RESUMO
The second international meeting on endemic mycoses of the Americas (IMEMA) and the first international symposium on implantation mycoses (ISIM) took place in Santiago del Estero, Argentina, on September 25-27, 2023. The conference provided a platform for researchers, clinicians, and experts to discuss the latest developments in the field of endemic and implantation mycoses. Topics included epidemiology, diagnostic advances, treatment strategies, and the impact of environmental factors on the spread of these fungal diseases. IMEMA and ISIM contributed to the regional discourse on the mycoses, emphasizing the importance of international cooperation in addressing these public health challenges.
IMEMA/ISIM, held in Santiago del Estero, Argentina, convened experts to discuss endemic and implantation mycoses, covering topics such as epidemiology, diagnostics, treatment, and advocacy. The event highlighted ongoing efforts in combating these diseases.
Assuntos
Doenças Endêmicas , Micoses , Humanos , Micoses/epidemiologia , Micoses/microbiologia , América/epidemiologia , Argentina/epidemiologia , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/epidemiologiaRESUMO
This study aimed to perform a seroepidemiological survey on the prevalence of sporotrichosis among cats living in the Northern area of Buenos Aires, where a four-fold increase of Sporothrix brasiliensis infections were diagnosed during the last decade. For this purpose, an in-house indirect ELISA test sensitized with S. brasiliensis crude antigens was used. The ELISA test showed 100.0% sensitivity and 95.0% specificity. Antibodies against S. brasiliensis antigens were detected in 3.7% (9/241) of healthy cats evaluated, suggesting likely exposure or infection to this fungus. This ELISA test would be a valuable screening tool for diagnosing sporotrichosis and for seroepidemiological surveys.
S. brasiliensis is the primary cause of feline sporotrichosis in Argentina. The seroprevalence of sporotrichosis infection in urban localities of Buenos Aires province is reported for the first time. An ELISA test using S. brasiliensis crude antigens is also described.
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BACKGROUND: The Americas are home to biologically and clinically diverse endemic fungi, including Blastomyces, Coccidioides, Emergomyces, Histoplasma, Paracoccidioides and Sporothrix. In endemic areas with high risk of infection, these fungal pathogens represent an important public health problem. OBJECTIVES: This report aims to summarise the main findings of the regional analysis carried out on the status of the endemic mycoses of the Americas, done at the first International Meeting on Endemic Mycoses of the Americas (IMEMA). METHODS: A regional analysis for the Americas was done, the 27 territories were grouped into nine regions. A SWOT analysis was done. RESULTS: All territories reported availability of microscopy. Seventy percent of territories reported antibody testing, 67% of territories reported availability of Histoplasma antigen testing. None of the territories reported the use of (1-3)-ß-d-glucan. Fifty two percent of territories reported the availability of PCR testing in reference centres (mostly for histoplasmosis). Most of the territories reported access to medications such as trimethoprim-sulfamethoxazole, itraconazole, voriconazole and amphotericin B (AMB) deoxycholate. Many countries had limited access to liposomal formulation of AMB and newer azoles, such as posaconazole and isavuconazole. Surveillance of these fungal diseases was minimal. CONCLUSIONS: A consensus emerged among meeting participants, this group concluded that endemic mycoses are neglected diseases, and due to their severity and lack of resources, the improvement of diagnosis, treatment and surveillance is needed.
Assuntos
Histoplasmose , Micoses , Humanos , Antifúngicos/uso terapêutico , Micoses/diagnóstico , Micoses/tratamento farmacológico , Micoses/epidemiologia , Itraconazol/uso terapêutico , Histoplasma , Histoplasmose/diagnóstico , Histoplasmose/tratamento farmacológico , Histoplasmose/epidemiologia , América/epidemiologiaRESUMO
Histoplasmosis is a worldwide systemic endemic mycosis caused by several cryptic species included within the Histoplasma capsulatum complex. Domestic and wild mammals are susceptible to infection by this fungus and could be used as indicators of its presence in the environment. The aim of the study was to identify the natural reservoirs of H. capsulatum in the Argentinean Humid Pampas eco-region analyzing a wildlife frozen-tissue collection and trace its distribution patterns over time and space. Tissue samples from 34 small wild mammals caught in the Humid Pampas were analyzed using two molecular markers: 100 kDa protein coding gene (Hcp100) and ITS1 rDNA. Results showed that 32.4% of them were infected with H. capsulatum and its DNA was detected in 5/17 Calomys laucha; 3/6 Calomys musculinus; 1/5 Akodon azarae, 1/3 Monodelphis dimidiata; and 1/2 Didelphis albiventris. In the single specimen studied of Cavia aperea, no H. capsulatum DNA was detected. This is the first H. capsulatum infection report in C. laucha and C. musculinus rodents and M. dimidiate opossum which proves that tissue collections are an important source of material for epidemiological studies of endemic disease over time.
