A case of miliary pulmonary cryptococcosis and review of literature.

We describe a case of cryptococcal fungemia in a 62-year-old male renal transplant patient. The diagnosis was established by isolation of Cryptococcus neoformans using the Isolator(®) blood culture lysis-centrifugation system. Testing for cryptococcal antigens was negative in the serum and cerebrospinal fluid. Transbronchial lung biopsies and bronchoalveolar lavage were negative. Antifungal therapy with fluconazole was started, resulting in fever remission, and a sustained clinical response was achieved. The literature on miliary pulmonary cryptococcosis is reviewed, and three similar cases were previously reported with disseminated cryptococcosis that resembled miliary tuberculosis on imaging. These emphasize the importance of eliminating causes other than tuberculosis in patients presenting with miliary pulmonary disease, even in countries with a high prevalence of tuberculosis.

Pleural effusion an unusual feature of paracoccidioidomycosis: report of two new cases with a systematic review of the literature.

Paracoccidioidomycosis (PCM) is an endemic disease restricted geographically to Latin America. Brazil accounts for about 80 % of the reported cases, and lungs are most frequently affected. A suggestive radiograph of PCM may only be seen late in the course of the disease. At the beginning, it mimics tuberculosis. On the other hand, pleural effusion on rare occasions has been reported in PCM. For this reason, we report two cases with such uncommon manifestation. Our first patient presented pleural effusion probably caused by PCM (a previously unreported cause of lung mass accompanied by effusion); the second with proved pleural effusion due to PCM. A systematic review of the literature was done.

Phaeohyphomycosis: a clinical-epidemiological and diagnostic study of eighteen cases in Rio Grande do Sul, Brazil.

The goal of this study was to review 18 cases of phaeohyphomycosis in Rio Grande do Sul. The records of all of the patients with a diagnosis of phaeohyphomycosis between 1995-2010 were reviewed. Twelve of the 18 patients (66.6%) were male. The average age of the patients was 50 years old (range: 16-74 years). Eleven patients (61%) presented with subcutaneous lesions. Seven patients (38.8%) had received a solid organ transplant. In all of the cases, the presence of melanin in the fungal cells was determined by Fontana-Masson staining of tissue sections and documented. Among the 18 patients, a total of 11 different fungal species were isolated. The causative organisms included Exophiala jeanselmei, Alternaria, Curvularia, Cladophialophora and Colletotrichum gloeosporioides. To our knowledge, this review reports the first case of subcutaneous phaeohyphomycosis caused by C. gloeosporioides in a lung transplant patient. The number of reported cases of phaeohyphomycosis has increased in the last decade. In a number of cases, this increased incidence may be primarily attributed to iatrogenic immunodeficiency.

Disseminated paracoccidioidomycosis (simulating metastatic lung cancer) and Strongyloides stercoralis hyperinfestation in a steroid-treated patient.

We report a case of disseminated paracoccidioidomycosis, initially suggestive of metastatic lung cancer. The infection was associated with strongyloides hyperinfestation as a result of iatrogenic hypercorticoidism. Examination of a smear prepared from aspirated tracheobronchial secretion and stained by Grocott-methenamine-silver revealed structures consistent with Paracoccidioides brasiliensis and Strongyloides stercoralis. At autopsy, the central nervous system and pulmonary paracoccidioidomycosis, as well as pulmonary strongyloidiasis, were confirmed, without evidence of malignant cells.

Histoplasmosis in children.

Histoplamosis is the most common primary systemic mycosis in the USA and is becoming more common as an opportunistic infection in HIV patients worldwide. In children the rate of asymptomatic infection is high. However, in infants with an immature immunological system, disseminated disease may occur. The clinical picture is variable depending on the immunological status. At the onset of the infection clinical manifestations are non specific (headache, fever, cough and nausea). Usually, these symptoms are self-limited and improve without treatment. However, patients with disseminated diseases present with prolonged fever, malaise, cough and weight loss. Hepatosplenomegaly is frequent in infants. Chest radiographs may be normal in 40 to 50% of patients with disseminated disease but findings such as lobar or diffuse infiltrates, cavitations, hilar adenopathy, or any combination of these may be found. Frequently, the clinical presentation is misdiagnosed as tuberculosis. Skin tests, serological reaction and specific cultures are used for diagnosis confirmation. Treatment indications and regimens are similar to those for adults, except that amphotericin B deoxycholate is usually well tolerated in children.

Histoplasma capsulatum fungemia in patients with acquired immunodeficiency syndrome: detection by lysis-centrifugation blood-culturing technique.

Progressive disseminated histoplasmosis (PDH) is an increasingly common cause of infection in patients with acquired immune deficiency syndrome (AIDS). We report 21 cases of PDH associated with AIDS diagnosed by lysis-centrifugation blood culture method. The most prevalent clinical findings were fever, weight loss, respiratory symptoms, and mucocutaneous lesions. Chest roentgenogram showed diffuse pulmonary infiltrates in 13 of 21 patients (62%). Bronchoalveolar fluid has yielded positive culture in four patients only in medium with cycloheximide.

