Whipple's disease: a fatal mimic

Whipple's Disease, a rare diagnosis caused by the slow-growing bacterium Tropheryma whipplei, most often presents with the classically described signs of malabsorption due to gastrointestinal colonization. However, it can also have signs and symptoms that clinically overlap with rheumatic diseases, potentially resulting in misdiagnosis. Furthermore, treatment with modern potent biologic immunosuppressive agents and classic disease modifying anti-rheumatic drugs (DMARDs) can lead to serious exacerbation of undiagnosed infections. We present the case of a middle-aged woman with long term complaints of arthalgias, who was diagnosed with seronegative rheumatoid arthritis and subsequently treated for almost 7 years with such immunosuppressive therapies. The patient's disease course included chronic diarrhea that abruptly intensified and culminated in fatal hypovolemic shock/sepsis. A diagnosis of WD was made by autopsy examination, wherein several organ systems were found to be heavily involved by Tropheryma whipplei organisms, and their identification was confirmed with histochemical and molecular evaluation. Notably, most bacterial organisms were located deeply in the submucosa/muscularis of affected organs, a practical reminder to practicing pathologists that challenges the classic histopathologic description of Whipple disease as an infiltration of predominantly lamina propria, and the potential for sampling bias in typically superficial endoscopic biopsies during routine procedures.

Bacteremia and sepsis by Arcanobacterium haemolyticum in a young immunocompetent patient / Bacteriemia y sepsis por Arcanobacterium haemolyticum en un paciente joven inmunocompetente

Abstract We report the case of a twenty-year-old immunocompetent male patient presenting to the emergency room with pharyngitis and fever. Blood cultures were drawn and Arcanobacterium haemolyticum (rough biotype) was recovered. The presence of the arcanolysin gene was investigated at the molecular level and the upstream region was amplified and sequenced in order to correlate it with the smooth or rough biotype. Although the isolate was susceptible to penicillin, vancomycin and gentamicin, empirical treatments first with amoxicillin/clavulanic acid (1g/12h) and then with ceftriaxone (1g/12h) failed and the infection evolved to sepsis. Finally, treatment with vancomycin (1 g/12 h) plus piperacillin/tazobactam (4.5g/8h) was effective. Lemierre's syndrome was ruled out. To the best of our knowledge, this is the first case of bacteremia by A. haemolyticum reported in Argentina.

Resumen Se describe el caso de un paciente varón inmunocompetente de veinte anos de edad que se presentó en la sala de emergencias con faringitis y fiebre. Se extrajeron muestras para realizar hemocultivos y se recuperó Arcanobacterium haemolyticum (biotipo rugoso). Se investigó la presencia del gen de la arcanolisina por un método molecular, y se amplificó y Faringitis; secuenció la región upstream de dicho gen para determinar su correlación con los biotipos lisos Bacteriemia; o rugosos. Aunque el aislamiento fue sensible a la penicilina, la vancomicina y la gentamicina, Sepsis; los tratamientos empíricos primero con amoxicilina/ácido clavulánico (1 g/12 h) y luego con Síndrome de Lemierre ceftriaxona (1 g/12 h) no fueron efectivos, y la infección evolucionó a sepsis. Finalmente, el tratamiento con vancomicina (1 g/12 h) más piperacilina/tazobactam (4,5g/8h) fue efectivo. Se descartó la presencia del síndrome de Lemierre. Según nuestro conocimiento, este es el primer caso de bacteriemia por A. haemolyticum reportado en Argentina.

Rhodococcus equi, primer reporte de un caso de enfermedad diseminada en el Perú / Rhodococcus equi, first case report of disseminated disease in Peru

Resumen Presentamos el caso de un paciente con infección por virus de inmunodeficiencia humana (VIH) con recuento de LTCD4+ 49 céls/mm3, que consultó por un cuadro de siete meses de baja de peso, dolor abdominal, diarrea crónica y lesiones cutáneas gomosas. El mielocultivo y hemocultivos fueron positivos para Rhodococcus equi. Además, se observaron lesiones histológicas en piel e intestino compatibles con este agente como malacoplaquia, reacción granulomatosa y cuerpos de Michaelis-Gutmann. Se descartó compromiso pulmonar mediante tomografía de tórax. Recibió terapia antibacteriana combinada con claritromicina, imipenem y vancomicina. A pesar del tratamiento, el paciente evolucionó desfavorablemente y falleció.

