Anal mycobacterial infections / Infecções micobacterianas do ânus

Abstract Background Mycobacterial infections are a serious public health problem worldwide. Involvement of the anal canal and perineum is very rare, but constitute an important differential diagnosis with other equally serious pathologies that may affect the region, such as malignant neoplasms and Crohn's disease. Objectives To conduct a literature review on mycobacterial infections of the perianal region considering the most recent information for diagnostic and therapeutic guidance of this disease. Methods Research was performed on the PUBMED and LILACS databases with the expressions Mycobacterium, Anal, Infection and Tuberculosis. We reviewed articles referring to series of treated cases, clinical reports and literature review published since 2005. Results Information was compiled on the epidemiology of mycobacterial infections; the clinical behavior of affected individuals; diagnostic options and their validity in clinical practice; and, finally, therapeutic options. Conclusions Mycobacterial infections of the anus and perineum are rare. The most common clinical presentations are the presence of ulceration and fistulization. The diagnosis involves more than one procedure for identifying the bacilli and should consider the presence of manifestations in more than one organ. The treatment is based on pharmacological intervention. Surgery is recommended for acute complications or chronic sequelae of the disease.

Resumo Introdução Infecções micobacterianas constituem um grave problema de saúde pública a nível mundial. As manifestações anoperineais são raras, mas constituem um importante diagnóstico diferencial com outras patologias igualmente graves que podem acometer a região, como as neoplasias malignas e a doença de Crohn. Objetivos Realizar um levantamento da literatura sobre infecções micobacterianas da região anoperineal, considerando as informações mais atuais para orientação diagnóstica e terapêutica dessa enfermidade. Métodos Foi realizada pesquisa nos bancos de dados PUBMED e LILACS com as expressões Mycobacterium, Anal, Infection e Tuberculosis. Foram revisados artigos referentes a séries de casos tratados, relatos clínicos e revisão da literatura publicada a partir de 2005. Resultados Foram compiladas informações sobre a epidemiologia das infecções micobacterianas; o comportamento clínico dos indivíduos afetados; opções diagnósticas e sua validade na prática clínica; e, por fim, opções terapêuticas. Conclusões Infecções micobacterianas da região anoperineal são raras. As apresentações clínicas mais comuns são a formação de ulceras e a fistulização. O diagnóstico envolve mais de um procedimento para identificação dos bacilos, e deve considerar a presença de manifestações em mais de um órgão. O tratamento é principalmente medicamentoso, sendo a cirurgia recomendada nas complicações agudas ou sequelas crônicas da doença.

Infecciones por micobacterias en otorrinolaringología: revisión de la literatura / Mycobacterial infections in otolaryngology: review

Las micobacterias constituyen un grupo de bacilos aeróbicos no capsulados y no móviles, algunos de los cuales son patógenos causantes de graves enfermedades en los mamíferos incluyendo tuberculosis y lepra. Chile, a pesar de pertenecer al grupo de países de baja prevalencia de tuberculosis en América, presentó un enlentecimiento en la curva de descenso de incidencia. Así mismo, se ha visto un aumento de micobacterias atípicas tanto en muestras pulmonares como extrapulmonares respecto a décadas anteriores. Por otra parte, las infecciones por micobacterias adquieren importancia en otorrinolaringología dado que la tuberculosis de cabeza y cuello representa alrededor del 10% a 35% de los casos de tuberculosis, siendo su localización más frecuente los ganglios linfáticos. La siguiente revisión abarcará los cuadros de infecciones por micobacterias en otorrinolaringología, sus manifestaciones clínicas, diagnóstico y tratamiento.

Mycobacteriums are a group of aerobic non-capsuled and non-mobile bacillus some of which can cause diseases in mammals such as tuberculosis and leprosy. Chile, despite belonging to the group of countries with low prevalence of tuberculosis in America, presented a slowing in the decline in incidence curve. At the same time there has been an increase in atypical mycobacterium in pulmonary and extrapulmonary samples, comparedto past decades. On the other hand infections by mycobacterium become important because the head and neck tuberculosis accounts for about 10%-35% of cases of tuberculosis, the most common site being the lymph nodes. The following review will cover mycobacterial infections in otolaryngology clinical manifestations, diagnosis and treatment.

