Infecciones fúngicas invasivas en niños hospitalizados en un centro de referencia de Uruguay / Invasive fungal infections in children hospitalized at a pediatric reference hospital in Uruguay / Infecções fúngicas invasivas em crianças internadas em um centro hospitalar de referência no Uruguai

Introducción: las infecciones fúngicas invasivas (IFI) son un problema de salud en creciente aumento. Objetivo: describir las características epidemiológicas, microbiológicas y clínicas de los menores de 15 años con IFI hospitalizados en el Hospital Pediátrico, Centro Hospitalario Pereira Rossell entre 2010- 2019. Metodología: estudio retrospectivo, mediante revisión de historias clínicas. Variables: edad, sexo, comorbilidades, factores de riesgo, clínica, patógenos, tratamiento y evolución. Resultados: se registraron 26 casos de IFI en 23 niños. La mediana de edad fue 8 años, de sexo femenino 17, con comorbilidades 17: infección por VIH 5, enfermedad hematooncológica 4. Todos presentaban factores de riesgo para IFI. Las manifestaciones clínicas de sospecha fueron: fiebre en 19, síntomas neurológicos 11, respiratorios 9, gastrointestinales 6, urinarios 2, sepsis/shock en 3. Los agentes identificados fueron: Candida spp en 14, Cryptococcus neoformans complex 8 y Aspergillus fumigatus complex 4. Tratamiento: se indicó fluconazol en 15, asociado a anfotericina B 11. Todas las infecciones por candida fueron sensibles a los azoles. Fallecieron 7 niños, la mediana de edad fue 1 año. En 4 se identificó Candida spp, Aspergillus fumigatus complex 2 y Cryptococcus neoformans complex 1. Conclusiones: las IFI son poco frecuentes, afectan en su mayoría a niños inmunocomprometidos asociando elevada mortalidad. El diagnóstico requiere alto índice de sospecha. Candida spp y Cryptococcus spp fueron los agentes más involucrados. El inicio precoz del tratamiento acorde a la susceptibilidad disponible se asocia a menor mortalidad.

Summary: Introduction: invasive fungal infections (IFI) are an increasing health problem. Objective: describe the epidemiological, microbiological and clinical characteristics of children under 15 years of age with IFI hospitalized at the Pereira Rossell Hospital Center between 2010-2019. Methodology: retrospective study, review of medical records. Variables: age, sex, comorbidities, risk factors, symptoms, pathogens, treatment and evolution. Results: 26 cases of IFI were recorded involving 23 children. Median age 8 years, female 17, comorbidities 17, HIV infection 5, hematological-oncological disease 4. All with risk factors. Suspicion symptoms: fever 19, neurological symptoms 11, respiratory 9, gastrointestinal 6, urinary 2, sepsis / shock 3. Identified agents: Candida spp 14, Cryptococcus neoformans complex 8 and Aspergillus fumigatus complex 4. Treatment: fluconazole 15, associated with amphotericin B 11. All candida infections were sensitive to azoles. 7 died, median age 1 year. In 4, Candida spp was isolated, Aspergillus fumigatus complex in 2 and Cryptococcus neoformans complex in 1. Conclusions: IFI are rare, mostly affecting immunocompromised children, associated with high mortality. The diagnosis requires a high index of suspicion. Candida spp and Cryptococcus spp were the most involved agents. Early treatment according to available susceptibility is associated with lower mortality.

Introdução: as infecções fúngicas invasivas (IFI) são um problema de saúde crescente. Objetivo: descrever as características epidemiológicas, microbiológicas e clínicas de crianças menores de 15 anos com IFI internadas no Centro Hospitalar Pereira Rossell entre 2010 e 2019. Metodologia: estudo retrospectivo, revisão de prontuários. Variáveis: idade, sexo, comorbidades, fatores de risco, sintomas, patógenos, tratamento e evolução. Resultados: foram registrados 26 casos de IFI em 23 crianças. Idade mediana 8 anos, sexo feminino 17, comorbidades 17, infecção por HIV 5, doença hemato-oncológica 4. Todos com fatores de risco. Suspeita clínica: febre 19, sintomas neurológicos 11, respiratórios 9, gastrointestinais 6, urinários 2, sepse/choque 3. Agentes identificados: Candida spp 14, Cryptococcus neoformans complexo 8 e Aspergillus fumigatus complexo 4. Tratamento: fluconazol 15, associado à anfotericina B 11. Todas as infecções por cândida foram sensíveis aos azóis. 7 morreram, idade média de 1 ano. Em 4 das crianças Cândida spp foi isolada, Aspergillus fumigatus complexo em 2 e Cryptococcus neoformans complexo em 1. Conclusões: IFIs são raras, afetando principalmente crianças imunocomprometidas, associadas a alta mortalidade. O diagnóstico requer alto índice de suspeita. Cândida spp e Cryptococcus spp são os agentes mais envolvidos. O tratamento precoce de acordo com a suscetibilidade disponível está associado a menor mortalidade.

Perfiles de expresión de los genes ERG11, MDR1 y AFR1 en Cryptococcus neoformans var. grubii aislados de pacientes con HIV / Gene expression profiles of ERG11, MDR1 y AFR1 in Cryptococcus neoformans var. grubbi isolated from HIV patients

Introducción. El fluconazol es el antifúngico más utilizado para la prevención y el tratamiento de infecciones causadas por el género Cryptococcus, agente etiológico de la criptococosis. La resistencia al fluconazol en los aislamientos de Cryptoccocus neoformans puede hacer fracasar el tratamiento y generar recaídas de la infección. Objetivo. Evaluar los perfiles de expresión de los genes AFR1, MDR1 y ERG11 en aislamientos clínicos de C. neoformans var. grubii, durante la respuesta in vitro a la inducción con fluconazol. Materiales y métodos. Se estudiaron 14 aislamientos de C. neoformans var. grubii provenientes de pacientes con HIV, de los cuales 6 eran sensibles al fluconaol y 8 presentaban sensibilidad disminuida. Los niveles de expresión de los genes ERG11, AFR1 y MDR1 se determinaron mediante PCR en tiempo real. Resultados. Los aislamientos resistentes al fluconazol mostraron sobreexpresión de los genes AFR1 y MDR1, mientras que la expresión de los fenotipos de resistencia evaluados se mantuvo homogénea en ERG11, en todos los aislamientos de C. neoformans var. grubii. Conclusiones. La sobreexpresión de los genes AFR1 y MDR1 que codifican las bombas de eflujo, contribuye a la resistencia al fluconazol en los aislamientos estudiados. Sin embargo, los patrones de resistencia que se registran en este hongo, sumado a los casos de recaídas en pacientes con HIV, no pueden atribuirse únicamente a los casos de resistencia por exposición al fármaco. Otros mecanismos podrían también estar involucrados en este fenómeno, como la resistencia emergente (resistencia mediante otros genes ERG) y la heterorresistencia, los cuales deben ser estudiados en estos aislamientos.

