A scoping study of pulmonary paracoccidioidomycosis: severity classification based on radiographic and tomographic evaluation

The lungs have great importance in patients with paracoccidioidomycosis since they are the portal of entry for the infecting fungi, the site of quiescent foci, and one of the most frequently affected organs. Although they have been the subject of many studies with different approaches, the severity classification of the pulmonary involvement, using imaging procedures, has not been carried out yet. This study aimed to classify the active and the residual pulmonary damage using radiographic and tomographic evaluations, according to the area involved and types of lesions.

Actinomicosis pulmonar en niños: reporte de dos casos peruanos / Pulmonary actinomycosis in children: report of two Peruvian cases

INTRODUCCIÓN: La actinomicosis es una enfermedad infecciosa poco frecuente, ocasionada por una bacteria Gram positiva. La especie más común es Actinomyces israelii. Dentro de sus formas de presentación, la torácica es la menos frecuente. PRESENTACIÓN DE CASOS: Reportamos dos pacientes con actinomicosis torácica de 8 y 13 años de diferentes zonas geográficas de Perú. El primer caso tuvo empiema necessitatis y el segundo, consolidación pulmonar y hemoptisis recurrente. Ambos tuvieron cierto grado de dificultad en su diagnóstico, pero con una buena respuesta al tratamiento antibiótico y quirúrgico. El diagnóstico fue mediante estudio histopatológico. Sin embargo, no se pudo identificar la especie de Actinomyces. CONCLUSIÓN: La actinomicosis torácica es poco frecuente en niños y se presenta como una lesión parenquimal con posible fistulización a la pared torácica. Este es uno de los pocos casos reportados en la literatura peruana, constituyendo una contribución al conocimiento de esta enfermedad y su manejo en pediatría.

INTRODUCTION: Actinomycosis is a rare infectious disease caused by Gram-positive bacteria. The most common species is Actinomyces israelii. Among its forms of presentation, the thoracic is the least frequent. CASE PRESENTATION: We report two patients with thoracic actinomycosis, 8 and 13 years old, from different geographical areas of Peru. The first case had empyema necessitans and the second, lung consolidation and recurrent hemoptysis. Both had a certain degree of difficulty in their diagnosis but responded favorably to antibiotics and surgical treatment. The diagnosis was based on the histopathological study. However, we were not able to ascertain the species of actinomyces. CONCLUSION: Thoracic actinomycosis is rare in children and presents as a parenchymal lesion with possible fistulization to the chest wall. This article is one of the few in the Peruvian literature, constituting a contribution to the knowledge of the disease and its management in pediatrics.

Características clínicas e epidemiológicas de casos de infecção pulmonar por Mycobacterium kansasii no Rio de Janeiro, no período de 2006 a 2016 / Clinical and epidemiological characteristics of M. kansasii pulmonary infections from Rio de Janeiro, Brazil, between 2006 and 2016

RESUMO Objetivo Avaliar características clínicas, tomográficas e microbiológicas dos pacientes com doença pulmonar causada pela M. kansasii (DPMK) atendidos em unidade ambulatorial no período 2006-2016. Métodos Estudo descritivo, em que foram analisados 38 pacientes. Foram analisadas as características demográficas, clínico-radiológicas, laboratoriais e terapêuticas. Resultados A média de idade foi 64 anos (DP=10,6; IIQ=57-72; mediana=65,0) e 22 (57,9%) eram pacientes do sexo masculino. Comorbidade pulmonar estava presente em 89,5%. A comorbidade mais frequente foi a bronquiectasia (78,9%). Tratamento anterior para tuberculose pulmonar (TBP) foi relatado em 65,9%. O esquema terapêutico mais utilizado foi rifampicina, isoniazida e etambutol (44,7%). A tomografia de tórax (TCT) mostrou bronquiectasia (94,1%), distorção arquitetural (76,5%), espessamento de septo (67,6%) e cavidades (64,7%). A doença foi bilateral em 85,2%. Houve 10,7% de resistência à rifampicina, 67,9% resistentes ao etambutol e sensibilidade à claritromicina. Conclusão Em pacientes com doença pulmonar estrutural, é importante a busca de DPMNT, principal diagnóstico diferencial com TBP. TC de tórax demonstra diferentes padrões que se sobrepõem ao de doença estrutural causada por TBP ou outras enfermidades pulmonares. Destaca-se a resistência ao etambutol, fármaco componente do esquema preconizado.