Disseminated Mycobacterium fortuitum Infection Associated with Venous Access Device.

Mycobacterium fortuitum is an important opportunistic pathogen among the rapidly growing Mycobacteria. Disseminated disease occurs as a consequence of bacteremia linked to vascular catheters, which carry high morbidity and mortality when they occur in immuno-compromised patients. Conventional culture methods often miss these organisms since they may grow more slowly (after 48 h) and are dismissed as skin contaminants because of their morphological resemblance to diphtheroids on grams staining. We report a case of 10 months old child with primitive neuroectodermal tumor who developed disseminated disease with M. fortuitum that was related to an indwelling intravascular device. The isolates were confirmed as M. fortuitum by polymerase chain reaction based DNA sequencing targeting heat shock protein 65 gene. The child was treated with, rifampicin, ethambutol and azithromycin. The patient improved remarkably and became afebrile 2 days after institution of therapy and removal of the catheter. The treatment was given for 3 months.

Rapid tests for the detection of the Mycobacterium abscessus subsp. bolletii strain responsible for an epidemic of surgical-site infections in Brazil

A single strain of Mycobacterium abscessus subsp. bolletii, characterised by a particular rpoB sequevar and two highly related pulsed field gel electrophoresis patterns has been responsible for a nationwide outbreak of surgical infections in Brazil since 2004. In this study, we developed molecular tests based on polymerase chain reaction restriction-enzyme analysis (PRA) and sequencing for the rapid identification of this strain. Sequences of 15 DNA regions conserved in mycobacteria were retrieved from GenBank or sequenced and analysed in silico. Single nucleotide polymorphisms specific to the epidemic strain and located in enzyme recognition sites were detected in rpoB, the 3' region of the 16S rDNA and gyrB. The three tests that were developed, i.e., PRA-rpoB, PRA-16S and gyrB sequence analysis, showed 100%, 100% and 92.31% sensitivity and 93.06%, 90.28% and 100% specificity, respectively, for the discrimination of the surgical strain from other M. abscessus subsp. bolletii isolates, including 116 isolates from 95 patients, one environmental isolate and two type strains. The results of the three tests were stable, as shown by results obtained for different isolates from the same patient. In conclusion, due to the clinical and epidemiological importance of this strain, these tests could be implemented in reference laboratories for the rapid preliminary diagnosis and epidemiological surveillance of this epidemic strain.

Enfermedad por Mycobacterium simiae y "Mycobacterium sherrisii" en la Argentina / Disease due to Mycobacterium simiae and "Mycobacterium sherrisii" in Argentina

Se presenta información reunida retrospectivamente sobre casos de micobacteriosis originados por Mycobacterium simiae (n = 4) y "M. sherrisii" (n = 6). Los casos ocurrieron entre pacientes con sida (n = 6), historia de silicosis (n = 2) o tuberculosis previa (n = 1). Un caso se perdió luego de diagnosticado y nueve fueron tratados con esquemas terapéuticos basados en claritromicina, etambutol y quinolonas. La respuesta fue muy pobre: cinco pacientes fallecieron (cuatro eran HIV positivos), tres permanecieron crónicos y sólo uno curó. Estas micobacterias originaron 2.1% de los casos de micobacteriosis registrados en un período de ocho años. La distinción de estas micobacterias raras de otras más frecuentes por métodos moleculares rápidos, parece ser clínicamente útil para advertir sobre la dificultad que puede presentar el tratamiento. Sin embargo, la diferenciación genotípica entre M. simiae y "M. sherrisii" parecería no ser clínicamente relevante, dado que no quedaron expuestas características que distingan a los pacientes afectados por los dos microorganismos tan estrechamente relacionados.

