Proposal of a histopathological predictive rule for the differential diagnosis between American tegumentary leishmaniasis and sporotrichosis skin lesions.

BACKGROUND: American tegumentary leishmaniasis (ATL) and sporotrichosis exhibit similar histopathology and low frequencies of microorganism detection. OBJECTIVES: This study seeks to identify microscopic alterations that can distinguish between these diseases. METHODS: Haematoxylin and eosin stained slides of 171 ATL and 97 sporotrichosis samples from active cutaneous lesions were examined for histopathological alterations. The lesions were diagnosed by isolating the agent (which was not visible) in culture. An intuitive diagnosis was assigned to each slide. The strength of the association between the histopathological findings and the diagnosis was estimated by an odds ratio, and each finding was graded according to a regression model. A score was assigned to each sample based on the histopathological findings. A study of the interobserver reliability was performed by calculating kappa coefficients of the histopathological findings and intuitive diagnoses. RESULTS: The markers 'macrophage concentration', 'tuberculoid granuloma' and 'extracellular matrix degeneration' were associated with ATL. 'Suppurative granuloma', 'stellate granuloma', 'different types of giant cells', 'granulomas in granulation tissue' and 'abscess outside the granuloma' were associated with a diagnosis of sporotrichosis. 'Macrophage concentration' and 'suppurative granuloma' had the highest (substantial and almost perfect, respectively) reliability. The regression model score indicated 92.0% accuracy. The intuitive diagnosis had 82.5% diagnostic accuracy and substantial reliability. CONCLUSIONS: Taking into account the clinical and epidemiological context, some histopathological alterations might be useful for the differential diagnosis between ATL and sporotrichosis cutaneous lesions in cases in which the aetiological agent is not visible.

Terbinafine (250 mg/day): an effective and safe treatment of cutaneous sporotrichosis.

BACKGROUND: There are a few studies on the treatment of sporotrichosis. The standard drug used is itraconazole. However, the use of itraconazole is limited by its interaction with other drugs. OBJECTIVE: To evaluate the effectiveness and safety of 250 mg terbinafine for the treatment of cutaneous sporotrichosis in patients in whom itraconazole use is not possible. METHODS: We performed a descriptive study of cutaneous sporotrichosis cases treated with 250 mg terbinafine for which itraconazole was contraindicated or resulted in severe or moderate pharmacological interactions. Sporotrichosis was diagnosed based on the isolation of S. schenckii. RESULTS: Fifty patients seen between July 2005 and September 2007 were included. Forty-five (92%) patients reported contact with a sick cat and 47 (94%) presented comorbidities (high blood pressure: 64.0%; diabetes mellitus: 30.0%; dyslipidemia: 16.7%; depression: 10.0%; migraine: 2.1%; Parkinsonís disease: 2.1%; peptic ulcer disease: 2.1%; heart failure: 2.1%, and arrhythmia: 2.1%). All patients used some medication interacting with itraconazole (psycholeptics: 36.0%; antidiabetic agents: 28.0%; hypolipemiant agents: 18.0%; calcium-channel blockers: 16.0%; anticonvulsants: 8.0%; cardiotropic drugs: 6.3%; antacids: 6.3%, and antiparkinsonian agent: 2.1%). Most patients (96%) were cured within a mean period of 14 weeks. The drug was discontinued due to a skin rash in one patient. There were no cases of recurrence of the mycosis within a mean follow-up period of 37 weeks. CONCLUSIONS: This study suggests that 250 mg/day terbinafine is an effective and well-tolerated alternative to drug therapy of cutaneous sporotrichosis in a population in which itraconazole use is not possible.

Normal skin of HIV-infected individuals contains increased numbers of dermal CD8 T cells and normal numbers of Langerhans cells.

