[Clinical problems in medical mycology: Problem number 48]. / Problemas clínicos en micología médica: problema número 48.

We present the case of a 42-year-old man, HIV-positive, with low CD4(+) T cell count (31 cells/µl), who was admitted to Hospital de Infecciosas F. J. Muñiz in Buenos Aires (Argentina) due to a severe lower back pain. He had a history of several highly active antiretroviral therapy treatments and he also had diabetes and chronic B and C viral hepatitis. A spinal cord CT scan showed two lytic bone lesions in L2 and L3. A bone biopsy was carried out and its microbiological study allowed the isolation of a methicillin-resistant Staphylococcus aureus. Intravenous vancomycin was prescribed, together with a corset and physical rest. A few days later the patient presented with acute dermatitis with papules, vesicles, scales and erythema, which spread over the whole lumbar region. The mycological study of the scales led to the isolation in culture of Candida albicans and Candida parapsilosis. With the diagnosis of decubitus candidiasis he was initially treated with a topical ointment containing 3% salicylic acid and 6% benzoic acid, but only slow, partial improvement was observed. The treatment was changed to oral fluconazole at a daily dose of 200mg. With the latter the patient showed a rapid, complete clinical response.

[Cryptococcal meningitis in patients with diabetes and AIDS]. / Criptococosis meníngea en pacientes con diabetes y sida.

INTRODUCTION: Cryptococcal meningitis is a severe AIDS-related infectious disease, with a high mortality rate. Diabetes mellitus (DM) is a metabolic disorder very common worldwide. Infectious diseases in diabetic patients are always more severe than in non-diabetic ones. The aim of this study was to compare the outcome of a group of HIV-positive patients with DM and cryptococcal meningitis with a similar group HIV-positive patients with cryptococcal meningitis, but without DM. MATERIAL AND METHODS: A total of 182 clinical records of HIV-positive patients suffering cryptococcal meningitis were reviewed, and 28 of them with similar clinical and epidemiological characteristics, were chosen. They included 14 patients with DM (group A) and the remaining 14 who did not suffer this metabolic disorder (group B). RESULTS: Only 21.4% (3/14 cases) of group A patients had negative CSF cultures after 10 weeks of treatment. In group B patients, 78.5% (11/14 cases) achieved negative CSF cultures before 10 weeks. A higher overall mortality rate was observed in the diabetic patients (85.7%, 12/14 cases) than in the non-diabetic group (21.4%, 3/14 cases). All CSF isolates were identified as Cryptococcus neoformans, and all strains were susceptible in vitro to amphotericin B and fluconazole. CONCLUSIONS: Cryptococcal meningitis in diabetic patients was associated with a poor clinical outcome and a high mortality rate. A longer treatment induction period is suggested in order to improve the outcome of cryptococcal meningitis in diabetic patients.

Soft-tissue masses as presentation of non-Hodgkin's lymphoma in AIDS patients.

Primary soft tissue Non-Hodgkin lymphomas are very rare and account only for 0.1 % of the cases. Generally, Non-Hodgkin lymphomas of the soft tissue present as large subcutaneous masses without evidence of nodal or skin involvement. We describe four cases of primary Non-Hodgkin lymphomas of the soft tissue in patients infected with the human immunodeficiency virus. The most common site of involvement was the chest wall in all the patients; histopathological and immunophenotypic examination of the biopsy smears revealed two cases of plasmablastic lymphomas, one Burkitt and one diffuse large B-cell lymphoma. Non-Hodgkin lymphomas should be included in the differential diagnosis of soft tissue masses in human immunodeficiency virus - seropositive patients.

Soft-tissue masses as presentation of non-Hodgkin's lymphoma in AIDS patients / Massas de tecidos moles como apresentacao do linfoma nao-Hodgkin em pacientes com AIDS

Primary soft tissue Non-Hodgkin lymphomas are very rare and account only for 0.1 % of the cases. Generally, Non-Hodgkin lymphomas of the soft tissue present as large subcutaneous masses without evidence of nodal or skin involvement. We describe four cases of primary Non-Hodgkin lymphomas of the soft tissue in patients infected with the human immunodeficiency virus. The most common site of involvement was the chest wall in all the patients; histopathological and immunophenotypic examination of the biopsy smears revealed two cases of plasmablastic lymphomas, one Burkitt and one diffuse large B-cell lymphoma. Non-Hodgkin lymphomas should be included in the differential diagnosis of soft tissue masses in human immunodeficiency virus - seropositive patients.

