An elevated HScore is associated with poor clinical outcomes in COVID-19 / Un HScore elevado se asocia a mal pronóstico en pacientes con COVID-19

BACKGROUND: Patients with Coronavirus Disease 2019 (COVID-19) frequently experience a hyperinflammatory syndrome leading to unfavorable outcomes. This condition resembles Secondary Hemophagocytic Lymphohistiocytosis (sHLH) described in neoplastic, rheumatic and other infectious diseases. A scoring system (HScore) that evaluates underlying immunosuppression, temperature, organomegaly, cytopenias, ferritin, triglycerides, fibrinogen and AST was validated for sHLH, and recently proposed to evaluate hyperinflammation in COVID-19. AIM: To assess the presence of sHLH among patients with COVID-19 admitted for hospitalization and to evaluate Hscore as a prognostic tool for poor outcomes. MATERIAL AND METHODS: One hundred forty-three patients aged 21-100 years (64% males) admitted because of COVID-19 were enrolled in a prospective study. HScore was calculated within 72 hours admission. The incidence of sHLH during hospitalization was evaluated. Additionally, the relationship between a HScore ≥ 130 points and either the requirement of mechanical ventilation or 60-days mortality was explored. RESULTS: The median HScore was 96 (33-169). A SHLH was diagnosed in one patient (incidence 0.7%), whose HScore was 169. After adjusting for age, sex, comorbidities and obesity, HScore ≥ 130 was independently associated with the composite clinical outcome (Hazard rartio 2.13, p = 0.022). CONCLUSIONS: sHLH is not frequent among COVID-19 patients. HScore can be useful to predict the risk for poor outcomes.

ANTECEDENTES: Los pacientes con Enfermedad por Coronavirus 2019 (COVID-19), experimentan frecuentemente un síndrome hiperinflamatorio que lleva a resultados desfavorables. Esta situación se asemeja al Síndrome Hemofagocítico Secundario (sHLH) descrito en enfermedades neoplásicas, reumatológicas y por otros agentes infecciosos. Un sistema simple de puntaje (HScore) que evalúa inmunosupresión, temperatura organomegalia, citopenias, ferritina, triglicéridos, fibrinógeno y AST ha sido validado para el diagnóstico de sHLH y ha sido propuesto recientemente para evaluar la hiperinflamación en COVID-19. OBJETIVO: Medir la frecuencia de sHLH entre pacientes con COVID-19 hospitalizados, y evaluar a HScore como una herramienta pronóstica. MATERIAL Y MÉTODOS: Ciento cuarenta y tres pacientes de 21 a 100 años (64% hombres) fueron ingresados en este estudio de cohorte prospectivo, unicéntrico. Se calculó HScore dentro de las primeras 72 horas desde el ingreso, y se midió la incidencia de sHLH durante la hospitalización. Adicionalmente, se evaluó la relación entre HScore ≥ 130 puntos y un desenlace compuesto de ventilación mecánica o muerte a los 60 días. RESULTADOS: La mediana de HScore fue 96 (33-169) puntos. Un paciente fue diagnosticado con sHLH (incidencia 0,7%). Luego de ajustar por edad, sexo, comorbilidades y obesidad, un HScore ≥ 130 se asoció de manera independiente con el desenlace compuesto. CONCLUSIONES: El sHLH no es frecuente en los pacientes con COVID-19. El uso de HScore puede ser útil para predecir el riesgo de desenlaces clínicos desfavorables.

Overall survival in Chilean patients with lymphoma and human immunodeficiency virus: A retrospective cohort study

ABSTRACT Introduction: People living with human immunodeficiency virus (PLWH) still face high morbidity and mortality resulting from lymphoma. Aim: To describe a population of PLWH and lymphoma in a Chilean public hospital and compare the overall survival (OS) with a previously reported cohort from the same institution. Methods: Retrospective single-center cohort study. All the patients diagnosed between 2010 and 2017 were included. Demographic and clinical variables were obtained from medical records. The overall survival (OS) was estimated in treated patients from diagnosis until death or October 2020. The OS was then compared with a cohort of patients diagnosed between 1992 and 2008. Main Results: Eighty-four patients were included. The most common histological types were Burkitt's lymphoma (BL), diffuse large B-cell lymphoma (DLBCL), Hodgkin's lymphoma (HL) and plasmablastic lymphoma (PBL) at 31%, 27%, 21% and 14%, respectively. The three-year OS for the whole cohort of BL, DLBCL, HL and PBL was 58.9%, 65.2%, 47.4%, 76.4% and 50%, respectively. Compared to the cohort of 1992 to 2008, a global increase in the OS was found after excluding HL and adjusting for age and clinical stage (HR 0.38, p = 0.002). However, when the main types were analyzed individually, the increase in the OS was statistically significant only in DLBCL (HR 0.29, p = 0.007). Most patients with DLBCL received CHOP chemotherapy, as in the previous cohort. Conclusion: The OS has improved in this population, despite no major changes in chemotherapy regimens, mainly due to the universal access to antiretroviral therapy.

Neumonía por Rothia mucilaginosa en un paciente inmunocomprometido posterior a un trasplante renal / Rothia mucilaginosa pneumonia in an immunocompromised patient after kidney transplant

Resumen Rothia mucilaginosa es una bacteria propia de la microbiota del tracto respiratorio superior, que se asocia en forma infrecuente a infecciones en pacientes inmunocomprometidos y con enfermedades pulmonares crónicas, principalmente neumonía y bacteriemia. Su tratamiento generalmente, se basa en el uso de antibacterianos β lactámicos. Se describe el caso de un paciente sometido a un trasplante renal con uso de fármacos inmunosupresores, que cursó con una infección diseminada por Cryptococcus neoformans. Tras el inicio de la terapia antifúngica, presentó un cuadro febril, con aparición de nuevos infiltrados radiológicos e insuficiencia respiratoria aguda, demostrándose en el estudio con lavado broncoalveolar, un cultivo positivo para R. mucilaginosa, descartándose otras etiologías. Evolucionó en forma favorable tras el uso de meropenem, con buena respuesta clínica y resolución de los infiltrados radiológicos.

Abstract Rothia mucilaginosa is a bacterium derived from the upper respiratory tract microbiota, which is rarely associated with infections in immunocompromised patients suffering chronic lung diseases, mainly pneumonia and bacteremia. Its treatment is generally based on the use of β-lactams. The case study of a kidney transplant patient using immunosuppressive drugs, who developed a disseminated Cryptococcus neoformans infection, is described. After starting antifungal therapy, he presented with fever, appearance of new radiological infiltrates and acute respiratory failure, demonstrating a positive culture for R. mucilaginosa in a study with bronchoalveolar lavage, ruling out other etiologies. He evolved favorably after the use of meropenem, with good clinical response and resolution of radiological infiltrates.

