Meningite criptocócica na gravidez: revisão de aspectos terapêuticos / Cryptococcal meningitis in pregnancy: review of the therapeutic aspects

A criptococose é uma infecção fúngica, cujo envolvimento do sistema nervoso central é caracteristicamente insidioso, apresentando sinais de irritação meníngea, sequelas neurológicas e alta mortalidade. A gestação, condição que leva a certo grau de imunossupressão, pode dificultar a resposta ao tratamento. Objetivando determinar a estratégia de tratamento mais efetiva para meningite criptocócica em grávidas sem outras condições de imunossupressão, o presente trabalho realizou um levantamento bibliográfico acerca do tema. Foram revisados cinco artigos, os quais evidenciaram ampla utilização de anfotericina B em monoterapia ou associada à flucitosina, inclusive no primeiro, segundo e terceiro trimestre de gestação. Também foi relatada a utilização de fluconazol e itraconazol. Em todos os relatos, os resultados foram favoráveis tanto para mãe quanto para a criança. Existem poucos dados disponíveis na literatura acerca do tema proposto. Preferencialmente, a conduta a ser realizada envolve internação da gestante como gravidez de alto risco e administração de anfotericina B. Embora os resultados apresentados tenham sido favoráveis tanto para a monoterapia com anfotericina B quanto para sua associação com flucitosina, ou para monoterapia com fluconazol ou itraconazol, são necessários estudos prospectivos, controlados e randomizados para determinar o esquema terapêutico significativamente mais eficaz para o tratamento da criptococose em gestantes

Cryptococcosis is an infection caused by a fungus, whose involvement in the central nervous system is characteristically insidious, presenting signs of meningitis, neurological sequelae, and high mortality. The pregnancy, a condition that leads to a certain degree of immunosupression, may hinder the response to treatment. With the aim of determining the most effective treatment for cryptococcal meningitis in pregnant women without other causes of immunodeficiency, this paper carried out a survey about the subject. Five articles were analyzed and they showed a wide utilization of amphotericin B as monotherapy or associated with flucytosine in the treatment of cryptococcal meningitis in pregnant women, which includes the usage during the first, second and third trimesters of pregnancy. It was also reported the usage of itraconazole and fluconazol. The results were positive in all articles for both mother and fetus. There are few data available in the literature about this theme. Preferably, the physician should proceed with the admission of the patient as a high-risk pregnancy and should administer amphotericin B. Although the presented results were favorable to monotherapy with amphotericin B and to its association with flucytosine, as well as to monotherapy with fluconazole or itraconazole, only randomized controlled trials will be able to determine the best significantly effective therapeutics for cryptococcosis in pregnant women

Treatment of severe chromoblastomycosis with itraconazole and 5-flucytosine association / Tratamento de cromoblastomicose severa com a associação itraconazole e 5-flucitosina

Chromoblastomycosis is a chronic human melanized fungi infection of the subcutaneous tissue caused by traumatic inoculation of a specific group of dematiaceous fungi through the skin, often found in barefooted agricultural workers, in tropical and subtropical climate countries. We report the case of a male patient presenting a slow-growing pruriginous lesion on the limbs for 20 years, mistreated over that time, which was diagnosed and successfully treated as chromoblastomycosis. Besides the prevalence of this disease, treatment is still a clinical challenge.

Cromoblastomicose é uma infecção fúngica crônica do tecido subcutâneo causada pela inoculação traumática de um grupo específico de fungos através da pele, encontrados eventualmente em trabalhadores do campo descalços em países de clima tropical e subtropical. Relatamos aqui o caso de um paciente do sexo masculino com uma lesão dermatológica de crescimento lento e pruriginosa nos membros inferiores por 20 anos, diagnosticada e tratada com sucesso para cromoblastomicose. Apesar da prevalência desta doença em nossa região, o tratamento ainda é um desafio.

Meningitis caused by Rhodotorula rubra in an human immunodeficiency virus infected patient.