Assuntos
Animais Selvagens/microbiologia , Reservatórios de Doenças/microbiologia , Histoplasma/isolamento & purificação , Histoplasmose/epidemiologia , Animais , Argentina/epidemiologia , DNA Fúngico/genética , Doenças Endêmicas , Estudos Epidemiológicos , Histoplasma/genética , Humanos , Bancos de Tecidos , Zoonoses/epidemiologiaRESUMO
We studied 23 clinical and environmental strains of Sporothrix schenckii sensu lato collected from 1984 to 2017 in Argentina. The molecular identification (partial sequencing of a fragment of the calmodulin gene) of the strains was performed. For the yeast and mycelial phases, the in vitro susceptibility testing by a microdilution reference method was determined against eight antifungal drugs. Strains studied were identified as S. schenckii sensu stricto 13 (56.5%), S. brasiliensis 8 (34.7%) and S. globosa 2 (8.7%). The most active antifungal drugs tested for the yeast and mycelial phases expressed as geometric mean (GM) value of the minimal inhibitory concentration (MIC) (µg mL-1 ) were terbinafine (0.07 and 0.24), posaconazole (0.13 and 0.58), itraconazole (0.38 and 1.10) and ketoconazole (0.22 and 0.89), while fluconazole (110.10 and 131.92) and flucytosine (2.96 and 79.03) were the less active. For voriconazole and amphotericin B the GM-MIC values were acceptably low for the yeast phase (0.39 and 0.72 µg mL-1 ), while the mycelial phase showed values ≥2-fold higher (8.76 and 1.88 µg mL-1 ), P < .05. Here, we described S. schenckii sensu stricto, S. brasiliensis and S. globosa, these species were isolated from humans, animals and soil and are circulating in Argentina since at least 1984.
Assuntos
Antifúngicos/farmacologia , Sporothrix/efeitos dos fármacos , Sporothrix/genética , Esporotricose/microbiologia , Animais , Argentina/epidemiologia , Calmodulina/genética , Flucitosina/farmacologia , Humanos , Itraconazol/farmacologia , Testes de Sensibilidade Microbiana , Filogenia , Análise de Sequência de DNA , Microbiologia do Solo , Sporothrix/isolamento & purificação , Esporotricose/epidemiologia , Triazóis/farmacologiaRESUMO
Paracoccidioidomycosis (PCM) is among the systemic mycoses which are endemic only in Latin America. In Argentina, the vast majority of the cases are reported at north of latitude 34.5° S. The disease is produced by thermodimorphic fungi of the genus Paracoccidoides: P. brasiliensis (S1), P. americana (PS2), P. restrepiensis (PS3), P. venezuelensis (PS4) y P. lutzii. The natural habitat of members of this genus is the soil, where they produce infectious conidia. Little is known, however, about their specific ecologic niche(s), and this knowledge gap hampers the design of measures to control the infection. Rural male workers are the group most at risk of developing PCM. Infection occurs by inhalation of aerosolized conidia and may either be asymptomatic or cause mild respiratory symptoms. In turn, this primary infection may be self-limited or progress to severe pulmonary or disseminated disease. The disease has two clinical presentations: (i) acute or subacute (juvenile), frequent in children, adolescents and people with immunodeficiencies; and (ii) chronic progressive, in adults. Active lesions often resolve into fibrotic scars which can cause dysphagia, dysphonia, adrenal insufficiency, and intestinal obstruction. Although efficient tools are available for diagnosis and treatment, the nonspecific nature of PCM clinical manifestations frequently delay the diagnosis. In addition, the poor adherence to long antifungal treatments allows the advance of the disease and the development of extensive fibrosis compromising severely and permanently respiratory and adrenal functions, thus altering the patient"s quality of life and even causing his/her death.
