Prevalence of chronic pulmonary aspergillosis regarding time of tuberculosis diagnosis in Brazil.

BACKGROUND: Data on the prevalence of chronic pulmonary aspergillosis (CPA) in patients with active or cured tuberculosis (TB) are scarce, mainly due to diagnostic difficulties. The diagnosis of CPA is based on pulmonary symptoms and chest computed tomography (CT) scans and is considered confirmed when there is microbiological or serological evidence of Aspergillus spp. OBJECTIVES: To estimate the prevalence of CPA in patients treated or undergoing treatment for PTB, seen in two referral hospitals in Mato Grosso do Sul, Brazil. PATIENTS AND METHODS: A total of 193 consecutive patients who were treated or previously treated for pulmonary tuberculosis underwent prospective evaluation: (a) clinical evaluation; (b) chest CT scan; (c) sputum examination-culture for fungi and smears for direct mycology; (d) detection of anti-Aspergillus fumigatus antibodies using an enzyme-linked immunosorbent assay Platelia® test; and (e) anti-Aspergillus spp. antibodies were assessed via a DID test. RESULTS: The global prevalence of CPA was 10.9% (95% confidence interval, 7.2%-16.1%), but it increased with the time of TB diagnosis. The variables independently associated with CPA were previous pulmonary tuberculosis over 4 years ago and haemoptysis. Cavities, pleural thickening and the presence of a fungal ball were the most frequent tomographic findings in patients with CPA. CONCLUSIONS: The high prevalence observed and its increase over time suggest the need for continuous surveillance of CPA in patients with active or previous pulmonary tuberculosis and throughout life, with clinical, tomographic and serological evaluations (ELISA) for a timely diagnosis and a better prognosis.

Cryptococcus bacillisporus (VGIII) Meningoencephalitis Acquired in Santa Cruz, Bolivia.

We describe a case of chronic meningoencephalitis with hydrocephalus caused by Cryptococcus bacillisporus (VGIII) in an immunocompetent patient from Santa Cruz, Bolivia. This first report of a member of the Cryptococcus gattii species complex from Bolivia suggests that C. bacillisporus (VGIII) is present in this tropical region of the country and complements our epidemiological and clinical knowledge of this group of emerging fungal pathogens in South America.

[Migratory vulvitis caused by imported gnathostomiasis]. / Vulvitis migratoria causada por gnatostomiasis importada.

Gnathostomiasis is an emerging disease in non-endemic countries. This zoonotic nematode requires aquatic freshwater environments to complete its life cycle where larvae get encrusted in fishes. Typically, the infection manifests as migratory subcutaneous lesion caused by the larvae trak, which produces an eosinophilic panniculitis. Here we describe a patient who presented a migratory lesion with no response to antimicrobial therapy, a careful travel and food history together with specific laboratory tests led to the correct diagnosis. Gnathostomiasis should be suspected in patients with migratory skin lesions who have consumed raw freshwater fish during travel to endemic countries in South America or Asia.

Vulvitis migratoria causada por gnatostomiasis importada / Migratory vulvitis caused by imported gnathostomiasis

Resumen La gnatostomiasis es una parasitosis emergente en países no endémicos. Este nematodo zoonótico requiere de agua dulce para su ciclo de vida, donde sus larvas se enquistan principalmente en peces. La migración subcutánea de las larvas produce habitualmente una paniculitis eosinofílica de rápido avance. Se describe un caso clínico de un paciente con una lesión migratoria, sin mejoría clínica con terapia antibacteriana. La búsqueda de factores de riesgo, sumado a la evolución y a los hallazgos de laboratorio hizo sospechar el diagnóstico. La gnatostomiasis debe ser sospechado en pacientes con lesiones de piel migratorias, que han consumido pescado crudo durante viajes a países endémicos en Sudamérica o Asia.

