Role of micronutrients in the management of coronavirus disease 2019.

Micronutrients play an important role in enhancing the immune system, therefore, proper nutritional support of micronutrients could have a positive impact on COVID-19 outcome.

Randomized Trial of Machine Perfusion Versus Cold Storage in Recipients of Deceased Donor Kidney Transplants With High Incidence of Delayed Graft Function

BACKGROUND: This study compared the use of static cold storage versus continuous hypothermic machine perfusion in a cohort of kidney transplant recipients at high risk for delayed graft function (DGF). METHODS: In this national, multicenter, and controlled trial, 80 pairs of kidneys recovered from brain-dead deceased donors were randomized to cold storage or machine perfusion, transplanted, and followed up for 12 months. The primary endpoint was the incidence of DGF. Secondary endpoints included the duration of DGF, hospital stay, primary nonfunction, estimated glomerular filtration rate, acute rejection, and allograft and patient survivals. RESULTS: Mean cold ischemia time was high but not different between the 2 groups (25.6 ± 6.6 hours vs 25.05 ± 6.3 hours, 0.937). The incidence of DGF was lower in the machine perfusion compared with cold storage group (61% vs. 45%, P = 0.031). Machine perfusion was independently associated with a reduced risk of DGF (odds ratio, 0.49; 95% confidence interval, 0.26-0.95). Mean estimated glomerular filtration rate tended to be higher at day 28 (40.6 ± 19.9 mL/min per 1.73 m2 vs 49.0 ± 26.9 mL/min per 1.73 m2; P = 0.262) and 1 year (48.3 ± 19.8 mL/min per 1.73 m2 vs 54.4 ± 28.6 mL/min per 1.73 m2; P = 0.201) in the machine perfusion group. No differences in the incidence of acute rejection, primary nonfunction (0% vs 2.5%), graft loss (7.5% vs 10%), or death (8.8% vs 6.3%) were observed...

Interrelationship between bone turnover markers, calciotropic hormones and leptin in obese Saudi children.

OBJECTIVE: Fat-bone relationship involves the interaction among endocrine, inflammatory, immune processes and bone turnover. We tried to assess the association between Leptin and bone turnover markers (OCN, ß-CTx, ALP), calciotropic hormones PTH and 25(OH)D in obese Saudi children. PATIENTS AND METHODS: A cross-sectional study performed with 60 obese children and 36 lean children. For all subjects, OCN, ALP, ß-CTx, PTH, 25(OH)D, leptin, Ca and Pi were investigated. Levels of leptin were measured by [ELISA] method, and OCN, ß-CTx, PTH and 25-(OH)D by an electrochemiluminescence immunoassay. RESULTS: Sixty obese Saudi children had means weight (38.3 vs. 13.8 kg), height (121.0 vs. 91.8 cm) leptin (23.04 vs.16.88 ng/ml), PTH (31.5 vs. 14.7 pg/ml), Pi (1.67 vs. 1.54 mmol/l) were significantly higher and 25(OH)D (21.02 vs. 29.45 ng/ml) was significantly lower than controls. There was no difference in serum OCN, ß-CTx, ALP and calcium between groups (p > 0.05). In the correlation study, OCN were significantly positively correlated with height, ALP, age, PTH, and ß-CTx (r = 0.347, 0.32, p < 0.05), (r = 0.35, 0.51, 0.66, p < 0.01 respectively), while serum 25(OH)D was negatively correlated with PTH, weight, height and BMI (r = -0.45, -0.55, -0.55, -0.47, p < 0.01 respectively). PTH was positively correlated with leptin and ß-CTx (r = 0.41, 0.44, p < 0.01), but not to ALP and BMI percentile. ß-CTx correlated significantly positive with Pi (r = 0.34 p < 0.05) and ALP with BMI percentile (r = 0.42, p < 0.05). Multiple regression analysis demonstrated that PTH was predicted by leptin and ß-CTx (R2 = 0.55); ß-CTx by leptin and OCN (R2 = 0.498); OCN by PTH and ß-CTx (R2 = 0.47); and 25(OH)D by PTH (R2 = 0.21). CONCLUSIONS: The obese children had increased levels of leptin and PTH with strong associated with bone turn over markers OCN, ß-CTx and deficiency of 25(OH)D which may be playing an important role in the pathogenesis of obesity and related bone metabolic risk diseases as osteoporosis and fractures.