Os linfomas Não-Hodgkin primários de tecidos moles são muito raros e responsáveis por somente 0,1% dos casos. Geralmente, os linfomas Não-Hodgkin de tecidos moles se apresentam como massas subcutâneas sem evidência de comprometimento dos nódulos ou da pele. Descrevemos aqui quatro casos de linfomas Não-Hodgkin primário de tecidos moles em pacientes infectados pelo vírus da imunodeficiência humana. O local mais comum de comprometimento foi a parede torácica em todos os pacientes; os exames histopatológico e imunofenotípico do esfregaço da biópsia revelaram dois casos de linfoma plasmablástico, um linfoma de Burkitt e um linfoma difuso de grandes células B. O linfoma Não-Hodgkin deve ser incluído no diagnóstico diferencial de massas de tecidos moles nos pacientes soropositivos para vírus da imunodeficiência humana.

[Clinical problems in medical mycology: Problem number 47]. / Problemas clínicos en micología médica: problema número 47.

A 66 year-old man, who had lived in Paraguay and was a rural worker, was admitted to Infectious Diseases Hospital F. J. Muñiz in Buenos Aires. He presented fever, loss of body weight, cough, mucopurulent expectoration, wide perianal ulceration, paresthesia and paresis of both legs as well as vesical and anal sphincter dysfunction. He was a heavy smoker and drinker. Thorax X-ray examination showed bilateral micronodular interstitial lesions. With a NMR of the dorsolumbar spine region a nodular lesion outside the spinal cord (which produced compression of this organ) was shown. The diagnosis of disseminated paracoccidiodomycosis was based on the finding of Paracoccidioides brasiliensis in the skin ulcer in histopathology and mycology studies, and on the positive results of serologic tests with paracoccidioidin antigen. The patient was treated with trimethoprim-sulfamethoxazole with good clinical outcome.

Acute meningoencephalomyelitis due to varicella-zoster virus in an AIDS patient: report of a case and review of the literature / Meningoencefalomielite aguda pelo vírus varicela-zoster em um paciente com AIDS: relato de um caso e revisão da literatura

Varicella-zoster virus (VZV) meningoencephalomyelitis is a rare but severe neurological complication of VZV reactivation in immunocompromised patients. We report the case of an HIV-infected individual who developed an acute and severe meningoencephalomyelitis accompanied by a disseminated cutaneous eruption due to VZV. The presence of VZV DNA in cerebrospinal fluid was confirmed by polymerase chain reaction (PCR) technique. The patient started undergoing an intravenous acyclovir therapy with a mild recovery of neurological manifestations. Varicella-zoster virus should be included as a cause of acute meningoencephalomyelitis in patients with AIDS. Early diagnosis followed by specific therapy should modify the rapid and fulminant course for this kind of patients.

A meningoencefalomielite pelo vírus varicela-zoster (VVZ) é uma complicação neurológica rara mas grave da reativação do VVZ em pacientes imunocomprometidos. Nós relatamos o caso de um indivíduo infectado por HIV que desenvolveu uma meningoencefalomielite aguda e grave acompanhada por uma erupção cutânea por causa do VVZ. A presença do DNA do VVZ no líquor foi confirmada pela técnica de reação em cadeia da polimerase (PCR). O paciente iniciou uma terapia intravenosa com aciclovir com uma leve recuperação das manifestações neurológicas. O vírus varicela-zoster deve ser incluído como uma causa de meningoencefalomielite nos pacientes com AIDS. O diagnóstico precoce seguido por terapia específica pode modificar o curso rápido e fulminante deste tipo de pacientes.

Human herpesvirus 6: report of emerging pathogen in five patients with HIV/AIDS and review of the literature / Herpes virus humano 6: relato de patógenos emergentes em cinco pacientes com HIV/AIDS e revisão da literatura

The reactivation of human herpesvirus 6 (HHV-6) in patients with AIDS can result in an acute and severe diffuse meningoencephalitis. We describe the epidemiological, clinical and outcome findings of five patients with diagnosis of HIV/AIDS and central nervous system involvement (CNS) due to HHV-6. Fever was present in all the patients. Meningeal compromise, seizures and encephalitis were present in some of the patients. Polymerase chain reaction (PCR) of cerebrospinal fluid (CSF) specimens was positive for HHV-6 in all the patients. HHV-6 should be included among opportunistic and emerging pathogens that involve the CNS in patients with AIDS.

