Epidemiological and Clinical Aspects of Cutaneous and Mucosal Leishmaniases in Portugal: Retrospective Analysis of Cases Diagnosed in Public Hospitals and Reported in the Literature between 2010 and 2020.

Leishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM® SPSS® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.

Nocardiosis: a single-center experience and literature review.

INTRODUCTION: Nocardiosis is a rare bacterial infection caused by Nocardia spp. However, an increasing incidence has been described whereby data about epidemiology and prognosis are essential. METHODS: A retrospective descriptive study was conducted among patients with positive Nocardia spp. culture, from January 2019 to January 2023, at a Terciary Hospital in Portugal. RESULTS: Nocardiosis was considered in 18 cases with a median age of 63.8-years-old. At least one immunosuppressive cause was identified in 70% of patients. Five patients had Disseminated Nocardiosis (DN). The lung was the most common site of clinical disease (77.8%) and Nocardia was most commonly identified in respiratory tract samples. The most frequently isolated species were Nocardia nova/africana (n = 7) followed by Nocardia cyriacigeorgica (n = 3) and Nocardia pseudobrasiliensis (n = 3). The majority of the patients (94.4%) received antibiotic therapy, of whom as many as 55.6% were treated with monotherapy. The most frequently prescribed antibiotic was trimethoprim-sulfamethoxazole. Selected antimicrobial agents were generally effective, with linezolid and cotrimoxazole (100% Susceptibility [S]) and amikacin (94% S) having the most activity against Nocardia species. The median (IQR) duration of treatment was 24.2 (1‒51.4) weeks for DN; The overall one-year case fatality was 33.3% (n = 6) and was higher in the DN (66.7%). No recurrence was observed. CONCLUSION: Nocardiosis is an emerging infectious disease with a poor prognosis, particularly in DN. This review offers essential epidemiological insights and underscores the importance of gaining a better understanding of the microbiology of nocardiosis. Such knowledge can lead to the optimization of antimicrobial therapy and, when necessary, guide appropriate surgical interventions to prevent unfavorable outcomes.

Adverse Events of Latent Tuberculosis Treatment With Isoniazid in People Living With HIV: A Case-Control Study in a Resource-Rich Setting.

Introduction Multiple risk factors, such as human immunodeficiency virus (HIV) infection and immunosuppressive therapies, increase the odds of latent tuberculosis infection (LTBI) reactivation and progression to active tuberculosis. A six-to-nine-month preventive treatment with isoniazid (INH) decreases the risk of LTBI reactivation, but its effectiveness can be limited by its long duration and adverse events (AEs), including liver toxicity. Due to comorbidities and polypharmacy, people living with HIV (PLHIV) may be at increased risk of INH-associated AEs. Our study aimed to assess the prevalence of AEs among patients receiving INH treatment for LTBI, to identify risk factors for their occurrence, and to evaluate whether PLHIV have higher odds of developing INH-associated AEs. Methods We conducted a single-center retrospective case-control study, including 130 outpatients with LTBI treated with INH between July 2019 and March 2022. Participants who developed AE (cases) were compared to controls, and a subgroup of PLHIV was compared to HIV-negative participants. Demographics, socioeconomic variables, comorbidities, and clinical variables were compared between study groups. Patient data were obtained from institutional electronic medical records, and outcomes were measured at regularly scheduled appointments. Results We included 130 participants, of which 54 were PLHIV. The PLHIV subgroup was significantly younger (p = 0.01) and demonstrated significantly higher prevalences of chronic liver disease, previous viral hepatitis, daily alcohol consumption, and intravenous drug use (IDU). One-third of the participants had an AE (45 cases, 34.6%), with liver toxicity being the most common (22.3%). Participants who developed AEs were significantly older (p = 0.030) and had a higher prevalence of economic hardship (p = 0.037), as well as higher scores of the Charlson comorbidity index (p = 0.002) than the controls. INH withdrawal occurred in 17 participants (13.1%) and was mainly associated with liver toxicity (p < 0.01) and gastrointestinal symptoms (p = 0.022). In the adjusted effect model, an age ≥ 65 years, economic hardship, and excessive alcohol consumption were significantly associated with higher odds of AEs, while HIV infection decreased the odds by 68.4% (p = 0.033). Conclusions In our study, INH-associated AEs were common, with liver toxicity being the most frequent. Older age, economic hardship, and excessive alcohol consumption increased the odds of INH-associated AEs, while PLHIV had lower odds of developing INH-associated AEs, even when adjusting for other variables in the multivariate analysis. Further studies should be conducted to assess if these results are replicable in a larger population and in different settings.

