Corticosteroid therapy associated with COVID-19: an ally or a risk factor for the establishment of secondary fungal co-infections?

Corticosteroid therapy to combat inflammation caused by SARS-CoV-2 seems to be a risk factor for developing secondary fungal co-infections. PubMed and ScienceDirect databases were searched, with the following word groups: [(aspergillosis OR mucormycosis OR candidiasis) AND (coronavirus disease) AND (corticoids). The selected articles present the main risk factors related to the establishment of secondary fungal co-infections in COVID-19 patients. Corticosteroid therapy used to combat inflammation caused by SARS-CoV-2 has been shown to be strongly associated with the establishment of mucormycosis and aspergillosis. Mucormycosis has been the main fungal co-infection related to corticosteroid therapy, causing a high number of deaths in COVID-19 patients. Diabetes mellitus was the most prevalent comorbidity, especially for the establishment of mucormycosis. Dexamethasone use seems to be associated with mucormycosis emergence and death. However, aspergillosis showed a greater relationship with patient recovery. Thus, risk factors such as diabetes mellitus, combined with corticosteroid use, have shown a relationship to the establishment of mucormycosis. The corticosteroids used in COVID-19 patients should be individually analyzed, considering the patient's medical history and the risk/benefit ratio of the use of these drugs.

Incidencia de infecciones en pacientes con artritis reumatoide en tratamiento corticoideo e inmunosupresor / Incidence of infections in patients with rheumatoid arthritis in corticosteroid and immunosuppressive treatment

Introducción La artritis reumatoide (AR) es una enfermedad inflamatoria autoinmune, que requiere tratamiento farmacológico por tiempo muy prolongado. Se prescribe para su tratamiento fármacos con capacidad antiinflamatoria y potencial efecto inmunosupresor. Con estos fármacos los pacientes presentan menor intensidad inflamatoria, pero a la vez existe el riesgo de procesos infecciosos, siendo éstos, una importante causa de morbilidad y mortalidad. Objetivo Analizar la incidencia de infección durante el tratamiento corticoideo vs inmunosupresor en la terapia crónica en pacientes con artritis reumatoide. Material y métodos Estudio de tipo analítico, observacional, retrospectivo, con selección por intención, no controlado, de cohorte, con estudio de riesgo, incidencia y asociación cruzada, realizado en el Servicio de Reumatología del Hospital de Clínicas de La Paz, Bolivia; en pacientes con diagnóstico de AR entre las gestiones 2010 - 2020, tanto en consultorio externo y sala de internación. Se seleccionaron pacientes con adultos, ambos sexos, con edad mayor a 18 años, con diagnóstico de artritis reumatoide según clasificación ACR 2010, clinimetría CDAI en grado de actividad, con indicación de tratamiento asociado (corticoide + metotrexato o incluso adición de cloroquina / hidroxicloroquina) de acuerdo a guías ACR/EULAR, que realice control regular (bimensual). Resultados La incidencia de procesos infecciosos asociada al uso de prednisona con dosis >7,5mg/día, tras 6 meses de tratamiento es de 19,39% y de 18,88% a los 12 meses. La incidencia de procesos infecciosos asociada al uso de metotrexate (dosis >12,5mg/semana), es de 12,76% a 6 meses de tratamiento y de 13,27% a 12 meses. Conclusiones En pacientes adultos de ambos sexos, sin factores de riesgo asociados, la corticoterapia prolongada (Prednisona en dosis mayor a 7.5mg/día durante más de 6 meses de tratamiento) produce el desarrollo de procesos infecciosos con mayor frecuencia y gravedad que la terapia con metotrexate incluso a dosis intermedia-alta (MTX >12.5mg / semana).