Introduction: Fluconazole is the most used antifungal drug for prevention and treatment of Cryptococcus spp. infections, the etiological agent of cryptococcosis. Resistance to fluconazole among Cryptococcus neoformans isolates can lead to treatment failure and generate relapses. Objective: To evaluate the expression profles of the AFR1, MDR1 and ERG11 genes in C. neoformans var. grubii clinical isolates during the in vitro response to fluconazole induction. Materials and methods: Fourteen C. neoformans var. grubii isolates recovered from HIV patients were studied, in which 6 showed sensitivities to fluconazole and 8 decreased sensitivity. The expression levels of ERG11, AFR1 and MDR1 genes were determined by real-time PCR from extracted mRNA. Results: AFR1 and MDR1 genes from C. neoformans var. grubii were overexpressed in fluconazole resistant isolates, whereas ERG11 maintains homogeneous expression in all the evaluated resistance phenotypes of C. neoformans var. grubii isolates. Conclusions: The overexpression of AFR1 and MDR1 genes, which codify for efflux pumps, contributes to fluconazole resistance in the studied isolates. However, the resistance patterns in this fungus and the relapse cases in HIV patients cannot be attributed solely to the exposure to the drug. Heteroresistance and the emerging resistance (resistance through other ERG genes), might be other mechanisms involved in this phenomenon, which must be studied in these isolations.

Utilidad del recuento de unidades formadoras de colonia de Cryptococcus sp. en líquido cefalorraquídeo de pacientes con criptococosis meníngea asociada al sida / Cryptococcus' colony forming unit count usefulness

Antecedentes: El recuento de unidades formadoras de colonia (UFC) de Cryptococcus en el líquido cefalorraquídeo (LCR) sería un marcador fiable para el pronóstico del paciente y una herramienta simple y económica. Objetivo: Evaluar la utilidad del recuento de UFC de Cryptococcus spp. y compararlo con las variaciones de antígeno capsular de Cryptococcus (AgCr) en LCR.Materiales y métodos: Se realizó la revisión de historias clínicas de pacientes con meningoencefalitis por Cryptococcus asociada con el sida en nuestro centro, entre febrero de 2016 y julio de 2020. Se evaluaron los valores de UFC y AgCr en LCR durante la evolución de la micosis. Resultados y discusión: Se analizaron datos de 94 episodios clínicos de 85 pacientes, con un total de 297 observaciones de muestras de LCR. Se evidenció el valor del recuento de UFC por ser un marcador de viabilidad y de carga fúngica. El recuento de UFC bajo no necesariamente coexistió con un nivel bajo de AgCr. Con respecto a la evolución en el tiempo, la mayoría de los pacientes fueron diagnosticados con una alta carga fúngica y su descenso ocurrió más rápido que el del AgCr, por lo que reflejaría la mejora del paciente, permitiendo tomar conductas al respecto.Palabras clave: Criptococosis, carga fúngica, ufc/mL.

Background. The Cryptococcus' colony-forming unit (CFU) count in cerebrospinal fluid (CSF) would be a reliable marker for patient prognosis and a simple and inexpensive tool. Objectives: To evaluate the usefulness of the CFU count of Cryptococcus spp. And to compare it with the variations of Cryptococcus' capsular antigen (CrAg) in CSF.Materials and methods. Clinical records of patients with aids-related meningoencephalitis caused by Cryptococcusassisted in our center between February 2016 and July 2020 were reviewed. CFU count and CrAg values in CSF were evaluated during the evolution of the mycosis.Results and Discussion. Data from 94 clinical episodes of 85 patients with a total of 297 observations of CSF samples were analyzed.The importance of using the CFU count was evidenced as it is a viability and fungal load marker.Low CFU count did not necessarily coexist with low CrAg.Regarding the evolution over time, most of the patients were diagnosed with a high fungal load and its decrease occurred faster than that the one of AgCr. This would reflect the improvement of the patient, allowing behaviors to be taken in this regard

Características clínicas, métodos diagnósticos y evolución de la criptococosis extrameníngea en personas viviendo con VIH / Clinical features, diagnosis methods and evolution in non meningeal cryptococcosis in people living with VIH

La criptococosis es una micosis grave que se manifiesta, en el 90% de los casos, como una meningoencefalitis, especialmente en las personas con VIH. El objetivo de este estudio es describir los casos de criptococosis extrameníngea en personas viviendo con VIH y conocer cuántas de estas padecen compromiso meníngeo concomitante. Además, determinar la relación con el título de antígeno polisacárido capsular de Cryptococcus en suero. Se realizó un estudio retrospectivo, observacional y analítico. Se incluyeron personas viviendo con VIH cuyo diagnóstico inicial de criptococosis se había realizado a partir de muestras extrameníngeas en el período comprendido entre 2012 y 2019. Los pacientes se dividieron en dos grupos. Grupo 1, pacientes sin compromiso meníngeo; Grupo 2, aquellos que finalmente tenían compromiso del SNC. De un total de 531 criptococosis registradas en ese período, se incluyeron 113 pacientes (21%), de los cuales en 58 se comprobó el compromiso meníngeo. No se observaron diferencias significativas en cuanto a la mortalidad entre ambos grupos.Ninguno de los pacientes con antigenemia por LFA (antígeno capsular en suero por inmunocromatografía) positiva, pero con antigenemia por aglutinación de partículas de látex (AL) negativa, tuvo compromiso meníngeo. Se observó que títulos de antígeno para Cryptococcus en suero por AL mayor o igual a 1/100 se correlacionaron con un aumento de 30 veces en la posibilidad de padecer meningitis. En todos los casos se debe descartar el compromiso del SNC. La AL sigue siendo una prueba útil y complementaria, debido a que en los casos con AL negativa no se observó compromiso meníngeo