Abstract We present the case of a patient with human immunodeficiency virus (HIV) with a LTCD4 + 49 cells/mm3, who was admitted due to a seven-month period of weight loss, abdominal pain, chronic diarrhea and rubbery skin lesions. Myeloculture and blood cultures were positive for Rhodococcus equi. In addition, histological lesions in the skin and intestine compatible with this agent were observed, such as malacoplachy, granulomatous reaction and Michaelis-Gutmann bodies. Pulmonary involvement was ruled out by chest tomography. The patient received antibacterial therapy combined with clarithromycin, imipenem, and vancomycin. Despite the treatment, the patient evolved unfavorably and died.

Clinical and pathological findings of Rhodococcus equi infection in foals / Achados clínicos e patológicos da infecção por Rhodococcus equi em potros

Infection by Rhodococcus equi is considered one of the major health concerns for foals worldwide. In order to better understand the disease's clinical and pathological features, we studied twenty cases of natural infection by R. equi in foals. These cases are characterized according to their clinical and pathological findings and immunohistochemical aspects. Necropsy, histologic examination, bacterial culture, R. equi and Pneumocystis spp. immunohistochemistry were performed. The foals had a mean age of 60 days and presented respiratory signs (11/20), hyperthermia (10/20), articular swelling (6/20), prostration (4/20), locomotor impairment (3/20) and diarrhea (3/20), among others. The main lesions were of pyogranulomatous pneumonia, seen in 19 foals, accompanied or not by pyogranulomatous lymphadenitis (10/20) and pyogranulomatous and ulcerative enterocolitis (5/20). Pyogranulomatous osteomyelitis was seen in 3 foals, one of which did not have pulmonary involvement. There was lymphoplasmacytic (4/20), lymphoplasmacytic and neutrophilic (1/20) or pyogranulomatous arthritis (1/20), affecting multiple or singular joints. Immunohistochemistry revealed to be a valuable tool for the detection of R. equi, confirming the diagnosis in all cases. Furthermore, pulmonary immunostaining for Pneumocystis spp. demonstrates that a coinfection with R. equi and this fungal agent is a common event in foals, seen in 13 cases.(AU)

Infecção por Rhodococcus equi é considerado um dos maiores problemas sanitários para potros em todo o mundo. Para melhor compreender a apresentação clínica e patológica da enfermidade, foram avaliados vinte casos de infecção natural por R. equi em potros. Os casos são caracterizados de acordo com seus achados clínicos e patológicos e aspectos imuno-histoquímicos. Foram realizados exames de necropsia, histologia, bacteriologia e imuno-histoquímica para R. equi e Pneumocystis spp. Os potros tinham idade media de 60 dias e apresentaram sinais respiratórios (11/20), hipertermia (10/20), aumento de volume articular (6/20), prostração (4/20), distúrbios locomotores (3/20) e diarreia (3/20), entre outros. As lesões mais importantes eram pneumonia piogranulomatosa, vista em 19 potros, acompanhada ou não por linfadenite piogranulomatosa (10/20) e enterocolite ulcerativa (5/20). Osteomielite piogranulomatosa foi constatada em três potros, um dos quais não apresentava envolvimento pulmonar. Artrites afetando uma ou múltiplas articulações eram caracterizadas por infiltrado linfoplasmocítico (4/20), linfoplasmocítico e neutrofílico (1/20) e piogranulomatoso (1/20). A imuno-histoquímica demonstrou ser uma ferramenta valiosa na detecção de R. equi, permitindo confirmar o diagnóstico em todos os casos avaliados. Além disso, a imuno-histoquímica para Pneumocystis spp. demonstra que a coinfecção por R. equi e o agente fúngico é um evento frequente em potros, constatado em 13 casos.(AU)

Rhodococcus equi como causa de neumonía en el síndrome de inmunodeficiencia adquirida / Rhodococcus equi as a cause of pneumonia in the acquired immunodeficiency syndrome

