Invasive non-type b haemophilus influenzae disease: report of eight cases / Doença invasiva causada por haemophilus influenzae não tipo b: relato de oito casos

ASTRACT Objective: To describe eight cases of invasive non-type b Haemophilus influenzae disease in children admitted to Hospital de Clínicas of Universidade Estadual de Campinas. Cases description: In 2015, there were eight cases of invasive non-type b H. influenzae disease. We tested the ampicillin sensitivity and beta-lactamase production of the strains identified and performed the genotyping. Molecular typing was determined by Pulsed-Field Gel Electrophoresis. Four patients were diagnosed with bacteremia; in two cases, H. influenzae was detected in the pleural fluid, and two patients had meningitis. Patients with comorbidities represented 37.5% of cases. Except for the strain of one patient - not sent to the reference laboratory -, all were ampicillin-sensitive and non-beta-lactamase-producing. Genotyping identified four non-capsular, one type c, and two type a strains. Molecular typing ruled out nosocomial transmission since all serotypes were distinct regarding genotype. Comments: The rise in cases of invasive non-type b H. influenzae infection was real. There was no nosocomial transmission, and we found no justification for the increase. These data indicate the need for surveillance to correctly diagnose, monitor, and understand the spectrum of non-type b H. influenzae disease.

ABSTRACT Objetivo: Descrever oito casos de doença invasiva por Haemophilus influenzae não tipo b em crianças internadas no Hospital de Clínicas da Universidade Estadual de Campinas. Descrição dos casos: Em 2015, ocorreram oito casos de doença invasiva por H. influenzae não tipo b. Nas cepas identificadas, testou-se a sensibilidade à ampicilina e a produção de betalactamase, e realizou-se a genotipagem. A tipagem molecular foi feita por Pulsed Field Gel Electrophoresis. Em quatro pacientes, o diagnóstico foi de bacteremia; em dois casos, H. influenzae foi identificado em líquido pleural, e dois pacientes tiveram meningite. Comorbidades foram encontradas em 37,5% dos pacientes. Com exceção da cepa de um dos pacientes (que não foi enviada ao laboratório de referência), todas eram sensíveis à ampicilina e não produtoras de betalactamase. A genotipagem identificou quatro cepas não capsulares, uma cepa tipo c e duas cepas tipo a. A tipagem molecular descartou a transmissão intra-hospitalar, já que todos os sorotipos eram distintos quanto ao genótipo. Comentários: O aumento dos casos de infecção invasiva por H. influenzae não tipo b foi real. Não houve transmissão intra-hospitalar e não foi encontrada justificativa para o aumento. Esses dados indicam a necessidade de vigilância para diagnosticar corretamente, monitorar e entender o espectro da doença causada por H. influenzae não tipo b.

Derrame pleural por micosis endémica en un paciente de 8 años: reporte de un caso / Pleural effusion due to endemic mycosis in an 8-year-old patient: a case report

Coccidioides is a fungus that is frequently found in dry places of sparse storms, with warm temperatures during most of the year. Two species are known to infect the human being: C. immitis and C. posadasii.It is endemic in northern Mexico, southern United States, as well as in some regions of Central America and South America. It is a highly contagious organism, but mostly it generates self-limited and asymptomatic diseases. Only 10 percent of cases with pulmonary symptoms are severe and may manifest as lobar pneumonia. Some cases of multiple foci and pleural effusion are diagnosed through biopsy with molecular methods. The treatment in many cases includes the use of azole antifungals for 3-6 months and follow-up with antibody titres

El Coccidioides es un hongo que se encuentra de manera frecuente en lugares secos, con temperaturas cálidas durante la mayoría del año. Son dos especies las que se conoce que infectan al ser humano la C. Immitis y C. Posadasii. Es endémico del norte de México, sur de Estados Unidos, así como algunas pequeñas regiones de centro y Sudamérica. Es un organismo altamente contagioso, pero en su mayoría genera enfermedades autolimitadas y de tipo asintomático, los pacientes con manifestaciones pulmonares solamenteen 10 por ciento son de presentación grave. Esta puede ser como una neumonía lobar, pero en algunos casos de focos múltiples y con derrame pleural, el diagnóstico es mediante biopsia en a fechas recientes con métodos moleculares. Los tratamientos en muchos casos requieren únicamente vigilancia. De requerir tratamiento se usa antimicótico 3-6 meses con azoles y seguimientos con títulos de anticuerpos

