In vitro susceptibility and multilocus sequence typing of Fusarium isolates causing keratitis.

Fungal keratitis is recognized as a significant cause of ocular morbidity and blindness especially in developing countries. In this study, we aimed to present the molecular identification and susceptibility of Fusarium isolates causing fungal keratitis in a university hospital in southern Brazil. The samples were identified using the second largest subunit of the RNA polymerase gene (RPB2) and the translation elongation factor 1-alpha (TEF1), while the antifungal susceptibility was tested by the broth microdilution method according to the Clinical and Laboratory Standards Institute (CLSI) methodology. The majority of the isolates belonged to the Fusarium solani species complex (F. solani, F. keratoplasticum and F. falciforme) and Fusarium oxysporum species complex. Antifungal susceptibility has shown that amphotericin B and natamycin were the most effective antifungals across all isolates, followed by voriconazole. Variation among Fusarium complexes in their antifungal sensitivities was observed in our study. The identification of Fusarium species from human samples is important not only from an epidemiological viewpoint, but also for choosing the appropriate antifungal agent for difficult-to-treat Fusarium infections such as keratitis.

Fusarium riograndense sp. nov., a new species in the Fusarium solani species complex causing fungal rhinosinusitis.

Invasive fusariosis has a high mortality and is predominantly observed in patients with leukemia. We report the first case of a novel species of Fusarium, Fusarium riograndense sp. nov, isolated from a lesion in the nasal cavity lesion of a patient with acute lymphoblastic leukemia. The etiological agent was identified by Multilocus Sequencing Typing (MLST), including RPB2, TEF-1α, and ITS-LSU sequences, the gold standard technique to identify new species of Fusarium. MLST and phenotypic data strongly supported its inclusion in the F. solani species complex (FSSC). The new species produced a red pigment in the Sabouraud Dextrose Agar similar to other members of the complex. The macroconiodia developed from phialides on multibranched conidiophores which merge to form effuse sporodochia with a basal foot-cell instead of papilla in basal cell shape. The microconidia were ellipsoidal, 0-1-septated, produced from long monophialides. Chlamydospores were produced singly or in pairs. Amphotericin B (MIC 1µg/mL) was the most active drug, followed by voriconazole (MIC 8µg/mL). The patient was successfully treated with voriconazole. Our findings indicate another lineage within FSSC capable causing of invasive human infection.

Corticosteroids for the management of severe intracranial hypertension in meningoencephalitis caused by Cryptococcus gattii: A case report and review.

Immune reconstitution inflammatory syndrome in meningitis caused by Cryptococcus gattii in immunocompetent patients after initiation of antifungal therapy appears to be the result of paradoxical antifungal treatment-induced clinical deterioration due to improved local immune responses to cryptococcal organisms. Recent anecdotal reports have suggested a favorable clinical response to corticosteroids in select patients with C. gattii central nervous system (CNS) infections. In this report, we describe a 65-year-old patient with meningoencephalitis caused by C. gattii who developed persistent intracranial hypertension and was successfully managed with antifungal therapy, repeated lumbar puncture and corticosteroids. Our observations suggest a possible benefit of dexamethasone in the management of select cases of C. gattii CNS infection with intracranial hypertension. Further studies are necessary to evaluate the long-term use of steroids in select patients with C. gattii with intracranial hypertension.

Disseminated histoplasmosis and AIDS: a prospective and multicentre study to evaluate the performance of different diagnostic tests.