RESUMEN Rhodococcus equi es un microorganismo emergente asociado a infecciones oportunistas en individuos inmunocomprometidos, especialmente en pacientes con infección por virus de inmunodeficiencia humana. Se desarrolló una búsqueda en la Biblioteca Virtual de Infomed, fueron revisados 215 trabajos científicos sin limitación de año y país, seleccionándose 55. El rhodococcus es un patógeno intracelular capaz de crecer y persistir dentro de los macrófagos que expresan en su superficie el receptor Mac-1 (CD11b/CC18), y posteriormente destruirlos. La manifestación clínica más frecuente es la neumonía de comienzo insidioso y en su evolución natural tiende a la cavitación. El diagnóstico se realiza mediante su identificación en cultivo de muestras de tejido afectado. Los hemocultivos son positivos en el 50% de los inmunodeprimidos En el diagnóstico radiográfico, los hallazgos más comunes referidos en la literatura científica son el compromiso lobar y la cavitación. La particular evolución que experimentan los pacientes con síndrome de inmunodeficiencia adquirida y neumonía por R. equi, obliga a implementar esquemas terapéuticos basados en antimicrobianos con actividad bactericida intracelular, administrados inicialmente por vía intravenosa y durante un tiempo prolongado e incluso la cirugía. La infección por R. equi es una complicación infrecuente en pacientes con síndrome de inmunodeficiencia adquirida, pero con una elevada tasa de letalidad, por lo que debe ser sospechado en pacientes que presenten una infección respiratoria de curso inhabitual. El diagnóstico precoz, el tratamiento antimicrobiano combinado y prolongado y el inicio de la Terapia Antiretroviral de Gran Actividad en forma temprana pueden mejorar la evolución y el pronóstico de estos pacientes.

ABSTRACT Rhodococcus equi is an emergent microorganism associated to opportunistic infections in immune-compromised individuals, especially in patients infected with the human immunodeficiency virus. A search was carried out in the Virtual Library of Infomed; 215 scientific works were reviewed without limits of publication years and countries. From them, 55 were chosen. Rhodococcus equi is an intracellular pathogen that is able to grow and live inside the macrophages expressing the Mac-1 (CD11b/CC18) receptor in the surface and destroying them later. The most common clinical manifestation is insidious beginning pneumonia, tending to cavitation in its natural evolution. The diagnosis is made through identification in culture of affected tissues samples. Blood cultures are positive in 50 % of the immune-depressed people. At the radiographic diagnosis, the most common findings referred to in the scientific literature are lobar compromise and cavitation. The particular evolution of the patients with acquired immune-deficiency syndrome and pneumonia due to Rhodococcus equi forces the implementation of therapeutic schemes based on antimicrobials with intracellular bactericide activity, administered firstly intravenously and during a long time, and even to perform the surgery. Rhodococcus equi infection is an infrequent complication in patients with acquired immunodeficiency syndrome, but having a high lethality rate, therefore it should be suspected in patients presenting a respiratory infection of unusual curse. The precocious diagnosis, combined and prolonged antimicrobial treatment and early beginning of the highly active antiretroviral therapy could improve the evolution and prognosis of these patients.

Endocarditis por Rothia aeria / Rothia aeria endocarditis. case report

Resumen Paciente de sexo femenino de 65 años, con antecedentes de hipertensión arterial crónica, resistencia a la insulina, histerectomía total y fractura tibioperonea antigua, es hospitalizada por cuadro febril, sin foco, de 2 meses de evolución, con sospecha de endocarditis por parámetros inflamatorios elevados y soplo diastólico en foco aórtico 2/6. Se estudia con ecocardiograma, transtorácico (ETT) y transesofágico (ETE), que muestra vegetación en velo aórtico coronario izquierdo de 9 mm por 7 mm e insuficiencia aórtica leve, motivo por el cual se toma hemocultivo resultando positivo para Rothia aeria. La paciente evoluciona con embolia de riñón derecho y bazo, y posteriormente, con hemorragia subaracnoidea. Inicia tratamiento antibiótico con ampicilina, vancomicina y gentamicina, con lo cual presenta una evolución satisfactoria y es dada de alta luego de 28 días de hospitalización. Al revisar la literatura, se puede llegar a la conclusión de que la endocarditis por Rothia es extremadamente infrecuente y que, en cuanto al cuadro clínico, tiene tendencia a una forma de presentación subaguda, con presencia de vegetaciones grandes mayores a 10mm y un alto grado de complicaciones neurológicas.

Abstract A 65-year-old female patient, with a history of chronic hypertension, insulin resistance, total histerectomy, and tibioperoneal fracture, is hospitalized for fever of unknown etiology. Basterial endocarditis was suspected due to elevated inflammatory parameters and a 2/6 diastolic murmur present in the aortic focus. Transthoracic and transesophageal echocardiography, showed a 9 mm by 7 mm vegetation in the left coronary aortic leaflet of and mild aortic insufficiency, Blood cultures were positive for Rothia aeria. She developed embolism of the right kidney and spleen, and subsequently, a subarachnoid hemorrhage. Antibiotic therapy was initiated with ampicillin, vancomycin and gentamicin, with a satisfactory evolution being discharged after 28 days of hospitalization. When reviewing the literature, it can be concluded that Rothia endocarditis is extremely rare and that, tends to have a subacute presentation with large vegetations, larger than 10 mm, and a high incidence of neurological complications.