Gnathostomiasis is an emerging disease in non-endemic countries. This zoonotic nematode requires aquatic freshwater environments to complete its life cycle where larvae get encrusted in fishes. Typically, the infection manifests as migratory subcutaneous lesion caused by the larvae trak, which produces an eosinophilic panniculitis. Here we describe a patient who presented a migratory lesion with no response to antimicrobial therapy, a careful travel and food history together with specific laboratory tests led to the correct diagnosis. Gnathostomiasis should be suspected in patients with migratory skin lesions who have consumed raw freshwater fish during travel to endemic countries in South America or Asia.

A prospective, multi-center study of Candida bloodstream infections in Chile.

BACKGROUND: Active surveillance is necessary for improving the management and outcome of patients with candidemia. The aim of this study was to describe epidemiologic and clinical features of candidemia in children and adults in tertiary level hospitals in Chile. METHODS: We conducted a prospective, multicenter, laboratory-based survey study of candidemia in 26 tertiary care hospitals in Chile, from January 2013 to October 2017. RESULTS: A total of 780 episodes of candidemia were included, with a median incidence of 0.47/1,000 admissions. Demographic, clinical and microbiological information of 384 cases of candidemia, from 18 hospitals (7,416 beds), was included in this report. One hundred and thirty-four episodes (35%) occurred in pediatric patients and 250 (65%) in adult population. Candida albicans (39%), Candida parapsilosis (30%) and Candida glabrata (10%) were the leading species, with a significant difference in the distribution of species between ages. The use of central venous catheter and antibiotics were the most frequent risk factors in all age groups (> 70%). Three hundred and fifteen strains were studied for antifungal susceptibility; 21 strains (6.6%) were resistant to fluconazole, itraconazole, voriconazole, anidulafungin or micafungin. The most commonly used antifungal therapies were fluconazole (39%) and echinocandins (36%). The overall 30-day survival was 74.2%, significantly higher in infants (82%) and children (86%) compared with neonates (72%), adults (71%) and elderly (70%). CONCLUSIONS: Our prospective, multicenter surveillance study showed a low incidence of candidemia in Chile, with high 30-day survival, a large proportion of elderly patients, C. glabrata as the third most commonly identified strain, a 6.6% resistance to antifungal agents and a frequent use of echinocandins.

Imported scrub typhus: first case in South America and review of the literature.

BACKGROUND: Scrub typhus is a neglected vector-borne zoonosis causing life-threatening illnesses, endemic in the Asian-Pacific region and, as recently discovered, in southern Chile. Scrub typhus is rarely reported in travelers, most probably due to the lack of clinical experience and diagnostic tests in non-endemic countries. We report the first case of imported scrub typhus in South America. CASE PRESENTATION: A 62-year-old tourist from South Korea presented severely ill with fever, rash, and eschar in Santiago, Chile. Laboratory exams showed thrombocytopenia and elevated inflammation parameters, hepatic enzymes, and LDH. With the clinical suspicion of scrub typhus, empirical treatment with doxycycline was initiated and the patient recovered rapidly and without complications. The diagnosis was confirmed by IgM serology and by real-time PCR, which demonstrated infection with Orientia tsutsugamushi (Kawasaki clade). CONCLUSIONS: Only due to the emerging clinical experience with endemic South American scrub typhus and the recent implementation of appropriate diagnostic techniques in Chile, were we able to firstly identify and adequately manage a severe case of imported scrub typhus in South America. Physicians attending febrile travelers need to be aware of this rickettsiosis, since it requires prompt treatment with doxycycline to avoid complications.

[Bartonella henselae infection, the importance of images for diagnosis and follow-up]. / Infección por Bartonella henselae: utilidad de las imágenes en el diagnóstico y seguimiento.

Bartonella henselae infection is a frequent zoonosis from the domestic cat. It is presented with regional lymphadenitis in the majority of cases. Searching and characterization of lymph nodes by diagnostic imaging can be useful in the differential diagnosis approach, with a clear advantage, because it is a noninvasive method. Currently, new diagnostic imaging techniques improves the quality of screening and characterization of adenopathies, such is the case of PET/CT, which allows a better evaluation of hypermetabolic lymph nodes, without considering the individual growth of each lymph node. In this article, three cases of cat scratch diseases serology and their respective imaging findings are reviewed.

