Paracoccidioidomicosis diseminada en paciente inmunocompetente: reporte de caso / Disseminated Paracoccidioidomycosis in immunocompetent patient: case report

Resumen La Paracoccidioidomicosis (PCM) es una infección micótica endémica en Latinoamérica que se caracteriza por compromiso multiorgánico. El diagnóstico tardío y la diseminación sistémica favorecen complicaciones como falla respiratoria e insuficiencia suprarrenal que condicionan el desenlace del paciente. Se presenta el caso de un paciente de 51 años de edad, procedente de la costa pacífica colombiana, inmunocompetente con PCM diseminada a sistema nervioso central (SNC), pulmones y glándulas suprarrenales con debut clínico de síndrome neurológico. Durante estancia hospitalaria presenta pico febril, colapso hemodinámico, aci dosis metabólica severa e hiperlactatemia. Se hemocultivó e inició tratamiento antimicrobiano de amplio espectro con piperacilina-tazobactam (4.5 gr/IV cada 8 horas), vancomicina (15 mg/kg) más anfotericina B desoxicolato (1 mg/kg/dia) y se trasladó a unidad de cuidado intensivo. En la muestras de tejido suprarrenal se identificaron levaduras multigemantes de Paracoccidioides spp e inflamacion crónica granulomatosa. A los seis días posteriores a su ingreso, el paciente continuó con deterioro hemodinámico, desequilibrio electrolítico, shock séptico e insuficiencia suprarrenal que conllevó a su deceso a pesar de las medidas terapéuticas establecidas. Se intenta exponer el desafío que representa el diagnóstico de PCM sistémica y promover su sospecha clínica para poder identificar la enfermedad de forma oportuna y evitar complicaciones que conduzcan a un desenlace fulminante.

Abstract Paracoccidioidomycosis (PCM) is an endemic fungal infection in Latin America characterized by multi-organ involvement. Late diagnosis and systemic dissemina tion favor complications such as respiratory failure and adrenal insufficiency, which determine the outcome of the patient. We present the case of a 51-year-old patient from the Colombian Pacific coast, immunocompetent with PCM spread to the central nervous system (CNS), lungs, and adrenal glands with a clinical debut of the neurological syndrome. During a hospital stay, he presented fever peak, hemodynamic collapse, severe metabolic acidosis, and hyperlactatemia. Blood culture and began broad-spectrum antimicrobial treatment with piperacillin-tazobactam (4.5 gr / IV every 8 hours), vancomycin (15 mg/kg) plus amphotericin B deoxycholate (1 mg/kg/day) and was transferred to the intensive care unit. Paracoccidioides spp multigene yeasts and chronic granulomatous inflammation were identified in adrenal tissue samples. Six days after admission, the patient continued with hemodynamic deterioration, electrolyte imbalance, septic shock, and adrenal insufficiency that led to death despite the established therapeutic measures. The aim is to expose the challenge posed by the diagnosis of systemic PCM and promote its clinical suspicion to identify the disease promptly and avoid complications that lead to a fulminant outcome.

Pseudomonas aeruginosa resistente a antimicrobianos en hospitales colombianos / Resistance to antibiotics in Pseudomonas aeruginosa in Colombian hospitals

Pseudomonas aeruginosa infections cause high morbidity and mortality. We performed a descriptive analysis of the rates of antibiotic resistance in isolates of P. aeruginosa in 33 hospitals enrolled in a surveillance network in Colombia. The study was conducted between January 2005 and December 2009 .9905 isolates of P. aeruginosa were identified, (4.9% of all strains). In intensive care units (ICU) P. aeruginosa showed an overall resistance to aztreonam, cefepime , ceftazidime, imipenem, meropenem , and piperacillin / tazobactam of 31.8% , 23.9% , 24.8%, 22.5%, 20.3% and 22.3%, respectively. Resistance rates increased for piperacillin/tazobactam, cefepime, and imipenem; remained unchanged for meropenem; and decreased for aminoglycosides, quinolones and ceftazidime. Resistance to one, two and three or more families of antibiotics was found in 17%, 12.5%, and 32.1%, respectively. In samples collected from the wards, the resistance rate was lower but usually over 10%. Antibiotic resistance in P. aeruginosa isolates in hospitalized patients and particularly in those admitted to ICUs in Colombia is high.

