Can COVID-19 impact the natural history of paracoccidioidomycosis? Insights from an atypical chronic form of the mycosis

ABSTRACT Paracoccidioidomycosis (PCM) is a systemic fungal infection caused by Paracoccidioides spp. It can occur as an acute/subacute form (A/SAF), a chronic form (CF) and rarely as a mixed form combining the features of the two aforementioned forms in an immunocompromised patient. Here, we report a 56-year-old male patient with CF-PCM who presented with atypical manifestations, including the development of an initial esophageal ulcer, followed by central nervous system (CNS) lesions and cervical and abdominal lymphatic involvement concomitant with severe SARS-CoV-2 infection. He was HIV-negative and had no other signs of previous immunodeficiency. Biopsy of the ulcer confirmed its mycotic etiology. He was hospitalized for treatment of COVID-19 and required supplemental oxygen in the intensive unit. The patient recovered without the need for invasive ventilatory support. Investigation of the extent of disease during hospitalization revealed severe lymphatic involvement typical of A/SAF, although the patient`s long history of high-risk exposure to PCM, and lung involvement typical of the CF. Esophageal involvement is rare in non-immunosuppressed PCM patients. CNS involvement is also rare. We suggest that the immunological imbalance caused by the severe COVID-19 infection may have contributed to the patient developing atypical severe CF, which resembles the PCM mixed form of immunosuppressed patients. Severe COVID-19 infection is known to impair the cell-mediated immune response, including the antiviral response, through T-lymphopenia, decreased NK cell counts and T-cell exhaustion. We hypothesize that these alterations would also impair antifungal defenses. Our case highlights the potential influence of COVID-19 on the course of PCM. Fortunately, the patient was timely treated for both diseases, evolving favorably.

Septic shock, hyperferritinemic syndrome, and multiple organ dysfunction without respiratory failure in a patient with disseminated histoplasmosis and advanced HIV disease

ABSTRACT AIDS-related disseminated histoplasmosis (DH) can cause septic shock and multiorgan dysfunction with mortality rates of up to 80%. A 41-year-old male presented with fever, fatigue, weight loss, disseminated skin lesions, low urine output, and mental confusion. Three weeks before admission, the patient was diagnosed with HIV infection, but antiretroviral therapy (ART) was not initiated. On day 1 of admission, sepsis with multiorgan dysfunction (acute renal failure, metabolic acidosis, hepatic failure, and coagulopathy) was identified. A chest computed tomography showed unspecific findings. Yeasts suggestive of Histoplasma spp. were observed in a routine peripheral blood smear. On day 2, the patient was transferred to the ICU, where his clinical condition progressed with reduced level of consciousness, hyperferritinemia, and refractory septic shock, requiring high doses of vasopressors, corticosteroids, mechanical ventilation, and hemodialysis. Amphotericin B deoxycholate was initiated. On day 3, yeasts suggestive of Histoplasma spp. were observed in the bone marrow. On day 10, ART was initiated. On day 28, samples of peripheral blood and bone marrow cultures revealed Histoplasma spp. The patient stayed in the ICU for 32 days, completing three weeks of intravenous antifungal therapy. After progressive clinical and laboratory improvement, the patient was discharged from the hospital on oral itraconazole, trimethoprim-sulfamethoxazole, and ART. This case highlights the inclusion of DH in the differential diagnosis of patients with advanced HIV disease, septic shock and multiorgan dysfunction but without respiratory failure. In addition, it provides early in-hospital diagnosis and treatment and comprehensive management in the ICU as determining factors for a good outcome.

Post COVID-19 Disseminated Mucormycosis in a 55-year-old patient in Western Amazon: Case report

A feared fungal disease surprised and became a warning to severe cases of COVID-19, especially to health professionals involved with the pandemic. Designated as black fungus for public health services in India, where reported data reflects an increase of more than eighty times the expected increase for Rhizopus among the communities. The disease has become even more worrisome due to the high mortality already established as an opportunistic infection, coupled with the reserved prognosis for all those infected and hospitalised by the SARS-CoV-2 severity criteria. This patient, who was submitted to corticosteroid therapy, in an excessive dose, therefore immunosuppressive, developed a severe, disseminated clinical form. It was verified the progression of the lesions and thus the high risk of trans- surgical lethality, or, also, by the insufficiency of conduct in removing the lesions to their satisfaction. Thus, the therapeutic option is the associated use of micafungin, liposomal amphotericin B and isavuconazole for the regressive phase. The patient remains hospitalised with progressive and discrete improvement. Until the opportunity of reevaluation of the surgery by the interspecialty collaboration.