Polirradiculoneuritis aguda asociada a infección por Virus Herpes Humano 7 en un paciente adulto inmunocompetente / Acute polyradiculoneuropathy associated with human Herpes Virus 7 in an immunocompetent patient: case report

Human herpes virus 7 (HHV-7) is a cause of encephalitis, meningitis and myeloradiculoneuropathy in adults who are immunocompetent or with immunosuppression. The involvement of the peripheral nervous system is always associated with myelitis. We report a case of acute polyradiculoneuropathy due to HHV-7, without involvement of central nervous system, in an immunocompetent patient. A 35-years-old man complained of lumbar pain radiating to both buttocks. On examination muscle strength and tendon reflexes were normal. He had asymmetric pinprick and light touch saddle hypoesthesia and also in the perineal region, dorsum and lateral aspect of the left foot. Magnetic resonance imaging showed mild thickening and contrast enhancement of cauda equina nerve roots. Polymerase chain reaction performed on cerebrospinal fluid was positive for HVV-7. Other inflammatory, infectious and neoplastic etiologies were ruled out. Lumbar pain and hypoesthesia improved progressively and neurological examination was normal after one month. He did not receive antiviral therapy.

Infección por Bartonella henselae: utilidad de las imágenes en el diagnóstico y seguimiento / Bartonella henselae infection, the importance of images for diagnosis and follow-up

Resumen La infección por Bartonella henselae es una zoonosis frecuente transmitida por el gato doméstico. En la mayoría de los casos se presenta con una linfadenitis regional. La búsqueda y caracterización de los ganglios linfáticos por imagenología puede ser útil en el diagnóstico diferencial, con la ventaja de ser un método no invasor. En la actualidad, nuevas técnicas de diagnóstico por imagen han mejorado la detección y caracterización de las adenopatías, tal es el caso de la tomografía por emisión de positrones (PET/CT) que permite la evaluación de ganglios linfáticos hipermetabólicos, de manera independiente del crecimiento individual de cada ganglio linfático. Se revisan tres casos de enfermedad por arañazo de gato y sus estudios imagenológicos respectivos.

Bartonella henselae infection is a frequent zoonosis from the domestic cat. It is presented with regional lymphadenitis in the majority of cases. Searching and characterization of lymph nodes by diagnostic imaging can be useful in the differential diagnosis approach, with a clear advantage, because it is a noninvasive method. Currently, new diagnostic imaging techniques improves the quality of screening and characterization of adenopathies, such is the case of PET/CT, which allows a better evaluation of hypermetabolic lymph nodes, without considering the individual growth of each lymph node. In this article, three cases of cat scratch diseases serology and their respective imaging findings are reviewed.

[Acute polyradiculoneuropathy associated with human Herpes Virus 7 in an immunocompetent patient. Case report]. / Polirradiculoneuritis aguda asociada a infección por Virus Herpes Humano 7 en un paciente adulto inmunocompetente.

Human herpes virus 7 (HHV-7) is a cause of encephalitis, meningitis and myeloradiculoneuropathy in adults who are immunocompetent or with immunosuppression. The involvement of the peripheral nervous system is always associated with myelitis. We report a case of acute polyradiculoneuropathy due to HHV-7, without involvement of central nervous system, in an immunocompetent patient. A 35-years-old man complained of lumbar pain radiating to both buttocks. On examination muscle strength and tendon reflexes were normal. He had asymmetric pinprick and light touch saddle hypoesthesia and also in the perineal region, dorsum and lateral aspect of the left foot. Magnetic resonance imaging showed mild thickening and contrast enhancement of cauda equina nerve roots. Polymerase chain reaction performed on cerebrospinal fluid was positive for HVV-7. Other inflammatory, infectious and neoplastic etiologies were ruled out. Lumbar pain and hypoesthesia improved progressively and neurological examination was normal after one month. He did not receive antiviral therapy.

