DISSEMINATED FUNGAL INFECTION WITH ADRENAL INVOLVEMENT: REPORT OF TWO HIV NEGATIVE BRAZILIAN PATIENTS / Infecções fúngicas disseminadas com acometimento das supra-renais: descrição de dois pacientes brasileiros HIV-negativos

Paracoccidioidomycosis and histoplasmosis are systemic fungal infections endemic in Brazil. Disseminated clinical forms are uncommon in immunocompetent individuals. We describe two HIV-negative patients with disseminated fungal infections, paracoccidioidomycosis and histoplasmosis, who were diagnosed by biopsies of suprarenal lesions. Both were treated for a prolonged period with oral antifungal agents, and both showed favorable outcomes.

A paracoccidioidomicose e a histoplasmose são infecções fúngicas sistêmicas endêmicas no Brasil. As formas clínicas disseminadas são incomuns em pacientes imunocompetentes. Nós descrevemos dois pacientes HIV-negativos com infecções fúngicas disseminadas, paracoccidioidomicose e histoplasmose, que foram diagnosticadas por biópsias de lesões de supra-renal. Ambos foram tratados por períodos prolongados com antifúngicos orais, evoluindo com boa resposta terapêutica.

DISSEMINATED FUNGAL INFECTION WITH ADRENAL INVOLVEMENT: REPORT OF TWO HIV NEGATIVE BRAZILIAN PATIENTS.

Paracoccidioidomycosis and histoplasmosis are systemic fungal infections endemic in Brazil. Disseminated clinical forms are uncommon in immunocompetent individuals. We describe two HIV-negative patients with disseminated fungal infections, paracoccidioidomycosis and histoplasmosis, who were diagnosed by biopsies of suprarenal lesions. Both were treated for a prolonged period with oral antifungal agents, and both showed favorable outcomes.

Elizabethkingia meningoseptica: Emergent bacteria causing pneumonia in a critically ill child.

Elizabethkingia meningoseptica is an unusual, highly resistant, gram- negative bacillus. While E. meningoseptica-associated meningitis outbreaks have been well-documented in hospital neonatal wards and among immunocompromised adults, reports describing this microorganism in critically ill children are scarce. The purpose of this report was to describe a case of a 3 year-old girl who developed pneumonia caused by E. meningoseptica in the setting of previous use of broad-spectrum antibiotics and to review the pediatric literature regarding this pathogen.

Outbreak of carbapenem-resistant Klebsiella pneumoniae: two-year epidemiologic follow-up in a tertiary hospital.

This study describes a carbapenem-resistant Klebsiella pneumoniae (CRKP) outbreak that occurred from October 2008-December 2010. Polymerase chain reaction assays were performed to detect the blaKPC gene and molecular typing was performed using pulsed-field gel electrophoresis (PFGE). There were 33 CRKP infections; PFGE revealed five genotypes: genotype A in five (15%), B in 18 (55%), C in eight (24%) and two unique profiles. Genotype B was disseminated in all hospital units and belonged to the same clone identified in 11 different hospitals in the state of São Paulo. Sixteen (48%) patients died. Seven isolates (21%) were resistant to polymyxin B and 45% were resistant to tigecycline and amikacin.

Outbreak of carbapenem-resistant Klebsiella pneumoniae: two-year epidemiologic follow-up in a tertiary hospital

This study describes a carbapenem-resistant Klebsiella pneumoniae (CRKP) outbreak that occurred from October 2008-December 2010. Polymerase chain reaction assays were performed to detect the blaKPC gene and molecular typing was performed using pulsed-field gel electrophoresis (PFGE). There were 33 CRKP infections; PFGE revealed five genotypes: genotype A in five (15%), B in 18 (55%), C in eight (24%) and two unique profiles. Genotype B was disseminated in all hospital units and belonged to the same clone identified in 11 different hospitals in the state of São Paulo. Sixteen (48%) patients died. Seven isolates (21%) were resistant to polymyxin B and 45% were resistant to tigecycline and amikacin.

Disseminated amphotericin-resistant fusariosis in acute leukemia patients: report of two cases.