Self-prescribed Ivermectin use is associated with a lower rate of seroconversion in health care workers diagnosed with COVID, in a dose-dependent response

ABSTRACT Background: Over-the-counter use of ivermectin amongst other drugs as SARS-CoV-2 treatment has been increasingly common, despite the lack of evidence on its clinical efficacy. Objective: To evaluate the effect of ivermectin use on production of antibodies against SARS-CoV-2 in health care workers (HCW) diagnosed with COVID-19 and of Th1/Th2 cytokines by stimulated peripheral blood mononuclear cells of the same cohort (PBMCs). Methods: This cross-sectional study evaluated seroconversion and neutralizing antibodies production in HCW at Complexo Hospitalar Universitário Professor Edgard Santos (Salvador, Brazil), diagnosed with COVID-19 from May to July, 2020, as well as in vitro production of antibody against SARS-CoV-2 and Th1/Th2 cytokines. Analyses were performed between December 2020 and February 2021. Participants were stratified according to the use of ivermectin (≤ 1 dose vs. multiple doses) for treatment of COVID-19. Results: 45 HCW were included (62% women). Mean age was 39 years, and disease severity was similar across groups. Neutralizing antibodies were detected less frequently in multiple doses (70%) vs. ≤ 1 dose (97%) groups, p = 0.02). PBMCs of patients in multiple doses group also were less likely to produce antibodies against SARS-CoV-2 following in vitro stimulation with purified spike protein in comparison with patients in ≤ 1 dose group (p < 0.001). PBMC's production of Th1/Th2 cytokines levels was similar across groups. Abdominal pain (15% vs 46%, p = 0.04), diarrhea (21% vs. 55%, p = 0.05) and taste perversion (0% vs. 18%, p = 0.05) were more frequently reported by participants that used multiple doses of ivermectin. Conclusions: Although there was no evidence for differential disease severity upon ivermectin use for treatment of COVID-19 it was associated with more gastro-intestinal side-effects and impairment of anti-SARS-CoV2 antibodies production, in a dose dependent manner. This potentially impacts the effectiveness of immune response and the risk of reinfection and warrants additional studies for clarifying the mechanisms and consequences of such immunomodulatory effects.

Clinical and physiological efficacy of the application of autologous fat with platelet rich plasma in treating faecal incontinence / Eficácia clínica e fisiológica da aplicação de gordura autóloga com plasma rico em plaquetas no tratamento da incontinência fecal

Abstract Purpose: Faecal incontinence (FI) is a frequent condition that can occur due to different causes; with negative impact on self-esteem and quality of life, secondary morbidity, disability and significant costs. For its treatment there is a wide range of options, being medical treatment, hygienic dietary modifications and biofeedback, the first line of treatment; reserving surgery for patients who do not respond or with severe FI; this with variable success rates and high cost. This study has the primary aim to assess the efficacy and describe the Technique of Application of Autologous Fat with Platelet Rich Plasma (AFPRiP) in patients with faecal incontinence as well as secondary endpoints of quality of life, manometric and ultrasound evaluation, safety of implantation, and complications. Methods: A single-centre prospective, experimental study, was conducted from January 2017 to February 2018 in Domingo Luciani Hospital. Wexner and FIQL scores were filled preoperative and compared at follow-up at 3, 6 and 12 months as well as anorectal manometry and endoanal ultrasound were performed before and 6 months after surgery. Results: Twelve patients were operated, mean time 43 min, no major complications. Wexner finding continence improvement from 10.4 pre to 4 in the 3rd month (p = 0.066) 4.74 at the 6th month (p = 0.001) and 5 at one year (p = 0.001); that is, improvement of >50% in 83.4%. FIQL 50.9 prior to 98.6 at 3rd month (p = 0.001) 95.5 to 6th month (p = 0.001) and 91.3 a year (p = 0.066). Conclusions: We conclude that AFPRiP is innovative, safe and with adequate results.

Resumo Objetivo: A incontinência fecal é uma condição frequente que pode ocorrer devido a diferentes causas, com impacto negativo na autoestima e qualidade de vida, morbidade secundária, incapacidade e custos significativos. Existem várias opções para o manejo da incontinência fecal; o tratamento médico, as modificações higiênicas da dieta e o biofeedback, são os de primeira linha. A cirurgia é recomendada apenas para pacientes que não respondem ao tratamento de primeira linha ou aqueles com incontinência fecal grave; as taxas de sucesso são variáveis e o custo do tratamento cirúrgico é elevado. Este estudo teve como objetivo principal avaliar a eficácia e descrever a técnica de aplicação de gordura autóloga com plasma rico em plaquetas (AFPRiP) em pacientes com incontinência fecal; o estudo também avaliou parâmetros secundários de qualidade de vida, manométricos e ultrassonográficos, bem como a segurança da implantação e suas complicações. Métodos: Um estudo experimental prospectivo, de centro único, foi realizado de janeiro de 2017 a fevereiro de 2018 no Hospital Domingo Luciani. A escala de Wexner e o FIQL foram preenchidos no pré-operatório e comparados no seguimento de três, seis e 12 meses; manometria anorretal e ultrassonografia endoanal foram realizadas antes e seis meses após a cirurgia. Resultados: Doze pacientes foram operados; o tempo médio da cirurgia foi de 43 minutos, sem maiores complicações. Na escala de Wexner, observou-se melhora na continência: de 10,4 pré-operatório a 4 no terceiro mês (p = 0,066), 4,74 no sexto mês (p = 0,001) e 5 em um ano (p = 0,001), uma melhoria de 83,4%. Já o FIQL evoluiu de 50,9 no período pré-operatório para 98,6 no terceiro mês (p = 0,001), 95,5 no sexto mês (p = 0,001) e 91,3 em um ano (p = 0,066). Conclusões: A AFPRiP é uma técnica inovadora, segura e que apresenta resultados adequados.

