Mycetoma, chromoblastomycosis and other deep fungal infections: diagnostic and treatment approach.

PURPOSE OF REVIEW: to review recent advances in the epidemiology, diagnosis, and treatment of deep fungal infections. RECENT FINDINGS: Mycetoma and chromoblastomycosis are the only deep fungal infections incorporated in the list of neglected tropical diseases. These infections start in the skin but progress to deep tissues if not recognized early. A wide array of fungal pathogens are the causative agents. Molecular methods allow for early and accurate identification of the pathogens, but are unfortunately not available in endemic areas. Treatment options are mostly based upon clinical experience rather than on well-designed clinical trials. SUMMARY: Deep fungal infections of the skin and soft tissues are rare conditions of wide world distribution but mostly reported from tropical countries. Urgent need for affordable and easily accessible molecular methods and well-conducted studies to allow for accurate diagnosis and to provide evidence to guide proper therapy are urgently needed.

Mean platelet volume and mean platelet volume to platelet count ratio as predictors of severity and mortality in sepsis.

INTRODUCTION: Sepsis is a public health problem due to its high prevalence and mortality. Mean platelet volume (MPV), a biomarker reported in routine blood counts, has been investigated and shows promise for determining fatal outcomes in septic patients. OBJECTIVE: Evaluate whether the mean platelet volume (MPV) and mean platelet volume-to-platelet count (MPV/P) ratio are predictors of clinical severity and mortality in patients with sepsis. METHODS: A prospective population cohort of 163 patients aged 18-97 years was recruited at the Intensive Care Unit of Pablo Arturo Hospital, Quito, Ecuador from 2017-2019 and followed up for 28 days. Patients were diagnosed with sepsis based on SEPSIS-3 septic shock criteria; in which the MPV and the MPV/P ratio were measured on days 1, 2, and 3. Sequential organ failure assessment (SOFA) score and presence of septic shock assessed clinical severity. Mortality on day 28 was considered the fatal outcome. RESULTS: The average age of the patients was 61,15 years (SD 20,94) and female sex was predominant. MPV cutoff points at days 1, 2 and 3 were >9,45fL, >8,95fL and >8, 85fL; and (MPV/P) ratio >8, 18, >4, 12 y >3, 95, respectively. MPV at days 2 (9,85fL) and 3 (8,55fL) and (MPV/P) ratio at days 1 (4,42), 2 (4,21), and 3 (8,55), were predictors of clinical severity assessed by septic shock, which reached significance in the ROC curves. MPV and (MPV/P) ratio were also predictors of clinical severity determined by SOFA at days 1, 2, and 3, where higher values were observed in non-survivors reaching significance in all categories. MPV and MPV/P ratio at days 1, 2 and 3 were independent predictor factors of mortality using Cox proportional hazards model (HR 2,31; 95% CI 1,36-3,94), (HR 2,11; 95% CI 1,17-3,82), (HR 2,13; 95% CI 1,07-4,21) and (HR 2,38; 95% CI 1,38-4,12), (HR 2,15; 95% CI 1,14-4,06), (HR 4,43; 95% CI, 1,72-11,37) respectively. CONCLUSIONS: MPV and the MPV/P ratio are predictors of clinical severity and mortality in sepsis. The MPV and its coefficient are indicators of the biological behavior of platelets in sepsis. They should be considered as a cost-effective and rapidly available tool that guides the treatment.

Diffuse Multibacillary Leprosy of Lucio and Latapí with Lucio's Phenomenon, Peru.

Diffuse multibacillary leprosy of Lucio and Latapí is mainly reported in Mexico and Central America. We report a case in a 65-year-old man in Peru. He also had Lucio's phenomenon, characterized by vascular thrombosis and invasion of blood vessel walls by leprosy bacilli, causing extensive skin ulcers.

Bedside diagnostics in dermatology: Viral, bacterial, and fungal infections.

Viral, bacterial, and fungal infections are frequently encountered in clinical practice, resulting in numerous cutaneous manifestations. Although diagnosis of these infections has changed over time because of technological advancements, such as polymerase chain reaction, bedside diagnostic techniques still play an important role in diagnosis and management, enabling rapid and low-cost diagnosis and implementation of appropriate therapies. This 2-part article will review both common and infrequent uses of bedside diagnostic techniques that dermatologists can incorporate into daily practice. This article examines the utility of bedside tests for the diagnosis of viral, bacterial, and fungal infections. The second article in this series reviews the use of bedside diagnostics for parasitic and noninfectious disorders.

