In Vitro Interactions of Amphotericin B Combined with Non-antifungal Agents Against Rhodotorula mucilaginosa Strains.

Rhodotorula species are emerging as opportunistic pathogens, causing catheter-associated fungemia in patients with compromised immunity. R. mucilaginosa is considered the most common species involved in human infections. Correct identification and susceptibility testing of Rhodotorula isolates recovered from the blood stream or central nervous system are essential to determine the best management of this unusual infection. The antifungal susceptibility tests showed that Rhodotorula was susceptible to low concentrations of amphotericin B (AMB) but was less susceptible to voriconazole. Combinations of AMB plus several non-antifungal medications were evaluated against 35 susceptible (Rm AMB-S) and resistant (Rm AMB-R) clinical Rhodotorula isolates using the broth microdilution checkerboard technique. We showed that in vitro exposure to increasing concentrations of AMB changed the susceptibility profile to these strains, which were named the Rm AMB-R group. The most synergistic interactions were AMB + simvastatin, followed by AMB + amlodipine and AMB + warfarin. Synergism and antagonism were observed in both groups for the combination AMB + cyclosporine A. AMB combined with a fluoroquinolone (AMB + levofloxacin) also demonstrated antagonism for the Rm AMB-S strains, but a high percentage of synergistic interactions was observed for the Rm AMB-R group. A combination drug approach can provide a different strategy to treat infections caused by AMB-resistant R. mucilaginosa.

Paracoccidioidomycosis Mimicking Sarcoidosis: A Review of 8 Cases.

Sarcoidosis is a multisystem disorder that is characterized by noncaseous epithelioid cell granulomas, which may affect almost any organ. Thoracic involvement is common and accounts for most of the morbidity and mortality associated with this disease. The diagnosis is based on exhaustive exclusion of differential diagnoses, particularly granulomatous infections. We report data on eight patients with paracoccidioidomycosis mimicking sarcoidosis. Five patients presented with a chronic pulmonary type infection and three had a disseminated form after immunosuppressive treatment. The mycological diagnosis in noncaseating granulomas is emphasized and reviewed.

Sphenoid sinus fungus ball by filaments of actinomycetes and Aspergillus fumigatus.

We present a case of sphenoid sinus fungus ball caused by Aspergillus fumigatus associated with actinomycosis. This case represents the first known reported infection caused by this rare association.

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.

Cryptococcosis in patients living with hepatitis C and B viruses.

Cryptococcosis, a systemic fungal infection, has become a significant, global public health problem. Patients with liver disease have an increased predisposition to infections, such as Cryptococcosis. To report the underlying disease, the variety of etiologic agents involved and the outcomes of the Cryptococcosis in patients living with HBV and/or HCV, we reviewed 34 medical records of patients who were diagnosed with Cryptococcosis by the Mycology Laboratory of Santa Casa Hospital, Porto Alegre, Brazil. Males corresponded to 79% of the patients, and the average patient age was 46.9 years. The cultures of 26/34 patients were positive: 25 patients were infected with Cryptococcus neoformans and one with C. gattii. A total of 14 deaths (41%) occurred. As a criterion of our study, all patients had viral hepatitis infection: 27 (80%) were infected with HCV, five (15%) were infected with HBV, and two patients were infected with both viruses. Because HBV and/or HCV are transmitted among drug users through infected blood, and the end-stage cirrhotic liver must be transplanted, these two population types were well represented in this study and were analyzed in detail. Cryptococcosis patients living with HCV and/or HBV appear to have the same symptoms, mean age and gender distribution as the general Cryptococcosis population. Once Cryptococcosis affects the brain, a high mortality rate ensues; therefore, physicians must be aware of the possible occurrence of this disease in patients living with HCV and HBV.

Pulmonary diseases with imaging findings mimicking aspergilloma.

Patients with preexisting lung cavities are at risk of developing intracavitary fungal colonization. Because Aspergillus spp. are the most commonly implicated fungi, these fungal masses are called aspergillomas. Their characteristic "ball-in-hole" appearance, however, may be found in a variety of other conditions that can produce radiologic findings mimicking aspergilloma. In this paper, we review the main diseases that may mimic the radiographic findings of aspergilloma, with brief descriptions of clinical, radiologic, and histopathologic findings.

Fungal diseases mimicking primary lung cancer: radiologic-pathologic correlation.

A variety of fungal pulmonary infections can produce radiologic findings that mimic lung cancers. Distinguishing these infectious lesions from lung cancer remains challenging for radiologists and clinicians. In such cases, radiographic findings and clinical manifestations can be highly suggestive of lung cancer, and misdiagnosis can significantly delay the initiation of appropriate treatment. Likewise, the findings of imaging studies cannot replace the detection of a species as the aetiological agent. A biopsy is usually required to diagnose the infectious nature of the lesions. In this article, we review the clinical, histologic and radiologic features of the most common fungal infections that can mimic primary lung cancers, including paracoccidioidomycosis, histoplasmosis, cryptococcosis, coccidioidomycosis, aspergillosis, mucormycosis and blastomycosis.