Uma temida doença fúngica surpreendeu e se tornou um alerta para casos graves de COVID-19, principalmente aos profissionais de saúde envolvidos com a pandemia. Designado como fungo preto para serviços de saúde pública na Índia, onde os dados relatados refletem um aumento de mais de oitenta vezes o aumento esperado para Rhizopus entre as comunidades. A doença tornou-se ainda mais preocupante devido à alta mortalidade já estabelecida como infecção oportunista, aliada ao prognóstico reservado para todos os infectados e internados pelos critérios de gravidade do SARS-CoV-2. Esse paciente, que foi submetido à corticoterapia, em dose excessiva, portanto imunossupressora, desenvolveu uma forma clínica grave e disseminada. Verificou-se a progressão das lesões e, portanto, o alto risco de letalidade transcirúrgica, ou, ainda, pela insuficiência de conduta na remoção das lesões a contento. Assim, a opção terapêutica é o uso associado de micafungina, anfotericina B lipossomal e isavuconazol para a fase regressiva. O paciente permanece internado com melhora progressiva e discreta. Até a oportunidade de reavaliação da cirurgia pela colaboração interespecialista.

Dimensiones de personalidad y consumo de alcohol en trabajadores de una empresa de seguridad privada / Personality dimensions and alcohol consumption in workers of a private security company

El estudio realizado fue no experimental correlacional de corte transversal con enfoque cuantitativo, en una población de 100 trabajadores de seguridad de una empresa en la ciudad de Quito, que desempeñaban funciones de guardias de seguridad. Los datos se recolectaron mediante dos instrumentos validados: cuestionario factorial de personalidad 16PF-V y el test AUDIT (por sus siglas en inglés: Alcohol Use Disorders Identification Test). Los rasgos de riesgo más observa-dos fueron: imperturbable-con poca ansiedad (52%) e introvertido-socialmente inhibido (49%), el 79% de los participantes no mostró dificultades con el consumo de alcohol. El nivel de consumo de alcohol se correlacionó positiva y estadísticamente significativa con la dimensión de personalidad ansiedad. Se destaca la necesidad de dar seguimiento constante a esta problemática y generar estrategias preventivas y de afrontamiento al respecto.

The research was non-experimental, correlational and cross-sectional with a quantitative approach. The population consisted of 100 security workers of a company who performed func-tions of security guards in the city of Quito. Data were collected using two validated instruments: the 16PF-V factorial personality questionnaire and the AUDIT test (for its acronym in English: Alcohol Use Disorders Identification Test). The most observed risk traits were: unper-turbed, with little anxiety (52%) and introverted, socially inhibited (49%), 79% of the partici-pants did not show difficulties with alcohol consumption. The level of alcohol consumption was positively correlated and statistically significant with the anxiety personality dimension. Moni-toring this problem and generating preventive and coping strategies in this regard is highlighted

Selección de pareja y tiempo de relación en padres de familia / Mate selection and relationship time in parents

Introducción: la selección de pareja es un proceso complejo donde se involucran factores biológicos, psicológicos, personales, sociales y emocionales. Objetivo: determinar los criterios para la selección de pareja según el tiempo de relación en los padres de estudiantes de la Unidad Educativa Vigotsky en la ciudad de Riobamba. Metodología: se hizo un estudio con enfoque cuantitativo, de tipo observacional descriptivo. La población estuvo integrada por padres de familia mayores de 20 años, cuyos hijos estudiaban en la institución mencionada, a partir de cual se seleccionó una muestra de 170 individuos mediante la técnica del tipo bola de nieve. los datos se recolectaron mediante la Escala de Selección de Pareja de Romero. Resultados: según los involucrados, los criterios más relevantes para la selección de pareja fueron los rasgos de personalidad (61,8%) y satisfacción de necesidades (65,3%); mientras que, los menos considerados fueron el atractivo (80,0%) y la similitud de intereses personales (48,2%). Conclusiones: la comparación del nivel de importancia de los criterios de selección de pareja según al tiempo de relación posibilitó determinar que el nivel bajo predominó en los aspectos no verbales en aquellas con menos de 10 años de unión. Además, el tiempo de relación se asoció significativa-mente con las dimensiones: aspectos no verbales, rasgos de personalidad y satisfacción de necesidades

