Nocardiosis pulmonar y del sistema nervioso central: el alcoholismo como factor de inmunocompromiso / Pulmonary and central nervous system nocardiosis: Alcoholism as an immunocompromising factor

La nocardiosis es una enfermedad de distribución mundial; de forma habitual se encuentra en zonas tropicales y afecta principalmente a pacientes inmunocomprometidos, sin embargo, también existen casos reportados de infección en personas inmunocompetentes. Esta infección es causada por actinomicetos del género Nocardia spp. que son bacterias Gram positivas, saprófitos ambientales. Aunque la exposición a Nocardia spp. es casi universal, solo una pequeña fracción de las personas expuestas desarrollan la enfermedad. Se presenta el caso de un hombre de 47 años, sin dato de inmunosupresión, procedente de un área rural de Boyacá, que consultó por un cuadro clínico de cefalea intensa e intermitente, con parestesias y, finalmente, alteración del estado de conciencia. Se practicó una resonancia magnética cerebral, en la que se evidenció una lesión que ocupaba espacio de localización córtico-subcortical en la región fronto-témporo-parietal izquierda, con efecto compresivo y desplazamiento de las cavidades del sistema ventricular. Se sospechó, inicialmente, una lesión neoplásica o un absceso cerebral. El paciente fue sometido a una resección quirúrgica, y el cultivo de la lesión documentó Nocardia africana/nova; en estudios posteriores, se evidenció un posible foco pulmonar primario. Como único factor de riesgo en el paciente, se documentó alcoholismo. Completó seis semanas de tratamiento antibiótico intrahospitalario con evolución clínica y radiológica, y egresó con plan de un año de terapia antibiótica ambulatoria. Aunque la enfermedad por Nocardia spp. afecta principalmente a pacientes inmunocomprometidos, la "evidencia" clínica demuestra que este microorganismo también puede ser una amenaza para individuos sin los factores de riesgo tradicionales para inmunosupresión.

Nocardiosis is a disease with worldwide distribution. It is usually found in tropical areas and mainly affects immunocompromised patients, however, there are also cases where its infection has been reported in immunocompetent patients. This pathology is caused by bacteria known as Nocardia spp., which are gram-positive microorganisms and environmental saprophytes, and although exposure to Nocardia spp. is almost universal, only a small fraction of exposed people develops the disease. We present the case of a 47-year-old man, with no evidence of immunosuppression, from a rural area of Boyacá, who was admitted due to intense and intermittent headache accompanied by paresthesia and, finally, a decrease in consciousness. A brain magnetic resonance was performed and evidenced a fronto-temporo- occipital space-occupying lesion in the cortico-subcortical region with a compressive effect and displacement of the ventricular system cavities. It was suspected at first a neoplastic lesion or a brain abscess. The lesion was surgically resected, and its culture showed Nocardia africana/nova. In later studies a possible primary pulmonary focus was evidenced. Alcoholism was the only risk factor documented. The patient completed 6 weeks of hospital antibiotic treatment with favorable clinical and radiological evolution and was discharged with a 1-year plan of outpatient antibiotic therapy. Although Nocardia spp. mainly affects immunocompromised patients, evidence shows that this microorganism can also be a threat to individuals without traditional immunosuppression risk factors.

Leucoencefalopatía multifocal progresiva: enfermedad grave en el paciente inmunosuprimido. Reporte de caso / Progressive multifocal leukoencephalopathy: severe disease in the immunosuppressed patient. Case report

RESUMEN INTRODUCCIÓN: Los pacientes con compromiso del sistema inmune pueden desarrollar una enfermedad neurológica incapacitante e incluso mortal, como lo es la leucoencefalopatía multifocal progresiva (LMP) producida por el virus de John Cunningham (JC). PRESENTACIÓN DEL CASO: Se presenta el caso de un hombre de 26 años con diagnóstico reciente de infección por virus de la inmunodeficiencia humana (VIH) que presentó síntomas constitucionales, déficit neurológico progresivo por hemiparesia espástica izquierda, disminución de la agudeza visual y cambios comportamentales. En las imágenes de resonancia magnética (IRM) cerebral contrastada se encontró afectación subcortical difusa de la sustancia blanca con compromiso de las fibras en U que, correlacionado con una prueba de reacción en cadena de la polimerasa (PCR) para virus JC en LCR, confirmó el diagnóstico de LMP. DISCUSIÓN: La LMP puede manifestarse por medio de síntomas cognitivos usualmente imperceptibles para el clínico, pero también como déficit sensorio-motor y visual que se puede corroborar en las IRM al identificar las lesiones típicas en la sustancia blanca, o bien por medio de detección del virus por PCR en líquido cefalorraquídeo. El manejo específico de la causa que desencadenó la inmunosupresión sigue siendo el pilar de tratamiento. CONCLUSIÓN: La mínima sospecha diagnóstica en aquellos pacientes con factores de riesgo y manifestaciones clínicas concordantes con la enfermedad debe llevar a que se confirme el diagnóstico y que se inicie prontamente el manejo terapéutico en búsqueda de restablecer la respuesta inmune.