A revision of mycobacterial disease due to M simiae (n = 4) and "M. sherrisii" (n = 6) identified during an eight-year period is presented. Cases occurred among patients with AIDS (n = 6), previous history of silicosis (n = 2) or tuberculosis (n = 2). One case was lost to follow-up and the remaining nine responded poorly to chemotherapy based on clarithromycin, ethambutol and fluoroquinolones. Five patients died of whom four were HIV-positive, three remained chronic and one was cured. These microorganisms originated 2.1% of mycobacterioses cases detected in an eight-year period. Timely identification of this group of uncommon mycobacteria by molecular methods seems to be clinically relevant in order to warn of difficulties inherent to the treatment. However, the distinction between both closely related microorganisms might not be crucial for case management as no distinctive characteristics were evident among patients affected by M. simiae or "M. sherrisii".

Infecções por micobactérias de crescimento rápido resistentes a desinfetantes: uma problemática nacional? / Infections by rapidly growing mycobacteria resistant to disinfectants: a national matter?

Rapidly growing mycobacteria (RGM) are opportunistic microorganisms and widely distributed into aqueous environment and soil. Human RGM infections are usually associated with contaminated solutions or medical instruments used during invasive procedures. RGM postsurgical infections have recently emerged in Brazil and have caused national alert, considering the risk factors and epidemiological aspects. This study aimed at analysing the main factors linked to the recent RGM outbreaks, with focus on the national epidemic of Mycobacterium massiliense infections related to the BRA100 strains resistant to 2 percent glutaraldehyde commercial solutions commonly used for preoperative high-level disinfection. Based on previous studies and laboratorial results of assays and colaborations, it has been observed that the cases have been associated with videolaparoscopy for different applications and elective esthetic procedures, such as lipoaspiration and mammary prosthesis implant. Furthermore, outbreaks between 2004 and 2008 and the epidemic in Rio de Janeiro state may be considered particular Brazilian events. Although there are a few epidemiological published studies, some hypotheses based on common aspects related to most national nosocomial occurrences are possible, such as lack of protocols for cleaning and high-level disinfection, use of 2 percent glutaraldehyde as high-level disinfectant for surgical instruments, and dissemination of M. massiliense BRA100 by unknown mechanisms.

Infecção por micobactérias de crescimento rápido após procedimentos videocirúrgicos: a hipótese do glutaraldeído / Rapidly growing mycobacteria infection after videosurgical procedures: the glutaraldehyde hypothesis

Between August 2006 and February 2007, in the state of Rio de Janeiro, Brazil, a massive outbreak of RGM infections after video laparoscopy was mainly associated to the recently described Mycobacterium massiliense species. All confirmed and probable cases reports described the use of high-level disinfection of medical devices by using 2 percent glutaraldehyde (2 percent GA) for 30 min before the surgical procedures. We investigated the susceptibility of the M. massiliense isolates recovered during the outbreak to high-level disinfection after 30 min, 1h, 6h and 10h of exposure to the commercial disinfectants. Reference strains for official mycobactericidal tests such as Mycobacterium abscessus, Mycobacterium bovis, Mycobacterium chelonae, Mycobacterium neoaurum and Mycobacterium smegmatis were included as controls. Although all the reference strains were eliminated in 30 min of exposure to 2 percent GA, we observed the recovery of all M. massiliense clinical isolates even after 10h of exposure. This study suggests that failures in high-level disinfection and the high tolerance of these M. massiliense clinical strains to the 2 percent GA were strongly associated to the magnitude of the outbreak.

