Cryptococcoma hipofisiario: un extraño caso de hipofisitis granulomatosa secundaria / Pituitary cryptococcoma: a strange case of secondary granulomatous hypophysitis

Resumen La hipofisitis es una afección con baja incidencia y prevalencia. Asimismo, las infecciones profundas por hongos en pacientes inmunocompetentes también re presentan un fenómeno infrecuente. Más raro aún es el caso que se describe a continuación, en donde se conjugan estos dos elementos mencionados, a saber: cryptococcoma hipofisario o hipofisitis granulomatosa causado por dicho patógeno en un huésped sin altera ción de la respuesta inmune. Luego de una búsqueda realizada en PubMed, existen limitados casos en la literatura médica de hipofisitis granulomatosa por Cryptococcus spp., que simuló por manifestaciones clínicas e imagenológicas un macro adenoma hipofisario. No encontramos informes en los que no haya evidencia de afectación del tejido meníngeo. La etiología micótica está escasamente descrita en las guías de referencia para hipofisitis y creemos que Cryp tococcus spp. debe ser tenido en cuenta en el diagnóstico diferencial de las hipofisitis granulomatosas secundarias dado que es un patógeno ubicuo y el tratamiento es sustancialmente diferente a otras entidades. Cobra mayor relevancia ante la tendencia actual al uso de glucocorticoides sistémicos a altas dosis para el tratamiento de la hipofisitis, que podría haber gene rado mayor daño de no haberse hecho el diagnóstico correcto.

Abstract Hypophysitis is a pathology with low incidence and prevalence. Likewise, deep fungal infections in immuno competent patients also represent a rare phenomenon. Even rarer is the case described below, where these two mentioned elements are combined, namely: pituitary cryptococcoma or granulomatous hypophysitis caused by said pathogen in a host without altered immune response. After research in PubMed, there are limited cases in the medical literature of granulomatous hypophysitis caused by Cryptococcus spp., which simulated a pituitary macroadenoma by clinical and imaging manifestations. We did not find reports in which there is no evidence of involvement of the meningeal tissue. The fungal etiology is scarcely described in the reference guidelines for hypophysitis and we believe that Cryptococcus spp. it should be taken into account in the differential diagnosis of secondary granuloma tous hypophysitis since it is a ubiquitous pathogen and the treatment is substantially different from other entities. It becomes more relevant given the current trend towards the use of high-dose systemic glucocorticoids for the treatment of hypophysitis, which could have generated greater damage if the correct diagnosis had not been made.

Herpes Simplex Virus Esophagitis in an Immunocompetent Patient

We present the case of a 17-year-old patient with no known comorbidity or history who was admitted due to dysphagia. Endoscopy revealed ulcerated lesions in the distal esophagus that were positive for herpes simplex virus type 1 (HSV-1) on immunohistochemistry. An examination of HSV-1 esophagitis in the immunocompetent patient is made.

Se presenta el caso de un paciente de 17 años sin ninguna comorbilidad ni antecedente conocido que ingresó por disfagia. La endoscopia reveló lesiones ulceradas en el esófago distal que resultaron positivas para virus del herpes simple tipo 1 (VHS-1) en la inmunohistoquímica. Se hace una revisión de la esofagitis por VHS-1 en el paciente inmunocompetente.

Histoplasmosis e infección por SARS-CoV-2 en un paciente críticamente enfermo

Introducción: La histoplasmosis es causada por el hongo dimórfico Histoplasma capsulatum, cuyas manifestaciones clínicas varían desde un cuadro asintomático hasta una enfermedad diseminada y altamente mortal. Objetivo: Presentar el caso de un paciente con diagnóstico de histoplasmosis diseminada e infección por SARS-CoV-2. Caso clínico: Se presenta el caso de un hombre de 79 años con antecedentes de hipertensión arterial sistémica y diabetes mellitus tipo 2. Ingresa por tos no productiva de una semana de evolución, disnea y fatiga de medianos esfuerzos; refiere tener prueba de antígeno positivo para infección por SARS-CoV-2. Durante la hospitalización presenta un deterioro clínico, dado por necesidad de ventilación mecánica, por infección respiratoria asociada a la COVID-19. Además, presenta adenopatías, hepatoesplenomegalia y pápulas umbilicadas del color de la piel sugestivas de infección fúngica diseminada. Ante e la sospecha de coinfección, se confirma la infección por Histoplasma capsulatum por medio de minilavado broncoalveolar e inicia tratamiento antifúngico; sin embargo, el paciente presenta deterioro clínico persistente y fallece. Conclusión: Los casos de coinfecciones con la COVID-19 en pacientes sin enfermedades crónicas o estados de inmunosupresión son escasos, es un reto para el personal médico su diagnóstico y requiere tener en cuenta infecciones micóticas pulmonares como la criptococosis o la histoplasmosis en la insuficiencia respiratoria asociada a la infección por el SARS-CoV-2.

