Epidemiological and Clinical Aspects of Cutaneous and Mucosal Leishmaniases in Portugal: Retrospective Analysis of Cases Diagnosed in Public Hospitals and Reported in the Literature between 2010 and 2020.

Leishmania infantum, a zoonotic vector-born parasite, is endemic in the Mediterranean region, presenting mostly as visceral (VL), but also as cutaneous (CL) and mucosal leishmaniasis (ML). This study aimed to describe the epidemiological and clinical aspects of the CL and ML cases diagnosed in mainland Portugal between 2010 and 2020. Collaboration was requested from every hospital of the Portuguese National Health System. Cases were screened through a search of diagnostic discharge codes or positive laboratory results for Leishmania infection. Simultaneously, a comprehensive literature search was performed. Descriptive statistics and hypothesis testing were performed using IBM® SPSS® Statistics. A total of 43 CL and 7 ML cases were identified, with a predominance of autochthonous cases (86%). In CL, immunosuppressed individuals constituted a significant proportion of patients (48%), and in this group, disseminated CL (22%) and simultaneous VL (54%) were common. In autochthonous cases, lesions, mostly papules/nodules (62%), were frequently observed on the head (48%). The approach to treatment was very heterogeneous. ML cases were all autochthonous, were diagnosed primarily in older immunosuppressed individuals, and were generally treated with liposomal amphotericin B. The findings suggest a need for enhanced surveillance and reporting, clinical awareness, and diagnostic capacity of these forms of leishmaniasis to mitigate underdiagnosis and improve patient outcomes. A holistic One Health approach is advocated to address the multifaceted challenges posed by leishmaniases in Portugal and beyond.

Seroprevalence of antibodies against SARS-CoV-2 among health care workers in a Portuguese hospital.

Background: Health care workers (HCW) are presumably exposed to a higher risk of infection by SARS-CoV-2 and could possibly represent a source of transmission to susceptible patients. Thus, characterization of SARS-CoV-2 infection among HCW is necessary to better understand the determinants of viral transmission and properly implement strategies to prevent dissemination and protect HCW and vulnerable patients. The aim of this study was to estimate the seroprevalence of antibodies against SARS-CoV-2 in a Portuguese tertiary hospital, in the period of July 2020 to March 2021, before the generalized use of the SARS-CoV-2 vaccine, characterize its evolution over time, and identify risk factors associated with seroconversion. Methods: HCW were approached to collect serum samples for qualitative SARS-CoV-2 antibody testing and completion of an online survey capturing demographics, previous symptoms, and details of health care and community exposure. Odds ratio with bivariable and multivariable logistic regression was used to assess characteristics associated with seroprevalence. Results: One thousand HCW were included for analysis. Two hundred nineteen HCW (22%) were seropositive for immunoglobulin G against SARS-CoV-2, and 166 (17%) were seropositive for immunoglobulin M, most of whom reported a previous diagnosis of SARS-CoV-2 infection. The risk factors associated with seroconversion included a previous COVID-19 diagnosis, contact with patients, occupational contact with colleagues, and outside contact. However, in a multivariate logistic regression analysis, only a previous diagnosis and outside contact were associated with seroconversion. Seropositivity decreased over time, especially 28 weeks after infection. Conclusion: HCWs have a high seroprevalence for SARS-CoV-2 infection, probably due to a combination of health care and community exposure. Seropositivity decreases over time, but further studies are needed to better understand our adaptive immune response.

Nocardiosis: When the Side Effects of Therapy Mimic Symptoms.

Nocardiosis is a rare infection caused by gram-positive aerobic actinomycetes, which are common in soil. Inoculation occurs by inhaling agent fragments that cause localized or systemic suppurative lesions. The diagnosis is established based on isolation in cultural examinations. Trimethoprim-sulfamethoxazole (TMP-SMX) is the first-line treatment, and an antimicrobial susceptibility test is useful in severe cases or when there is no clinical response. The duration of treatment is determined by the affected site. However, the treatment cycles are long, and recurrence is common, which has a negative impact on the prognosis. We describe a case of an immunocompetent male with a recent diagnosis of pulmonary nocardiosis who, after starting therapy, presented with symptoms that could be explained by either disease progression or an adverse pharmacological reaction. Throughout this case, with atypical evolution, the authors review the diagnostic and therapeutic approach to Nocardia infection and alert to the importance of the differential diagnosis and available therapeutic options.

NDM-1 Introduction in Portugal through a ST11 KL105 Klebsiella pneumoniae Widespread in Europe.