Introducción: Pseudomonas aeruginosa causa infecciones con altas tasas de morbilidad y mortalidad. Objetivo: Conocer las tasas de resistencia de P. aeruginosa en instituciones hospitalarias colombianas. Material y Métodos: Se realizó un análisis descriptivo de las tasas de resistencia a los antimicrobianos en los aislados de P. aeruginosa en 33 hospitales inscritos a una red de vigilancia en Colombia. Se estudió la resistencia entre enero de 2005 y diciembre de 2009. Se usaron las normas del Clinical and Laboratory Standard Institute (2009) para determinar la resistencia. Resultados: Se identificaron 9.905 aislados de P. aeruginosa (4,9% de todos los aislados). En las unidades de cuidado intensivo (UCI) P. aeruginosa mostró una resistencia global a aztreonam, cefepime, ceftazidima, imipenem, meropenem y piperacilina/tazobactam de 31,8%, 23,9%, 24,8%, 22,5%, 20,3%, y 22,3%, respectivamente. Las tasas de resistencia aumentaron para piperacilina/tazobactam, cefepime e imipenem; se mantuvo sin cambios para meropenem y disminuyó para los aminoglucósidos, quinolonas y ceftazidima. Resistencia a uno, dos y tres o más familias de antimicrobianos se encontró en 17%, 12,5% y 32,1%, respectivamente. En las salas de hospitalización la resistencia fue ligeramente inferior, pero usualmente mayor a 10%. Conclusión: La resistencia en los aislados de P. aeruginosa en pacientes hospitalizados y especialmente en los admitidos a las UCI, en Colombia es elevada, incluyendo los aislados con multi-resistencia.

The identification of two Trypanosoma cruzi I genotypes from domestic and sylvatic transmission cycles in Colombia based on a single polymerase chain reaction amplification of the spliced-leader intergenic region.

A single polymerase chain reaction (PCR) reaction targeting the spliced-leader intergenic region of Trypanosoma cruzi I was standardised by amplifying a 231 bp fragment in domestic (TcIDOM) strains or clones and 450 and 550 bp fragments in sylvatic strains or clones. This reaction was validated using 44 blind coded samples and 184 non-coded T. cruzi I clones isolated from sylvatic triatomines and the correspondence between the amplified fragments and their domestic or sylvatic origin was determined. Six of the nine strains isolated from acute cases suspected of oral infection had the sylvatic T. cruzi I profile. These results confirmed that the sylvatic T. cruzi I genotype is linked to cases of oral Chagas disease in Colombia. We therefore propose the use of this novel PCR reaction in strains or clones previously characterised as T. cruzi I to distinguish TcIDOMfrom sylvatic genotypes in studies of transmission dynamics, including the verification of population selection within hosts or detection of the frequency of mixed infections by both T. cruzi I genotypes in Colombia.

[Resistance to antibiotics in Pseudomonas aeruginosa in Colombian hospitals]. / Pseudomonas aeruginosa resistente a antimicrobianos en hospitales colombianos.

Pseudomonas aeruginosa infections cause high morbidity and mortality. We performed a descriptive analysis of the rates of antibiotic resistance in isolates of P. aeruginosa in 33 hospitals enrolled in a surveillance network in Colombia. The study was conducted between January 2005 and December 2009 .9905 isolates of P. aeruginosa were identified, (4.9% of all strains). In intensive care units (ICU) P. aeruginosa showed an overall resistance to aztreonam, cefepime , ceftazidime, imipenem, meropenem , and piperacillin / tazobactam of 31.8% , 23.9% , 24.8%, 22.5%, 20.3% and 22.3%, respectively. Resistance rates increased for piperacillin/tazobactam, cefepime, and imipenem; remained unchanged for meropenem; and decreased for aminoglycosides, quinolones and ceftazidime. Resistance to one, two and three or more families of antibiotics was found in 17%, 12.5%, and 32.1%, respectively. In samples collected from the wards, the resistance rate was lower but usually over 10%. Antibiotic resistance in P. aeruginosa isolates in hospitalized patients and particularly in those admitted to ICUs in Colombia is high.

Neumonía organizada criptogénica como presentación inicial de la artritis reumatoide / Cryptogenic organizing pneumonia as initial presentation of rheumatoid arthritis

Se presenta el caso de una mujer de 65 años a quien se diagnostica neumonía organizada criptogénica (NOC), como primera manifestación de artritis reumatoide (AR). La paciente presentó tos y posteriormente disnea. La tomografía computarizada de tórax mostró opacidades parenquimatosas con broncograma de aire en los lóbulos superiores. Ocho semanas después presenta criterios clínicos y serológicos para AR, se diagnosticó NOC por biopsia abierta de pulmón, con excelente respuesta clínica y radiológica al tratamiento con corticosteroides. (Acta Med Colomb 2012; 37: 27-30).