Nocardiosis: a single-center experience and literature review

ABSTRACT Introduction: Nocardiosis is a rare bacterial infection caused by Nocardia spp. However, an increasing incidence has been described whereby data about epidemiology and prognosis are essential. Methods: A retrospective descriptive study was conducted among patients with positive Nocardia spp. culture, from January 2019 to January 2023, at a Terciary Hospital in Portugal. Results: Nocardiosis was considered in 18 cases with a median age of 63.8-years-old. At least one immunosuppressive cause was identified in 70% of patients. Five patients had Disseminated Nocardiosis (DN). The lung was the most common site of clinical disease (77.8%) and Nocardia was most commonly identified in respiratory tract samples. The most frequently isolated species were Nocardia nova/africana (n = 7) followed by Nocardia cyriacigeorgica (n = 3) and Nocardia pseudobrasiliensis (n = 3). The majority of the patients (94.4%) received antibiotic therapy, of whom as many as 55.6% were treated with monotherapy. The most frequently prescribed antibiotic was trimethoprim-sulfamethoxazole. Selected antimicrobial agents were generally effective, with linezolid and cotrimoxazole (100% Susceptibility [S]) and amikacin (94% S) having the most activity against Nocardia species. The median (IQR) duration of treatment was 24.2 (1-51.4) weeks for DN; The overall one-year case fatality was 33.3% (n = 6) and was higher in the DN (66.7%). No recurrence was observed. Conclusion: Nocardiosis is an emerging infectious disease with a poor prognosis, particularly in DN. This review offers essential epidemiological insights and underscores the importance of gaining a better understanding of the microbiology of nocardiosis. Such knowledge can lead to the optimization of antimicrobial therapy and, when necessary, guide appropriate surgical interventions to prevent unfavorable outcomes.

A Rare Cause of Low Back Pain: A Challenging Diagnosis.

One of the rarest causes of low back pain is septic arthritis of a lumbar facet joint. We report the case of a 92-year-old diabetic woman with a history of four days of back pain, dysuria, and fever. Due to a sudden worsening of lumbar pain, she went to the emergency department. Physical exam revealed pain with pressure over the D12 vertebral apophyses and the lower-left paraspinal musculature. Laboratory data showed a normochromic normocytic anemia with a hemoglobin of 9.3 g/dL, white cell count of 14.61x10e3/µL (83.1% neutrophils), serum creatinine 1.46 mg/dL and C-reactive protein of 32.11 mg/dL. In urinalysis, nitrites and leukocyturia were identified. CT scan showed an acute D12 fracture and fat stranding at L5, with no irregularities in the discs or in other lumbar spaces. Escherichia coli was isolated in blood culture. Lumbar MRI confirmed the diagnosis of septic arthritis of an L5-S1 facet joint and L5 vertebrae osteomyelitis. The patient was successfully treated with intravenous ceftriaxone for eight weeks. As far as we know, this is the second report of septic arthritis of the facet joint caused by Escherichia coli.

Secondary Organising Pneumonia Among COVID-19 Patients: A Retrospective Case-Control Study.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Secondary organising pneumonia (OP) induced by SARS-CoV-2 infection is a recently recognised complication of COVID-19. We aimed to evaluate the prevalence of OP among hospitalised patients with COVID-19 pneumonia and to assess whether disease severity and other clinical factors and comorbidities are correlated with OP development. We conducted a retrospective case-control study including hospitalised patients due to COVID-19 who performed a chest CT scan during hospitalisation and compared patients with clinical and radiological evidence of OP to patients without evidence of OP. Demographics, comorbidities, disease severity, dexamethasone/remdesivir treatment, laboratory results, and outcomes were compared between groups. One hundred fifteen patients were included, of whom 48 (41.7%) fulfilled clinical and imaging criteria for OP. Among OP patients, the most common chest CT-scan findings were consolidations, arciform condensations, and subpleural bands. OP patients had longer hospitalisation (19.5 vs 10 days, p=0.002) and more frequent ICU admission, but no significant differences in readmittance or mortality rates within 180 days compared to controls. In the adjusted effects model, the need for supplementary oxygen on the 21st day after symptom onset, the presence of Ordinal Scale for Clinical Improvement (OSCI) = 4, when compared to OSCI ≤ 3, and higher C-reactive protein on admission, were significantly associated with higher odds for OP. No other differences were identified between OP and controls after adjusting for other factors. The use of remdesivir or dexamethasone did not impact the diagnosis of OP. Only 38% of OP patients required treatment with high-dose corticosteroids. In conclusion, SARS-CoV-2-induced OP may be more frequent than previously thought, especially among hospitalised patients and patients with a more severe disease, particularly those who fail to improve after the second week of disease or who present higher inflammatory markers on admission. It increases the length of stay, but not all patients require specific treatment and OP may improve despite the absence of high-dose corticosteroid treatment.