A novel association between IL1-Ra (receptor antagonist) gene polymorphism and T1DM in Al-Madina Al-Mounawra.

OBJECTIVE: The Interleukin-1 receptor antagonist (IL1-Ra) is initiated to terminate the acute pro-inflammatory event and prevent chronic inflammation from damaging healthy cells. We aim to draw the attention of IL1-Ra (VNTR) gene polymorphism and determine whether IL1-Ra confer susceptibility to type 1 diabetes mellitus (T1DM) and evaluate the genotype and allele distribution of IL1-Ra gene in a Saudi population. PATIENTS AND METHODS: Case control study included (100) T1DM Saudi children, plus 102 healthy unrelated individuals as control group. They were evaluated for variable number of tandem repeat (VNTR) of IL1-Ra gene polymorphism. Polymerase chain reaction amplification of VNTR of 86bp in intron 2 of IL1-Ra was performed. RESULTS: A1A1 and A1A2 genotypes with alleles A1 and A2 frequency were the most common both in cases and controls (healthy population); prevalence (28%, 56% & 57.8%, 39.2% respectively) and (58%, 38% and 77.5%, 22.5% respectively). In addition IL1-Ra gene polymorphism had higher risk significantly different between diabetic children and controls. (A1/A2) genotype had higher frequency statistically significant in DM patients than controls [56% vs. 39.2%, p < 0.02] and had twice time risk [OR = 1.97, 95% CI = 1.1-3.4, p < 0.02]. With further stratification, there was strong association between diabetic patients carriage IL1-Ra (A2) allele and controls [38% vs. 22.5%, p = 0.001] which had higher risk [OR = 2.11, 95% CI = 1.4-3.2, p = 0.001] for susceptibility of diabetes. CONCLUSIONS: This study emphasizes a positive association between IL1-Ra (VNTR) polymorphism and DM among Saudi children. This may suggest that (A2) allele may play important role in disease susceptibility.

Yellow fever vaccination in organ transplanted patients: is it safe? A multicenter study.

BACKGROUND: Yellow fever (YF) may be very serious, with mortality reaching 50%. Live attenuated virus YF vaccine (YFV) is effective, but may present, although rare, life-threatening side effects and is contraindicated in immunocompromised patients. However, some transplant patients may inadvertently receive the vaccine. METHODS: A questionnaire was sent to all associated doctors to the Brazilian Organ Transplantation Association through its website, calling for reports of organ transplanted patients who have been vaccinated against YF. RESULTS: Twelve doctors reported 19 cases. None had important side effects. Only one had slight reaction at the site of YFV injection. Eleven patients were male. Organs received were 14 kidneys, 3 hearts, and 2 livers. Twelve patients received organs from deceased donors. Mean age at YFV was 45.6 ± 13.6 years old (range 11-69); creatinine: 1.46 ± 0.62 mg/dL (range 0.8-3.4); post-transplant time: 65 ± 83.9 months (range 3-340); and time from YFV at the time of survey: 45 ± 51 months (range 3-241). Immunosuppression varied widely with different drug combinations: azathioprine (7 patients), cyclosporine (8), deflazacort (1), mycophenolate (10), prednisone (11), sirolimus (3), and tacrolimus (4). CONCLUSIONS: YFV showed no important side effects in this cohort of solid organ transplanted patients. However, owing to the small number of studied patients, it is not possible to extend these findings to the rest of the transplanted population, assuring safety. Therefore, these data are not strong enough to safely recommend YFV in organ transplanted recipients, as severe, even life-threatening side effects may occur.

Interferon-γ +874 polymorphism in the first intron of the human interferon-γ gene and kidney allograft outcome.

BACKGROUND: Despite advances in immunosuppressive therapy in the past decade, allograft rejection remains an important cause of kidney graft failure. Cytokines play a major role in the inflammatory and immune responses that mediate allograft outcomes. Several studies have shown that the production of cytokines varies among individuals. These variations are determined by genetic polymorphisms, most commonly within the regulatory region of cytokine genes. The aim of the present study was to assess the effect of allelic variation on acute rejection episodes (ARE) or chronic allograft nephropathy (CAN) after kidney transplantation. METHODS: To determine a possible correlation between the interferon (INF)-γ +874 polymorphism and kidney allograft outcome, we isolated genomic DNA from 74 patients who underwent isolated kidney allografts and were classified into 2 groups--a rejection and a nonrejection group--for comparison with a control group of 163 healthy subjects. RESULTS: We genotyped INF-γ +874 polymorphisms in all groups. The transplant group showed a significantly increased homozygous genotype T/T (P = .0118) compared with healthy controls. Similarly, considering only patients with CAN, the homozygous genotype T/T (P = .0067) was significantly increased compared with the healthy controls. The rejection group indicated a significant increased homozygous genotype T/T compared with the control group (P = .0061). CONCLUSION: Homozygous genotype T/T was associated with increased levels of INF-γ and greater numbers among the rejection and CAN cohorts.

