Unmasked immune reconstitution inflammatory syndrome towards B-cell non-Hodgkin lymphoma during treatment of esophageal actinomycosis in a patient with advanced HIV: a case report.

BACKGROUND: Actinomycosis is an unusual chronic bacterial infection, even rarer in people living with HIV. It is not considered an AIDS-defining disease. However, the role in co-presentation or overlap with other opportunistic conditions of advanced HIV is unknown. CASE PRESENTATION: A 49-year-old Peruvian male presented with a 4-month history of dysphagia, odynophagia, hyporexia and wasting. He underwent an upper digestive endoscopy, in which ulcers with a necrotic center were observed, therefore, the initial diagnostic assumption was esophageal cancer. Subsequent pathology report excluded neoplasms and confirmed the diagnosis of actinomycosis. Serology for human immunodeficiency virus was requested, yielding a positive result. Antimicrobial treatment with amoxicillin and antiretroviral therapy were indicated, with slow clinical improvement. After 4 months, epigastric discomfort presented, for which a new upper digestive endoscopy was performed, revealing a deep gastric ulcer, which was compatible with diffuse large B-cell non-Hodgkin lymphoma. CONCLUSION: Esophageal actinomycosis in people living with HIV is very rare. We suggest HIV-associated immunosuppression is not enough to allow for actinomycosis to develop, and masked underlying entities should be sought. The existence of such entities in people living with HIV should raise awareness of the possibility of unmasked immune reconstitution inflammatory syndrome once treatment has started.

[Vibrio cholerae NO-O1/NO-O139 bacteremia in a cirrhotic patient. First case report in Peru and literatura review]. / Bacteremia por Vibrio cholerae NO-O1/NO-O139 en un paciente cirrótico. Primer reporte de caso en el Perú y revisión de la literatura.

Non-O1, non-O139 Vibrio cholerae (NOVC) strains are an uncommon cause of gastroenteritis. However, they have been recently associated with severe extraintestinal infections in immunocompromised hosts. Among them, bacteremia in cirrhotic patients is noteworthy. We present the case of a 58-year-old woman with cirrhosis that developed septic shock, multiple organ failure and died four days after admission. Blood cultures yielded Gram-negative rods identified as Vibrio cholerae. Further serogrouping by slide agglutination and a negative PCR for ctxA gen confirmed the strain to be NOVC. Antimicrobial susceptibility testing showed sensitivity to ampicillin, chloramphenicol, tetracycline and ciprofloxacin; and resistance to trimethoprim-sulfamethoxazole. To the best of our knowledge, this is first report in Peru, described in the Hospital Nacional Dos de Mayo, of NOVC bacteremia.

Case Report: Disseminated Paracoccidioidomycosis and Strongyloides Hyperinfection in a Patient with Human T-Lymphotropic Virus Type 1/2 Infection.

Co-occurrence of paracoccidioidomycosis and strongyloidiasis in immunosuppressed patients, particularly those infected with human T-lymphotropic virus type 1/2, is infrequent. We describe the case of a Peruvian farmer from the central jungle with human T-lymphotropic virus type 1/2 infection, with 2 months of illness characterized by respiratory and gastrointestinal symptoms associated with fever, weight loss, and enlarged lymph nodes. Strongyloides stercoralis and Paracoccidioides brasiliensis were isolated in sputum and bronchoalveolar lavage samples, respectively. The clinical evolution was favorable after the patient received ivermectin and amphotericin B. We hypothesize that autoinfestation by S. stercoralis in human T-lymphotropic virus type 1/2-infected patients may contribute to the disseminated presentation of Paracoccidioides spp. Understanding epidemiological context is crucial for suspecting opportunistic regional infections, particularly those that may coexist in immunosuppressed patients.

Oligosymptomatic diphtheria infection in adults: two contacts of the Peruvian index case after 20 years without disease report.