Disseminated fusariosis has emerged as a significant, usually fatal infection in immunocompromised hosts despite antifungal treatment. We describe here two patients with acute leukemia who developed disseminated amphotericin-resistant fusariosis, and review of six studies of cases series in the literature. Two Fusarium solani strains were isolated from blood and skin cultures of one patient, and one strain from the blood culture of the second patient. Both patients died despite antifungal treatment. Strains were identified by sequencing of ITS1 and ITS4 regions. Random amplified polymorphic DNA analysis of the three F. solani isolates showed a low degree of similarity. Screening for Fusarium spp. contaminants within our facility was negative. Using the CLSI M-38-A2 broth dilution method and E tests(®), we found that the MICs were low for voriconazole (0.12 and 0.5 mg/L, respectively), unexpectedly high for amphotericin B (≥8 and ≥32 µg/mL, respectively) and itraconazole (≥16 mg/ml). Patients with leukemia or persistent neutropenia should be assessed for disseminated fungal infections, including biopsy and skin cultures. Antifungal susceptibility tests are important due to the possibility of the strains being amphotericin resistant. Treatments must be aggressive, with high doses of antifungals or combined therapy.

Prevalence, distribution and antifungal susceptibility profiles of Candida parapsilosis, Candida orthopsilosis and Candida metapsilosis bloodstream isolates.

The Candida parapsilosis group encompasses three species: C. parapsilosis, Candida orthopsilosis and Candida metapsilosis. These species are phenotypically indistinguishable, and molecular methods are needed for their detection. We analysed 152 unique blood culture isolates of the C. parapsilosis group obtained during 1997-2011. The isolates were screened by PCR amplification of the gene encoding secondary alcohol dehydrogenase, followed by digestion with the restriction enzyme BanI. Isolates with RFLP patterns distinct from those of the C. parapsilosis group were characterized as C. parapsilosis sensu stricto (90.8 %), C. orthopsilosis (8.6 %) and C. metapsilosis (0.6 %). Antifungal susceptibility tests indicated that all isolates were susceptible to itraconazole, amphotericin B and caspofungin. Although C. orthopsilosis and C. metapsilosis isolates were susceptible to fluconazole, higher MICs (≥2 mg l(-1)) were observed for C. orthopsilosis. Three isolates (2.0 %) of C. parapsilosis sensu stricto were resistant to voriconazole. Five C. parapsilosis isolates (3.3 %) were intermediate, and a single isolate (0.7 %) was resistant (MIC 16 mg l(-1)) to fluconazole. These data were confirmed using reference strains. It was observed that C. parapsilosis isolates were less susceptible to all triazoles, and this finding deserves further attention to assess the appearance of cross-resistance phenomena. In conclusion, C. metapsilosis and C. orthopsilosis are involved in a small but significant number of invasive infections in Brazil.

Bone marrow involvement in a patient with paracoccidioidomycosis: a rare presentation of juvenile form.

Paracoccidioides brasiliensis rarely shows bone marrow involvement and its response to treatment with itraconazole in children needs further assessment. We describe here a child with a juvenile disseminated form of paracoccidioidomycosis, which showed reticuloendothelial system involvement and the presence of Paracoccidioides brasiliensis in the bone marrow. The patient showed an effective and rapid response to itraconazole therapy.

Evaluation of the histopathological hepatic lesions and opportunistic agents in Brazilian HIV patients.

INTRODUCTION: to evaluated the type histopathological hepatic lesions and opportunistic agents in Brazilian HIV-infected patients. METHODS: we examined 52 percutaneous liver biopsies of 50 HIV-infected patients who had at least two of the following conditions: fever of unknown origin, unexplained severe emaciation, hepatomegaly or abnormal liver chemistry. The specimens were cultured for mycobacteria and fungi and stained by standard procedures. RESULTS: reactive patterns, granulomatous hepatitis and chronic active hepatitis were verified in 28 (54%), 11 (21%) and 8 (15%) of the patients respectively. Opportunistic infections were diagnosed in 18 (36%) patients: mycobacteria in 12 (24%), Cryptococcus neoformans in 5 (10%) patients and mycobacteria and yeast was isolated from the same liver fragment in one patient. CONCLUSIONS: mycobacteriosis was the most common opportunistic infection and liver tissue culture is an important method to detect opportunistic agents, even in the absence of histological lesions.

Evaluation of the histopathological hepatic lesions and opportunistic agents in Brazilian HIV patients / Avaliação das alterações histológicas hepáticas e infecções oportunistas em pacientes brasileiros infectados pelo HIV

INTRODUCTION: to evaluated the type histopathological hepatic lesions and opportunistic agents in Brazilian HIV-infected patients. METHODS: we examined 52 percutaneous liver biopsies of 50 HIV-infected patients who had at least two of the following conditions: fever of unknown origin, unexplained severe emaciation, hepatomegaly or abnormal liver chemistry. The specimens were cultured for mycobacteria and fungi and stained by standard procedures. RESULTS: reactive patterns, granulomatous hepatitis and chronic active hepatitis were verified in 28 (54 percent), 11 (21 percent) and 8 (15 percent) of the patients respectively. Opportunistic infections were diagnosed in 18 (36 percent) patients: mycobacteria in 12 (24 percent), Cryptococcus neoformans in 5 (10 percent) patients and mycobacteria and yeast was isolated from the same liver fragment in one patient. CONCLUSIONS: mycobacteriosis was the most common opportunistic infection and liver tissue culture is an important method to detect opportunistic agents, even in the absence of histological lesions.

