Efficacy of imipenem therapy for Nocardia actinomycetomas refractory to sulfonamides.

BACKGROUND: Actinomycetomas are chronic, granulomatous, subcutaneous infections caused by actinomycetes bacteria. Despite prolonged high-dose and combination antibiotic therapies, some cases remain resistant with risks of bone and visceral involvement. OBJECTIVES: We sought to evaluate the efficacy and safety of imipenem monotherapy, and in combination with amikacin for the treatment of severe and refractory disease, and to identify the disease characteristics that might predict therapy failure with first-line sulfonamides. METHODS: A retrospective study was performed of all microbiologically confirmed cases of actinomycetomas treated since 1995 at a tertiary center for mycology. Eleven patients (Nocardia, n = 10) were treated with sulfonamide combinations (trimethoprim/sulfamethoxazole and dapsone). Eight patients (Nocardia, n = 7) refractory to previous therapies including sulfonamides received a 3-week course of either parenteral imipenem monotherapy (1.5 g daily, n = 3) or combination therapy with amikacin (1 g daily, n = 5), which was repeated at 6-month intervals. RESULTS: Eleven patients with limited disease and mean disease duration of 1.7 years responded successfully to sulfonamides after a mean treatment period of 15 months (range 6-48 months). Patients receiving imipenem had mean disease duration of 10 years, with visceral and bone involvement in 4 patients. Imipenem treatment was well tolerated, and 4 patients achieved clinical and microbiological cure after one to two courses of treatment, the others demonstrating greater than 75% clinical improvement and negative culture results. LIMITATIONS: Patient cohorts in this study were small because strict criteria for inclusion included species identification and adequate follow-up periods. The efficacy data for imipenem +/- amikacin therapy cannot be extrapolated to all Nocardia mycetomas, as the cohort treated in this study had particularly refractory infection. CONCLUSIONS: Sulfonamides are effective for limited disease of relatively short duration. Imipenem monotherapy or in combination with amikacin is well tolerated and demonstrates efficacy in severe disease refractory to sulfonamides.

The emergence of mucormycosis as an important opportunistic fungal infection: five cases presenting to a tertiary referral center for mycology.

BACKGROUND: Mucormycosis, a rare opportunistic fungal infection, is re-emerging in importance with the increase in prevalence of immunosuppressive states, both as a result of therapy and disease. METHODS: We report five cases of mucormycosis diagnosed by the Dermatology Department and managed jointly with the Medical and Surgical Services of "Dr Manuel Gea Gonzalez" General Hospital in Mexico City, a tertiary referral center for mycology. We also review the current literature including recent advances in medical therapy. RESULTS: Four of the five cases were of the rhino-orbital-cerebral variant, commonly associated with significant mortality, and one of these patients died despite early diagnosis and aggressive management. The fifth case was primary cutaneous mucormycosis and this patient survived infection without relapse. Diabetic ketoacidosis predisposed to infection in four cases and the other was associated with advanced human immunodeficiency virus infection. Radiologic imaging was important in cases of facial involvement in order to evaluate the extent of disease and possible intracranial involvement. All cases were managed with systemic antifungals and surgical debridement, together with the treatment of predisposing factors. CONCLUSIONS: These cases illustrate the need for early clinical recognition and prompt therapy, as well as the requirement for tissue biopsy in order to demonstrate the characteristic morphologic features of this fungal agent in the absence of positive mycology culture results. This report also highlights that, although rhino-orbital-cerebral mucormycosis requires effective multidisciplinary management, the disease not uncommonly presents to dermatologists for diagnosis.

[Actinomycetoma and Nocardia sp. Report of five cases treated with imipenem or imipenem plus amikacin]. / Actinomicetoma por Nocardia sp. Informe de cinco casos tratados con imipenem solo o combinado con amikacina.

INTRODUCTION: Dapsone with trimethoprim-sulfamethoxazol is currently the standard treatment for actinomycetoma. In select cases, amikacin, streptomycin, kanamycin, amoxicillin/clavulanic acid or phosphomycin may be also added. Imipenem has shown to be effective both in vitro and in vivo against some actinomycetes. Amikacin with Imipenem has a synergistic effect. OBJECTIVES: To report our preliminary findings using imipenem alone or with amikacin for severe or multi-resistant mycetomas due to Nocardia sp. MATERIAL AND METHODS: We present 5 cases of chronic mycetoma infection previously treated with anti-bacterial multidrug regimens. All patients were hospitalized and treated with imipenem 500 mg IV, three times a day for three weeks. Three patients received in addition amikacin. RESULTS: We included 3 male and 2 female patients. The average length of disease duration was 7.4 years. In 3 cases mycetoma was located on the back; one of them involved the rib and the lung. One case was localized in the abdominal wall, and another one involved the posterior side of the cervical region. Two patients achieved clinical and bacteriological cure one year after treatment with Imipenem, and the remaining three displayed clinical improvement, even though grains were observed, cultures where negative. None of the 5 patients studied showed clinical evidence of adverse reactions to Imipenem. CONCLUSIONS: Imipenem is a strong antibiotic and constitutes an important treatment alternative for severe or multi-resistant mycetoma especially for cases with bone and visceral involvement.