A reativação do herpesvírus humano 6 (HHV-6), em um hospedeiro com AIDS, pode resultar em meningoencefalite aguda difusa. Nós descrevemos a epidemiologia, a clínica e resultados encontrados em cinco pacientes com diagnóstico de HIV/AIDS e comprometimento do sistema nervoso central (SNC) devido ao HHV-6. Todos os pacientes apresentaram febre. Sinais e sintomas de comprometimento meníngeo, convulsões e encefalite podem ser encontrados. A reação em cadeia da polimerase (PCR) de amostras do líquor foi positiva para HHV-6 em todos os pacientes. O HHV-6 deve ser incluído entre os patógenos emergentes oportunistas que comprometem o SNC de pacientes com AIDS.

Non-Hodgkin lymphomas of the oral cavity in AIDS patients in a reference hospital of infectious diseases in Argentina: report of eleven cases and review of the literature.

INTRODUCTION: Extranodal non-Hodgkin lymphoma (NHL) were commonly described in AIDS patients and are related with an atypical morphology and aggressive clinical course. MATERIALS AND METHODS: In this single institutional study we evaluated the epidemiological, clinical, immunological, virological, histopathological and the outcome of eleven HIV/AIDS patients with oral cavity lymphomas (OCL). RESULTS: Nine were males and seven intravenous drug abusers. The median of age was 33 years and the median of CD4 T cell counts at the time of diagnosis was 97 cell/µL. The majority of tumors presented as large and ulcerated masses involving the gingiva, the palate and the jaw. Six of these tumors were diffuse large B-cell lymphomas (DLBCL); three were Burkitt's lymphomas and the final case was a plasmablastic lymphoma. An association with Epstein-Barr virus (EBV) was found in three of the ten tested cases by in situ hybridization (EBER 1 and 2 probes) and immunohistochemistry (LMP-1). Human herpes virus-8 (HHV-8) was detected by polymerase chain reaction (PCR) in only one neoplasm. Six patients died without specific treatment; four received chemotherapy and highly active antiretroviral therapy (HAART) and three of them presented a prolonged survival. DISCUSSION: Combination of HAART and chemotherapy should modify the poor prognosis of AIDS patients with OCL.

Magnetic resonance imaging findings in AIDS patients with central nervous system cryptococcosis.

Cryptococcosis is an opportunistic fungal infection caused by Cryptococcus neoformans. Generally, the disease affects the central nervous system, especially in patients with human immunodeficiency virus infection. Central nervous system involvement can be either meningeal or parenchymal. As the infection spreads along the Virchow-Robin spaces these structures may dilate with the mucoid and gelatinous material produced by the organism's capsule. The lesions associated with the dilatation of Virchow-Robin spaces are referred to as gelatinous pseudocysts. Bigger lesions are known as cryptococcomas. In this article we describe five patients with neurocryptococcosis associated with AIDS and parenchymal lesions compatible with gelatinous pseudocysts and cryptococcomas.

Burkitt's lymphoma of the duodenum in a patient with AIDS.

Non-Hodgkin's lymphoma of B-cell type is the second most common neoplasm after Kaposi's sarcoma, among patients with human immunodeficiency virus infection. Most non-Hodgkin's lymphoma cases that are associated with acquired immunodeficiency syndrome involve extranodal sites, especially the digestive tract and the central nervous system. We report a case of primary lymphoma of the duodenum in a patient with AIDS. Upper gastrointestinal endoscopy revealed pseudopolypoid masses found in the second portion of the duodenum. A complete diagnostic study including histological, immunohistochemical and virological analyses showed high-grade B-cell Burkitt's lymphoma. The Epstein-Barr virus genome was detected in biopsies by immunohistochemical and in situ hybridization.

Burkitt's lymphoma of the duodenum in a patient with AIDS

Non-Hodgkin's lymphoma of B-cell type is the second most common neoplasm after Kaposi's sarcoma, among patients with human immunodeficiency virus infection. Most non-Hodgkin's lymphoma cases that are associated with acquired immunodeficiency syndrome involve extranodal sites, especially the digestive tract and the central nervous system. We report a case of primary lymphoma of the duodenum in a patient with AIDS. Upper gastrointestinal endoscopy revealed pseudopolypoid masses found in the second portion of the duodenum. A complete diagnostic study including histological, immunohistochemical and virological analyses showed high-grade B-cell Burkitt's lymphoma. The Epstein-Barr virus genome was detected in biopsies by immunohistochemical and in situ hybridization.