ABSTRACT Objective To evaluate clinical, tomographic, and microbiological characteristics of pulmonary disease caused by M. kansasii (MKPD) in patients treated at an outpatient unit from 2006-2016. Methods We studied thirty eight patients, and analyzed socio-demographic, clinical-radiological, laboratory, and therapeutic characteristics. Results The mean age was 64 years (SD = 10.6; IIQ = 57-72; median = 65.0), and 22 (57.9%) male patients. Pulmonary comorbidity was present in 89.5% of the patients. The most frequent comorbidity was bronchiectasis (78.9%). Previous treatment for pulmonary tuberculosis (PTB) was found in 65.9%. The most used therapeutic regimen was rifampicin, isoniazid and ethambutol (44.7%). Chest tomography (CT) showed bronchiectasis (94.1%), architectural distortion (76.5%), septum thickening (67.6%), and cavities (64.7%). Disease was bilateral in 85.2%. We observed 10.7% resistance to rifampicin, 67.9% resistance to ethambutol, and sensitivity to clarithromycin. Conclusion In patients with structural lung disease, it is important to search for NTM, the main differential diagnosis with PTB. Chest CT showed different patterns that overlapped with structural disease caused by PTB or other lung diseases. We observed resistance to ethambutol, a drug component of the recommended regimen.

Sífilis secundaria con compromiso pulmonar / Secondary syphilis with pulmonary involvement

La sífilis es una enfermedad de transmisión sexual causada por una espiroqueta, Treponema palidum. Presentamos el caso de una mujer de 62 años de edad, que consultó por fiebre de 38°, dolor torácico en puntada de costado y lesiones pruriginosas en piel. Se realizó examen de laboratorio de sangre periférica, radiografía y tomografía de tórax. Recibió tratamiento antibiótico y fue diagnosticada como neumonía aguda de la comunidad. Debido a la respuesta parcial de los síntomas y persistencia de lesiones pruriginosas se realizó biopsia de piel que informó Treponema palidum, el cual fue confirmado con test serológico VDRL y FtA-abs positivo. La paciente recibió 4 dosis de penicilina G benzatínica con favorable evolución de las lesiones en piel y mejoría de las imágenes radiológicas.

We present the case of a 62-year-old woman who consulted for fever (38°), stabbing thoracic pain (on one side), and pruritic skin lesions. She underwent peripheral blood tests, chest X-rays and CT. Her symptoms were interpreted as severe community-acquired pneumonia. After a treatment with antibiotics, her skin lesions persisted, and other symptoms were only partially relieved. A skin biopsy was performed, which revealed Treponema pallidum. Such finding was confirmed through positive serum VDRL and FTA-ABS tests. The patient received 4 doses of benzathine penicillin G with favorable evolution of skin lesions and improvement of radiological images.

Secondary syphilis with pulmonary involvement mimicking lymphoma: a case report

Abstract We present a case of atypical presentation of secondary syphilis with extensive lymph node involvement and pulmonary lesions, initially suspected as lymphoma. The patient presented with weight loss, dry cough, chest pain, palpable lymph nodes in several peripheral chains, and multiple pulmonary nodules and masses on chest imaging. The key features for secondary syphilis diagnosis were a lymph node biopsy suggestive of reactive lymphadenopathy, positive serologic tests for syphilis, and complete recovery after antisyphilitic treatment.

The pulmonary microbiome: challenges of a new paradigm / Microbioma pulmonar: desafios de um novo paradigma

ABSTRACT The study of the human microbiome-and, more recently, that of the respiratory system-by means of sophisticated molecular biology techniques, has revealed the immense diversity of microbial colonization in humans, in human health, and in various diseases. Apparently, contrary to what has been believed, there can be nonpathogenic colonization of the lungs by microorganisms such as bacteria, fungi, and viruses. Although this physiological lung microbiome presents low colony density, it presents high diversity. However, some pathological conditions lead to a loss of that diversity, with increasing concentrations of some bacterial genera, to the detriment of others. Although we possess qualitative knowledge of the bacteria present in the lungs in different states of health or disease, that knowledge has advanced to an understanding of the interaction of this microbiota with the local and systemic immune systems, through which it modulates the immune response. Given this intrinsic relationship between the microbiota and the lungs, studies have put forth new concepts about the pathophysiological mechanisms of homeostasis in the respiratory system and the potential dysbiosis in some diseases, such as cystic fibrosis, COPD, asthma, and interstitial lung disease. This departure from the paradigm regarding knowledge of the lung microbiota has made it imperative to improve understanding of the role of the microbiome, in order to identify possible therapeutic targets and to develop innovative clinical approaches. Through this new leap of knowledge, the results of preliminary studies could translate to benefits for our patients.