Preanalytical conditions can interfere with M. tuberculosis detection by PCR in respiratory samples

OBJECTIVES: Tuberculosis is one of the most prevalent infections in humans. Although culture is the reference for diagnosis, its sensitivity is compromised, especially in paucibacillary samples. Because polymerase chain reaction (PCR) amplifies mycobacterial DNA, it is more sensitive than culture for the diagnosis of Mycobacterium tuberculosis (Mtb). However, its performance can be affected by intrinsic sample inhibitors and by the extraction/detection techniques used. METHODS: We evaluated the influence of preanalytical conditions on Mtb detection in samples of sputum (SPU), bronchoalveolar lavage (BAL), and pleural fluid (PF) using combinations of extraction/detection methods. Respiratory samples were prepared to contain different concentrations of red blood cells and nucleated cells to which increasing amounts of Mtb colonies were inoculated and submitted to PCR. RESULTS: Up to 102 CFU/ml of Mtb were detected in the SPU in all methods, except for the Roche extraction/detection method, regardless of the preanalytical sample condition. In BAL samples, medium and high concentrations of cells and high concentrations of red blood cells contributed to a lower Mtb detection, regardless of the extraction method used. In PF, red blood cells were the variable that most interfered with Mtb detection, with better recovery (102 CFU/ml) observed with the Qiagen/Nanogen combination. CONCLUSION: The choice of Mtb extraction and detection method is of fundamental importance for PCR analytical sensitivity, especially when paucibacillary samples and/or samples containing potential PCR inhibitors are analyzed.

Pleural effusion adenosine deaminase: a candidate biomarker to discriminate between Gram-negative and Gram-positive bacterial infections of the pleural space

OBJECTIVES: Delay in the treatment of pleural infection may contribute to its high mortality. In this retrospective study, we aimed to evaluate the diagnostic accuracy of pleural adenosine deaminase in discrimination between Gram-negative and Gram-positive bacterial infections of the pleural space prior to selecting antibiotics. METHODS: A total of 76 patients were enrolled and grouped into subgroups according to Gram staining: 1) patients with Gram-negative bacterial infections, aged 53.2±18.6 years old, of whom 44.7% had empyemas and 2) patients with Gram-positive bacterial infections, aged 53.5±21.5 years old, of whom 63.1% had empyemas. The pleural effusion was sampled by thoracocentesis and then sent for adenosine deaminase testing, biochemical testing and microbiological culture. The Mann-Whitney U test was used to examine the differences in adenosine deaminase levels between the groups. Correlations between adenosine deaminase and specified variables were also quantified using Spearman’s correlation coefficient. Moreover, receiver operator characteristic analysis was performed to evaluate the diagnostic accuracy of pleural effusion adenosine deaminase. RESULTS: Mean pleural adenosine deaminase levels differed significantly between Gram-negative and Gram-positive bacterial infections of the pleural space (191.8±32.1 U/L vs 81.0±16.9 U/L, p<0.01). The area under the receiver operator characteristic curve was 0.689 (95% confidence interval: 0.570, 0.792, p<0.01) at the cutoff value of 86 U/L. Additionally, pleural adenosine deaminase had a sensitivity of 63.2% (46.0-78.2%); a specificity of 73.7% (56.9-86.6%); positive and negative likelihood ratios of 2.18 and 0.50, respectively; and positive and negative predictive values of 70.6% and 66.7%, respectively. CONCLUSIONS: Pleural effusion adenosine deaminase is a helpful alternative biomarker for early and quick discrimination of Gram-negative from Gram-positive bacterial infections of the pleural space, which is useful for the selection of antibiotics.

Enfoque diagnóstico en el paciente con derrame pleural / Diagnostic approach in pleural effusion

En el estudio diagnóstico del paciente con derrame pleural se deben considerar la historia clínica y el análisis de las imágenes para acotar el diagnóstico diferencial. El uso adecuado de las técnicas de imágenes contribuye a realizar procedimientos en forma segura. Se debe realizar una toracocentesis diagnóstica y/o evacuadora y se debe analizar completamente el líquido pleural. A veces es necesario realizar biopsia pleural para lo cual existen diversas técnicas disponibles. En los pacientes con pleuritis crónica inespecífica se debe hacer seguimiento por dos años para evaluar el desarrollo de malignidad.

