Características Clínicolaboratoriais da Criptococose em Pacientes Admitidos em Pronto Socorro Hospital das Clínicas, Universidade Federal de Minas Gerais, Referência Terciária do Sistema Único de Saúde: Análise Retrospectiva desde 2000 a 2013 / Clinical Laboratory Characteristics of Cryptococcosis in Patients Admitted to the Emergency Room Hospital das Clínicas, Federal University of Minas Gerais, Tertiary Reference of the Unified Health System: Retrospective Analysis from 2000 to 2013

A criptococose é uma micose sistêmica, de ocorrência relativamente rara, potencialmente grave, geralmente oportunista e de elevada frequência em pacientes imunossuprimidos, com amplo espectro de acometimento de órgãos, tropismo especial para o sistema nervoso central (SNC), evolução subaguda ou crônica, e manifestações clínicas variadas. Este estudo descritivo, retrospectivo, observacional, transversal, objetivou descrever os dados demográficos, clínicos, comorbidades, sintomas ou sinais, e o prognóstico de pacientes com neurocriptococose, atendidos e internados no Hospital das Clínicas (HC) da Universidade Federal de Minas Gerais desde 2000 até 2013. O HC é unidade universitária, pública e geral, de nível terciário e quaternário, com 450 leitos de internação, integrado ao Sistema Único de Saúde (SUS), com clientela universalizada, cerca de 40% do total proveniente do interior do estado de Minas Gerais, predominando da região Metropolitana de Belo Horizonte, aberto à transferência de pacientes de todo o território mineiro, com área de abrangência de população de mais de cinco milhões de pessoas, de todas as faixas etárias e todas as especialidades médicas, encaminhados pela intensidade de sua expressão clínica, especialmente em situação crítica, o que torna sua casuísticade máxima gravidade. Os pacientes foram internados a partir do Pronto Socorro do HC que admite, em média, 80 pacientes com urgência clínicas por dia, incluindo obstétricas, e excluídas aquelas devido à acidente ou violência de qualquer natureza. Foram analisados 40 pacientes com neurocriptococose o que significou 0,13% de toda demanda de admissão de urgência para o período estudado, cerca de 603.000 pessoas, isto é 12% da população referida, e associou-se à letalidade de 25%; com frequência da distribuição de acordo com o gênero em 2:1, entre homens e mulheres, respectivamente; e nas faixas etárias entre 20-40, 40-60 e mais de 60 anos de idade, de 36%, 42%, e 22%, respectivamente, sendo a proporção entre 20 a 60 e mais de 60 de aproximadamente, 2:1. A neurocriptococose associou-se em mais de 50% dos pacientes com a: SIDA (57,5%); internação prévia (52,5%) relacionada à quimio e corticoterapia, transplante, cirurgias para ressecção de neoplasias; e, em menos de 20% com doença cardiovascular hipertensiva sistêmica (17,5%), cirurgia prévia (15%) e tuberculose (5%). A sintomatologia isolada presente em pelo menos 40% dos pacientes foi: cefaleia (70%), astenia (50%), febre (45%), vômitos (40%); entretanto, em até um terço deles constituiu-se de: emagrecimento (30%), tontura (30%), dor abdominal (27,5%), convulsão (22,5%). As anormalidades mais e menos especificamente indicadoras de acometimento do SNC foram cefaleia; e, vômito, tontura e convulsão,respectivamente. As alterações do exame neurológico foram relacionadas aos distúrbios da consciência (35%), lesão focal (30%), alteração da marcha (25%) e distúrbio do comportamento (15%). A concomitância de cefaléia, convulsão e vômitos foi anotada em 5% dos pacientes; enquanto de cefaléia e convulsão em 22,5%. Foi observada, à admissão hospitalar, em 40%, dos pacientes a associação de cefaléia e vômito; mas todos os pacientes com vômito e também os com lesão focal apresentavam cefaleia. A presença de cefaleia não foi descrita em 35% dos pacientes com alteração da consciência à admissão hospitalar. O diagnóstico presuntivo de neurocriptococose deve ser realizado, independentemente da sintomatologia clínica neurológica, o que realça a percepção geral do paciente, incluindo epidemiologia, história familiar, história prévia, manifestações clínicas, presença de imunossupressão, para surpreender a criptococose, e iniciar a terapêutica o mais apidamente possível para que possa ser reduzida sua letalidade. A limitação deste estudo relaciona-se ao fato de ter sido retrospectivo, em que o controle dos dados registrados é muito limitada, sendo impossível corrigir a ausência de dados registrados. (AU)