RESUMO O estudo do microbioma humano - e, mais recentemente, o do sistema respiratório - através de sofisticadas técnicas de biologia molecular, desvendou a imensa diversidade de colonização microbiana nos seres humanos, sejam saudáveis, sejam portadores de diferentes doenças. Aparentemente, ao contrário do que se acreditava, existe uma colonização não patogênica dos pulmões por microrganismos, como bactérias, fungos e vírus. Esse microbioma pulmonar fisiológico apresenta uma densidade baixa de colônias, porém uma elevada diversidade; por outro lado, alguns estados patológicos levam a uma perda dessa diversidade, com aumento da concentração de alguns gêneros bacterianos em detrimento de outros. Ainda, além do conhecimento qualitativo das bactérias presentes no pulmão em diversos estados de saúde ou de doença, o conhecimento avança para o entendimento da interação que essa microbiota tem com o sistema imune local e sistêmico, modulando a resposta imunológica. Compreendendo essa intrínseca relação entre a microbiota e os pulmões, estudos apresentam novos conceitos sobre os mecanismos fisiopatogênicos da homeostase do sistema respiratório e a possível disbiose em estado de algumas doenças, como fibrose cística, DPOC, asma e doenças intersticiais. Essa quebra de paradigma do conhecimento da microbiota presente nos pulmões fez com que se torne premente entender melhor o papel do microbioma para identificar possíveis alvos terapêuticos e abordagens clínicas inovadoras. Através desse novo salto de conhecimento é que os resultados dos estudos preliminares poderão ser traduzidos em benefícios aos nossos pacientes.

Nontuberculous mycobacterial lung disease in a high tuberculosis incidence setting in Brazil / Doença pulmonar por micobactérias não tuberculosas em uma região de alta incidência de tuberculose no Brasil

ABSTRACT Objective: The incidence of lung disease caused by nontuberculous mycobacteria (NTM) has been increasing worldwide. In Brazil, there are few studies about nontuberculous mycobacterial lung disease (NTMLD), and its prevalence is yet to be known. Our objective was to determine the specific etiology of the disease in the state of Rio Grande do Sul, Brazil, as well as the frequency and diversity of NTM species in our sample of patients. Methods: This is a retrospective analysis of the medical records of patients diagnosed with NTMLD treated in a referral center located in the city of Porto Alegre, Brazil, between 2003 and 2013. Results: Our sample comprised 100 patients. The most prevalent NTM species were Mycobacterium avium complex (MAC), in 35% of the cases; M. kansasii, in 17%; and M. abscessus, in 12%. A total of 85 patients had received previous treatment for tuberculosis. Associated conditions included structural abnormalities in the lungs, such as bronchiectasis, in 23% of the cases; COPD, in 17%; and immunosuppressive conditions, such as AIDS, in 24%. Conclusions: MAC and M. kansasii were the most prevalent species involved in NTMLD in the state, similarly to what occurs in other regions of Brazil. Data on regional epidemiology of NTMLD, its specific etiology, and associated conditions are essential to establish appropriate treatment, since each species requires specific regimens. Most patients with NTMLD had received previous tuberculosis treatment, which might lead to development of resistance and late diagnosis.

RESUMO Objetivo: A incidência de doença pulmonar causada por micobactérias não tuberculosas (MNT) tem aumentado em todo o mundo. No Brasil, há poucos estudos sobre doença pulmonar por MNT, e sua prevalência ainda não é conhecida. Nosso objetivo foi determinar a etiologia específica da doença no estado do Rio Grande do Sul, bem como a frequência e a diversidade das espécies de MNT em nossa amostra de pacientes. Métodos: Análise retrospectiva dos prontuários de pacientes diagnosticados com doença pulmonar por MNT atendidos em um centro de referência localizado na cidade de Porto Alegre, RS, entre 2003 e 2013. Resultados: Nossa amostra foi composta por 100 pacientes. As espécies de MNT mais prevalentes foram Mycobacterium avium complex (MAC, complexo M. avium), em 35% dos casos; M. kansasii, em 17%; e M. abscessus, em 12%. Um total de 85 pacientes havia feito tratamento anterior para tuberculose. Condições associadas incluíram anormalidades estruturais nos pulmões, como bronquiectasias, em 23% dos casos; DPOC, em 17%; e condições imunossupressoras, como AIDS, em 24%. Conclusões: MAC e M. kansasii foram as espécies mais prevalentes envolvidas na doença pulmonar por MNT no estado, à semelhança do que ocorre em outras regiões do Brasil. Dados sobre a epidemiologia regional da doença pulmonar por MNT, sua etiologia específica e condições associadas são fundamentais para se estabelecer um tratamento adequado, já que cada espécie requer um esquema específico. A maioria dos pacientes com doença pulmonar por MNT havia feito tratamento anterior para tuberculose, o que pode levar a desenvolvimento de resistência e diagnóstico tardio.