Dysregulation of the skin immune system (SIS) could explain the high prevalence of skin disorders in HIV+ individuals. The present study was carried out to determine whether alterations in the cell population of SIS and epidermal immunoactivation occur in the normal skin of HIV+ individuals. Forty-five biopsies were taken from the normal upper arm skin of 45 HIV+ patients and of 15 healthy controls. HIV+ individuals were divided into three categories according to their CD4 cell blood count (<200, 200-499 and > or = 500/microl). Hematoxylin-eosin was used to stain tissue sections for morphological analysis and immunohistochemistry was used for the evaluation of the frequency of macrophages, Langerhans cells, and CD lymphocyte subsets. In addition, semiquantitative analysis of LFA-1, ICAM-1 and HLA-DR was determined in epidermal cells. Macrophages, Langerhans cells, and CD lymphocyte subsets did not differ significantly between any of the patient categories and the control group. When all HIV+ individuals were compared as a group to the control group, a significant increase in dermal CD8+ T lymphocytes (P < 0.01) and lower CD4-CD8 ratios (P < 0.01) were observed in the HIV+ individuals. Epidermal ICAM-1 and HLA-DR expression was negative in both HIV+ and normal skin biopsies. No evidence of a depletion of the SIS population or of epidermal immunoactivation in normal skin from HIV+ individuals was demonstrable, suggesting that alterations in the central immune system are not necessarily reflected in the SIS of HIV-infected patients.

Poor response to tuberculosis treatment with regimens without rifampicin in immunosuppressed AIDS patients.

A prospective study was conducted on 79 advanced immunosuppressed AIDS patients from 1997 to 1999, during which nine cases of tuberculosis (TB) were diagnosed. The main clinical and laboratory characteristics and the response to TB treatment were reviewed. The clinical manifestations of TB were: pulmonary (six cases), extrapulmonary (two cases) and disseminated (one case). These patients were being treated with highly active antiretroviral treatment (HAART) and were not responding. In three cases an optional regimen without rifampicin (RMP) was indicated to maintain HAART during TB treatment. A clinical response to TB treatment (disappearance of fever) was observed in 6/9 patients during a mean of 73 days (SD = 96). The three unresponsive patients were those treated without RMP. A switch to TB regimens containing RMP was proposed and successful. In our study, though it was limited by a small sample size, the response to TB regimens without rifampin was poor in immunosupressed patients failing HAART.

Adult T-cell leukemia/lymphoma associated with HTLV-1 infection in a Brazilian adolescent.

We present the case of a 15-year-old patient infected with HTLV-1 who developed a cutaneous T-cell lymphoma, confirmed by histopathological and immunohistochemical examination, as well as clinically and hematologically confirmed leukemia. The patient died 3 months after initial presentation of the disease. The rarity of the disease in this age group justifies the present report.

Pathology of sporotrichosis in 10 cats in Rio de Janeiro.

Ten cats with sporotrichosis were examined clinically and pathologically. They were in very poor general condition, and had widespread ulcerated cutaneous lesions and respiratory signs. Gross internal abnormalities were found only in the lungs and lymph nodes. Histologically, an inflammatory infiltrate and yeast-like structures were observed in the skin, lungs, liver and lymph nodes. The spleen was congested and contained fungal elements. No microscopical changes were observed in the pancreas, kidneys and heart. Sporothix schenckii was isolated from all the skin samples and nasal swabs obtained in vivo, and from all the samples of lung, liver, spleen, lymph nodes, heart and kidney taken postmortem.

[Chagas' disease in a urban population of the health district of Rio Verde, Mato Grosso do Sul State, Brazil]. / Doença de Chagas na população urbana do distrito sanitário de Rio Verde, Mato Grosso do Sul, Brasil.