Actinomicetoma por Nocardia sp: informe de cinco casos tratados con imipenem solo o combinado con amikacina / Actinomycetoma and Nocardia sp: report of five cases treated with imipenem or imipenem plus amikacin

Antecedentes: El tratamiento estándar del actinomicetoma es dapsona con trimetoprim/sulfametoxazol. En casos seleccionados amikacina, estreptomicina, kanamicina, amoxicilina/ácido clavulánico o fosfomicina. El imipenem ha mostrado tener actividad in vitro e in vivo contra algunos actinomicetos; tiene un efecto sinérgico combinado con amikacina. Objetivos: Comunicar la respuesta al tratamiento con imipenem solo o combinado con amikacina en micetomas por Nocardia sp graves o multirresistentes. Material y métodos: Presentamos cinco pacientes con actinomicetoma que habían recibido múltiples tratamientos. Se hospitalizaron tres semanas para recibir imipenem (500 mg cada ocho horas) intravenoso por vía periférica por 21 días. En dos casos se combinó con amikacina. Resultados: Tres pacientes fueron hombres y dos mujeres. En tres casos la localización fue en el dorso, uno de ellos con afección ósea y pulmonar; en un caso hubo afección de la pared abdominal y en otro en la región cervical posterior. La evolución promedio fue de 7.4 años. En dos casos se logró curación clínica y bacteriológica a un año de seguimiento. En el paciente con afección pulmonar también hubo mejoría radiográfica. En el resto de los casos se logró cierre de la mayoría de las fístulas y una disminución importante de la inflamación, aunque hubo presencia de granos con cultivo negativo. Ningún tratamiento provocó efectos colaterales. Conclusiones: El imipenem es un antibiótico de amplio espectro y consideramos que es una buena alternativa para tratar actinomicetomas graves, resistentes al tratamiento habitual o con complicaciones viscerales.

INTRODUCTION: Dapsone with trimethoprim-sulfamethoxazol is currently the standard treatment for actinomycetoma. In select cases, amikacin, streptomycin, kanamycin, amoxicillin/clavulanic acid or phosphomycin may be also added. Imipenem has shown to be effective both in vitro and in vivo against some actinomycetes. Amikacin with Imipenem has a synergistic effect. OBJECTIVES: To report our preliminary findings using imipenem alone or with amikacin for severe or multi-resistant mycetomas due to Nocardia sp. MATERIAL AND METHODS: We present 5 cases of chronic mycetoma infection previously treated with anti-bacterial multidrug regimens. All patients were hospitalized and treated with imipenem 500 mg IV, three times a day for three weeks. Three patients received in addition amikacin. RESULTS: We included 3 male and 2 female patients. The average length of disease duration was 7.4 years. In 3 cases mycetoma was located on the back; one of them involved the rib and the lung. One case was localized in the abdominal wall, and another one involved the posterior side of the cervical region. Two patients achieved clinical and bacteriological cure one year after treatment with Imipenem, and the remaining three displayed clinical improvement, even though grains were observed, cultures where negative. None of the 5 patients studied showed clinical evidence of adverse reactions to Imipenem. CONCLUSIONS: Imipenem is a strong antibiotic and constitutes an important treatment alternative for severe or multi-resistant mycetoma especially for cases with bone and visceral involvement.

[Cutaneous Histoplasmosis and AIDS]. / Histoplasmosis cutánea y SIDA.

Histoplasmosis is usually a lung infection due to Histoplasma capsulatum var Capsulatum. Skin lesions are present in 10 to 17% of cases and it appears to have higher prevalence in Mexico. We report on three cases, all males with AIDS, of 26, 33 and 44 years of age. They presented fever, lymphadenopathy and weight loss. One had lingual ulcer and the other two, disseminated erythemato-violaceus plaques, papular and fistular lesions. The histopathologic study showed granulomatous lesions and Histoplasma capsulatum was isolated in cultures. All patients were treated successfully with amphotericin B with a total of 1.5 gm accumulative dose. Clinical skin lesions of histoplasmosis and good response to treatment are discussed.