The changing epidemiology of carbapenem-resistant Klebsiella pneumoniae in Southern European countries is challenging for infection control, and it is critical to identify and track new genetic entities (genes, carbapenemases, clones) quickly and with high precision. We aimed to characterize the strain responsible for the first recognized outbreak by an NDM-1-producing K. pneumoniae in Portugal, and to elucidate its diffusion in an international context. NDM-1-producing multidrug-resistant K. pneumoniae isolates from hospitalized patients (2018-2019) were characterized using FTIR spectroscopy, molecular typing, whole-genome sequencing, and comparative genomics with available K. pneumoniae ST11 KL105 genomes. FT-IR spectroscopy allowed the rapid (ca. 4 h after incubation) identification of the outbreak strains as ST11 KL105, supporting outbreak control. Epidemiological information supports a community source but without linkage to endemic regions of NDM-1 producers. Whole-genome comparison with previous DHA-1-producing ST11 KL105 strains revealed the presence of different plasmid types and antibiotic resistance traits, suggesting the entry of a new strain. In fact, this ST11 KL105 clade has successfully disseminated in Europe with variable beta-lactamases, but essentially as ESBL or DHA-1 producers. We expand the distribution map of NDM-1-producing K. pneumoniae in Europe, at the expense of a successfully established ST11 KL105 K. pneumoniae clade circulating with variable plasmid backgrounds and beta-lactamases. Our work further supports the use of FT-IR as an asset to support quick infection control.

Outbreak of KPC-producing Klebsiella pneumoniae at a Portuguese university hospital: Epidemiological characterization and containment measures.

Background: KPC-producing K pneumoniae (KPC-Kp) is a public health problem with important clinical and epidemiological implications. We describe an outbreak of KPC-Kp at vascular surgery and neurosurgery wards in a central hospital in Porto, Portugal. Methods: A case of KPC-Kp was considered to be a patient positive for KPC-Kp with strong epidemiological plausibility of having acquired this microorganism in the affected wards and/or with genetic relationship ≥92% between KPC-Kp isolates. Active surveillance cultures (ASCs) and real-time polymerase chain reaction were used for the detection of carbapenemase genes through rectal swab in a selected population. Molecular analysis was performed using pulsed-field gel electrophoresis at the National Reference Laboratory. Patient risk factors were collected from the electronic medical record system. Information regarding outbreak containment strategy was collected from the Infection Control Unit records. Results: Of the 16 cases, 11 (69%) were identified through active screening, representing 1.4% of the total 766 ASCs collected. The most frequent risk factors identified were previous admission (63%), antibiotic exposure in the past 6 months (50%), and immunodepression (44%). The length of stay until KPC-Kp detection was high (0-121 days, mean 35.6), as was the total length of stay (5-173 days, mean 56.6). Three patients (19%) were infected by KPC-Kp, 2 of whom died. One previously colonized patient died later because of KPC-Kp infection. Conclusions: Multifactorial strategy based on contact precautions (with patient and healthcare professional cohorts) and ASC, as well as Antibiotic Stewardship Program reinforcement, allowed to contain this KPC-Kp outbreak.

Jaundice as a Rare Manifestation of Epstein-Barr Virus Primary Infection.

Epstein-Barr virus (EBV) primary infection usually presents with classic symptoms of infectious mononucleosis (IM) like fever, lymphadenopathies and tonsillopharyngitis. Liver damage is frequently mild and self-limited and there are only a few cases of severe EBV-induced cholestatic hepatitis and jaundice reported in the literature. The authors present the case of a 22-year-old woman who was admitted with acute fever and jaundice. Physical examination revealed posterior cervical lymphadenopathies and painful hepatosplenomegaly. Laboratorial findings suggested an obstructive cause for jaundice but ultrasound and magnetic resonance cholangiopancreatography excluded biliary duct pathology. Heterophile antibodies were negative but EBV-specific antibodies revealed isolated positive viral capsid antigen (VCA) immunoglobin (Ig) M suggesting the diagnosis of early phase of EBV primary infection. The diagnosis of EBV-induced cholestatic hepatitis was confirmed after identification of EBV deoxyribonucleic acid (DNA) in blood and by liver biopsy. Supportive management was provided and, despite an initial clinical deterioration, the patient had a favorable outcome. EBV is a virus with a high prevalence worldwide, mainly subclinical, and jaundice is a rare manifestation of the infection. Although the majority of the patients recover without sequelae, progression to liver failure has been described and a careful assessment for complications is mandatory. Therefore, EBV infection should be included in the comprehensive differential diagnosis of jaundice in all age groups.

