Detección y genotipificación de Pneumocystis jirovecii en muestras de pacientes mexicanos VIH positivos y negativos.

INTRODUCTION: Pneumocystis jirovecii is an atypical fungus particularly detected in HIV-positive or transplant patients. OBJECTIVE: To detect and genotype Pneumocystis jirovecii in patient samples from two hospitals in Mexico City. METHOD: Eighty-nine respiratory tract samples, corresponding to 53 patients (30 HIV-positive and 23 HIV-negative) with respiratory symptoms and to 11 healthy individuals included as negative control, were processed. DNA was extracted from the ITS region and amplified by nested polymerase chain reaction from the internal transcribed spacer, with one fragment being obtained at each round (693 and 550 bp). Genotypes and their phylogenetic relationship were determined by sequencing the 550 bp fragment. RESULTS: Forty-eight samples from 30 HIV-positive patients were received from a single hospital, out of which 11 (36.6 %) were positive for Pneumocystis jirovecii. No sample was positive in HIV-negative patients or healthy subjects. The most frequently detected haplotypes were Eg and Em. CONCLUSIONS: The frequency of Pneumocystis jirovecii infection was high in the studied Mexican population. The most common genotype was different from those reported in other countries. It is necessary to address this health problem through early detection of this infection.

INTRODUCCIÓN: Pneumocystis jirovecii es un hongo atípico detectado particularmente en pacientes VIH-positivos o con trasplante. OBJETIVO: Detectar y genotipificar Pneumocystis jirovecii en muestras de pacientes de dos hospitales de la ciudad de México. MÉTODO: Fueron procesadas 89 muestras respiratorias, correspondientes a 53 pacientes (30 VIH positivos y 23 VIH negativos) con sintomatología respiratoria y 11 personas sanas incluidas como control negativo. El DNA fue extraído y amplificado por PCR anidada de la región del espaciador transcrito interno, obteniendo un fragmento en cada ronda (de 693 y 550 pb). Los genotipos y su relación filogenética fueron determinados por secuenciación del fragmento de 550 pb. RESULTADOS: Cuarenta y ocho muestras de 30 pacientes VIH-positivos provenían de un solo hospital, de las cuales 11 (36.6 %) fueron positivas a Pneumocystis jirovecii. Ninguna fue positiva en pacientes VIH-negativos o personas sanas. Los haplotipos detectados con mayor frecuencia fueron Eg y Em. CONCLUSIONES: La frecuencia de infección por Pneumocystis jirovecii fue alta en la población mexicana estudiada. El genotipo más frecuente fue diferente a los reportados en otros países. Es necesario encauzar este problema de salud hacia la detección temprana de esta infección.

Detección y genotipificación de Pneumocystis jirovecii en muestras de pacientes mexicanos VIH positivos y negativos / Detection and genotyping of Pneumocystis jirovecii in samples from HIV positive and negative Mexican patients

Resumen Introducción: Pneumocystis jirovecii es un hongo atípico detectado particularmente en pacientes VIH-positivos o con trasplante. Objetivo: Detectar y genotipificar Pneumocystis jirovecii en muestras de pacientes de dos hospitales de la ciudad de México. Método: Fueron procesadas 89 muestras respiratorias, correspondientes a 53 pacientes (30 VIH positivos y 23 VIH negativos) con sintomatología respiratoria y 11 personas sanas incluidas como control negativo. El DNA fue extraído y amplificado por PCR anidada de la región del espaciador transcrito interno, obteniendo un fragmento en cada ronda (de 693 y 550 pb). Los genotipos y su relación filogenética fueron determinados por secuenciación del fragmento de 550 pb. Resultados: Cuarenta y ocho muestras de 30 pacientes VIH-positivos provenían de un solo hospital, de las cuales 11 (36.6 %) fueron positivas a Pneumocystis jirovecii. Ninguna fue positiva en pacientes VIH-negativos o personas sanas. Los haplotipos detectados con mayor frecuencia fueron Eg y Em. Conclusiones: La frecuencia de infección por Pneumocystis jirovecii fue alta en la población mexicana estudiada. El genotipo más frecuente fue diferente a los reportados en otros países. Es necesario encauzar este problema de salud hacia la detección temprana de esta infección.