In Peru, diphtheria infection was eradicated in the last two decades. However, recently, diphtheria pharyngeal infection was confirmed and reported in a 5-year-old boy (index case). We report two more cases of this outbreak (in the index case parents) with confirmed diphtheria infection and tox gene identified by molecular assay, who were in close contact with the index case and never presented any symptoms. Both parents had a congestive pharynx with erythematous plaques at the back of it. In adults, diphtheria infection can be oligosymptomatic or mimic viral pharyngitis, which could lead to misdiagnosis and, furthermore, an increased risk of transmission in regions with lower immunization rates.

[Disseminated histoplasmosis and haemophagocytic syndrome in HIV patients: A case series in a Peruvian hospital]. / Histoplasmosis diseminada y síndrome hemofagocítico en pacientes VIH: serie de casos en un hospital peruano.

BACKGROUND: Disseminated histoplasmosis (DH) is an opportunistic fungal infection in severely immunocompromised patients with HIV infection. Haemophagocytic syndrome (HFS), which can occur in these co-infected patients when the immune response is significantly altered, is often associated with high mortality. AIMS: To describe the epidemiological, clinical, analytical and microbiological characteristics, along with studying the presence of HFS, in patients with DH-HIV. METHODS: A retrospective study was conducted on a case series using data from the clinical records of patients diagnosed with DH and HIV infection during the years 2014 and 2015. RESULTS: DH was diagnosed in 8 (1.3%) of 597 HIV patients. All patients were in stage C3, and 75% (6/8) were not receiving combined antiretroviral therapy (CART). The remaining two patients had recently begun CART (possible immune reconstitution syndrome). Five (62.5%) of the 8 patients met criteria for HFS. The most frequent clinical symptoms were lymphoproliferative and consumptive syndrome, respiratory compromise, and cytopenia. Histoplasma was isolated in lymph nodes of 75% (6/8) of the patients, in blood samples in 25% (2/8), and also in intestinal tissue in one patient. The antifungal therapy was amphotericin B deoxycholate, without adjuvants. The overall mortality was 50%. CONCLUSIONS: In this case series, DH-HIV co-infection frequently progressed to HFS with high mortality. The clinical picture may resemble that of other systemic opportunistic infections, such as tuberculosis, or can take place simultaneously with other infections. Clinical suspicion is important in patients with severe cytopenia and lymphoproliferative and consumptive syndrome in order to establish an early diagnosis and prescribing a timely specific therapy.

Acute toxoplasmosis complicated with myopericarditis and possible encephalitis in an immunocompetent patient.

We document a case of a 34-year-old man with no medical previous history, presenting with lymphoproliferative syndrome associated to Toxoplasma gondii infection complicated with myopericarditis and possible encephalitis, whose diagnosis was made with lymph node biopsy, cardiac imaging, serology compatible with acute toxoplasmosis and clinical response after treatment.

Use of antibiotics in inpatients from a national hospital in Lima, Peru. / Uso de antibióticos en pacientes internados en un hospital nacional de Lima, Perú.

OBJECTIVE: To determine the point prevalence and characteristics of antibiotic use in different hospitalization areas of the Hospital Nacional Dos de Mayo. MATERIALS AND METHODS: We carried out a 3-week cross-sectional study with a census approach (using methodology from the World Health Organization) to determine the point prevalence of antibiotic use in inpatients from hospitalization areas, regardless of whether or not they were on an antibiotic regimen. RESULTS: We identified 358 patients, with a mean age of 49 (± 25.3) years, predominantly adults (88%). Antibiotics were used in 51.7% of the hospitalized patients; only 57.3% of the prescriptions followed a regimen based on clinical practice guidelines for antibiotic treatment, while 28.5% did not follow any standardized recommendation. Therapies were empirical in 86.8% and directed in 13.2% of the cases. CONCLUSIONS: Antibiotics were used in more than 50% of hospitalized patients. However, about one third of the prescriptions were not based on any clinical practice guidelines. Despite the existence of an antimicrobial control program in the hospital, appropriate antimicrobial use still needs to be optimized.