Primer aislamiento de Candida auris en Chile / First isolation de Candida auris in Chile

Resumen Candida auris es una levadura multi-resistente emergente con rápida diseminación mundial. Desde el primer reporte el 2009, varios aislados a través de los cinco continentes han sido identificados como agentes de infecciones asociadas a la atención en salud. Brotes independientes y simultáneos por C. auris se han vuelto prioridad para la comunidad hospitalaria y científica. Además, los errores en identificación y los perfiles de multi-resistencia, raramente observados para otras especies de Candida, resultan en una difícil erradicación y fallas terapéuticas frecuentes en infecciones por C. auris. Presentamos el primer aislamiento de una cepa de C. auris en un hospital en Santiago, en un paciente proveniente de la India, que fue admitido para tratamiento de su pie diabético. La cepa fue recuperada de un cultivo de tejido e identificada por VITEK® 2 Compact. La identificación de C. auris fue confirmada por MALDI-TOF MS y secuenciación. El aislado fue resistente a fluconazol y susceptible a anfotericina y caspofungina, según puntos de corte recomendados por el CDC. La emergencia de C. auris es alarmante debido a que el modo de transmisión dentro del ambiente hospitalario no es claro y probablemente es multifactorial.

Candida auris is an emerging multi-drug-resistant fungus that is rapidly spreading worldwide. Since the first reports in 2009, many isolates across five continents have been identified as agents of hospital-associated infections. Independent and simultaneous outbreaks of C. auris are becoming a major concern for healthcare and scientific community. Moreover, laboratory misidentification and multi-drug-resistant profiles, rarely observed for other non-albicans Candida species, result in difficult eradication and frequent therapeutic failures of C. auris infections. In this article we present the first case of isolation of a strain of C. auris at a hospital in Santiago, in a patient coming from India, who was admitted for treatment of diabetic foot complications. The strain was recovered from a tissue culture and identified by VITEK® 2 Compact. The accurate identification of C. auris was confirmed by means of MALDI-TOF MS and DNA sequence analysis. The isolate was resistant to fluconazole, retaining only susceptibility to amphotericin and caspofungin with MIC breakpoints recommended by CDC. The emergence of C. auris is alarming because the mode of transmission within the healthcare environment is not clear and is likely to be multifactorial.

Host characteristics predict outcome among adult patients admitted by severe acute respiratory infection / Características del huésped predicen el desenlace en adultos hospitalizados por infección respiratoria aguda grave

Background: Except for influenza pandemics, different observational studies have failed to demonstrate differences in mortality between various etiologies in adult patients hospitalized for respiratory infections. Aim: To compare clinical and mortality differences between different viral pathogens associated with severe acute respiratory infections (SARI) in hospitalized adults. Material and Methods: One-year prospective study in a sentinel center. We included 132 patients with SARI hospitalized for any of the nine viruses under study by PCR. Clinical variables were compared, excluding cases of coinfection. Results: A viral coinfection was identified in 12% and influenza infection in 56% of cases. Eighty percent of patients were aged ≥ 65 years, with a high frequency of comorbidities, 27% were bedridden. Twenty four percent were admitted to critical care units, 20% required ventilatory assistance and 16% died. Cases occurred throughout the year, with an expected seasonal peak between autumn and spring and a predominance of infections not associated with influenza during summer months. In the multivariate analysis, only being bedridden was significantly associated with mortality at discharge (Odds ratio 23.46; 95% confidence intervals 3.33-165.12, p < 0.01), without association with age, comorbidity, viral pathogen involved, laboratory parameters, clinical presentation or CURB65 score. No major clinical dissimilarities were found between different viral pathogens. Conclusions: In our series of patients, mostly elderly, only bedridden status was significantly associated with mortality at discharge in patients hospitalized for SARI. Viral pathogens were not relevant.

Los factores del huésped son más importantes que el tipo viral para predecir el desenlace en pacientes hospitalizados por infecciones respiratoria aguda grave. Exceptuando las pandemias de influenza, diferentes estudios observacionales no han logrado demostrar diferencias en mortalidad entre diferentes patógenos en pacientes adultos hospitalizados por infecciones respiratorias. Objetivo: Comparar diferencias clínicas y en mortalidad entre diferentes patógenos virales asociados a infección respiratoria aguda grave (IRAG) en adultos hospitalizados. Método: Estudio prospectivo durante un año en un centro centinela. Se incluyeron casos de IRAG hospitalizados por alguno de los 9 virus bajo estudio por RCP. Se compararon variables clínicas y desenlace. Resultados: Ingresaron 132 pacientes con IRAG. Se identificó coinfección viral en 12,1% e infección por influenza en 56,1%. La mayor parte era de la tercera edad (80,3%) con una alta frecuencia de comorbilidad y 27,3% estaba postrado. Veintitres coma cinco por ciento ingresó a unidad de cuidados críticos, 19,7% requirió asistencia ventilatoria y 15,9% fallecieron. Los casos ocurrieron todo el año, con un aumento estacional esperado entre otoño y primavera y predominio de infecciones no asociadas a influenza en verano. En el análisis multivariado, sólo la postración se asoció significativamente a mortalidad al egreso (ORa 23,46 IC95 3,33-165,12, p = 0,002), sin asociación con la edad, comorbilidad, patógeno viral involucrado, parámetros de laboratorio, presentación clínica o puntuación CURB65. No se encontraron discordancias clínicas mayores entre diferentes agentes virales. Conclusiones: En nuestra serie de pacientes, mayoritariamente de la tercera edad, sólo la postración se asoció significativamente a mortalidad al egreso en pacientes hospitalizados por IRAG. El patógeno viral no resultó ser relevante.

Hepatitis sifilítica: reporte de una serie de casos / Syphilitic hepatitis: report of three cases

Liver involvement occurs in 0.2 to 3% of patients with syphilis. We report three patients with liver involvement in syphilis. A 52-year-old male presenting with erythema and malaise. Laboratory showed a gamma glutamyl transpeptidase (GGT) of 853 u/l, alkaline phosphatases of 1,010 U/L and VDRL was positive. Treatment with penicillin resolved the skin problem and normalized liver enzymes. A HIV positive 30-year-old male in peritoneal dialysis presenting with itching, malaise and markedly elevated GGT and alkaline phosphatases. VDRL was positive. He was treated with penicillin with remission of symptoms and enzyme normalization. A 43-year-old male presenting with erythema, malaise, arthralgias and elevated GGT and alkaline phosphatases. VDRL was positive and treatment with penicillin reverted symptoms and laboratory abnormalities.