The diagnostic approach in patients with pleural effusion must begin considering clinical aspects and image interpretation. Different imaging techniques can safely guide invasive procedures. Diagnostic or therapeutic thoracentesis must be performed and pleural fluid must be completely analyzed. Some patient will require pleural biopsy, and different techniques are available. Patients with chronic unspecific pleuritis histological diagnosis after pleural biopsy, must be followed for two years long to be sure no malignancy is developed.

The performance of an in-house nested-PCR technique for pleural tuberculosis diagnoses

Introduction This study evaluated the performance of an in-house nested-PCR system for the detection of the Mycobacterium tuberculosis complex in pleural fluid, blood and urine samples from pleural effusion tuberculosis patients by health services physicians in Pernambuco, Brazil. Methods A prospective double-blind study with 37 hospitalized patients of both sexes, aged over 15, was used to investigate the diagnosis of pleural effusion. The criteria used to define the cases included the demonstration of bacillus in biological samples by smear or culture or by a granulomatous finding in the histopathological examination, associated with an evident response to specific treatments to each clinical situation. Pleural fluid, blood and urine samples were collected and subjected to routine tests and the nested PCR technique to assess for M. tuberculosis amplification. Results In total, 37 pleural effusion patients took part in the study, of whom 19 (51.3%) had tubercular etiologies and 18 (48.7%) had etiologies from other causes. When the pleural fluid, blood and/or urine sample in-house nested-PCR sensitivities were evaluated simultaneously, the results were positive regardless of the biological specimen (the sensitivity was 84.2%); however, when the blood and/or urine samples were analyzed together, the sensitivity was 72.2%. When the pleural fluid samples were evaluated alone, the sensitivity was only 33.3%. Conclusions The performance of the diagnostic pleural tuberculosis nested-PCR was directly related to the diversity of the samples collected from the same patient. Additionally, this study may identify a need to prioritize non-invasive blood and urine collection for this diagnosis. .

Pneumonia adquirida na comunidade e derrame pleural parapneumônico relacionados a Mycoplasma pneumoniae em crianças e adolescentes / Mycoplasma pneumoniae-related community-acquired pneumonia and parapneumonic pleural effusion in children and adolescents

OBJETIVO: Determinar a prevalência e as características da pneumonia adquirida na comunidade (PAC) e derrames pleurais parapneumônicos (DPP) relacionados a Mycoplasma pneumoniae em um grupo de crianças e adolescentes. MÉTODOS: Estudo observacional retrospectivo com 121 pacientes hospitalizados com PAC e DPP em um hospital de referência terciária, entre 2000 e 2008, divididos em seis grupos (G1 a G6) segundo o agente etiológico: M. pneumoniae com ou sem coinfecção, em 44 pacientes; outros agentes que não M. pneumoniae, em 77; M. pneumoniae sem coinfecção, em 34; Streptococcus pneumoniae, em 36; Staphylococcus aureus, em 31; e coinfecção M. pneumoniae/S. pneumoniae, em 9, respectivamente. RESULTADOS: Na comparação entre os grupos, G1 apresentou frequências maiores em gênero feminino, tosse seca, uso prévio de beta-lactâmicos e na duração dos sintomas até a admissão, assim como menor uso de assistência ventilatória e de drenagem torácica que G2, enquanto G3 teve maiores frequências em uso prévio de beta-lactâmicos e tosse seca, maior duração dos sintomas antes da admissão e menor frequência de uso de drenos torácicos que G4 e G5, ao passo que G3 teve média de idade maior e menor frequência de náuseas/vômitos que G4, assim como menor uso de assistência ventilatória que G5. A coinfecção M. pneumoniae/S. pneumoniae aumentou a duração dos sintomas até a admissão. CONCLUSÕES: Nesta amostra, a prevalência de PAC e DPP por M. pneumoniae foi de 12,75%. Embora a doença apresentasse quadros mais leves que aquela por outros organismos, a evolução foi mais prolongada. Nossos dados sugerem a necessidade de uma maior diligência na investigação de M. pneumoniae em crianças e adolescentes com PAC e DPP em nosso meio.