Cryptococcosis is a serious mycosis that manifests itself, in 90% of cases, as meningoencephalitis, especially in AIDS patients. The objective of this study is to describe the extra-meningeal cases of cryptococcosis in people living with HIV and to know how many of them suffer from concomitant meningeal involvement. Also, to determine its relationship with the Cryptococcus capsular polysaccharide antigen titer in serum.A retrospective, observational and analytical study was carried out. HIV-positive patients whose initial diagnosis had been made from extrameningeal samples in the period between 2012 and 2019 were included. The patients were divided into 2 groups. Group 1: patients without meningeal involvement; group 2: those who finally had CNS involvement.Of a total of 531 cryptococcosis registered in this period, 113 patients (21%) were included, of whom meningeal involvement was confirmed in 58. No significant differences were observed in terms of mortality in both groups.None of the patients with positive LFA antigenemia (Capsular antigen detection by lateral Flow assay) but negative latex particle agglutination (LA) antigenemia had meningeal involvement. LFA was found to be highly sensitive and allows early diagnosis, but it does not replace other diagnostic procedures.Serum Cryptococcus antigen titers for by LA greater than or equal to 1/100 were found to correlate with a 30-fold increase in the likelihood of meningitis.In all cases, CNS involvement must be ruled out. LA continues to be a useful and complementary test, because in cases with negative LA, no meningeal involvement was observed

Criptococosis diseminada por terapia biológica, se debe gestionar el riesgo / Disseminated cryptococcosis by biological therapy: We must manage the risk

Introducción. Se han descrito múltiples efectos adversos con el uso de la terapia biológica para enfermedades autoinmunitarias, muchos de ellos secundarios al estado de inmunosupresión, como las infecciones bacterianas, fúngicas o virales. Caso clínico. Se presenta el caso de una mujer de 64 años con diagnóstico comprobado de criptococosis diseminada secundaria al uso de tofacitinib. Se descartaron otras causas de inmunosupresión, como infección por el virus de la inmunodeficiencia humana (HIV). Tres años antes se le había diagnosticado artritis reumatoide y se encontraba en tratamiento farmacológico con un agente biológico que inhibe las enzimas JAK. Se han descrito muy pocos casos de criptococosis pulmonar y meníngea en este tipo de pacientes. Conclusión. Este reporte de caso es útil para que otros médicos tratantes tengan presente la posibilidad de este tipo de infección fúngica invasora asociada con la terapia biológica y el enfoque de gestión de riesgo.

Introduction: Multiple adverse effects have been described for the biological therapy in autoimmune diseases including many secondary to immunosuppression producing bacterial, fungal, or viral infections. Clinical case: We present the case of a 64-year-old female patient with proven disseminated cryptococcosis secondary to the use of tofacitinib. Other possible causes of immunosuppression such as the human immunodeficiency virus (HIV) were ruled out. The patient had been in treatment for rheumatoid arthritis diagnosed three years before. This drug is a biological agent that inhibits JAK enzymes. Very few cases of pulmonary and meningeal cryptococcosis in this type of patient have been described in the literature. Conclusion: This case report should be useful for other clinicians to bear in mind the possibility of this type of invasive fungal infection associated with biological therapy and to take a risk-management approach.

Acompanhamento do comportamento do HIV através de exames laboratoriais em portadora do vírus: relato de caso / Monitoring of HIV behavior through laboratory tests in a virus carrier: case report

O vírus da imunodeficiência humana é o agente etiológico da AIDS, doença crônica que destrói o sistema imunológico e é caracterizada pela baixa contagem de células TCD4, alta contagem de partículas virais no sangue e manifestações clínicas da doença. O diagnóstico se dá com o aparecimento de infecções oportunistas, que levam a contagem de TCD4 a níveis menores que 200 céls/mm³. Os exames laboratoriais para o diagnóstico do HIV foram os principais avanços para o início do tratamento, reduzindo a transmissão. Detecção de anticorpos, detecção de antígenos e amplificação do genoma do vírus são alguns dos exames laboratoriais utilizados para diagnóstico. Os dois principais biomarcadores são os exames de contagem de células TCD4, que verifica o sistema imune, e a quantificação de carga viral, que informa a quantidade de partículas virais, mostrando a progressão da infecção. Quanto maior a carga viral, maior o dano ao sistema imune. Uma carga viral indetectável é inferior a 50 cópias/mL, mas valores menores ou iguais a 200 cópias/mL também impedem a transmissão. Uma declaração de consenso afirma que Indetectável é igual a Intransmissível. Portanto, quando indetectável, a transmissão inexiste. O presente estudo relata e discute o caso clínico de uma paciente diagnosticada com HIV/AIDS aos 28 anos, que sobreviveu, apesar do diagnóstico tardio, e sob presença de doença oportunista com um grave grau de diminuição de células TCD4 (22 cél/mm³). Por meio do diagnóstico, introdução e adesão correta da terapia antirretroviral e monitorização de exames laboratoriais, conseguiu evitar a morte e ter uma vida semelhante à de um HIV negativo. Ultrapassou a expectativa de vida que na descoberta era de 10 anos, com uma qualidade de vida considerável, não sendo transmissora do vírus, diminuindo assim o estigma e preconceito. O biomédico é peça fundamental nesse contexto, considerando que deve fornecer informações precisas e fidedignas, tão necessárias ao acompanhamento de pessoas vivendo com HIV, para que autoridades e profissionais de saúde adotem medidas adequadas, tanto na prevenção, quanto no diagnóstico e monitoramento da doença.