Cryptococcus gattii fungemia: report of a case with lung and brain lesions mimicking radiological features of malignancy.

A 64-year-old apparently immunocompetent white man developed lung and brain lesions of disseminated cryptococcosis. The radiologic features mimicked those of lung cancer metastatic to the central nervous system. C. gattii was recovered from cultures of bronchoalveolar lavage fluid, brain biopsy, and blood. The same fungus was recovered from pulmonary and brain specimens at autopsy. Serum and cerebrospinal fluid cryptococcal antigen tests were diagnostic in our case and should be included in the diagnostic evaluation of unexplained pulmonary and cerebral lesions. A literature search showed few reports of fungemia by this species of Cryptococcus, contrasting to C. neoformans.

[Nosocomial infection due to Trichosporon asahii: clinical revision of 22 cases]. / Infección nosocomial por Trichosporon asahii: revisión clínica de 22 casos.

Twenty two cases of nosocomial infection caused by Trichosporon asahii, detected during a period of six years (1999-2005) is described. The patients were predominantly males with an average age of 47.3 years-old. The predominant diseases in the study group were respiratory insufficiency, cancer, diabetes, chronic renal insufficiency, cirrhosis and AIDS. The main predisposing conditions were antibiotic therapy, mechanical ventilation, urethral catheterization, catheter, corticoids, transplant, immunosuppressive therapy, chemotherapy, granulocytopenia, surgical procedures and continuous ambulatory peritoneal dialysis. The most used antifungal drugs were fluconazole and amphotericin B. In some cases several antifungals were administered. Five patients did not receive antifungal treatment, and one patient received granulocyte colony stimulating factor (G-CSF). Nine patients showed clinical improvement, nine died and the progress of four patients is unknown. T. asahii is an emergent pathogen in patients with immunodeficiency and its presence in these type hosts can not be considered colonization, as there is an important risk of invasive infection. So, in susceptible patients to develop trichosporonosis it is advisable to take into consideration this disease especially in intensive clinical care units.

Nocardia nova causing empyema necessitatis afterlung re-transplantation: a case report.

We report herein a case of thoracic infection due to Nocardia nova following lung re-transplantation performed for emphysema related to alpha-1-antitrypsin deficiency. The infection extended from the lung into the pleural space, thoracic wall, and mediastinum, presenting as pericarditis and empyema necessitatis. Nocardia nova was identified by 16S ribosomal deoxyribonucleic acid (rDNA) sequencing and phylogenetic analysis. According to a literature search of PubMed, LILACS and MEDLINE databases, we describe herein the first case of empyema necessitatis caused by N. nova species in a transplanted patient.

Disseminated nocardiosis due to Nocardia farcinica: diagnosis by thyroid abscess culture.

A previously healthy 75-year-old white male dentist presented with a 6-month history of low-back pain treated with chronic steroid therapy had a Nocardia farcinica infection diagnosed by aspirate of thyroid abscess and six blood cultures. Despite the treatment with parenteral combination of trimethoprim/sulfamethoxazole, the patient failed to respond and died after two days of therapy. Autopsy revealed disseminated nocardiosis, involving lungs with pleural purulent exudate in both sides, heart, thyroid, kidneys, brain, bones, and lumbosacral soft tissue with destruction of L2-L4.

COMPARISON BETWEEN FOUR USUAL METHODS OF IDENTIFICATION OF Candida SPECIES.

Infection by Candida spp. is associated with high mortality rates, especially when treatment is not appropriate and/or not immediate. Therefore, it is necessary to correctly identify the genus and species of Candida. The aim of this study was to compare the identification of 89 samples of Candida spp. by the manual methods germ tube test, auxanogram and chromogenic medium in relation to the ID 32C automated method. The concordances between the methods in ascending order, measured by the Kappa index were: ID 32C with CHROMagar Candida(κ = 0.38), ID 32C with auxanogram (κ = 0.59) and ID 32C with germ tube (κ = 0.9). One of the species identified in this study was C. tropicalis,which demonstrated a sensitivity of 46.2%, a specificity of 95.2%, PPV of 80%, NPV of 81.1%, and an accuracy of 80.9% in tests performed with CHROMagar Candida;and a sensitivity of 76.9%, a specificity of 96.8%, PPV of 90.9%, NPV of 91%, and an accuracy of 91% in the auxanogram tests. Therefore, it is necessary to know the advantages and limitations of methods to choose the best combination between them for a fast and correct identification of Candida species.

Respiratory tract intracavitary colonization due to Scedosporium apiospermum: report of four cases.

Four cases of respiratory tract intracavitary colonization (fungus ball) due to Scedosporium apiospermum (teleomorph, Pseudallescheria boydii) are reported. The need for a careful search for anneloconidia, in order to establish the etiologic diagnosis in the clinical specimen by microscopy, is emphasized.

The spectrum of computerized tomography (CT) findings in central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii in immunocompetent children.