The case of a 65 year old woman who was diagnosed with cryptogenic organizing pneumonia (NOC) as a first manifestation of rheumatoid arthritis (RA). The patient subsequently developed cough and dyspnea. Chest computed tomography showed parenchymal opacities with air bronchogram in the upper lobes. Eight weeks later, he presented clinical and serological criteria for RA, NOC diagnosis by open lung biopsy, with excellent clinical and radiological response to treatment with corticosteroids. (Acta Med Colomb 2012; 37: 27-30).

[Trypanosoma rangeli parasite-vector-vertebrate interactions and their relationship to the systematics and epidemiology of American trypanosomiasis]. / Interacción tripanosoma-vector-vertebrado y su relación con la sistemática y la epidemiología de la tripanosomiasis Americana.

INTRODUCTION: Trypanosoma rangeli is a species of trypanosome second to T. cruzi, that is infective to humans in Latin America. Variability in the biological, biochemical and molecular characteristics between different isolates isolates of this parasite have been recorded. OBJECTIVE: Morphological and molecular characteristics were recorded from strains of T. rangeli that were isolated from different species of Rhodnius and maintained in different vertebrate species. MATERIALS AND METHODS: Nineteen strains of T. rangeli were isolated from R. prolixus, R. pallescens and R. colombiensis in Colombia, R. ecuadoriensis in Peru and R. pallescens in Panama. Polymorphism of blood trypomastigotes in ICR mice was evaluated and pleomorphism of P53 strain of T. rangeli KP1(-) inoculated in mouse, marsupial and canine was studied. RAPD analysis (randomly amplified polymorphic DNA analysis) of 12 strains isolated from four species of Rhodnius was performed. RESULT: Based on the total length of blood trypomastigotes, three discrete groups were observed. The P53 strain showed significant differences in the size of blood trypomastigotes in mouse, marsupial and canine. RAPD analysis showed that the strains segregated into two branches corresponding to strains of T. rangeli KP1(+) and T. rangeli KP1(-). All strains of T. rangeli KP1(-) clustered according to the species of Rhodnius from which they were isolated. CONCLUSION: These data reveal, for the first time, a close association amongst T. rangeli strains and Rhodnius species, confirming that each species of Rhodnius transmits to vertebrate hosts a parasite population with clear phenotypic and genotypic differences. This is further evidence that supports the concept of clonal evolution of these parasites.

Conducta sexual y anticonceptiva en estudiantes de medicina / Sexual and Contraceptive Behavior in Medical Students

Introducción: estudios previos y la percepción del personal que labora en el Servicio Médico de la Universidad del Valle sugieren un comportamiento sexual poco responsable por parte del estamento estudiantil. Objetivo: el presente estudio describe el comportamiento sexual y anticonceptivo en estudiantes de primer, tercer y último año del programa de Medicina. Resultados: al Programa de Medicina ingresan adolescentes tardíos con proporción creciente de mujeres y, en su mayoría, de estrato socioeconómico medio y alto; los estudiantes hombres inician sus relaciones coitales más precozmente que las mujeres (p<0,001), si bien estas últimas están iniciando cada vez más temprano, al punto de no encontrar diferencias entre los sexos en la cohorte del primer año. Se evidencia un comportamiento sexual similar en los dos sexos, con un pequeño porcentaje de ambos sexos que se mantiene virgen (alrededor del 5,3%). Los métodos anticonceptivos más utilizados son el condón y la píldora. La conducta sexual responsable (uso de anticonceptivo en todas las relaciones coitales) prácticamente no se modifica entre los semestres. Existe un incremento significativo en embarazos, abortos inducidos y enfermedades de transmisión sexual (ETS) entre los estudiantes de un nivel de formación y otro. Los argumentos expuestos para no utilizar siempre un contraceptivo son insensatos.

Introduction: Previous research and data arising from the “Universidad del Valle” medical school Health Service suggest that students exhibit irresponsible sexual behavior. Objective: This paper describes sexual behavior and contraceptive methods commonly used among first, third and last year students. Results: Students entering the program are frequently late adolescents, with a growing female proportion, coming from high and middle social and economic classes. Although male students begin coital contacts earlier than females (p<0.001), in recent years this is tending to balance, showing no differences in the freshmen cohorts. Both genders have similar sexual behavior, with a small percentage remaining virgin until internship. Condom and oral contraceptives are favored as contraceptive methods. Medical students exhibit a high degree of risk-taking behavior, therefore unwanted pregnancies, abortions and STDs are frequent and become more prevalent in upper levels. Reasons exposed to avoid the use of contraceptive methods seem invalid and irrelevant.