[Usefulness of routine investigation of fungal infections through bronchoscopy in HIV-infected and non-HIV-infected patients in a general hospital, reference to AIDS]. / Utilidade da investigação rotineira de infecção fúngica pela broncoscopia em pacientes infectados ou não pelo HIV em um hospital geral, referência para SIDA.

The diagnostic yields and the spectrum of pulmonary fungal-infection obtained in samples collected by fiberoptic bronchoscopy from HIV-positive and HIV-negative patients were evaluated from 1990 to 1995. A total of 1943 bronchoscopies were performed during this period, 47% in the HIV-positive group and 53% in the HIV-negative group. Of 908 HIV-positive patients, 38 (4%) had a fungus isolated from the pulmonary sample whereas of 1035 HIV-negative patients, only 4 (0.2%) had a fungus isolated. Histoplasmosis and Cryptococcosis were more frequently found in HIV-positive than in HIV-negative patients (p < 0.001). Paracoccidioides brasiliensis was found in only 3 patients, all of them immunocompetent. The study demonstrated that, despite the low yields, the HIV-positive group may benefit from routine screening for fungal elements in specimens obtained by fiberoptic bronchoscopy.

Isolation of Trichophyton raubitschekii in Rio de Janeiro (Brazil).

We report the first report of the isolation of Trichophyton raubitschekii in Brazil. The patients (n = 4) had typical lesions of tinca corporis. The identification of the isolates as members of this recently described species was based on morphological and physiological characteristics.

Fungal infections in neutropenic patients. A 8-year prospective study.

In this paper we report a eight-year prospective study designed to further characterize incidence, epidemiology, specific syndromes, treatment and prognosis associated with fungal infections in neutropenic patients. During the study period 30 fungal infections were diagnosed in 30 patients among 313 episodes of fever and neutropenia (10%). There were 15 cases of candidiasis, 5 pulmonary aspergillosis, 3 sinusitis by Aspergillus fumigatus, 5 infections by Fusarium sp., one infection by Trichosporon sp., and one infection due to Rhodotorula rubra. Blood cultures were positive in 18 cases (60%). The predisposing factors for fungal infection in multivariate analysis were the presence of central venous catheter (p < 0.001), longer duration of profound (< 100/mm3) neutropenia (p < 0.001), the use of corticosteroids (p < 0.001), gram-positive bacteremia (p = 0.002) and younger age (p = 0.03). In multivariate analysis only recovery of the neutropenia (p < 0.001) was associated with good prognosis whereas the diagnosis of infection by Fusarium sp. (p = 0.006) was strongly associated with a poor outcome. The death rate was 43%. There was no statistically significant difference in the death rate between patients who did receive (52%) or did not receive (50%) antifungal treatment. Identifying patients at risk, specific syndromes and prognostic factors may help to reduce the high mortality associated with disseminated fungal infections in neutropenic patients.

Antibiotic regimen as an independent risk factor for disseminated fungal infections in neutropenic patients in Brazil.

In a cohort of 79 febrile episodes in 50 consecutive neutropenic patients seen at the University Hospital, Federal University of Rio de Janeiro, Brazil, between 1987 and 1991, it was observed that the cumulative incidence of disseminated fungal infections rose from 3% to 19% after the introduction of a new empirical antibiotic regimen. In order to identify risk factors, as well as to assess the impact of the new antibiotic regimen on the emergence of fungal infections, a nested case-control study was undertaken, in which 10 cases of disseminated fungal infections were compared with 30 randomly chosen controls, drawn from the same cohort. In a multiple logistic regression analysis, the predictive factors for disseminated fungal infection were younger age (odds ratio 0.85, 95% confidence interval 0.75-0.97) and use of the new antibiotic regimen (odds ratio 14.18, 95% confidence interval 1.05-191.80) The probable explanation for the emergence of fungal infections is that the new antibiotic regimen, by lowering the incidence of bacteraemia-related deaths, allowed patients to be at risk for the development of disseminated fungal infections.

Amphotericin B followed by itraconazole in the treatment of disseminated fungal infections in neutropenic patients.

The role of the new triazoles in the treatment of disseminated fungal infections in neutropenic patients is at present under scrutiny. Six neutropenic patients with disseminated fungal infections were treated with amphotericin B during neutropenia and itraconazole after bone marrow recovery. There were three pulmonary aspergillomas, one Aspergillus fumigatus sinusitis, one Fusarium-mycosis and one disseminated candidosis. Four patients were cured of the infection. This approach seems to be safe and effective in the treatment of disseminated fungal infections in neutropenic patients, with the advantages of low side-effects and the possibility of early discharge from hospital.