Asociación Micobacterias-VIH/SIDA en Pacientes Atendidos en un Hospital Universitario en Bogotá, Colombia / Mycobacteria-HIV/AIDS association in patients attending a teaching-hospital in Bogotá, Colombia

Objetivo El objetivo del presente estudio fue evaluar la frecuencia de infecciones micobacterianas en pacientes infectados por el VIH y su repercusión en la sobreviva de los pacientes a mediano plazo, además los factores clínicos y epidemiológicos asociados a la coinfección. Métodos La frecuencia de infección micobacteriana se determinó en una cohorte de 92 pacientes VIH positivos en el Hospital San Juan de Dios en Bogotá (Colombia), en 1996, mediante el empleo de métodos bacteriológicos estandarizados a partir de diferentes muestras clínicas. Los factores asociados con la enfermedad fueron medidos utilizando las razones de prevalencia RP IC= 95 por ciento y la regresión logística como método multivariado. La probabilidad de sobrevivir a tres meses fue evaluada usando las curvas de Kaplan Meir y se midieron los factores asociados con la sobrevida usando razones de tasas de incidencia y el modelo de Cox Resultados El 8 por ciento de los pacientes tenían tuberculosis y el 8,6 por ciento estaba infectado con micobacterias atípicas, siendo el complejo Mycobacterium avium (CMA), el más frecuente, seguido por M. fortuitum y M. chelonae. En un paciente se encontró M. tuberculosis y CMA y en otros dos se encontraron dos especies diferentes de micobacterias atípicas. Pacientes con tuberculosis, en estadios III y IV de enfermedad VIH tenían una sobreviva del 16 por ciento. Conclusiones La frecuencia de la asociación Tuberculosis/VIH-SIDA y Micobacteriosis/VIH-SIDA fue similar. La micobacteria atípica aislada con mayor frecuencia fue CMA. La sobrevida disminuyó en los pacientes con tuberculosis siendo menor si la cepa era multirresistente. El hallazgo clínico mas frecuentemente asociado a la tuberculosis fue la fiebre y la pérdida de peso se asoció a la presencia de micobacteriosis. La sangre fue la mejor muestra para el aislamiento de micobacterias.

Objective Evaluating the frequency of mycobacterium infection in an HIV-positive population and its influence on medium-term survival, along with clinical and epidemiological factors associated with co-infection. Methods Several clinical specimens were studied for mycobacteria in a sample of 92 HIV+ patients at the San Juan de Dios teaching-hospital in Bogota, Colombia, during 1996. Factors associated with infection were measured using a prevalence ratio (PR), CI=95 percent, and logistic regression was used in the multivariable models. The likelihood of survival for three months was measured using Kaplan-Meir curves and factors associated with survival were assessed using Rate ratios and Cox's model. Results Eight percent of the patients had tuberculosis and 6 percent of them were found to be infected with atypical mycobacterium. Mycobacterium avium complex (MAC) was the most frequent species, followed by M. fortuitum and M. chelonae. Mixed infections with M. tuberculosis and MAC were diagnosed in one patient and two different species of atypical mycobacterium were isolated in other two cases. Patients suffering from tuberculosis and stages III or IV HIV infection had a 16 percent survival rate. Conclusions Tuberculosis-HIV/AIDS frequency and atypical Mycobacterium-HIV/AIDS' association were very similar. The most frequently isolated atypical mycobacterium specie in this study was MAC. Survival rate was lower for patients infected by M. tuberculosis and even lower when a multi-resistant strain was involved. The most important clinical factor associated with M. tuberculosis was the presence of fever and loss of weight with mycobacterial infection. Blood provided the best samples for isolating mycobacteria.

Micobactérias não-tuberculosas: diversidade das espécies no estado de São Paulo / Nontuberculous mycobacteria: species diversity in São Paulo state, Brazil