Introduction: mate selection is a complex process involving biological, psychological, personal, social and emotional factors. Objective: to determine the criteria for mate selection according to the relationship time in the parents of students of the Vigotsky Educational Unit in the city of Riobamba. Methodology: a study was carried out with a quantitative approach, of a descriptive observational type. The population was made up of parents over 20 years of age, whose children studied at the aforementioned institution. A sample of 170 individuals was selected using the snowball-type technique. Data were collected using the Romero Mate Selection Scale. Results: The most relevant criteria for partner selection were personality traits (61.8%) and satisfaction of needs (65.3%. On the other hand, attractiveness (80.0%) and the similarity of personal interests (48.2%) were the least considered. Conclusions: It was determined that the low level prevailed in the non-verbal aspects in those ones with less than 10 years of union based on the comparison of the level of importance of the mate selection criteria according to the time of the relationship. In addition, the relationship time was significantly associated with the dimensions: non-verbal aspects, personality traits and needs satisfaction.

Niveles de ansiedad-rasgo en estudiantes de la carrera de Odontología de la Universidad Central del Ecuador / Trait anxiety levels in students of the Dentistry career of the Central University of Ecuador

La presente investigación se desarrolló con el objetivo de describir el nivel de ansiedad-rasgo en estudiantes de la carrera de Odontología de la Universidad Central del Ecuador, mediante un estudio descriptivo transversal que involucró a 293 estudiantes universitarios de séptimo a noveno semestre. Los datos se recopilaron mediante el Inventario de Ansiedad Rasgo Estado (IDARE), los que mostraron un predominio del nivel medio (58,02%), seguido del alto (39,6%). El 42,38% de las mujeres se catalogó con un alto nivel de ansiedad-rasgo. Entre esa variable y la edad se estableció una dependencia estadísticamente significativa. Los menores de 23 años resultaron más afectados por esa entidad psicológica. La frecuencia del nivel medio se manifestó mayoritariamente en los tres semestres estudiados, aunque el nivel alto estuvo más presente en los alumnos de octavo semestre

This research was developed in order to describe the level of trait anxiety in students of the school of dentistry of the Central University of Ecuador. A cross-sectional descriptive study was carried out, which involved 293 university students from seventh to ninth semester. The data were collected using the State Trait Anxiety Inventory, which showed a predominance of the medium level (58.02%), followed by the high level (39.6%). 42.38% of the women were classi-fied as having a high level of trait anxiety. A statistically significant dependence was established between this variable and age. Those ones under 23 years of age were more affected by this psychological entity. The frequency of the medium level was manifested mainly in the three semesters studied; however, the high level was more present in the eighth semester students.

COVID-19: respuesta inmune y perspectivas terapéuticas

RESUMEN La enfermedad causada por el nuevo coronavirus (COVID-19) se caracteriza por presentar fiebre y tos, afectar el tracto respiratorio inferior y estar asociada con la edad, comorbilidades y un sistema inmune debilitado. Típicamente se ha evidenciado linfopenias en los casos graves y una desmedida producción de citocinas inflamatorias (tormenta de citocinas), lo que explicaría el rol de la respuesta hiperinflamatoria en la patogénesis de la COVID-19. Las respuestas inflamatorias secundarias por reinfecciones del virus podrían inducir el aumento o la mejora dependiente de anticuerpos (ADE, por sus siglas en inglés), un fenómeno virémico que podría ser un mecanismo alternativo de infección celular y que se deberá tener en cuenta cuando se diseñen vacunas o inmunoterapias que involucren el estímulo de anticuerpos neutralizantes o el uso de anticuerpos monoclonales. Actualmente no existen vacunas ni tratamientos que demuestren seguridad y eficacia en pacientes con COVID-19; sin embargo, se espera la conclusión de los resultados de la aplicación de una vacuna de ácidos nucleicos ARNm (mensajero del ácido ribonucleico) y de un fármaco antiviral (remdisivir) que se encuentran en ensayos clínicos fase III. Por el momento la mejor medida para evitar la propagación de la infección es el aislamiento social exhaustivo y viene siendo adoptado por varios países según recomendación de la Organización Mundial de la Salud (OMS).