[Maternal death from severe malaria due to Plasmodium vivax]. / Muerte materna por malaria grave por Plasmodium vivax.

Here we describe the case of a 19-year-old woman, in her 29th week of gestation, who was from Llumpe (Ancash, Peru) and had a history of traveling to Chanchamayo (Junín, Peru) and Rinconada (Ancash, Peru). The patient presented at Chacas Hospital (Chacas, Ancash, Peru) with general malaise, dehydration, respiratory distress, jaundice, the sensation of thermal rise, and abdominal pain. Analysis of blood smears revealed 60% hemoparasites. She was transferred to Ramos Guardia Hospital (Huaraz, Peru) where she presented increasing respiratory distress, choluria, hematuria, and decreased urine output, moreover she was positive for Plasmodium. From there she was transferred to Cayetano Heredia Hospital (Lima, Peru), where she was admitted to the intensive care unit (ICU) with multiple organ failure, stillbirth, and leading to death. She underwent mechanical ventilation, was administered clindamycin, and was prescribed quinine, which she did not received due a lack by availability. The evolution of the illness was torpid, and she ultimately developed multiple organ failure and died. Plasmodium vivax infection was confirmed. Accordingly, we emphasize the importance of improving our diagnostic capabilities and management techniques to enable clinicians to provide adequate and timely treatment.

Muerte materna por malaria grave por Plasmodium vivax / Maternal death from severe malaria due to Plasmodium vivax

RESUMEN Se presenta el caso de una mujer de 19 años con 29 semanas de gestación, procedente de Llumpe (Ancash) con antecedentes de viajes a las localidades de Chanchamayo (Junín) y Rinconada (Ancash). Ingresó al Hospital de Chacas (Ancash) por presentar mal estado general, deshidratación, dificultad respiratoria, ictericia, sensación de alza térmica y dolor abdominal, tuvo reporte de: hemoparásitos 60% en frotis sanguíneo. Fue transferida al Hospital Ramos Guardia (Huaraz) donde presentó mayor dificultad respiratoria, coluria, hematuria, disminución del débito urinario y reporte de Plasmodium (+), luego fue transferida al Hospital Cayetano Heredia (Lima) donde ingresó a la Unidad de Cuidados Intensivos (UCI), con evolución a falla multiorgánica, óbito fetal y muerte materna. Se confirmó infección por Plasmodium vivax. Destacamos la importancia de mejorar nuestras capacidades de diagnóstico y manejo para brindar un tratamiento adecuado y oportuno.

ABSTRACT Here we describe the case of a 19-year-old woman, in her 29th week of gestation, who was from Llumpe (Ancash, Peru) and had a history of traveling to Chanchamayo (Junín, Peru) and Rinconada (Ancash, Peru). The patient presented at Chacas Hospital (Chacas, Ancash, Peru) with general malaise, dehydration, respiratory distress, jaundice, the sensation of thermal rise, and abdominal pain. Analysis of blood smears revealed 60% hemoparasites. She was transferred to Ramos Guardia Hospital (Huaraz, Peru) where she presented increasing respiratory distress, choluria, hematuria, and decreased urine output, moreover she was positive for Plasmodium. From there she was transferred to Cayetano Heredia Hospital (Lima, Peru), where she was admitted to the intensive care unit (ICU) with multiple organ failure, stillbirth, and leading to death. She underwent mechanical ventilation, was administered clindamycin, and was prescribed quinine, which she did not received due a lack by availability. The evolution of the illness was torpid, and she ultimately developed multiple organ failure and died. Plasmodium vivax infection was confirmed. Accordingly, we emphasize the importance of improving our diagnostic capabilities and management techniques to enable clinicians to provide adequate and timely treatment.

Cystoisospora and cyclospora.

PURPOSE OF REVIEW: The present review focuses on recent epidemiological and diagnostic advances in cystoisosporiasis and cyclosporiasis. RECENT FINDINGS: Continuous outbreaks of these parasites occur worldwide. Sporadic cases in the United States are travel acquired, but also domestically acquired. New molecular diagnostic methods allow for accurate early diagnosis in humans, and might potentially decrease the burden of disease by detecting these parasites in vehicles of transmission. SUMMARY: Better understanding of the epidemiology of Cyclospora cayetanensis and to a less extent to Cystoisospora belli has been gained recently. However, several gaps still remain in knowledge on the transmission and on mechanisms of persistent infection in immunosuppressed patients and prevention. New molecular methods might help in filling these gaps and in controlling transmission.