O gênero Mycobacterium é constituído por espécies do complexo M. tuberculosis e outras denominadas micobactérias não-tuberculosas (MNT). Até o momento, mais de cem MNT foram descritas. Os objetivos deste estudo foram avaliar a diversidade das espécies de MNT identificadas no estado de São Paulo, no período de 1991 a 1997, que antecedeu a expansão da terapia anti-retroviral, e determinar a freqüência dos casos que atenderam alguns critérios bacteriológicos para o diagnóstico das infecções causadas pelas MNT. MATERIAL E MÉTODOS: Foram analisadas 1.892 cepas isoladas de sítios estéreis e não-estéreis de 1.248 pacientes atendidos no estado de São Paulo. RESULTADOS: Do total de pacientes, 1.199 (96,1 por cento) tiveram suas cepas identificadas e 3,9 por cento apresentaram resultados não-conclusivos. As dez espécies encontradas foram o complexo M. avium (MAC), M. kansasii, M. chelonae, M. fortuitum, M. szulgai, M. xenopi, M. marinum, M. gordonae, M. terrae e M. nonchromogenicum. Quarenta e sete (7,8 por cento) casos pulmonares tiveram diagnóstico confirmado pelo isolamento da mesma espécie em três ou mais amostras e 67 (34 por cento) pacientes tiveram o diagnóstico bacteriológico confirmado por isolamento em sítios estéreis. CONCLUSÕES: As espécies de MNT mais freqüentemente isoladas no estado de São Paulo foram MAC e M. kansasii. Uma publicação nacional com recomendações para diagnóstico e tratamento dessas infecções seria fundamental para a conduta correta no diagnóstico e no tratamento de micobacterioses.

Prevalencia de micobacteriosis y de tuberculosis en pacientes de un hospital de referencia de la provincia de Córdoba / Prevalence of mycobacteriosis and tuberculosis in a reference hospital, Cordoba province

Las micobacterias ambientales (MA) constituyen un importante grupo de especies bacterianas que se encuentran en el medio ambiente, pueden colonizar y ocasionalmente producir enfermedad enel hombre. En este trabajo se investigó la frecuencia de casos de micobacteriosis en relación con los de tuberculosis durante un período de diez años (1.991-2.000). Se estudiaron 16.700 muestras de 9.300 pacientes adultos de ambos sexos asistidos en el Hospital Regional de Tuberculosis de la Provincia de Córdoba, por consulta espontánea. Los aislamientos se realizaron por cultivo en los medios de Lowenstein Jensen y Stonebrink. Las colonias de bacilos ácidoalcohol resistentes (BAAR) se identificaron por pruebas bioquímicas y moleculares. El total de casos diagnosticados fue de 716, de los cuales 684 (95,5%) correspondieron a al complejo Mycobacterium tuberculosis y a micobacterias ambientales 32 (4,5%). Los casos de micobacteriosis se definieron por reiterados aislamientos con desarrollo representativo de una micobacteria ambiental, sospecha clínica y radiológica. De los 32 casos de micobacteriosis, el 75% del total correspondió aMycobacterium avium-intracellulare,15,6% a Mycobacterium fortuitum, 3,1% a Mycobacterium kansasii y 6,3% a Mycobacterium chelonae.Los casos de tuberculosis fueron 94,5% de localización pulmonar y 5,5% extrapulmonar.

Environmental mycobacteria (EM) constitute an important group of bacteria species found in the environment. They can colonize and occasionally produce disease in man. Sixteen thousand three hundred samples from 9300 adult symptomatic patients from the Hospital Regional of Tuberculosis in Cordoba were bacteriolocally investigated. The isolations were performed by culture on Lowenstein Jensen and Stonebrink culture media. The colonies of acid fast bacilli (AFB) were identified by biochemical and molecular tests. Among 716 culture positive cases, 684 (95.5%) were due to Mycobacterium tuberculosis complex and 32 to environmental mycobacteria.Serial samples allowed the confirmation of the etiologicalagent in culture and correlated with consistent clinical and radiological abnormalities. Seventy-five percente of these patients were affected by M. avium complex, 15.6% by M. fortuitum, 3.1% Mycobacterium kansasii and 6.3% Mycobacterium chelonae. Among tuberculosis cases, 94.5% and 5.5% had pulmonary and extrapulmonary disease respectively.