OBJECTIVE: To determine the prevalence and the characteristics of Mycoplasma pneumoniae-related community-acquired pneumonia (CAP) and parapneumonic pleural effusion (PPE) in children and adolescents. METHODS: This was a retrospective observational study involving 121 patients with CAP/PPE hospitalized in a tertiary referral hospital between 2000 and 2008, divided into six groups according to the etiologic agent (G1 to G6, respectively): M. pneumoniae with or without co-infection, in 44 patients (group 1); etiologic agents other than M. pneumoniae, in 77 (group 2); M. pneumoniae without co-infection, in 34 (group 3); Streptococcus pneumoniae, in 36 (group 4); Staphylococcus aureus, in 31 (group 5); and M. pneumoniae/S. pneumoniae co-infection, in 9 (group 6). RESULTS: In comparison with group 2, group 1 showed higher frequencies of females, dry cough, and previous use of beta-lactam antibiotics; longer duration of symptoms prior to admission; and lower frequencies of use of mechanical ventilation and chest tube drainage. In comparison with groups 4 and 5, group 3 showed higher frequencies of previous use of beta-lactam antibiotics and dry cough; longer duration of symptoms prior to admission; a lower frequency of use of chest tube drainage; a higher mean age and a lower frequency of nausea/vomiting (versus group 4 only); and a lower frequency of use of mechanical ventilation (versus group 5 only). M. pneumoniae/S. pneumoniae co-infection increased the duration of symptoms prior to admission. CONCLUSIONS: In this sample, the prevalence of M. pneumoniae-related CAP/PPE was 12.75%. Although the disease was milder than that caused by other microorganisms, its course was longer. Our data suggest that M. pneumoniae-related CAP and PPE in children and adolescents should be more thoroughly investigated in Brazil.

Evaluation of polymerase chain reaction for diagnosis of "tuberculous pleurisy"

Differential diagnosis between tuberculous pleurisy [TBP] and non-tuberculosis pleural effusion represents a critically important clinical problem. In recent years, several noninvasive methods have been found for diagnosis of tuberculous pleurisy. This study aimed to evaluate the value of detection of the genome of Mycobacterium tuberculosis [MTB] by polymerase chain reaction [PCR] method for the diagnosis of tuberculous pleurisy and compare the results with those of conventional methods. In this cross-sectional study, we studied 62 patients [42 men and 20 women] with pleural effusion in Ghaem Hospital, affiliated to Mashhad University of Medical Sciences from January 2006 to June 2007. A total of 20 patients had tuberculous pleurisy [45.4%], 15 patients had malignant pleural effusion [34%], 3 patients had pleural effusion with various "non-tuberculosis non-malignant" etiologies [6.8%] and 6 patients had transudative pleural effusion [13.6]. The sensitivity, specificity, positive predictive value and negative predictive value of PCR in tuberculous pleurisy were 85%, 100%, 100% and 88.8%, respectively. The value of PCR test and pleural biopsy was similar in the diagnosis of TBP. However, PCR detected MTB in pleural effusion when conventional pleural biopsy failed to do so

Derrame pleural / Pleural effusion

El derrame pleural se define como la acumulación anormal de líquido en el espacio pleural que se produce por aumento en la producción o disminución del drenaje, causas comunes en patologías clínicas. Dentro de las causas del incremento de la producción podemos enunciar un aumento de la permeabilidad capilar pleural, disminución de la presión oncótica capilar y aumento de la presión hidrostatica capilar, son menos claras las causas de la disminución del drenaje pero se destacan la alteración de la contractibilidad linfàtica pleural, infiltración de vasos y nódulos linfáticos por enfemedades neoplàsicas y alteraciones a nivel pleural que impidan que el líquido este en contacto con los poros linfáticos. El objetivo de esta revisión es el analisis de las bases fisiológicas de la pleura y la producción del líquido pleural, los aspectos fisiopatológicos del derrame pleural, el enfoque diagnóstico y el manejo médico-quirúrgico del mismo de acuerdo a las diferentes causas que lo producen.