Interleukin-17 and kidney allograft outcome.

UNLABELLED: Acute rejection episodes (ARE) are important complications that involve the interplay between mechanisms that maintain graft tolerance and promote rejection. The proinflammatory cytokine interleukin-17 (IL-17) has been implicated in many conditions in humans and mice. In kidney transplant patients, the evaluation IL-17 levels has been performed in only a few patients. We performed a cross-sectional study correlating quantitative IL-17 levels and clinical outcomes. PATIENTS AND METHODS: We studied 19 specimens from biopsies performed in patients (n = 19) who received isolated kidney grafts. ARE signs were present in 9 (47%) patients who provide specimens; whereas, 10 (53%) others showed no signs of rejection. Eighteen healthy control sample IL-17 underwent measurement, all of which were performed by an enzyme-linked immunosorbent assay method. We assessed other factors, such as the recipients demographic data, cold ischemia time, HLA mismatches, time elapsed from transplantation to the biopsy, posttransplantation status, antibody panel, donor type, and immunosuppressive treatment. RESULTS: IL-17 levels were clearly increased among samples derived from patients with ongoing rejection (125.7 +/- 27.06 pg/mL) in contrast, to the nonrejection group, (30 +/- 13.32 pg/mL) (P < .05). Healthy controls showed no detectable IL-17 levels. CONCLUSIONS: These findings suggested that IL-17 was important in the pathophysiology of acute kidney rejection.

HLA polymorphisms as incidence factor in the progression to end-stage renal disease in Brazilian patients awaiting kidney transplant.

Chronic renal failure (CRF) leads in the majority of instances to end-stage renal disease (ESRD) requiring renal replacement therapy. Age, gender, genetics, race, hypertension, and smoking among others are factors associated with ESRD. Our interest was to evaluate the possible associations of class I and II HLA antigens with ESRD renal disease independent of other factors, among patients with CRF, having various diagnoses in the Brazilian population of the São Paulo state. So 21 HLA-A, 31 HLA-B, and 13 HLA-DR were detected in 105 patients who were compared with 160 healthy controls of both sexes who were not related to the patients evaluated until 2005. We calculated allelic frequencies, haplotypes frequencies, etiological fractions (EF), preventive fractions, and relative risks (RR). We compared demographic data of patients and controls. The antigens positively associated with ESRD were: HLA-A78 (RR = 30.31 and EF = 0.96) and HLA-DR11 (RR = 18.87 and EF = 0.65). The antigens HLAB14 (RR = 29.90 and EF = 0.75) was present at a significantly lower frequency among patients compared with controls. In contrast, no haplotype frequency showed statically significant associations. Further molecular studies may clarify types and subtypes of alleles involved with ESRD progression.

Human leukocyte antigen-G expression after kidney transplantation is associated with a reduced incidence of rejection.