Abstract Introduction: Pneumocystis jirovecii is an atypical fungus particularly detected in HIV-positive or transplant patients. Objective: To detect and genotype Pneumocystis jirovecii in patient samples from two hospitals in Mexico City. Method: Eighty-nine respiratory tract samples, corresponding to 53 patients (30 HIV-positive and 23 HIV-negative) with respiratory symptoms and to 11 healthy individuals included as negative control, were processed. DNA was extracted from the ITS region and amplified by nested polymerase chain reaction from the internal transcribed spacer, with one fragment being obtained at each round (693 and 550 bp). Genotypes and their phylogenetic relationship were determined by sequencing the 550 bp fragment. Results: Forty-eight samples from 30 HIV-positive patients were received from a single hospital, out of which 11 (36.6 %) were positive for Pneumocystis jirovecii. No sample was positive in HIV-negative patients or healthy subjects. The most frequently detected haplotypes were Eg and Em. Conclusions: The frequency of Pneumocystis jirovecii infection was high in the studied Mexican population. The most common genotype was different from those reported in other countries. It is necessary to address this health problem through early detection of this infection.

First report of infectious endocarditis due to Histoplasma capsulatum in Mexico / Primer reporte de endocarditis infecciosa por Histoplasma capsulatum en México

Background: Infectious endocarditis of fungal origin is rare but of high mortality. The agents involved are mainly opportunists of the genus Candida and Aspergillus; however other fungi can also cause this disease. Clinical case: The case of a woman who suffered unknown origin intermittent fever for several months; and in who, by blood culture (after lysis-centrifugation) and molecular biology techniques, Histoplasma capsulatum was identified as etiological agent. The histological study showed abundant intracellular yeasts and hyphae in intracardiac vegetations. Conclusion: This first report of infectious endocarditis by H. capsulatum in Mexico highlights the importance of using in addition to manual blood culture (lysis-centrifugation) and histological study, faster and more sensitive diagnostic methods, such as serology and molecular biology, to confirm or rule out an invasive fungal infection and identify the agents.

Introducción: la endocarditis infecciosa de etiología micótica es una patología poco frecuente, pero con elevada mortalidad. Los agentes implicados generalmente son oportunistas de los géneros Candida y Aspergillus; sin embargo, otros hongos también pueden ocasionar la enfermedad. Caso clínico: se presenta el caso de una mujer quien cursó con fiebre intermitente de causa desconocida por varios meses y en la que, por medio de estudios de imagen, hemocultivo manual (después de lisis-centrifugación) y técnicas de biología molecular, se identificó Histoplasma capsulatum. El estudio histológico de las vegetaciones intracardiacas mostró abundantes levaduras e hifas. Conclusión: este primer reporte de endocarditis infecciosa por H. capsulatum en México pone en evidencia la importancia de utilizar, además del hemocultivo manual (lisis-centrifugación) y el estudio histológico, métodos de diagnóstico más rápidos y sensibles, como la serología y la biología molecular, para confirmar o descartar una infección fúngica invasiva e identificar los agentes.

First case of chromoblastomycosis due to Phoma insulan / Primer caso de cromoblastomicosis causado por Phoma insulan

Chromoblastomycosis is a chronic infection, caused by pigmented fungi affecting skin and subcutaneous tissues characterized by verrucous nodules or plaques. Fonsecaea pedrosoiand Cladophialophora carrionii are the prevalent agents in the endemic areas. Phoma is an uncommon agent of human infection and involved mainly with phaeohyphomycosis cases. The case of a patient with a history of laceration in foot followed by verrucous aspect and scaly lesions, which had evolved for 27 years is presented. On physical examination disease was clinically compatible with chromoblastomycosis and the microscopic examination of scales showed fumagoid cells. On culture a dematiaceous fungus was grown. The agent was confirmed to be Phoma insulana based on its morphology and PCR-sequencing. This fungal agent has not been previously reported in association with this pathology (AU)

La cromoblastomicosis es una infección crónica causada por hongos pigmentados que afecta la piel y el tejido subcutáneo y que se caracteriza por nódulos o placas verrugosas. Fonsecaea pedrosoi y Cladophialophora carrionii son los agentes prevalentes en las áreas endémicas. Phoma es un agente raro de infección humana y está involucrado principalmente en casos de feohifomicosis. Se presenta el caso de un paciente con antecedente de laceración en el pie, seguida de lesiones de aspecto verrugoso y descamativas, que evolucionaron durante 27años. En el examen físico la enfermedad fue clínicamente compatible con cromoblastomicosis y el examen microscópico de escamas mostró células fumagoides. En el cultivo creció un hongo dematiáceo. El agente fue confirmado como Phoma insulana en base a su morfología y PCR seguida de secuenciación. Este agente fúngico no ha sido reportado previamente en asociación con esta patología (AU)

First case of chromoblastomycosis due to Phoma insulana.