Disseminated gonococcal infection and the inaugural diagnosis of latent autoimmune diabetes in a young adult

Disseminated gonococcal infection (DGI) is a rare and emerging disease that should be considered in individuals who present with acute polyarthralgias, skin lesions and/or tenosynovitis, even in the absence of genitourinary symptoms.We describe a 29 years old man presenting with fever, arthralgias, skin lesions and signs of tenosynovitis. The diagnostic approach identified a disseminated gonococcal infection and an unrecognized and latent autoimmune diabetes.We emphasize not only the particularities of diagnostic and treatment approach currently required by this emergent infection, but also the importance of investigation of rare risk factors associated with an underlying immunosuppression. In latent autoimmune diabetes of adults a timely recognition and individualized treatment are fundamental for prognostic

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Disseminated Gonococcal Infection: A Case Report of Arthritis-Dermatitis Syndrome.

The bacteremic spread of the sexually transmitted pathogen, Neisseria gonorrhoeae (N. gonorrhoeae), results in disseminated gonococcal infection (DGI), which can lead to a variety of clinical signs and symptoms, such as multiple skin lesions, tenosynovitis and arthralgias/arthritis. The Centers for Disease Control and Prevention listed that drug-resistant N. gonorrhoeae (cephalosporin resistance) poses an urgent threat due to antimicrobial resistance. The authors describe the case of a young woman presenting in the emergency department (ED) with skin lesions and malaise. DGI was confirmed by blood cultures, nucleic acid amplification testing (NAAT) in cervical mucosa and urine gonococcal probe. One week of intravenous ceftriaxone was administrated with complete clinical and analytical resolution. The patient made a full clinical recovery. Clinicians must be aware of the signs and symptoms of this rare yet reemerging disease.

Presentation and diagnosis of acute Q fever in Portugal - A case series.

Q fever is a worldwide zoonotic infection caused by the obligate intracellular bacterium Coxiella burnetii that can course with acute or chronic disease. This series describes 7 cases of acute Q fever admitted in a Portuguese University Hospital between 2014 and 2015. All cases presented with hepatitis and had epidemiological history. Diagnosis was done by PCR on majority (5) and by serology and PCR in only 2. Serological tests can be negative in the initial period of the disease. Molecular biology methods by polymerase chain-reaction are extremely important in acute disease, allowing timely diagnosis and treatment.

Acute HIV infection presenting as hemophagocytic syndrome with an unusual serological and virological response to ART.

BACKGROUND: HIV clinical presentation in the acute stage is variable and some of its virological and immunological aspects are not completely understood. Most cases of HIV- associated reactive hemophagocytic syndrome have been reported in patients with advanced stages of HIV and to our knowledge, there are only 8 cases in the English literature presenting during acute HIV infection, most in East Asia, being this the first case in a European patient. CASE PRESENTATION: We report a case of a European Caucasian 27- year old woman with a primary HIV- infection presenting with extremely low CD4+ T cell count who developed a haemophagocytic syndrome after starting ART and in whom we documented a very unusual serological and virological response, characterized by an impaired HIV- antibody production and a 12 month time frame to reach an undetectable viral load, despite no evidence of resistance. CONCLUSIONS: This case report apart from describing an unusual clinical presentation of an acute HIV infection as hemophagocytic syndrome provides useful information that might contribute for understanding some subtle issues in acute HIV infection, namely the dynamics of virological and immunological aspects after antiretroviral therapy initiation.

Chronic Q fever: A missed prosthetic valve endocarditis possibly for years.

Chronic Coxiella burnetii endocarditis usually develops in people with underlying heart disease and accounts for 60-70% of chronic Q fever. Onset is generally insidious and manifestations are atypical. The authors report a case of Coxiella burnetii prosthetic valve endocarditis in a 53 years- old patient with recurrent mechanical valve dehiscence on mitral position. He lived in a rural area with sheep and goats on the surroundings. During a 9 year- period, he was submitted to three cardiac mitral valve surgeries two of which with no Q fever diagnosis suspicion. Diagnosis was based on a positive serology test (Indirect imunofluorescence). Treatment consisted in a combination of prolonged course of hydroxychloroquine plus doxycycline and surgical replacement of the mitral valve, with a favorable outcome. With this case report, the authors pretend to highlight the not always expected diagnosis of Q fever endocarditis. If not considered, Coxiella burnetii endocarditis may lead to multiple cardiac surgeries, greater morbidity and potentially death.