The human immunodeficiency virus is the etiological agent of AIDS, a chronic disease that destroys the immune system and is characterized by low TCD4 cell count, high viral particle count in blood and clinical manifestations of the disease. The diagnosis is due to the appearance of opportunistic infections, which lead to TCD4 counts below 200 cells / mm³. Laboratory tests for the diagnosis of HIV were the main advances in starting treatment, reducing transmission. Antibody detection, antigen detection and virus genome amplification are some of the laboratory tests used for diagnosis. The two main biomarkers are the TCD4 cell count tests, which checks the immune system, and viral load quantification, which reports the number of viral particles, showing the progression of infection. The higher the viral load, the greater the damage to the immune system. An undetectable viral load is less than 50 copies / mL, but values less than or equal to 200 copies / mL also prevent transmission. A consensus statement states that Undetectable equals Non-Transmissible. Therefore, when undetectable, transmission does not exist. The present study reports and discusses the clinical case of a patient diagnosed with HIV / AIDS at age 28, who survived despite late diagnosis and under the presence of opportunistic disease with a severe degree of TCD4 cell reduction (22 cells / mm³). Through the diagnosis, introduction and correct adherence of antiretroviral therapy and monitoring of laboratory tests, she was able to avoid death and have a life similar to that of an HIV negative. Exceeded the life expectancy that in the discovery was 10 years, with a considerable quality of life, not transmitting the virus, thus reducing the stigma and prejudice. The biomedical is a key player in this context, considering that he must provide accurate and reliable information, which is so necessary for the monitoring of people living with HIV, so that authorities and health professionals adopt appropriate measures, both in prevention, diagnosis and monitoring of the disease.

Criptococosis diseminada en paciente inmunocompetente imitando un cáncer de pulmón metastásico / Disseminated cryptococcosis in an immunocompetent patient imitating metastatic lung cancer

El cáncer de pulmón es la principal causa de muerte en el mundo por cáncer, y en Colombia es la segunda. Su pronóstico es pobre cuando se ha documentado enfermedad metastásica en el sistema nervioso central. El diagnóstico se basa en el resultado definitivo de patología. Aunque los hallazgos imagenológicos pueden ser muy sugestivos de malignidad, hay reportes de otras enfermedades que pueden imitar cáncer, tales como infecciones o tumores benignos, los cuales pueden llevar a adoptar conductas terapéuticas inapropiadas. Las infecciones fúngicas como las producidas por Criptococcus neoformans, son capaces de generar lesiones que pueden imitar neoplasias. El objetivo de esta publicación es reportar el caso de un hombre a quien inicialmente se le sospechó un carcinoma pulmonar metastásico al sistema nervioso central, y finalmente se le diagnosticó una criptococosis diseminada posterior a su fallecimiento

Lung cancer is the leading cause of death from cancer in the world and the second in Colombia, its prognosis is bad when the diagnosis of metastatic disease in the central nervous system is documented. The diagnosis is based on the definitive pathologic result. Although the imaging findings can be highly suggestive of malignancy, there are reports of other conditions that can mimic lung cancer, such as infections or benign tumors, which can lead to inappropriate treatment. Fungal infections such as those caused by Criptococcus neoformans are capable of generating lesions that can mimic neoplasms. The objective of this article is to report the case of a man who was initially diagnosed with metastatic lung carcinoma to the central nervous system, and was finally diagnosed with disseminated cryptococcosis after his death

Hemolymph of triatomines presents fungistatic activity against Cryptococcus neoformans and improves macrophage function through MCP-I/TNF-α increase

Triatomines are blood-feeding arthropods belonging to the subfamily Triatominae (Hemiptera; Reduviidae), capable of producing immunomodulatory and water-soluble molecules in their hemolymph, such as antimicrobial peptides (AMPs). In this work, we evaluated the antifungal and immunomodulatory activity of the hemolymph of Meccus pallidipennis (MPH) and Rhodnius prolixus (RPH) against Cryptococcus neoformans. Methods: We assessed the activity of the hemolymph of both insects on fungal growth by a minimum inhibitory concentration (MIC) assay. Further, RAW 264.7 macrophages were cultivated with hemolymph and challenged with C. neoformans. Then, their phagocytic and killing activities were assessed. The cytokines MCP-1, IFN-γ, TNF-α, IL-10, IL-12, and IL-6 were measured in culture supernatants 4- and 48-hours post-infection. Results: Both hemolymph samples directly affected the growth rate of the fungus in a dose-dependent manner. Either MPH or RPH was capable of inhibiting fungal growth by at least 70%, using the lowest dilution (1:20). Treatment of RAW 264.7 macrophages with hemolymph of both insects was capable of increasing the production of MCP-I and TNF-α. In addition, when these cells were stimulated with hemolymph in the presence of C. neoformans, a 2- and a 4-fold increase in phagocytic rate was observed with MPH and RPH, respectively, when compared to untreated cells. For the macrophage killing activity, MPH decreased in approximately 30% the number of viable yeasts inside the cells compared to untreated control; however, treatment with RPH could not reduce the total number of viable yeasts. MPH was also capable of increasing MHC-II expression on macrophages. Regarding the cytokine production, MCP-I and TNF-α, were increased in the supernatant of macrophages treated with both hemolymphs, 4 and 48 hours after stimulation. Conclusion: These results suggested that hemolymph of triatomines may represent a source of molecules capable of presenting antifungal and immunomodulatory activity in macrophages during fungal infection.(AU)

Prevalencia y susceptibilidad de Cryptococcus neoformans aislados del suelo y excretas de palomas en la ciudad de Maceió ­ AL, Brasil / Prevalência e suscetibilidade de Cryptococcus neoformans isolados do solo e de excretas de pombos na cidade de Maceió ­ AL, Brasil

Introducción: Cryptococcus neoformans es una levadura encapsulada, que se encuentra en fuentes ambientales, incluyendo excrementos de palomas. Tiene una gran relevancia clínica porque es el agente etiológico de la criptococosis, considerada una causa importante de mortalidad en personas inmunocomprometidas en todo el mundo. Objetivo: determinar la prevalencia y susceptibilidad de C. neoformans aislados del suelo y excremento de palomas en la ciudad de Maceió ­ Alagoas, Brasil. Metodología: Se recolectaron 150 muestras (50 de excretas secas, 50 de excretas frescas y 50 del suelo) y cultivaron en Agar Dextrosa Sabouraud. Las colonias aisladas sugestivas de C. neoformans se sometieron a identificación y caracterización mediante análisis morfológicos, actividad de la enzima fenol-oxidasa, sensibilidad a la cicloheximida, desarrollo a 37°C, hidrólisis de urea, asimilación de carbono y nitrógeno y fenotipificación en medio canavanina-glicina-azul de bromotimol. La prueba de susceptibilidad antifúngica se realizó utilizando la técnica de difusión en agar. Resultados: se obtuvieron 36 (24%) muestras positivas para C. neoformans, de las cuales 33 fueron de excretas secas y 3 del suelo cercano al excremento. El perfil de susceptibilidad fue de 100.0% para anfotericina B y 87.4% para ketoconazol, no obstante, hubo un alto porcentaje de resistencia a fluconazol (91.5%) e itraconazol (80.0%). Conclusión: estos hallazgos confirman que las excretas de palomas secas son reservorios de C. neoformans en el medio ambiente, caracterizando un problema de salud única. Además, la anfotericina B exhibió una alta actividad in vitro, representando buena alternativa en el tratamiento de la criptococosis.