OBJETIVO: Determinar la prevalencia puntual y características del uso de antibióticos en distintas salas de hospitalización del Hospital Nacional Dos de Mayo. MATERIALES Y MÉTODOS: Se realizó un estudio transversal de tres semanas de duración mediante un abordaje censal de los pacientes hospitalizados, con o sin régimen antibiótico (bajo la metodología de la Organización Mundial de la Salud) para determinar la prevalencia puntual sobre el uso de antibióticos. RESULTADOS: Se identificaron 358 pacientes, la media de edad fue de 49 años y desviación estándar de 25,3 y fueron predominantemente adultos (88%). El uso de antibióticos fue del 51,7%; solo el 57,3% de prescripciones siguió pautas basadas en guías de práctica clínica para indicación antibiótica, mientras que el 28,5% no seguían ninguna recomendación estandarizada. Las terapias fueron empíricas en el 86,8% de pacientes y dirigidas en el 13,2%. CONCLUSIÓN: En más del 50% de los pacientes hospitalizados se utilizaron antibióticos. Sin embargo, cerca de la tercera parte de prescripciones no seguían una indicación basada en alguna guía de práctica clínica. A pesar de existir un programa de control de antimicrobianos en el hospital, aún requiere optimizarse el uso adecuado de antimicrobianos.

Lateral amyotrophic sclerosis-like onset after combined antiretroviral treatment initiation.

Motor neuron disease (MND) have an incidence of 2 in 100 000 persons, resulting in the death of 1 in every 500 people affected. The most common disease in MND spectrum is amyotrophic lateral sclerosis (ALS). We describe the case of an ALS-like syndrome in a HIV patient. This case report presents a 38 years old male from Peru with HIV who after 2 months of combined antiretroviral treatment (cART) initiation was admitted to the hospital for spastic paraplegia. On his first admission, rapid plasma reagent (RPR) was positive and he was treated for neurosyphilis and discharged. Nevertheless, one month after, he was admitted for the second time because paraplegia persisted. Laboratory tests, electromyography and imaging were performed, and ALS was diagnosed. Normally, HIV treated patient with ALS tend to have a better prognosis, however this was not the case. In this case report, we discuss possible association between ALS and immune reconstitution inflammatory syndrome in HIV patients.

Hospital-acquired SARS-CoV-2 pneumonia in a person living with HIV.

We report the case of a 38 year-old man living with well-controlled HIV on antiretroviral therapy who developed cerebellar symptoms and was admitted to hospital for management of an intraventricular cryptococcoma. During his hospital stay he contracted SARS CoV-2 infection within the hospital setting with a fatal outcome.

[Klebsiella pneumoniae NEW DELHI METALO-LACTAMASE IN A PERUVIAN NATIONAL HOSPITAL]. / Klebsiella pneumoniae Nueva Delhi metalo-betalactamasa en el Hospital Nacional Dos de Mayo. Lima, Perú.

The emergence of Enterobacteria producing carbapenemases of type New Delhi Metalo beta-lactamases (NDM), >represent, today, a real problem of world public health. The presence of this resistance mechanism limits or nullifies the therapeutic options to combat these bacteria. In Latin America, the figures are getting higher, as they are reported in Guatemala, Colombia, Chile, Argentina, among others. Peru has not, to date, described the presence of this resistance pattern; however for several years it has been presumed to exist. Nine cases of Klebsiella pneumoniae NDM are described, as infectious or colonizing agents, in critically ill patients, mostly with neurosurgical pathology, of Hospital Nacional Dos de Mayo in Lima - Peru. The patients in the series described below represent the first reports of Klebsiella pneumoniae NDM in Peru.

La emergencia de enterobacterias productoras de carbapenemasas de tipo Nueva Delhi Metalo beta-lactamasas (NDM), representan, hoy en día, un verdadero problema de salud pública mundial. La presencia de este mecanismo de resistencia limita o anula las opciones terapéuticas para combatir a estas bacterias. En Latinoamérica, las cifras son cada vez más elevadas, pues se reportan en Guatemala, Colombia, Chile, Argentina, entre otros. Perú no ha descrito, hasta la fecha, la presencia de este patrón de resistencia; sin embargo, desde hace varios años se presume de su existencia. Se describen nueve casos de Klebsiella pneumoniae NDM, como agentes infecciosos o colonizantes, en pacientes críticamente enfermos, en su mayoría con patología neuroquirúrgica, del Hospital Nacional Dos de Mayo, en Lima - Perú. Los pacientes de la serie descrita a continuación, representan los primeros reportes de Klebsiella pneumoniae NDM en el Perú.