Successful treatment of Balamuthia mandrillaris amoebic infection with extensive neurological and cutaneous involvement.

Granulomatous amoebic encephalitis caused by Balamuthia mandrillaris is an uncommon infection for which there is no optimal therapy. We describe a young, female patient who presented with extensive cutaneous and neurological involvement and who recovered after receiving prolonged treatment with miltefosine, fluconazole, and albendazole.

Cervical tumor caused by the sexually mature stage of Fasciola hepatica.

A 58-year-old man presented with an asymptomatic 5cm left anterior cervical tumor that had been present for over a year. Histological analysis revealed chronic inflammation and granuloma with giant cells surrounding Fasciola hepatica eggs. Fas2 antigen was detected in the tissue by immunohistochemistry. Serology for F. hepatica was positive, but stool examinations were negative and eosinophil count was normal. A month later, the tumor recurred, and an adult parasite was found during excision. The patient received triclabendazole, and after 6 months serology was negative. Erratic localization of F. hepatica reveals a pathology involving chronic inflammation caused by a sexually mature parasite, although according to theory only immature parasites are located in ectopic lesions.

Polymorphism in the rpoT gene in Mycobacterium leprae isolates obtained from Latin American countries and its possible correlation with the spread of leprosy.

The genotypes of Mycobacterium leprae isolates originating from Mexico, Peru and Paraguay were analysed for the polymorphism of short tandem repeats in the rpoT gene. The genotype with four copies of the six-base tandem repeats in the rpoT gene was prominently predominant in Mexico, but the genotype of all isolates from Peru and Paraguay contained three copies of the six-base tandem repeats. These obvious different distributions might reflect the spread of leprosy by the different strains of M. leprae harboured by the various human races that moved to the American continent, as has been demonstrated in other infectious diseases.

Cutaneous anthrax in Lima, Peru: retrospective analysis of 71 cases, including four with a meningoencephalic complication.

Anthrax is a zoonosis produced by Bacillus anthracis, and as an human infection is endemic in several areas in the world, including Peru. More than 95% of the reported naturally acquired infections are cutaneous, and approximately 5% of them can progress to meningoencephalitis. In this study we review the clinical and epidemiological characteristics of the patients with diagnosis of cutaneous anthrax evaluated between 1969 and 2002 at the Hospital Nacional Cayetano Heredia (HNCH) and the Instituto de Medicina Tropical Alexander von Humboldt in Lima, Peru. Seventy one patients were included [49/71 (69%) of them men], with a mean age of 37 years. The diagnoses were classified as definitive (44%) or probable (56%). The most common occupation of the patients was agriculture (39%). The source of infection was found in 63 (88.7%) patients. All the patients had ulcerative lesions, with a central necrosis. Most of the patients (65%) had several lesions, mainly located in the upper limbs (80%). Four patients (5.6%) developed meningoencephalitis, and three of them eventually died. In conclusion, considering its clinical and epidemiological characteristics, cutaneous anthrax must be included in the differential diagnosis of skin ulcers. A patient with clinical suspicion of the disease should receive effective treatment soon, in order to avoid neurological complications which carry a high fatality rate.

Cutaneous anthrax in Lima, Peru: retrospective analysis of 71 cases, including four with a meningoencephalic complication

El ántrax es una zoonosis producida por el Bacillus anthracis y la infección humana es endémica en diversas partes del mundo, incluyendo el Perú. Más del 95% de las infecciones adquiridas naturalmente son cutáneas y aproximadamente 5% de ellas pueden evolucionar para meningoencefalitis. En este estudio revisamos las características clínicas y epidemiológicas de los pacientes con diagnóstico de ántrax cutáneo evaluados entre 1969 y 2002 en el Hospital Nacional Cayetano Heredia (HNCH) y en el Instituto de Medicina Tropical Alexander von Humboldt, en Lima, Perú. Se incluyeron 71 pacientes [49/71 (69%) del sexo masculino], con edad media de 37 años. Los diagnósticos fueron clasificados como definitivos (44%) o probables (56%). La ocupación más frecuente fue la agricultura (39%). La fuente de infección fue identificada en 63 (88.7%) pacientes. Todos presentaron lesiones ulcerativas con necrosis central. La mayoría de ellos (65%) tuvieron lesiones múltiples, principalmente localizadas en miembros superiores (80%). Cuatro pacientes (5.6%) desarrollaron meningoencefalitis y tres de ellos fallecieron. En conclusión, considerando sus particulares características clínicas y epidemiológicas, el ántrax cutáneo debe ser siempre incluido en el diagnóstico diferencial de las lesiones cutáneas ulcerativas. Los pacientes con sospecha clínica de la enfermedad deben recibir tratamiento precoz con el objetivo de evitar complicaciones neurológicas, las cuales presentan elevados índices de fatalidad.