Clinical aspects in patients with pulmonary infection caused by mycobacteria of the Mycobacterium abscessus complex, in the Brazilian Amazon / Aspectos clínicos em pacientes com infecção pulmonar por micobactérias do complexo Mycobacterium abscessus na Amazônia brasileira

ABSTRACT Objective: To describe the clinical manifestations of patients with pulmonary infection caused by mycobacteria of the Mycobacterium abscessus complex (MABSC), and to compare these manifestations with those of patients infected with other nontuberculous mycobacteria (NTM). Methods: This was a retrospective cohort study involving 43 patients divided into two groups: the MABSC group, consisting of patients with pulmonary infection caused by MABSC (n = 17); and the NTM group, consisting of patients with pulmonary infection caused by NTM other than MABSC (n = 26). Patients were previously treated with a regimen of rifampin, isoniazid, pyrazinamide, and ethambutol before the diagnosis of NTM was confirmed by two culture-positive sputum samples. The nucleotide sequences of the hsp65, 16S rRNA, and/or rpoB genes were analyzed to identify the mycobacteria. Data were collected on demographic, clinical, and radiological characteristics, as well as on treatment responses and outcomes. Results: Loss of appetite was the only clinical manifestation that was significantly more common in the MABSC group than in the NTM group (p = 0.0306). The chance of having to use a second treatment regimen was almost 12 times higher in the MABSC group than in the NTM group. Treatment success was significantly higher in the NTM group than in the MABSC group (83.2% vs. 17.6%; p < 0.0001). The chance of recurrence was approximately 37 times higher in the MABSC group than in the NTM group. Conclusions: In the study sample, treatment response of pulmonary disease caused by MABSC was less favorable than that of pulmonary disease caused by other NTM.

RESUMO Objetivo: Descrever as manifestações clínicas de pacientes com infecção pulmonar por micobactérias do complexo Mycobacterium abscessus (CMA) e compará-las com as daqueles infectados com outras micobactérias não tuberculosas (MNT). Métodos: Estudo de coorte retrospectivo envolvendo 43 pacientes divididos em dois grupos: grupo CMA, com pacientes com infecção pulmonar por CMA (n = 17); e grupo MNT, com pacientes com infecção pulmonar por MNT que não CMA (n = 26). Os pacientes foram previamente tratados com o esquema rifampicina, isoniazida, pirazinamida e etambutol antes de o diagnóstico de MNT ser confirmado com culturas positivas em duas amostras de escarro diferentes. As sequências nucleotídicas dos genes hsp65, RNAr 16S e/ou rpoB foram analisadas para a identificação das micobactérias. Foram coletadas características demográficas, clínicas e radiológicas, assim como respostas terapêuticas e desfechos. Resultados: A única manifestação clínica significativamente mais frequente no grupo CMA que no grupo MNT foi hiporexia (p = 0,0306). A chance de haver a necessidade de utilização de um segundo esquema terapêutico foi quase 12 vezes maior no grupo CMA que no grupo MNT. O sucesso terapêutico foi significativamente maior no grupo MNT que no grupo CMA (83,2% vs. 17,6%; p < 0,0001). A chance de recidiva no grupo CMA foi aproximadamente 37 vezes maior que no grupo MNT. Conclusões: Na amostra estudada, a resposta terapêutica da doença pulmonar causada por CMA evoluiu de forma menos favorável do que naquela causada pelas demais MNT.

