Primer reporte de caso autóctono de tinea nigra en Chile / First autochthonous case report of tinea nigra in Chile

Resumen La tinea nigra es una infrecuente micosis superficial causada por el hongo dematiáceo Hortaea werneckii. Se presenta habitualmente en zonas costeras tropicales, siendo muy escasos los reportes en países sudamericanos con climas más templados. Habitualmente corresponde a infecciones importadas por viajeros. Se presenta el caso de una paciente adulta chilena, sin historia previa de viajes recientes, cursando con cuadro clínico y microbiológico compatible con tinea nigra palmar, tratado con itraconazol oral y sertaconazol tópico con respuesta favorable. Esta paciente corresponde al primer caso reportado en Chile de origen autóctono.

Abstract Tinea nigra is an infrequent superficial mycosis caused by the dematiaceous fungus Hortaea werneckii. It usually occurs in tropical coastal areas, with very few reports in South American countries with temperate climates, generally corresponding to infections imported by travelers. We present the case of a Chilean adult patient, with no previous history of recent trips, with clinical and microbiological background consistent with palmar tinea nigra, treated with oral itraconazole and topical sertaconazole with a favorable response. This article is the first case reported in Chile, of autochthonous origin.

Aspergilosis pulmonar invasiva en paciente neutropenico / Invasive pulmonary aspergillosis in neutropenic patient

La aspergilosis pulmonar invasiva (API) es una infección micótica oportunista necrotizante en pacientes inmunocomprometidos. El germen causante de la enfermedad tiene tropismo vascular que ocasiona trombosis y necrosis isquémica con la formación de cavidades, y según el grado de deterioro inmunitario se asocia a una mortalidad elevada. La clásica triada en pacientes neutropénicos comprende: la fiebre, el dolor pleurítico y la hemoptisis. La radiografía de tórax puede ser normal en la aspergilosis pulmonar invasiva o mostrar algunos signos radiológicos característicos como la consolidación, nódulos, y el signo de halo o el signo del aire creciente, en la tomografía computarizada. Lo más frecuente es la consolidación pulmonar que se presenta en alrededor del 60% de los pacientes. La mortalidad por API excede el 50% en pacientes neutropénicos, y es mayor a 90% en los casos de trasplante de médula ósea. El medicamento de elección es el voriconazol, otras alternativas es la anfotericina B. Los resultados del tratamiento no son siempre satisfactorios debido a la tardanza en la iniciación de la terapia farmacológica y la limitación en el número de agentes antimicóticos activos disponibles. Se presenta el caso de un paciente de sexo masculino de 61 años, con diagnóstico de API por la importancia que merece en la identificación temprana de esta patología, diagnóstico y tratamiento oportunos, evitando complicaciones que lleven a una mortalidad elevada

Invasive pulmonary aspergillosis (IPA) is an necrotizing opportunistic fungal infection in immunocompromised patients necrotizing. The germ causing the disease has vascular tropism that causing thrombosis and ischemic necrosis with the formation of cavities, and the degree of immune impairment is associated with high mortality. The classic triad in neutropenic patients include: fever, pleuritic pain and hemoptysis. The chest radiograph may be normal in the IPA or showing some characteristic radiological signs such as consolidation, nodules, and the sign of halo or air crescent sign, on computed tomography. The most frequent presentation is pulmonary consolidation having about 60% of patients. API mortality exceeds 50% in neutropenic patients, and more than 90% in cases of bone marrow transplantation. The drug of choice is voriconazole, amphotericin B in other alternatives. Treatment results are not always satisfactory because of the delay in the initiation of drug therapy and the limitation on the number of active antifungal agents available. Its reports the case of a male patient of 61 years, diagnosed with API for the importance it deserves in the early identification of this pathology, diagnosis and treatment, avoiding complications with high mortality.