Bacteriemia causada por Rothia mucilaginosa después de neumonía en un paciente con trasplante de células progenitoras hematopoyéticas / Bacteremia caused by Rothia mucilaginosa after pneumonia, in a patient with hematopoietic stem cell transplantation

La Rothia mucilaginosa forma parte de la flora normal y no suele causar una enfermedad invasiva. Los pacientes inmunodeprimidos tienen mayor riesgo de infección grave. En este artículo, presentamos el caso de un paciente con neuroblastoma recidivante hospitalizado por neumonía. Después de la mejoría clínica, los síntomas respiratorios del paciente empeoraron de nuevo. En el hemocultivo, se aisló la bacteria Rothia mucilaginosa. El empeoramiento de los síntomas respiratorios puede explicarse por la diseminación hematopoyética de la bacteria. Se le administró tratamiento con meropenem y vancomicina durante 14 días, cuyos resultados fueron satisfactorios. Se sabe que esta bacteria poco frecuente tiene una alta tasa de mortalidad si no se trata de forma adecuada, y debe considerarse especialmente en los pacientes inmunodeprimidos con neoplasias malignas.

Rothia muciloginosa is a member of normal flora and rarely causes invasive disease. Immunosupressed patients have increased risk for severe infection. Here, we report a male patient with relapsed neuroblastoma hospitalized for pneumonia. After clinical improvement, patient's respiratory symptoms worsened again. Rothia muciloginosa was isolated from blood culture. The worsening of respiratory symptoms can be explained by hematogenous spread of bacteria. He was successfully treated with meropenem and vancomycin for 14 days. This rarely seen bacterium is known to have high mortality rates unless treated appropriately and should be considered especially in patients with malignancy due to their immunsupressed situation.

The first reported catheter-related Brevibacterium casei bloodstream infection in a child with acute leukemia and review of the literature

Brevibacterium spp. are catalase-positive, non-spore-forming, non motile, aerobic Gram- positive rods that were considered apathogenic until a few reports of infections in immunocompromised patients had been published. To the best of our knowledge, this is the first report of B. casei catheter-related bloodstream infection in a child with acute leukemia. We aim to enhance the awareness of pediatric hematology and infectious disease specialists about this pathogen and review of the literature.

Infección por Rhodococcus equi en pacientes con SIDA: Análisis retrospectivo de 13 pacientes en Argentina / Rhodococcus equi infection in AIDS patients: Retrospective analysis of 13 patients in Argentina

Introduction: Rhodococcus equi is a gram positive coccoid rod that causes pulmonary infections in immunosuppressed patients. Methods: We retrospectively analyzed epidemiological, clinical, microbiological, radiological, and immunological features as well as the outcomes of 13 AIDS patients with R. equi infection. Results: Between January 1994 and December 2012, 13 patients attending the AIDS department of the Infectious Diseases reference hospital in Buenos Aires were diagnosed with R. equi infection. All were men, the median age was 27 years. At the time of diagnosis, the median of CD4+ T cell counts was 11 cells/μl Twelve patients presented pulmonary disease with isolation of the microorganism from sputum or bronchoalveolar lavage; in the other patient the diagnosis was postmortem with positive culture of cerebrospinal fluid. The most frequent clinical manifestations were fever, haemoptysis, and weight loss. The predominant radiological finding was lobe consolidation with cavitation. Nine patients died after a median survival of 5.5 months. In all of them, cultures persisted positive until the last admission. The other 4 patients did continue clinical follow-ups. Conclusion: The insidious course of R. equi disease and the difficulties in the isolation of the microorganism contribute to the delay in the diagnosis and to the high mortality rate of this opportunistic infection.

