Intralesional combined digoxin and furosemide versus intralesional 5-flurouracil for the treatment of recalcitrant plantar warts: a prospective, randomized study.

There are many therapeutic modalities for plantar warts, however treating it remains challenging. Intralesional injection of 5-fluorouarcil and combined digoxin and furosemide were observed to be effective and safe, however no comparison study between them was done. Our study was conducted to evaluate the efficacy of both therapies in the treatment of plantar warts. 90 adult patients with multiple recalcitrant plantar warts were included in our study. They were randomly allocated to one of three groups; combined digoxin and furosemide, 5-fluorouarcil, or normal saline group. Fortnightly injections were done into all studied warts till complete clearance or up to 5 sessions. Warts were evaluated clinically and dermoscopically. Clinical response was reported in 24 patients (80%) of the combined digoxin and furosemide group with 40% complete response and in 24 patients (80%) of the 5-fluorouarcil group with 33.3% complete response. No statistically significant difference was observed between the two groups concerning efficacy and safety. Intralesional injection of 5-fluorouarcil and combined digoxin and furosemide are nearly equivalent in efficacy and safety for plantar wart treatment. Dermoscopy helps to take the truthful judgment about complete clearance of warts.

HIV-associated disseminated cryptococcosis-An unusual clinical and diagnostic picture with successful cure by single dose liposomal amphotericin B treatment.

BACKGROUND: Cryptococcosis is an invasive, opportunistic fungal infection seen especially in human immunodeficiency virus (HIV) infected patients. Cryptococcal meningitis (CM) is the second leading cause of mortality in HIV patients. We report a case of disseminated cryptococcosis presenting with altered mental status in a newly diagnosed HIV infection. METHODS AND RESULTS: A 50-year-old with a short history of altered mental sensorium and a history of low-grade fever and weight loss for few months presented at a tertiary care hospital in North India. He was detected positive for HIV-1. Cryptococcal antigen (CRAG) was positive in Cerebrospinal fluid (CSF), and negative in serum. The fungal culture in CSF was sterile while the fungal blood culture grew Cryptococcus neoformans. The patient was treated with single high-dose Liposomal Amphotericin B (LAmB) therapy followed by Fluconazole and Flucytosine for the next two weeks followed by fluconazole daily for consolidation and maintenance therapy. Antiretroviral therapy (ART) was started 4 weeks after induction therapy. After 6 months, the patient is doing fine. CONCLUSION: Single dose LAmB along with the backbone of fluconazole and flucytosine appears promising in disseminated cryptococcal infection in HIV-infected individuals.

Disseminated phaeohyphomycosis due to Cladophialophora bantiana in an immunocompetent child.

A 3-year-old boy presented with acute headache, vomiting and right focal clonic seizures without history of fever, joint pain or altered sensorium. Neuroimaging showed multifocal contrast enhancing lesions with significant perilesional edema. CECT chest and abdomen showed multiple variable sized nodules in the lungs and hypodense lesion in liver with mesenteric lymphadenopathy. There was persistent eosinophilia with maximum upto 35 %. Liver biopsy and brain biopsy revealed Cladophialophora bantiana. He was treated with IV liposomal amphotericin and voriconazole for 6 weeks with repeat neuroimaging showing more than 50 % resolution of the intracranial lesions. He was transitioned to oral combination of flucytosine and voriconazole. At 14 months follow-up, he remained symptom free with complete radiological resolution of the lesions and no eosinophilia. High suspicion, an aggressive approach in obtaining microbiological diagnosis and timely combination antifungal therapy may give satisfactory outcome without surgery.