Laryngeal Histoplasmosis: report first case in Colombia / Histoplasmosis laríngea: reporte de primer caso en Colombia

Laryngeal histoplasmosis is a fungal infection that is frequent in Colombia. Laryngeal histoplasmosis usually occurs in immunocompromised patients through the dissemination of the fungus from the lungs to other organs. Histoplasmosis isolated laryngeal (primary) is rare. If a patient presents with a history of immunosuppression by renal transplant, primary laryngeal histoplasmosis with supraglottic granulomatous inflammation that was treated with amphotericin B and Itraconazole, with complete resolution of laryngeal lesions.

Histoplasmosis es una infección fúngica que es frecuente en Colombia. La histoplasmosis laríngea por lo general se presenta en pacientes inmunocomprometidos por la difusión del hongo desde los pulmones a otros órganos. La enfermedad laríngea aislada (primaria) es rara. Se presenta el caso de un paciente con antecedente de inmunosupresión por trasplante renal, con histoplasmosis laríngea primaria que produjo inflamación granulomatosa supraglótica, tratado con Anfotericina B e Itraconazol, con resolución completa de las lesiones laríngeas.

Parinaud's oculoglandular syndrome and possibly causing cortical cataract / Síndrome oculoglandular de Parinaud como possível causa de catarata cortical

According to the World Health Organization, cataract is the leading cause of blindness and visual impairment throughout the world. However, the etiology of cataracts often remains unknown. This report describes the development of cortical cataract in a patient after Parinaud's oculoglandular syndrome caused by the fungus Sporothrix schenckii.

De acordo com a Organização Mundial de Saúde, a catarata é a principal causa de cegueira e deficiência visual em todo o mundo. No entanto, a etiologia das cataratas frequentemente permanece desconhecida. Este relato descreve o desenvolvimento de catarata cortical em um paciente após Síndrome oculoglandular de Parinaud causada pelo fungo Sporothrix schenckii.

Keratomycosis caused by Exserohilum rostratum.

We report a case of keratomycosis caused by Exserohilum rostratum. A 46-year-old farmer presented with history of pain, watery discharge and redness of the right eye for the past 2 weeks following trauma with vegetable matter. On ocular examination, a central corneal ulcer of about 8 mm with a greyish-white slough, feathery edges and diffuse corneal edema was seen in the right eye. KOH examination of corneal scrapings revealed thick, brown, branched, septate hyphae. Culture of corneal scrapings on Sabouraud dextrose agar showed velvety greenish-black colony with a black pigment on the reverse. The culture was identified as E. rostratum on the basis of microscopic morphology. The patient responded well to treatment with topical natamycin and oral itraconazole.

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.

Resultados de profilaxis con itraconazol 800 mg/día vía oral en adultos con leucemia aguda y neutropenia de alto riesgo: Hospital del Salvador 2006-2008 / Itraconazole 800 mg for the prophylaxis of fungal infections in patients with acute leukemia and severe neutropenia

Background: Systemic fungal infections and specifically invasive aspergillosis (IA) are associated with a high morbi-mortality rate in patients with hematologic malignancies. Itraconazole kinetic studies show that plasma levels are not satisfactory, even though there is a reduction of the severity in clinical cases. Aim: To evaluate the results of oral prophylaxis with high dose itraconazole, 400 mg bid, among patients with adult acute leukemia. Material and Methods: Prospective analysis of 93 high risk febrile episodes (with an absolute neutrophil count of less than 500 x mm3 for more 10 days), that occurred in 76 patients. Results: Seventy five percent of episodes occurred in patients with acute myeloid leukemia and 25 percent in patients with acute lymphoblastic leukemia. Fifty two percent occurred during the induction of chemotherapy. Median duration of severe neutropenia was 21 days (range 10-48). Median duration of itraconazole prophylaxis was 17 days (range 6-34). A low frequency of invasive fungal infections was observed (17 percent). According to diagnostic criteria, 5 percent of episodes corresponded to persistent fever , 1 percent and 11 percent of episodes, to probable or possible IA, respectively. No confirmed or proven IA was observed. Mortality of IA was 18 percent. No serious adverse events due to itraconazole were observed. Conclusions: The use of high dose itraconazole prophylaxis in adult patients with acute leukemia and severe neutropenia was associated to low incidence and mortality of invasive mycoses.