Assuntos
Doenças Negligenciadas , Paracoccidioides/classificação , Paracoccidioidomicose , Humanos , Paracoccidioidomicose/diagnóstico , Paracoccidioidomicose/parasitologia , Paracoccidioidomicose/terapiaRESUMO
Coccidioides immitis and C. posadasii are the etiologic agents of coccidioidomycosis, an endemic fungal disease of the Americas. In Colombia, this mycosis is uncommon, and only five cases, two of them imported, have been documented.By means of DNA sequencing, C. immitis was identified in formalin-fixed, paraffin-embedded archival tissues samples from the 5th Colombian patient diagnosed in 1997. The patient was born in Pinto, Department of Magdalena, and had never visited other geographic regions, a reason to consider that the mycosis had been acquired locally.This species is primarily found in California although it has been occasionally reported in other geographic areas such as Mexico and Brazil. This is the first indigenous report of C. immitis-associated coccidioidomycosis in a Colombian patient.
Assuntos
Coccidioides/isolamento & purificação , Coccidioidomicose/diagnóstico , Técnicas de Diagnóstico Molecular , Patologia Molecular , Biópsia , Coccidioides/genética , Coccidioidomicose/microbiologia , Coccidioidomicose/patologia , Colômbia , Formaldeído , Humanos , Masculino , Pessoa de Meia-Idade , Parafina , Pacientes , Fixação de TecidosRESUMO
Coccidiomycosis is a potentially life-threatening fungal infection endemic to certain regions of Argentina. The infection is caused by Coccidioides spp. and is primarily diagnosed by Coccidioides antibody (Ab) detection. Access to rapid, highly accurate diagnostic testing is critical to ensure prompt antifungal therapy. The sona Coccidioides Ab Lateral Flow Assay (LFA) performs faster and requires less laboratory infrastructure and equipment compared with other Ab detection assays, potentially providing a substantial improvement for rapid case screening in coccidioidomycosis-endemic regions; however, validation of this test is needed. Thus, we aimed to evaluate the analytical performance of the sona Coccidioides Ab (LFA) and compare agreement with anti-Coccidioides Ab detection assays. A total of 103 human sera specimens were tested, including 25 specimens from patients with coccidioidomycosis and 78 from patients without coccidioidomycosis. The sona Coccidioides Ab Lateral Flow Assay (LFA) was performed with a sensitivity of 88%, and specificity and accuracy of 87%. Furthermore, the Coccidioides Ab LFA had good agreement with other anti-Coccidioides Ab detection assays. Our findings suggest the sona Coccidioides Ab LFA has satisfactory performance and may be useful for diagnosing coccidioidomycosis in endemic regions.
RESUMO
Introduction: Paracoccidioidomycosis is a systemic mycosis endemic in Latin America. Climate change and host migration emphasize the need to optimize this infection diagnosis. Objective: To evaluate the implementation of Paracoccidioides spp. DNA detection in the mycological diagnosis of patients with suspected paracoccidioidomycosis. Materials and methods: It is a retrospective study with laboratory data from patients with clinical suspicion of paracoccidioidomycosis, who consulted a university hospital from a non-endemic area. Results: We analyzed the laboratory results of samples from 19 patients with suspected paracoccidioidomycosis. Seventeen out of 19 patients were born in or had visited an endemic area in Latin America. Fourteen adult male patients were confirmed to have paracoccidioidomycosis by conventional diagnosis: the direct examination was positive in 12 samples while fungal growth was found only in 4. Anti-Paracoccidioides spp. antibodies were detected in 10 patients, 8 of them with proven paracoccidioidomycosis. Nested PCR for Paracoccidioides spp. detection was performed on clinical samples from 14 patients, and positive results were obtained for 9 out of 10 patients with the conventional diagnosis of paracoccidioidomycosis. Conclusions: The incorporation of molecular techniques to detect Paracoccidioides spp. DNA complements the conventional diagnosis of paracoccidioidomycosis. This tool allows the prescription of antifungal treatment in those cases where the fungus is not observed in the clinical samples.