Chromoblastomycosis is a chronic infection, caused by pigmented fungi affecting skin and subcutaneous tissues characterized by verrucous nodules or plaques. Fonsecaea pedrosoi and Cladophialophora carrionii are the prevalent agents in the endemic areas. Phoma is an uncommon agent of human infection and involved mainly with phaeohyphomycosis cases. The case of a patient with a history of laceration in foot followed by verrucous aspect and scaly lesions, which had evolved for 27 years is presented. On physical examination disease was clinically compatible with chromoblastomycosis and the microscopic examination of scales showed fumagoid cells. On culture a dematiaceous fungus was grown. The agent was confirmed to be Phoma insulana based on its morphology and PCR-sequencing. This fungal agent has not been previously reported in association with this pathology.

Onychomycosis incidence in type 2 diabetes mellitus patients.

The onychomycosis incidence was determined in 250 type 2 diabetes mellitus (T2DM) patients who were registered at the Internal Medicine Service from a Mexico city General Hospital throughout a year (January-December 2006). Out of the total of studied T2DM patients, 93 (37.2%) showed ungual dystrophy and from these, in 75.3% a fungal etiology was corroborated. Out of 70 patients, 34 were men and 36 women, with an average of 63.5 years. Correlation between T2DM evolution time and onychomycosis was significant (P < 0.01). Distal-lateral subungual and total dystrophic onychomycosis were the most frequent clinical types (55.1% and 33.7%, respectively). Fifty-eight fungal isolates were obtained; 48.6% corresponded to dermatophytes, Trichophyton rubrum being the first species (37.1%). All these strains corresponded to two morphological varieties: "yellow" and typical downy. From the yeast-like isolates, 12 corresponded to Candida spp., firstly C. albicans and C. parapsilosis; three to Cryptococcus spp. (C. albidus, C. uniguttulatus and C. laurentii); two Trichosporon asahii; and only one to Pichia ohmeri. Six non-dermatophytic molds were isolated: two Chrysosporium keratinophylus, two Scopulariopsis brevicaulis, one Aspergillus fumigatus, and one Acremonium sp. The fungal mixture corresponded to T. mentagrophytes with C. guilliermondii; T. mentagrophytes with C. glabrata; T. rubrum with C. glabrata; T. rubrum with P. ohmeri.

[Antifungal and phagocytic immunostimulation treatment of chronic disseminated dermatophytosis]. / Dermatofitosis diseminada crónica asociada a fagocitosis deficiente tratada con antimicóticos e inmunoestimulación fagocitaria.

A 39 years old man with a long-standing disseminated dermatophytosis even with several antifungal treatments is presented. From lesions, Trichophyton rubrum var. typical downy, T. tonsurans and Candida albicans were isolated and showed sensivity to azolic compounds in vitro. The phagocytic activity in vitro compared with normal control was depressed. Treatment with itraconazole and immunomodulation using a bacterial antigen was indicated. During the last two years the patient has been clinical and mycologically healthy, and his phagocytosis activity has become normal. In patients with chronic and relapsing dermatophytosis, the immune response evaluation is recommended, and immunomodulation could be useful as a rational measure in patients with a particular immunodeficiency.

Dermatofitosis diseminada crónica asociada a fagocitosis deficiente tratada con antimicóticos e inmunoestimulación fagocitaria / Antifungal and phagocytic immunostimulation treatment of chronic disseminated dermatophytosis

Se presenta el caso de un hombre de 39 años de edad con dermatofitosis crónica diseminada. De las lesiones se aislaron Trichophyton rubrum var. vellosa típica, T. tonsurans y Candida albicans, todos sensibles in vitro a compuestos azólicos. La actividad fagocítica in vitro comparada con un control normal mostró deficiencia en la misma. Se indicó tratamiento con itraconazol e inmunoestimulación con antígeno bacteriano. Durante los dos últimos años el paciente se ha mantenido clínica y micológicamente sano y su actividad fagocitaria es normal. En los pacientes con dermatofitosis crónica recidivante es recomendable la valoración de la respuesta inmune y la inmunomodulación puede ser útil como parte del tratamiento.