Pulse dose of oral itraconazole is effective in the treatment of onychomycosis

Onychomycosis is a recalcitrant disease of the nails caused by dermatophytes, yeasts, and molds. To see the efficacy of pulse dose of oral itraconazole in the treatment of onychomycosis. It was an open clinical trial which was carried out for a period of 2 years from March 2009 to February 2011, in the outpatient department of Dermatology and Venereology, Bangabandhu Sheikh Mujib Medical University [BSMMU] Dhaka. Bangladesh. Thirty patients with onychomycosis were recruited purposively. 30 patients of onychomycosis were treated with oral itraconazole 400 mg/day, seven days a month for three months. Mean age of the respondents was 36.57 +/- 14.01 years and male to female ratio was 1:1. Among the patients, 36.7% cases had involvement of toenails and 63.3% cases had involvement of fingernails. In 6.7% cases onychomycosis was mild, 80.0% cases moderate and in 13.3% cases severe. Three months after treatment with itraconazole, improvement was found in 66.7% cases and marked improvement in 33.3%. Before treatment, culture was found positive in 30% cases and three months after treatment, culture became negative in 66.7% cases. Monthly one week cycle of oral itraconazole 400 mg daily for 3 months is effective therapeutic option for onychomycosis

In vitro Evaluation of Antibiotic Lock Technique for the Treatment of Candida albicans, C. glabrata, and C. tropicalis Biofilms

Candidaemia associated with intravascular catheter-associated infections is of great concern due to the resulting high morbidity and mortality. The antibiotic lock technique (ALT) was previously introduced to treat catheter-associated bacterial infections without removal of catheter. So far, the efficacy of ALT against Candida infections has not been rigorously evaluated. We investigated in vitro activity of ALT against Candida biofilms formed by C. albicans, C. glabrata, and C. tropicalis using five antifungal agents (caspofungin, amphotericin B, itraconazole, fluconazole, and voriconazole). The effectiveness of antifungal treatment was assayed by monitoring viable cell counts after exposure to 1 mg/mL solutions of each antibiotic. Fluconazole, itraconazole, and voriconazole eliminated detectable viability in the biofilms of all Candida species within 7, 10, and 14 days, respectively, while caspofungin and amphotericin B did not completely kill fungi in C. albicans and C. glabrata biofilms within 14 days. For C. tropicalis biofilm, caspofungin lock achieved eradication more rapidly than amphotericin B and three azoles. Our study suggests that azoles may be useful ALT agents in the treatment of catheter-related candidemia.

Surgical Treatment of Native Valve Aspergillus Endocarditis and Fungemic Vascular Complications

Systemic infection with Aspergillus is an opportunistic disease that affects mainly immunocompromised hosts, and is associated with a high mortality rate. It typically occurs in patients with several predisposing factors, but Aspergillus endocarditis of native valves is rare and experience in diagnosis and treatment is limited. We report a case of native valve endocarditis caused by Aspergillus. A 35-yr-old male patient who underwent pericardiocentesis four months previously for pericardial effusion of unknown etiology presented with right leg pain and absence of the right femoral artery pulse. Cardiac echocardiography revealed severe mitral insufficiency with large mobile vegetations, and computed tomographic angiography showed embolic occlusion of both common iliac arteries. We performed mitral valve replacement and thromoembolectomy, and Aspergillus was identified as the vegetation. We started intravenous amphotericin B and oral itraconazole, but systemic complications developed including superior mesenteric artery aneurysm and gastrointestinal bleeding. After aggressive management, the patient was discharged 78 days post surgery on oral itraconazole. He was well at 12 months post discharge but died in a traffic accident 13 months after discharge.