Introdução: Cryptococcus neoformans é um fungo leveduriforme encapsulado, encontrado em fontes ambientais, incluindo excretas de pombos. Apresenta grande relevância clínica por ser agente etiológico da criptococose, considerada importante causa de mortalidade em indivíduos imunocomprometidos em todo o mundo. Objetivo: determinar a prevalência e suscetibilidade de C. neoformans isolados do solo e de excretas de pombos na cidade de Maceió, Alagoas. Metodologia: foram coletadas 150 amostras (50 de excretas secas, 50 de excretas frescas e 50 do solo) e cultivadas em Ágar Sabouraud Dextrose. As colônias isoladas sugestivas de C. neoformans foram submetidas à identificação e caracterização por meio de análises morfológicas, atividade da enzima fenoloxidase, sensibilidade à cicloheximida, termotolerância à 37ºC, hidrólise da ureia, assimilação de carbono e nitrogênio e quimiotipagem em ágar L-canavanina-glicina-azul de bromotimol. O teste de suscetibilidade antifúngica foi realizado por meio da técnica de difusão em ágar. Resultados: foram obtidas 36 (24%) amostras positivas para C. neoformans, das quais 33 (91,6%) foram provenientes de excretas secas e 3 (8,3%) do solo próximo a excrementos. O perfil de suscetibilidade foi de 100,0% para a anfotericina B e 87,4% para o cetoconazol, não obstante, verificou-se alto percentual de resistência ao fluconazol (91,8%) e itraconazol (80%). Conclusão: estes achados confirmam que excretas de pombos secas são reservatórios de C. neoformans no ambiente, caracterizando um problema de saúde única. Além disso, a anfotericina B apresentou elevada atividade, in vitro, representando boa alternativa no tratamento da criptococose.

Antigenemia temprana de Cryptococcus en pacientes asintomáticos VIH positivos en Barranquilla, Colombia / Cryptococcus early antigenemia in HIV positive asymptomatic patients in Barranquilla, Colombia

Resumen La criptococosis meníngea presenta alta mortalidad mundial, especialmente en población VIH/sida. La OMS recomienda detectar el antígeno capsular de Crypto coccus como estrategia para un diagnóstico temprano y poder minimizar complicaciones. Objetivo: realizar antigenemia temprana de Cryptococcus mediante in munocromatografía/ensayo de flujo lateral en pacientes asintomáticos VIH+. Material y método: estudio descriptivo observacional; entre julio-2016 y mayo-2019 se procesaron mediante ensayo de flujo lateral, muestras de suero de 169 pacientes asintomáticos VIH+, con CD4 ≤120 cel/μL en Barranquilla, Colombia. Ante resultado positivo, se indicó profilaxis con fluconazol; se hizo seguimiento a todos los casos. Resultados: la antigenemia fue positiva en cinco pacientes (2,96%); uno falleció, cuatro recibieron profilaxis y la prueba se negativizó en dos. Los pacientes con resultado negativo inicial no desarrollaron durante el estudio sinto matología compatible con esta micosis. Discusión: el ensayo de flujo lateral de Cryptococcus está recomendado para el diagnóstico temprano de la criptococosis en población VIH/sida. Conclusión: detectar tempranamente el antígeno circulante de Cryptococcus mediante ensayo de flujo lateral en pacientes asintomáticos VIH+, permitió instaurar profilaxis oportuna, hacer seguimiento y control para reducir la mortalidad asociada con la criptococosis meníngea.

Abstract Meningeal cryptococcosis presents high levels of global mortality, especially in the HIV/AIDS population. The WHO recommends detecting the capsular antigen as an important strategy for early diagnosis and be able to minimize complications. Objective: Perform early cryptococcal antigenemia by immunochromatographic/ lateral flow assay in asymptomatic HIV+ patients. Material and method: descriptive observational study; between July-2016 and May-2019, serum samples from 169 asymptomatic HIV+ patients with CD4 ≤120 cells/μL were processed by lateral flow assay in Barranquilla, Colombia. Given a positive result, prophylaxis with fluconazole was indicated; all cases were followed up. Results: antigenemia was positive in five (2.96%) patients; one died; four received prophylaxis, and the test turned negative in two. The patients with an initial negative result, did not developed symptoms compatible with this mycosis during the study period. Discussion: lateral flow assay for Cryptococcus is recommended for the early diagnosis of cryptococcosis in the HIV/AIDS population. Conclusion: early detection of circulating Cryptococcus antigen by lateral flow assay in HIV+ patients allowed the establishment of timely prophylaxis, follow-up, and control to reduce mortality associated with meningeal cryptococcosis.

Primary cutaneous cryptococcosis: the importance of early diagnosis

Abstract The species of the Cryptococcus neoformans complex show different epidemiological patterns in the infection of immunosuppressed or immunocompetent individuals, and a common tropism peculiarity for the central nervous system. Primary cutaneous cryptococcosis is a rare clinical entity, with manifestations that are initially restricted to the skin through fungal inoculation, and the absence of systemic disease. The authors report in the present study the case of a 61-year-old immunocompetent man, with a rapidly evolving mucoid tumor on abrasions in contact with bird droppings on the forearm. The early identification of the polymorphic skin manifestations and treatment are crucial for the favorable prognosis of the infection, which can be life-threatening.