Rhodotorula spp. are common saprophytes but may be responsible for systemic infections in immunocompromised patients. Meningitis caused by Rhodotorula spp. in human immunodeficiency virus (HIV) infected patients has been reported only rarely. We present a case of meningitis caused by Rhodotorula rubra in HIV infected patient. The presumptive diagnosis of cryptococcal meningitis was made on the basis of India ink preparation, Gram staining and latex agglutination test (LAT) for cryptococcal antigen. The final diagnosis was confirmed by isolation of Rhodotorula rubra from cerebrospinal fluid on culture. LAT was considered false positive. Amphotericin B and 5-fluorocytosine were administered but the patient succumbed to his illness.

Disseminated infection with Cryptococcus neoformans var neoformans in an 8 years immunocompetent girl.

Disseminated cryptococcosis is a rare and often fatal disease in children. The majority of cases usually occur in individuals with defective cell-mediated immunity, most commonly due to HIV infection. The authors here in report an 8-year-old girl from Nepal who presented with fever, cough, headache, lymphadenopathy, hepatosplenomegaly and cutaneous lesions. Lymph node biopsy revealed multiple granulomas composed of histiocytes and epitheliold cells along with numerous yeast forms of cryptococcus. Cultures of CSF, sputum and urine yielded cryptococcus neoformans. Surprisingly,the immune function in terms of T-cell number, CD4 : CD8 ratio, serum immunoglobulins and HIV serology was normal. After the diagnosis of disseminated cryptococcosis was established, the patient was treated with 5-fluorocytosine (100 mg/kg/day) for initial two weeks and amphotericin B (1 mg/kg/day) for 13 weeks. Patient responded well to the treatment with disappearance of presenting symptoms, cutaneous lesions, and lymphadenopathy, though she still had hepatosplenomegaly, which also decreased. Unfortunately, she developed loss of vision in 10th week of therapy. The patient was discharged on oral fluconazole (6 mg/kg/day) and no recurrence was found during the follow-up period of more than 9 months. This is the first case of disseminated cryptococcosis with no detectable immune deficit, from India.

Candida tropicalis meningitis in a young infant.

Candida tropicalis is a rare species of Candida causing meningitis. The authors report a young infant who developed Candida tropicalis meningitis following a prolonged stay in a neonatal intensive care unit for respiratory distress and intra-cranial hemorrhage. The child was successfully treated with recommended doses of Amphotericin B and 5-flucytosine for eight weeks.

Cladosporium bantianum meningitis in a neonate.

Cladosporium bantianum meningitis has been reported mostly in adult farmers between 20 and 30 years of age. We report a 6-day-old male neonate who was admitted with fever, focal seizures and not accepting feeds. Initial investigations suggested a diagnosis of pyogenic meningitis but antibiotic therapy for 14 days did not result in any significant clinical improvement. Repeat CSF examination after 14 days suggested a diagnosis of C. bantianum meningitis which was supported by presence of multiple abscesses in the cerebral cortex on CT scan of the head and confirmed by CSF culture. Clinical response to antifungal therapy remained unsatisfactory.

Meningoencefalitis por cryptococcus: reporte de un caso clínico y revisión de la literatura / Cryptococcal meningoencefalitis: a clinical case report and literature review

La infección por cryptococcus en el niño es muy infrecuente especialmente si es inmunocompetente. Se presenta un preescolar inmunocompetente con meningoencefalitis grave con líquido cefalorraquídeo claro y signos neurológicos de focalización, tratado como meningoencefalitis herpética. Evolucionó inicialmente con leve mejoría, reingresando por aumento del compromiso neurológico. Se amplió el estudio etiológico y se detectó cryptococcus en el LCR. Se comenta el cuadro clínico de la meningoencefalitis cryptococócica su diagnóstico y revisión de la literatura. Nos parece aconsejable incluir el test de tinta china en toda meningoencefalitis a líquido claro de etiología no precisada

Systemic phaeohyphomycosis in pregnancy and the puerperium

Systemic fungal infections are rare. In pregnancy, treatment is problematic because of the risk of possible teratogenic effects of the antifungal drugs. We present the case of a 32 year-old woman who presented during pregnancy with a two-month history of painless subcutaneous nodules. Excision biopsy of one lesion showed dematiaceous fungal elements. Anti-fungal treatment was deferred and the pregnancy proceeded uneventfully. The remaining nodules were excised at the time of caesarean section delivery. Three weeks into the puerperium, she developed generalised seizures and investigations indicated systemic fungal infection with positive cultures for Aureobasidium spp which responded to appropriate antifungal therapy of flucytosine and itraconazole.

