieve better understanding and prevention of this problem.(AU)

Justificación y Objetivos: La neurocriptococosis es una enfermedad fúngica que afecta especialmente a pacientes inmunocomprometidos. Fueron citados casos en pacientes inmunocompetentes en algunos relatos. Por no considerársela de notificación obligatoria en Brasil hasta 2020, poco se sabe aún sobre su epidemiología en el sur del país. El estudio objetivó describir aspectos epidemiológicos relativos a la enfermedad en pacientes supuestamente inmunocompetentes. Métodos: Estudio retrospectivo, observacional, en base a una serie de casos atendidos entre 2018 y 2019 en un hospital público de Joinville, Santa Catarina. Pacientes con diagnóstico clínico confirmado por presencia de Cryptococcus spp., utilizándose el método de tinta china en líquido cefalorraquídeo fueron evaluados respecto de aspectos clínicos, tratamiento y complicaciones durante su internación. Resultados: Hubo 2 pacientes en 2018 y 6 en 2019 con diagnóstico confirmado, todos sin factores aparentes de inmunocompromiso y sin factor de riesgo ambiental evidente. Mayoría de hombre, media etaria de 39 años. Fueron hallazgos comunes en su presentación la fiebre y confusión mental. La variante C. neoformans fue hallada en 75% de los casos. Todos recibieron anfotericina B como mínimo durante 13 días, en asociación o no con fluconazol. Seis pacientes presentaron nefrotoxicidad por anfotericina B, dos sufrieron fallecimiento intrahospitalario, y dos resultaron con secuelas neurológicas. Conclusión: La mortalidad y las complicaciones relativas al tratamiento de la neurocriptococosis en inmunocompetentes fueron altas en la muestra estudiada. La inclusión de la enfermedad como patología de notificación obligatoria podrá mejorar los datos epidemiológicos para entender mejor y prevenir la enfermedad.(AU)

Systemic sporotrichosis in an alcoholic patient

Abstract A 44-year-old male patient presented with nodules that evolved with inflammation, following drainage of seropurulent secretion and ulceration. The patient had a 6 year-history of alcohol addiction and reported contact with cats. At the physical examination, the patient had skin-colored and erythematous nodules, and ulcers covered with thick, blackened crusts on the face, trunk and limbs. A culture of a nodule fluid revealed growth of Sporotrix sp. He also had pulmonary involvement and therefore the disease was classified as systemic sporotrichosis, a rare form that usually affect patients infected with HIV. Chronic alcohol abuse was considered the factor of immunosuppression for the patient.

Pseudomycetoma of the scalp caused by Microsporum canis

Abstract Pseudomycetoma is an extremely rare deep mycosis, caused by dermatophytic fungi that penetrate the tissue from infected follicles of tinea capitis. Both clinically and histopathology are similar to eumycetoma, being distinguished through the isolation of the fungus, which in the case of pseudomycetoma can be Microsporum spp. or Trichophyton spp. genre. We present a 24-year-old man with an exuberant tumor in the occipital region with fistula, whose histopathological examination evidenced grains composed of hyaline hyphae and the culture for fungi isolated the agent Microsporum canis. Combined treatment of surgical excision followed by oral griseofulvin for two years was performed, with resolution of the condition.

Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient

Abstract Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl-Neelsen staining showed intact bacilli, the culture was positive for Mycobacterium tuberculosis, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.

Pneumonia por toxoplasmose em paciente imunocompetente / Toxoplasma pneumonia in an immunocompetent patient: case repor

Com grande distribuição mundial e incidência significativa, a toxoplamose é uma doença comum em mamíferos e pássaros, causada pelo protozoário Toxoplasma gondii. No homem, o parasitismo na fase proliferativa intracelular pode se apresentar sem sintomas, ou causar clínica transitória caracterizada por febre, fadiga e linfadenopatia. Por se tratar de patologia com sintomas inespecíficos e comuns a muitas outras, é fundamental a correta pesquisa de diagnósticos diferenciais, como citomegalovírus e Epstein-Barr. Relatamos o caso de um jovem e hígido, que desenvolveu pneumonia e, após confirmação sorológica para toxoplasmose e o tratamento adequado, apresentou melhora clínica.

With great worldwide distribution and significant incidence, toxoplamosis is a common disease in mammals and birds, caused by the protozoan Toxoplasma gondii. In humans, the parasitism in its intracellular proliferative phase may present no symptoms, or cause a transient condition characterized by fever, fatigue, and lymphadenopathy. Because it is a pathology with nonspecific symptoms that are common to many other conditions, it is fundamental to find the correct research of differential diagnoses, such as for Cytomegalovirus and Epstein Barr. We report a case of a young and healthy man who developed pneumonia and, after serological confirmation for toxoplasmosis and the appropriate treatment, presented clinical improvement

Cutaneous protothecosis in kidney transplant recipient

Abstract Protothecosis is a rare condition caused by the aclorophylated algae of the genus Prototheca. In humans, protothecosis, caused mainly by P. wickerhamii, manifests itself in three forms: cutaneous, articular and systemic. It can occur in both immunocompetent and immunosuppressed individuals, being much more common in the latter. We present a new case of protothecosis in Brazil in a kidney transplant recipient.