Criptococosis y linfocitopenia T CD4 idiopática: Reporte de un caso / Cryptococcosis and idiopathic CD4 T lymphocytopenia: A case report

Resumen La linfocitopenia T CD4 idiopática (LCI) es un síndrome clínico inusual que se caracteriza por un déficit de células T CD4+ circulantes en ausencia de infección por VIH u otra condición de inmunosupresión. Los pacientes con dicha enfermedad pueden presentarse asintomáticos o con infecciones oportunistas, las más frecuentes son por criptococo, micobacterias o virales como herpes zoster. Presentamos el caso de un hombre de 32 años, sin antecedentes, en quien se descartó infección por retrovirus, con recuento de linfocitos T CD4+ menor a 300 células/m3; se diagnosticó LCI posterior al diagnóstico de criptococomas cerebrales mediante hallazgos imagenológicos los cuales fueron congruentes con estudios microbiológicos.

Summary Idiopathic CD4 T lymphocytopenia (ICL) is an unusual clinical syndrome characterized by a deficit of circulating CD4 + T cells in the absence of HIV infection or another immunosuppression condition. Patients with this disease may present asymptomatic or with opportunistic infections, the most frequent are cryptococcus, mycobacteria or viral such as herpes zoster. We present a case of a 32-year-old man with no prior disease, in whom retrovirus infection was discarded, with CD4 + T lymphocyte count less than 300 cells/m3; ICL was diagnosed after the diagnosis of brain cryptococomas by imaging findings which were consistent with microbiological studies.

Criptococosis diseminada en paciente positivo para COVID-19 / Disseminated cryptococcosis in a patient with COVID-19

Paciente de 59 años quien ingresa al servicio de urgencias con un cuadro de 2 días de evolución de cefalea holocraneana de intensidad moderada 7/10, picos febriles no cuantificados, disnea grado III, adinamia, hiporexia, ageusia y tos no productiva, refiriendo contacto estrecho con hermana confirmada para infección por COVID-19, por lo que se investiga antígeno para COVID-19 con resultado positivo. Se confirma la existencia del síndrome respiratorio agudo grave (SARS-CoV-2) con coinfección por Cryptococus neoformans. El manejo con corticoide sistémico genera un importante inmunocompromiso que predispone al paciente a coinfecciones por gérmenes comunes y oportunistas, como lo es la infección por Cryptococcus neoformans/ Gatti. En este caso la infección por COVID-19 y el desarrollo de SARS-CoV-2 fue la etiología de la infección micótica por cryptococo.

Here, we report a case of a 59-year-old patient with a 2-day history of moderate intensity (7/10) holocranial headache, unquantified febrile peaks, grade III dyspnea, adynamia, hyporexia, ageusia and nonproductive cough admitted to the emergency department. He referred close contact to a sister with confirmed COVID-19. His COVID-19 antigen test results were positive. Severe acute respiratory syndrome (SARS-CoV-2) associated with Cryptococcus neoformans infection was confirmed. The use of systemic corticosteroid therapy leads to immunocompromise and predisposes the patient to common and opportunistic infections such as Cryptococcus neoformans and Cryptococcus gatiii infection. In this case COVID-19 infection and the development of SARS-CoV-2 was the etiology of the Cryptococcus fungal infection.

Trends and patterns of mortality arising from fungal infections in Brazil in a period of 11 years / Tendências e padrões de mortalidade em decorrência de infecções fúngicas no Brasil, em um período de 11 anos

Objective: To investigate the mortality attributed to fungal infections, in Brazil between 2003 and 2013. Methods: This ecological study relied on official data collected from the Sistema de Informação Sobre Mortalidade ­ Mortality Information System database. The mycoses were identified by the 10th revision of the International Classification of Diseases, which included categories B35­B49 in its first chapter. Results: Overall, 11,991,935 deaths were reported in the aforementioned period. The deaths of 4,192 individuals were primarily attributed to mycoses. High annual mortality rates were observed in all Brazilian regions, except in the Northeast. The main recorded mycoses were paracoccidioidomycosis (35.6%) and cryptococcosis (24.1%). There was a downward trend in the number of deaths due to paracoccidioidomycosis. In addition, 10,925 death certificates listed mycoses as an associated cause of death. Cryptococcosis (89.7%) and histoplasmosis (89.4%) were the most common mycoses associated with deaths in HIV patients. Conclusions: There was a downward trend in the number of deaths stemming from invasive fungal infections. However, opportunistic mycoses follow been a significant cause of death, especially in HIV patients.

Objetivo: Investigar a mortalidade atribuída para as infecções fúngicas, no Brasil, entre 2003 e 2013. Métodos: Trata-se de um estudo ecológico, em que os dados foram obtidos do Sistema de Informação sobre Mortalidade (SIM), disponíveis na plataforma do DATASUS. As micoses foram identificadas por meio da 10ª revisão da Classificação Internacional de Doenças (CID-10), a qual incluiu as categorias B35-B49 no primeiro capítulo da CID-10. Resultados: No total, 11.991.935 óbitos foram notificados no período do estudo. Os óbitos de 4,192 indivíduos foram atribuídos às micoses. Foram observadas elevadas taxas de mortalidade em todas as regiões brasileiras, com exceção do Nordeste. As principais micoses registradas foram paracoccidioidomicose (35,6%) e criptococose (24,1%). Houve uma tendência na redução do número de óbitos em relação à paracoccidioidomicose. Além disso, em 10.925 declarações de óbitos informavam que as micoses foram causas associadas ao óbito. Criptococose (89,7%) e Histoplasmose (89,4%) foram as micoses mais comumente associadas ao óbito, principalmente em pacientes HIV positivos. Conclusões: Houve uma tendencia na diminuição dos óbitos por infecções fúngicas invasivas. Entretanto, micoses oportunistas continuam sendo importantes causas de morte, especialmente em indivíduos HIV positivos.