Educational programs to enhance medical expertise in tropical diseases: the Gorgas Course experience 1996-2001.

In 1995, the American Society of Tropical Medicine and Hygiene (ASTMH) adopted defined criteria for accreditation of clinical training programs in tropical diseases. The first data on the development, enrollment, and outcomes of such a program are presented. A nine-week Diploma course, the Gorgas Course in Clinical Tropical Medicine, given on-site in the tropics (Lima, Cusco, and Iquitos, Peru) has trained 157 individuals from 38 countries from 1996 through 2001. The average age of participants was 38.3 with 11.3 years since graduation. Graduates were 44.5% primary care physicians, 22.2% infectious diseases specialists, 12.7% emergency medicine specialists, 13.5% other specialists, and 7.1% nurses. Residents and fellows accounted for 32.8% and full-time academic faculty for 11.0%. Approximately half of all eligible Gorgas graduates have taken the ASTMH certification examination. In response to the enrollees' profiles and needs, adult learning theory has been extensively used in course design. Stable professional relationships between multiple educational partners are required for an endeavor of this scope.

Safety and local tolerability of intramuscularly administered ertapenem diluted in lidocaine: a prospective, randomized, double-blind study versus intramuscular ceftriaxone.

BACKGROUND: Ertapenem is a new, structurally unique, parenteral beta-lactam antimicrobial agent that can be administered once daily. OBJECTIVE: This study compared the local tolerability of ertapenem 1 g once a day administered intramuscularly (IM) versus IM ceftriaxone, with both drugs reconstituted in lidocaine. METHODS: In this prospective, double-blind, multicenter study, adult patients with lower respiratory tract infection, skin infection, or urinary tract infection requiring initial parenteral therapy were randomly assigned in a 3:1 ratio to treatment with IM ertapenem 1 g once daily or IM ceftriaxone 1 g once daily. Although study drugs were administered by unmasked personnel, the patients, investigators, and the sponsor medical reviewer were blinded. Patients who improved clinically could be switched to oral amoxicillin-clavulanate after at least 2 days of IM therapy. Tolerability and safety analyses were carried out for the treated population, and efficacy analyses were performed for the modified intent-to-treat population. RESULTS: A total of 117 patients were randomized. The 87 patients in the ertapenem group and 30 in the ceftriaxone group received IM therapy for a mean duration of 4.1 and 3.8 days, respectively. During treatment, 35.6% (31/87) of patients treated with ertapenem and 43.3% (13/30) of those treated with ceftriaxone experienced > or =1 symptom at the local injection site; the most common symptom was tenderness, followed by pain. Symptoms were moderate to severe in only 1 patient (1.1%) in the ertapenem group and 3 patients (10.0%) in the ceftriaxone group. Clinical drug-related adverse events were reported during IM therapy in 14 patients (16.1%) in the ertapenem group and 5 patients (16.7%) in the ceftriaxone group. Mean +/- SD creatine kinase concentrations, measured in all patients, were 204.8+/-234.8 U/L at the end of IM ertapenem therapy and 382.9+/-721.1 U/L at the end of IM ceftriaxone therapy; at follow-up, values had returned to normal or had decreased in all cases. CONCLUSIONS: Ertapenem 1 g (reconstituted in lidocaine) administered once daily IM was generally well tolerated. The tolerability and safety profiles of IM ertapenem therapy in this study were comparable to those of IM ceftriaxone therapy.

Ofidismo por bothrops pictus en el Hospital Nacional Cayetano Heredia: estudio prospectivo de 23 casos / Ophidism by Bothrops pictus in the Hospital Nacional Cayetano Heredia: prospective study of 23 cases