INTRODUÇÃO: avaliar os tipos de lesões histopatológicas e infecções oportunistas de Brasileiros infectados pelo HIV. MÉTODOS: Foram analisadas 52 biópsias hepáticas percutâneas de 50 pacientes que apresentavam pelo menos duas das alterações: febre de origem indeterminada, emagrecimento inexplicado, hepatomegalia ou anormalidades na bioquímica hepática. O fragmento de tecido hepático foi submetido a histopatologia por métodos habituais e cultura para micobacteria e fungo. RESULTADOS: padrão reacional, hepatite granulomatosa e hepatite crônica ativa foram encontrados em 28 (54 por cento), 11 (21 por cento) e 8 (15 por cento) dos pacientes respectivamente. Infecções oportunistas foram diagnosticadas em 18 (36 por cento) dos pacientes: micobacteria em 12 (24 por cento), Cryptococcus neoformans em 5 (10 por cento) pacientes e micobacteria e fungo foram isolados no mesmo fragmento em um paciente. CONCLUSÕES: micobacteriose foi a infecção oportunista mais comum e a cultura de tecido hepático foi um importante método para detecção de infecções, mesmo na ausência de lesões histológicas.

Treatment of chronic hepatitis C virus infection among Brazilian haemophiliacs.

Chronic hepatitis C virus (HCV) infection is now the most important cause of liver cirrhosis and hepatocellular carcinoma worldwide. HCV infection prevalence is high among haemophiliacs (39%-98%), who got infected when received inadequately or non-virus-inactivated large-pool clotting factors concentrates before 1992. Current treatment reduces the probability of developing advanced stages of liver disease. The objective of this study was to evaluate efficacy and safety of the treatment with interferon alpha (IFN) and ribavirin in haemophiliacs. From July 2000 to November 2002, 18 patients were treated with IFN, three million units thrice weekly combined with daily oral doses of 1,000 or 1,250 mg of ribavirin for a minimum of 48 weeks. Eleven patients (61%) showed end of treatment virological response, while nine [(50%): 95% CI: 27-73%] showed sustained virological response as defined by undetectable HCV-RNA six months after treatment. All those nine had persistently undetectable HCV-RNA two to four years post-treatment. There was no treatment interruption due to adverse events. Therefore, the rate of sustained virological response was 50%, with good tolerance.

Treatment of chronic hepatitis C virus infection among Brazilian haemophiliacs

Chronic hepatitis C virus (HCV) infection is now the most important cause of liver cirrhosis and hepatocellular carcinoma worldwide. HCV infection prevalence is high among haemophiliacs (39 percent-98 percent), who got infected when received inadequately or non-virus-inactivated large-pool clotting factors concentrates before 1992. Current treatment reduces the probability of developing advanced stages of liver disease. The objective of this study was to evaluate efficacy and safety of the treatment with interferon alpha (IFN) and ribavirin in haemophiliacs. From July 2000 to November 2002, 18 patients were treated with IFN, three million units thrice weekly combined with daily oral doses of 1,000 or 1,250 mg of ribavirin for a minimum of 48 weeks. Eleven patients (61 percent) showed end of treatment virological response, while nine [(50 percent): 95 percent CI: 27-73 percent] showed sustained virological response as defined by undetectable HCV-RNA six months after treatment. All those nine had persistently undetectable HCV-RNA two to four years post-treatment. There was no treatment interruption due to adverse events. Therefore, the rate of sustained virological response was 50 percent, with good tolerance.