Altered IgG glycosylation at COVID-19 diagnosis predicts disease severity.

The nature of the immune responses associated with COVID-19 pathogenesis and disease severity, as well as the breadth of vaccine coverage and duration of immunity, is still unclear. Given the unpredictability for developing a severe/complicated disease, there is an urgent need in the field for predictive biomarkers of COVID-19. We have analyzed IgG Fc N-glycan traits of 82 SARS-CoV-2+ unvaccinated patients, at diagnosis, by nano-LC-ESI-MS. We determined the impact of IgG Fc glyco-variations in the induction of NK cells activation, further evaluating the association between IgG Fc N-glycans and disease severity/prognosis. We found that SARS-CoV-2+ individuals display, at diagnosis, variations in the glycans composition of circulating IgGs. Importantly, levels of galactose and sialic acid structures on IgGs are able to predict the development of a poor COVID-19 disease. Mechanistically, we demonstrated that a deficiency on galactose structures on IgG Fc in COVID-19 patients appears to induce NK cells activation associated with increased release of IFN-γ and TNF-α, which indicates the presence of pro-inflammatory immunoglobulins and higher immune activation, associated with a poor disease course. This study brings to light a novel blood biomarker based on IgG Fc glycome composition with capacity to stratify patients at diagnosis.

A Rare Case of a Migrating Inguinal Hernia Mesh Presenting as Acute Appendicitis.

Acute appendicitis is a very common event. Migration of hernia mesh is rare, especially intraluminal migrations. We aim to report a case of a migrated inguinal mesh presenting as an acute appendicitis. A 58-year-old male previously submitted to ONSTEP right inguinal hernia repair with a PolySoft™ hernia patch eight years before, was admitted in the emergency department with acute appendicitis, and submitted to laparoscopic appendectomy. Intraoperatively, the "recoil ring" from the inguinal hernia patch was extended from the anterior abdominal wall to the appendix, perforating it and progressing intraluminally. Appendectomy was performed, as well as removal of the mesh by an anterior approach. Hernia mesh migration to an intraluminally position is extremely rare with only a few cases described in literature. Pathogenesis of migration is still poorly understood. Clinicians should consider hernia mesh migration in their differential diagnosis for causes of acute appendicitis, in the right clinical setting, when a previous hernia defect correction is present. To the best of our knowledge, this is the first reported case of inguinal hernia mesh migration to the appendix, presenting as acute appendicitis.

The Impact of SARS-CoV-2 Viral Load on the Mortality of Hospitalized Patients: A Retrospective Analysis.