Cryptococcosis is a systemic, relatively rare, potentially severe, often opportunistic and systemic mycosis in immunosuppressed patients with a broad spectrum of organ involvement, a special central nervous system (CNS) tropism, subacute or chronic clinical manifestations. This descriptive, retrospective, observational, cross-sectional study aimed to describe the demographic, clinical, comorbidities, symptoms or signs, and the prognosis of patients with neurocryptococcosis, attended and hospitalized at the Hospital das Clínicas (HC) of the Universidade Federal de Minas Gerais since 2000 until 2013. The HC is a university unit, public and general, tertiary and quaternary level, with 450 beds of hospitalization, integrated into the Unified Health System (SUS), with a universalized clientele, about 40% of the total coming from the interior of the state of Minas Gerais, predominating in the metropolitan region of Belo Horizonte, which is open to the transfer of patients from all over Minas Gerais, with an area of population of more than five million people, of all age groups and all medical specialties. intensity of its clinical expression, especially in a critical situation, which makes its series of age.The patients were hospitalized from the HC Emergency Room, which admitted, on average, 80 urgently needed clinics per day, including obstetrics, and excluded due to accidents or violence of any kind. We analyzed 40 patients with neurocryptococcosis, which represented 0.13% of all urgent admission demands for the period studied, about 603,000 people, ie 12% of the referred population, and was associated with a 25% lethality; with frequency of distribution according to gender in 2: 1, between men and women, respectively; and in the age groups between 20-40, 40-60 and over 60 years of age, of 36%, 42%, and 22% respectively, the ratio being between 20 to 60 and more than 60 of approximately 2: 1. Neurocryptococcosis was associated in more than 50% of patients with: AIDS (57.5%); previous hospitalization (52.5%) related to chemo and corticoid therapy, transplantation, surgeries for resection of neoplasias; and in less than 20% with systemic hypertensive cardiovascular disease (17.5%), previous surgery (15%) and tuberculosis (5%). The isolated symptoms present in at least 40% of the patients were: headache (70%), asthenia (50%), fever (45%), vomiting (40%); (30%), dizziness (30%), abdominal pain (27.5%), and seizure (22.5%). The most and least specific abnormalities of CNS involvement were headache; and, vomiting, dizziness and convulsion, respectively. Changes in neurological examination were related to disturbances of consciousness (35%), focal lesion (30%), gait alteration (25%) and behavior disorder (15%). The concomitance of headache, convulsion and vomiting was noted in 5% of the patients; while headache and seizure in 22.5%. The association of headache and vomiting was observed in 40% of patients; but all patients with vomiting and those with focal lesion also had headache. The presence of headache was not described in 35% of patients with altered consciousness at hospital admission. The presumptive diagnosis of neurocryptococcosis should be performed independently of the clinical neurological symptomatology, which highlights the general perception of the patient, including epidemiology, family history, previous history, clinical manifestations, presence of immunosuppression, to start cryptococcosis, and initiate therapy. as soon as possible so that their lethality can be reduced. The limitation of this study is the fact that it was retrospective, in which the control of the recorded data is very limited, and it is impossible to correct the absence of recorded data. (AU)

Genotypes of Cryptococcus neoformans and Cryptococcus gattii as agents of endemic cryptococcosis in Teresina, Piauí (northeastern Brazil).

Throughout Brazil, Cryptococcus neoformans is the cause of cryptococcosis, whereas Cryptococcus gattii is endemic to the northern and northeastern states. In this study, the molecular types of 63 cryptococcal isolates recovered from the cerebrospinal fluid of meningitis patients diagnosed between 2008-2010 in Teresina, Piauí, Brazil, were analysed. Out of the 63 patients, 37 (58.7%) were human immunodeficiency virus (HIV)-positive and 26 (41.3%) were HIV-negative. URA5-restriction fragment length polymorphism analysis identified 37/63 (58.7%) isolates as the C. neoformans VNI genotype, predominantly in HIV-positive patients (32/37, 86.5%), and 24/63 (38.1%) as the C. gattii VGII genotype, mostly in HIV-negative patients (21/26, 80.8%). The occurrence of C. gattii VGII in six apparently healthy children and in seven adolescents/young adults in this region reaffirms the endemic occurrence of C. gattii VGII-induced primary cryptococcosis and early cryptococcal infection. Lethality occurred in 18/37 (48.6%) of the HIV-positive subjects and in 13/26 (50%) of the HIV-negative patients. Our results provide new information on the molecular epidemiology of C. neoformans and C. gattii in Brazilian endemic areas.

Genotypes of Cryptococcus neoformans and Cryptococcus gattii as agents of endemic cryptococcosis in Teresina, Piauí (northeastern Brazil)

Throughout Brazil, Cryptococcus neoformans is the cause of cryptococcosis, whereas Cryptococcus gattii is endemic to the northern and northeastern states. In this study, the molecular types of 63 cryptococcal isolates recovered from the cerebrospinal fluid of meningitis patients diagnosed between 2008-2010 in Teresina, Piauí, Brazil, were analysed. Out of the 63 patients, 37 (58.7 percent) were human immunodeficiency virus (HIV)-positive and 26 (41.3 percent) were HIV-negative. URA5-restriction fragment length polymorphism analysis identified 37/63 (58.7 percent) isolates as the C. neoformans VNI genotype, predominantly in HIV-positive patients (32/37, 86.5 percent), and 24/63 (38.1 percent) as the C. gattii VGII genotype, mostly in HIV-negative patients (21/26, 80.8 percent). The occurrence of C. gattii VGII in six apparently healthy children and in seven adolescents/young adults in this region reaffirms the endemic occurrence of C. gattii VGII-induced primary cryptococcosis and early cryptococcal infection. Lethality occurred in 18/37 (48.6 percent) of the HIV-positive subjects and in 13/26 (50 percent) of the HIV-negative patients. Our results provide new information on the molecular epidemiology of C. neoformans and C. gattii in Brazilian endemic areas.