Introducción: Rhodococcus equi es un cocobacilo grampositivo que provoca compromiso pulmonar en pacientes inmunodeprimidos. Métodos: En el presente trabajo se analizaron de manera retrospectiva los hallazgos epidemiológicos, clínicos, microbiológicos, imagenológicos, inmunológicos y la evolución de 13 pacientes con SIDA y enfermedad por R. equi. Resultados: Entre enero de 1994 y diciembre de 2012, 13 pacientes internados en la División de VIH/SIDA del hospital de referencia para Enfermedades Infecciosas de la ciudad de Buenos Aires egresaron con diagnóstico de enfermedad por R. equi. Todos eran varones y la mediana de edad fue 27 años. La mediana de linfocitos T CD4+ fue de 11 céls/μl Doce pacientes presentaron enfermedad pulmonar con aislamiento del microorganismo del esputo o del lavado bronco-alveolar; en el restante se recibió post mortem el cultivo positivo de líquido cefalorraquídeo. Las manifestaciones clínicas más frecuentes fueron fiebre, hemoptisis y pérdida de peso. La imagen radiológica predominante fue la consolidación con cavitación. Nueve pacientes fallecieron, con una mediana de supervivencia de 5,5 meses. En todos ellos el cultivo persistió positivo hasta la última internación. Los cuatro restantes abandonaron los controles y no pudieron ser evaluados en el tiempo. Conclusión: El curso insidioso de la enfermedad por R. equi y las dificultades en la identificación del microorganismo, contribuyen al retardo en el diagnóstico y a la elevada mortalidad de esta infección oportunista en esta población de pacientes.

Micetoma actinomicótico por Actinomadura madurae / Actinomycotic mycetoma due to Actinomadura madurae

Mycetoma is a chronic, granulomatous, subcutaneous, inflammatory lesion caused by true fungi (eumycetoma) or filamentous bacteria (actinomycetoma). Mycetoma commonly affects young people between 20 and 40 years old. The most common affected site is the foot. The characteristic clinical triad is tumefaction, draining sinuses and discharging grains. We report a healthy 31-year-old male, with a 6-year history of a progressive inflammatory tumor associated with sinus tracts and granules on his left sole. Actinomycetoma was suspected. The clinical diagnosis was confirmed by microbiological and histopathological study. Polymerase chain reaction and DNA sequencing identified Actinomadura madurae. To our knowledge, this is the second case of mycetoma reported in Chile. Our report emphasizes the need to consider this diagnosis in patients with chronic granulomatous disease associated with sinus tracts, fistulas and grains.

El micetoma es una lesión subcutánea inflamatoria granulomatosa crónica causada por hongos (eumiceto-ma) o bacterias filamentosas (actinomicetoma). Afecta a adultos entre los 20-40 años y el sitio más comúnmente afectado es el pie. La tríada característica es un aumento de volumen del tejido afectado, con trayectos sinuosos y gránulos excretados. Comunicamos el caso de un hombre de 31 años, sano, con una historia de 6 años de un tumor asociado a trayectos sinuosos y gránulos en la región plantar izquierda. El diagnóstico clínico de micetoma fue confirmado mediante estudio microbiológico e histológico. La amplificación y secuenciación del AlDN bacteriano identificó Actinomadura madurae. Es el segundo caso de actinomicetoma reportado en Chile. Consideramos importante considerar este diagnóstico en pacientes con enfermedad granulomatosa crónica asociado a trayectos sinuosos, fístulas y gránulos.

Propuesta de un método para evaluar resistencia genética en Schizolobium parahybum (Vell) Blake (Pachaco) frente a Ceratocystis spp: evidencias preliminares de resistencia en Ecuador / Proposal for a method to evaluate genetic resistance in Schizolobium parahybum (Vell) Blake (Pachaco) against ceratocystis spp: preliminary evidence of resistance in Ecuador

Se condujo una investigación en el Trópico Húmedo Ecuatoriano (THE), dirigida a encontrar un método eficiente para evaluar la resistencia genética en árboles de Schizolobium parahybum (pachaco) frente al complejo Ceratocystis: C. paradoxa, C. moniliformis, y C. fimbriata. Se estudiaron dos métodos basados en el empleo de dos tipos de tejidos vegetales: a) tejidos de ramas laterales, y 2) tejidos de corteza fustal. Se emplearon cinco rodales de pachaco, tres de los cuales son considerados de introducción original de la especie forestal al THE desde la amazonía, y dos que son descendientes de los primeros. Los resultados permitieron definir que el método basado en tejidos de corteza fustal, fue el más eficiente y logísticamente viable. La metodología final aplicada, consistió en extraer corteza desde árboles adultos, reducirla a secciones pequeñas de 1,5 cm x 4 cm (6 cm2) y mantenerlas en una cámara húmeda durante 96 horas. Una vez distribuidas las secciones de corteza, se inocularon con 0,45mL-1 de una suspensión calibrada a razón de 30.000 unidades de infección (ascosporas, conidias y micelio). Para la evaluación, se empleó una escala arbitraria de 0 a 4 que permitió estimar el crecimiento de micelio y número de peritecios para cada uno de los hongos. Esta metodología permitió discriminar entre árboles: resistentes (0,0 a 1,0), moderadamente resistentes (1,1 a 2,0), susceptibles (2,1 a 3,0), y muy susceptibles (3,1 a 4,0), lo cual la hace viable para futuros trabajos de selección de individuos y mejoramiento genético de la especie.