O linfoma não-Hodgkin de células B é a segunda neoplasia mais comum em pacientes com infecção pelo vírus da imunodeficiência humana depois do sarcoma de Kaposi. A maioria dos casos de linfoma não-Hodgkin associados com a síndrome da imunodeficiência adquirida envolve locais extraganglionares, especialmente o trato digestivo e o sistema nervoso central. Nós relatamos um caso de linfoma primário do duodeno em um paciente com AIDS. Uma endoscopia digestiva alta mostrou massas pseudopolipóides encontradas na segunda porção do duodeno. Um estudo diagnóstico completo incluindo exames histológicos, imunohistoquímicos e virológicos mostrou um linfoma de células B tipo Burkitt. Detectou-se genoma do vírus Epstein-Barr em biópsias por hibridização in situ e imuno-histoquímica.

Aporte de las neuroimágenes al diagnóstico del compromiso del sistema nervioso central en la enfermedad HIV/sida / Contribution of the neurographs to the diagnosis of the commitment of the central nervous system in the HIV/sida disease

El compromiso del sistema nervioso central en la enfermedad HIV/SIDA avanzada incluye un amplio espectro de manifestaciones clínicas, entre las que predominan aquellas complicaciones asociadas con el propio retrovirus, como el complejo demencial, las infecciones oportunistas y los tumores marcados de la enfermedad. En esta revisión analizamos el aporte de las neuroimágenes al diagnóstico no invasivo de las complicaciones intracraneales más comunes en estos pacientes asociados con la inmodeficiencia severa a la que conduce el retrovirus.

Primary liver AIDS-related lympoma.

Non-Hodgkin's lymphomas (NHL) are the second most frequent malignancies in AIDS patients. The majority of NHL associated with AIDS involves extranodal sites, especially the digestive tract and the central nervous system. Primary liver lymphoma (PLL) is an uncommon neoplasm among these patients. Ultrasonography and computed tomography scans may be helpful in the diagnosis of focal hepatic lymphoma. Image-guided fine-needle biopsy with histopathology of the liver lesions is the gold standard for the diagnosis of hepatic lymphoma. We report a case of PLL as the initial manifestation of AIDS in a patient without any previous infection by hepatitis C or B virus, presented as multiple and large hepatic masses.

Primary liver AIDS-related lympoma / Linfoma não-Hodgkin primário do fígado em paciente com SIDA

Non-Hodgkin's lymphomas (NHL) are the second most frequent malignancies in AIDS patients. The majority of NHL associated with AIDS involves extranodal sites, especially the digestive tract and the central nervous system. Primary liver lymphoma (PLL) is an uncommon neoplasm among these patients. Ultrasonography and computed tomography scans may be helpful in the diagnosis of focal hepatic lymphoma. Image-guided fine-needle biopsy with histopathology of the liver lesions is the gold standard for the diagnosis of hepatic lymphoma. We report a case of PLL as the initial manifestation of AIDS in a patient without any previous infection by hepatitis C or B virus, presented as multiple and large hepatic masses.

Os linfomas não-Hodgkin (LNH) são as segundas neoplasias mais freqüentes nos pacientes com síndrome da imunodeficiência adquirida (SIDA). A maioria dos LNH associados à AIDS envolvem locais extra-ganglionares, especialmente o trato digestivo e o sistema nervoso central. O linfoma não-Hodgkin primário do fígado (LPF) é uma neoplasia incomum nestes pacientes. A ultrassonografia (US) e a tomografia computadorizada (TC) podem ser úteis no diagnóstico de linfoma não-Hodgkin hepático apresentando-se como lesões multifocais. A biópsia com agulha fina guiada por imagens (US, TC) juntamente com a histopatologia das lesões do fígado constitui o padrão-ouro para o diagnóstico de linfoma hepático. Este trabalho relata um caso de LPF como manifestação inicial de AIDS em um paciente sem infecção prévia pelo vírus da hepatite C e B, que se apresentou como massas hepáticas múltiplas e de grandes dimensões.