ABSTRACT INTRODUCTION: Patients with immunocompromised or weakened immune system can develop a disabling and even life-threatening neurological disorder such as progressive multifocal leukoencephalopathy (PML) caused by John Cunningham (JC) virus. CASE PRESENTATION: We present the case of a 26-year-old man with a recent diagnosis of human immunodeficiency virus (HIV) infection who presented constitutional symptoms, progressive neurological deficit due to left spastic hemiparesis with decreased visual acuity and behavioral changes. The brain Magnetic Resonance Imaging (MRI) showed diffuse subcortical involvement of the white matter including the U-fibers, which, correlated with a detection of JC virus DNA by polymerase chain reaction (PCR) cerebrospinal fluid, confirmed the diagnosis of PML. DISCUSSION: PML can range from subtle cognitive impairment imperceptible to the clinician to sensory-motor deficits and visual disturbances that can be corroborated in MRI by identifying the typical lesions in the white matter or by detecting the virus by PCR in cerebrospinal fluid. The specific management of the cause that triggered the immunosuppression continues to be the mainstay of treatment. CONCLUSION: At the minimum diagnostic suspicion in patients with risk factors and clinical manifestations consistent with the disease should proceed to confirm the diagnosis and promptly immune reconstitution.

Infección pulmonar por Strongyloides stercoralis en paciente inmunocomprometido. Reporte de caso / Pulmonary infection caused by Strongyloides stercoralis in an immunocompromised patient. Case report

El Strongyloides stercoralis es un nemátodo intestinal capaz de completar su ciclo de vida dentro del huésped humano. Se presenta el caso clínico de una mujer de 57 años con residencia en la zona amazónica por 10 años, la que presenta antecedentes patológicos personales de hiperten-sión arterial, osteoporosis y diabetes mellitus tipo 2, lo que la cataloga como inmunocomprome-tida. Esta asiste a servicios de emergencia con cuadro agudo característico de infección de vías urinarias, recibe tratamiento en la unidad de cuidados intensivos por shock séptico de origen urinario versus pulmonar. La prueba de laboratorio clínico mediante muestra tomada a través de broncoaspiración arroja la existencia de larvas activas de Strongyloides stercoralis. La paciente mejoró sus condiciones de salud luego de un mes de evolución, respondiendo satisfactoriamente a la antibioticoterapia con carbapenémicos y el antiparasitario ivermectina. Los pacientes con factores de riesgo subyacentes tienen alta probabilidad a este tipo de infección agravada. La estrongiloidásis grave tiene una alta tasa de mortalidad, por lo que un diagnóstico temprano es indispensable para mejorar el pronóstico.

Strongyloides stercoralis is an intestinal nematode capable of completing its life cycle within the human host. The clinical case of a 57-year-old woman who has lived in the Amazon region for 10 years is presented. She has a personal pathological history of arterial hypertension, osteopo-rosis, and type 2 diabetes mellitus, which classifies her as immunocompromised. She attends emergency services with acute symptoms characteristic of urinary tract infection, receives treat-ment in the intensive care unit for septic shock of urinary versus pulmonary origin. The clinical laboratory test using a sample taken through bronchial aspiration shows the existence of active larvae of Strongyloides stercoralis. The patient's health conditions improved after a month of evolution, responding satisfactorily to antibiotic therapy with carbapenems and the antiparasitic ivermectin. Patients with underlying risk factors are at high risk for this type of aggravated infection. Severe strongyloidiasis has a high mortality rate, so early diagnosis is essential to improve prognosis

Radiological patterns of pulmonary fungal infection in pediatric hematology and oncology patients

Abstract Objective: To describe the radiological findings in pediatric patients with hematological or oncological diseases who also have an invasive fungal infection (IFI). Materials and Methods: This was a retrospective study of all patients with IFI admitted to a pediatric hematology and oncology hospital in Brazil between 2008 and 2014. Clinical and demographic data were collected. Chest computed tomography (CT) scans of the patients were reviewed by two independent radiologists. Results: We evaluated the chest CT scans of 40 pediatric patients diagnosed with an IFI. Twenty-seven patients (67.5%) had nodules with the halo sign, seven (17.5%) had cavities, two (5.0%) had nodules without the halo sign, and seven (17.5%) had consolidation. The patients with the halo sign and cavities were older (123 vs. 77 months of age; p = 0.03) and had less severe disease (34% vs. 73%; p = 0.04). Ten patients had a proven IFI: with Aspergillus sp. (n = 4); with Candida sp. (n = 5); or with Fusarium sp. (n = 1). Conclusion: A diagnosis of IFI should be considered in children and adolescents with risk factors and abnormal CT scans, even if the imaging findings are nonspecific.