Histoplasmosis pulmonar diseminada (enfermedad de Darling): a propósito de un caso / Disseminated pulmonary histoplasmosis (Darling's disease): a purpose of a case

La histoplasmosis es una micosis sistémica que afecta al hombre y a los animales, causada por el Hongo Histoplasma capsulatum, se relaciona especialmente con el guano de las aves, y las cuevas habitadas por murciélagos. La infección se produce habitualmente por vía respiratoria, raramente la puerta de entrada es cutánea. El mecanismo de contagio es a través de la inhalación de esporas en el polvo del aire; la población más afectada es la que vive en zonas rurales, especialmente los granjeros; este padecimiento también se ha presentado en forma epidémica. Es una enfermedad de variada, manifestación clínica que puede ir de una simple infección respiratoria asintomática, hasta una enfermedad diseminada, caracterizada por fiebre, anemia progresiva, hepatoesplenomegalía, linfadenopatías, úlceras en el aparato digestivo y necrosis de suprarrenales. Ocurre con mayor frecuencia en individuos del sexo masculino sin distinción de raza. El tratamiento es a base de derivados del imidazol: ketoconazol, itraconazol, fluconazol y anfotericina B.

Fatal cerebral abscess caused by Cladophialophora bantiana.

Primary cerebral phaeohyphomycosis is caused by pigmented fungi that exhibit distinct neurotropism often in immunocompetent individuals. A 20-yr-old male presented with multiple brain abscess which was subsequently proven microbiologically to be due to Cladophialophora Bantiana. In spite of near total excision and appropriate antifungal agents succumbed to his illness. We report this case to highlight its rarity and high mortality in an immunocompetent host. There is no initial clinical or laboratory feature that makes a preoperative diagnosis possible and relies on microbiological confirmation.

Suspensión de la profilaxis secundaria en pacientes adultos con histoplasmosis diseminada y síndrome de inmunodeficiencia adquirida / Suspension of secondary prophylaxis in adults with disseminated histoplasmosis and acquired immunodeficiency syndrome

Evaluar el efecto de suspender la profilaxis secundaria en pacientes con síndrome de inmunodeficiencia adquirida que padecieron histoplasmosis diseminada. Estudio de cohortes, prospectivo. Se incluyeron pacientes con síndrome de inmunodeficiencia adquirida e histoplasmosis diseminada tratada y cumplían profilaxis secundaria con anfotericina B itraconazol, desde enero de 1998 hasta diciembre de 2005. Al suspender la profilaxis, los linfocitos T de CD4 mayor o igual de 150 cél/mm3. Los eventos finales evaluados: recaída, muerte y enfermedades oportunistas. Se incluyeron 51 pacientes. Al diagnosticar la histoplasmosis diseminada, el recuento de linfocitos T CD4 era 31,96 cél/mm3 y la carga viral: 157 028 copias ARN/mL. Los pacientes recibieron tratamiento antifúngico. Todos los pacientes iniciaron tratamiento antirretroviral. La profilaxis secundaria utilizada fue anfotericina B o itraconazol. El tiempo de tratamiento antirretroviral fue de 6 meses al suspender la profilaxis. El tiempo de seguimiento después de interrumpida la profilaxis fue de 36 meses (tiempo total: 1329 meses). 50 pacientes (98 por ciento) no tuvieron recaída, 1 paciente (2 por ciento) recayó, quien suspendió el tratamiento antirretroviral. La interrupción de la profilaxis secundaria antifúngica en pacientes con síndrome de inmunodeficiencia adquirida e histoplasmosis diseminada es segura, debe realizarse en pacientes asintomáticos, que cumplan tratamiento antirretroviral y linfocitos T CD4 mayor de 150 cél/mm3. El único factor implicado en recaída fue la suspensión del tratamietno antirretroviral.

Recurrent respiratory papillomatosis complicated by aspergillosis: a case report with review of literature.

Pulmonary extension of recurrent invasive papillomatosis often poses a diagnostic challenge to the examining bronchoscopist, pathologist, radiologist and surgeon, in distinguishing it as a benign lesion that is confined to the mucosa and extending along the branches of the tracheobronchial tree from true invasion of a malignant tumor. We document here a case of recurrent invasive respiratory papillomatosis which initially presented as a laryngeal papilloma. After multiple recurrences, the patient presented with bronchopulmonary involvement, complicated by invasive aspergillosis in a non-immunocompromised setting.