La intradermo-reacción con sensitinas en población paraguaya / The intradermal-reaction with sensitins in paraguayan population

La aplicación de Sensitinas utilizando la Intradermo-reacción de Mantoux nos permite investigar el perfil inmunológico de un organismo frente a determinadas cepas de Micobacterias no tuberculosas. La tasa de infección por estas Micobacterias no había sido estudiada hasta hoy en la población paraguaya, aunque nosotros ya habíamos comunicado el primer caso nacional de enfermedad por Mycobacterium fortuitum. La presente investigación nos permitió comprobar, sobre 210 pacientes estudiados, una tasa de reactores significativos de 24,7 por ciento a las sensitinas utilizadas, con neto predominio de reactores a M. avium y fortuitum

La intradermo-reacción con sensitinas en población paraguaya no becegeizada / Intradermal reaction with sensitins in paraguayan population who had never received BCG vaccine

Este trabajo constituye la 2a. parte del trabajo previo denominado "La intradermo-reacción con sensitinas en población paraguaya". En la presente investigación hemos incluído exclusivamente a individuos que no habían recibido la vacuna BCG, encontrando, sobre 44 pacientes estudiados, una tasa de reactores significativos de 29,7 por ciento a las sensitinas utilizadas. Dentro de estos pacientes reactores, constatamos en ambos estudios un neto predominio de reactores al M. avium (60 por ciento y 90,9 por ciento respectivamente). Con esto, queda comprobada la alta tasa de infección de la población paraguaya a las micobacterias no TBC y específicamente al M. avium

Frecuencia de micobacterias no tuberculosas en Chile / Frequency of non tuberculous mycobacteria in Chile

Se estudian 984 cultivos positivos para micobacterias, obtenidos durante el eño 1985 en los Laboratorios de Bacteriología de la TBC de la red nacional, 963 cepas correspondieron a Micobacterias Tuberculosis humanas y 21 cepas a micobacterias sospechosos de TBC pulmonar. Los resultados se analizan en relación al antecedente de tratamiento, tipo de muestra, condiciones clínicas y morfológicas de las colonias. Las cifras obtenidas a loa parámetros antes señalados, debido a que se tratan de agentes microbianos contaminantes, confirmándose ente hecho en las muestras de aspiración gástrica y bronquial en que la frecuencia de aislamiento es mayor debido a la utilización de instrumental en su obtención. Factores ambientales (humedad, contaminación) desarrollo de las colonias (tamaño) influyeron en la definición de la morfología de los primocultivos. Se aislan 5 cepas de micobacterias no tuberculosas provenientes de 3 casos de micobacteriosis que se encontraban en estudio durante el período de la investigación. Estas micobacterias responsables de enfermedad correspondiente a M. Kansassi, M. Szulgai y M. Avium intracellulere

Micobacteriosis y tuberculosis bovina en humanos en la República Argentina (años 1982-84) / Mycobacterium infections and bovine tuberculosis in humans in the República Argentina (years 1982-84)

Se realizó un estudio con la participación de 15 laboratorios, de 6 regiones de la República Argentina (provincia de Buenos Aires, Santa Fe, regiones Nordeste, Centro, Noroeste y Sur) para determinar la importancia relativa de las micobacterias atípicas y de M. bovis como causa de enfermedad en el hombre. En 3 años (1982-84 inclusive) se obtuvieron 13.544 cultivos positivos para micobacterias atípicas micobacterias en 7.672 pacientes: 437 (3,22%) de esos cultivos fueron y 49 (0,36%) M. bovis, siendo el resto M. tuberculosis. Los casos de micobacteriosis diagnosticados fueron 27, o sea 0,35% de los pacientes, y los casos de tuberculosis debidos a M. bovis fueron 36 (0,47%). En 26 de los 27 casos de micobacteriosis el agente causal fue el complejo M. avium-intracellulares-scrofulaceum (MAIS) y en uno M. chelonei. Todos fueron detectados en adultos, con localización pulmonar, con la excepción de un caso ganglionar, en una niña. La región del Centro presentó el mayor porcentaje de patologías debidas a micobacterias atípicas. La importancia relativa de la tuberculosis de origen bovino fue baja, con valores mayores en la región de Santa Fe, siendo los pacientes en su mayoría obreros de frigoríficos o trabajadores rurales