Tuberculosis y actinomicosis: Un caso pediatrico de comorbilidad / Pulmonary actinomycosis and tuberculosis: A comorbidity pediatric case

La actinomicosis es una infección supurativa crónica, producida por bacterias Gram-positivas anaeróbicas o especies Actinomyces microaerófilas. Es rara en niños y adolescentes; es más común en inmunodeprimidos. El Mycobacterium tuberculosis colabora en el desarrollo de la enfermedad. La afectación pulmonar aparece como un cuadro de condensación crónica que no mejora con el tratamiento antibiótico convencional. Las complicaciones clásicas de afectación de la pared torácica con fistulización y supuración en «granulo de azufre¼ son descritas con menor frecuencia en la actualidad. El diagnóstico es un verdadero desafío y se establece mediante el aislamiento de las especies de Actinomyces. El tratamiento de elección para todas las formas clínicas de la enfermedad es el uso prolongado de antibióticos. Objetivo. Presentar un caso pediátrico de comorbilidad entre tuberculosis y actinomicosis. Resaltar la importancia de la sospecha diagnóstica de actinomicosis frente a todo proceso supurado crónico.

Actinomycosis is a chronic suppurative infection, produced by anaerobic Gram-positive bacteria or microaerobic Actinomyces species. It is rare in children and adolescents and it is more common in immunocompromised. Mycobacterium tuberculosis collaborates on the development of the disease. Pulmonary involvement appears as a picture of chronic condensation that does not improve with conventional antibiotic treatment. Classic complications affecting the thoracic wall with drainage in «sulfur granule¼ and fistulization are described less frequently nowadays. The diagnosis is a real challenge and it is set by using the isolation of species of Actinomyces. The treatment of choice for all clinical forms of the disease is the prolonged use of antibiotics. Objective: to present a pediatric case of comorbidity between tuberculosis and actinomycosis and to highlight the importance of diagnostic suspicion of actinomycosis in the presence of all chronic suppurative processes.

Elevated serum CA 19-9 levels in patients with pulmonary nontuberculous mycobacterial disease

Abstract Increased serum CA 19-9 levels in patients with nonmalignant diseases have been investigated in previous reports. This study evaluates the clinical significance of serum CA 19-9 elevation in pulmonary nontuberculous mycobacterial disease and pulmonary tuberculosis. The median CA 19-9 level was higher in patients with pulmonary nontuberculous mycobacterial disease than in patients with pulmonary tuberculosis (pulmonary nontuberculous mycobacterial disease: 13.80, tuberculosis: 5.85, p < 0.001). A multivariate logistic regression analysis performed in this study showed that Mycobacterium abscessus (OR 9.97, 95% CI: 1.58, 62.80; p = 0.014) and active phase of pulmonary nontuberculous mycobacterial disease (OR 12.18, 95% CI: 1.07, 138.36, p = 0.044) were found to be risk factors for serum CA 19-9 elevation in pulmonary nontuberculous mycobacterial disease. The serum CA 19-9 levels showed a tendency to decrease during successful treatment of pulmonary nontuberculous mycobacterial disease but not in pulmonary tuberculosis. These findings suggest that CA 19-9 may be a useful marker for monitoring therapeutic responses in pulmonary nontuberculous mycobacterial disease, although it is not pulmonary nontuberculous mycobacterial disease-specific marker.

Infección pulmonar por Mycobacterium avium en paciente VIH/SIDA: Primer reporte en Perú / Mycobacterium avium lung infection in HIV/AIDS patient: First report in Peru

El complejo Mycobacterium avium (MAC) es un patógeno que se encuentra en el medioambiente y causa infecciones tanto en pacientes inmunocompetentes como inmunocomprometidos. Se presenta el caso de un paciente VIH positivo varón de 38 años infectado por P. jirovecii y aparentemente infectado por Mycobacterium tuberculosis desde el año 2009, el cual fue tratado con antibioticoterapia para pneumocistosis y terapia antituberculosis (TB) logrando mejoría parcial. En el año 2012 se le realizó nuevamente examen de cultivo y un nuevo tratamiento anti TB, frente a la sospecha de estar en presencia de una cepa de TB multidrogorresistente se recomienda realizar la identificación micobacteriana. El examen de cultivo fue positivo y el resultado genotípico resultó positivo para MAC. Se reporta el primer caso de un paciente VIH/SIDA con infección pulmonar por MAC en el Perú, así como una breve revisión de los aspectos epidemiológicos, clínicos y de tratamiento.

The Mycobacterium avium complex (MAC) is a pathogen found in the environment which causes infections in immunocompetent and immunocompromised patients. One case is presented: an HIV positive, 38 year old male patient, infected with P. jirovecii and apparently infected with Mycobacterium tuberculosis since 2009. He was treated with antibiotic therapy for pneumocystosis and antituberculosis (TB) therapy, which achieved a partial improvement. In 2012, the patient underwent a culture test and new anti TB treatment. Upon suspicion of a drug resistant TB strain, it was recommended to perform the mycobacterial identification. The culture test was positive and the genotypic result was positive for MAC. The first case of an HIV/AIDS patient with MAC lung infection in Peru is reported, as well as a brief review of the epidemiological, clinical and treatment aspects to the case.