Introduction: Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum, whose clinical manifestations range from asymptomatic to disseminated and highly fatal disease. Objective: To present the case of a patient diagnosed with disseminated histoplasmosis and SARS-CoV-2 infection. Clinical case: The case of a 79-year-old man is presented with a history of systemic arterial hypertension and type 2 diabetes mellitus. He was admitted for a week with nonproductive cough, dyspnea, and fatigue on moderate exertion, and reported having a positive antigen test for SARS- CoV-2. During hospitalization, he presented clinical deterioration, needing mechanical ventilation due to respiratory infection associated with COVID-19. Despite this, he presented lymphadenopathy, hepatosplenomegaly, and umbilicated skin-colored papules suggestive of disseminated fungal infection. Suspecting co-infection, infection by Histoplasma capsulatum was confirmed by means of mini-bronchoalveolar lavage and antifungal treatment was initiated; however, the patient presented persistent clinical deterioration and died. Conclusion: Cases of co-infections with COVID-19 in patients without chronic diseases or immunosuppressive states are rare, their diagnosis being a challenge for medical personnel and requiring consideration of pulmonary fungal infections such as cryptococcosis or histoplasmosis in associated respiratory failure. to SARS-CoV-2 infection.

Absceso en miocardio secundario a neumonía adquirida en la comunidad por Pseudomona aeruginosa en lactante inmunocompetente: reporte de caso / Myocardial abscess secondary to community acquired Pseudomona aeruginosa pneumonia in an immunocompetent infant: case report

La Pseudomona aeruginosa es una causa importante de infecciones asociadas a la atención de la salud y en las neumonías adquiridas en la comunidad, rara vez se identifica como el agente patógeno, siendo estas de progresión rápida y de mal pronóstico. Se trata de un menor de un año de edad inmunocompetente el cual fallece en casa una semana después de una lesión en la planta del pie derecho que según familiares le sacaron "pus", tratado con antinflamatorios y analgésicos. Se le realizó necropsia que evidenció cicatriz en planta de pie derecho sin lesiones traumáticas. Pulmones de consistencia indurada, con adherencias y áreas que impresionan necróticas, asociada a efusión pleural. El estudio histológico reportó un proceso infeccioso pulmonar agudo abscedado que se diseminó por continuidad a tejido cardiaco y en estudios microbiológicos de pulmón y bazo se reportó Pseudomona aeruginosa.

Pseudomona aeruginosa is an important cause of health care-associated infections and in community-acquired pneumonias, it is rarely identified as the pathogenic agent, being of rapid progression and poor prognosis. This is a one-year-old immunocompetent minor who died at home one week after a lesion in the sole of the right foot which, according to family members, caused "pus", treated with anti-inflammatory and analgesic drugs. A necropsy was performed, which showed a scar on the sole of the right foot with no traumatic lesions. Lungs of indurated consistency, with adhesions and areas that appear necrotic, associated with pleural effusion. The histological study reported an abscessed acute pulmonary infectious process that spread by continuity to cardiac tissue and microbiological studies of lung and spleen reported Pseudomona aeruginosa.

Complicaciones ORL severas por mononucleosis infecciosa en adolescentes sanos: 2 casos clínicos y revisión de la literatura / ENT severe complications of infectious mononucleosis in healthy adolescents: report of two cases and literature review

Resumen La mononucleosis infecciosa (MI) es un cuadro clínico generalmente benigno y autolimitado en la infancia y adolescencia debido a la primoinfección del virus de Epstein-Barr caracterizado por la triada de faringitis, fiebre y adenopatías. El riesgo de complicaciones aumenta con la edad y la inmunosupresión, siendo las complicaciones letales más frecuentes las asociadas a rotura esplénica, alteraciones neurológicas y obstrucción de la vía aérea por el aumento del tamaño amigdalar. Los abscesos cervicales asociados a MI son poco frecuentes, siendo mayoritariamente periamigdalinos e intraamigdalares. Presentamos dos casos quirúrgicos de abscesos cervicales profundos de gran tamaño con afectación retrofaríngea y parafaríngea en adolescentes sanos de corta edad (14 y 15 años), sin ningún tipo de inmunosupresión o factores de riesgo, uno de ellos asociado además, a una relevante hemorragia amigdalar espontanea, condición no descrita previamente en la literatura en relación a MI en un paciente tan joven.