Hypertriglyceridemic waist and arterial hypertension in adults: a systematic review and meta-analysis / Cintura hipertrigliceridémica e hipertensión arterial en adultos: una revisión sistemática y metaanálisis

Objective: To develop a systematic review and meta-analysis to determine the association between hypertriglyceridemic waist (CHTG) and arterial hypertension (HBP) in adults. Materials: The present study is a systematic review (SR) with meta-analysis of analytical cross-sectional observational studies. Search strategies will be used in different databases, which will be Pubmed, SCOPUS, Web of Science, Embase. The qualitative analysis was presented in a table with the characteristics of each study. For quantitative analysis, random-effects meta-analysis was performed due to the heterogeneity of the studies. These variables were compared using Odds Ratios (OR) as a measure of association with their corresponding 95% confidence interval. Results: Five studies were included for statistical analysis. Overall, a statistically significant association was found between both variables (OR: 1.36; 95% CI 1.07 to 1.71). In turn, there was a high heterogeneity (I squared 92%). Conclusions: This SR found that CHTG is associated with the presence of hypertension. However, given the few studies found, it is recommended to carry out more primary studies with a prospective design before carrying out a next SR on the subject, and with standardized cut-off points to make a more homogeneous comparability.

Objetivo: Desarrollar una revisión sistemática y metaanálisis para determinar la asociación entre la cintura hipertrigliceridémica (CHTG) e hipertensión arterial (HTA) en adultos. Materiales: El presente estudio es una revisión sistemática (RS) con metanálisis de estudios observacionales de corte transversal analítico. Se utilizarán estrategias de búsqueda en diferentes bases de datos las cuales serán Pubmed, SCOPUS, Web of Science, Embase. El análisis cualitativo fue presentado en una tabla con las características de cada estudio. Para el análisis cuantitativo, se realizó el metaanálisis de efectos aleatorios debido a la heterogeneidad de los estudios. Dichas variables fueron comparadas usando como medida de asociación Odds Ratios (OR) con su correspondiente intervalo de confianza al 95%. Resultados: Se incluyeron 5 estudios para el análisis estadístico. De manera global, se encontró asociación estadísticamente significativa entre ambas variables (OR: 1,36; IC 95% 1,07 a 1,71). A su vez, se presentó una alta heterogeneidad (I cuadrado del 92%). Conclusiones: La presente RS encontró que la CHTG está asociado con la presencia de HTA. No obstante, dado los pocos estudios encontrados, se recomienda la realización de más estudios primarios con un diseño prospectivo antes de la realización de una siguiente RS del tema, y con puntos de corte estandarizados para hacer una comparabilidad más homogénea.

Diagnóstico de carcinoma urotelial durante estudio de bacteremia por Streptococcus gordonii / Diagnosis of uroepithelial carcinoma during bacteremia by Streptococcus gordonii

Resumen La bacteremia por Streptococcus gordonii es infrecuente. Su aislamiento en hemocultivo traduce alta significancia clínica y debe dirigir el abordaje diagnóstico hacia la búsqueda de entidades subyacentes como neoplasias hematológicas, cardiopatías valvulares, neumonía, alteraciones estructurales de cabeza y cuello, inmunosupresión, y otras condiciones asociadas. No se han identificado reportes en pacientes con neoplasia de vías urinarias como posible condicionante de bacteremia por este agente. Se describe el caso de un paciente que, durante el estudio de bacteremia por este microorganismo, fue diagnosticado de carcinoma urotelial de alto grado.