El presente estudio prospectivo consta de 23 casos de ofidismo hospitalizados en el Servicio de Medicina Tropical del Departamento de Enfermedades Transmisibles y Dermatológicas del Hospital Nacional Cayetano Heredia, dichos pacientes fueron atendidos entre enero de 1990 y abril de 1998, de ellos el 82,6 por ciento eran varones, siendo la media de 37,7 años. Todos identificaron la serpiente agresora como "jergón de la costa" y cinco de ellos pudieron capturar al ofidio, siendo clasificado como bothrops pictus. En los primeros meses de 1988 se tuvo la mayor cantidad de pacientes internados: (ocho pacientes (34.8 por ciento). La mayoría procedieron del cono norte de Lima (61 por ciento). Un 47,8 por ciento fueron agricultores, siendo la mayor cantidad de accidentes botrópicos registrados durante las estaciones de verano y otoño (69,6 por ciento). La mayoría de los accidentes ocurrieron en el campo (47,7 por ciento), y la región más afectada fue en los miembros superiores (65,2 por ciento). El 34,8 por ciento acudió al Hospital periférico dentro de las 6 primeras horas postmordedura, habiendo recibido el 87 por ciento algún tratamiento previo a la admisión, se usó Corticoides intramuscular en un 39,1 por ciento y antibióticos en un 26 por ciento. Los síntomas predominantes fueron dolor y edema local en todos los casos. Entre los signos clínicos hallados predominó aumento de volumen local en un 95,7 por ciento, eritema 87 por ciento, equimosis 47,8 por ciento, impotencia funcional 43,5 por ciento, flictena 21,7 por ciento, necrosis leve 13 por ciento, linfoadenomegalia 8,7 por ciento y cianosis distal 4.3 por ciento. A la admisión se empleó suero antibotrópico polivalente en un 69,6 por ciento, usando la vía endovenosa en el 75 por ciento de casos y la vía intramuscular en sólo el 6,3 por ciento reportándose en un sólo caso reacción adversa. El tiempo de hospitalización fue de 1 a 10 días en el 91,3 por ciento de los pacientes. Como complicación importante se presentó un sólo caso de insuficiencia renal aguda que evolucionó favorablemente (el único paciente derivado de Lambayeque). No se reportó ningún caso fatal.

Tétanos en el Hospital Nacional Cayetano Heredia 1971-1990. Evolución y tratamiento / Tetanus at the Hospital Nacional Cayetano Heredia from 1971 to 1990: Clinical findings, evolution and treatment

Se revisó las historias clínicas de 76 pacientes con tétanos del adulto (>14 años de edad). Al final , 28 casos (36.8//) fueron leves, 12 (15.8 por ciento) moderados, 24 (31.6 por ciento) severos y 12 (15.8 por ciento) muy severos. Las complicaciones más frecuentes fueron neumonía e infección del tracto urinario en 27 casos (35.5 por ciento) cada una y retención urinaria en 24 (31.6 por ciento). El promedio de las dosis máximas de diazepán/día empleadas en los casos severos/muy severos (S/MS) (563 mg/día) estuvo muy por debajo de la recomendada en este hospital (20 mg/kg/día). La letalidad global fue de 34.2 por ciento (26/76). la letalidad para los casos leves fue 3.6 por ciento (1/28), para los moderados 8.3 por ciento (1/12), para los severos 58.3 por ciento (14/24) y 83.3 por ciento (10/12), para los muy severos. La letalidad para el grupo S/MS fue 66.7 por ciento (24/36). Las causas probables de muerte más frecuentes fueron: infección sobreagregada en 9 (34.6 por ciento), hiperactividad simpática en 7 (26.9) y espasmo no controlado en 5 (23.7 por ciento). El número de casos no permitió detectar una diferencia significativa en la letalidad entre los pacientes severos tratados con antitoxina intratecal (25.0 por ciento) vs antitoxina sistémica (60.0 por ciento); entre los atendidos en la unidad de cuidados intensivos (28.6 por ciento) vs otros servicios (64.7 por ciento); ni entre aquéllos tratados con ventilación mecánica (37.5 por ciento) vs sin ella (62.5 por ciento)

Criterios de pronóstico en el tétanos del adulto / Prognostic criteria of tetanus in adults

Se reviso las historias clínicas de 76 pacientes con tétanos del adulto. Los factores asociados significativamente a los casos severos o muy severos fueron: una edad mayor o igual a 70 años, un periodo de incubación menor o igual a 7 dias, un tiempo de enfermedad menor igual a 4 dias y una puerta de entrada quirúrgica. se evaluo tres clasificaciones de pronóstico diferentes. Debido al tamaño pequeño de la muestra, los resultados de letalidad encontrados tienen intervalos de confianza muy amplios, lo que no permite detectar diferencias significativas en la letalidad entre las tres clasificaciones. Consideramos que la clasificación que toma en cuenta el tiempo de enfermedad y la presencia de espasmos, es la mas simple y facil de reproducir en el medio urbano y urbano-marginal