Introducción: La paracoccidioidomicosis es una micosis sistémica y endémica en Latinoamérica. El cambio climático y el movimiento migratorio del huésped enfatizan la necesidad de optimizar el diagnóstico de esta infección. Objetivo: Evaluar la implementación de la detección de ADN de Paracoccidioides spp. al diagnóstico micológico de pacientes con sospecha de paracoccidioidomicosis. Materiales y métodos. Estudio retrospectivo con datos de laboratorio de pacientes con sospecha de paracoccidioidomicosis en un hospital de área no endémica. Resultados: Se analizaron los resultados de las muestras de 19 pacientes con sospecha clínica de paracoccidioidomicosis. El 90 % de los pacientes había nacido o visitado un área endémica de esta micosis en Latinoamérica. En 14 pacientes varones adultos se confirmó paracoccidioidomicosis por diagnóstico convencional. El examen directo fue positivo en 12 pacientes con enfermedad comprobada y en 4 de ellos se obtuvo crecimiento del hongo. Se detectaron anticuerpos contra Paracoccidioides spp. en ocho pacientes con la enfermedad. Se realizó PCR anidada con muestras de 14 pacientes para detectar ADN de Paracoccidioides spp. En 9 de los 10 pacientes con diagnóstico convencional de paracoccidioidomicosis se obtuvo una prueba de PCR positiva. Conclusiones: La implementación de técnicas moleculares para detectar ADN de Paracoccidioides spp. complementa el diagnóstico convencional de paracoccidioidomicosis y permite instaurar el tratamiento antifúngico, sobre todo en los casos clínicos donde no se observa la presencia del hongo en las muestras clínicas. La migración actual de poblaciones humanas dificulta el diagnóstico de paracoccidioidiomicosis y otras infecciones endémicas, por lo que se requiere optimizar el diagnostico micológico en los laboratorios clínicos para tratar pacientes con este tipo micosis desatendida.
Assuntos
Hospitais , Tolnaftato , Reação em Cadeia da PolimeraseRESUMO
Histoplasmosis is a major cause of mortality in individuals with advanced human immunodeficiency virus (HIV) disease (AHD). We evaluated in patients with AHD a lateral flow assay (LFA) developed by MiraVista® Diagnostics (MVD LFA). Histoplasmosis was defined based on the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) case definitions. We also compared the results of this LFA with those obtained using a commercial enzyme immunoassay (EIA) developed by IMMY, Clarus Histoplasma GM EIA, IMMY (HGM EIA). A retrospective observational study was conducted at Hospital Juan A. Fernández, located in Buenos Aires, Argentina. The study included 48 urine specimens from patients aged >18 years with AHD. Urine specimens included 17 patients with disseminated histoplasmosis and 31 specimens from patients without evidence of histoplasmosis. Specimens were tested using the MVD LFA and the HGM EIA. The MVD LFA and the HGM EIA had similar analytical performance, with a sensitivity of 94%, specificity of 100%, positive predictive value of 100%, negative predictive value of 97%, and an accuracy of 98%. Comparison of the MVD LFA with the HGM EIA demonstrated a Kappa agreement index of 0.906. The LFA evaluated in this study had high analytical performance; it provided rapid diagnosis of histoplasmosis with minimal requirements for laboratory training, equipment, and laboratory infrastructure.