UNLABELLED: HLA-G is a non-classic Human Leukocyte Antigen (HLA-G) Class I of low polymorphism and restricted tissue distribution that displays tolerogenic functions. In heart transplantation and in combined liver/renal allograft transplantation, the expression of HLA-G has been associated with a lower incidence of acute graft rejection episodes and absence of chronic dysfunction. Since the expression of HLA-G in renal biopsies has been investigated only in few patients who received a combined kidney and liver transplant, in this study we performed a cross-sectional study, systematically comparing the expression of HLA-G in post-transplanted renal grafts, stratifying patients according to the presence or absence of rejection. PATIENTS AND METHODS: Seventy-three renal specimens (10 with acute rejection and 13 with chronic allograft nephropathy, and 50 with no signs of rejection) were immunohistochemically evaluated for HLA-G expression. RESULTS: In the group as a whole, HLA-G molecules were detected in 40 cases (54.8%). Among specimens that presented HLA-G expression, 2 out of 40 (5%) exhibited acute rejection, 2 (5%) exhibited chronic allograft nephropathy, and the remaining 36 (90%) exhibited no signs of rejection. The comparison between patients with rejection and those without rejection showed that the expression of HLA-G was significantly increased in specimens exhibiting no signs of rejection (p<0.0001). Considering only patients with acute rejection, 8 out of 10 patients showed no HLA-G expression in their kidney biopsies when compared to patients exhibiting no signs of rejection and absence of HLA-G was observed in 14 out of 50 (p=0.0032). Similarly, considering only patients with chronic allograft nephropathy, absence of HLA-G expression was observed in 11 out of 13 specimens, whereas in patients without rejection absence of HLA-G was observed in 14 out of 50 (p=0.003). Therapy with tacrolimus was significantly associated with the expression of HLA-G and a better graft prognosis. CONCLUSIONS: Our results suggest that HLA-G expression in the kidney allograft and the use of tacrolimus are associated with a lower frequency of acute renal rejection and chronic allograft nephropathy.

Frequency of insertion/deletion polymorphism in exon 8 of HLA-G and kidney allograft outcome.

Human leukocyte antigen-G (HLA-G) is a non-classical major histocompatibility complex (MHC) class Ib molecule predominantly expressed in cytotrophoblasts, where it acts as a specific immunosuppressor. Literature data have shown that grafts in some settings, such as cardiac and liver/kidney-associated transplantations, express HLA-G and this expression is associated with less severe rejection and also reduces the incidence of rejection. Fourteen-base pair deletion/insertion polymorphism has been reported in exon 8 of the 3'-untranslated region of HLA-G. This polymorphism within exon 8 of the HLA-G gene might influence transcription activity, which in turn may influence the stability of HLA-G transcripts. This influences the stability of the HLA-G protein and therefore is of potential functional relevance. In order to determine a possible correlation between the 14-bp insertion/deletion polymorphism and kidney allograft outcome, we isolated genomic DNA from 83 patients who had received isolated kidney allografts, and we classified the 83 specimens into two groups, grafts presenting Banff features of rejection group and a non-rejection group, and compared them with a control group of 97 healthy subjects. The 14-bp polymorphism at exon 8 was genotyped in all groups. There was no significant difference in allelic frequencies of 14-bp insertion/deletion polymorphism between normal controls and kidney transplant patients. In the RG, the homozygous genotype +14/+14 bp (P = 0.0238) was significantly increased in the group with acute rejection compared with the healthy control group. Analysis of other HLA-G polymorphisms and functional studies on immune regulation are essential to elucidate the role of HLA-G in kidney allografts.

Posttransplantation conversion to sirolimus-based immunosuppression: a single center experience.

Sirolimus (SRL) has become an option in kidney transplantation, especially among patients who develop chronic allograft nephropathy (CAN). This study sought to evaluate the safety and efficacy of SRL in 103 kidney recipients of mean age 40 years, including 78 recipients of organs from deceased donors. The major reason for conversion was calcineurin inhibitor (CNI) nephrotoxicity (42.3%) followed by CAN (35.4%). A preconversion kidney biopsy was performed in 89 patients with CAN diagnosed in 51. Mean time to conversion was 40.5 months. The new therapy was: SRL/mycophenolate mofetil (MMF)/prednisone (Pred) in 79 patients; SRL/tacrolimus (TAC)/Pred in 15; and other SRL combinations in 9. The target SRL trough level was 5.0 to 8.0 ng/mL. To evaluate the impact of conversion on renal function, we compared the proteinuria and inverse serum creatinine at 3 months before conversion, at conversion, and at 1, 3, 6, 12, and 24 months postconversion. The overall mean follow-up time was 13.2 months. The analysis showed significant improvement in renal function at month 1 postconversion (P<.05) with stabilization thereafter. The SRL/MMF combination frequently induced anemia and/or leukopenia (n=23). Infections included pneumonia (n=10), herpes zoster (n=7), herpes simplex (n=3), cytomegalovirus (n=2), histoplasmosis (n=2), tuberculosis (n=2), and neurocryptococcosis (n=1). Reasons for SRL discontinuation were myelotoxicity (n=4), infection (n=3), nephrotoxicity (n=3), gastrointestinal intolerance (n=3), myopathy (n=1), pneumonitis (n=1), hyperlipidemia (n=1), and other reasons (n=3). Graft loss occurred in 29 patients due to CAN (n=21) followed by death (cardiovascular, n=2; infectious, n=2), acute rejection (n=3), and infection following immunosuppression withdrawal (n=1). We concluded that SRL represented an option but reducing associated immunosuppression should strongly be considered to minimize the frequent side effects, especially infections.