Severe acute respiratory infections (SARI) from influenza in adult patients in Chile: the experience of a sentinel hospital / La infección respiratoria aguda grave asociada a la gripe en pacientes adultos en Chile: experiencia de un hospital centinela / Infecção respiratória aguda grave (SARI) decorrente da influenza em pacientes adultos no Chile: experiência de um hospital-sentinela

ABSTRACT Objective To 1) describe clinical characteristics of adult patients in Chile with severe acute respiratory infections (SARI) associated with influenza viruses, and 2) analyze virus subtypes identified in specimens collected from those patients, hospital resources used in clinical management, clinical evolution, and risk factors associated with a fatal outcome, using observational data from the SARI surveillance network (SARInet). Methods Adults hospitalized from 1 July 2011 to 31 December 2015 with influenza-associated SARI at a SARI sentinel surveillance hospital in Santiago were identified and the presence of influenza in all cases confirmed by reverse transcription polymerase chain reaction (RT-PCR), using respiratory samples. Results A total of 221 patients (mean age: 74.1 years) were hospitalized with influenza-associated SARI during the study period. Of this study cohort, 91.4% had risk factors for complications and 34.3% had been vaccinated during the most recent campaign. Pneumonia was the most frequent clinical manifestation, occurring in 57.0% of the cohort; other manifestations included influenza-like illness, exacerbated chronic bronchitis, decompensated heart failure, and asthmatic crisis. Cases occurred year-round, with an epidemic peak during autumn-winter. Both influenza A (H1N1pdm09 and H3N2) and B virus co-circulated. Critical care beds were required for 26.7% of the cohort, and 19.5% needed ventilatory assistance. Multivariate analysis identified four significant factors associated with in-hospital mortality: 1) being bedridden (adjusted odds ratio (aOR): 22.3; 95% confidence interval (CI): 3.0-164); 2) admission to critical care unit (aOR: 8.9; CI: 1.44-55); 3) Pa02/Fi02 ratio < 250 (aOR: 5.8; CI: 1.02-33); and 4) increased serum creatinine concentration (> 1 mg/dL) (aOR: 5.47; CI: 1.20-24). Seasonal influenza vaccine was identified as a significant protective factor (aOR: 0.14; CI: 0.021-0.90). Conclusions Influenza-associated SARI affected mainly elderly patients with underlying conditions. Most patients evolved to respiratory failure and more than one-quarter required critical care beds. Clinical presentation was variable. Death was associated with host characteristics and disease-associated conditions, and vaccine was protective. Virus type did not influence outcome.

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RESUMO Objetivo Descrever as características clínicas de pacientes adultos com infecção respiratória aguda grave (SARI) associada ao vírus da influenza e analisar os subtipos virais identificados em amostras coletadas destes pacientes, os recursos hospitalares empregados no tratamento clínico, a evolução clínica e os fatores de risco clínicos associados a um desfecho fatal, a partir de dados observacionais da rede de vigilância de SARI (SARInet) no Chile. Métodos Foram identificados os adultos hospitalizados com SARI associada a influenza em um hospital-sentinela de vigilância de SARI, em Santiago, de 1o de julho de 2011 a 31 de dezembro de 2015. A ocorrência de influenza foi confirmada em amostras respiratórias em todos os casos com a reação em cadeia da polimerase via transcriptase reversa (RT-RCP). Resultados Ao todo, 221 pacientes (idade média de 74,1 anos) foram hospitalizados com SARI associada a influenza no período de estudo. Nesta coorte, 91,4% apresentavam fatores de risco para complicação e 34,3% haviam sido vacinados na última campanha de vacinação. Pneumonia foi a manifestação clínica mais frequente, ocorrendo em 57,0% da coorte. Outras manifestações foram doença gripal, bronquite crônica exacerbada, insuficiência cardíaca descompensada e crise asmática. Os casos estiveram distribuídos ao longo do ano, com pico epidêmico no outono-inverno. Houve circulação simultânea dos vírus da influenza A (H1N1pdm09 e H3N2) e B. Leitos de terapia intensiva foram necessários em 26,7% da coorte e suporte ventilatório, em 19,5%. Na análise multivariada, quatro fatores importantes associados à mortalidade hospitalar foram identificados: estar restrito ao leito (odds ratio ajustado [ORaj] 22.3; intervalo de confiança de 95% [IC 95%] 3.0-164); ser admitido na unidade de terapia intensiva (ORaj 8.9, IC 95% 1.4 4-55); relação Pa02/Fi02 <250 (ORaj 5.8; IC 95% 1.02-33) e aumento da creatinina sérica (>1 mg/dl) (ORaj 5.47; IC 95% 1.20-24). A vacinação sazonal contra influenza foi identificada como importante fator de proteção (ORaj 0.14; IC 95% 0.021-0.90). Conclusões A SARI associada a influenza acometeu sobretudo pacientes idosos com doenças preexistentes. A maioria dos pacientes evoluiu com insuficiência respiratória e mais de um quarto precisou de cuidados intensivos. O quadro clínico foi variável. Morte foi associada às características do hospedeiro e problemas relacionados à doença. A vacinação teve efeito protetor e o tipo viral não influiu no desfecho.

Expansão da circulação do vírus Zika da África à América, 1947-2018: revisão da literatura / Expansión de la circulación del virus Zika de África a América, 1947-2018: una revisión de literatura / Expansion of Zika virus circulation from Africa to the Americas, 1947-2018: a literature review

Objetivo: descrever as expansões temporal e geográfica da circulação do vírus Zika (ZIKV) em países e territórios, desde seu isolamento até 2018. Métodos: revisão não sistemática da literatura do período entre 1947 e 2018, utilizando a base MEDLINE e estimativas da Organização Mundial da Saúde. Resultados: desde seu isolamento em 1947, a circulação do ZIKV expandiu-se pela África, Ásia e Pacífico, até chegar à América em 2013, causando manifestações clínicas graves; as maiores soroprevalências foram registradas na ilha de Yap (74%) e no Brasil (63%); mutações genéticas, a ausência de imunidade e a alta susceptibilidade dos vetores podem ter influenciado sua transmissibilidade e ajudam a explicar a magnitude de sua expansão. Conclusão: a expansão da circulação do ZIKV nas Américas foi a mais ampla já registrada, possivelmente resultado de características populacionais e geográficas dos locais por onde o vírus circulou.

Objetivo: Describir las expansiones temporal y geográfica de la circulación del virus Zika en países y territorios, desde su aislamiento hasta 2018. Métodos: Revisión no sistemática de la literatura del período comprendido entre 1947 y 2018 utilizando la base MEDLINE y estimaciones de la Organización Mundial de la Salud. Resultados: Desde su aislamiento en 1947 la circulación del virus Zika se expandió por África, Asia y el Pacífico hasta llegar a América en 2013, causando manifestaciones clínicas graves. Las mayores seroprevalencias se registraron en la isla Yap (74%) y en Brasil (63%). Mutaciones genéticas, ausencia de inmunidad y alta susceptibilidad de los vectores pueden haber influenciado su transmisibilidad y ayudan a explicar la magnitud de su expansión. Conclusión: La expansión de la circulación del virus Zika en las Américas fue la más amplia ya registrada, posiblemente como resultado de características poblacionales y geográficas de los lugares por donde el virus circuló.