Resumo Objetivo: O objetivo deste estudo é descrever os achados radiológicos de infecções fúngicas invasivas em crianças com doenças onco-hematológicas em um único centro, de acordo com a classificação antiga e a atual de imagens típicas e atípicas. Materiais e Métodos: Foram revisados os prontuários de todos os pacientes com infecção fúngica invasiva que foram internados em um hospital pediátrico de oncologia e hematologia de 2008 a 2014. Foram coletados dados clínicos e demográficos. As tomografias de tórax dos pacientes foram laudadas por dois radiologistas independentes. Resultados: Foram identificados 40 pacientes com infecção fúngica invasiva que realizaram tomografias de tórax. Vinte e sete pacientes apresentaram nódulos com sinal do halo (67,5%), sete tiveram cavitações (17,5%), dois tiveram nódulos sem halo (5,0%) e sete apresentaram consolidações (17,5%). Os pacientes que apresentavam achados de nódulos com sinal do halo e cavitações eram mais velhos (123 versus 77 meses; p = 0,03) e tinham menos sinais de doença grave (34% versus 73%; p = 0,04) do que os outros pacientes. Dez crianças apresentaram infecção confirmada (Aspergillus sp., n = 4; Candida sp., n = 5; Fusarium sp., n = 1). Conclusão: O diagnóstico de infecção fúngica invasiva deve ser considerado em crianças com fatores de risco e tomografias de tórax alteradas, mesmo que os achados das imagens sejam inespecíficos.

Immunomodulatory effects of Blaps rynchopetera extract

Purpose: To explore the potential immunomodulatory effects of total extract and different polar parts from Blaps rynchopetera Fairmaire. Methods: Phagocytic activity was evaluated by neutral red assay, and the effect of the immune function was investigated by normal and immunocompromised mice models. Results: In vitro, total extract, as well as chloroform, ethyl acetate, n-butanol and water fractions could individually enhance the phagocytic ability of mouse peritoneal macrophages; in addition, chloroform and ethyl acetate fractions had an increasing tendency when combined stimulation with lipopolysaccharide (LPS). In vivo, ethyl acetate fraction (EAF) could enhance the immune organ index, increase the serum hemolysin level and peripheral blood immune cells of immunocompromised mice, while for normal mice, the effect was inconspicuous. Conclusions: Blaps rynchopetera extracts had noteworthy immunomodulatory effect, especially for individuals with immune disorders.

Coevality of Secondary Syphilis with Condyloma Acuminata in a HIV reactive MSM: Rare Triple Sexually Transmitted Infections

Summary@#Secondary syphilis is a rare infectious sexually transmitted disease caused by Treponema pallidum in present era. It affects skin as well as other organs of the body. We hereby present a case of an adult male who presented with a one-month history of multiple brownish red maculopapular lesions all over the skin of the body involving the palms, soles, oral cavity and genitalia. His serology was positive for HIV, VDRL and TPHA with a low CD4 count. The patient was treated with three weekly doses of parenteral Benzathine penicillin G, antiretroviral therapy and podophyllin for condyloma acuminata to which he responded well.

Comparison of clinical features of pneumocystis pneumonia complicated with acute respiratory failure between human immunodeficiency virus-infected patients and non-human immunodeficiency virus-infected immunocompromised patients / 中华传染病杂志

Objective:To compare the clinical characteristics and analyze the prognostic factors between human immunodeficiency virus (HIV)-infected patients and non-HIV-infected immunocompromised patients with pneumocystis pneumonia (PCP) complicated with acute respiratory failure (ARF) in intensive care unit (ICU).Methods:The clinical data of patients with PCP complicated with ARF admitted in ICU of The First Affiliated Hospital of Zhengzhou University and The Sixth People′s Hospital of Zhengzhou City between May 2018 and October 2020 were retrospectively reviewed. All subjects were divided into HIV-infected group and non-HIV-infected immunocompromised group. General characteristics and underlying diseases of patients in the two groups were analyzed. Laboratory parameters, treatment and outcomes between two groups were compared. Independent sample t test, Mann-Whitney U test and chi-square test were used for statistical analysis, and univariate and multivariate logistic regression models were used to identify the risk factors for the clinical outcome. Results:A total of 129 PCP complicated with ARF patients were enrolled, including 75 HIV-infected patients and 54 non-HIV-infected immunocompromised patients. Only 10.7%(8/75) patients of HIV-infected group received anti-retroviral therapy (ART), but none of the patients in either groups had previously received trimethoprim-sulfamethoxazole (TMP-SMX) for PCP prophylaxis. Acute physiology and chronic health evaluation (APACHE) Ⅱ score of HIV-infected group was 18.7±6.0, which was higher than that in non-HIV-infected immunocompromised group (13.1±4.4) when admitted in ICU ( t=-5.45, P<0.001). Hypoproteinemia was common in both groups. Ninety-six percent (72/75) of HIV-infected patients had CD4 + T lymphocyte counts lower than 200/μL and 84.0%(63/75) of patients had CD4 + T lymphocyte counts even lower than 50/μL, while 5.74%(31/54) of patients in non-HIV-infected immunocompromised group had CD4 + T lymphocyte counts lower than 200/μL. The CD4 + /CD8 + T lymphocyte counts ratio was 0.05(0.02, 0.12) in HIV-infected group, which was lower than that in non-HIV-infected immunocompromised group (0.96(0.64, 1.44)), and the difference was statistically significant ( Z=-9.16, P<0.001). The length of ICU stay and hospital stay of non-HIV-infected immunocompromised patients were 10.0(7.0, 14.0) days and 18.0(11.8, 32.5) days, respectively, which were both longer than those in HIV-infected patients (7.0(4.0, 9.0) days and 13.0(7.0, 23.0) days, respectively), and the differences were both statistically significant ( Z=-3.58 and -2.73, respectively, both P<0.050). The hospital mortality of HIV-infected patients was 57.3%(43/75), which was significantly higher than that in non-HIV-infected immunocompromised patients (38.9%, 21/54) ( χ2=4.27, P=0.039). Multivariable logistic regression identified that lactic dehydrogenase (LDH), C-reactive protein (CRP) and APACHE Ⅱ score were the risk factors for the clinical outcome of HIV-infected patients (odds ratio ( OR)= 1.006, 1.015 and 1.736, respectively, all P<0.050). The partial pressure of oxygen in arterial blood/fractional concentration of inspiratory oxygen (PaO 2/FiO 2), LDH and CD4 + T lymphocyte counts were the risk factors for the clinical outcome of non-HIV infected immunocompromised patients ( OR=0.970, 1.008 and 0.989, respectively, all P<0.050). Conclusions:PCP patients with ARF are critically ill with high mortality rate. LDH, CRP and APACHEⅡscore are predictors for prognosis of HIV-infected patients with PCP, while PaO 2/FiO 2, LDH and CD4 + T lymphocyte counts are predictors for prognosis of non-HIV infected immunocompromised patients with PCP.