Introduction Coronavirus disease 2019 (COVID-19) has emerged worldwide since December 2019. The standard method for diagnosis is via nucleic acid amplification testing, usually with a reverse-transcription polymerase chain reaction (RT-PCR). Hospitalized infected individuals may require ventilation and may have higher mortality rates. We aim to evaluate the clinical impact of nasopharyngeal viral load on these outcomes. Materials and methods We conducted a retrospective cohort study of patients hospitalized with COVID-19 from 17 March 2020 to 1 June 2020 at a tertiary care hospital. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral load was assessed using cycle threshold (Ct) values from an RT-PCR assay applied to nasopharyngeal swab samples. We compared the clinical characteristics of survivors vs. non-survivors and assessed whether the viral load was independently associated with in-hospital 30-day mortality. Results We evaluated 197 patients. Thirty-day mortality was verified in 71 (36%) subjects. In the adjusted effects model, only the E-gene Ct value [odd ratio (OR) .873; confidence interval (CI) 95% .769-.992; p .037], age, the number of days of symptoms before admission, lactate dehydrogenase (LDH), and the oxygen saturation (SatO2)-to-fraction of inspired oxygen (FiO2) ratio remained significantly associated with 30-day mortality. There was no identified association between the viral loads and disease severity, the need for ventilation, or length of stay. Discussion Our results are, in part, concordant with previous papers. One possible limitation to our study is the fact that possibly included disproportionately more patients with poorer outcomes since hospitalization was required. Therefore, further research is required. Conclusion SARS-CoV-2 viral load on admission may be an independent predictor of 30-day mortality among hospitalized patients with COVID-19. Providing this information to clinicians could potentially be used to guide risk stratification.

SARS-CoV-2 Infection Drives a Glycan Switch of Peripheral T Cells at Diagnosis.

COVID-19 is a highly selective disease in which SARS-CoV-2 infection can result in different clinical manifestations ranging from asymptomatic/mild to severe disease that requires hospitalization. In this study, we demonstrated that SARS-CoV-2 infection results in a glycosylation reprogramming of circulating lymphocytes at diagnosis. We identified a specific glycosignature of T cells, defined upon SARS-CoV-2 infection and apparently triggered by a serological factor. This specific glycan switch of T cells is detected at diagnosis being more pronounced in asymptomatic patients. We further demonstrated that asymptomatic patients display an increased expression of a viral-sensing receptor through the upregulation of DC-SIGN in monocytes. We showed that higher levels of DC-SIGN in monocytes at diagnosis correlates with better COVID-19 prognosis. This new evidence pave the way to the identification of a novel glycan-based response in T cells that may confer protection against SARS-CoV-2 infection in asymptomatic patients, highlighting a novel prognostic biomarker and potential therapeutic target.

Clinical Features and Prognostic Factors of 245 Portuguese Patients Hospitalized With COVID-19.

Introduction Since the declaration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in March 2020, Portugal was considered a role model with regards to the first COVID-19 wave. However, a third wave started in 2021 started, turning the country into the worst in the world regarding new infections and death rate per capita in the last weeks of January 2021. No significant data regarding the country's first wave of hospitalized patients have been published. Those data may help understand the differences over time regarding patients and the clinical approach to them. Herein, we present data of COVID-19 patients hospitalized at the main tertiary hospital of the second-most affected county at the time and identify risk factors associated with disease progression and outcomes. Materials and methods We performed a prospective observational study of patients admitted with COVID-19 to a central hospital between March 20 and June 1, 2020. The primary endpoint of this study was 30-day mortality or the need for ventilatory support and the secondary outcomes were both outcomes individually. Results 245 patients were included, with a median age of 79 years, 52% males. Hypertension (n = 172) and dyslipidemia (n = 114) were the most frequent comorbidities. Half of the patients (n = 121) were treated with hydroxychloroquine. The primary outcome occurred in 114 patients; mortality at 30 days was 35%. Age (OR 1.05; 1.02-1.07) and active cancer (OR 3.89; 1.43-10.57) were associated with the primary outcome, with dyslipidemia being protective (OR 0.46; 0.25-0.80). Treatment with hydroxychloroquine or lopinavir/ritonavir was not associated with the main outcome. Patients who had been symptomatic for more than 7 days had lower mortality (OR 0.23; 0.09-0.63). Discussion In the present study, age and cancer were associated with higher mortality, as noted in prior articles. The population had a higher median age than reported in previous studies, which may explain the increased mortality. The protective association of dyslipidemia was not previously described. This association was not related to statin intake. Conclusion The reported high mortality of COVID-19 is rarely seen in other infectious diseases. Our elderly population probably reflects more reliably the incidence of COVID-19 in European countries with constricted age pyramids.

Peripheral arterial tonometry as a method of measuring reactive hyperaemia correlates with organ dysfunction and prognosis in the critically ill patient: a prospective observational study.