Cryptococcosis by Cryptococcus neoformans/Cryptococcus gattii Species Complexes in non-HIV-Infected Patients in Southeastern Brazil

Abstract INTRODUCTION: The clinical manifestations of cryptococcosis are usually associated with the infecting agents Cryptococcus neoformans (CN) and C. gattii (CG) species complexes and the host. In this study, non-HIV-infected patients, at a university hospital in southeastern Brazil, had epidemiological and clinical data associated with cryptococcal disease and isolated Cryptococcus species: CN - 24 patients and CG - 12 patients. METHODS: The comparison was comprised of demographic data, predisposing factors, clinical and laboratory manifestations, and outcomes of cryptococcosis patients treated between 2000 and 2016. Immunocompetent and immunosuppressed patients were also compared, irrespective of the infecting species. Cryptococcus spp. were genotyped by PCR-RFLP analysis of the URA5 gene. RESULTS: Infections by the CN species complex (100% VNI genotype) were associated with drug immunosuppression and fungemia, and patients infected with the CG species complex (83% VG II and 17% VGI genotypes) had more evident environmental exposure and higher humoral response. CN and CG affected patients with or without comorbidities. CONCLUSIONS: Diabetes mellitus, other chronic non-infectious diseases, and alcoholism were likely predisposing factors for infection by both CN and CG species. Immunocompetent patients, independent of the infecting Cryptococcus species complexes, showed a higher occurrence of meningitis and a trend toward less fungal dissemination and longer survival than immunosuppressed hosts.

Criptococosis pulmonar en un paciente con colitis ulcerativa tratado con prednisolona y azatioprina / Pulmonary cryptococcosis in a patient with ulcerative colitis treated with prednisolone and azathioprine

Resumen La enfermedad inflamatoria intestinal comprende la enfermedad de Crohn (EC) y la colitis ulcerativa (CU). Esta última es una patología crónica caracterizada por una inflamación difusa de la mucosa colónica, que afecta el recto y se extiende de forma proximal. Su curso clínico es intermitente, con exacerbaciones y remisiones. Su tratamiento, por lo general, es farmacológico, con corticoides, inmunomoduladores e inhibidor del factor de necrosis tumoral (anti tumor necrosis factor, TNF), los cuales causan un estado de inmunosupresión en el paciente, que puede asociarse en algunos casos a infecciones oportunistas. En la literatura se describe la aparición de la criptococosis pulmonar en pacientes con infección por el virus de inmunodeficiencia humana (VIH). En otros casos se asocia al tratamiento farmacológico de pacientes con EC, así como con otras infecciones oportunistas, tales como la tuberculosis y el herpes. Presentamos uno de los primeros casos de criptococosis pulmonar en un paciente con diagnóstico de colitis ulcerativa, quien recibió tratamiento escalonado con salicilatos, inmunomoduladores y terapia biológica. La infección fue documentada clínica, radiológica e histológicamente. El paciente recibió el tratamiento adecuado y presentó una evolución satisfactoria.

Abstract Inflammatory bowel disease comprises Crohn's disease (CD) and ulcerative colitis (UC), the latter being a chronic disease characterized by diffuse inflammation of the colonic mucosa that affects the rectum and extends proximally. Its clinical course is intermittent with exacerbations and remissions and its treatment is generally pharmacological, with steroids, immunomodulators, and anti-tumor necrosis factor inhibitors (TNF), which cause the patient to be in a state of immunosuppression associated, in some cases, with opportunistic infections. The literature describes the occurrence of pulmonary cryptococcosis in patients with human immunodeficiency virus (HIV) infection, in cases associated with drug treatment of patients with CD, as well as with other opportunistic infections such as tuberculosis and herpes. This is one of the first cases of pulmonary cryptococcosis reported in a patient diagnosed with ulcerative colitis, who received step therapy with salicylates, immunomodulators, and biological therapy. The infection was documented clinically, radiologically, and histologically. The patient received the appropriate treatment and had a satisfactory evolution.

Production of a latex agglutination reagent for the rapid diagnosis of cryptococcal meningitis / Producción de un reactivo de látex para el diagnóstico rápido de criptococosismeníngea

Abstract Cryptococcosis is a fungal disease affecting more than one million people per yearworldwide. Its main etiological agents are Cryptococcus neoformans species complex and Cryp-tococcus gattii species complex. Cryptococcal meningitis (CM) is considered an AIDS-definingcondition. Rapid diagnosis by cryptococcal antigen assays, either the latex agglutination test(LA) or the lateral flow assay, is key to decreasing mortality due to cryptococcal disease. Theaim of the study was to develop a latex agglutination reagent (LA-ANLIS) for the rapid and reliable diagnosis of cryptococcosis in Argentina. This reagent will be produced in order to supplythe NMLN (National Mycology Laboratory Network). The evaluation of LA-ANLIS performanceand its comparison with the Cryptococcus Antigen Latex Agglutination Test System (LA-IMMY)(Immuno-Mycologics, Inc., USA) were conducted in 94 samples of cerebrospinal fluid. LA-ANLISand LA-IMMY compared exhibited 100% positive agreement and 97% negative agreement. LA-ANLIS showed 94% sensitivity and 97% specificity with the positive and negative predictivevalues of 94% and 97%, respectively. The LA-ANLIS is a reliable, reproducible and cost-effectivereagent, especially useful in countries where the commercial kit is not generally available andmust be obtained at a high cost. National production of reagents is the best choice for a reliableaccess to the rapid diagnosis of CM in Argentina.

Resumen La criptococosis es una enfermedad fúngica que afecta a más de un millón de personas por año en todo el mundo. Los principales agentes etiológicos pertenecen a los complejos de especies Cryptococcus neoformans y Cryptococcus gattii. La criptococosis meníngea (CM) se considera una enfermedad marcadora de sida. El diagnóstico rápido de esta enfermedad a través de la detección del antígeno de Cryptococcus, ya sea por aglutinación en partículas de látex o por inmunocromatografía, es clave para disminuir la mortalidad. El objetivo del presente estudio fue desarrollar un reactivo de aglutinación en partículas de látex para el diagnóstico rápido y certero de la CM en Argentina. Este reactivo (denominado en adelante LA-ANLIS) será producido para abastecer a la Red Nacional de Laboratorios de Micología. Se evaluó el desempeno del reactivo LA-ANLIS, y se realizó una comparación con el reactivo comercial Immuno-Mycologics, Inc. (en adelante, LA-IMMY) utilizando 94 muestras de líquido cefalorraquídeo. Hubo un 100% de acuerdo positivo y un 97% de acuerdo negativo entre los resultados obtenidos con los reactivos LA-ANLIS y LA-IMMY. El reactivo LA-ANLIS mostró una sensibilidad del 94% y una especificidad del 97%; los valores predictivos positivo y negativo fueron del 94 y del 97%, respectivamente. Se concluye que el LA-ANLIS es un reactivo confiable y rentable, que arroja resultados reproducibles, por lo que es especialmente útil en países donde los reactivos comerciales generalmente no están disponibles o sus costos son elevados. La producción nacional de reactivos es la mejor opción para asegurar el acceso de todos los hospitales al diagnóstico rápido de la CM en Argentina.