Hallazgo histopatológico de Strongyloides stercoralis en enfermedad de Crohn: reporte de caso / Histopathologic finding of Strongyloides stercoralis in a patient with Crohn's disease: Case report

Resumen Caso clínico: Se describe un caso clínico poco frecuente en un paciente inmunocomprometido con hallazgo histopatológico de infestación parasitaria. Es un paciente masculino de edad media que habita en zona subtropical con diagnóstico de enfermedad de Crohn tratado con corticoide e inmunomoduladores, presentaba dolor abdominal y anemia crónica de 1 año de evolución, analítica negativa para parásitos, reactantes de fase aguda normales, gastroscopia y colonoscopia previas (6 meses) sin hallazgos relevantes. Por la persistencia del cuadro clínico se repitieron los estudios endoscópicos en los que se visualizaron hemorragias subepiteliales con resultados histopatológicos de Strongyloides stercoralis. Conclusión: En el contexto de un paciente inmunocomprometido, en zona endémica y con evolución tórpida, debe obligar a realizar un diagnóstico diferencial en el que se debe sospechar siempre de infestación parasitaria. Aunque la endoscopia no se necesita para el diagnóstico de estrongiloidiasis, su intervención puede ser oportuna.

Abstract Clinical case: The following is a rare clinical case in an immunocompromised patient with histopathological findings of parasitic infestation. The patient is a middle-aged male who lives in a subtropical area and has a diagnosis of Crohn's disease treated with corticosteroids and immunomodulators. The patient presented with abdominal pain and chronic anemia for 1 year, with negative laboratory tests for parasites and normal acute phase reactants. Gastroscopy and colonoscopy were performed before the consultation (6 months) without relevant findings. Due to the persistence of the symptoms, endoscopic studies were repeated, finding subepithelial bleeding with histopathological results of Strongyloides stercoralis. Conclusion: In the context of an immunocompromised patient living in an endemic area and with a torpid evolution, a differential diagnosis should be made always suspecting a parasitic infestation. Although endoscopy is not necessary to diagnose strongyloidiasis, its use may be convenient.

Isolated cerebral mucormycosis masquerading as a tumor in an immunocompetent patient

Mucormycosis is an opportunistic fungal disease that commonly presents as cutaneous or rhinocerebral infections associated with immunocompromised states. It may exceptionally present as isolated involvement of the brain with a varied clinical presentation, which may be difficult to diagnose early, leading to increased mortality. Herein, we report the case of a 42-year-old immunocompetent female with left-sided limb weakness and a history of recurrent vomiting and headache for the last two years. Clinically, glioma was suspected, but histopathological examination revealed a few broad aseptate fungal hyphae. As no other organ was involved, the diagnosis of isolated cerebral mucormycosis was rendered. Reporting this case, we show an unusual presentation of a central nervous system mucormycosis masquerading a tumor in an immunocompetent patient. The case also highlights the importance of a careful histopathological examination to avoid missing the presence of occasional fungal hyphae. Ideally, recognition of fungal hyphae in the brain, during intraoperative consultation, can prompt brain tissue culture for definitive diagnosis and early empirical antifungal therapy, which may prove life-saving.