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.

First reported case of cellulitis due to Cryptococcus gattii in lung transplantation recipient: a case report.

Cryptococcus gattii are closely related species of encapsulated yeast-like fungi involved in the etiology of cryptococcosis, especially in immunocompetent individuals. Dissemination with involvement of many organ systems is common. On the other hand, cellulitis in an immunossupressed patient caused by C. gattii is rare. We present a case of disseminated disease caused by Cryptococcus gattii in a lung transplant recipient who manifested cellulitis. The disease was also complicated by a lung carcinoma. We emphasize that cryptococcal cellulitis related to C. gattii in solid organ transplant (SOT) recipients should be considered in the differential diagnosis of acute bacterial skin infections.

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.

The activity of echinocandins, amphotericin B and voriconazole against fluconazole-susceptible and fluconazole-resistant Brazilian Candida glabrata isolates.

The extensive use of azole antifungal agents has promoted the resistance of Candida spp to these drugs. Candida glabrata is a problematic yeast because it presents a high degree of primary or secondary resistance to fluconazole. In Brazil, C. glabrata has been less studied than other species. In this paper, we compared the activity of three major classes of antifungal agents (azoles, echinocandins and polyenes) against fluconazole-susceptible (FS) and fluconazole-resistant (FR) C. glabrata strains. Cross-resistance between fluconazole and voriconazole was remarkable. Among the antifungal agents, the echinocandins were the most effective against FS and FR C. glabrata and micafungin showed the lowest minimal inhibitory concentrations.

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.

Cryptococcosis in children.

Cryptococcosis is a systemic-opportunistic mycosis caused by two species of the encapsulated yeast-like organism, Cryptococcus neoformans and C. gattii, which cause infection in immunocompromised individuals and in immunologically normal hosts, respectively. Most susceptible to infection are patients with T-cell deficiencies. The spectrum of disease ranges from asymptomatic pulmonary lesions to disseminated infection with meningoencephalitis. After the emergence of AIDS, cryptococcal infections have become much more common. The mycosis occurs less frequently in children than in adults. The purpose of this article is to discuss the aetiology, clinical presentation, predisposing conditions and outcomes in cases of cryptococcosis in children. Emphasis is placed upon paediatric cases occuring in Brazil and in particular to highlight the difference between cases diagnosed in Porto Alegre (South - subtropical climate) and in Belem (North - equatorial climate).

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 recovery from the urine and a short review of genitourinary histoplasmosis.

Although virtually any organ can be involved in disseminated histoplasmosis, the recovery of Histoplasma capsulatum from the urine is a rare finding. Here we describe that a renal transplant recipient had H. capsulatum recovered from urinary sediment. The organism was also recovered from urine cultures. The potential implications of this finding are discussed, and the literature on genitourinary histoplasmosis is reviewed.

Invasive pulmonary aspergillosis due to a mixed infection caused by Aspergillus flavus and Aspergillus fumigatus.

Invasive pulmonary aspergillosis is typically caused by a single Aspergillus species, most frequently Aspergillus fumigatus. Here we report that a lung transplant recipient developed invasive aspergillosis due to a mixed infection caused by Aspergillus flavus and A. fumigatus. The implications for this unusual finding are discussed.

[Histopathological techniques for diagnosing cryptococcosis due to capsule-deficient Cryptococcus: case report]. / Técnicas histopatológicas no diagnóstico de criptococose por Cryptococcus deficiente de cápsula: relato de caso.

A case of cryptococcosis due to capsule-deficient Cryptococcus is presented, in which culturing of the clinical specimen and tests for capsular antigen in cerebrospinal fluid and serum were negative. The histopathological techniques evaluated were hematoxylin-eosin, Grocott methenamine silver, Mayers mucicarmine and Fontana-Masson. The diagnosis of cryptococcosis due to capsule-deficient Cryptococcus was confirmed by means of the Fontana-Masson technique and by direct immunofluorescence. The potential of the histochemical techniques is discussed.

Aspergillus niger causing tracheobronchitis and invasive pulmonary aspergillosis in a lung transplant recipient: case report.

A case of invasive aspergillosis caused by Aspergillus niger in a lung transplant recipient is described. The patient presented hyperglycemia starting postoperatively, with other complications such as cytomegalovirus infection. The associated predisposing factors and other implications are discussed. Aspergillus niger seems to be a fungal species of low virulence that requires the presence of a severely immunosuppressed host to cause invasive disease.

Analysis of independent risk factors for death among pediatric patients with candidemia and a central venous catheter in place.

OBJECTIVE: To use multivariate analysis to determine risk factors for death among pediatric patients with candidemia and a central venous catheter in place. DESIGN: Retrospective cohort study conducted at Santa Casa Complexo Hospitalar, a 1,200-bed teaching hospital in southern Brazil. METHODS: All cases of candidemia in pediatric patients (age,