A research was conducted in the Humid Tropics of Ecuador (THE), aimed at finding an efficient method to evaluate genetic resistance in Schizolobium parahybum (Pachaco) trees against Ceratocystis complex: C. paradoxa, C. moniliformis and C. fimbriata. We studied two methods based on the use of two types of plant tissues: a) tissue of lateral branches, and 2) stem bark tissues. Five forest of pachaco were used, three of which are considered original introduction of forestry specie to THE from the Amazon, and two who are descendants of the former. The results allowed to define the method based on stem bark tissue was the most efficient and logistically feasible. The final methodology applied, consisted in to remove bark from mature trees, reducing it to small sections of 1.5 cm x 4 cm (6cm2) and maintained in a moist chamber for 96 hours. Once distributed the sections of bark, were inoculated with 0.45mL-1 of a suspension calibrated at a rate of 30.000 units of infection (ascospores, conidia and mycelium). For evaluation, we used an arbitrary scale from 0 to 4, which allowed to estimate the growth of mycelium and perithecia number for each of the fungi. This methodology allows us to discriminate between trees: resistant (0.0 to 1.0), moderately resistant (1.1 to 2.0), susceptible (2.1 to 3.0), and very susceptible (3.1 to 4 , 0), which makes it viable for future selection of individuals and breeding of the forest species.

Minimicetoma por Nocordia brasiliensis: un caso infantil en Veracruz / Minimicetoma by Nocordia brasiliensis: a children's event in Veracruz

El término minimicetoma designa a los micetomas de pequeño tamaño, con morfología atípica y superficial, causados por Nocardia brasiliensis. Se comunica un paciente de sexo masculino, de 10 años de edad, originario y residente de Xalapa (Veracruz), que presentó un minimicetoma por N. brasiliensis, confirmado por estudio micológico e histopatológico. El tratamiento con penicilina procaínica durante 10 días, en conjunto con trimetoprima/sulfametoxazol y diaminodifenisulfona por 6 meses, tuvo resultados satisfactorios.

Minimycetoma is an atypical small mycetoma usually caused by Nocardia brasiliensis. We report a 10-year-old male from Xalapa (Veracruz) with a minimycetoma due to N. brasiliensis confirmed by mycological and histopathological studies. Simultaneous treatment with procainic penicillin for ten days and trimethoprim/sulfamethoxazol and dapsone showed satisfactory results after 6 months.

Rhodococcus equi infection after reduction mammaplasty in an immunocompetent patient / Infección por Rhodococcus equi luego de cirugía de reducción mamaria en huésped inmunocompetente

The majority of infections caused by R. equi occur in hosts with some degree of cell-mediated immunodeficiency. Immunocompetent individuals are infrequently affected and usually present with localized disease. Infections of the skin or related structures are uncommon and are usually related to environmental contamination. The microbiology laboratory plays a key role in the identification of the organism since it may be mistaken for common skin flora. We describe a 31 year-old woman without medical problems who presented nine weeks after breast reduction with right breast cellulitis and purulent drainage from the surgical wound. She underwent incision and drainage, and cultures of the wound yielded Rhodococcus equi. The patient completed six weeks of antimicrobial therapy with moxifloxacin and rifampin with complete resolution.

La mayoría de las infecciones causadas por Rhodococcus equi ocurren en huéspedes con algún grado de inmunodeficiencia celular. Los individuos inmunocompetentes son afectados con baja frecuencia y suelen presentarse con enfermedad localizada. Las infecciones de la piel o partes blandas son poco frecuentes y están usualmente relacionadas con contaminación ambiental. El laboratorio de microbiología juega un papel clave en la identificación del organismo, ya que este puede confundirse con flora normal de la piel. Se describe una mujer de 31 años sin problemas médicos que consultó nueve semanas después de haber sido sometida a cirugía de reducción mamaria, con celulitis del seno derecho y drenaje purulento de la herida quirúrgica. Se practicó incisión y drenaje quirúrgico y los cultivos de la herida demostraron R. equi. La paciente recibió seis semanas de tratamiento antimicrobiano con moxifloxacina y rifampicina demostrando resolución completa.