Objective: to describe the temporal and geographical expansion of Zika virus (ZIKV) circulation in countries and territories, from the time it was first isolated until 2018. Methods: This was a non-systematic literature review covering the period from 1947 to 2018 using the MEDLINE database and World Health Organization estimates. Results: Since its isolation in 1947, ZIKV circulation spread through Africa, Asia and the Pacific before reaching the Americas in 2013, causing serious clinical manifestations; the highest seroprevalence rates were recorded in Yap (74%) and in Brazil (63%); genetic mutations, absence of immunity and high vector susceptibility may have influenced ZIKV transmissibility and help to explain the magnitude of its expansion. Conclusion: The spread of ZIKV circulation in the Americas was the most extensive recorded thus far, possibly as a result of population and geographical characteristics of the sites where the virus circulated.

Long-term impact of competitive biddings and an antimicrobial stewardship program in a general hospital in Chile / Impacto de un programa de control de antimicrobianos (PCA) y licitaciones públicas sobre el consumo de estos medicamentos

ABSTRACT Background: The long-term effect of an antimicrobial stewardship program (ASP) and its integrated impact with competitive biddings have been seldom reported. Aim: To evaluate the long-term effect of an ASP on antimicrobial consumption, expenditure, antimicrobial resistance and hospital mortality. To estimate the contribution of competitive biddings on cost-savings. Material and Methods: A comparison of periods prior (2005-2008) and posterior to ASP initiation (2009 and 2015) was done. An estimation of cost savings attributable to ASP and to competitive biddings was also performed. Results: Basal median antimicrobial consumption decreased from 221.3 to 170 daily defined doses/100 beds after the start of the ASP. At the last year, global antimicrobial consumption declined by 28%. Median antimicrobial expenditure per bed (initially US$ 13) declined to US$ 10 at the first year (-28%) and to US$ 6 the last year (-57%). As the reduction in consumption was lower than the reduction in expenditure during the last year, we assumed that only 48.4% of savings were attributable to the ASP. According to antimicrobial charges per bed from prior and after ASP implementation, we estimated global savings of US$ 393072 and US$ 190000 directly attributable to the ASP, difference explained by parallel competitive biddings. Drug resistance among nosocomial bacterial isolates did not show significant changes. Global and infectious disease-associated mortality per 1000 discharges significantly decreased during the study period (p < 0.05). Conclusions: The ASP had a favorable impact on antimicrobial consumption, savings and mortality rates but did not have effect on antimicrobial resistance in selected bacterial strains.

Antecedentes: Existe poca información sobre el impacto a largo plazo de un programa de control de antimicrobianos (PCA) y su efecto combinado con licitaciones públicas de fármacos. Objetivo: Evaluar el impacto de un PCA sobre el consumo, gasto, mortalidad y estimar la contribución de las licitaciones. Material y Métodos: Comparación antes (2005-2008) - después (2009-2015) del PCA y estimación porcentual del ahorro atribuible al PCA y licitaciones. Resultados: El consumo bajó de 221,3 a 170 dosis diarias definidas por 100 días camas (medianas) al primer año. En el último año el consumo declinó un 27,6%. La mediana del gasto por cama ocupada se redujo de 13 a 10 US$ el primer año y a 6 US$ el último año (-57%). Debido a que el gasto bajó más que el consumo, estimamos que solo el 48,4% del ahorro fue debido al PCA (cuociente de ambas reducciones: −27,6%/-57%). De acuerdo con el gasto en antimicrobianos por cama entre ambos períodos, se calculó un ahorro global de 393.000 US$ y de 190.000 US$ directamente atribuible al PCA, siendo la diferencia explicada por licitaciones. Los porcentajes de resistencia en cepas de infecciones nosocomiales no mostraron incrementos o reducciones significativas en el tiempo y la mortalidad por egresos asociada a enfermedades infecciosas (Códigos CIE 10) se redujo significativamente (p < 0,05). Conclusiones: El PCA se asoció a largo plazo a un impacto favorable sobre el consumo de antimicrobianos, gasto por antimicrobianos y egresos por enfermedades infecciosas sin un impacto en la resistencia antimicrobiana. Las licitaciones tuvieron un efecto aditivo en el ahorro.

Seguridad de las fluoroquinolonas: riesgos habitualmente olvidados para el clínico / Safety of fluoroquinolones: risks usually forgotten for the clinician

Resumen Las quinolonas constituyen una familia de antimicrobianos de amplio uso y si bien son consideradas segura para los pacientes, el conocimiento del perfil de seguridad es necesario para que los profesionales estén alertas a lo que deben vigilar. Sobre el sistema músculo-esquelético, las quinolonas tienen el potencial de dañar cartílagos, provocando incluso muy excepcionalmente rotura de tendón. A nivel endocrino se ha observado hipoglicemia/hiperglicemia, por lo que en pacientes diabéticos se recomienda el control cuidadoso de la glicemia. Las reacciones adversas cardiovasculares son poco frecuentes, pero pueden ir desde alteraciones del ECG como prolongación del QT sin traducción clínica a graves arritmias que pueden ser de riesgo vital. En el sistema nervioso, destaca la aparición de alteraciones del sistema nervioso central y la neuropatía periférica. Durante la evaluación de la seguridad de las quinolonas es importante considerar las potenciales interacciones con otros medicamentos. En niños se prefiere no usar las fluoroquinolonas debido al potencial riesgo de daño a los cartílagos de crecimiento, efectos que no parecen ser tan dramáticos a la luz de la evidencia actual. A pesar del optimismo se debe evaluar la seguridad del tratamiento de estos antimicrobianos en todo paciente pediátrico.

Quinolones are a group of widely used antimicrobials. Although they are considered safe for patients, knowledge of the safety profile is necessary so that professionals become aware of what is necessary to monitor. At the musculoskeletal level, quinolones have the potential to damage cartilage, causing even tendon rupture in infrequent cases. Hypoglycemia / hyperglycemia has been observed at the endocrine level, thus, careful monitoring of glycemia in patients with quinolone is recommended in diabetic patients. At the cardiovascular level, arrhythmias induced by these antimicrobials are rare but severe. At the level of the nervous system, the appearance of alterations of the central nervous system and the peripheral neuropathy are emphasized. When assessing the safety of quinolones, it is important to consider potential interactions with other substances (medical products). In children it is preferred not to use fluoroquinolones because of the potential risk of cartilage damage and growth, effects that do not seem to be so dramatic in the face of new evidence. Despite optimism, the safety of the treatment of these antimicrobials should be evaluated in every pediatric patient.