Abstract Infectious mononucleosis (MI) is a generally benign and self-limited condition in childhood and adolescence due to the primary EBV infection characterized by the triad of pharyngitis, fever, and lymphadenopathies. The risk of complications increases with age and immunosuppression. The most frequent fatal complications are those associated with splenic rupture, neurological alterations, and airway obstruction due to increased tonsillar size. Cervical abscesses associated with MI are rare, being mostly peritonsillar and intra-tonsil. We present two surgical cases of big deep cervical abscesses with retropharyngeal and parapharyngeal involvement in healthy very young adolescents (14 and 15 years old), without any type of immunosuppression or risk factors, one of them associated with a clinically relevant spontaneous tonsillar bleeding, which had not been described in the literature associated with MI in such young patient.

Characteristics and oncological results of epidermoid anal carcinoma: Comparison analysis between immunocompetent and immunosuppressed patients.

OBJECTIVE: Most evidence, including recent randomized controlled trials, analysing anal squamous cell carcinoma (SCC) do not consider immunocompromise patient population. The aim of this study was to compare clinical and oncological outcomes among immunocompetent and immunocompromised patients with anal squamous cell carcinoma. METHOD: Multicentric retrospective comparative study including 2 cohorts of consecutive patients, immunocompetent and immunocompromised, diagnosed with anal SCC. This study evaluated clinical characteristics, clinical response to radical chemoradiotherapy (CRT) and long-term oncological results including both local and distant recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 84 patients, 47 (55.6%) female, diagnosed with anal SCC from January 2012 to December 2017 were included, 22 (26%) and 62 (74%) patients in immunocompromised and immunocompetent groups respectively. Patients in immunocompromised group were significantly younger (53 vs. 61 years; P = 0.001), with smaller tumoral size (P = 0.044) and reported higher rates of substance abuse including tobacco use (P = 0.034) and parenteral drug consumption (P = 0.001). No differences were found in administered therapies (P = 301) neither in clinical response to chemoradiotherapy (83 vs. 100%). Moreover, similar 5-year OS (60 vs. 64%; P = 0.756) and DFS (65 vs. 68%; P = 0.338) were observed. CONCLUSION: The present study shows no significant differences in long-term oncological results among immunocompetent and immunocompromised patients diagnosed with anal SCC, with a similar oncologic treatment. This evidence might be explained due to the close monitoring and adequate therapeutic control of HIV positive patients.

Characteristics and oncological results of epidermoid anal carcinoma: Comparison analysis between immunocompetent and immunosuppressed patients. / Características y resultados oncológicos del carcinoma epidermoide de ano: análisis comparativo entre los pacientes inmunocompetentes y los inmunodeprimidos.

OBJECTIVE: Most evidence, including recent randomized controlled trials, analysing anal squamous cell carcinoma (SCC) do not consider immunocompromise patient population. The aim of this study was to compare clinical and oncological outcomes among immunocompetent and immunocompromised patients with anal squamous cell carcinoma. METHOD: Multicentric retrospective comparative study including 2 cohorts of consecutive patients, immunocompetent and immunocompromised, diagnosed with anal SCC. This study evaluated clinical characteristics, clinical response to radical chemoradiotherapy (CRT) and long-term oncological results including both local and distant recurrence, overall survival (OS) and disease-free survival (DFS). RESULTS: A total of 84 patients, 47 (55.6%) female, diagnosed with anal SCC from January 2012 to December 2017 were included, 22 (26%) and 62 (74%) patients in immunocompromised and immunocompetent groups respectively. Patients in immunocompromised group were significantly younger (53 vs. 61 years; P=0.001), with smaller tumoral size (P=0.044) and reported higher rates of substance abuse. including tobacco use (P=0.034) and parenteral drug consumption (P=0.001). No differences were found in administered therapies (P=301) neither in clinical response to chemoradiotherapy (83 vs. 100%). Moreover, similar 5-year OS (60 vs. 64%; P=0.756) and DFS (65 vs. 68%; P=0.338) were observed. CONCLUSION: The present study shows no significant differences in long-term oncological results among immunocompetent and immunocompromised patients diagnosed with anal SCC, with a similar oncologic treatment. This evidence might be explained due to the close monitoring and adequate therapeutic control of HIV positive patients.