Actinomicosis torácica por actinomyces odontolyticus / Pulmonary actinomycosis by actinomyces odontolyticus. A case report and review of the literature

Introduction: Actinomycosis is an infrequent infection caused by bacteria from Actinomyces genus that manifests as a chronic, suppurative and progressive disease. Thoracic actinomycosis occurs in 18 percent of the cases, and infection by Actinomyces odontolyticus is even less frequent. The clinical presentation mimics tuberculosis or neoplastic processes. Clinical case: We report the case of a 75 years old man with COPD and Diabetes Mellitus type 2. He was referred to our clinic presenting a history of chronic cough, progressive dyspnea, fever and occasional bouts of haemoptysis. Chest radiograph showed a peripherally-located parenchymal opacity in the upper right lobe with over a year of evolution that later became a cavitary mass mimicking bronchogenic neoplasm or tuberculosis. The patient underwent bronchoscopic and CT- guided biopsy that showed necrosis and inflammatory cells. In the culture of cavitary fluids grew Actinomyces odontolyticus. We concluded that it was a thoracic actinomycosis. Penicillin 20 million units per day for six weeks was given, followed by oral amoxicillin for 6 months with good clinical and radiological response. Comments: To our knowledge this is the first report in Chile of lung infection caused by Actinomyces odontolyticus. Actinomycosis is a great masquerader, in this case we made the diagnosis with a fluid culture. This microorganism must be considered in the differential diagnostic in cavitary lung diseases.

Introducción: La actinomicosis pulmonar es una infección infrecuente causada por una bacteria del género Actinomyces, se manifiesta como un proceso crónico, supurativo de curso progresivo, el compromiso torácico ocurre aproximadamente en el 18 por ciento de los casos y la infección por Actinomyces odontolyticus es aun menos frecuente. Caso clínico: Se presenta el caso de un paciente hombre de 75 años de edad con antecedentes de EPOC y Diabetes Mellitus tipo 2, que fue derivado a nuestra clínica por cursar con una reagudización infecciosa persistente caracterizada por tos productiva, disnea progresiva,fiebre y episodios reiterados de hemoptisis de escasa cuantía. En la radiografía de tórax y tomografia computada, se detectaron opacidades mal definidas en lóbulo superior derecho de un año de evolución, que posteriormente se transforman en una masa cavitada adyacente a la pared toráxica simulando una neoplasia broncogénica o tuberculosis. El paciente fue sometido a fibrobroncoscopía realizándose biopsia y punción transbronquial. Posteriormente se efectuó biopsia por punción trans-toráxica guiada radiológicamente y en una muestra de tejido de aspecto necrótico y en líquido de la cavidad enviado a cultivo se pudo aislar Actinomyces odontolyticus. Concluyéndose que se trataba de una actinomicosis tóraco-pulmonar, se procedió a tratar con penicilina sódica 20 10(6) UI/dia por seis semanas y después se programó tratamiento por seis meses con amoxicilina vía oral, con buena respuesta clínica y radiológica. Comentarios: En nuestro conocimiento esta sería la primera comunicación en Chile de una lesión pulmonar producida por Actinomyces odontolyticus. La Actinomicosis, es un gran imitador, en este caso realizamos el diagnóstico con cultivo de líquido por punción. Este microorganismo debe ser considerado en el diagnóstico diferencial de lesiones cavitarias pulmonares.

Infección pulmonar por mycobacterium avium complex en el huésped inmunocompetente / Mycobacterium avium complex pulmonary disease in immunocompetent adult patients

Las micobacterias no tuberculosas (MNT) se reconocen cada vez más como importantes patógenos pulmonares. El complejo Mycobacterium avium-intracellulare (MAC) causa la mayoría de las infecciones pulmonares por MNT. Aunque el organismo fue identificado en la década de 1890, su potencial patogenicidad en seres humanos fue reconocida sólo cincuenta años después. Los pacientes con enfermedad pulmonar preexistente o inmunodeficiencia están en mayor riesgo de desarrollar infección por MAC. Sin embargo, la mayoría de los casos se producen en mujeres de edad avanzada inmunocompetentes en asociación con infiltrados nodulares y bronquiectasias. Recientemente, la enfermedad pulmonar también se ha descrito en pacientes inmunocompetentes expuestos a equipos de hidroterapia o jacuzzis contaminados con MAC. En relación a dos pacientes adultos inmunocompetentes con enfermedad pulmonar por MAC examinamos el cuadro clínico, los criterios diagnósticos y el tratamiento de esta entidad.