Granulomas pulmonares y en médula ósea: más allá de la tuberculosis. A propósito de un caso / Differential diagnosis of bone marrow and lung granulomas: Report of one case

The differential diagnosis of pulmonary tuberculosis and lymphoma with pulmonary infiltration is very difficult, given their similar clinical characteristics. We report a 59 year old female with weight loss, fever, dyspnea and cough of several months of duration. She had a cavitated mass in lung imaging. A positive conventional PCR lead to the diagnosis of tuberculosis, but she had negative smears and cultures for Mycobacterium tuberculosis. The patient did not respond to treatment and her clinical condition worsened. A peripheral lymph node biopsy confirmed the presence of a diffuse large B cell non-Hodgkin lymphoma. Bone marrow pathology showed non caseating granulomas, again with negative microbiological tests for M. tuberculosis. Findings in the bone marrow were interpreted as a secondary sarcoid reaction to cancer and PCR results as a false positive. The lymphoma was treated, achieving complete remission. This case highlights the importance of the differential diagnosis between these two entities.

Enfermedad de Chagas del sistema nervioso central en un paciente con SIDA demostrada por métodos cuantitativos moleculares / Chagas disease affecting the central nervous system in a patient with AIDS demonstrated by quantitative molecular methods

Although infrequent, Trypanosoma cruzi reactivation is possible among patients with HIV/AIDS infection that develop a tumor-like or granulomatous lesion in the CNS. We report the case of a 60 years old male patient with HIV/AIDS and low CD4 lymphocytes count with cerebellar symptoms and mild paresis, associated to supra and infratentorial hypodense lesions and positive serology tests both to T. gondii and Trypanosoma cruzi. Empirical therapy against toxoplasmosis was prescribed together with antiretroviral therapy but without a favorable response. Brain Chagas disease was confirmed by quantitative PCR in the CSF but he died despite nifurtimox treatment. Despite its rare occurrence, Chagas disease affecting the CNS is possible among patients with HIV/AIDS infection. Epidemiological exposure, a positive Chagas serological test and the image pattern of brain lesions support the suspicion. Diagnosis can be confirmed by molecular test in CSF samples, including new quantitative methods. Despite an adverse prognosis, specific therapy can be attempted besides antiretroviral treatment.

La reactivación de la infección por Trypanosoma cruzi es un diagnóstico infrecuente pero posible en pacientes con infección por VIH/SIDA y una lesión de tipo tumoral o granulomatosa en el sistema nervioso central. Presentamos el caso clínico de un paciente de 60 años con VIH/SIDA y recuentos bajos de linfocitos CD4, con síntomas cerebelosos y paresia leve, lesiones hipodensas supra e infratentoriales y serología positiva para Toxoplasma gondii y T. cruzi. Se trató empíricamente como una toxoplasmosis cerebral y con terapia antiretroviral, sin respuesta clínica. La enfermedad de Chagas cerebral se confirmó por RPC cuantitativa en el LCR. El paciente falleció a pesar de recibir terapia con nifurtimox. Apoyan la posibilidad de un Chagas cerebral en pacientes con VIH/SIDA, la exposición epidemiológica, la serología positiva y el patrón de distribución de las lesiones en las imágenes. El diagnóstico puede mejorarse con técnicas moleculares cuantitativas en LCR. A pesar de su mal pronóstico, se puede intentar una terapia específica junto al tratamiento antiretroviral.

Espondilodiscitis: experiencia clínica en un hospital general de Chile / Spondylodiscitis: clinical experience in a Chilean general hospital

Introducción: La espondilodiscitis (ED) implica prolongados períodos de hospitalización, de latencia diagnóstica y riesgo de complicaciones a largo plazo. No existen publicaciones recientes en Chile al respecto. Objetivos: Caracterizar un grupo de pacientes con ED. Pacientes y Métodos: Serie clínica, que incluyó pacientes en un período de ocho años. Resultados: 37 pacientes, 37,8% mujeres y 62,2% hombres, con promedio etario 66,8 años; 64,9% adultos mayores, 35,1% diabéticos y 21,6% con co-morbilidad urológica. Los principales síntomas fueron dolor y fiebre. 89,2% tuvo elevación de VHS. 86,5% contó con resonancia magnética, que siempre fue confirmatoria, siendo la columna lumbar la localización más frecuente (43,2%). Se identificó etiología en 28/37 pacientes: en 71,4% cocáceas grampositivas (Staphylococcus aureus predominantemente), sólo en 10,7% M. tuberculosis. Staphylococcus aureus estuvo asociado a co-morbilidades médicas en forma significativa (p < 0,05) y el grupo de bacilos gramnegativos a historia hepatobiliar y/o intestinal (p < 0,05). El método de mayor rendimiento fue el cultivo obtenido por punción quirúrgica. El tratamiento antimicrobiano fue indicado en promedio por 63,8 días (IQR 53-72), con reacciones adversas en 18,9%. La estadía hospitalaria fue 38,9 días promedio, no existiendo fallecidos durante este período. 18,9% presentó secuelas motoras. Discusión: La mayoría de pacientes con ED correspondió a adultos mayores, siendo S. aureus la principal etiología. Hubo una baja frecuencia de M. tuberculosis. Resultó considerable la magnitud de efectos adversos asociados a la terapia antimicrobiana y las complicaciones neurológicas.

Background: Spondylodiscitis (SD) involves long periods of hospitalization, diagnostic latency and risk of long-term complications. No updated series are available in Chile and a change in demographic features and etiology is suspected. Aim: To characterize a group of patients with SD. Patients and Methods: Clinical series including patients over an 8 year period. Results: We identified 37 patients; 37.8% women and 62.2% men (mean age 66.8 years); 64.9% were elderly; 35.1% had diabetes and 21.6% urological comorbidity. Main symptoms were pain and fever. Erythrocyte sedimentation rate was elevated in 89.2%, and 86.5% patients had MRI, which was always confirmatory. Lumbar spine was the most common site of infection (43.2%). Etiology was identified in 28/37 patients: 71.4% yielded grampositive cocci (Staphylococcus aureus predominantly), Mycobacterium tuberculosis was identified in only 10.7%. Staphylococcus aureus was associated to medical comorbidities (p < 0,05) and gramnegative bacilli to hepatobiliar or intestinal symptoms (p < 0,05). Culture obtained by a surgical procedure had the highest yield. The average duration of antibiotic therapy was 63.8 days (IQR 53-72). Treatment-related side effects were detected in 18.9% of patients. The average hospital stay was 38.9 days. No deaths occurred during hospitalization. Motor sequelae were present in 18.9% of this series. Discussion: Most patients with SD were older adults. Staphylococcus aureus was predominant and M. tuberculosis was uncommon. Antibiotic side effects were relevant as well as the neurological complications.