Fatores de risco para resistência ao imipenem e epidemiologia molecular das infecções hospitalares por Pseudomonas aeruginosa, em hospital terciário

Introdução: P. aeruginosa é predominante um patógeno hospitalar responsável por infecções com elevada taxa de óbito. A ascensão da resistência de P. aeruginosa aos carbapenens nos últimos anos e a disseminação clonal de cepas multi-resistentes descrita através de estudos baseados na genotipagem tem sido alvo dos estudos mais recentes. Objetivos: 1-Avaliar a epidemiologia molecular e o perfil de sensibilidade aos antimicrobianos. 2- Determinar os fatores de riscos para aquisição de infecções hospitalares por P. aeruginosa resistentes ao imipenem. 3- Determinar a curva de sobrevida das infecções por P. aeruginosa resistentes ao imipenem. Casuística e Métodos: No período de outubro de 2000 a setembro de 2002, foram realizadas tipagens moleculares, pela técnica de eletroforese em campo pulsado em 63 cepas e determinado o perfil de sensibilidade pela técnica de microdiluição em sistema semi-automatizado, confirmado por disco difusão. No período de outubro de 2000 a março de 2002, foi conduzido em estudo caso-controle para determinar os fatores de risco para aquisição de infecções hospitalares por P. aeruginosa resistentes ao imipenem. Os pacientes classificados como casos foram os que apresentavam infecções resistentes ao imipenem, definida como CIM _> 8ug/MI e os controles sensíveis ao imipenem (CIM 1-4 ug/mL). Casos e controles foram avaliados quanto à exposição aos potenciais fatores de risco relacionados aos caracteres epidemiológicos, aos dados clínicos e laboratoriais. Foi realizada a curva de sobrevida. Resultados: Nos 59 pacientes avaliados, ocorreu uma alta taxa de resistência ao imipenem (50,8%), com predomínio nas infecções do trato urinário. O antibiograma das cepas resistentes ao imipenem mostrou sensibilidade de 28% ao aztreonam, 43% a peperacilina/tazobactam e 100% a polimixina. Foram submetidas a genotipagem 63 cepas obtidas de 53 pacientes, com identificação de 28 cepas diferentes, com predomínio em 46% das cepas de um clone denominado...

Fatores de risco para resistência ao imipenem e epidemiologia molecular das infecções hospitalares por Pseudomonas aeruginosa, em hospital terciário / Risk factors and molecular epidemiology nosocomial infection caused by imipenem resistant pseudomonas aeruginosa, in tertiary-care hospital

Introdução: P. aeruginosa é predominante um patógeno hospitalar responsável por infecções com elevada taxa de óbito. A ascensão da resistência de P. aeruginosa aos carbapenens nos últimos anos e a disseminação clonal de cepas multi-resistentes descrita através de estudos baseados na genotipagem tem sido alvo dos estudos mais recentes. Objetivos: 1-Avaliar a epidemiologia molecular e o perfil de sensibilidade aos antimicrobianos. 2- Determinar os fatores de riscos para aquisição de infecções hospitalares por P. aeruginosa resistentes ao imipenem. 3- Determinar a curva de sobrevida das infecções por P. aeruginosa resistentes ao imipenem. Casuística e Métodos: No período de outubro de 2000 a setembro de 2002, foram realizadas tipagens moleculares, pela técnica de eletroforese em campo pulsado em 63 cepas e determinado o perfil de sensibilidade pela técnica de microdiluição em sistema semi-automatizado, confirmado por disco difusão. No período de outubro de 2000 a março de 2002, foi conduzido em estudo caso-controle para determinar os fatores de risco para aquisição de infecções hospitalares por P. aeruginosa resistentes ao imipenem. Os pacientes classificados como casos foram os que apresentavam infecções resistentes ao imipenem, definida como CIM _> 8ug/MI e os controles sensíveis ao imipenem (CIM 1-4 ug/mL). Casos e controles foram avaliados quanto à exposição aos potenciais fatores de risco relacionados aos caracteres epidemiológicos, aos dados clínicos e laboratoriais. Foi realizada a curva de sobrevida. Resultados: Nos 59 pacientes avaliados, ocorreu uma alta taxa de resistência ao imipenem (50,8%), com predomínio nas infecções do trato urinário. O antibiograma das cepas resistentes ao imipenem mostrou sensibilidade de 28% ao aztreonam, 43% a peperacilina/tazobactam e 100% a polimixina. Foram submetidas a genotipagem 63 cepas obtidas de 53 pacientes, com identificação de 28 cepas diferentes, com predomínio em 46% das cepas de um clone denominado b. O genótipo b foi estatísticamente significante em relação à prevalência de cepas resistentes ao imipenem, com predomínio na Urologia e isolados em urina. A regressão logística univariada mostrou como fatores potenciais: internação na enfermaria de Urologia, tempo entre a admissão e o isolamento da P. aeruginosa maior que 15 dias, uso de imipenem, quinolonas, o número de antimicrobianos prescritos...