RESUMO
Histoplasma capsulatum is a dimorphic fungus associated with respiratory and systemic infections in mammalian hosts that have inhaled infective mycelial propagules. A phylogenetic reconstruction of this pathogen, using partial sequences of arf, H-anti, ole1, and tub1 protein-coding genes, proposed that H. capsulatum has at least 11 phylogenetic species, highlighting a clade (BAC1) comprising three H. capsulatum isolates from infected bats captured in Mexico. Here, relationships for each individual locus and the concatenated coding regions of these genes were inferred using parsimony, maximum likelihood, and Bayesian inference methods. Coalescent-based analyses, a concatenated sequence-types (CSTs) network, and nucleotide diversities were also evaluated. The results suggest that six H. capsulatum isolates from the migratory bat Tadarida brasiliensis together with one isolate from a Mormoops megalophylla bat support a NAm 3 clade, replacing the formerly reported BAC1 clade. In addition, three H. capsulatum isolates from T. brasiliensis were classified as lineages. The concatenated sequence analyses and the CSTs network validate these findings, suggesting that NAm 3 is related to the North American class 2 clade and that both clades could share a recent common ancestor. Our results provide original information on the geographic distribution, genetic diversity, and host specificity of H. capsulatum.
RESUMO
The yeast phase of 22 Histoplasma capsulatum clinical isolates from Mexico, Argentina, Colombia, and Guatemala and three reference strains, one from Panama and two from the United States of America (USA), were screened for thermosensitivity characteristics using different analyses. Growth curves at 0, 3, 6, 12, 24, and 30â¯h of incubation at 37 and 40⯰C, the growth inhibition percentage at 40⯰C, and the doubling time at 37 and 40⯰C were determined for all yeasts studied. Most of the isolates examined exhibited thermotolerant phenotypes at 40⯰C, whereas a thermosensitive phenotype at 40⯰C was only detected in the Downs reference strain from the USA. Growth inhibition values lower than 33.8% supported the predominance of the thermotolerant phenotype at 40⯰C. The doubling time means found for the different isolates were 5.14â¯h⯱â¯1.47â¯h at 37⯰C and 5.55â¯h⯱â¯1.87â¯h at 40⯰C. This is the first report to underscore the predominance of thermotolerant and delayed doubling time phenotypes in H. capsulatum clinical isolates from different regions of Latin America.
Assuntos
Histoplasma/crescimento & desenvolvimento , Histoplasma/isolamento & purificação , Termotolerância/fisiologia , Histoplasma/genética , Histoplasmose/microbiologia , América Latina , Fenótipo , Filogenia , Valores de Referência , Temperatura , Fatores de TempoRESUMO
In 1892 Alejandro Posadas described the first worldwide case of coccidioidomycosis in a patient named Domingo Escurra. A preserved necropsy piece from the patient's remains is conserved in the Museum of Pathology of the Medical School, Buenos Aires University. Paraffin-embedded specimens obtained from this piece served to identify the fungus involved in the case. Histological slices from different lesion sites were submitted to a genus-specific immunohistochemical staining in order to select the more suited areas in terms of abundance/integrity of fungal esporangia and endospora. Fungal DNA was amplified from selected deparaffinated slices using a nested PCR designed to amplify a segment of the gen Ag2/PRA and differentiate C. immitis from C. posadasii. This PCR was also applied to two reference strains (C. immitis M38-05, C. posadasii 1-NL) and isolates obtained from four recent coccidioidomycosis cases occurred in Argentina. Amplified products were submitted to sequencing of both DNA strands. The obtained sequences were edited, aligned and compared with C. posadasii (Access N degrees AY536446, strain Silveira) and C. immitis (Access N degrees AY536445) deposited in GenBank. DNA sequences from Escurra's lesions were 100% homologous to the recent Argentinean cases and the reference strain 1-NL. A single point C(R)G difference in position 1228 was observed with respect to sequence of strain C. posadasii Silveira. For the first time, Coccidioides DNA is recovered from a museum piece which is more than 100-year-old. Our results confirm that the original case of Posadas's disease was caused by the recently described C. posadasii.