Cotrimoxazol en infecciones óseas: toxicidad e impacto clínico y económico / Cotrimoxazole in bone-related infections: toxicity and clinical and economic impact

Background: Cotrimoxazole is a therapeutic option for bone-related infections but is associated to hyperkalemia and renal failure. Tolerance to this drug may reduce length of stay (LOS) and hospital charges. Aims: To evaluate renal, potassium toxicity, clinical outcome, and use of hospital resources in patients treated with cotrimoxazole for bone-related infections. Methods: Retrospective analysis of adult patients with bone-related infections confirmed by culture and treated with this drug. Serum potassium and creatinine levels were analyzed during follow-up and risk factors for hyperkalemia were searched. Length of stay (LOS) and hospital charges were compared. Clinical outcome was evaluated as a secondary endpoint. Results: From 2011 to 2014, 23 patients were identified (mean age 64.7 years). Diabetes mellitus, peripheral vascular disease, and previous amputations prevalence were high (82.6%, 47.8%, and 43.5%, respectively). Median serum potassium concentration increased significantly at first control (4.35 mEq/L to 4.9 mEq/L; p < 0.001), and also creatinine serum concentration (0.9 to 1.1 mg/dL; p < 0.05). Seven patients developed hyperkalemia. Cotrimoxazole was discontinued in 10 patients (43.5%), and in 6, discharge was postponed. Drugs active against the renin-angiotensin system (DAARAS) were associated with kyperkalemia (OR 10.8 IC95 1.37-85; p < 0.05). LOS was higher among patients with cotrimoxazole toxicity (median LOS 56 versus 30 days, p < 0.05). Patients with no cotrimoxazole interruption had less drug-related hospital charges (median values of 563 versus 2820 USD, respectively; p < 0.01). Conclusions: Cotrimoxazole use must be monitored in order to detect hyperkalemia or renal toxicity and suspend its prescription. Patients that use DAARAS have a higher risk of kyperkalemia. LOS and drug-related hospital charges are reduced when patients can tolerate cotrimoxazole.

Antecedentes: Cotrimoxazol es una alternativa en infecciones óseas pero se ha asociado al desarrollo de falla renal e hiperkalemia. Objetivo: Evaluar toxicidad renal, hiperkalemia, estadía y gastos hospitalarios y evolución clínica en un grupo de pacientes con infecciones óseas tratados con este compuesto. Pacientes y Métodos: Estudio retrospectivo-descriptivo de pacientes adultos con infecciones óseas confirmadas con cultivos y tratados con este compuesto. Seguimiento de creatinina y kalemia y búsqueda de factores de riesgo para hiperkalemia, comparación de gastos y estadía hospitalaria y análisis de eficacia clínica. Resultados: Desde el año 2011 al 2014 se identificaron 23 pacientes (promedio de edad 64,7 años). La prevalencia de diabetes mellitus tipo 2 (82,6%), enfermedad vascular periférica (47,8%) y amputaciones previas (43,5%) fue elevada. La mediana de la kalemia basal aumentó significativamente al primer control (4,35 a 4,9 mEq/L) al igual que la creatinina plasmática (0,9 a 1,1 mg/dL). Siete pacientes desarrollaron hiperkalemia (30,4%). Se suspendió cotrimoxazol en 10 casos (43,5%) y en 6 casos se postergó el alta. El uso de fármacos activos contra el sistema renina-angiotensina (FASRA) se asoció a hiperkalemia (OR 10,8 IC95 1,37-85; p < 0,05). La estadía hospitalaria fue mayor en el grupo con toxicidad a cotrimoxazol (mediana de 56 versus 30 días; p < 0,05) y los pacientes sin suspensión de terapia tuvieron menos gastos por fármacos (medianas de 563 vs 2.820 USD, p < 0,01). Conclusiones: El uso de cotrimoxazol debe ser monitorizado para detectar hiperkalemia o toxicidad renal y suspender su prescripción. Los pacientes que usan FASRA tienen mayor riesgo de hiperkalemia. La estadía y gastos hospitalarios por fármacos son menores en pacientes que toleran el cotrimoxazol.

Encefalomielitis aguda diseminada grave: Comunicación de un caso asociado a infección por virus parainfluenza 3 / Severe acute disseminated encephalomyelitis associated with parainfluenza 3 infection: Case report

Disseminated encephalomyelitis (ADEM) is an infrequent condition with considerable morbidity and mortality in adult patients. It requires a high level of suspicion and diagnosis emerges by gathering clinical information, laboratory exams and images studies. ADEM is related to an immunological phenomena occurring after a bacterial/viral infection or recent vaccination. Glucocorticoids are the first line treatment, reserving immunoglobulins and plasmapheresis to refractory cases. We report a male patient aged 25, with ADEM associated to parainfluenza 3 virus respiratory infection that required mechanical ventilation and that had a complete recovery only after plasmapheresis.

La encefalomielitis aguda diseminada es una enfermedad infrecuente pero de elevada morbi-mortalidad en pacientes adultos. Demanda una sospecha y diagnóstico precoz que requiere el concurso de información clínica, pruebas de laboratorio y estudio de imágenes. De sustrato inmunológico, se puede relacionar a una infección viral, bacteriana o inmunización reciente. Los glucocorticoides son el tratamiento de elección, mientras que la inmunoglobulina intravenosa y la plasmaféresis se reservan para casos refractarios. Se presenta el caso de una encefalomielitis aguda diseminada grave, en un paciente de sexo masculino de 25 años, asociado a una infección respiratoria por virus parainfluenza 3. Requirió conexión a ventilación mecánica y tuvo una respuesta completa con plasmaféresis.

Pacientes con infección por VIH/SIDA en una Unidad de Pacientes Críticos: La experiencia de un hospital general en un país en desarrollo / HIV/AIDS patients in a Critical Care Unit: The experience of a general hospital in a developing country

Introduction and aims: Despite general availability of HAART in Chile, admissions of HIV/AIDS patients to Intensive-Intermediate Care Units (IICU) are still happening, and a characterization of patient's profile, mortality and potentially avoidable admissions is necessary. Methods: Observational retrospective study in one general hospital in Chile of HIV/AIDS patients admitted to IICU during 9 years. Results: During 2005-2013, 32 patients were admitted to IICU, with 87,5% in AIDS stage, only 53,1% knew his/her condition, 43,8% were receiving HAART and 16.6% chemoprophylaxis for opportunistic infections, A CD4 count < 200/µL was registered in 75,9% of patients. Most admissions were driven by infectious conditions (84,4%) and 48,1% developed septic shock, IICU hospitalizations were motivated by respiratory failure, neurologic compromise, sepsis or a mixture of them (87,5%), By univariate analysis, admissions by respiratory failure were associated to no HAART, oral candidiasis or CD4 < 250/µL (p < 0.01). Eight patients died during their first hospitalization (25%) and other 5 in the following month after discharge. Death during hospitalization was significantly associated to vasoactive drug use ≥ 7 days (OR 16.5; IC95 2.1-128 p < 0.01). In multivariate analysis, APACHE score ≥ 18 was associated with death during hospitalization of after discharge (OR 3,3 IC95 1,1-10; p < 0,05), Four patients (12,5%) had potentially avoidable admissions. Conclusions: Despite HAART availability in Chile, hospitalizations of patients with HIV/AIDS are still happening, affecting those that either are unaware of his/her condition, are not receiving HAART and/or chemoprophylaxis. These admissions generate premature deaths and happen even after discharge in severely ill patients.