[Respiratory infections and bacteremia caused by Neisseria meningitidis serogroup W]. / Infecciones respiratorias bacteriémicas por Neisseria meningitidis serogrupo W.

N. meningitidis serogroup W has recently been introduced into Chile. This serogroup has been associated with hypervirulent strains capable of causing outbreaks. Furthermore, there is data suggesting that the spectrum of clinical manifestations varies among different serogroups. Here we describe three cases of community acquired respiratory infections caused by N. meningitidis W, which were diagnosed by blood culture during 2013 in our hospital.

[Atypical mycobacterial infections in five adult patients without evidence of immunosuppression. Making an experience]. / Micobacterias atípicas en cinco pacientes adultos sin evidencias de inmunosupresión. Construyendo una experiencia.

We aim to communicate the experience gathered during the management of infections by atypical mycobacteria in immunocompetent patients in a general practice. Between 2008 and 2013, 5 patients with non-tuberculous mycobacterial infections were identified: 2 with cutaneous involvement and 3 with lung infection. None of them had evidence of immunosuppression. A patient with elbow bursitis by M. chelonae presented with a high mononuclear count in fluid analysis with mycobacterial growth at the fifth day of culture. He evolved satisfactorily with clarithromycin. A case with M. fortuitum skin infection had a delayed initial diagnosis with progression to local draining lymph nodes; the culture when requested was positive after 13 days of incubation. Patients with pulmonary infection presented with prolonged cough and sputum and had in common to be postmenopausal women displaying small nodules and bronchiectases at lung images, a classical pattern. Time elapsed between respiratory sampling and a definitive inform ranged from 40 to 89 days. Non-tuberculous mycobacterial infections in non-immunosuppresed patients can generate diagnostic and therapeutic challenges. Delay in identification contributes to this problem.

Micobacterias atípicas en cinco pacientes adultos sin evidencias de inmunosupresión: Construyendo una experiencia / Atypical mycobacterial infections in five adult patients without evidence of immunosuppression: Making an experience

We aim to communicate the experience gathered during the management of infections by atypical mycobacteria in immunocompetent patients in a general practice. Between 2008 and 2013, 5 patients with non-tuberculous mycobacterial infections were identified: 2 with cutaneous involvement and 3 with lung infection. None of them had evidence of immunosuppression. A patient with elbow bursitis by M. chelonae presented with a high mononuclear count in fluid analysis with mycobacterial growth at the fifth day of culture. He evolved satisfactorily with clarithromycin. A case with M. fortuitum skin infection had a delayed initial diagnosis with progression to local draining lymph nodes; the culture when requested was positive after 13 days of incubation. Patients with pulmonary infection presented with prolonged cough and sputum and had in common to be postmenopausal women displaying small nodules and bronchiectases at lung images, a classical pattern. Time elapsed between respiratory sampling and a definitive inform ranged from 40 to 89 days. Non-tuberculous mycobacterial infections in non-immunosuppresed patients can generate diagnostic and therapeutic challenges. Delay in identification contributes to this problem.

El objetivo de este trabajo es reportar la experiencia acumulada sobre infecciones por micobacterias atípicas en pacientes sin inmunosupresión. Entre el año 2008 y 2013 se observaron cinco pacientes con infección por micobacterias atípicas: dos con infección cutánea y tres con infección pulmonar. Ninguno de estos pacientes tenía evidencias de inmunosupresión. Un paciente con bursitis de codo por M. chelonae tuvo un estudio citoquímico con aumento de celularidad de predominio mononuclear y desarrollo de bacterias al quinto día; respondió favorablemente a claritromicina. Un caso con infección cutánea por M. fortuitum evolucionó en forma prolongada con supuración ganglionar antes del diagnóstico y el cultivo solicitado a los 13 días fue positivo. Los tres pacientes con aislados pulmonares presentaron tos y expectoración y tenían en común ser mujeres en edad post-menopáusica y presentar pequeños infiltrados nodulares asociados a bronquiectasias en el estudio de imágenes pulmonares, un patrón descrito en la literatura científica. En estos tres casos, la latencia entre la toma de muestra y el informe definitivo tuvo un rango de 40 a 89 días. El aislamiento de micobacterias atípicas en muestras de expectoración en pacientes sin inmunosupresión se da en un contexto típico pero plantea dificultades diagnósticas y terapéuticas. El lento crecimiento de estos microorganismos en el laboratorio contribuye a este problema.