Assuntos
Coccidioides/genética , Coccidioidomicose/história , DNA Fúngico/análise , Antígenos de Fungos/genética , Argentina , Sequência de Bases , Cadáver , Coccidioidomicose/microbiologia , História do Século XIX , Humanos , Dados de Sequência Molecular , Reação em Cadeia da PolimeraseRESUMO
Histoplasmosis and leishmaniasis are neglected and endemic diseases in Argentina, and generally are found associated with immunosuppression. We report the case of an immunocompetent 16-years-old man with simultaneous occurrence of central nervous system histoplasmosis and cutaneous leishmaniasis. Upon admission, the patient showed a one-month old skin lesion in a leg and mild paraparesis. Imaging studies detected thickening and edema in the spinal cord and the cerebrospinal fluid analysis was within normal range. The case was diagnosed as a demyelinating disorder and treated with high-dose short-term steroids. Seventy-two hours later the patient showed severe paraparesis and nuclear magnetic resonance imaging revealed nodular lesions in the spinal cord. Histoplasma capsulatum belonging to the phylogenetic species LamB was isolated from cerebrospinal fluid samples. The patient received intravenous antifungal therapy with amphotericin B for 30 days, followed by oral fluconazole and itraconazole for one year. Three months after initiation of antifungal treatment, the cutaneous lesion recrudesced and Leishmania amastigotes were observed on microscopic examination. The cutaneous leishmaniasis was treated with intramuscular meglumine antimoniate. The patient's outcome was favorable after treatment for both diseases.
La histoplasmosis y la leishmaniasis son enfermedades olvidadas, endémicas en Argentina, y generalmente se asocian a inmunocompromiso. Presentamos el caso de un varón de 16 años, inmunocompetente, con histoplasmosis del sistema nervioso central y leishmaniasis cutánea. Inicialmente, el paciente presentó una lesión en la pierna de un mes de evolución seguida de paraparesia leve, diagnosticada como un proceso de desmielinización mediante estudios de imágenes. El cuadro fue tratado con altas dosis de corticoides y en 72 horas evolucionó a paraparesia grave con lesiones nodulares en las vértebras cervicales, observadas en las imágenes de resonancia magnética nuclear. Se aisló Histoplasma capsulatum de líquido cefalorraquídeo, genotípicamente identificado como perteneciente a la especie filogenética LamB. El paciente recibió tratamiento intravenoso con anfotericina B deoxicolato durante 30 días y posteriormente fluconazol e itraconazol oral durante un año. A los tres meses de iniciado el tratamiento con antifúngicos se reactivó la lesión de la pierna y en el examen directo se observaron amastigotes de Leishmania. La leishmaniasis cutánea fue tratada con antimoniato de meglumina intramuscular. La respuesta clínica al tratamiento de ambas enfermedades fue favorable.
Assuntos
Infecções Fúngicas do Sistema Nervoso Central/complicações , Histoplasmose/complicações , Leishmaniose Cutânea/complicações , Adolescente , Antibacterianos/administração & dosagem , Antifúngicos/administração & dosagem , Infecções Fúngicas do Sistema Nervoso Central/diagnóstico , Infecções Fúngicas do Sistema Nervoso Central/tratamento farmacológico , Histoplasmose/diagnóstico , Histoplasmose/tratamento farmacológico , Humanos , Imunocompetência , Leishmaniose Cutânea/diagnóstico , Leishmaniose Cutânea/tratamento farmacológico , MasculinoRESUMO
ABSTRACT The yeast phase of 22 Histoplasma capsulatum clinical isolates from Mexico, Argentina, Colombia, and Guatemala and three reference strains, one from Panama and two from the United States of America (USA), were screened for thermosensitivity characteristics using different analyses. Growth curves at 0, 3, 6, 12, 24, and 30 h of incubation at 37 and 40 °C, the growth inhibition percentage at 40 °C, and the doubling time at 37 and 40 °C were determined for all yeasts studied. Most of the isolates examined exhibited thermotolerant phenotypes at 40 °C, whereas a thermosensitive phenotype at 40 °C was only detected in the Downs reference strain from the USA. Growth inhibition values lower than 33.8% supported the predominance of the thermotolerant phenotype at 40 °C. The doubling time means found for the different isolates were 5.14 h ± 1.47 h at 37 °C and 5.55 h ± 1.87 h at 40 °C. This is the first report to underscore the predominance of thermotolerant and delayed doubling time phenotypes in H. capsulatum clinical isolates from different regions of Latin America.