Criptocose em crianças no Estado do Pará, Brasil / Cryptococcosis in children in the State of Pará, Brazil

Relatam-se 14 casos de criptococose em crianças, diagnosticados em Belém, PA. Em nove pacientes a variedade do agente etiológico foi estudada e identificada como Cryptococcus neoformans var. gattii. A média de idade destes pacientes foi 7,8 anos (variaçäo, 5-13 anos). Havia 5 meninas e 4 meninos (razäo, 1,25:1). Cinco foram a óbito em três meses apesar do tratamento com anfotericina B (associada com fluconazol 3 ou fluocitosina 1). Säo comentados a existência de áreas de alta endemia da infecçäo por var. gattii no Pará e a gravidade da doença causada por essa variedade fúngica

Tratamiento de las micosis profundas. Estado actual / Treatment of deep mycosis. Present state

Se hace una revisión de los antifúngicos disponibles en el mercado internacional en la actualidad, se profundiza más en el anfotericín B, con sus virtudes y reacciones adversas, así como de otros antifúngicos, sobre todo los derivados azoles, imidazólicos y los triazoles, como compuestos con buenos resultados y menos reacciones secundarias, en particular el fluconazol y el itraconazol y sus características

Criptococose não associada à AIDS no Rio Grande do sul: relato de oito casos e revisão da literatura sul-RioGrandense / Cryptococcosis not related to AIDS in Rio Grande do Sul: a report of 8 cases and a review of the literature

Relatam-se oito casos de criptococose não associada à AIDS diagnosticados em Santa Maria, RS, no período 1961-1995. É revisada a literatura sul-riograndense sobre a micose e comentada a prevalência da infecção pela var. neoformans em pacientes sem doença predisponente nas regiões subtropicais.

We report eight cases of cryptococcosis in non-AIDS patients diagnosed in Santa Maria, RS, during 1961-1995. A review of the literature is performed and the prevalence of the infection caused by var neoformans in patients without underlying disease in subtropical regions is commented.

Rhodotorula glutinis fungemia: a case report and literatura review

A fatal case of Rhodotorula glutinis fungenia in an 11-year-old boy with acute lymphoblastc leukemia undergoing third reinduction chemotherapy is reported. This is the first case of fungemia by Rhodotorula glutinis reported in Brazil.

Cryptococcal meningitis

Meningitis is the most common manifestation of dissiminated cryptococcosis. Cryptococcal meningitis is the most common systemic mycotic infecction in AIDS, which is the most frequent predisposing condition. The most severe complication is acute cerebral hypertension. Medical options for therapy have broadened considerably, but generally include initial intensive treatment follwed, in patients with AIDS, by chronic supression. With agressive management of cryptococcal meningitis, mortality may be reduced to 10 percent or less.

Clinical efficacy of itraconazole with initial flucytosine in AIDS-related cryptococcal meningitis: a preliminary study.

This open, prospective study systematically examined the clinical efficacy of itraconazole and initial flucytosine in AIDS-associated cryptococcal meningitis. Clinical as well as mycological responses were evaluated in 10 patients. Satisfactory outcome was achieved in 8 patients (cure in 4 and improvement in 4). In all, 5 patients died, three as a result of cryptococcal meningitis. The remaining 5 patients have been followed for 5-12 months. The treatment proved to be well-tolerated and safe.

Feohifomicosis causada por una especie de cladosporium:localización en nalgas / Phaehyphomycosis causing by cladosphoryum specie:buttock localization

Se presenta un paciente con un cuadro de feohifomicosis causado por cladosporium cladosporoides. Se hace una revisión de sus características clínicas,resaltando la escasa frecuencia de esta micosis profunda y la buena respuesta obtenida con la terapeútica aplicada durante 24 meses de tratamiento y control evolutivo