ABSTRACT Disease caused by the new coronavirus (COVID-19) is characterized by fever, cough, and affection of the lower respiratory tract. It is associated with age, comorbidities and a weakened immune system. Typically, lymphopenias have been evidenced in severe cases and an excessive production of inflammatory cytokines (cytokine storm), which would explain the role of the hyperinflammatory response in the pathogenesis of COVID-19. Secondary inflammatory responses from virus reinfections may induce antibody-dependent enhancement (ADE), a viremic phenomenon that may be an alternative mechanism of cellular infection and should be considered when designing vaccines or immunotherapies involving the stimulation of neutralizing antibodies or the use of monoclonal antibodies. Currently, no vaccines or treatments demonstrate safety and efficacy in patients with COVID-19. However, the results from phase III clinical trials which involve the application of an mRNA (messenger ribonucleic acid) nucleic acid vaccine and an antiviral drug (remdisivir), are yet to be concluded. For the time being, the best measure to prevent the spread of COVID-19 is by implementing social isolation, this measure has been adopted by several countries as recommended by the World Health Organization (WHO).

Uterine cavity embryonal rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is a rare solid tumor in childhood and adolescence. The higher incidence is predominant during the first two decades of life. According to the Intergroup RMS Study Group, the embryonal RMS (ERMS), botryoidal variant, constitutes a histological subtype characterized as a "grape-like" lesion of 2.0 cm to 9.5 cm. The treatment involves chemotherapy, surgery, and/or radiotherapy. We present the case of a 14-year-old female patient diagnosed with ERMS, botryoidal variant, which originated in the uterine cervix with vaginal externalization. The initial therapeutic approach comprised an initial prolapsed mass excision followed by Wertheim­Meigs surgery due to the tumor extension. No consensual protocol to ERMS treatment is found in the medical literature; however, a combined approach seems to offer a better result. The postoperative time period was uneventful and the patient followed an adjuvant therapy with vincristine, d-actinomycin, and cyclophosphamide. A comprehensive evaluation of the therapeutic options preserving the reproductive function­unfortunately not always possible­is part of a multi-disciplined care team concerning the pediatric patients.

Congenital pulmonary airway malformation

Congenital pulmonary airway malformation (CPAM) is a developmental malformation of the lower respiratory tract. We report the case of a male newborn diagnosed with cystic lung disease during prenatal ultrasound. A cesarean section was performed at the 32nd gestational week because of premature rupture of the membranes, and soon after the delivery the newborn developed respiratory failure and died. The aim of this study is to report an autopsy case because of its rarity, and to briefly discuss the CPAM subtypes and differential diagnosis of cystic lung diseases of childhood.

Gastric lethal hemorrhage due to Dieulafoy's disease

Gastric Dieulafoy's lesion (DL) is a potentially fatal entity that causes upper digestive hemorrhage as a consequence of the erosion of an abnormal large-caliber artery in the submucosa of the gastrointestinal tract. We report the case of a 59-year-old female patient admitted to the emergency facility due to melena without any active sign of bleeding during the esophagogastroduodenoscopy. Unexpectedly, she progressed presenting a massive hematemesis followed by an irreversible cardiorespiratory arrest. The aim of this study is to draw attention to DL as a possible cause of massive and fatal digestive hemorrhage, and to describe the anatomical autopsy findings.

Increased angiogenesis in primary myelofibrosis: latent transforming growth factor-β as a possible angiogenic factor

Objective: The aim of this work was to demonstrate a possible relationship between anti-latency-associated peptide human latent transforming growth factor beta 1 (latent TGF-β1) expression in megakaryocytes and microvascular density in bone marrow biopsies from patients with essential thrombocythemia and primary myelofibrosis. Methods: Microvascular density was evaluated by immunohistochemical analysis and the expression of latent TGF-β1 in samples (100 megakaryocytes per bone marrow sample) from 18 essential thrombocythemia and 38 primary myelofibrosis (19 prefibrotic and 19 fibrotic) patients. Six bone marrow donor biopsies were used as controls. Fibrosis in the bone marrow biopsies was evaluated according to the European Consensus. Results: The average fibrosis grade differed between essential thrombocythemia and primary myelofibrosis groups when compared to the control group. Latent TGF-β1 expression differed significantly between the fibrotic primary myelofibrosis (PMF) group and the control group (p-value < 0.01). A high degree of neo-angiogenesis (demonstrated by analysis of CD34 expression) was detected in patients with myelofibrosis. There were correlations between latent TGF-β1 expression and microvascular density (r = 0.45; p-value < 0.0009) and between degree of microvascular density and fibrosis grade (r = 0.80; p-value < 0.0001). Remarkable differences for neo-angiogenesis were not observed between patients with essential thrombocythemia and controls. Conclusion: Angiogenesis participates in the pathogenesis of primary myelofibrosis, in both the prefibrotic and fibrotic stages, while latent TGF-β is differentially expressed only in the prefibrotic stage...