Assuntos
Termotolerância/fisiologia , Histoplasma/isolamento & purificação , Histoplasma/crescimento & desenvolvimento , Fenótipo , Filogenia , Valores de Referência , Temperatura , Fatores de Tempo , Histoplasma/genética , Histoplasmose/microbiologia , América LatinaRESUMO
La histoplasmosis y la leishmaniasis son enfermedades olvidadas, endémicas en Argentina, y generalmente se asocian a inmunocompromiso. Presentamos el caso de un varón de 16 años, inmunocompetente, con histoplasmosis del sistema nervioso central y leishmaniasis cutánea. Inicialmente, el paciente presentó una lesión en la pierna de un mes de evolución seguida de paraparesia leve, diagnosticada como un proceso de desmielinización mediante estudios de imágenes. El cuadro fue tratado con altas dosis de corticoides y en 72 horas evolucionó a paraparesia grave con lesiones nodulares en las vértebras cervicales, observadas en las imágenes de resonancia magnética nuclear. Se aisló Histoplasma capsulatum de líquido cefalorraquídeo, genotípicamente identificado como perteneciente a la especie filogenética LamB. El paciente recibió tratamiento intravenoso con anfotericina B deoxicolato durante 30 días y posteriormente fluconazol e itraconazol oral durante un año. A los tres meses de iniciado el tratamiento con antifúngicos se reactivó la lesión de la pierna y en el examen directo se observaron amastigotes de Leishmania. La leishmaniasis cutánea fue tratada con antimoniato de meglumina intramuscular. La respuesta clínica al tratamiento de ambas enfermedades fue favorable.
Histoplasmosis and leishmaniasis are neglected and endemic diseases in Argentina, and generally are found associated with immunosuppression. We report the case of an immunocompetent 16-years-old man with simultaneous occurrence of central nervous system histoplasmosis and cutaneous leishmaniasis. Upon admission, the patient showed a one-month old skin lesion in a leg and mild paraparesis. Imaging studies detected thickening and edema in the spinal cord and the cerebrospinal fluid analysis was within normal range. The case was diagnosed as a demyelinating disorder and treated with high-dose short-term steroids. Seventy-two hours later the patient showed severe paraparesis and nuclear magnetic resonance imaging revealed nodular lesions in the spinal cord. Histoplasma capsulatum belonging to the phylogenetic species LamB was isolated from cerebrospinal fluid samples. The patient received intravenous antifungal therapy with amphotericin B for 30 days, followed by oral fluconazole and itraconazole for one year. Three months after initiation of antifungal treatment, the cutaneous lesion recrudesced and Leishmania amastigotes were observed on microscopic examination. The cutaneous leishmaniasis was treated with intramuscular meglumine antimoniate. The patient´s outcome was favorable after treatment for both diseases.
Assuntos
Humanos , Masculino , Adolescente , Leishmaniose Cutânea/complicações , Infecções Fúngicas do Sistema Nervoso Central/complicações , Histoplasmose/complicações , Leishmaniose Cutânea/diagnóstico , Leishmaniose Cutânea/tratamento farmacológico , Infecções Fúngicas do Sistema Nervoso Central/diagnóstico , Infecções Fúngicas do Sistema Nervoso Central/tratamento farmacológico , Histoplasmose/diagnóstico , Histoplasmose/tratamento farmacológico , Imunocompetência , Antibacterianos/administração & dosagem , Antifúngicos/administração & dosagemRESUMO
La paracoccidioidomicosis (PCM) es una de las micosis sistémicas que son endémicas exclusivamente en América Latina. Está causada por hongos termodimorfos del género Paracoccidoides: P. brasiliensis (S1), P. americana (PS2), P. restrepiensis (PS3), P. venezuelensis (PS4) y P. lutzii. Paracoccidioides habita y produce conidios infecciosos en suelos de zonas subtropicales húmedas. En Argentina está presente al norte del paralelo 34.5° S. Poco se sabe sobre su nicho ecológico específico, lo que dificulta el diseño de medidas de control de la PCM. La infección ocurre en hospederos susceptibles cuando inhalan conidios aerosolizados. Los trabajadores rurales varones son el grupo más expuesto a contraer PCM. La primoinfección puede ser asintomática o causar un cuadro respiratorio leve; este, a su vez, puede autolimitarse o progresar a enfermedad, ya sea pulmonar o diseminada. Existen dos formas de presentación: (i) aguda/subaguda, en niños, adolescentes y personas con sistemas inmunes comprometidos; y (ii) crónica progresiva, en adultos. La cicatrización de las lesiones resulta en secuelas fibróticas que pueden causar disfagia, disfonía, insuficiencia suprarrenal y obstrucción intestinal. Aunque existen herramientas para su diagnóstico, la PCM es rara vez sospechada precozmente porque sus manifestaciones clínicas iniciales son inespecíficas. Sumados, el diagnóstico tardío y la baja adherencia a los efectivos pero largos tratamientos antimicóticos permiten el avance de la enfermedad y el desarrollo de fibrosis tisular extensa, lo que compromete gravemente la función respiratoria y suprarrenal, altera permanentemente la calidad de vida del paciente y puede causar su muerte.