Monoartrite como manifestação de paracoccidioidomicose / Monoarthritis as manifestation of paracoccidioidomycoses

Os autores relatam o caso de uma paciente de 29 anos com quadro crônico de monoartrite em joelho direito. Após cirurgia e biópsia sinovial foi diagnosticada a infecção pelo Paracoccidioides brasiliensis. Propedêutica complementar mostrou acometimento pulmonar isolado, com tomografia computadorizada revelando opacidades em “vidro fosco” com esparsa distribuição lobular e espessamento de septos interlobulares. Foi iniciado tratamento com itraconazol 100 mg/dia e acompanhamento ambulatorial. Ressalta-se a importância de reconhecer a doença nos pacientes com manifestações clínicas semelhantes nas áreas endêmicas.

Esporotricose óssea e cutânea em canino / Cutaneos and osseous sporotrichosis in dog

A esporotricose é uma micose subcutânea causada pelo fungo dimórfico Sporothrix schenckii. Este artigo descreve o primeiro caso de esporotricose óssea e cutânea, em canino, na cidade de Pelotas, Rio Grande do Sul. O animal apresentava lesões ulceradas e crostosas, há aproximadamente três anos no plano nasal e membro torácico direito, dispnéia e apatia. Para confirmação do diagnóstico, foram realizados exames micológico, histopatológico, radiológico e hematológico. O animal foi tratado durante três meses com 10mg/kg de itraconazol,por via oral, obtendo-se a cura das lesões. Este estudo alerta clínicos de pequenos animais para a ocorrência desta micose em caninos na região de Pelotas, RS.

The sporotrichosis is a subcutaneous mycosis caused by dimorphic fungus Sporothrix schenckii. This article describes the first cutaneous and osseous sporotrichosis case in canine in the Pelotas city, Rio Grande do Sul. The animal presented crusts and ulcerated lesions,approximately the three years in the nasal plan and right hind-foot,dispneic and apathy. Mycological, histopathological, radiological and hematological diagnosis was realized. The animal was treated by three months with itraconazole, administered orally at a dosage of 10mg/kg, until lesions disappeared. This study alert small animals clinicians for the occurrence of this mycosis in dogs in the region of Pelotas, RS.

Perfil epidemiológico, clínico e terapêutico da esporotricose no Instituto de Pesquisa Clínica Evandro Chagas- FIOCRUZ, Rio de Janeiro, no período de 2002 a 2004 / The epidemiological, clinical and therapeutic profile of the sporotrichosis in the Instituto de Pesquisa Clínica Evandro Chagas- FIOCRUZ, Rio de Janeiro from 2002 through 2004

A esporotricose assumiu, a partir de 1998, uma importância sem precedentes no estado do Rio de Janeiro onde atingiu proporções epidêmicas. A casuística apresentada neste manuscrito é a maior já documentada no país e a maior epidemia da doença por transmissão zoonótica do mundo. O presente estudo relata as características epidemiológicas, clínicas e terapêuticas de 572 casos de esporotricose humana com diagnostico laboratorial confirmado pelo isolamento de Sporothrix schenckii em cultura. Todos os pacientes foram atendidos no ambulatório de esporotricose do Instituto de Pesquisas Evandro Chagas (Fundação Oswaldo Cruz – Rio de Janeiro) no período de 2002 a 2004. A infecção esteve relacionada à transmissão por gatos domésticos, que também desenvolveram a doença. A forma clínica mais freqüente foi a cutâneo-linfática, seguida das formas cutânea localizada e cutânea disseminada. A doença foi mais freqüente em adultos do sexo feminino. O itraconazol na dose de 100mg, em dose única diária foi eficiente na maioria dos casos tratados (96,5por cento), por um período médio de 12 semanas, sem reações adversas graves.

Study of oral itraconazole and terbinafine pulse therapy in onychomycosis.

