RESUMO
PURPOSE: Nursing home-acquired pneumonia (NHAP) patients are at higher risk of multi-drug resistant infection (MDR) than those with community-acquired pneumonia (CAP). Recent evidence suggests a single risk factor for MDR does not accurately predict the need for broad-spectrum antibiotics. The goal of this study was to compare the rate antibiotic failure between NHAP and CAP patients. METHODS: Demographic characteristics, co-morbidities, clinical and laboratory variables, antibiotic therapy, and mortality data were collected retrospectively for all patients with pneumonia admitted to an Internal Medicine Service between April 2017 and April 2018. RESULTS: In total, 313 of 556 patients had CAP and 243 had NHAP. NHAP patients were older, and were more likely to be dependent, to have recent antibiotic use, and to experience treatment failure (odds ratio (OR) 1.583; 95% CI 1.102-2.276; p = 0.013). In multivariate analysis, patient's origin did not predict treatment failure (OR 1.083; 95% CI 0.726-1.616; p = 0.696). DISCUSSION: Higher rates of antibiotic failure and mortality in NHAP patients were explained by the presence of other risk factors such as comorbidities, more severe presentation, and age. Admission from a nursing home is not a sufficient condition to start broader-spectrum antibiotics.
RESUMO
Paracoccidioidomycosis (PCM), which is caused by the dimorphic fungus Paracoccidioides spp, is the most prevalent systemic mycosis in immunocompetent individuals in Brazil. The fungus lives in the soil and usually infects the patient through inhalation of airborne propagules, the lungs being the portal of entry. In areas of larger endemicity, such as Brazil, the annual incidence reaches 3 cases per 100,000 inhabitants. Cutaneous lesions in PCM are frequent and ulcer or ulcerous-vegetative lesions are the commonest morphological type, followed by the infiltrative pattern. The histology shows a dermal granulomatous inflammation. Infiltrative PCM can be easily misdiagnosed, once clinical and histological similarities may occur specially with cutaneous sarcoidosis. We describe a case of cutaneous paracoccidioidomycosis misdiagnosed as sarcoidosis both in clinical examination and in the histopathological analysis. Further exams confirmed Paracoccidioides sp. as the causative agent through mycological cultures and Grocott's stain. We believe this case may help physicians around the world to suspect and consider PCM as a differential diagnosis, especially if the patient has traveled to endemic area or the current therapy for sarcoidosis lacks clinical improvement. (AU)
Importância do problema: Paracoccidioidomicose (PCM) é a micose sistêmica mais prevalente em indivíduos imunocompetentes no Brasil, sendo causado pelo fungo dimórfico Paracoccidioides spp. O fungo vive no solo e geralmente sua porta de entrada no paciente ocorre pelos pulmões por inalação de propágulos presentes no ar. Em áreas de maior endemicidade, como no Brasil, a incidência chega a três casos por 100 mil habitantes. As lesões cutâneas na PCM são frequentes. Lesões ulceradas ou ulcerovegetantes são os tipos morfológicos mais comuns, sendo o padrão infiltrativo o segundo mais descrito. A histologia demonstra inflamação granulomatosa na derme. A PCM infiltrativa pode ser facilmente confundida com sarcoidose, visto que ambas possuem similaridades clínicas e histopatológicas. Comentários: Nós descrevemos um caso de PCM cutânea com diagnóstico inicial incorreto de sarcoidose, tanto pelo quadro morfológico, como pelo exame histopatológico semelhante. Exames posteriores revelaram a presença de Paracoccidioides sp na coloração pelo Grocott e na cultura do material para fungos. Os autores acreditam que esse caso possa ajudar médicos a suspeitarem e considerarem PCM no diagnóstico diferencial de lesões cutâneas infiltrativas, especialmente se houver história epidemiológica de viagem a área endêmica ou resposta insatisfatória ao tratamento para sarcoidose. (AU)