Paracoccidioidomycosis (PCM) is among the systemic mycoses which are endemic only in Latin America. In Argentina, the vast majority of the cases are reported at north of latitude 34.5° S. The disease is produced by thermodimorphic fungi of the genus Paracoccidoides: P. brasiliensis (S1), P. americana (PS2), P. restrepiensis (PS3), P. venezuelensis (PS4) y P. lutzii. The natural habitat of members of this genus is the soil, where they produce infectious conidia. Little is known, however, about their specific ecologic niche(s), and this knowledge gap hampers the design of measures to control the infection. Rural male workers are the group most at risk of developing PCM. Infection occurs by inhalation of aerosolized conidia and may either be asymptomatic or cause mild respiratory symptoms. In turn, this primary infection may be self-limited or progress to severe pulmonary or disseminated disease. The disease has two clinical presentations: (i) acute or subacute (juvenile), frequent in children, adolescents and people with immunodeficiencies; and (ii) chronic progressive, in adults. Active lesions often resolve into fibrotic scars which can cause dysphagia, dysphonia, adrenal insufficiency, and intestinal obstruction. Although efficient tools are available for diagnosis and treatment, the nonspecific nature of PCM clinical manifestations frequently delay the diagnosis. In addition, the poor adherence to long antifungal treatments allows the advance of the disease and the development of extensive fibrosis compromising severely and permanently respiratory and adrenal functions, thus altering the patient´s quality of life and even causing his/her death.
Assuntos
Humanos , Paracoccidioides/classificação , Paracoccidioidomicose/diagnóstico , Paracoccidioidomicose/parasitologia , Paracoccidioidomicose/terapia , Doenças NegligenciadasRESUMO
The genetic diversity of 47 Histoplasma capsulatum isolates from infected bats captured in Mexico, Brazil, and Argentina was studied, using sequence polymorphism of a 240-nucleotides (nt) fragment, which includes the (GA)(n) length microsatellite and its flanking regions within the HSP60 gene. Three human clinical strains were used as geographic references. Based on phylogenetic analyses of 240-nt fragments achieved, the relationships among H. capsulatum isolates were resolved using neighbour-joining and maximum parsimony methods. The tree topologies obtained by both methods were identical and highlighted two major clusters of isolates. Cluster I had three sub-clusters (Ia, Ib, and Ic), all of which contained Mexican H. capsulatum samples, while cluster II consisted of samples from Brazil and Argentina. Sub-cluster Ia included only fungal isolates from the migratory bat Tadarida brasiliensis. An average DNA mutation rate of 2.39 × 10(-9) substitutions per site per year was estimated for the 240-nt fragment for all H. capsulatum isolates. Nucleotide diversity analysis of the (GA)(n) and flanking regions from fungal isolates of each cluster and sub-cluster underscored the high similarity of cluster II (Brazil and Argentina), sub-clusters Ib, and Ic (Mexico). According to the genetic distances among isolates, a network of the 240-nt fragment was graphically represented by (GA)(n) length haplotype. This network showed an association between genetic variation and both the geographic distribution and the ecotype dispersion of H. capsulatum, which are related to the migratory behaviour of the infected bats studied.