[T1 ESP]Pneumocystis jirovecii y SARS-CoV-2; COVID-19 / [T1 ENG]Pneumocystis jirovecii and SARS-CoV-2; COVID-19

Resumen Pneumocystis jirovecii, es un agente fúngico oportunista causante de neumonía (pneumocistosis) que puede ser mortal en personas con condición de inmunocompromiso, incluyendo pacientes VIH con recuento de linfocitos T CD4+ < 200 céls/mm3 y en pacientes inmunocomprometidos por otras etiologías como trasplantes de órgano sólido y cáncer, entre otras. Muchas personas pueden ser portadoras sanas de este agente etiológico y actuar como reservorio y fuente de infección. Artículos relacionados con coinfección entre SARS-CoV-2 y los de carácter oportunistas como P. jirovecii y Aspergillus fumigatus empiezan a publicarse, donde se argumenta que esta infección viral tiene un alto riesgo de coinfección y se manifiesta la importancia de no excluir los patógenos respiratorios, como P. jirovecii, entre otros. La coinfección con P. jirovecii puede no ser detectada en pacientes con infección grave por SARS-CoV-2, dado que pueden compartir características clínicas comunes como infiltrados multifocales bilaterales e hipoxemia profunda entre otras. Por lo tanto, es necesario realizar pruebas diagnósticas adicionales para P. jirovecii en pacientes con infección por SARS-CoV-2, especialmente cuando se presenten otras características clínicas que pueden apoyar la coinfección, como hallazgos quísticos en la TC torácica y niveles elevados en sangre de 1,3-D-glucano, incluso en ausencia de factores de riesgo clásicos para P. jirovecii, para el diagnóstico de neumonía por Pneumocystis en pacientes con sospecha de infección por SARS-CoV-2.

Abstract Pneumocystis jirovecii, is an opportunistic fungal agent that causes pneumonia (pneumocistosis) that can be fatal in people with immunocomprome status, including HIV patients with CD4+ T lymphocyte count < 200 cels/mm3 and in patients immunocompromised by other aetiologies such as solid organ transplants and cancer, among others. Many people may be healthy carriers of this etiological agent and act as a reservoir and source of infection. Articles related to co-infection between SARS-CoV-2 and opportunistic articles such as P. jirovecii and Aspergillus fumigatus begin publication, where it is argued that this viral infection has a high risk of co-infection, expressing the importance of not excluding respiratory pathogens, such as P. jirovecii, among others. Co-infection with P. jirovecii, may not be detected in patients with severe SARS-CoV-2 infection as they may share common clinical characteristics such as bilateral multifocal infiltrates and deep hypoxemia among others. Therefore, additional diagnostic tests for P. jirovecii, are necessary in patients with SARS-CoV-2 infection, especially when other clinical characteristics that may support co-infection are present such as cystic findings in thoracic CT and elevated blood levels of 1.3-D-glucan, including in the absence of classic risk factors for P. jirovecii, for the diagnosis of Pneumocystis pneumonia in patients with suspected SARS-CoV-2 infection.

Infección invasiva por Candida spp. En pacientes inmunocomprometidos: Descripción de curso clínico experiencia diagnóstica, manejo y seguimiento en centro de alta complejidad / Invasive infection by Candida spp. in immunocompromised patients: A description of clinical, diagnostics, therapeutic and follow up experience in high complexity healthcare center

Introducción: Candida spp. Es la principal causa de fungemia, cuya incidencia ha aumentado en los últimos años. Existen datos locales insuficientes sobre este tipo de infecciones. Materiales y métodos: Este fue un estudio observacional retrospectivo de 44 pacientes diagnosticados con candidiasis invasiva hospitalizados en la Fundación Valle del Lili, el cual es un centro de cuarto nivel afiliado a la Universidad Icesi en el Suroccidente Colombiano, entre los años 2012 a 2017. Resultados: Se identificaron 44 pacientes con candidiasis invasiva, 27 de ellos mujeres (61%). La mediana de edad fue de 56 años (36 - 70). Más del 50% tenían una enfermedad crónica subyacente, uso de antibióticos (84%), catéter venoso central (80%), ventilación mecánica (68%) y nutrición enteral (66%) El 80% requirió manejo en unidad de cuidados intensivos (UCI) donde debutaron con sepsis (68%) y falla respiratoria (61%). En el 90% de los casos se aisló alguna especie de Candida spp. A partir de hemocultivo y sólo al 22% se le realizó prueba de sensibilidad. El tratamiento de elección fue con fluconazol (80%), asociado a caspofungina (70%). La tasa de mortalidad fue del 49%, con una mediana de 33 (22-49,5) días desde el ingreso hasta el fallecimiento. C. albicans fue el principal microorganismo aislado. La resistencia a azoles en especies no albicans existe en nuestro medio. Conclusión: La candidiasis se presenta como candidemia asociada a infección bacteriana concomitante, que cobra mayor importancia en el contexto del paciente inmunosuprimido asociado a elevadas tasas de mortalidad.

Introduction: Candida spp. is the main cause of fungemia, whose incidence has increased in recent years. There are insufficient local data about this pathology. Materials and methods: This was an observational, retrospective chart review of 44 patients diagnosed with invasive candida who were hospitalized at Fundación Valle del Lili, which is a fourth level center affiliated to Icesi university between 2012 and 2017. Results: We identified 44 patients with invasive candidiasis, 27 of them women (61%). The median age was 56 years (36 - 70). More than 50% had an underlying chronic disease, use of antibiotics (84%), central venous catheter (80%), mechanical ventilation (68%) and enteral nutrition (66%). 80% required management in an intensive care unit. Sepsis (68%) and respiratory failure (61%) were the most common clinical presentation. Almost 90% of the cases, had positive blood cultures, but only 22% presented susceptibility tests. The treatment was mainly fluconazole (80%), associated with caspofungin (70%). The mortality rate was 49%, median of 33 (22-49.5) days from admission to death. Candida albicans was the main isolated organism. Azole resistance in non-albicans species was observed. Conclusion: Candidiasis presents as bacterial infection associated candidemia, which becomes more important in the context of the immunosuppressed patient with high mortality rates.