Absceso cerebral por Nocardia sp. En un paciente inmunocompetente en el Perú: reporte de caso / Brain abscess due to Nocardia sp. In an immunocompetent patient in Peru: a case report

RESUMEN La nocardiosis cerebral es una entidad rara que ha sido reportada principalmente en inmunosuprimidos, y en la actualidad no se dispone de guías clínicas que recomienden un tratamiento de primera línea. Presentamos el caso de un adulto mayor, inmunocompetente, con cuadro de encefalopatía y hemiparesia izquierda, asociado a lesiones compatibles con absceso cerebral múltiple y sugerente de etiología infecciosa. Recibió, inicialmente, tratamiento para la tuberculosis, absceso bacteriano y toxoplasmosis, sin respuesta clínica favorable. Se inició un tratamiento empírico para la nocardiosis con meropenem y trimetoprim/sulfametoxazol, y se logró mejoría clínica e imagenológica. La ocurrencia de eventos adversos obliga el uso temporal de medicamentos alternativos. Se resaltan algunos criterios a considerar para incluir la nocardiosis en el diagnóstico diferencial en los casos de absceso cerebral múltiple y se mencionan los métodos diagnósticos de laboratorio y los fármacos para iniciar un tratamiento empírico.

ABSTRACT Cerebral nocardia infections is a rare entity, which has been mainly reported in immunosuppressed patients. Currently, there are no clinical guidelines for first-line treatment. Our case refers to an older immunocompetent adult, with encephalopathy and left hemiparesis, associated with lesions compatible with multiple brain abscess and suggestive of infectious etiology. He initially received treatment for tuberculosis, bacterial abscess, and toxoplasmosis, without a favorable clinical response. An empirical treatment for nocardiosis started, by using meropenem and trimethoprim / sulfamethoxazole, and clinical and imaging improvement was achieved. The occurrence of adverse events forces the temporary use of alternative medications. We highlight some criteria for including nocardiosis in the differential diagnosis in cases of multiple brain abscess and mention laboratory diagnostic methods and drugs to initiate empirical treatment.

A rare cause of headache and fever in a healthy woman / Una rara causa de cefalea y fiebre en una mujer sana

Abstract Cryptococcocis is a fungal infection that primarily affects immunocompromised hosts; disseminated infection is uncommon in immunocompetent patients. We describe a case of a previously healthy woman without risk factors, who was admitted to the emergency department with headache, fever and altered mental status. As a result, a cryptococcal disseminated infection was diagnosed.

Resumen La criptococosis es una infección por hongos que afecta principalmente a huéspedes inmunodeprimidos; la infección diseminada es infrecuente en pacientes inmunocompetentes. Reportamos el caso de una mujer previamente sana, sin factores de riesgo, ingresada a urgencias por cefalea, fiebre y alteración del estado mental quien posteriormente fue diagnosticada con criptococosis diseminada.

Poliartritis séptica y fascitis necrotizante en un paciente inmunocompetente. Reporte de caso / Septic polyarthritis and necrotizing fascitis in an immunocompetent patient. Case report

La presentación de poliartritis séptica en un paciente inmunocompetente es infrecuente, aún más lo es la presentación de la mencionada junto con fascitis necrotizante en el contexto de infección por Streptococcus Pyogenes (SP). Se presenta el caso de un paciente masculino de 54 años, recluido, sin antecedentes médicos relevantes, inmunocompetente, quien debuta con un cuadro clínico de poliartritis séptica en rodilla bilateral y tobillo izquierdo. Recibe manejo con múltiples lavados y desbridamientos quirúrgicos, desarrolla fascitis necrotizante de la cara posterior de la pierna izquierda, recibe a su vez manejo quirúrgico para dicha condición (incluyendo aplicación de terapia de vacío), al igual que antibioticoterapia enfocada al manejo del germen aislado (Penicilina + vancomicina). Sin embargo, tras un mes de manejo conjunto con servicios de Cirugía Plástica, Dermatología, Ortopedia, así como vigilancia en Unidad de Cuidados Intensivos, termina con un desenlace fatal tras presentar falla multiorgánica. La infección por el SP puede resultar en una elevada morbilidad para él paciente e incluso un desenlace mortal secundario a un compromiso sistémico de muy difícil manejo. El diagnóstico oportuno, así como un tratamiento médico y quirúrgico agresivo pueden no ser suficientes para el control de la infección, incluso en pacientes sin compromiso inmunológico previo. Asimismo, un enfoque multidisciplinario debe corresponder al estándar de manejo con el fin de controlar aquellas condiciones predisponentes de infección. Este es el primer caso reportado en la literatura nacional en relación con estas dos fatales condiciones. Finalmente se pretende resaltar que a pesar de que esta infección suele comprometer infantes y pacientes inmunocomprometidos, no se debe obviar su diagnóstico en pacientes previamente sanos, especialmente en casos de infecciones de rápida diseminación y poca respuesta al manejo adecuado.