Three cases of infection with Fusarium species in neutropenic patients.

Three cases are reported of disseminated infection due to Fusarium species in severely neutropenic patients. The clinical findings in all patients included fever, painful disseminated nodular skin lesions and severe myalgia. The outcome was fatal despite early administration of amphotericin B. The portal of entry of the organism was probably the nasal sinus in two cases.

Cutaneous involvement of systemic fungal infections in neutropenic patients.

Skin nodules can be the first evidence of a disseminated fungal infection in febrile neutropenic patients. We present our experience in the diagnosis of this clinical problem in five patients treated for serious hematologic conditions in our Service. There were two cases of Candida sp., two of Fusarium sp., and one of Trichosporon sp.. The immediate assessment of any suspicious lesion, including a biopsy of the lesion for microbiological and histopathologic examinations, will usually lead to the correct diagnosis.

Cryptococcus neoformans varieties as agents of cryptococcosis in Brazil.

The study of the clinical isolates of Cryptococcus neoformans from 83 Brazilian patients with disseminated cryptococcosis showed that 75 were C. neoformans var. neoformans and 8 were var. gattii. Twenty-seven isolates were serotyped; all 19 var. neoformans were serotype A and all 8 var. gattii were serotype B. The correlation of the varieties of C. neoformans with the presence or not of hosts predisposing conditions to the mycosis showed that: (1) cryptococcosis caused by gattii variety occurred in 7 (58.3%) of the 12 nonimmunosuppressed patients, and (2) cryptococcosis caused by neoformans variety occurred in 65 (98.5%) of the 66 AIDS patients and in all 5 patients with other immunosuppressive conditions. The comparison of the distribution of the gattii and neoformans varieties between the nonimmunosuppressed and immunosuppressed patients showed a significant statistical difference (p < 0.01).

PIP: 8 mycologists reviewed the medical records of 83 patients with disseminated crypttococcosis living in Brazil to examine the varieties of Cryptococcus neoformans. 12 patients were not immunosuppressed (group 1). 65 patients had AIDS (group 2). 5 patients either also had another disease and/or used immunosuppressive drugs (group 3). Almost all the clinical isolates were from the cerebrospinal fluid and/or blood (80 isolates [96.4%]. C. neoformans var. gattii caused cryotococcosis in 58.3% (7) of the nonimmunosuppressed patients. C. neoformans var. neoformans was responsible for crypttococcosis in all but 1 of the AIDS patients (98.5%) and in all 5 patients who had another disease and/or used immunosuppressive drugs. 6 of the 8 cases with crypttococcosis caused by C. neoformans var. gatti lived in rural areas during their first 10 years. A statistically significant difference existed between the nonimmunosuppressed group (group 1) and the immunosuppressed patients (groups 2 and 3) in the comparison of the distribution of the gattii and neoformans varieties (p.01). The omnipresence of C. neoformans var. neoformans, the urban population's regular exposure to C. neoformans var. neoformans, and predisposing conditions (i.e., immunosuppression) to crypttococcosis likely accounted for the neoformans variety mainly being the cause of crypttococcosis in areas in Brazil where C. neoformans var. gattii is indigenous.

[Mycetoma due to Actinomadura madurae. A report of 2 cases]. / Micetoma por Actinomadura madurae. Relato de dois casos.

Actinomadura madurae mycetoma was diagnosed in two patients by the dermatologic outpatient clinic of the Clementino Fraga Filho University Hospital (UFRJ) and the Antonio Pedro University Hospital (UFF). The first case was a 27-year-old Negro male from the outskirts of Rio de Janeiro, who was injured prior to the onset of the disease in 1988. The affected left foot showed swelling, nodules, sinus tracts, purulent discharge containing grains, and serious bone involvement with lytic lesions. Histological examination showed deeply basophilic stained grains with typical wide-fringed borders. The mycological examination revealed an actinomycete identified as A. madurae by culture. Oral tetracycline for six months did not improve the clinical-radiological picture and the patient was submitted to amputation. The second case was a 70-year-old white male, with previous injury in 1974, which occurred in Pernambuco State. Enlargement of the right foot draining sinuses formation with discharge of pus and grains. In tissue sections the grains were large and surrounded by amorphous eosinophilic clubs radially oriented. There was discrete improvement by tetracycline and sulfonamide. No follow-up.