In this open, randomized and comparative study, the safety and efficacy of systemic intermittent itraconazole and terbinafine was examined in 30 patients with onychomycosis. The patient with positive mycological culture and also the patients with positive microscopy and negative culture were investigated. Patients were randomly assigned: 15 patients in each group received either 200mg itraconazole or 250 mg terbinafine twice daily during the first week of a 4 weeks cycle. The treatment duration was 16 weeks and was followed-up for 36 weeks. Both the treatment regimen showed significant reduction in onychomycosis affected areas after 8 weeks and maximum reduction was observed at the end of 36 weeks. At the end point of the follow-up period, the clinical cure rates (no residual deformity or with some deformity) were 86.7% in the itraconazole group and 100% in the terbinafine group. The mycological cure rates were 86.7% and 100% respectively. However, no statistically significant differences between the treatment groups were seen in clinical, mycological (P= 0.864) and severity assessment (P= 0.220). Nausea, abdominal cramp, headache, back pain and flu like syndrome are the adverse effects more frequently reported. At least one adverse effect was reported by 17 patients, of them 12 belonged to itraconazole group and 5 to terbinafine group and the difference was statistically significant (P= 0.027). The overall therapeutic effectiveness, safety and cost affectivity were in favor of Terbinafine pulse therapy.

Molecular characterization of Acanthamoeba isolated from amebic keratitis related to orthokeratology lens overnight wear

In an effort to characterize, on the molecular scale, the Acanthamoeba initially isolated from the cornea of an amoebic keratitis patient associated with overnight-wear orthokeratology lens in Korea, we conducted mitochondrial DNA restriction fragment length polymorphism, 18S rDNA sequencing, and drug sensitivity analyses on the isolate (KA/PE1). The patient was treated with polyhexamethylene biguanide, chlorhexidine and oral itraconazole, which resulted in resolution of the patient's ocular inflammation. The majority of the molecular characteristics of the KA/PE1 were determined to be identical, or quite similar, to those of A. castellanii Ma strain, which had been isolated also from amoebic keratitis. The risk of Acanthamoeba keratitis as a potential complication of overnight orthokeratology is briefly discussed.

Intravenous Itraconazole vs. Amphotericin B Deoxycholate for Empirical Antifungal Therapy in Patients with Persistent Neutropenic Fever

BACKGROUND: Amphotericin B dexoycholate is currently the standard empirical antifungal therapy for neutropenic patients with hematologic malignancies and who also have persistent fever that does not respond to antibacterial therapy. The antifungal triazoles offer a potentially safer and effective treatment alternative to Amphotericin B dexoycholate. METHODS: We assessed the efficacy and safety of intravenous itraconazole, as compared with the efficacy and safety of amphotericin B deoxycholate, as an empirical antifungal therapeutic agent in a matched case-control clinical trial from June 2004 to August 2005. RESULTS: Efficacy was evaluated in 96 patients (48 received itraconazole and 48 received amphotericin B deoxycholate) and all the patients who received the study drugs were evaluated for safety. The baseline demographic characteristics were well matched. The overall success rates were 47.9% for itraconazole and 43.8% for amphotericin B deoxycholate (% difference: 4.1 % [95% confidence interval for the difference: -15.8 to 24]), which fulfilled the statistical criteria for the non-inferiority of itraconazole. The proportions of patients who survived for at least seven days after discontinuation of therapy or who were prematurely discontinued from the study were not significantly different between the two groups. The rates of breakthrough fungal infections and resolution of fever during neutropenia were similar in both groups. More patients who received amphotericin B deoxycholate developed nephrotoxicity, hypokalemia or infusion-related events than did those patients who received itraconazole (nephrotoxicity: 16.7% vs. 1.8%, hypokalemia: 66.7% vs. 24.6%, and infusion-related events: 41.7% vs. 3.5%, respectively). CONCLUSIONS: Intravenous itraconazole is as effective as amphotericin B deoxycholate and it is generally better tolerated than amphotericin B deoxycholate when it is given as empirical antifungal therapy for Korean patients with persistent neutropenic fever.