Predictions of mortality may help in the selection of patients who benefit from intensive care. Endothelial dysfunction is partially responsible for many of the organic dysfunctions in critical illness. Reactive hyperaemia is a vascular response of the endothelium that can be measured by peripheral arterial tonometry (RH-PAT). We aimed to assess if reactive hyperaemia is affected by critical illness and if it correlates with outcomes. Prospective study with a cohort of consecutive patients admitted to an Intensive Care Unit. RH-PAT was accessed on admission and on the 7th day after admission. Early and late survivors were compared to non-survivors. The effect of RH-PAT variation on late mortality was studied by a logistic regression model. The association between RH-PAT and severity scores and biomarkers of organic dysfunction was investigated by multivariate analysis. 86 patients were enrolled. Mean ln(RHI) on admission was 0.580 and was significantly lower in patients with higher severity scores (p < 0.01) and early non-survivors (0.388; p = 0.027). The model for prediction of early-mortality estimated that each 0.1 decrease in ln(RHI) increased the odds for mortality by 13%. In 39 patients, a 2nd RH-PAT measurement was performed on the 7th day. The variation of ln(RHI) was significantly different between non-survivors and survivors (- 24.2% vs. 63.9%, p = 0.026). Ln(RHI) was significantly lower in patients with renal and cardiovascular dysfunction (p < 0.01). RH-PAT is correlated with disease severity and seems to be an independent marker of early mortality, cardiovascular and renal dysfunctions. RH-PAT variation predicts late mortality. There appears to be an RH-PAT impairment in the acute phase of severe diseases that may be reversible and associated with better outcomes.

Composition of the immunoglobulin G glycome associates with the severity of COVID-19.

A large variation in the severity of disease symptoms is one of the key open questions in coronavirus disease 2019 (COVID-19) pandemics. The fact that only a small subset of people infected with severe acute respiratory syndrome coronavirus 2 develops severe disease suggests that there have to be some predisposing factors, but biomarkers that reliably predict disease severity have not been found so far. Since overactivation of the immune system is implicated in a severe form of COVID-19 and the immunoglobulin G (IgG) glycosylation is known to be involved in the regulation of different immune processes, we evaluated the association of interindividual variation in IgG N-glycome composition with the severity of COVID-19. The analysis of 166 severe and 167 mild cases from hospitals in Spain, Italy and Portugal revealed statistically significant differences in the composition of the IgG N-glycome. The most notable difference was the decrease in bisecting N-acetylglucosamine in severe patients from all three cohorts. IgG galactosylation was also lower in severe cases in all cohorts, but the difference in galactosylation was not statistically significant after correction for multiple testing.

Pulmonary mucormycosis: A case report.

Mucormycosis is a rare fungal infection caused by Mucorales order fungi. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas, pulmonary mucormycosis is a rare manifestation in patients with haematological malignancy and transplant recipients. We report a case of pulmonary mucormycosis presenting with a late acute onset diabetes on a patient immunosuppressed with a low dose of steroids. We aim to illustrate the need for a high clinical suspicion for the diagnosis of mucormycosis and to report the importance of early and aggressive inhiation of antifungal therapy.

Reactive hyperemia correlates with the presence of sepsis and glycocalyx degradation in the intensive care unit: a prospective cohort study. / A hiperemia reativa correlaciona-se com presença de sepse e degradação de glicocálix na unidade de terapia intensiva: um estudo de coorte prospectiva.

OBJECTIVE: To investigate whether reactive hyperemia measured by peripheral arterial tonometry correlates with markers of endothelial dysfunction and may be used to identify sepsis in critical illness. METHODS: A prospective study was performed using a cohort of critically ill patients. Endothelial dysfunction was assessed on admission by quantifying reactive hyperemia-peripheral arterial tonometry and plasma levels of endothelin-1, soluble E-selectin, endocan and syndecan-1. Septic patients were compared to patients without evidence of infection. RESULTS: Fifty-eight septic patients were compared to 28 controls. The natural logarithm of reactive hyperemia-peripheral arterial tonometry was negatively correlated with cardiovascular comorbidities, disease severity and plasma levels of soluble E-selectin (p = 0.024) and syndecan-1 (p < 0.001). The natural logarithm of reactive hyperemia-peripheral arterial tonometry was lower in septic patients than in controls (0.53 ± 0.48 versus 0.69 ± 0.42, respectively). When adjusted for age, the multivariable model predicted that each 0.1-unit decrease in natural logarithm of reactive hyperemia-peripheral arterial tonometry increased the odds for infection by 14.6%. m. CONCLUSION: Reactive hyperemia-peripheral arterial tonometry is closely related to soluble E-selectin and syndecan-1, suggesting an association between endothelial activation, glycocalyx degradation and vascular reactivity. Reactive hyperemia-peripheral arterial tonometry appears to be compromised in critically ill patients, especially those with sepsis.