Infección del líquido pleural y ascítico por Listeria monocytogenes: caso clínico / Pleural and ascitic fluid infection by Listeria monocytogenes: report of one case

Ascitic and pleural fluids infection by Listeria monocytogenes is uncommon. The association of spontaneous bacterial peritonitis and empyema caused by this microorganism has been seldom reported. A 61 year-old male with an alcoholic cirrhosis and an upper right ¡obectomy for a lung cáncer, consulted because of an exacerbation of dyspnea, abdominal pain and fever. Listeria monocytogenes was isolated from ascitic and pleural fluids and from blood cultures. He was successfully treated with ampicillin and a chest tube for drainage.

Thoracic empyema due to Candida albicans.

Few cases of empyema thoracis due to Candida species have been reported from the world and India. A 46-year-old male with esophageal carcinoma, who had taken radiotherapy, presented with fever and dyspnea. The chest X-ray showed findings suggestive of empyema. The diagnosis was confirmed by culturing Candida albicans from aspirated fluid and blood culture. The patient responded to antifungal treatment. High index of suspicion is required to diagnose such rare cases.

Tuberculosis: an unusual presentation.

Patient with tuberculosis may present with atypical, unusual or complex features. The reported case is of 31 years lady admitted with fever, breathlessness and features of cardiac failure. She was detected to have right lower lung consolidation, minimal bilateral pleural effusion, features suggestive of sub-acute pericarditis and subsequent chest x-ray revealed miliary mottling as well. Later on Acid Fast Bacilli were detected in sputum and pleural fluid. Clinicians need to keep complex presentation of TB in mind to manage the case at its earlier stage to avoid residual complication.

Hospital-based case series of 175 cases of serologically confirmed brucellosis in Bikaner.

OBJECTIVE: To study the clinical spectrum of brucellosis in Bikaner (Northwest India). METHODS: A total of 175 cases were diagnosed as brucellosis during the period of six year (June 1997 to May 2003). They were studied for clinical profile and treated by rifampicin and doxycyclin and additionally streptomycin for initial 14 days in patients of neurobrucellosis. These patients were followed up to 3 months. RESULTS: Patients of brucellosis presented with a wide spectrum of clinical manifestations. Out of 175 cases 155 were from rural area. Age ranged between 12-60 years (124 males, 51 females). Analysis of risk factors revealed history of raw milk ingestion (86.86%), occupational contact with animals (81.14%), handling of infected material (62.28%), household contact (16%) and 2 patients were veterinarian. Joint pain (83.43%) and fever (77.71%) were the commonest presenting feature. Sacroiliac joint was most commonly involved (46.86%). 31 cases had involvement of multiple joints. Other mode of presentation were neurobrucellosis (18.86%), manifested as polyradiculoneuropathy, myeloradiculopathy, meningoencephalopathy and polyradiculomyeloencephalopathy; predominant pulmonary involvement (4.0%) presented as bronchitis, pneumonia and pleural effusion; epididymoorchitis, infective endocarditis, nephrotic syndrome and recurrent abortion. All patients responded well to the treatment. CONCLUSION: Brucellosis is an important emerging zoonotic disease but it is often under-diagnosed due to lack of suspicion and diagnostic facilities despite the fact that cattle farming (an important high risk group) is one of the main occupation in rural area. This report should infuse the awareness about this reemerging disease specifically in high-risk group.

Utility of closed pleural biopsy in the diagnosis of tuberculous pleural effusion