The burden of histoplasmosis has been poorly documented in most of the endemic areas for the disease, including Brazil. Also, modern non-culture-based diagnostic tests are often non-available in these regions. This was a prospective cohort study in HIV-infected patients with suspected disseminated disease evaluated with different diagnostic tests. Patients were enrolled in three referral medical centres in Porto Alegre, Brazil. Among 78 evaluated patients, disseminated histoplasmosis was confirmed in eight individuals (10.3%) by the means of classical (culture/histopathology) tests. Antigen detection in the urine was found to be more sensitive: IMMY® ALPHA ELISA detected 13 positive cases (16.7%) and the in-house ELISA test developed by the Centers for Disease Prevention and Control (CDC) detected 14 (17.9%). IMMY® and CDC tests provided concordant results in 96.2% of cases. This is the first study to compare the performance of the in-house CDC ELISA test with the IMMY® commercial test for the diagnosis of histoplasmosis, and a high degree of concordance was observed. The study revealed that H. capsulatum is an important agent of disseminated disease in AIDS patients in Brazil, reinforcing the importance of making available modern diagnostic tests as well as safer antifungal agents for the treatment of histoplasmosis.

Different patterns of dermatological presentations in patients co-infected with human immunodeficiency virus and hepatitis C virus (HCV), and those infected with HCV alone.

BACKGROUND: Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) share the same transmission routes. About 30% of HIV-positive patients are co-infected with HCV. Of the various HCV-related extrahepatic events, those involving the skin may be the first sign of infection. AIM: To specify the skin presentations in patients co-infected with HIV and HCV (co-infected patients; CP) and compare them with those found in patients with HCV mono-infection (mono-infected patients; MP). METHODS: This was a cross-sectional study, in which the studied population consisted of MP and CP from a tertiary hospital in the South of Brazil, who underwent complete skin examination and laboratory tests. RESULTS: In total, 201 patients were assessed, of whom 108 were CP, and 93 were MP. Pruritus tended to be more common in MP. MP also had significantly more dermatological conditions (mean of 5.2) than CP (mean of 4.5). In total, 104 different skin diseases were identified. There was a higher prevalence of infectious diseases and pigmentation disorders, such as verruca vulgaris and facial melasma, in CP, whereas trunk and facial telangiectasias, palmar erythema, and varicose veins were more common in MP. CONCLUSION: We found a high prevalence of skin conditions both in MP and in CP; however, the patterns of the dermatological conditions were different. CP were found to have significantly fewer skin lesions than MP, but had a higher prevalence of infectious and pigmentation disorders. By contrast, vascular conditions were more common in MP.

Ramsay Hunt syndrome in patients infected with human immunodeficiency virus.

Ramsay Hunt syndrome (RHS) is defined as herpes zoster infection of the head and neck that involves the facial nerve. Immunocompromised people, such as those infected with human immunodeficiency virus (HIV), are predisposed to herpes zoster. However, reports of RHS in patients with HIV are rare. We report two cases of RHS in patients with HIV at our hospital, located in southern Brazil. We hope this report will increase the awareness of this condition among doctors caring for patients with HIV.

Laboratory features for presumptive diagnosis of disseminated tuberculosis in HIV-infected patients.

Rapid diagnosis is crucial for adequate treatment of disseminated mycobacteriosis. We conducted a retrospective cohort study to identify clinical and laboratorial features of disseminated mycobacteriosis in human immunodeficiency virus (HIV) infected patients that could help to differentiate tuberculosis (TB) from non-tuberculous mycobacteria (NTM) disease. All patients diagnosed from 1996 to 2006 were reviewed. TB was diagnosed in 65 patients and NTM in 31. Patients with TB had higher median levels of aspartate aminotransferase (AST) (69.0 vs. 45.0, P = 0.02) and lactate dehydrogenase (LDH) (725.0 vs. 569.0, P = 0.03). AST and LDH may be valuable tools in differentiating disseminated TB from NTM in HIV-infected patients.

Mucocutaneous manifestations of disseminated histoplasmosis in patients with acquired immunodeficiency syndrome: particular aspects in a Latin-American population.