Nontuberculous mycobacteria (NTM) are increasingly recognized as important pulmonary pathogens. Mycobacterium avium intracellulare complex (MAC) causes most lung infections due to NTM. Although the organism was identified in the 1890s, its potential to cause human disease was only recognized 50 years later. Patients with preexisting lung disease or immunodeficiency are at greatest risk for developing MAC infection. The majority of MAC pulmonary cases, however, occur in immunocompetent elderly women in association with nodular infiltrates and bronchiectasis. More recently, pulmonary disease has also been described in immunocompetent patients after exposure to MAC-contaminated hot tubs. We describe two cases of MAC lung disease in immunocompetent adult patients without preexisting lung disease and we review clinical manifestations, diagnostic criteria and treatment of this entity.

Isolation of a rare nocardia wallacei from an HIV-positive patient with pulmonary infection in southern Saudi Arabia

This study aimed to clarify the taxonomic position of an actinomycete isolated from an HIV-positive male patient with pulmonary complications in Asir, southern region of Saudi Arabia. The strain was found to have phenotypic properties typical of nocardiae and 16S rRNA gene analysis clustered the isolate with Nocardia wallacei [accession KC677696] in the phylogenetic branch of the amikacin resistance Nocardia transvalensis complex. We consider that nocardiosis is usually missed or misdiagnosed clinically and recognition of these bacteria based on phenotypic tests is strenuous, but definitive identification is attainable by molecular methods

Phenotypic and genotypic characterization of Rhodococcus equi isolated from sputum

INTRODUCTION: Rhodococcus equi is an opportunistic pathogen, causing rhodococcosis, a condition that can be confused with tuberculosis. Often, without identifying M. tuberculosis, physicians initiate empiric treatment for tuberculosis. R. equi and M. tuberculosis have different susceptibility to drugs. Identification of R. equi is based on a variety of phenotypic, chromatographic, and genotypic characteristics. OBJECTIVE: This study aimed to characterize bacterial isolates from sputum samples suggestive of R. equi. METHODS: The phenotypic identification included biochemical assays; thin-layer chromatography (TLC) and polymerase chain reaction (PCR) were used for genotypic identification. RESULTS: Among 78 Gram-positive and partially acid-fast bacilli isolated from the sputum of tuberculosis-suspected patients, 51 were phenotypically and genotypically characterized as R. equi based on literature data. Mycolic acid analysis showed that all suspected R. equi had compounds with a retention factor (Rf) between 0.4-0.5. Genotypic characterization indicated the presence of the choE gene 959 bp fragments in 51 isolates CAMP test positive. Twenty-two CAMP test negative isolates were negative for the choE gene. Five isolates presumptively identified as R. equi, CAMP test positive, were choE gene negative, and probably belonged to other bacterial species. CONCLUSIONS: The phenotypic and molecular techniques used constitute a good methodological tool to identify R. equi.

Actinomycosis affecting the spinal cord: a case report / Actinomicose comprometendo a medula espinhal: um relato de caso

Actinomycosis is a rare, chronic, suppurative, granulomatous infection caused by a group of gram-positive anaerobic bacteria belonging to the natural flora of the oral cavity and gastrointestinal and urogenital tracts. It may involve several organs. This case study refers to pulmonary actinomycosis with chest wall involvement and cord compression in a 29-year-old male who presented with fever, cough, hemoptysis, neck pain, and paresis and plegia of the lower limbs of 5-month duration.

A actinomicose é uma infecção rara, crônica, supurativa e granulomatosa, causada por um grupo de bactérias anaeróbias Gram-positivas que pertencem à flora natural da cavidade oral, do aparelho gastrointestinal e urogenital. Pode envolver diversos órgãos. O estudo refere-se à actinomicose pulmonar com envolvimento da parede torácica e compressão medular em um paciente masculino com 29 anos que apresentava febre, tosse, hemoptise e cervicalgia, além de paresia e plegia em membros inferiores com cinco meses de evolução.