A 39 years old man with a long-standing disseminated dermatophytosis even with several antifungal treatments is presented. From lesions, Trichophyton rubrum var. typical downy, T. tonsurans and Candida albicans were isolated and showed sensivity to azolic compounds in vitro. The phagocytic activity in vitro compared with normal control was depressed. Treatment with itraconazole and immunomodulation using a bacterial antigen was indicated. During the last two years the patient has been clinical and mycologically healthy, and his phagocytosis activity has become normal. In patients with chronic and relapsing dermatophytosis, the immune response evaluation is recommended, and immunomodulation could be useful as a rational measure in patients with a particular immunodeficiency.

Frecuencia de micosis en pacientes inmunosuprimidos de un hospital regional de la Ciudad de México / Frequency of mycoses in immunosuppressed patients in a regional hospital in Mexico City

OBJETIVO: Aislar e identificar hongos en diferentes especímenes de pacientes inmunocomprometidos, atendidos en un hospital de la Ciudad de México, y determinar su asociación con micosis. MATERIAL Y MÉTODOS: Se realizó un estudio de tipo observacional transversal en pacientes del Hospital Regional General Ignacio Zaragoza, de junio de 1999 a mayo de 2000. De 108 pacientes se procesaron 268 especímenes para estudio micológico que incluyó examen directo, frotis, cultivos y microcultivos en medios específicos además de pruebas bioquímicas. La mayoría de pacientes tenía diagnóstico clínico de tuberculosis pulmonar y de síndrome de inmunodeficiencia adquirida. RESULTADOS: Se obtuvieron 183 aislamientos de levaduras y 66 de hongos filamentosos. Se diagnosticaron 45 micosis que en su mayoría correspondieron a candidosis pulmonar (32 casos). Las especies de Candida más frecuentes asociadas a patología fueron Candida albicans y C parapsilosis. Se obtuvieron cinco aislamientos de Cryptococcus neoformans variedad neoformans, uno de C albidus, tres de Histoplasma capsulatum y uno de Geotrichum candidum, asociados a infección micótica. CONCLUSIONES: El 41.6 por ciento de los pacientes estudiados presentaron una micosis asociada principalmente a síndrome de inmunodeficiencia adquirida y a tuberculosis pulmonar.

OBJECTIVE: To isolate and identify the fungi in specimens collected from immunocompromised patients seen in Mexico City hospital, and to assess their association with mycosis. MATERIAL AND METHODS: A total of 268 specimens from 108 patients were processed for mycological study, including direct examination, smears, cultures, and microcultures in specific media, in addition to biochemical tests. Most of the patients had been diagnosed with pulmonary tuberculosis and Acquired Immunodeficiency Syndrome (AIDS). RESULTS: One hundred and eighty-three yeasts and 66 mycelial fungi were isolated. Forty-five mycoses were diagnosed; the most frequent mycosis was pulmonary candidosis (32 cases). Candida albicans and C parapsilosis were the predominant species associated with mycotic infection. Five Cryptococcus neoformans var. neoformans, one C albidus, three Histoplasma capsulatum and one Geotrichum candidum isolats were associated with mycosis. CONCLUSIONS: Of the studied patients, 41.6 percent showed a mycotic infection, principally associated with AIDS and pulmonary tuberculosis.

[Frequency of mycosis in immunosuppressed patients at a regional hospital of Mexico City]. / Frecuencia de micosis en pacientes inmunosuprimidos de un hospital regional de la Ciudad de México.

OBJECTIVE: To isolate and identify the fungi in specimens collected from immunocompromised patients seen in Mexico City hospital, and to assess their association with mycosis. MATERIAL AND METHODS: A total of 268 specimens from 108 patients were processed for mycological study, including direct examination, smears, cultures, and microcultures in specific media, in addition to biochemical tests. Most of the patients had been diagnosed with pulmonary tuberculosis and Acquired Immunodeficiency Syndrome (AIDS). RESULTS: One hundred and eighty-three yeasts and 66 mycelial fungi were isolated. Forty-five mycoses were diagnosed; the most frequent mycosis was pulmonary candidosis (32 cases). Candida albicans and C parapsilosis were the predominant species associated with mycotic infection. Five Cryptococcus neoformans var. neoformans, one C albidus, three Histoplasma capsulatum and one Geotrichum candidum isolates were associated with mycosis. CONCLUSIONS: Of the studied patients, 41.6% showed a mycotic infection, principally associated with AIDS and pulmonary tuberculosis. The English version of this paper is available at:http://www.insp.mx/salud/index.html.