The present study was designed to evaluate the diagnostic yield and safety of closed pleural biopsy using Abram's needle in patients with suspected tuberculous pleural effusions. 115 patients [86 males and 29 females] with suspected tuberculous pleural effusion were retrospectively observed in the period from January 2004 to December 2006. All patients were clinically evaluated and in addition to routine laboratory investigations, chest X-ray and sputum for acid fast bacilli [AFB] were examined. Thoracocentesis, followed by closed pleural biopsy was performed in all patients in the same setting. A total of 2 - 3 pleural biopsy pieces were obtained in each patient and were sent for histopathological examination. Pleural fluid was examined for microbiology [Gram stain, Ziehl-Neelson stain], biochemistry [protein, LDH, sugar] and cytology [for malignant cells, total and differential cell count]. The analysis of pleural fluid showed exudative fluid in 111 patients [97%] and transudate in four patients [3%]. Histological analysis revealed caseous granulomatous inflammation in 47 patients [41%] and non-caseous granulomatous inflammation in 16 patients [14%] Non-specific inflammation was observed in 38 [33%] patients and malignancy in four patients [3%] and the biopsies were inadequate for examination in 10 patients [9%]. Out of the 115 patients, 92 were finally diagnosed as pleural TB in which histopathological examination aided in the diagnosis of 63 patients [69%]. The pleural fluid culture was positive in four patients [4.4%] and the direct AFB was positive in two patients [2.2%]. The procedure was well tolerated and complications were detected only in 11 patients. We concluded that closed pleural biopsy was a simple, safe, and effective method to rapidly diagnose pleural tuberculosis

Listeria monocytogenes peritonitis in cirrhotic patients: first description in Brazil / Peritonite bacteriana espontânea causada por Listeria monocytogenes em pacientes com cirrose: primeiro relato de caso no Brasil

Two cases of spontaneous bacterial peritonitis (SBP) caused by Listeria monocytogenes in cirrhotic patients are reported. In one of the cases, the microorganism was isolated from pleural effusion and ascites. SBP is a serious and common complication of patients with ascites caused by hepatic cirrhosis and the culture of the ascitic fluid is an important tool for the diagnosis and for the more appropriate treatment. Although a third generation cephalosporin has usually been employed for empiric treatment of SBP, it does not provide adequate coverage against Listeria spp. In such cases the use of ampicillin (with or without sulbactam) or sulfamethoxazole-trimethoprim is recommended. The last one is used for secondary prophylaxis, instead of norfloxacin. To summarize, Listeria monocytogenes infection is a rare cause of SBP, whose treatment should be specific for the bacteria.

Foram relatados dois casos de peritonite bacteriana espontânea (PBE) por Listeria monocytogenes em pacientes com cirrose. Em um dos casos isolamos também o agente no líquido pleural. A PBE é uma complicação comum e grave de pacientes com ascite por cirrose e a cultura do líquido ascítico é de grande importância para o diagnóstico e para o tratamento mais adequado. Embora uma cefalosporina de terceira geração seja geralmente utilizada para o tratamento empírico da PBE, ela não oferece cobertura adequada contra a Listeria spp. Nesses casos, recomenda-se o uso de ampicilina (com ou sem sulbactam) ou sulfametoxazol-trimetoprim. Para a profilaxia secundária indica-se o uso deste último, ao invés da norfloxacina. Em resumo, a infecção por Listeria monocytogenes é uma causa rara de PBE e o tratamento específico deve ser administrado.

Empiema por actinomyces: el gran simulador / Empyema due to Actinomyces: a diagnostic challenge

El derrame pleural aislado, como única manifestación de la actinomicosis es una situación muy rara y un desafío diagnóstico para el clínico, no sólo por su infrecuencia sino por la dificultad técnica para cultivar al gérmen. La típica apariencia microscópica de este bacilo Gram-positivo ramificado en los cultivos suele ser la clave del dianóstico. Se informa un caso de derrame pleural masivo izquierdo por Actinomyces israelii, sin afectación del parénquima pulmonar, de difícil diagnóstico, que mejoró clínica y radiológicamente en forma completa con el drenaje quirúrgico y tratamiento antibiótico prolongado.

Vibrio cholerae non-O1,non-O139 Isolated from Pleural Effusion Following Total Gastrectomy

We isolated non-O1, non-O139 Vibrio cholerae from pleural effusion in a patient with recurred advanced gastric caner after total gastrectomy. We also recovered the organism from the patient's stool culture. The patient did not experience gastrointestinal symptoms such as diarrhea except heartburn and epigastric discomfort from stomach cancer before admission. The suspected route of infection is directly from the gastrointestinal tract through the previous surgical wounds. After antibiotic treatment, no more V. cholerae was isolated and the patient was well discharged from the hospital. This is the first report of V. cholerae infection associated with pleural effusion in a long-term latent carrier of the organism.