Colonización de catéter por Leclercia adecarboxylata: reporte de un caso pediátrico / Catheter colonization by Leclercia adecarboxylata: a pediatric case report

Las infecciones causadas por Leclercia adecarboxylata (L. adecarboxylata) son raramente reportadas en la literatura. Se trata de una enterobacteria anaerobia Gram-negativa que presenta distribución universal y, si bien suele ser parte de infecciones polimicrobianas, existen reportes crecientes de infecciones únicamente por este germen en pacientes inmunocomprometidos.Se reporta el caso de un paciente masculino de 8 años con leucemia linfoblástica aguda, que presentó una colonización de catéter por L. adecarboxylata, en el que se realizó tratamiento sin extracción del dispositivo, con evolución favorable

Infections caused by Leclercia adecarboxylata are rarely reported. It is an anaerobic Gram-negative enterobacteria with universal distribution, and although it is mostly found in polymicrobial infections, monomicrobial infections caused by this bacteria, especially in immunocompromised hosts, have been recently reported.We present the case of an 8-year-old patient, with acute lymphoid leukemia, that suffered a catheter colonization by L. adecarboxylata. He received antibiotic treatment without removal of the device with complete resolution of infectio

Isolated renal mucormycosis: a rarity

Mucormycosis is a rare, opportunistic, highly aggressive, fungal infection primarily noted in immunocompromised individuals. Isolated involvement of any organ is rare in general. Isolated renal involvement is unusual, with only a few cases reported in literature to date. We present a rare case of isolated renal mucormycosis successfully managed with systemic anti-fungal therapy and nephron sparing surgery.

Compromiso pulmonar por cryptoccus laurentii en paciente inmunocomprometido / Pulmonary Involvement with Cryptococcus Laurentii in an Immunocompromised Patient

La criptococosis afecta predominantemente a pacientes con compromiso de la inmunidad celular. Se presenta el caso de un paciente masculino de 45 años, con antecedentes de VIH y linfoma de Hodgkin, internado por fiebre persistente sin neutropenia. El PET-TC evidenció imágenes hipermetabólicas pulmonares y ganglionares se sospechó recaída de su enfermedad y/o proceso infeccioso. Se realizó BAL, se aisló en cultivo Crytococcus laurentii. Recibió tratamiento con anfotericina B y fluconazol, cultivos de control negativos. Se repitió TC de control sin infiltrados pulmonares y persistencia de adenopatías. Realizó tratamiento con ESHAP evolucionando con buena respuesta.

Cryptococcosis mostly affects patients with cell-mediated immunity involvement. We present the case of a male patient, 45 years old, with history of HIV and Hodgkin's lymphoma, who was admitted to the hospital due to persistent fever without neutropenia. The PET-TC (Positron Emission Tomography - Computed Tomography) showed hypermetabolic pulmonary and lymph node images. We suspected disease relapse and/or the presence of an infectious process. We performed a BAL (Bronchoalveolar Lavage) and Cryptococcus laurentii was isolated in culture. The patient received treatment with amphotericin B and fluconazole, with negative control cultures. The CT control was repeated without pulmonary infiltrates and persistence of adenopathies. The patient received treatment with ESHAP and evolved with good response.

Invasive fungal disease in humans: are we aware of the real impact?

Despite the medical advances and interventions to improve the quality of life of those in intensive care, people with cancer or severely immunocompromised or other susceptible hosts, invasive fungal diseases (IFD) remain severe and underappreciated causes of illness and death worldwide. Therefore, IFD continue to be a public health threat and a major hindrance to the success of otherwise life-saving treatments and procedures. Globally, hundreds of thousands of people are affected every year with Candida albicans, Aspergillus fumigatus, Cryptococcus neoformans, Pneumocystis jirovecii, endemic dimorphic fungi and Mucormycetes, the most common fungal species causing invasive diseases in humans. These infections result in morbidity and mortality rates that are unacceptable and represent a considerable socioeconomic burden. Raising the general awareness of the significance and impact of IFD in human health, in both the hospital and the community, is hence critical to understand the scale of the problem and to raise interest to help fighting these devastating diseases.