OBJETIVO: Investigar se a hiperemia reativa correlaciona-se com marcadores de disfunção endotelial e pode ser utilizada para identificar sepse na doença crítica. MÉTODOS: Trata-se de estudo prospectivo em uma coorte de pacientes críticos. A disfunção endotelial foi avaliada quando da admissão, por meio da quantificação de hiperemia por tonometria arterial periférica e níveis plasmáticos de endotelina 1, E-selectina solúvel, endocana e sindecano 1. Os pacientes sépticos foram comparados com pacientes sem evidência de infecção. RESULTADOS: Cinquenta e oito pacientes sépticos foram comparados com 28 controle. O logaritmo natural da tonometria arterial periférica teve correlação negativa com comorbidades cardiovasculares, severidade da doença e níveis plasmáticos de E-selectina solúvel (p = 0,024) e sindecano 1 (p < 0,001). O logaritmo natural da tonometria arterial periférica foi mais baixo nos pacientes sépticos quando comparado com os de pacientes controle (0,53 ± 0,48 versus 0,69 ± 0,42, respectivamente) e, quando ajustado à idade, o modelo multivariado predisse que cada 0,1 de diminuição em unidades de logaritmo natural da tonometria arterial periférica levou a aumento de 14,6% na probabilidade de infecção. CONCLUSÃO: A hiperemia reativa avaliada por tonometria arterial periférica tem estreita relação com E-selectina solúvel e sindecano 1, o que sugere associação entre ativação endotelial, degradação de glicocálix e reatividade vascular. A hiperemia reativa por tonometria arterial periférica parece estar comprometida em pacientes críticos, especialmente os com sepse.

A hiperemia reativa correlaciona-se com presença de sepse e degradação de glicocálix na unidade de terapia intensiva: um estudo de coorte prospectiva / Reactive hyperemia correlates with the presence of sepsis and glycocalyx degradation in the intensive care unit: a prospective cohort study

RESUMO Objetivo: Investigar se a hiperemia reativa correlaciona-se com marcadores de disfunção endotelial e pode ser utilizada para identificar sepse na doença crítica. Métodos: Trata-se de estudo prospectivo em uma coorte de pacientes críticos. A disfunção endotelial foi avaliada quando da admissão, por meio da quantificação de hiperemia por tonometria arterial periférica e níveis plasmáticos de endotelina 1, E-selectina solúvel, endocana e sindecano 1. Os pacientes sépticos foram comparados com pacientes sem evidência de infecção. Resultados: Cinquenta e oito pacientes sépticos foram comparados com 28 controle. O logaritmo natural da tonometria arterial periférica teve correlação negativa com comorbidades cardiovasculares, severidade da doença e níveis plasmáticos de E-selectina solúvel (p = 0,024) e sindecano 1 (p < 0,001). O logaritmo natural da tonometria arterial periférica foi mais baixo nos pacientes sépticos quando comparado com os de pacientes controle (0,53 ± 0,48 versus 0,69 ± 0,42, respectivamente) e, quando ajustado à idade, o modelo multivariado predisse que cada 0,1 de diminuição em unidades de logaritmo natural da tonometria arterial periférica levou a aumento de 14,6% na probabilidade de infecção. Conclusão: A hiperemia reativa avaliada por tonometria arterial periférica tem estreita relação com E-selectina solúvel e sindecano 1, o que sugere associação entre ativação endotelial, degradação de glicocálix e reatividade vascular. A hiperemia reativa por tonometria arterial periférica parece estar comprometida em pacientes críticos, especialmente os com sepse.