Microchimerism evaluation in recipients of living-related or unrelated deceased allograft renal transplants.

The presence of microchimerism in the peripheral blood of solid organ graft recipients has been associated with long-term solid organ acceptance, immunologic tolerance, and less aggressive immunosuppressive therapy. Molecular biology assays are among the most sensitive methods to detect microchimerism, primarily to evaluate Y chromosome sequences in females as indirect evidence of circulating male nucleated donor cells. We screened for the presence of the SRY sequence region in peripheral blood of 13 female recipients of male kidney grafts: 5 living-related and 8 deceased grafts. Only patients who received grafts from related living donors exhibited microchimerism. Five of 13 patients studied exhibited better graft outcomes, including the 4 who were positive for the SRY sequences.

Candidíase em pacientes transplantados renais / Candidiasis in kidney transplant patients

O objetivo do trabalho foi verificar a prevalência de candidíase em transplantados renais. Foram avaliados os prontuários dos pacientes transplantados no Hospital das Clínicas de Ribeirão Preto de fevereiro de 1968 a fevereiro de 1995. Nesse período foram transplantados 620 pacientes. Destes, 87 apresentaram 107 episódios de candidíase. Locais mais acometidos: trato urinário com 55 episódios, trato respiratório com 28, e trato gastrointestinal com 16. O agente etiológico mais freqüente foi C. albicans com 65 casos seguido de C. tropicalis com 12 e C. glabrata com 11 casos. As infecções do trato urinário mostraram incidência maior (61,7%) nos primeiros 6 meses. A maioria se apresentou clínicamente como infecção bacteriana. No trato respiratório, as infecções foram caracterizadas por recuperação do agente no escarro. No trato gastrointestinal, 9/16 episódios foram esofágicos, com epigastralgia, dor retroesternal, às vezes acompanhados de candidíase oral ou odinofagia. Nos outros episódios o agente foi recuperado nas fezes com quadro clínico de gastroenterite. Nas infecções dos tratos urinário e respiratório, houve associação da candidíase com antibioticoterapia prévia (76% e 67% respectivamente), além de infecções bacterianas concomitantes (34% e 64% respectivamente). As infecções por Candida sp tiveram prevalência geral em torno de 14,5%. A localização predominante foi no trato urinário e, em seguida, nos tratos respiratório e gastrointestinal, apresentando alto índice de associação com antibioticoterapia prévia e infecções bacterianas.

The medical records of 620 patients submitted to renal transplant from February 1968 to February 1995 were surveyed for Candida infection. Of these, 87 presented 107 episodes of candidiasis. In 42.9% the infection appeared up to 6 months after the transplant. The most frequent involved sites were: urinary tract, respiratory tract, and gastrointestinal tract. The most frequent etiological agents were: C. albicans, C. tropicalis and C. glabrata. Most urinary tract infections occurred in the first 6 months (61.7%) and manifested clinically as a bacterial infection. In the respiratory tract infections were characterized by isolation of the agent in sputum. In the gastrointestinal infections, 9/16 episodes were esophageal. There were 3 deaths directly related to Candidiasis (one pulmonary and 2 disseminated cases). In the urinary tract, and respiratory tract infections there was association of candidiasis with previous antibiotic treatment (76% and 67%, respectively), and with concomitant bacterial infections (34% and 64%, respectively). The overall prevalence of Candida infections was 14.5%. The predominant location was in the urinary tract (51.0%), followed by the respiratory (26.0%) and gastrointestinal tract (15.0%), with a high rate of association with previous antibiotic treatment and bacterial infections.

Use of ciprofloxacin as a prophylactic agent in urinary tract infections in renal transplant recipients.