BACKGROUND: Mucocutaneous lesions in human immunodeficiency virus (HIV)-infected patients with disseminated histoplasmosis have a wide spectrum of clinical manifestations, making its diagnosis difficult. Studies have been restricted to case reports and series with small numbers of patients not specifically focusing on the dermatological aspects of histoplasmosis. AIMS: To describe the characteristics of mucocutaneous lesions of disseminated histoplasmosis in HIV-infected patients. METHODS: A retrospective and prospective study was conducted on 36 HIV-infected patients with mucocutaneous histoplasmosis in a tertiary-care hospital in Brazil. RESULTS: Mucocutaneous histoplasmosis was diagnosed by histopathology in 33 of the 36 patients (91%) and/or culture in 23 (64%). Their CD4+ cell counts ranged from 2 to 103 cells/mm(3). The average number of different morphological types of lesions was three per patient. Despite the variability of the lesions, papules (50%), crusted papules (64%) and oral mucosal erosions and/or ulcers (58%) were the most frequent dermatological lesions. A diffuse pattern of distribution of the skin lesions was found in 58% of the cases. There was significant association between the CD4+ cell counts and the morphological variability of lesions per patient. Variation in the lesions seemed to be associated with higher CD4+ cell counts. CONCLUSION: Doctors caring for HIV-infected patients should be aware of the wide spectrum of dermatological lesions observed in disseminated histoplasmosis and the importance of detecting and isolating the fungus in mucocutaneous tissues.

High prevalence of metallo-beta-lactamase-mediated resistance challenging antimicrobial therapy against Pseudomonas aeruginosa in a Brazilian teaching hospital.

The prevalence of metallo-beta-lactamase (MBL) production among Pseudomonas aeruginosa nosocomial isolates from a Brazilian teaching hospital was determined. A total of 512 P. aeruginosa isolates were recovered from 245 patients during a 10-month period. Ninety-four (38.4%, 95% CI 32.2-44.8%) isolates were MBL producers. Most resistance to beta-lactams was mediated by MBL. Forty-one (16.7%) were resistant to all drugs except polymyxin B and 33 (80.5%) of these were MBL producers. Clonal dissemination, documented by DNA macrorestriction, played a major role for the spread of MBL isolates. The blaSPM-1 gene was demonstrated by PCR in 14 randomly selected MBL isolates. The extremely high prevalence of MBL production found challenges the choice of therapeutics for P. aeruginosa, and measures to control horizontal dissemination of MBL producers are urgently required.

Risk factors for imipenem-resistant Pseudomonas aeruginosa: a comparative analysis of two case-control studies in hospitalized patients.

Risk factors for acquisition of imipenem-resistant Pseudomonas aeruginosa by hospitalized patients were assessed at a tertiary care hospital. Two case-control studies with different control groups were used. In Study 1, patients with imipenem-resistant P. aeruginosa (IRPA) (case group) were compared with patients selected at random from the same unit. In Study 2, the case group was compared with patients with imipenem-susceptible P. aeruginosa (ISPA). Ninety-three patients with IRPA and 93 control patients were included in Study 1, and 93 IRPA patients and 65 patients with ISPA were included in Study 2. Carbapenem treatment [odds ratio (OR) 5.82], mechanical ventilation (OR 3.22) and hospital admission in the previous year (OR 2.59) were associated with IRPA in Study 1. An interaction between carbapenem and vancomycin was found to be a significant risk factor for IRPA (OR for carbapenem in patients with vancomycin use 43.71). In Study 2, carbapenem exposure (OR 12.82) and renal failure (OR 5.00) were associated with IRPA. Our study confirmed that carbapenem exposure is the main risk factor for IRPA, and found that the use of both carbapenem and vancomycin can increase this effect.

Candida tropicalis fungemia in a tertiary care hospital.