Recent Advances in the Diagnosis and Management of Pneumocystis Pneumonia / 결핵

In human immunodeficiency virus (HIV)-infected patients, Pneumocystis jirovecii pneumonia (PCP) is a wellk-nown opportunistic infection and its management has been established. However, PCP is an emerging threat to immunocompromised patients without HIV infection, such as those receiving novel immunosuppressive therapeutics for malignancy, organ transplantation, or connective tissue diseases. Clinical manifestations of PCP are quite different between patients with and without HIV infections. In patients without HIV infection, PCP rapidly progresses, is difficult to diagnose correctly, and causes severe respiratory failure with a poor prognosis. High-resolution computed tomography findings are different between PCP patients with HIV infection and those without. These differences in clinical and radiological features are due to severe or dysregulated inflammatory responses that are evoked by a relatively small number of Pneumocystis organisms in patients without HIV infection. In recent years, the usefulness of polymerase chain reaction and serum β-D-glucan assay for rapid and non-invasive diagnosis of PCP has been revealed. Although corticosteroid adjunctive to anti-Pneumocystis agents has been shown to be beneficial in some populations, the optimal dose and duration remain to be determined. Recent investigations revealed that Pneumocystis colonization is prevalent and that asymptomatic carriers are at risk for developing PCP and can serve as the reservoir for the spread of Pneumocystis by airborne transmission. These findings suggest the need for chemoprophylaxis in immunocompromised patients as well as infection control measures, although the indications remain controversial. Because a variety of novel immunosuppressive therapeutics have been emerging in medical practice, further innovations in the diagnosis and treatment of PCP are needed.

Consenso sobre riesgo de complicaciones infecciosas en pacientes usuarios de medicamentos biológicos seleccionados. Parte I / Consensus of infectious complications in patients treated with selected biological therapies: first Part

Resumen La incorporación de terapias biológicas ha significado un gran avance en el manejo de diversas patologías de origen autoinmune, neoplásico u otros. Si bien su uso ha implicado mejoras significativas en el pronóstico de estas enfermedades, no está exento de complicaciones, entre estas, las infecciosas. El objetivo de este consenso fue evaluar el perfil de seguridad, desde la mirada infectológica, de las terapias biológicas de uso más frecuente y dar recomendaciones para la prevención de infecciones en pacientes tratados con ellas, basándose en la evidencia de mayor calidad disponible para los biológicos seleccionados. El consenso cuenta de dos manuscritos. Esta primera parte detalla los riesgos de desarrollar complicaciones infecciosas dependiendo del tipo de biológico utilizado para determinada patología. La revisión incluyó búsqueda amplia en MEDLINE y Epistemonikos de revisiones sistemáticas y meta-análisis de estudios clínicos controlados y caso/control que examinaban infecciones posteriores al tratamiento con anti-TNF alfa, anti-CD20, anti-CD52, CTLA4-Ig y anti-integrinas. Esta búsqueda se complementó con revisión de cohortes multicéntricas de usuarios de biológicos, del MMWR del CDC, Atlanta, E.U.A. y de registros nacionales y/o de sociedades científicas en la que se hiciera mención a complicaciones infecciosas derivadas del uso de biológicos.

The use of biological therapies has meant a great improvement in the management of several conditions like autoimmune, neoplastic or others diseases. Although its use has implied significant improvements in the prognosis of these diseases, it is not exempt from complications: infectious diseases as one of them. The objective of this consensus was to evaluate, from an infectious viewpoint, the safeness of the most frequently used biological therapies and give recommendations for the prevention of infections in patients treated with these drugs. These recommendations were based on the highest quality evidence available for the selected biologics. The consensus counts of two manuscripts. This first part details the risks of developing infectious complications depending on the type of biological used for a certain pathology. This evaluation included a broad search in MEDLINE and Epistemonikos of systematic reviews and meta-analyzes of controlled clinical trials and casecontrol examining post-treatment infections with anti-TNF alpha, anti-CD20, anti-CD52, CTLA4-Ig and anti-integrins. The research was complemented by a review of: multicentre cohorts of biological users, the MMWR of the CDC, Atlanta, U.S.A., and national registers and scientific societies in which infectious complications derived from the use of biological therapies were mentioned.

Consenso sobre riesgo de complicaciones infecciosas en pacientes usuarios de medicamentos biológicos seleccionados. Parte II: Guía clínica chilena de Prevención de Infecciones Asociadas al Uso de Terapias Biológicas (PREVITEB) / Consensus of infectious complications in patients treated with selected biological therapies. Screening of hepatitis B in high risk Chilean and immigrant pregnant women: Management of mother to child transmission Second part: Chilean Guidelines for Prevention of Infections associated to use of Biological Therapies (PREVITEB)

Resumen La incorporación de terapias biológicas ha significado un gran avance en el manejo de diversas patologías de origen autoinmune, neoplásico u otros. Si bien su uso ha implicado mejoras significativas en el pronóstico de estas enfermedades, no está exento de complicaciones, entre éstas, las infecciosas. El objetivo de este consenso fue evaluar el perfil de seguridad, desde la mirada infectológica, de las terapias biológicas de uso más frecuente y dar recomendaciones para la prevención de infecciones en pacientes tratados con ellas, basándose en la evidencia de mayor calidad disponible para los biológicos seleccionados. El consenso cuenta de dos manuscritos. Esta segunda parte corresponde a la guía clínica que detalla estas recomendaciones mediante estrategias de cribado, terapias profilácticas e indicación de vacunas, según corresponde, para infecciones bacterianas, y por micobacterias en particular, virus, hongos y parásitos, tanto para adultos como para niños.