The tuberculin skin test still matters for the screening of latent Tuberculosis infections among Inflammatory Bowel Disease patients.

BACKGROUND AND AIMS: There is a high risk of Tuberculosis among patients medicated with anti-tumour necrosis factor α (anti-TNFα) that can be mitigated by treating latent Tuberculosis infections (LTI). This study aimed to evaluate the performance of Tuberculin Skin test (TST) and Quantiferon-TB Gold in Tube (QFT-GIT) in a population of patients suffering from Inflammatory Bowel Diseases. METHODS: The cohort analyzed in this study consisted of 250 patients, of whom 15% were therapy-naïve and 85% were medicated: 70% under immunosuppressive therapy and 30% on anti-TNFα. A LTBI was diagnosed following a positive result in either of the tests and their performance and concordance were evaluated. RESULTS: Fifty-eight and 24 patients had a positive TST and QFT-GIT, respectively. In 72 (29%) patients LTBI was diagnosed, of whom 8 (21%) were therapy-naïve. TST had an overall higher sensitivity (81% vs. 35%) and a higher Negative Predictive Value (93% vs. 80%) when compared to QFT-GIT test; this superiority was consistently maintained irrespective of the presence and kind of backbone immunosuppressive therapies. The concordance between both tests was weak. CONCLUSIONS: Our results underscore the need to maintain the TST on LTBI diagnosis in patients about to start or switch anti-TNFα therapy in an intermediate Tuberculosis incidence context.

Fungal prosthetic valve endocarditis with mycotic aneurysm: Case report.

Fungal prosthetic valve endocarditis is an extremely severe form of infective endocarditis, with poor prognosis and high mortality despite treatment. Candida albicans is the most common etiological agent for this rare but increasingly frequent condition. We present a case of fungal prosthetic valve endocarditis due to C. albicans following aortic and pulmonary valve replacement in a 38-year-old woman with a history of surgically corrected tetralogy of Fallot, prior infective endocarditis and acute renal failure with need for catheter-based hemodialysis. Antifungal therapy with liposomal amphotericin B was initiated prior to cardiac surgery, in which the bioprostheses were replaced by homografts, providing greater resistance to recurrent infection. During hospitalization, a mycotic aneurysm was diagnosed following an episode of acute arterial ischemia, requiring two vascular surgical interventions. Despite the complications, the patient's outcome was good and she was discharged on suppressive antifungal therapy with oral fluconazole for at least a year. The reported case illustrates multiple risk factors for fungal endocarditis, as well as complications and predictors of poor prognosis, demonstrating its complexity.

Candida parapsilosis prosthetic valve endocarditis.

Candida endocarditis is a rare infection associated with high mortality and morbidity. There are still some controversies about Candida endocarditis treatment, especially about the treatment duration. We report a case of a Candida parapsilosis endocarditis that presented as a lower limb ischemia. The patient was surgically treated with a cryopreserved homograft aortic replacement. We used intravenous fluconazole 800 mg as initial treatment, followed with 12 months of 400 mg fluconazole per os. The patient outcome was good.

Hepatitis C and leptospirosis: simultaneous acute infections or recurrence of occult hepatitis C.

People who inject drugs are vulnerable to several infections. To the best of our knowledge, this is the first case report of a simultaneous diagnosis of leptospirosis and acute infection or recurrence of occult hepatitis C in an HIV-infected drug user. We report a case of a 47-year-old Caucasian man with HIV infection, on antiretroviral therapy, and with a history of hepatitis C (positive anti-hepatitis C virus (HCV) and HCV RNA persistently negative) who was admitted with febrile acute hepatitis. He was a former injecting drug user, on opioid substitution therapy, who relapsed to injection drug use 3 weeks prior to admission. Work up revealed positive HCV RNA and Leptospira DNA in his urine. Four weeks later he had an undetectable HCV load, and also at 6 months of follow-up. This case highlights the presence of two concomitant infectious aetiologies of acute hepatitis in an HIV-infected drug user.