Meningite criptocócica na gravidez: revisão de aspectos terapêuticos / Cryptococcal meningitis in pregnancy: review of the therapeutic aspects

A criptococose é uma infecção fúngica, cujo envolvimento do sistema nervoso central é caracteristicamente insidioso, apresentando sinais de irritação meníngea, sequelas neurológicas e alta mortalidade. A gestação, condição que leva a certo grau de imunossupressão, pode dificultar a resposta ao tratamento. Objetivando determinar a estratégia de tratamento mais efetiva para meningite criptocócica em grávidas sem outras condições de imunossupressão, o presente trabalho realizou um levantamento bibliográfico acerca do tema. Foram revisados cinco artigos, os quais evidenciaram ampla utilização de anfotericina B em monoterapia ou associada à flucitosina, inclusive no primeiro, segundo e terceiro trimestre de gestação. Também foi relatada a utilização de fluconazol e itraconazol. Em todos os relatos, os resultados foram favoráveis tanto para mãe quanto para a criança. Existem poucos dados disponíveis na literatura acerca do tema proposto. Preferencialmente, a conduta a ser realizada envolve internação da gestante como gravidez de alto risco e administração de anfotericina B. Embora os resultados apresentados tenham sido favoráveis tanto para a monoterapia com anfotericina B quanto para sua associação com flucitosina, ou para monoterapia com fluconazol ou itraconazol, são necessários estudos prospectivos, controlados e randomizados para determinar o esquema terapêutico significativamente mais eficaz para o tratamento da criptococose em gestantes

Cryptococcosis is an infection caused by a fungus, whose involvement in the central nervous system is characteristically insidious, presenting signs of meningitis, neurological sequelae, and high mortality. The pregnancy, a condition that leads to a certain degree of immunosupression, may hinder the response to treatment. With the aim of determining the most effective treatment for cryptococcal meningitis in pregnant women without other causes of immunodeficiency, this paper carried out a survey about the subject. Five articles were analyzed and they showed a wide utilization of amphotericin B as monotherapy or associated with flucytosine in the treatment of cryptococcal meningitis in pregnant women, which includes the usage during the first, second and third trimesters of pregnancy. It was also reported the usage of itraconazole and fluconazol. The results were positive in all articles for both mother and fetus. There are few data available in the literature about this theme. Preferably, the physician should proceed with the admission of the patient as a high-risk pregnancy and should administer amphotericin B. Although the presented results were favorable to monotherapy with amphotericin B and to its association with flucytosine, as well as to monotherapy with fluconazole or itraconazole, only randomized controlled trials will be able to determine the best significantly effective therapeutics for cryptococcosis in pregnant women

Tratamiento de las micosis profundas. Estado actual / Treatment of deep mycosis. Present state

Se hace una revisión de los antifúngicos disponibles en el mercado internacional en la actualidad, se profundiza más en el anfotericín B, con sus virtudes y reacciones adversas, así como de otros antifúngicos, sobre todo los derivados azoles, imidazólicos y los triazoles, como compuestos con buenos resultados y menos reacciones secundarias, en particular el fluconazol y el itraconazol y sus características

Cura biológica de la criptococosis experimental murina con la asociación de anfotericina B y 5 fluorocitosina / Biological cure of murine experimental cryptococcosis with the association of anphotericin B and 5 fluorocytosine

Se evaluó la capacidad de la asociación de anfotericina B (AMB) (6mg/kg/día por medio) con 5-fluorocitosina (5FC)(300mg/kg/día), durante 2 semanas, para producir la cura biológica de la criptococosis esperimental murina. Nueve de 12 (75 por ciento) ratones Balb/C tratados, sacrificados a los 90, 180 y 210 días de evolución (3 en cada oportunidad), presentaron hepatosplenomegalia en forma inconstante y macro, microscopia, histopatología y siembra masiva de cerebro negativas. Los 3 ratones restantes (25 por ciento) murieron espontáneamente a los 81, 148 y 150 días post infección, con presencia, en la mayor parte de ellos, de macro, microscopia, histopatología y siembra masiva de cerebro positivas. Según lo apreciado en este modelo experimental, estudiado hasta los 210 días postinfección, la asociación de AMB con 5FC logró la cura biológica de esta infección experimental por lo menos a nivel de su localización más importante, el sistema nervioso central

Estudio comparativo de 7 tratamientos antifungicos en un modelo experimental de criptococosis murina (1* parte) / Comparative study of 7 antifungal treatment in experimental model of murine cryptococcosis