The use of biological therapies has meant a great improvement in the management of several conditions like autoimmune, neoplastic or others diseases. Although its use has implied significant improvements in the prognosis of these diseases, it is not exempt from complications: infectious diseases as one of them. The objective of this consensus was to evaluate, from an infectious viewpoint, the safeness of the most frequently used biological therapies and give recommendations for the prevention of infections in patients treated with these drugs. These recommendations were based on the highest quality evidence available for the selected biologics. The consensus counts of 2 manuscripts. This second part is a guideline that details these recommendations through screening strategies, prophylactic therapies and vaccines indications for bacterial, mycobacterial, viral, fungal and parasitic infections, both for adults and children.

Rinosinusitis fúngica invasiva aguda: actualización en pacientes adultos y pediátricos / Acute invasive fungal rhinosinusitis: update in adults and pediatric patients

RESUMEN La rinosinusitis fúngica invasiva aguda (RSFIA) es una enfermedad poco frecuente caracterizada por una infiltración fúngica de la submucosa y vasos sanguíneos de las cavidades nasal y paranasal. Afecta a pacientes con grados variables de inmunosupresión, destacando entre estas patologías subyacentes la diabetes mellitus y las neoplasias malignas hematológicas. Presenta una alta tasa de mortalidad, pudiendo reducirse significativamente si el diagnóstico y el tratamiento se realizan precozmente. Este artículo tiene por objetivo presentar una revisión actualizada de la literatura respecto a la presentación clínica, microbiología, factores de riesgos, métodos diagnósticos, tratamiento y pronóstico de la RSFIA, tanto en adultos como en niños.

ABSTRACT Acute invasive fungal rhinosinusitis (AIFS) is a rare disease characterized by fungal infiltration of the submucosa and blood vessels of the nasal y paranasal cavities. It affects almost exclusively patients with different degrees of immunosuppression, with underlying pathologies such as diabetes mellitus and hematological malignancies. AIFS has a high mortality rate, but it can be significantly reduced if the diagnosis and treatment are carried out early in the course of disease. This article aims to present an updated literature review regarding clinical presentation, microbiology, risk factors, diagnostic methods, treatment and prognosis of AIFS, both in adults and children.

Delftia acidovorans pneumonia with lung cavities formation / Neumonia con formación de cavidades pulmonares causada por Delftia acidovorans

Abstract Case Description: A 52-year-old female patient was admitted to our clinic with complaints of cough, sputum, fever and fatigue. The patient has been receiving immunosuppressive therapy for thrombocytopenic purpura for 5 years. Clinical Finding: Inspiratory crackles were heard on both hemithorax. Oxygen saturation measured with the pulse oximeter was 97%. Chest X-ray showed diffuse reticular opacities that were more prominent in the upper zones of both lungs. WBC counts were 17,600 mm3 and Platelet counts were 29,000 mm3. Thorax CT showed that there were many thin-walled cavities and millimetric nodules accompanied by ground-glass infiltrates in the upper and middle lobes. Gram staining of bronchial fluid, taken by bronchoscopy, revealed Gram-negative bacilli and intense polymorphonuclear leukocytes. The bacteria were defined as Delftia acidovorans by BD Phoenix automated system. Treatment and outcomes: The patient was hospitalized with suspicion of opportunistic pulmonary infections and cavitary lung disease. After the empirical treatment of intravenous piperacillin-tazobactam and oral clarithromycin, her clinical and radiological findings significantly regressed, and she was discharged with outpatient follow-up. Clinical Relevance: This is the first example of cavitary pneumonia due to Delftia acidovorans in an immunocompromised patient. We would like to emphasize that Delftia pneumonia should be considered in the differential diagnosis of pulmonary cavitary involvement in such patients.

Resumen Descripción del caso: Una mujer de 52 años llegó a la clínica con tos, esputo, fiebre y fatiga. El paciente estuvo recibiendo terapia inmunosupresora durante 5 años para el tratamiento de la púrpura trombocitopénica. Hallazgo clínico: se escucharon crepitaciones inspiratorias en ambos hemitórax. La saturación de oxígeno fue del 97%. La radiografía de tórax mostró opacidades reticulares difusas que eran más prominentes en las zonas superiores de ambos pulmones. Los recuentos de leucocitos fueron de 17,600 mm3 y los recuentos de plaquetas fueron de 29,000 mm3. La TC de tórax mostró muchas cavidades de pared delgada y nódulos milimétricos acompañados de infiltrados vitrales en los lóbulos superior y medio. La tinción de Gram del líquido bronquial reveló bacilos gramnegativos y leucocitos polimorfonucleares. Las bacterias fueron identificadas como Delftia acidovorans. Tratamiento y resultados: La paciente fue hospitalizado con una sospecha de infección oportunista pulmonar y enfermedad pulmonar cavitaria. Después del tratamiento empírico de piperacilina-tazobactam intravenosa y claritromicina oral, los síntomas y signos retrocedieron significativamente, y fue dada de alta con seguimiento ambulatorio. Relevancia clínica: este es el primer registro de neumonía cavitaria causado por Delftia acidovorans en una paciente inmunocomprometida. Enfatizamos que la neumonía por Delftia debe considerarse en el diagnóstico diferencial de la afectación de la cavidad pulmonar en tales pacientes.