Frequency and geographical distribution of genotypes and mating types of Cryptococcus neoformans and Cryptococcus gattii species complexes in Argentina / Frecuencia y distribución geográfica de genotipos y tipos sexuales de los complejos de especies Cryptococcus neoformans y Cryptococcus gattii en Argentina

Abstract The aim of this work was to know the frequency and geographical distribution of genotypes and mating types of Cryptococcus neoformans and Cryptococcus gattii species complexes isolated from human infections in Argentina during the period from April 2009 to April 2011. A multicenter study was conducted, in which 372 isolates were obtained from 61 laboratories throughout the country. Of those, 98.8% of the isolates belonged to the C. neoformans species complex and 1.1% to the C. gattii species complex. Genotype VNI (MATa) was the most frequently isolated (n = 326, 87.6%), followed by VNII (MATa) (n = 22, 5.9%), the recently described VNII-VNIV (aADa) hybrid (n = 14, 3.8%), VNIV (MATa) (n=4, 1.1%), VNIII (aADa) hybrid (n = 1, 0.3%), and VNIII (aADa) hybrid (n = 1, 0.3%). The Argentine Central region showed the greatest number of cases and genotype diversity. Interestingly, a relative high frequency was observed in genotype VNII (MATa) in the Cuyo, Northeast and Northwest regions and, also in VNII-VNIV (aADa) hybrids in the Northwest region. C. gattii species complex was isolated at a low rate; 3 VGI (MATa) and 1 VGII (MATa) isolates were obtained from the Northwest and Central regions. In conclusion, this study shows that genotype frequencies seem to vary among regions in Argentina and reveals a relatively high frequency of rare hybrids in the Northwest region. Further regional clinical and environmental studies may help to elucidate if those varia-tions in frequencies are associated with the existence of regional ecological niches or any other regional factors.

Resumen El objetivo de! trabajo fue conocer la frecuencia y la distribución geográfica de genotipos y tipos sexuales de aislados pertenecientes a los complejos de especies Cryptococcus neoformansy Cryptococcus gattii obtenidos de infecciones humanas en Argentina. Entre abril de 2009 y abril de 2011 se realizó un estudio multicéntrico del que se obtuvieron 372 aislados de 61 laboratorios de diferentes zonas del país. El 98,8% de los aislados pertenecieron al complejo C. neoformansy el 1,1% al complejo C. gattii. El genotipo VNI (MATa) fue el más frecuente (n = 326; 87,6%), le siguieron VNII (MATa) (n = 22; 5,9%), el híbrido VNII-VNIV (aADa) (n = 14; 3,8%), VNIV (MATa) (n =4; 1,1%) y los híbridos VNIII (aADa) (n = 1; 0,3%) y VNIII (aADa) (n = 1; 0,3%). La región Centro mostró el mayor número de casos y la mayor diversidad de genotipos. Cabe destacar que el genotipo VNII (MATa) tuvo una frecuencia relativamente alta en las regiones de Cuyo, Noreste y Noroeste. En esta última región, también fue alta la frecuencia del híbrido VNII-VNIV (aADa). La frecuencia de aislamiento de miembros del complejo C. gattii fue baja: se obtuvieron 3 aislados VGI (MATa) y 1 VGII (MATa) de las regiones Centro y Noroeste. En conclusión, este estudio muestra que las frecuencias de genotipos varían entre las distintas regiones de Argentina y señala la presencia de híbridos poco comunes en una frecuencia relativamente alta dentro de la región Noroeste. Contar con mayor número de estudios clínicos y ambientales regionales podría ayudar a elucidar si tales variaciones están asociadas a la existencia de nichos ecológicos particulares o a algún otro factor regional.

Fatores de virulência e susceptibilidade a antifúngicos de Cryptococcus Spp / Virulence factors and susceptibility to Cryptococcus Spp. antifungals

Criptococose é uma doença grave que afeta tanto imunocomprometidos quanto imunocompetentes, com isso analisar a virulência é fundamental para novas terapêuticas. Objetivo: Analisar a capacidade de virulência e susceptibilidade aos antifúngicos de Cryptococcus spp. isolados de líquor de pacientes de hospital do norte do Paraná. Métodos: A partir de dois isolados clínicos C. neoformans e C. gattii, realizou-se a confirmação da identificação. Para a virulência, avaliou-se o tamanho da cápsula, capacidade de sobrevivência após exposição a neutrófilos, produção de melanina e urease. No antifungigrama por difusão em disco utilizou-se: anfotericina B, cetoconazol, voriconazol, itraconazol e miconazol. Resultados: C. gattii destaca-se por maior desenvolvimento da cápsula além da melhor capacidade de sobreviver a fagocitose em relação ao C. neoformans. No antifungigrama, ambos os isolados se apresentam sensíveis às drogas estudadas. Conclusão: Esses achados contribuem para a compreensão das diferentes patogêneses entre C. gattii e C. neoformans.

Cryptococcosis is a serious disease that can affect both immunocompromised and immunocompetent individuals, thus the virulence analysis is fundamental for the development of new treatments. Objective: To analyze the virulence and susceptibility of Cryptococcus spp. isolated from cerebrospinal fluid of patients from a hospital in the north of Paraná. Methods: From two clinical isolates, C. neoformans and C. gattii were confirmed and identified. For virulence, capsule size, survival capacity after exposure to neutrophils, melanin production and urease were evaluated. In the disc-diffusion method, the following antifungals were used: amphotericin B, ketoconazole, voriconazole, itraconazole and miconazole Results: It was observed that C. gattii presents greater results for development of the capsule beside presenting the best ability to survive phagocytosis in relation to C. neoformans. In the disc-diffusion method, both isolates presented sensitivity to the studied drugs. Conclusion: These findings contribute to the understanding of the different pathogens between C. gattii and C. neoformans.