A violência psicológica na relação entre professor e aluno com dificuldades de aprendizagem / The psychological violence in the relationship between teacher and student with learning difficulties / La violencia psicológica en la relación entre profesor y estudiantes con dificultades de aprendizaje

Neste trabalho, buscou-se investigar as ações do professor que se caracterizam por violência psicológica no cotidiano escolar. A pesquisa, pautada nas diretrizes epistemológicas da investigação qualitativa, foi realizada em uma escola pública que atende crianças dos anos iniciais do Ensino Fundamental. Os participantes foram quatro crianças e sua professora. Para a coleta dos dados, foram utilizados os seguintes instrumentos: observação com recurso do diário de campo, videogravação e entrevista semiestruturada. As ações identificadas como violência psicológica foram: rejeição, humilhação e indiferença. Observou-se que a escola passou a ser objeto de um temor proveniente de vivências marcadas por ações de segregação, punição e desrespeito à condição dos alunos com dificuldades de aprendizagem e, consequentemente, ao saber dessas crianças que fracassavam nesse importante cenário de seu desenvolvimento.(AU)

This research aims to investigate the teacher actions that are characterized psychological violence in school routine. The research, based on epistemological guidelines of qualitative investigation, was realized in a public school that serves children in the early years of the Elementary School. The participants were four children and their teacher. In order to collect data, the following instruments were applied: observation with the use of field notes, video recording and a semi-structured interview. The actions identified as psychological violence were: rejection, humiliation and indifference. In this study, it was possible to notice that school became an object of fear coming from experiences marked by segregation, punishment and non-respect actions towards their conditions, and consequently, by knowing these children failed in so important scenery of their development.(AU)

En este trabajo trato investigar las acciones de la profesora que se caracterizan por violencia psicológica en el cotidiano escolar. La pesquisa, pautada en las directrices epistemológicas de la investigación cualitativa, fue realizada en una escuela pública que atiende niños de los años iniciales de la Escuela Primaria. Los participantes fueron cuatro niños y su profesora. Para la coleta de los dados, fueron utilizados los siguientes instrumentos: observación con recurso del diario de campo, videograbación y entrevista semi-estructurada. Las acciones identificadas como violencia psicológica fueron: rechazo, humillación e indiferencia. Observado que la escuela paso a ser objeto de un temor proveniente de vivencias marcadas por acciones de segregación, punición y falta de respeto a la condición de los estudiantes con dificultades de aprendizaje y, consecuentemente al saber de esos niños que fracasaban en ese importante escenario de su desenvolvimiento.(AU)

A violência psicológica na relação entre professor e aluno com dificuldades de aprendizagem / The psychological violence in the relationship between teacher and student with learning difficulties / La violencia psicológica en la relación entre profesor y estudiantes con dificultades de aprendizaje

Neste trabalho, buscou-se investigar as ações do professor que se caracterizam por violência psicológica no cotidiano escolar. A pesquisa, pautada nas diretrizes epistemológicas da investigação qualitativa, foi realizada em uma escola pública que atende crianças dos anos iniciais do Ensino Fundamental. Os participantes foram quatro crianças e sua professora. Para a coleta dos dados, foram utilizados os seguintes instrumentos: observação com recurso do diário de campo, videogravação e entrevista semiestruturada. As ações identificadas como violência psicológica foram: rejeição, humilhação e indiferença. Observou-se que a escola passou a ser objeto de um temor proveniente de vivências marcadas por ações de segregação, punição e desrespeito à condição dos alunos com dificuldades de aprendizagem e, consequentemente, ao saber dessas crianças que fracassavam nesse importante cenário de seu desenvolvimento.

This research aims to investigate the teacher actions that are characterized psychological violence in school routine. The research, based on epistemological guidelines of qualitative investigation, was realized in a public school that serves children in the early years of the Elementary School. The participants were four children and their teacher. In order to collect data, the following instruments were applied: observation with the use of field notes, video recording and a semi-structured interview. The actions identified as psychological violence were: rejection, humiliation and indifference. In this study, it was possible to notice that school became an object of fear coming from experiences marked by segregation, punishment and non-respect actions towards their conditions, and consequently, by knowing these children failed in so important scenery of their development.

En este trabajo trato investigar las acciones de la profesora que se caracterizan por violencia psicológica en el cotidiano escolar. La pesquisa, pautada en las directrices epistemológicas de la investigación cualitativa, fue realizada en una escuela pública que atiende niños de los años iniciales de la Escuela Primaria. Los participantes fueron cuatro niños y su profesora. Para la coleta de los dados, fueron utilizados los siguientes instrumentos: observación con recurso del diario de campo, videograbación y entrevista semi-estructurada. Las acciones identificadas como violencia psicológica fueron: rechazo, humillación e indiferencia. Observado que la escuela paso a ser objeto de un temor proveniente de vivencias marcadas por acciones de segregación, punición y falta de respeto a la condición de los estudiantes con dificultades de aprendizaje y, consecuentemente al saber de esos niños que fracasaban en ese importante escenario de su desenvolvimiento.