Falla de tratamiento en neumonía adquirida en la comunidad: coccidioidomicosis en un viajero / Treatment failure in community-adquired pneumonia: coccidioidomycosis in a traveler patient

Treatment failure in community-acquired pneumonia is defined as a clinical condition with inadequate response to antimicrobial therapy. Resistant and unusual microorganisms and noninfectious causes are responsible for treatment failure. Coccidioides immitis is a fungus that causes pneumonia in the northern hemisphere, especially in the United States and northern Mexico. We report a case of pulmonary coccidioidomycosis imported from Mexico to Chile. After a comprehensive study, histopathology was able to establish Coccidiodes immitis as the causative agent, achieving clinical and radiological improvement with antifungal therapy.

La neumonía de evolución tórpida son aquellas en que no se logra una respuesta clínica adecuada con el uso de terapia antimicrobiana. Existen múltiples causas a esta falta de respuesta: resistencia antimicrobiana, microorganismos no cubiertos o infecciones por microorganismos atípicos. Coccidioides immitis es un hongo causante de neumonía en el hemisferio norte, especialmente en E.U.A y norte de México. No existen reportes de casos pulmonares importados en Chile. Presentamos el caso de una mujer adulta con una neumonía que no respondió al tratamiento antimicrobiano habitual. Una vez realizado un estudio exhaustivo, se logró establecer mediante el estudio histopatológico la existencia de una coccidiodomicosis como entidad causal, logrando una respuesta clínica y radiológica favorable al tratamiento antifúngico.

Breakthrough bacteremia due to Clostridium tertium in a patient with neutropenic fever, and identification by MALDI-TOF mass spectrometry.

Clostridium tertium is rare in a human clinical specimen and its pathogenicity is often uncertain. However, the organism has been increasingly recognized as a cause of bacteremia and other infections in immunocompromised patients, especially those with hematologic malignancies. The diagnosis and treatment of C. tertium are difficult due to its growth pattern, micromorphology, and antibiotic resistance. The organism can easily be misidentified as Gram-positive aerobic rods such as Bacillus species, usually considered as a contaminant. Furthermore, it is not covered by empirical treatment with many broad-spectrum antibiotics. Here we report a case of breakthrough bacteremia due to C. tertium that occurred in a patient with acute leukemia and neutropenic fever, who was treated with an empirical regimen of ceftazidime and amikacin. The bacterium was rapidly identified by new mass spectrometry technology (MALDI-TOF MS) and the patient recovered under meropenem and vancomycin treatment, without complications.

Epidemiology of candidemia in Latin America: a laboratory-based survey.

BACKGROUND: The epidemiology of candidemia varies depending on the geographic region. Little is known about the epidemiology of candidemia in Latin America. METHODS: We conducted a 24-month laboratory-based survey of candidemia in 20 centers of seven Latin American countries. Incidence rates were calculated and the epidemiology of candidemia was characterized. RESULTS: Among 672 episodes of candidemia, 297 (44.2%) occurred in children (23.7% younger than 1 year), 36.2% in adults between 19 and 60 years old and 19.6% in elderly patients. The overall incidence was 1.18 cases per 1,000 admissions, and varied across countries, with the highest incidence in Colombia and the lowest in Chile. Candida albicans (37.6%), C. parapsilosis (26.5%) and C. tropicalis (17.6%) were the leading agents, with great variability in species distribution in the different countries. Most isolates were highly susceptible to fluconazole, voriconazole, amphotericin B and anidulafungin. Fluconazole was the most frequent agent used as primary treatment (65.8%), and the overall 30-day survival was 59.3%. CONCLUSIONS: This first large epidemiologic study of candidemia in Latin America showed a high incidence of candidemia, high percentage of children, typical species distribution, with C. albicans, C. parapsilosis and C. tropicalis accounting for the majority of episodes, and low resistance rates.