Abstract Streptococcus gordonii bacteremia is rare. Its isolation in blood culture translates into high clinical significance and the diagnostic approach should be directed towards the search for underlying entities such as hematologic malignancies, valvular heart disease, pneumonia, structural changes of the head and neck, immunosuppression and other related conditions. No reports have been identified in patients with urinary tract neoplasia as a possible condition of bacteremia by this agent. The case of a patient who was diagnosed with high-grade urothelial carcinoma during the study of bacteremia by this microorganism is described.

[Hemorrhagic erucism due to Lonomia spp. in a girl]. / Niña con erucismo hemorrágico por Lonomia spp.

Accidents caused by urticating or poisonous setae from lepidoptera caterpillars are known as erucism. These accidents are produced by accidental contact, especially in children, with bristles on the insect's body surface, connected to venom glands. Symptoms may be local or systemic, with deadly clinical presentations. The accident caused by Lonomia spp. caterpillars can trigger bleeding disorders, which is considered the most severe type of erucism. The case of a 5-year-old girl is reported. She was from the town of Villarondos, in the Peruvian Amazon, department of Huánuco, who accidentally knelt down on caterpillar bristles, and subsequently experienced hemolytic anemia, plateletopenia, and coagulation disorder. The diagnosis was made based on the medical history, clinical manifestation, laboratory examination results, and response to antilonomic serum. The clinical, laboratory, and therapeutic aspects of erucism due to Lonomia spp. are discussed.

Lepra: sospecha diagnóstica en área no endémica. Serie de casos y revisión de la literatura / Leprosy: a suspected diagnosis in a non-endemic area. Case series and literature review

RESUMEN La lepra es una enfermedad crónica granulomatosa causada por el bacilo Mycobacterium Leprae que afecta piel y células de Schwann. En zonas no endémicas el diagnóstico de lepra suele ser dificultoso debido a la baja sospecha clínica. Durante el periodo de 2012 al 2019, se diagnosticaron y trataron tres casos de lepra en el servicio de infectología del Hospital Nacional Dos de Mayo. El tiempo de enfermedad promedio fue 4 años. Los pacientes iniciaron con pápulas pruriginosas en regiones corporales específicas, progresando a nódulos generalizados. Se constató parestesia e hipoestesia táctil, térmica, dolorosa y vibratoria; las cuales progresaron a anestesia. El diagnóstico se realizó mediante baciloscopía en secreción linfática y biopsia de nódulos cutáneos. Se describen las características clínicas de cada uno de los pacientes. Se remarca la importancia de la sospecha diagnóstica de esta entidad desatendida en áreas no endémicas.

ABSTRACT Leprosy (Hansen's disease) is a chronic granulomatous condition caused by Mycobacterium leprae, a microorganism that affects the skin and Schwann's cells. Making a diagnosis of this condition is difficult in non-endemic areas because of low clinical suspicion. During the 2012-2019 time period, three cases of Hansen's disease were diagnosed and treated in the ID service of Dos de Mayo Hospital. The average time history of the disease was 4 years. Patients started their condition with the appearance of pruriginous papular lesions affecting specific body regions, progressing to generalized nodular lesions. Paresthesia and tactile, thermal, pain, and vibratory hypoesthesia were found. These manifestations later progressed to anesthesia. Diagnosis was made through bacilloscopy in lymphatic fluid and skin node biopsy. Clinical features for each patient are also described. We emphasize the importance of clinical suspicion for diagnosing this unattended disease in non-endemic areas.

Uso de antibióticos en pacientes internados en un hospital nacional de Lima, Perú / Use of antibiotics in inpatients from a national hospital in Lima, Peru