Septic polyarthritis in an immunocompetent patient is highly rare, even more when it coexists with necrotizing fasciitis caused by Streptococcus Pyogenes (SP). A 54 year old, immunocompetent male patient is presented herein. The patient had no relevant previous illness, before the installation of a septic arthritis of both knees and he's left ankle. He receives treatment with sequential surgical debridement, then develops necrotizing fasciitis of the posterior aspect of the left leg requiring adequate treatment for such condition (including Vacuum Assisted Closure), as well as antibiotic therapy for the specific infecting microorganism (Penicillin + Vancomycin). Nonetheless, after a month of surgical management between Plastic Surgery, Dermatology, Orthopaedics as well as surveillance in the Intensive Care Unit, the patient dies after multi organic failure. Infection caused by SP might entail high morbidity for a patient and even end with death of the aforementioned caused by a hard to manage systemic organic failure. The adequate diagnosis, as well as aggressive medical and surgical management could not be enough for controlling the infection, even in patients without previous immunological compromise. At the same time, a multidisciplinary approach must be the standard of treatment, aiming to control predisposing infectious conditions. This is the first case reported in national literature related to these two fatal conditions. Finally, one of the purposes of this report is to highlight that despite reports of this microorganism infecting infants and immunocompromised patients, it must not be obviated in healthy patients, especially in cases of rapidly spreading infection and scarce response to adequate management.

Onicomicosis en paciente inmunocompetente por Aspergillus sección Candidi / Onychomycosis in immunocompetent patient by Aspergillus section Candidi

Introducción: los hongos miceliales no dermatofitos (HMND) pueden causar un gran número de infecciones, entre ellas, la onicomicosis. Su implicancia como agentes patógenos y su significado clínico en esta afección, se encuentran sujetos al cumplimiento de los criterios de Walshe y Mary P. English. Presentamos un caso de onicomicosis causada por un hongo hifomiceto poco frecuente, del género Asper-gillus sección Candidi, en una paciente inmunocompetente y su estrategia terapéutica. Materiales y métodos: se estudió una paciente inmunocompetente, de 43 años de edad, con lesión en uña de primer dedo del pie derecho, de 10 años de evolución. Se realizó toma de muestra para examen micológico. Resultados: el examen directo reveló la presencia de hifas hialinas irregulares, ramificadas y tabica-das, compatibles con HMND. En muestras seriadas, desarrollaron colonias blanco algodonosas, cuya micromorfología fue concordante con Aspergillus sección Candidi. La identificación fue confirmada en la Unidad de Micología del Hospital de Infecciosas Francisco Javier Muñiz de la Ciudad Autónoma de Buenos Aires, Argentina. Allí también se realizaron pruebas de sensibilidad a antifúngicos, resultando sensible a itraconazol y terbinafina. Conclusión: exponemos un caso de onicomicosis causada por Aspergillus sección Candidi, HMND no queratinolítico, de escasa frecuencia de aparición, siendo el primer caso descripto y publicado en Argentina. También se planteó una estrategia terapéutica efectiva, que condujera a la cura clínica y microbiológica, de la uña de la paciente.