Abstract Objective: To investigate whether reactive hyperemia measured by peripheral arterial tonometry correlates with markers of endothelial dysfunction and may be used to identify sepsis in critical illness. Methods: A prospective study was performed using a cohort of critically ill patients. Endothelial dysfunction was assessed on admission by quantifying reactive hyperemia-peripheral arterial tonometry and plasma levels of endothelin-1, soluble E-selectin, endocan and syndecan-1. Septic patients were compared to patients without evidence of infection. Results: Fifty-eight septic patients were compared to 28 controls. The natural logarithm of reactive hyperemia-peripheral arterial tonometry was negatively correlated with cardiovascular comorbidities, disease severity and plasma levels of soluble E-selectin (p = 0.024) and syndecan-1 (p < 0.001). The natural logarithm of reactive hyperemia-peripheral arterial tonometry was lower in septic patients than in controls (0.53 ± 0.48 versus 0.69 ± 0.42, respectively). When adjusted for age, the multivariable model predicted that each 0.1-unit decrease in natural logarithm of reactive hyperemia-peripheral arterial tonometry increased the odds for infection by 14.6%. m. Conclusion: Reactive hyperemia-peripheral arterial tonometry is closely related to soluble E-selectin and syndecan-1, suggesting an association between endothelial activation, glycocalyx degradation and vascular reactivity. Reactive hyperemia-peripheral arterial tonometry appears to be compromised in critically ill patients, especially those with sepsis.

Botulism disguised as parotitis.

Botulism is an acute toxin-mediated neuroparalytic syndrome caused by some Clostridium species. It typically presents itself as an acute symmetric descending paralysis of cranial and peripheral nerves, which can potentially evolve to respiratory failure and death. We report a case of botulism diagnosed in a patient presenting with a parotitis probably due to xerostomia, even though he had already sought medical assistance for blurred vision and dysphagia. The neurological symptoms resolved without administration of antitoxin and botulism diagnosis was confirmed with identification of both toxins B and F in patient's serum. We aim to illustrate the need for a high clinical suspicion for the diagnosis of botulism and to report an atypical case of botulism with the production of toxins B and F, the latter being of rare occurrence.

Skin and soft tissue infections in the intensive care unit: a retrospective study in a tertiary care center. / Infecções da pele e de tecidos moles na unidade de terapia intensiva: estudo retrospectivo em um centro terciário.

OBJECTIVE: To identify factors that may influence outcomes in patients with severe skin and soft tissue infections in the intensive care unit. METHODS: A retrospective observational study was conducted in a cohort of 1,123 critically ill patients admitted to an intensive care unit with a primary or secondary diagnosis of severe skin and soft tissues infection between January 2006 and December 2014. RESULTS: Thirty patients were included, 20 (66.7%) of whom were diagnosed with necrotizing fasciitis; in these patients, perineal area involvement was most commonly identified. Abscess was diagnosed in 8 (26.7%) patients, most commonly involving the cervical area. Risk factors such as immunosuppression and previous surgical trauma were commonly observed in this population. The most commonly isolated microorganism was Escherichia coli. Multidrug resistant microorganisms were commonly detected, even in the absence of traditional risk factors; among these patients, previous use of antibiotics was the most common risk factor for drug resistance. The rate of mortality was significantly higher in patients with necrotizing fasciitis (55%, p = 0.035) and associated with disease severity, presence of septic shock, cardiac arrest and leucocytosis. CONCLUSION: Different risk factors and etiologies of severe skin and soft tissue infections were identified. Necrotizing fasciitis and drug-resistant bacteria were significant predictors of mortality, even in the absence of traditional risk factors. Obtaining a better understanding of trends in the risk factors and microorganisms associated with severe skin infections may help in the determination of prompt treatment and antibiotic choices.

OBJETIVO: Descrever o prognóstico, os fatores de risco e a etiologia das infecções da pele e dos tecidos moles na unidade de terapia intensiva. MÉTODOS: Estudo retrospectivo de uma coorte de 1.123 pacientes graves admitidos a uma unidade de terapia intensiva com o diagnóstico de infecção grave de pele ou tecidos moles. RESULTADOS: Foram selecionados 30 pacientes, sendo 20 (66,7%) com fasceíte necrotizante, predominantemente da região perineal; 8 (26,7%) com abscesso cutâneo; e 2 (6,6%) com celulite. A maioria dos pacientes tinha fatores de risco, como imunossupressão e lesões cutâneas. O microrganismo isolado predominante foi Escherichia coli. Pacientes com fasceíte necrotizante na admissão à unidade de terapia intensiva apresentaram mortalidade significativamente maior (55%; p = 0,035), assim como aqueles com maior índice de severidade, choque séptico, parada cardiorrespiratória e leucocitose. Organismos resistentes à antibioticoterapia foram comuns, mesmo na ausência de fatores de risco. Quando presente, o fator de risco mais comum foi o uso prévio de antibiótico. CONCLUSÃO: Foram identificados fatores de risco e microrganismos diferentes dos classicamente descritos na literatura, além de elevada mortalidade da fasceíte necrotizante e presença de microrganismos multirresistentes na ausência de fatores de risco. Dada a aparente evolução etiológica das infecções da pele e tecidos moles, a identificação de novos fatores de risco e etiologia pode contribuir para uma terapêutica antimicrobiana mais adequada.