Antecedentes y Objetivos: A pesar de la disponibilidad de la terapia viral de gran actividad (TARGA) en Chile el ingreso de pacientes con infección por VIH/SIDA a la Unidad de Pacientes Críticos (UPC) siguen ocurriendo. Se necesita mayor información en Chile sobre el perfil de estos pacientes, su mortalidad y el porcentaje de ingresos evitables. Método: Estudio observacional retrospectivo de pacientes adultos que ingresaron a la UPC en un hospital general durante 9 años. Resultados: En el período 2005-2013 se identificaron 32 pacientes que ingresaron a UPC. El 87,5% estaba en etapa SIDA al ingreso, 53,1% sabía su diagnóstico, sólo 43,8% recibía terapia TARGA y 16,6% quimioprofilaxis. Un 75,9% tenía un recuento CD4 < 200/µL. La mayoría de los ingresos fue por una causa infecciosa (84,4%) y 48,1% presentaron shock séptico. Por sistemas, los ingresos a UPC fueron liderados por falla respiratoria, compromiso neurológico, sepsis o una mezcla de ellos (87,5%). Por análisis univariado, el ingreso por falla respiratoria se asoció a ausencia de HAART, candidiasis oral o un recuento CD4 < 250/µL (p < 0,01). Ocho pacientes fallecieron en la primera hospitalización (25%) y otros cinco en los meses siguientes al alta. El desenlace fatal en el hospital estuvo significativamente asociado al uso de fármacos vasoactivos por ≥ 7 días (OR 16,5; IC 95 2,1-128 p < 0,01). En el análisis multivariado, un score APACHE ≥ 18 se asoció en forma independiente a fallecimiento en el hospital o post alta (OR 3,3 IC 95 1,1-10; p < 0,05). Cuatro pacientes (12,5%), tuvieron hospitalizaciones potencialmente evitables. Conclusiones: Las hospitalizaciones de pacientes con infección VIH a UPC siguen ocurriendo a pesar de la disponibilidad de TARGA en Chile, afectando a pacientes que desconocen su condición, no están en tratamiento o con profilaxis. Estos ingresos generan muertes prematuras, las que ocurren incluso después del alta en los pacientes más graves.

Aspergilosis invasiva en unidad de cuidado intensivo / Invasive Aspergilosis in ICU

La aspergilosis invasiva (AI) es causada por la inhalación de conidias del moho Aspergillus spp. , el cual tiene como hábitat el suelo. Ha sido descrita en pacientes con trasplante de médula ósea y neutropenia grave (<500 neutrófilos/mm 3 ). Los pacientes que ingresan a la unidad de cuidado intensivo (UCI) también pueden ser susceptibles a la AI, con otros factores de riesgo tales como: enfermedad pulmonar obstructiva crónica (EPOC), cirrosis hepática, enfermedades autoinmunes en manejo inmunosupresor y trasplante de órgano sólido, en donde la mortalidad puede llegar al 80%. Se describe el caso de un hombre de 56 años con antecedente de tabaquismo, sin confirmación espirométrica de EPOC, que presentó AI pulmonar durante su estancia en UCI. El diagnóstico fue confirmado por histopatología de úlcera en carina, cultivo de aspirado traqueal y galactomanan en lavado broncoalveolar. Voriconazol fue su tratamiento, con buena respuesta clínica.

Invasive aspergilosis (IA) is caused by Aspergillum particles inhalation such as mildew and yeast. They live in the soil as a natural habitat. This infection has been described in patients with a bone marrow transplant and serious neutropenia (<500mm 3 ). Inward patients of intensive care unit (ICU) can be also susceptible to them, and even more with risk factors associated such as chronic obstructive pulmonary disease (COPD), liver cirrhosis, autoimmune diseases with inmunosupressor therapy and solid organ transplantation, where mortality can reach 80% of cases. A case of IA in a man of 56 years old is described. He had smoking history without previous spirometric assessment. The patient developed IA during stay at the intensive care unit. Aspergillus septate hiphae were observed in the biopsy at the carina's ulcer. Galactomannan assay was positive in bronchioalvelar fluid. The patient had good clinical response to treatment with Voriconazole.

Criptococosis en pacientes inmunosuprimidos sin infección por VIH/SIDA: un nuevo problema clínico en Chile / Cryptococcal infections in non-HIV infected patients: a new clinical problem in Chile

Cryptococcal infections are classically associated to HIV/AIDS patients without therapy, but its presence among other immunosuppressed patients is less recognized. We report 3 lethal cases in non HIV-patients. Two of them presented with meningitis associated to renal transplant or corticosteroid use and, the third, with a necrotic skin infection in the context of progressive liver cirrhosis. In the former two patients, meningeal infection was suspected late, and in the latter, the diagnosis was established postmortem. Cryptococcal infections in non-HIV immunosupressed patients can affect different sites, are suspected late and have a high case-fatality ratio.

La mayoría de los casos de infecciones criptocócicas se presenta en pacientes con infección por VIH/SIDA con inmunosupresión avanzada. En otro tipo de pacientes inmunosuprimidos es menos conocida, pero ha ido aumentando en frecuencia. Presentamos tres casos de infecciones criptocócicas en pacientes inmunosuprimidos no infectados por VIH, que se manifestaron como meningitis en un receptor de trasplante renal y en un paciente con terapia corticosteroidal y una infección cutánea progresiva necrótica con diseminación secundaria en un paciente con cirrosis hepática avanzada. En todos los casos, la infección fue identificada tardíamente. La infección en el paciente con cirrosis se estableció postmortem. Las infecciones criptocócicas en pacientes sin infección por VIH pueden ocurrir en diferentes sitios, se sospechan tardíamente y tienen alta letalidad.