In order to evaluate some aspects of the Chagas' disease on urban population of the 12 municipalities of the sanitarian district of Rio Verde, Mato Grosso do Sul state, on 1998 we carried out a serological survey investigating anti-T. cruzi IgG by indirect immunofluorescence on blood samples collected on filter paper of 14,709 resident persons, confirmed by indirect hemagglutination and ELISA in serum. The parasitaemia was evaluated by indirect xenodiagnosis on 134 chagasic patients and the morbidity evaluated by anamnesis, physical exam and electrocardiogram in 191 pairs of chagasic/non-chagasic patients. The seropositivity was 1.83% (0.93% in autochtonous, 5.01% in alochtonous), xenodiagnosis was positive in 17.2% of the individuals (12.3% in autochtonous, 20.8% in alochtonous) and 24.6% of the seropositive patients presented chronic chagasic cardiopathy (19.1% in autochtonous, 27.8 in alochtonous). The analysis of the dates showed that alochtonous population is the main responsible for presence of the infection and morbidity of Chagas disease in the studied area.

Leptospirosis patient with AIDS: the first case reported.

A case of renal icterohemorrhagic leptospirosis involving a patient with acquired immunodeficiency syndrome (AIDS) is reported. Despite the low levels of CD4+ T lymphocytes, the clinical course of leptospirosis was similar to that observed in non-immunodepressed patients, and no worsening of AIDS occurred due to the infection by the spirochete. Serologic conversion was observed in the microscopic agglutination test, with maximum titer of 1:3,200. The patient had positive urine cultures for Leptospira interrogans for two months, whereas blood cultures were negative.

[Reactivation of Trypanosoma cruzi infection in patients with acquired immunodeficiency syndrome]. / Reativação da infecção por Trypanosoma cruzi em paciente com síndrome de imunodeficiência adquirida.

A patient with AIDS and asymptomatic Chagas's disease and positive xenodiagnosis was taking ketoconazole in order to suppress parasitemia and prevent reactivation of Chagas's disease. Ketoconazole was unplanned suspended after 6 months, and the patient was admitted with fever, headache, vomiting, tachycardia, postural hypotension, hepatosplenomegaly, and positive xenodiagnosis one month later. Treatment with benzonidazole was begun leading to suppression of parasitemia. The patient had probability a neurotoxoplasmosis associated and progressed to coma and death with sepsis. No parasite was found in autopsy.

Disseminated dermatophytosis caused by Microsporum gypseum in an AIDS patient: response to terbinafine and amorolfine.

A 51-year-old white male, native of Rio de Janeiro, Brazil, with advanced AIDS and in chronic use of imidazoles for oral candidosis, presented erythematous, desquamative, pruriginous plaques of 1 month evolution on the trunk, inguinal/crural region, and lower limbs. The diagnosis of dermatophytosis was based on the isolation of Microsporum gypseum from scales scraped from the skin lesions. The lesions regressed after 30 days treatment with itraconazole, 100 mg day(-1). After interruption of this antifungal, the mycosis recurred 2 months later, along with a toe onychomycosis also caused by M. gypseum. Attempted reintroduction of itraconazole at higher dose was unsuccessful. Patient responded well to treatment with terbinafine 250 mg day(-1) for 45 days. However, the medication had to be interrupted as a result of the emergence of a disseminated erythematous/papulous rash. Topical treatment with amorolfine cream was then performed, with a good clinical and mycological response.

Molecular epidemiology of Cryptococcus neoformans isolates from AIDS patients of the Brazilian city, Rio de Janeiro.

A high biodiversity of Cryptococcus neoformans isolates is known to exist in some Brazilian urban areas, raising the possibility that patients may encounter multiple inoculum sources in their daily life. C. neoformans isolates from two groups of AIDS patients with cryptococcosis from Rio de Janeiro were studied by polymerase chain reaction (PCR) fingerprinting and randomly amplified polymorphic DNA (RAPD) analysis. The first group contained 60 serial isolates obtained from 19 patients over periods ranging from 18 to 461 days; the intent was to determine whether the original strain persisted or whether reinfection with a new strain occurred. The second group was made up of 22 isolates from 11 patients, and consisted of a pair of isolates collected from blood and cerebrospinal fluid from each patient either before or shortly after treatment was initiated. The aim was to determine if the patient was infected by different strains simultaneously. All isolates were subtyped by PCR fingerprinting, using minisatellite (M13), and microsatellite [(GACA)4 and (GTG)5] specific primers, and RAPD analysis employing the combined primers 5SOR and CN1. The majority of isolates were C. neoformans var. grubii, specifically, molecular types VNI or VNII, but numerous distinguishable subtypes were found. Only three isolates were C. n. var. gattii (molecular types VGI or VGII). Except in two cases, all isolates obtained from the same patient showed identical PCR profiles independent of time of isolation or body site. Almost all patients, however, carried unique genotypes not found in any other patient. Our results confirm that persistent cryptococcal infection is caused by relapse rather than reinfection, but they also show that in exceptional cases, patients may be infected with more than one C. neoformans strain.