Introduction Rheumatoid arthritis is an autoimmune inflammatory disease, which requires pharmacological treatment for a very long time. It is prescribed for its treatment drugs with anti-inflammatory capacity and potential immunosuppressive effect. With these drugs patients present lower inflammatory intensity, but at the same time there is a risk of infectious processes, these being an important cause of morbidity and mortality. Objective To analyze the risk of infection with corticosteroid vs. immunosuppressive treatment in chronic therapy in patients with rheumtaoid arthritis. Material and methods Analytical, observational, retrospective study, with selection by intention, uncontrolled, cohort, with study of risk, incidence and cross association, carried out in the Rheumatology Service of the Hospital de Clínicas, La Paz, Bolivia, in patients who were diagnosed with RA between the 2010 - 2020 management, both in the outpatient clinic and the hospitalization room. Patients were selected with adults, both sexes, aged over 18 years, with a diagnosis of rheumatoid arthritis according to ACR 2010 classification, CDAI clinimetry in degree of activity, with indication of associated treatment (corticoid + methoroxate or even addition of chloroquine / hydroxychloroquine) according to ACR/EULAR guidelines, which perform regular control (bi monthly). Results: The incidence of infectious processes associated with the use of prednisone with doses >7.5mg/day, after 6 months of treatment is 19.39% and 18.88% at 12 months. The incidence of infectious processes associated with the use of metotrexate (dose >12.5mg/week), is 12.76% at 6 months of treatment and 13.27% at 12 months. Conclusions In adult patients of both sexes, without associated risk factors, prolonged corticotherapy (Prednisone in doses greater than 7.5mg/day for more than 6 months of treatment) produces the development of infectious processes with greater frequency and severity than therapy with metotrexate even at intermediate-high dose (MTX >12.5mg / week).

Efeitos da corticoterapia materna nos valores hemogasométricos de cordeiros nascidos a termo e prematuros / Effects of maternal blood gas values corticotherapy of Lambs born at term and premature

O objetivo do estudo foi avaliar as variáveis hemogasométricas de cordeiros nascidos a termo e prematuros do nascimento às 48 horas de vida. Foram constituídos quatros grupos experimentais: PN (cordeiros nascidos de parto normal, n=15, média de 146 dias de gestação); PNDEX (cordeiros nascidos de parto normal, cujas mães receberam 16 mg de dexametasona aos 141 de gestação, n=8, média de 143 dias de gestação); PRE (cordeiros prematuros nascidos de cesarianas aos 138 dias de gestação, n=10) e PREDEX (cordeiros prematuros nascidos de cesarianas aos 138 dias de gestação, cujas mães receberam 16 mg de dexametasona dois dias antes do parto, n=9). Imediatamente após o nascimento, os cordeiros de todos os grupos apresentaram quadro de acidose respiratória (pH baixo e pCO2 elevada), com maior ênfase nos animais prematuros. A concentração de HCO3 - diminuiu entre 15 e 60 minutos de vida, principalmente nos grupos PRE e PREDEX, com posterior aumento no M24h. Os valores de diferença de base foram menores nos cordeiros prematuros, os quais apresentaram respiração abdominal, intensa dispneia e grande quantidade de líquido pulmonar. A estabilização do equilíbrio ácidobase ocorreu em todos os animais ao longo das primeiras 24 horas de vida. A dexametasona teve influência positiva sobre a condição clínica dos animais prematuros, resultando em adequada ventilação e perfusão tecidual, o que garantiu maior taxa de sobrevivência.(AU)

The aim of the study was to evaluate blood gas parameters of full-term and premature lambs from birth to 48 hours of life. Four experimental groups were formed: NDG (normal delivery group - lambs vaginally delivered, n=15, average of 146-day gestation); NDEXG (normal delivery with dexamethasone group - lambs vaginally delivered whose mothers received 16 mg of dexamethasone at 141 days of gestation, n=8, average of 143-day gestation); PRE (premature lambs born by cesarean section at 138 days of gestation, n=10) and PREDEX (premature lambs born by cesarean section at 138 days gestation, whose mothers received 16mg of dexamethasone two days before, n=9). Immediately after birth, lambs from all groups showed respiratory acidosis (low pH and high pCO2), most obviously in premature animals. The concentration of HCO3 - was lower between 15 and 60 minutes of life, especially in PRE and PREDEX groups with subsequent increase in M24h. The values of base excess were lower in premature lambs, which showed abdominal breathing, severe dyspnea and lots of lung fluid. The stabilization of acid-base balance occurred in all animals during the first 24 hours of life. Dexamethasone had a positive effect on the clinical condition of the premature lambs, resulting in adequate ventilation and tissue perfusion, which guaranteed higher survival rate.(AU)

Sordera súbita: a la luz de la evidencia / Sudden deafness: in light of the evidence

La sordera súbita es una condición de hipoacusia neurosensorial aguda usualmente unilateral, de instalación en un período menor o igual a 72 horas, que en la mayoría de los casos es idiopática; sin embargo, causas infecciosas, autoinmunes y vasculares, se han propuesto como los principales mecanismos involucrados. La sordera súbita es considerada una urgencia otorrinolaringológica, sin embargo el tratamiento de ésta continúa siendo un tema controvertido.