Se realizó un estudio comparativo de 7 tratamientos antifúngicos en un modelo experimental de criptococosis murina. Fueron inoculados por vía intraperitoneal con 10 células de Cryptococcus neoformans var. neoformans, 100 ratones Balb C, divididos en 10 grupos de 10 animales cada uno. Cinco días después de la infección, 7 grupos recibieron los siguientes tratamientos, durante 2 semanas: anfotericina B (6 mg/kg%día por medio, por vía intraperitoneal), itraconazol, fluconazol y Sch 39.304 (todos ellos a razón de 16 mg/kg/día por gastrocisis), 5-fluorocitosina sola (300 mg/kg/día) y en combinación con anfotericina B y con fluconazol, en iguales dosis y por iguales vías que cuando fueron administradas solas. Los 3 grupos restantes fueron usados como control y recibieron los solventes de las drogas. El tiempo de sobrevida, el aspecto macroscópico de cerebro, higado, pulmones y bazo, la presencia de levaduras capsuladas en el examen microscópico de estos mismos órganos y la siembra masiva de pulmones y cerebro, fueron tomados como parámetros de efectividad de las drogas. La combinación de anfotericina B y 5-fluorocitosina fue el tratamiento más efectivo, ya que produjo la negativización de los exámenes macro y microscópicos como también del 90%de las siembras masivas y prolongó el tiempo de sobrevida más allá de 60 días en todos los animales. La anfotericina B sola fue superior a los compuestos azólicos; con tiempos de sobrevida similares a los de la combinación de anfotericina B con 5-fluorocitosina y negativizó los exámenes macroscópicos, en el 60%de los ratones tratados. El Sch 39.304 mostró los tiempos de sobrevida más largos entre los derivados azólicos. Ninguno de los componentes de este grupo modificó los restantes parámetros estudiados. La asociación de 5-fluorocitosina con fluconazol no mostró mayor efectividad que cuando ambas drogas se administraron separadamente

Anfotericina B no tratamento da neurocriptococose em pacientes submetidos a transplante renal / Amphotericin B in the treatment of neurocryptococcosis in patients subjected to renal transplantation

Foram estudados 35 casos de neurocriptococose, 17 dos quais em pacientes submetidos a transplante renal. O objetivo foi avaliar a resposta terapêutica observada no grupo de pacientes transplantados renais neurocriptococose, com ênfase à funçäo renal, submetidos a esquema medicamentoso que inclui a anfotericina B. A resposta observada foi comparada aos resultados obtidos no grupo dos demais pacientes com a mesma infecçäo, submetidos ao mesmo esquema medicamentoso, porém sem insuficiência renal prévia. Dos 35 paciente, 10 faleceram nos primeiros dias do tratamento e, assim, 25 foram efetivamente tratados para neurocriptococose. Destes 25, 18 apresentavam outra condiçäo clínica associada, sendo esta transplante renal em 15 deles. Os medicamentos utilizados basicamente foram a anfotericina B intravenosa e intra-raqueana associada à 5-fluorocitosina via oral. Sete pacientes faleceram durante o tratamento. Assim, dos 35 pacientes que inicialmente compunham a casuística, 17 faleceram, (48,57%) e 18 foram tratados com sucesso, nenhum deles apresentado recidiva. As intercorrências observadas durante o tratamento säo discutidas e é feita correlaçäo dos dados obtidos neste estudo aos disponíveis na literatura. A análise dos resultados obtidos permite ressaltar: a necessidade do surgimento de medicamentos mais eficazes e menos tóxicos para a terapêutica da neurocriptococose, sendo até o momento a anfotericina B o principal medicamento existente; o esquema terapêutico atualmente indicado consiste na associaçäo anfotericina B e 5-fluorocitosina, havendo vantagens na utilizaçäo simultânea da anfotericina B pelas vias intravenosa e intra-raqueana. A análise dos resultados permite concluir por näo haver contra-indicaçäo ao uso da anfotericina B por via intravenosa em tranpslante renais com neurocriptococose