Introduction: non-dermatophyte mycelial fungi (HMND) can cause a large number of infections, including onychomycosis. Its implica-tion as pathogens and its clinical significance in this condition are subject to compliance with Walshe's and Mary P. English's criteria. We present a case of onychomycosis caused by hyphomycete rare fungus, of the genus Aspergillus section Candidi, in an immunocompetent patient and its therapeutic strategy. Materials and methods: a 43-year-old immunocompetent patient with a 10-year-old right-toe nail lesion was studied. Samples were taken for mycological examination. Results: the direct examination revealed the presence of irregu-lar, branched and tabulated hyaline hyphae, compatible with HMND. In serial samples, they developed white cotton colonies, whose micromorphology was consistent with Aspergillus, section Candidi. The identification was confirmed at the Mycology Unit of Francisco Javier Muñiz Infectious Hospital in the Autonomous City of Buenos Aires, Argentina. Susceptibility to antifungals was also tested there, resulting in susceptibility to itraconazole and terbinafine. Conclusion: we present a case of onychomycosis caused by Aspergillus section Candidi, non-keratinolytic HMND, of rare occurrence, being the first case described and published in Argentina. An effective therapeutic strategy was also proposed that led to the patient's toenail's clinical and microbiological cure.

Vittaforma Corneae keratoconjunctivitis: An emerging pathology among travelers returning from Southeast Asia. / Queratoconjuntivitis por Vittaforma corneae: una enfermedad emergente entre los viajeros que regresan del sudeste asiático.

Microsporidium keratoconjunctivitis is an very rare disease. It is related to outbreaks in Asia due to exposure to contaminated water or soil. Microsporidium keratoconjunctivitis is a a self-limited disease, but it could have long term courses. We present the case of a 29 year old woman who started with pain, redness and blurred vision after a holiday in Singapore and did not respond to conjunctivitis treatment. PCR sequencing and PAS staining of corneal epithelial biopsy identified Vittaforma corneae as the causative organism. Treatment was initiated with corneal debridement, oral albendazol, and intensive topical voriconazole, levofloxacin and propamidine, but the conjunctival and corneal disease was only resolved 5 months later with the introduction of topical steroids to treat her severe limbitis. Suspicion of Microsporidium keratoconjunctivitis should be raised amongst ophthalmologists in unilateral keratitis with mild conjunctivitis in travelers from Asia.

Endocarditis bacteriana por Kocuria kristinae en un paciente inmunocompetente. Reporte de caso / Bacterial endocarditis by Kocuria kristinae in an immunocompetent patient. Case report

Los miembros del género Kocuria corresponden a cocos Gram positivos ubicuos, generalmente inocuos y que hacen parte de la flora saprófita de un porcentaje importante de la población; ocasionalmente han sido descritos como los agentes responsables de patologías infecciosas, principalmente dentro del contexto de pacientes que concomitantemente cursan con enfermedades crónicas y estados de inmunosupresión. Son escasos los casos reportados como causa de endocarditis en pacientes inmunocompetentes a nivel global por especies de este género. Se expone el caso de una mujer inmunocompetente de 44 años, sin antecedentes de importancia, en quien solo el diagnóstico microbiológico permitió confirmar la presencia de Kocuria kristinae como agente causal de su endocarditis infecciosa; la literatura señala la dificultad existente al momento de diferenciar la endocarditis producida por Staphylococcus spp. versus Kocuria kristinae por su evolución clínica similar, indicando la importancia de la microbiología al momento de identificar y diagnosticar apropiadamente.

Members of the genus Kocuria correspond to ubiquitous, generally harmless, Gram-positive cocci that are part of the saprophytic flora of a significant percentage of the population; occasionally they have been described as the agents responsible for infectious pathologies, mainly in the context of patients who concomitantly have chronic diseases and are under an immunosuppression state. There are few cases reported as a cause of endocarditis in immunocompetent patients globally by species of this genus. We present the case of a 44-year-old immunocompetent woman, with no relevant history, in whom only the microbiological diagnosis confirmed the presence of Kocuria kristinae as the causative agent of her infectious endocarditis; Literature points out the difficulty existing when differentiating endocarditis produced by Staphylococcus spp. versus Kocuria kristinae because of their similar clinical evolution, indicating the importance of microbiology when identifying and diagnosing accurately.

Artritis séptica por Streptococcus equi: reporte de un caso y revisión de la literatura / Septic arthritis due to Streptococcus equi: a case report and review of the literatura

En humanos las infecciones producidas por Streptococcus equi son de rara ocurrencia, tienen una amplia variedad de formas de presentación, incluyendo compromiso articular, el cual ha sido pocas veces descrito en humanos y aún menos en pacientes inmunocompetentes. En este artículo se presenta un caso de artritis séptica por S. equi que ocurrió por una exposición ocupacional en un paciente inmunocompetente y la revisión de la literatura relacionada.