Sudden deafness is usually a condition of acute unilateral sensorineural hearing loss, installation less than or equal to 72 hours period, which in most cases are idiopathic; however, infectious, autoimmune and vascular causes, have been proposed as key mechanisms involved. Sudden deafness is considered an ENT urgency, however this treatment remains controversial.

Parasitosis intestinal en pacientes tratados con corticoides

Se presenta el reporte del examen coproparasitológico de 23 pacientes de con enfermedades reumatológicas y tratamiento inmunosupresor del Servicio de Reumatología del Hospital de Clínicas (Asunción, Paraguay) en el año 2013. Se detectaron 16 pacientes parasitados, siendo en orden de frecuencia: Entamoeba coli (41%), Giardia lambia (23%), Strongyloides stercoralis (14%), el resto 1 caso de Hymenolepis nana y Ascaris lumbricoides.

The report of the coproparisotologic exam of 23 patients, with rheumatic diseases and receiving immunosuppresive therapy from the Rheumatology Service of the Hospital de Clínicas (Asunción, Paraguay) in 2013, is presented. Sixteen patients with parasites were detected with this frequency order: Entamoeba coli (41%), Giardia lambia (23%), Strongyloides stercoralis (14%). The remaining was 1 case of Hymenolepis nana and Ascaris lumbricoides.

Cutaneous cryptococcosis due to Cryptococcus gattii in a patient on chronic corticotherapy / Criptococose cutânea causada por Cryptococcus gattii em um paciente sob corticoterapia crônica

Cryptococcus gattii é agente causador de uma micose endêmica que afeta principalmente os pulmões e o sistema nervoso central de pacientes imunocompetentes em regiões tropicais e subtropicais do globo. Relato de caso. Um paciente de 66 anos, portador de doença pulmonar obstrutiva crônica, não infectado pelo vírus HIV, em corticoterapia sistêmica prolongada, desenvolveu extensa ulceração do antebraço esquerdo, associada a adenomegalia supraclavicular ipsilateral, em conseqüência à infecção por Cryptococcus gattii. O paciente foi tratado com fluconazol 400mg/dia durante 8 meses, obtendo resolução completa da lesão. Este caso enfatiza que, ainda que raramente, C. gattii pode causar infecção cutâneo-linfática oportunista, em paciente imunocomprometido pelo uso sistêmico de corticosteróides vivendo na região sudeste do Brasil.

Cryptococcus gattii causes a form of endemic mycosis that most commonly affects the lungs and central nervous system of immunocompetent patients living in tropical and subtropical areas of the world. Case report. A 66-year-old man who had chronic obstructive pulmonary disease without HIV infection and had been on systemic corticotherapy for several years developed extensive ulceration of the left forearm that was associated with ipsilateral supraclavicular adenomegaly, consequent to infection with Cryptococcus gattii. The patient was treated with fluconazole 400mg/day for eight months, which led to complete healing of the lesion. This case emphasizes that, although rare, C. gattii may cause opportunistic cutaneous-lymphatic infection in patients living in the southeastern region of Brazil who are immunocompromised through chronic corticotherapy.

Adiaspiromicose pulmonar tratada sem antifúngicos / Pulmonary adiaspiromycosis treated without antifungal drugs

Relata-se caso de lavrador de 40 anos acometido por adiaspiromicose pulmonar, com diagnóstico etiológico estabelecido mediante biópsia por toracoscopia. Optou-se por tratamento com corticosteróide, sem antifúngicos, tendo o paciente respondido bem, com melhora clínico-radiológica após três semanas do início dos sintomas.

The case of a 40-year-old agricultural worker affected by pulmonary adiaspiromycosis is reported. An etiological diagnosis had been established by means of a biopsy via thoracoscopy. Treatment with corticosteroids without antifungal drugs was chosen, and the patient responded well to this, with improvements in clinical and radiological conditions three weeks after the beginning of the symptoms.