Neumonía por Rhodococcus equi: hallazgos clínico-radiológicos en ocho pacientes con sida / Pneumonia caused by Rhodococcus equi: clinical and radiological findings in 8 AIDS patients

INTRODUCIÓN: el Rhodococcus equi, es una bacteria que pertenece al orden de los Actinomicetales. Su presentación en el hombre es poco frecuente. Es con la epidemia del VIH/sida que se han ido incrementando los casos. En los humanos el órgano principal de esta infección es el pulmón, provoca una neumonía que se caracteriza por una evolución clínica y radiológica lenta. OBJETIVO: describir las alteraciones radiográficas iniciales causadas por la infección por R. equi en 8 pacientes con sida, su evolución radiológica y la presentación clínica e inmunológica. MÉTODOS: se realizó un estudio retrospectivo descriptivo de las imágenes radiológicas pulmonares observadas en el período entre agosto de 1994 y enero de 2008 en pacientes con síndrome de inmunodeficiencia humana adquirida (sida) e infección respiratoria causada por Rhodococcus equi. RESULTADOS: el cuadro clínico se caracterizó por la fiebre elevada hasta 39 °C, tos con expectoración y disnea. La presentación radiológica más frecuente fue la opacidad homogénea en 62,5 por ciento de los casos, predominó la afectación pulmonar en los lóbulos inferiores. La evolución radiológica se caracterizó por la opacidad con cavitación en su interior en 4 casos, fibrosis en 4 casos y 1 tuvo resolución total de las lesiones. El conteo de linfocitos T CD4 + estuvo disminuido en los 8 pacientes. La evolución de los pacientes osciló entre los 2 y 33 meses. CONCLUSIONES: el diagnóstico de neumonía por R. equi debe ser considerado, en aquellos pacientes portadores de VIH/sida con estado inmunológico comprometido y proceso respiratorio con manifestación radiológica de consolidación pulmonar con evolución hacia la cavitación, con evolución clínica y radiológica tórpida y prolongada.

INTRODUCTION: the Rhodococcus equi is one bacterium of the order Actinomycetales. It rarely appears in humans, but the HIV/AIDS epidemic has increased the number of cases and the main affected organ is the lung. It causes pneumonia characterized by a slow clinical and radiological progression. OBJECTIVE: to describe the initial radiological alterations from R. equi infection in 8 AIDS patients, the radiological evolution and the clinical and immunological presentation. METHODS: a retrospective descriptive study of radiological pulmonary images from AIDS patients with respiratory infection due to Rhodococcus equi was conducted. RESULTS: these patients presented with high fever (39ºC), cough with expectoration and shortness of breath. Homogeneous opacity was the most frequent radiological presentation (62,5 percent of cases), located predominantly in the lower lobules. The radiological evolution was characterized by opacity with inner cavitation in 4 cases, fibrosis in 4 cases, and one case showed total recovery of lesions. The CD4+ T-cell count was low in all the patients. The evolution ranged from 2 to 33 months. CONCLUSIONS: the R equi pneumonia diagnosis should be borne in mind when dealing with HIV/AIDS patients with compromised immunological condition and breathing process with radiological manifestation of pulmonary consolidation evolving into cavitation, and torpid and prolonged clinical and radiological evolution.

Dermatofilosis humana y animal. Presentación de un caso atípico y revisión de la literatura / Human and animal dermatophilosis. An unusual case report and review of the literature

La dermatofilosis es una infección causada por una bacteria Gram positiva perteneciente al orden de los Actinomycetales, llamada Dermatophilus congolensis. Se presenta como una dermatosis de carácter agudo, subagudo o crónico que afecta preferentemente al ganado pero también a una amplia variedad de animales domésticos y salvajes y al hombre. Tiene distribución universal, pero con mayor prevalencia en climas húmedos, tropicales y subtropicales. Es considerada una zoonosis menor que puede causar grandes perjuicios económicos en la industria del ganado y el cuero. Se realiza una revisión del tema junto con la presentación de un caso clínico sumamente atípico.

Dermatophilosis is an acute, subacute or chronic skin disease affecting a wide range of species of animals and man. It is caused by a Gram (+) bacteria of the order of the Actinomycetales named Dermatophilus congolensis. Presenting as an acute, subacute or chronic dermatosis affecting primarily cattle, but a wide variety of domestic and wild animals, and humans, as well. It is distributed worldwide but more prevalent in the humid tropical and subtropic areas. It is essential to emphasize the importance of this disease in livestock industry and leather production. The disease is reviewed and an unusual case is reported.