Cranial CT scans of eleven immunocompetent children with central nervous system (CNS) infection due to Cryptococcus neoformans var. gattii were retrospectively reviewed. These children had an average age of 8.8 years and positive culture for C. n. var. gattii in cerebrospinal fluid. The most common signs and symptoms were headache, fever, nuchal rigidity, nausea and vomiting. No normal cranial CT was detected in any patient. Hypodense nodules were observed in all patients. The remaining scan abnormalities were as follows: nine had diffuse atrophy, six had hydrocephalus, and five had hydrocephalus coexistent with diffuse atrophy.

[Paracoccidioidomycosis and gastrectomy]. / Paracoccidioidomicose e gastrectomia.

In a review of the clinical records of 757 cases of paracoccidioidomycosis 11 (1.5%) of the patients had been previously submitted to gastrectomy. It is suggested that after gastrectomy individuals present a higher risk for the development of such infections, similar to that which occurs in tuberculosis.

[Disseminated histoplasmosis in Rio Grande do Sul]. / Histoplasmose disseminada no Rio Grande do Sul.

This report describes epidemiological, clinical and laboratorial aspects of 111 cases of disseminated histoplasmosis from Rio Grande do Sul over a 25-year period (1977-2002). AIDS and non-AIDS patients were analyzed was the predisposing disease in 63.1% of the patients. In both groups there were mostly men, without evidence of exposure to microfoci contaminated with Histoplasma capsulatum. The main clinical features were systemic (fever and weight loss were present in 97.1 and 92.7% of AIDS and non-AIDS cases), followed by respiratory and mucocutaneous manifestations. Seromycology (positive in 54.5% and 65.3% in AIDS and non-AIDS cases) was useful as a screening test. The high index of cutaneous involvement in AIDS patients (44.3%) compared with North American reports (p <0.01) suggests that different strains of Histoplasma capsulatum may induce different clinical manifestations of the same disease.

Use of Mueller-Hinton broth and agar in the germ tube test.

Candida albicans is often isolated from clinical samples, thus its presumptive differentiation from other species of the same genus can be based on its ability to form the germ tube in human serum. Nevertheless, there are two other species that share this characteristic: C. dubliniensis and C. africana. The aim of this study was to compare four different substrates to perform the germ tube (GT) test. The Candida spp. isolates were identified using a manual system (135 C. albicans, 24 C. tropicalis and one C. dubliniensis). The germ tube test was performed with fresh, previously frozen serum and Mueller-Hinton (MH) broth and agar. GT was observed in 96% (130/136) of the isolates through the fresh serum technique, 94% (128/136) through previously frozen serum, 92% (125/136) in MH agar, and 90% (122/136) in MH broth. The sensitivity of each test was higher than 90%, with 100% specificity. Both the MH agar and broth were able to identify the true positives, and false positives were not found. However, some C. albicans isolates were not identified. MH agar and broth may be used in laboratory for the rapid presumptive identification of C. albicans, as an alternative method for germ tube test.

Nocardia cyriacigeorgica intracavitary lung colonization: first report of an actinomycetic rather than fungal ball in bronchiectasis.

We report the first case of an isolated endobronchial mass caused by Nocardia cyriacigeorgica in an immunocompetent patient with a history of lung surgery; this is a rare presentation of an emerging opportunistic pathogen. The infection was successfully eradicated by surgery. Microbiologists and clinicians should pay more attention to this group of filamentous bacteria, which in the past have often been neglected by medical personnel.

Scedosporium apiospermum eumycetoma successfully treated with oral voriconazole: report of a case and review of the Brazilian reports on scedosporiosis.

We describe a case of white-grain eumycetoma caused by Scedosporium apiospermum in an immunocompetent host that was successfully treated with oral voriconazole, and we review the Brazilian reports on scedosporiosis.

Histoplasmosis presenting with multiple pulmonary nodules. A case mimicking radiological features of pulmonary metastasis.

We present a case of histoplasmosis with multiple pulmonary nodules in a patient with a history of melanoma. This case closely simulated malignancy, including the presence of feeding vessel sign, which occurs in pulmonary metastasis. We emphasize the need to be aware of this infection in areas where histoplasmosis is endemic.

Determination of germ tube, phospholipase, and proteinase production by bloodstream isolates of Candida albicans.

INTRODUCTION: Candida albicans is a commensal and opportunistic agent that causes infection in immunocompromised individuals. Several attributes contribute to the virulence and pathogenicity of this yeast, including the production of germ tubes (GTs) and extracellular hydrolytic enzymes, particularly phospholipase and proteinase. This study aimed to investigate GT production and phospholipase and proteinase activities in bloodstream isolates of C. albicans. METHODS: One hundred fifty-three C. albicans isolates were obtained from blood samples and analyzed for GT, phospholipase, and proteinase production. The assays were performed in duplicate in egg yolk medium containing bovine serum albumin and human serum. RESULTS: Detectable amounts of proteinase were produced by 97% of the isolates, and 78% of the isolates produced phospholipase. GTs were produced by 95% of the isolates. A majority of the isolates exhibited low levels of phospholipase production and high levels of proteinase production. CONCLUSIONS: Bloodstream isolates of C. albicans produce virulence factors such as GT and hydrolytic enzymes that enable them to cause infection under favorable conditions.