The most common form of bacterial infection in renal transplant recipients is urinary tract infection (UTI), and some studies have shown that prophylaxis can reduce this incidence. In the present investigation we evaluated 80 patients submitted to renal transplantation at the Renal Transplant Unit of the University Hospital of Ribeirao Preto, SP. The study was prospective, double blind and randomized. The patients were divided into two groups, one receiving placebo and the other ciprofloxacin at the dose of 250 mg twice a day for the first 10 d and 250 mg/d for 6 months after transplantation. Of the 41 patients who received ciprofloxacin 28 completed the study, and of the 39 patients who received placebo 30 completed the study. The largest number of UTI occurred in the placebo group, with a significant difference from the ciprofloxacin group during the first month after surgery (p < 0.05). In the group treated with ciprofloxacin, only 6/40 patients (15%) developed UTI, as opposed to 19/39 (48.7%) for the placebo group. The total number of infectious episodes was higher in the placebo group (26) than in the ciprofloxacin group (12). The medication was well tolerated throughout the study period.

[Candidiasis in kidney transplant patients]. / Candidíase em pacientes transplantados renais.

The medical records of 620 patients submitted to renal transplant from February 1968 to February 1995 were surveyed for Candida infection. Of these, 87 presented 107 episodes of candidiasis. In 42.9% the infection appeared up to 6 months after the transplant. The most frequent involved sites were: urinary tract, respiratory tract, and gastrointestinal tract. The most frequent etiological agents were: C. albicans, C. tropicalis and C. glabrata. Most urinary tract infections occurred in the first 6 months (61.7%) and manifested clinically as a bacterial infection. In the respiratory tract infections were characterized by isolation of the agent in sputum. In the gastrointestinal infections, 9/16 episodes were esophageal. There were 3 deaths directly related to Candidiasis (one pulmonary and 2 disseminated cases). In the urinary tract, and respiratory tract infections there was association of candidiasis with previous antibiotic treatment (76% and 67%, respectively), and with concomitant bacterial infections (34% and 64%, respectively). The overall prevalence of Candida infections was 14.5%. The predominant location was in the urinary tract (51.0%), followed by the respiratory (26.0%) and gastrointestinal tract (15.0%), with a high rate of association with previous antibiotic treatment and bacterial infections.

Pregnancy and kidney transplantation: experience in a developing country.

Between January 1968 and December 1992, 136 kidney transplants were performed in the University Hospital of Ribeirão Preto, with women of childbearing age (14 to 40 years) as receptors. From this population, 19 patients became pregnant at least once after transplantation, and 2 were transplanted inadvertently during the first trimester of their pregnancies. There was a total of 25 pregnancies and 27 offspring. The mean age at the time of conception was 28.6 years (23 to 41 years), with a mean interval of 3.5 years from transplant to conception (< 1 to 16 years). All patients continued their immunosuppressive regimens during the entire pregnancy, but only 5 of 25 were taking cyclosporine. There were two miscarriages (8%) and two therapeutic abortions (8%); of those that passed the 20th week of pregnancy, the mean gestation time at delivery was 35 weeks (range, 28 to 38 weeks) with an incidence of prematurity (gestation < 37 weeks) of 67%, and their offspring weighed from 670 to 3,100 g (mean, 2,236 g), presenting a very high incidence of low birthweight (64%). There was one stillborn and one neonatal death. The most common complications that occurred during pregnancy were infections (especially urinary tract and vaginal mycotic infections) followed by hypertension. The obstetric complications were distributed as follows: premature rupture of membranes in 27%, fetal distress in 24%, preterm labor in 24%, and oligohydramnios in 10%. Lower segment cesarean section was necessary in 16 of 21 cases (76%), and all were for obstetric reasons. One patient died during the puerperium because of sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

Nocardia infection in renal transplant recipient: diagnostic and therapeutic considerations

In the present report the authors discuss the diagnostic difficulties, therapeutic measures and the clinical course of Nocardia infection which occurred among renal transplant recipients at the University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (UH-FRP), from 1968 to 1991. Among 500 individuals submitted to renal transplant, 9 patients developed Nocardiosis at varying times after transplant (two months to over two years). All the patients had pulmonary involvement and their most common symptoms were fever, cough and pleural pain. Dissemination of the process is common and three patients presented cutaneous abscesses, four CNS involvement and one had pericarditis due to Nocardia. The diagnostic is quite difficult since there is no specific clinical picture, concomitant infections are frequent and the microorganism presents slow growth in culture (ranging from four to forty days, in our experience). In this report, three cases were only diagnosed by necropsy. The treatment of choice is a combination of Sulfamethoxazole and Trimethoprim (SMX-TMP). In the present series, overall mortality was 77 (7 cases) and in five of the patients who died the diagnosis was late. All the patients who had CNS involvement died.