Human infections caused by Streptococcus equi are rare, have a wide variety of forms of presentation, including joint involvement, which has been rarely described in humans and even less in immunocompetent patients. In this article we present a septic arthritis case due to S. equi that occurred due to an occupational exposure in an immunocompetent patient, and a review of the related literature as well. The publication of this case report was accepted by the institutional ethics committee and the consent signed by the patient was obtained.

Spinal epidural abscess caused by Streptococcus agalactiae in an immunocompetent patient. / Absceso epidural espinal por Streptococcus agalactiae en un paciente inmunocompetente.

BACKGROUND: Streptococcus agalactiae is an uncommon microorganism that causes spinal epidural abscess (SEA) and usually affects individuals with a predisposing condition or potential source of infection. CASE DESCRIPTION: We present the case of an immunocompetent 53-year-old patient with an unremarkable past medical history who developed progressive low extremity weakness, bowel and bladder dysfunction and genital sensory impairment. A neurological exam on admission revealed flaccid proximal paraparesis, T10 sensory level, atonic anal sphincter and normal myotatic reflexes. Urgent neuroimaging showed a large thoracic epidural spinal abscess. Laminectomy and abscess drainage were immediately performed and systemic antibiotic treatment was initiated. Abscess cultures revealed Streptococcus agalactiae. After an exhaustive workup no predisposing factors or local or systemic source for the infection were found. CONCLUSIONS: We report a singular case of spinal epidural abscess caused by Streptococcus agalactiae in a healthy patient with no predisposing factors. This case also highlights the importance of an early diagnosis and treatment to obtain a better neurological outcome.

Criptococosis Cutánea Primaria / Primary Cutaneous Cryptococcosis

RESUMEN La Criptococosis es una infección crónica que afecta a pacientes inmunucompetentes e inmunodeprimidos; producida por la levadura encapsulada del hongo Criptococo neoformans. Afecta principalmente al pulmón, a partir del cual puede diseminarse. La forma cutánea se divide en primaria cuando es producida por inoculación directa del hongo, y secundaria como consecuencia de un foco a distancia. Presentamos el caso clínico de un paciente de sexo masculino de 57 años de edad inmunocompetente, con diagnóstico de Criptococosis cutánea primaria, forma de presentación poco frecuente.

ABSTRACT Cryptococcosis is a chronic infection that affects immunocompetent and immunosuppressed patients caused by the encapsulated yeast Cryptococcus neoformans. It primarily affects the lungs and it may disseminate. The cutaneous form is divided into primary, occurring after direct inoculation or secondary, due to dissemination from a distant site of infection. We present a case of a 57 years-old immunocompetent male with primary Cutaneous Cryptococcosis which is infrequent.

[Uncommon mycoses]. / Micosis infrecuentes.

BACKGROUND: Fungal infections should be suspected in severe wounds that have been contaminated with organic material or soil, even when the patient is immunocompetent. The aim of this article is to contribute to a better understanding and knowledge of the antifungal sensitivity and epidemiology of some rare pathogens that may trigger severe infections. CASE REPORT: Four different moulds were isolated from the wounds of an immunocompetent woman who was involved in a road accident: Lichtheimia corymbifera, Scedosporium boydii, Fusarium solani and Purpureocillium lilacinum. Some of them were isolated from different sites. A profile of in vitro resistance was performed with an Epsilometer (Etest™) using five antifungal agents: voriconazole, posaconazole, itraconazole, anidulafungin an amphotericin B. The results obtained were consistent with those from other cases reported in the literature. CONCLUSIONS: Early aggressive surgery, antifungal therapy and, above all, frequent debridement of necrotic tissue, are the tools against filamentous fungi infections. Antifungal sensitivity of any mould involved in an infection has to be determined, in order to a better understanding of these rare pathogens whose incidence is increasing.

[Obstructive tracheobronchitis due to Aspergillus fumigatus in an immunocompetent patient]. / Traqueobronquitis obstructiva por Aspergillus fumigatus en un paciente inmunocompetente.