Candida tropicalis is a frequent cause of fungemia in hospitals in Latin America. Candida albicans (33%) was the most frequently isolated species, followed by Candida parapsilosis (27%), and Candida tropicalis (24%) in tertiary care hospital in Brazil. We identified and retrospectively reviewed 27 cases of C. tropicalis fungemia that occurred at Hospital de Clinicas de Porto Alegre from 1996 to 1999. The mean age of the patients was 32 years (range 6 months to 88 years). Eight patients (29.6%) had hematological malignancy, and four (14.8%) had solid tumors. All the patients were taking broad-spectrum antibiotics, including vancomycin for at least 7 days. Antibiotics were given through a central venous catheter for the majority of the patients (77.7%). Relevant risk factors for candidemia in our patients included neutropenia (59.2%), and use of corticosteroids (37.0%) or cytotoxic drugs (40.7%). The onset of fever was the most frequent clinical manifestation (92.5%) of fungemia. Most of the patients (81.4%) were treated with amphotericin B or fluconazole. Overall mortality was 48.1%, and 7 (53.4%) of 13 deaths occurred within 10 days of the detection of candidemia. Results of the in vitro susceptibility testing of nine isolates of C. tropicalis from seven patients did not show resistance to fluconazole and amphotericin B.C. tropicalis presents as an important cause of fungemia in oncological and nononcological patients with central venous catheters taking broad-spectrum antibiotics. Although there was no evidence of resistance of C. tropicalis to amphotericin B and fluconazole, patients treated with antifungal agents presented with a high mortality rate in the hospital setting.

Case Report. Disseminated aspergillosis complicating pregnancy.

We report a case of disseminated aspergillosis in a hitherto healthy 24-year-old woman during her 24th week of pregnancy. Relevant findings at autopsy revealed innumerable septate, dichotomously branched (45 degrees ) hyphae compatible with Aspergillus in lung and liver tissues. Cerebral histology showed cerebral vessels occluded by hyphae causing cerebral infarction. There was no evidence of invasive aspergillosis in the placenta and fetal tissues. Aspergillus sp. was confirmed by amplification of a specific 357-base-pair amplicon from a paraffin block containing lung tissue. This case illustrates a previously uncharacterized spectrum of disseminated aspergillosis, indicating the need for a heightened awareness that Aspergillus species are opportunistic agents for invasive and disseminated infection in pregnancy.

Histoplasmosis of the thyroid.

Fungal infection of the thyroid is rare. Most reported cases have involved Aspergillus, Coccidioides, and Candida species in the setting of disseminated disease. Infection of the thyroid with Histoplasma capsulatum is rarely reported as part of disseminated disease, even in geographic areas where histoplasmosis is endemic. We report a 52-year-old woman with a previous Hashimoto's disease and non-Hodgkin's lymphoma in which a diffuse enlarged thyroid gland with a large nodule was the only apparent locus of histoplasmosis. Fine-needle aspiration of the thyroid was an important diagnostic tool in establishing the diagnosis of histoplasmosis of the thyroid. The patient was initially treated with itraconazole (400 mg/day) for the fungal infection and six cycles of chemotherapy for the lymphoma. At a 6-month follow-up examination, the patient was doing well on suppressive therapy of itraconazole (200 mg/day), with no symptoms and with regression of the thyroid nodule and cervical adenopathy.

Short report: use of the polymerase chain reaction to detect Paracoccidioides brasiliensis in murine paracoccidioidomycosis.

The polymerase chain reaction (PCR) was used to detect the presence of Paracoccidioides brasiliensis in a murine model of disseminated paracoccidioidomycosis. Using a previously identified P. brasiliensis-specific DNA sequence, P. brasiliensis DNA was detected in serum of five experimentally infected mice. The PCR method was able to detect as little as 10 pg of P. brasiliensis DNA in serum, and it was more sensitive than blood culture isolation (five of five were PCR positive versus two of five blood culture positive). There were no amplified fragments in serum from three noninfected control mice. Lung colony counts were similar in all infected mice and reflected a similar degree of P. brasiliensis infection at the time the samples were drawn. The relatively short processing time for the PCR, when compared with culture, its sensitivity, and the possibility of using serum samples for analysis, are important factors favoring this method for the diagnosis of paracoccidioidomycosis. Future studies should include the detection of P. brasiliensis in patients with different clinical forms of paracoccidioidomycosis.