Rhodococcus equi isolation from sputum of patients with suspected tuberculosis

Rhodococcus equi has emerged as an opportunistic pathogen associated with pulmonary, invasive or systemic infections in immunocompromised patients. We report the identification of 51 R. equi isolates found in sputum samples of 546 individuals suspected to have pulmonary tuberculosis in two Public Health Hospital Units in Brazil. The epidemiology of R. equi infection as well as the phenotypic identification and drug susceptibility profile of isolates are described in this paper.

Prevalência de gardnerella e mobiluncus em exames de colpocitologia em Tomé-Açu, Pará / Prevalence of gardnerella and mobiluncus in vaginal cytology examinations in Tome-Açu-Pará

Objetivo: a Gardnerella vaginalis, isoladamente ou associada ao Mobiluncus sp., é um dos principais agentes causadores de infecções em mulheres em idade reprodutiva, seja pela falta de hábitos de higiene adequados, número de parceiros sexuais ou desequilíbrios da microflora vaginal. Assim, buscou-se verificar a prevalência de G vaginalis e/ou Mobiluncus sp., associadas às condições sócio-culturais em mulheres atendidas no Hospital de Quatro Bocas de Tomé-Açu - Pará, através de exame preventivo de câncer de colo do útero. Método e Resultados: analisados materiais cervico-vaginais e informações sócio-culturais de 156 mulheres, com faixas etárias de 17 e 73 anos, período de outubro de 2003 a julho de 2004, para o diagnóstico de prevenção de câncer ginecológico. Todas as amostras foram processadas de modo convencional e analisadas no Laboratório de Citopatologia da Universidade Federal do Pará por três observadores (estudo cego). Como resultados verificou-se que das 156 mulheres pesquisadas , a maior prevalência estava associada à G vaginalis (48,15%), faixa etária de 21 a 30 anos, ou pela associação G vaginalis e Mobiluncus sp (36,36%). Em relação ao grau de escolaridade e ocupação, a maior prevalência ocorreu em mulheres com r grau incompleto (47,37%), com atividades do lar (21,05%) e comércio (22,81%). Conclusões: estes dados reforçam pesquisas que relacionam a prevalência de G vaginalis e/ou Mobiluncus sp, em mulheres com vida sexual e menor grau de escolaridade.

Objective: gardnerella vaginalis, alone or associated to Mobiluncus sp., is one of the main etiological agents ofinfection in women of reproductive age, due to lack of appropriate hygiene habits, number of sexual partners ar imbalance of the vaginal microbiota. Therefore, our objective was to assess the prevalence of bacterial vaginosis caused by G vaginalis and/or Mobiluncus sp., and associate this to the sociocultural conditions in women attended ai Hospital de Quatro Bocas in Tomé-Açu - Pará - Brazil, through gynecological cancer screening. Methods and Results: cervico-vaginal smears and socio-cultural information of 156 women aged 17 to 73 were analyzedfor diagnosis and prevention of gynecological cancer from October 2003 to July 2004. Ali samples were processed in the conventional way and analyzed at Universidade Federal do Pará's Laboratory of Cytopathology by three observers (a blind study). Among ali 156 women, the largest prevalence was associated to G vaginalis (48,15%) in 21 to 30- year-old women, ar to the association of G vaginalis and Mobiluncus sp (36,36%). As for the occupation and instruction degree, the infection was most prevalent in women with incomplete primary school (47,37%), housewives (21,05%) and market workers (22,81 %). Conclusions: our data reaffirm previous researches that relate the prevalence ofbacterial vaginosis caused by G vaginalis and /or Mobiluncus sp. to low instruction degree in sexually active women.

Doença de Whipple / Whipple's disease

Os autores apresentam uma revisão sobre a doença de Whipple, uma rara enfermidade causada pelo bacilo Gram-positivo Tropheryma whipplei, que cursa, principalmente, com manifestações gastrintestinais - entre as quais síndrome de má absorção -, musculoesqueléticas, com artralgia, envolvimento do sistema nervoso central e febre baixa, podendo ser fatal se não tratada. O diagnóstico é confirmado pela biópsia do duodeno ou de outros órgãos envolvidos e(ou) pela detecção do agente pela utilização da reação de polimerase em cadeia (PCR). A terapia consiste em antibioticoterapia, devendo ser buscada a confirmação da cura com nova biópsia.