Diagnosis and Management of Systemic Endemic Mycoses Causing Pulmonary Disease.

Systemic endemic mycoses cause high rates of morbidity and mortality in certain regions of the world and the real impact on global health is not well understood. Diagnosis and management remain challenging, especially in low-prevalence settings, where disease awareness is lacking. The main challenges include the variability of clinical presentation, the fastidious and slow-growing nature of the fungal pathogens, the paucity of diagnostic tests, and the lack of options and toxicity of antifungal drugs. Coccidioidomycosis and paracoccidioidomycosis are restricted to the Americas only, and while histoplasmosis and blastomycosis also occur predominantly in the Americas, these mycoses have also been reported on other continents, especially in sub-Saharan Africa. Talaromycosis is endemic in tropical and subtropical regions in South-East Asia and southern China. Systemic endemic mycoses causing pulmonary disease are usually acquired via the airborne route by inhalation of fungal spores. Infections can range from asymptomatic or mild with flu-like illnesses to severe pulmonary or disseminated diseases. Skin involvement is frequent in patients with paracoccidioidomycosis, blastomycosis, sporotrichosis, and talaromycosis and manifests as localized lesions or diffuse nodules in disseminated disease, but can also occur with other endemic mycoses. Culture and/or characteristic histopathology from clinical samples is the diagnostic standard for endemic mycoses. Immunological assays are often not available for the diagnosis of most endemic mycoses and molecular amplification methods for the detection of fungal nucleic acids are not standardized at present. The first-line treatment for mild to moderate histoplasmosis, paracoccidioidomycosis, blastomycosis, sporotrichosis, and talaromycosis is itraconazole. Severe illness is treated with amphotericin B. Patients with severe coccidioidomycosis should receive fluconazole. Treatment duration depends on the specific endemic mycosis, the severity of disease, and the immune status of the patient, ranging between 6 weeks and lifelong treatment.

Clinical and therapeutic features of pulmonary nontuberculous mycobacterial disease, Brazil, 1993-2011.

To identify clinical and therapeutic features of pulmonary nontuberculous mycobacterial (PNTM) disease, we conducted a retrospective analysis of patients referred to the Brazilian reference center, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil, who received a diagnosis of PNTM during 1993­2011 with at least 1 respiratory culture positive for NTM. Associated conditions included bronchiectasis (21.8%), chronic obstructive pulmonary disease (20.7%), cardiovascular disease (15.5%), AIDS (9.8%), diabetes (9.8%), and hepatitis C (4.6%).Two patients had Hansen disease; 1 had Marfan syndrome. Four mycobacterial species comprised 85.6% of NTM infections: Mycobacterium kansasii, 59 cases (33.9%); M. avium complex, 53 (30.4%); M. abscessus, 23 (13.2%); and M. fortuitum, 14 (8.0%). A total of 42 (24.1%) cases were associated with rapidly growing mycobacteria. In countries with a high prevalence of tuberculosis, PNTM is likely misdiagnosed as tuberculosis, thus showing the need for improved capacity to diagnose mycobacterial disease as well as greater awareness of PNTM disease prevalence.

Tratamento da tuberculose sensível e resistente / Treatment of Drug-Sensitive and Drug-Resistant Forms of Tuberculosis

O diagnóstico precoce e o tratamento efetivo são as principais medidas para o controle da tuberculose. Esquemas terapêuticos padronizados, fornecimento gratuito de medicamentos, de acordo com a complexidade do caso e da unidade de saúde, como se recomenda no Brasil, compõem o cenário adequado para a administração e o controle do tratamento. A estratégia de tratamento diretamente observado, recomendada pela Organização Mundial da Saúde, foi adotada no Brasil como política de governo desde a década passada e se soma às medidas anteriores para melhorar o controle da tuberculose. Esse artigo descreve o histórico da quimioterapia antituberculose e sua evolução com os regimes para formas sensíveis e multirresistentes, assim como as modificações efetuadas no sistema de tratamento da tuberculose no Brasil, à luz das normas nacionais atuais

Early diagnosis and efective treatment are the principal means of ensuring tuberculosis control. The appropriate scenario in which to administer and monitor treatment includes standardized treatment regimens and the provision of medications free of charge, according to the complexity of the case and the health facility infrastructure, as recommended in Brazil. The directly observed treatment, short course strategy, recommended by the World Health Organization, was adopted as a governmental policy in Brazil more than a decade ago. This strategy complements previously implemented measures for the control of tuberculosis. This article describes the history of antituberculosis chemotherapy and regimens for treating drug-sensitive and multidrug- -resistant forms, as well as changes to the national system of tuberculosis treatment in Brazil, in view of the current Brazilian guidelines