Efecto de Uncaria tomentosa (Uña de gato) sobre la población y activación decélulas dendríticas en sangre periférica de pacientes con artritis reumatoidea / Effect of Uncaria tomentosa (Catïs claw) over dendritic cells population and activation in peripheral blood of rheumatoid arthritis patients

Introducción: la artritis reumatoide (AR) es una enfermedad autoinmune caracterizada por un proceso inflamatorio crónico articular. En los últimos años se está resaltando la importancia de las células dendríticas en AR, debido a su capacidad de presentar autoantígenos y estimular a linfocitos T autoreactivos. En este estudio se ensayó la capacidad de Uncaria tomentosa (Uña de Gato, UG), una planta peruana con propiedades inmunomoduladoras, sobre la población de células dendríticas circulantes y sobre la expresión de sus moléculas de maduración y coestimulación. Objetivos: determinar la población de células dendríticas (DC) de origen mieloide (DCm) y plasmocitoide (DCp) por citometría de flujo en pacientes con AR. Evaluar la variación en la expresión de moléculas HLA-DR y CD86 en ambas subpoblaciones celulares expuestas a diferentes concentraciones de un extracto hidroalcohólico de UG con 5 por ciento de alcaloides oxindólicos pentacíclicos (UG-POA). Material y método: se evaluaron DC a partir de muestras de sangre periférica de pacientes con AR y adultos controles sanos, enfrentadas a diferentes concentraciones de UG. Las muestras fueron marcadas con anticuerpos monoclonales específicos, evaluadas por citometría de flujo y analizadas con el software Summit 4.3. El análisis estadístico fue realizado mediante Test de rangos de Friedman para muestras relacionadas, Test T de student y Prueba de Tendencias y Análisis de Medidas Repetidas. Resultados: encontramos que UG-POA disminuyó de manera dosis dependiente la subpoblación de DCm de sangre periférica de pacientes con AR, sin afectar la subpoblación de DCp y aumentó la expresión de las moléculas HLA-DR y CD86 en DCm. Conclusiones: la UG-POA disminuye la subpoblación de DCm, mientras incrementa la expresión de moléculas HLA-DR y CD86 en pacientes con AR definida. Estos hallazgos añadirían un mecanismo adicional al efecto inmuno-modulador de la UG en procesos inflamatorios crónicos.

Introduction: Rheumatoid arthritis (RA) is an autoimmune disease characterized by a chronic inflammatory process with in the joints. Recently, the importance of dendritic cells (DC) has been emphasized in this condition due to their remarkable ability for presenting autoantigens and for stimulating auto-reactive T-cells. The ability of Uncariatomentosa (CatÆs claw), a native Peruvian plant with immune-modulating properties on the circulating dendritic cell population and on their maturation and co-stimulation capacities was assessed. Objectives: To determine subsets of myeloid and plasmacytoid dendritic cells (mDC and pDC, respectively) in patients with RA with the use of flow cytometry. To evaluate variations in the expression of HLA-DRand CD86 molecules in both subsets of DC in response to different concentrations of a hydro-alcoholic extract of Catïs claw with 5 per cent of pentacyclic oxindole alkaloids. Materials and methods: Peripheral blood dendritic cells were taken from RA patients and healthy controls, and they were incubated with different concentrations of Catïs claw. Then, cells were labeled with specific monoclonal antibodies and they were separated using flow cytometry and they were analyzed with a Summit 4.3. software. Statistical analysis was performed using Friedmanïs, T-student, trends and repeat measure analysis tests. Results: We found that Catïs claw extract decreased in a dose-dependent fashion mDC population in the peripheral blood of RA patients without affecting pDC, and it also increased HLA-DR and CD86 expression on mDC. Conclusions: Catïs claw reduced the mDC subset, while it increased HLA-DR and CD86 expression in RA patients. This is an additional mechanism for the known immune-modulating effect of Catïs claw in chronic inflammatory conditions.

Tumor sincrônico gástrico e colonônico: relato de caso / Gastric tumorsynchronous and colon

Racional - Para que um tumor seja considerado sincrônico deve ser excluída a possibilidade de metástase, tempo de diagnóstico entre o primeiro e o segundo tumor não deve ultrapassar seis meses. Tumores sincrônicos são relativamente raros, mas sabe-se da ocorrência simultânea dos tumores gástrico e colônico; em vista disso é prudente a conduta de se procurar o segundo tumor quando do diagnóstico do primeiro. No caso do Brasil esta...