BACKGROUND: Aspergillus tracheobronchitis (ATB) is an uncommon type of invasive pulmonary aspergillosis in which fungal involvement is limited to the tracheobronchial tree. While the more severe forms, such as pseudomembranous and ulcerative ATB, occur almost exclusively in immunocompromised patients, the milder obstructive form may occur in patients without immune deficiency. CASE REPORT: The case of a 32 year-old man with no previous history of illness, who was evaluated for recurrent right lower lobe pneumonia, is presented. Microbiological sputum studies revealed growth of Serratia marcescens, and a limited growth of Aspergillus fumigatus, the latter interpreted as a contaminant in the specimen. Bronchoscopy revealed a dense mucous plug at level B10 of the right lower lobe, which could not be removed; no other macroscopic findings of interest were observed. During his hospital admission, the patient expectorated the mucous plug and had a significant subsequent bronchorrhoea. A substantial number of colonies of A. fumigatus grown in the sputum cultures. The patient was given voriconazole, leading to a clinical resolution, with no recurrences. CONCLUSIONS: Obstructive ATB is characterised by the excessive production of thick, hyphae-laden mucus, which can obstruct the airway lumen and generate relapsing post-obstructive pneumonias. It is important to consider this diagnosis in immunocompetent patients with recurrent respiratory infections and who show repeated isolation of Aspergillus colonies in the sputum, even in small quantities.

Absceso glúteo por Rhodococcus Equi: presentación atípica de enfermedad emergente / Gluteus abscess due to RhodococcusEqui: atypical presentation of emerging disease

Resumen Rhodococcusequi, bacteria aislada principalmente en potros, se considera en la actualidad un patógeno zoonótico emergente en seres humanos, la mayoría inmunocomprometidos, coincidiendo con la epidemia de VIH y los avances en la medicina de trasplantes y la quimioterapia del cáncer, lo que justifica la revisión sobre su patogenia, características clínicas, diagnóstico y tratamiento. Más frecuente en hombres que en mujeres, el inicio de las infecciones es generalmente insidioso y los síntomas que presentan varían según el sitio de la infección, la enfermedad respiratoria, caracterizada por neumonía necrosante es la manifestación más común, y tiende a seguir un curso subagudo, mientras las personas inmunocompetentes son afectadas con baja frecuencia y suelen presentarse con enfermedad localizada. Las infecciones de la piel o partes blandas, incluyendo abscesos, son poco frecuentes incluso en huéspedes inmunocomprometidos y están usualmente relacionadas con contaminación ambiental. El laboratorio de microbiología juega un papel clave en la identificación del organismo, ya que este puede confundirse con flora normal de la piel. El caso que se presenta corresponde a una paciente adulta inmunocompetente, con infección de herida quirúrgica por R equiluego de una cirugía estética, requirió tratamiento antibiótico, múltiples lavados quirúrgicos y debridamientos, más drenaje de absceso, con mejoría del proceso infeccioso. Este caso sugiere la importancia clínica de la identificación precisa de patógenos inusuales, capaces de entorpecer la evolución normal de un proceso quirúrgico y de producir un alto costo de atención de salud y el alcance medidas preventivas relacionadas con la vigilancia de la salud.

Abstract Rhodococcusequi, a bacterium isolated mainly in foals, is currently considered an emerging zoonotic pathogen in humans, most of them immunocompromised, coinciding with the HIV epidemic and advances in transplant medicine and cancer chemotherapy, which justifies the review on its pathogenesis, clinical characteristics, diagnosis and treatment. More frequent in men than in women, the onset of infections is usually insidious and the symptoms they present vary according to the site of infection, the respiratory disease, characterized by necrotizing pneumonia is the most common manifestation, and tends to follow a subacute course , while immunocompetent people are affected with low frequency and usually have localized disease. Infections of the skin or soft tissues, including abscesses, are rare even in immunocompromised hosts and are usually related to environmental contamination. The microbiology laboratory plays a key role in the identification of the organism, since it can be confused with normal flora of the skin. The case presented corresponds to an adult immunocompetent patient, with surgical wound infection by R equiafter cosmetic surgery, required antibiotic treatment, multiple surgical washes and debridements, and abscess drainage, with improvement of the infectious process. This case suggests the clinical importance of the precise identification of unusual pathogens, capable of obstructing the normal evolution of a surgical process and of producing a high cost of health care and the scope of preventive measures related to health surveillance.

Neumonia por Pneumocystis jirovecii en niño inmunocompetente: revisión de un caso / Pneumocystis jirovecii in immunocompetent children: a case report

We describe an unusual case of severe pneumonia due to Pneumocystis jirovecii in a previously healthy 2-month-old patient who had been hospitalized for RSV bronchiolitis.

Se describe un caso inusual de neumonía grave por Pneumocystis jirovecci en un paciente de 2 meses de vida previamente sano, quien había sido hospitalizado por una bronquiolitis por VRS.