Cáncer, neutropenia febril e imágenes pulmonares: Hallazgos en el lavado broncoalveolar en niños / Cancer, febrile neutropenia and pulmonary images: Findings in bronchoalveolar lavage in children

Introduction: Lung infections are a serious complication in children with cancer. Bronchoalveolar lavage (BAL) has been demonstrated to be an effective procedure for achieving etiologic diagnosis. Method: We did a retrospective analysis of BAL data performed between November 2005 and October 2008 in children with cancer, severe neutropenia and lung infiltrates for assessing its performance, clinical utility and safety. Thirty-seven BAL were evaluated in 35 patients. Results: Focal infiltrates were demonstrated in imaging studies associated with 19/37 BAL; in 8 an infectious agent was found. Interstitial pattern was observed in 15/37, in which there were 4 positive studies, proving a higher microbiological performance in BAL associated with focal lesions. BAL yielded significant microbiological findings in 32.4% (12/37). Sixteen microorganisms were identified in the study: bacteria in 8 cases, Mycobacterium tuberculosis (n: 2), Pseudomonas aeruginosa (n: 2), Acinetobacter baumannii (n: 1), A. Iwoffii (n: 1), group viridans Streptococcus (n: 1), Mycoplasma pneumoniae (n: 1); viruses in 3 cases, metapneumovirus (n: 2) cytomegalovirus (n: 1) and fungal infection in 5 cases, Pneumocystis jiroveci (n: 2) Aspergillus fumigatus (n: 1), Aspergillus niger (n: 1), Candida albicans (n: 1). Therapeutic adjustments were done in 6/37 episodes (16.2%). Conclusion: BAL has a significant role in the evaluation of pulmonary infiltrates in pediatric oncological patients, requiring a prompt and safe diagnosis, which is crucial for the survival with minimal morbidity. Our results suggest that BAL by fiberbronchoscopy should be considered as an initial diagnostic tool in these patients.

Las infecciones pulmonares en niños con cáncer son una complicación grave. El lavado broncoalveolar (LBA) es un procedimiento efectivo para llegar a un diagnóstico etiológico. Se analizaron los resultados de LBA realizados entre noviembre de 2005 y octubre de 2008, en niños con cáncer y neutropenia grave e infiltrados pulmonares para conocer su rendimiento, utilidad clínica y seguridad. Se evaluaron 37 LBA en 35 pacientes. En 19/37 casos los infiltrados radiológicos fueron focales, en 8 se encontró etiología por LBA. En 15/37 casos las imágenes fueron intersticiales encontrándose etiología en 4, resultando un rendimiento microbiológico superior en las lesiones focales. Las muestras del LBA fueron positivas en 32,4% de los episodios (12/37). Se detectaron 16 microorganismos: 8 bacterias, a saber Mycobacterium tuberculosis (n: 2), Pseudomonas aeruginosa (n: 2), Acinetobacter baumannii (n: 1), A. Iwoffii (n: 1), Streptococcus grupo viridans (n: 1) y Mycoplasma pneumoniae (n: 1); 3 virus: metapneumovirus (n: 2) y citomegalovirus (n: 1); 5 hongos: Pneumocystis jiroveci (n: 2), Aspergillus fumigatus (n: 1), Aspergillus niger (n: 1) y Candida albicans (n: 1). Se reportaron cambios en la conducta terapéutica en 6 de 37 pacientes (16,2%) con inicio de nuevas terapias o suspensión de tratamientos empíricos. El LBA tuvo un adecuado rendimiento, sin complicaciones importantes por lo que debe ser considerado precozmente y realizado con un estudio protocolizado.

Lung Infection Caused by Mycobacterium riyadhense Confused with Mycobacterium tuberculosis: The First Case in Korea

A slowly growing, non-chromogenic mycobacterial strain was isolated from sputum and bronchial lavage fluid samples of a patient presenting with productive cough, blood-tinged sputum, low-grade fever, and weakness. A positive acid-fast bacilli sputum smear result prompted the initiation of an anti-tuberculosis regimen. Multiplex real-time PCR showed a negative result for Mycobacterium tuberculosis complex and a positive result for nontuberculous mycobacteria. The DNA chip test confirmed this organism as a member of the genus Mycobacterium, but could not specify the species. Interestingly, the mycolic acid patterns obtained by HPLC nearly overlapped with those of M. simulans. The sequences of the Mycobacterium 16S rRNA gene and 16S-23S internal transcribed spacer region were unique and were found to have 100% similarity with those of M. riyadhense. After a review of the literature, we report this case as the first Korean case of M. riyadhense lung infection.