Nutritional status impairments in HIV-infected patients are associated with increased TNF-alpha and IL-6 serum levels but not with viral load.

BACKGROUND: Cytokines may alter metabolic pathways and contribute to malnutrition among human immunodefiency virus (HIV)-positive individuals. PATIENTS AND METHODS: Tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), soluble IL-2 receptors (sIL-2R), beta2-microglobulin serum levels and plasma viral load of 45 HIV-positive patients were determined and correlated to nutritional status impairment. Patients were grouped by CD4 counts into categories I (< 200/microl), II (200-499/microl), III (> or = 500/microl). There were 15 healthy controls. A nutritional grading system, based on anthropometric and laboratory data, was devised. Scores ranged from 0 to 5 (eutrophic to malnutrition). RESULTS: AIDS patients' cytokines and immune marker levels were significantly higher than those of the controls, but not always higher than those of other categories. AIDS patients had higher nutritional deficit grades than category III (p < 0.05) or the controls (p < 0.02) which, except for viral load, correlated with the parameters studied. CONCLUSION: Nutritional status impairments in HIV-positive individuals were associated with immune activation but not with viral load.

Search for evidence of a Th2 profile in HIV+ patients.

BACKGROUND: Hypersensitivity dermatoses are common in human immunodeficiency virus-positive (HIV+) patients, particularly as the disease progresses. Studies have shown that a switch to T-helper 2 (Th2) might represent a turning point in HIV. This study investigated whether increases in the number of skin mast cells, immunoglobulin E (IgE) serum levels, and eosinophilia, involved in the Th2 response in allergic disease, might also be present in HIV+ patients. If so, these alterations might explain one of the mechanisms of skin hypersensitivity in these patients. METHODS: Forty-five skin biopsies from the normal skin of the upper arm of HIV+ patients and 15 controls were included in the study. HIV+ individuals were classified into three equal categories according to their immunologic status: Category I (< 200/microL), Category II (200-499/microL), and Category III (> 500/microL). Anti-tryptase antibody was employed in tissue sections to show mast cells; IgE serum levels and eosinophils in peripheral blood count were investigated; delayed-type hypersensitivity (DTH) skin tests (candidin, trichophytin, and PPD 2U) were evaluated. RESULTS: Normal cutaneous mast cell and eosinophil counts were the same in all categories and in the control group, but increased IgE levels (P < 0. 01) and DTH skin test anergy (P < 0.006) were observed among acquired immunodeficiency syndrome (AIDS) patients. CONCLUSIONS: The density of skin mast cells in HIV infection was not modified in the course of the disease. Mast cells do not seem to be primarily responsible for triggering hypersensitivity dermatoses among AIDS patients, although data in support of the Th2 response, as seen in increased IgE serum levels and DTH anergy, are present.

Isolation of Sporothrix schenckii from the nails of domestic cats (Felis catus).

We report the first isolation of Sporothrix schenckii from the nail surfaces of cats. The fungus grew from nail clippings of three cats associated with three household outbreaks of sporotrichosis involving cats and human beings. The identification of the isolates was based on macroscopic and microscopic morphological characteristics at 25 degrees C and conversion of S. schenckii to the yeast-like form at 37 degrees C.