RESUMEN Objetivo: Determinar la prevalencia puntual y características del uso de antibióticos en distintas salas de hospitalización del Hospital Nacional Dos de Mayo. Materiales y métodos: Se realizó un estudio transversal de tres semanas de duración mediante un abordaje censal de los pacientes hospitalizados, con o sin régimen antibiótico (bajo la metodología de la Organización Mundial de la Salud) para determinar la prevalencia puntual sobre el uso de antibióticos. Resultados: Se identificaron 358 pacientes, la media de edad fue de 49 años y desviación estándar de 25,3 y fueron predominantemente adultos (88%). El uso de antibióticos fue del 51,7%; solo el 57,3% de prescripciones siguió pautas basadas en guías de práctica clínica para indicación antibiótica, mientras que el 28,5% no seguían ninguna recomendación estandarizada. Las terapias fueron empíricas en el 86,8% de pacientes y dirigidas en el 13,2%. Conclusión: En más del 50% de los pacientes hospitalizados se utilizaron antibióticos. Sin embargo, cerca de la tercera parte de prescripciones no seguían una indicación basada en alguna guía de práctica clínica. A pesar de existir un programa de control de antimicrobianos en el hospital, aún requiere optimizarse el uso adecuado de antimicrobianos.

ABSTRACT Objective: To determine the point prevalence and characteristics of antibiotic use in different hospitalization areas of the Hospital Nacional Dos de Mayo. Materials and methods: We carried out a 3-week cross-sectional study with a census approach (using methodology from the World Health Organization) to determine the point prevalence of antibiotic use in inpatients from hospitalization areas, regardless of whether or not they were on an antibiotic regimen. Results: We identified 358 patients, with a mean age of 49 (± 25.3) years, predominantly adults (88%). Antibiotics were used in 51.7% of the hospitalized patients; only 57.3% of the prescriptions followed a regimen based on clinical practice guidelines for antibiotic treatment, while 28.5% did not follow any standardized recommendation. Therapies were empirical in 86.8% and directed in 13.2% of the cases. Conclusions: Antibiotics were used in more than 50% of hospitalized patients. However, about one third of the prescriptions were not based on any clinical practice guidelines. Despite the existence of an antimicrobial control program in the hospital, appropriate antimicrobial use still needs to be optimized.

Bacteremia por Vibrio cholerae NO-O1/NO-O139 en un paciente cirrótico: Primer reporte de caso en el Perú y revisión de la literatura / Vibrio cholerae NO-O1/NO-O139 bacteremia in a cirrhotic patient: First case report in Peru and literatura review

Vibrio cholerae serogrupo NO-O1/NO-O139 (VCNO) es causa infrecuente de gastroenteritis. Sin embargo, se le asocia a infección extra-intestinal severa en huéspedes inmunocomprometidos, y entre ellas, la bacteremia en pacientes con cirrosis hepática es digna de mención. A continuación, presentamos el caso de una mujer de 58 años, con el diagnóstico de cirrosis hepática de fondo, que desarrolló progresivamente choque séptico, disfunción orgánica múltiple y desenlace fatal al cuarto día de su admisión. Los resultados obtenidos post mortem, de los hemocultivos previamente tomados, aislaron bacilos gram negativos compatibles con Vibrio cholerae. Posteriormente, se identificó el serogrupo NO-O1/NO-O139, a través de aglutinación en placa y PCR negativo para el gen ctxA. El antibiograma mostró susceptibilidad conservada a ampicilina, cloranfenicol, tetraciclina y ciprofloxacino, con resistencia al trimetoprim-sulfametoxazol. El presente caso, descrito en el Hospital Nacional Dos de Mayo, es hasta la fecha, el primer reporte de bacteremia VCNO en el Perú.

Non-O1, non-O139 Vibrio cholerae (NOVC) strains are an uncommon cause of gastroenteritis. However, they have been recently associated with severe extraintestinal infections in immunocompromised hosts. Among them, bacteremia in cirrhotic patients is noteworthy. We present the case of a 58-year-old woman with cirrhosis that developed septic shock, multiple organ failure and died four days after admission. Blood cultures yielded Gram-negative rods identified as Vibrio cholerae. Further serogrouping by slide agglutination and a negative PCR for ctxA gen confirmed the strain to be NOVC. Antimicrobial susceptibility testing showed sensitivity to ampicillin, chloramphenicol, tetracycline and ciprofloxacin; and resistance to trimethoprim-sulfamethoxazole. To the best of our knowledge, this is first report in Peru, described in the Hospital Nacional Dos de Mayo, of NOVC bacteremia.