Severe interstitial pneumonia due to murine typhus in a patient returning from Bali.

Murine typhus has been increasingly reported as a cause of fever in returning travelers from Southeast Asia. We report a case of a previously healthy traveler returning from Bali with an non-specific febrile illness which quickly progressed to a severe form of interstitial pneumonia. After a careful epidemiological evaluation and laboratory analysis, murine typhus was diagnosed.

Infecções da pele e de tecidos moles na unidade de terapia intensiva: estudo retrospectivo em um centro terciário / Skin and soft tissue infections in the intensive care unit: a retrospective study in a tertiary care center

RESUMO Objetivo: Descrever o prognóstico, os fatores de risco e a etiologia das infecções da pele e dos tecidos moles na unidade de terapia intensiva. Métodos: Estudo retrospectivo de uma coorte de 1.123 pacientes graves admitidos a uma unidade de terapia intensiva com o diagnóstico de infecção grave de pele ou tecidos moles. Resultados: Foram selecionados 30 pacientes, sendo 20 (66,7%) com fasceíte necrotizante, predominantemente da região perineal; 8 (26,7%) com abscesso cutâneo; e 2 (6,6%) com celulite. A maioria dos pacientes tinha fatores de risco, como imunossupressão e lesões cutâneas. O microrganismo isolado predominante foi Escherichia coli. Pacientes com fasceíte necrotizante na admissão à unidade de terapia intensiva apresentaram mortalidade significativamente maior (55%; p = 0,035), assim como aqueles com maior índice de severidade, choque séptico, parada cardiorrespiratória e leucocitose. Organismos resistentes à antibioticoterapia foram comuns, mesmo na ausência de fatores de risco. Quando presente, o fator de risco mais comum foi o uso prévio de antibiótico. Conclusão: Foram identificados fatores de risco e microrganismos diferentes dos classicamente descritos na literatura, além de elevada mortalidade da fasceíte necrotizante e presença de microrganismos multirresistentes na ausência de fatores de risco. Dada a aparente evolução etiológica das infecções da pele e tecidos moles, a identificação de novos fatores de risco e etiologia pode contribuir para uma terapêutica antimicrobiana mais adequada.

ABSTRACT Objective: To identify factors that may influence outcomes in patients with severe skin and soft tissue infections in the intensive care unit. Methods: A retrospective observational study was conducted in a cohort of 1,123 critically ill patients admitted to an intensive care unit with a primary or secondary diagnosis of severe skin and soft tissues infection between January 2006 and December 2014. Results: Thirty patients were included, 20 (66.7%) of whom were diagnosed with necrotizing fasciitis; in these patients, perineal area involvement was most commonly identified. Abscess was diagnosed in 8 (26.7%) patients, most commonly involving the cervical area. Risk factors such as immunosuppression and previous surgical trauma were commonly observed in this population. The most commonly isolated microorganism was Escherichia coli. Multidrug resistant microorganisms were commonly detected, even in the absence of traditional risk factors; among these patients, previous use of antibiotics was the most common risk factor for drug resistance. The rate of mortality was significantly higher in patients with necrotizing fasciitis (55%, p = 0.035) and associated with disease severity, presence of septic shock, cardiac arrest and leucocytosis. Conclusion: Different risk factors and etiologies of severe skin and soft tissue infections were identified. Necrotizing fasciitis and drug-resistant bacteria were significant predictors of mortality, even in the absence of traditional risk factors. Obtaining a better understanding of trends in the risk factors and microorganisms associated with severe skin infections may help in the determination of prompt treatment and antibiotic choices.