[Treatment failure in community-acquired pneumonia: coccidioidomycosis in a traveler patient]. / Falla de tratamiento en neumonía adquirida en la comunidad: coccidioidomicosis en un viajero.

Treatment failure in community-acquired pneumonia is defined as a clinical condition with inadequate response to antimicrobial therapy. Resistant and unusual microorganisms and noninfectious causes are responsible for treatment failure. Coccidioides immitis is a fungus that causes pneumonia in the northern hemisphere, especially in the United States and northern Mexico. We report a case of pulmonary coccidioidomycosis imported from Mexico to Chile. After a comprehensive study, histopathology was able to establish Coccidiodes immitis as the causative agent, achieving clinical and radiological improvement with antifungal therapy.

Pandemic influenza A (H1N1) 2009 with neurological manifestations, a case series.

OBJECTIVES: Describe a series of atypical presentations of pandemic influenza A (H1N1) 2009. METHODS: Description of case series using hospital records. RESULTS: Six patients aged 1 to 65 years with confirmed pandemic influenza A (H1N1) 2009 infection presented with neurological complications within 2 to 5 days after the first signs of influenza-like illness. All six were admitted with seizures or altered mental status. No abnormalities were found in brain scans or cerebral spinal fluid studies of any of the six. All were discharged without sequelae within days of admission. CONCLUSIONS: This is only the second report of pandemic influenza presenting with neurological manifestations. Clinicians caring for patients when pandemic influenza is prevalent in their communities should maintain a high level of awareness of the potential atypical presentations with which this disease can appear.

The north and south of candidemia: Issues for Latin America.

Candidemia is a growing problem in tertiary care hospitals all over the world. It is generally difficult to diagnose, leads to prolonged hospitalization, has a mortality rate of around 50% and is a financial burden to healthcare systems. The different distribution profiles of Candida species underlying candidemia seen in Latin America, North America, Canada and Europe, along with the emergence of antifungal drug resistance, make it essential to optimize regional guidelines for treating hematogenous candidiasis. This article reviews the importance of candidemia epidemiology and diagnosis from region to region and highlights the antifungal agents currently available to clinicians, comparing antifungal susceptibility profiles that dominate therapeutic strategies for candidemia in specific high-risk populations.

[Community acquired infections with methicillin resistant strains of Staphylococcus aureus: report of five cases]. / Staphylococcus aureus comunitario resistente a cloxacilina: Comunicación de los primeros cinco casos descritos en Chile.

Community acquired infections with methicillin resistant strains of Staphylococcus aureus (MRSA) infections have a more aggressive clinical course and involve mostly skin and lungs. These infections appear as outbreaks among prisoners, sportsmen, men having sex with men and military personnel. The higher aggressiveness of these strains is due to the production of several toxins, mainly Panton- Valentine leukocidine. The detection of the gene that codes for this toxin is a distinctive feature of these strains. We report five patients with community acquired MRSA infections. The clinical presentation was a skin infection in all. One patient had a pleuropneumonia in addition. Apart for resistance to beta-lactam antimicrobials, the strains were resistant to erythromycin and ciprofloxacin. Patients were treated with vancomycin, clotrimoxazole or intravenous clindamycin with a good evolution. An epidemiological surveillance for community acquired MRSA strain infections should be started and measures to adequately treat infected patients and avoid dissemination should be implemented.