Presentation of histoplasmosis as mononucleosis syndrome in an immunocompetent patient.

Histoplasmosis is a fungal disease usually occurring in endemic areas that can affect immuno-impaired patients in whom pulmonary involvement is the rule. We present the case of an 18 year-old immunocompetent, male patient, resident of the State of Florida, who showed signs of mononucleosis syndrome that included odynophagia, cervical adenomegaly, sporadic fever and rash; however, no pulmonary involvement or visceromegaly were present. Faced with this atypical and unexpected clinical picture, histoplasmosis infection was eventually diagnosed following cervical lymph-node biopsy. Disseminated histoplasmosis may have unexpected manifestations, as is pointed out in the case described below.

Comparison between MALDI-TOF MS and MicroScan in the identification of emerging and multidrug resistant yeasts in a fourth-level hospital in Bogotá, Colombia.

BACKGROUND: The introduction of MALDI-TOF MS in the clinical microbiology laboratory has modified the approaches for the identification of fungi. Thanks to this tool, it is possible to identify cryptic species, which possess critical susceptibility patterns. Clinical strains were identified using the MicroScan and MALDI-TOF MS systems. Discrepant results from both methods were investigated using ITS rDNA barcoding. Finally, these isolates were also tested for in vitro susceptibility. RESULTS: The percentage of agreement between both methods to 498 yeast isolates was of 93.6% (32 discrepant isolates). The concordance of ITS sequencing with MALDI-TOF MS was higher (99%) than that of MicroScan (94%). Several of these discordant yeasts displayed high MICs for antifungal agents. CONCLUSIONS: Our study highlights the need of the MS and molecular approaches such as MALDI-TOF MS and ITS rDNA barcoding for the correct identification of emerging or cryptic yeast species; besides, some of these could be multidrug resistant. This work was the first experience in the implementation of the MALDI-TOF MS technology in Colombia. We found the first uncommon yeasts including Candida auris and we could identify Trichosporon faecalis. Our work highlights a clear necessity of an accurate yeast identification as a much more pertinent technique than the susceptibility profiles, because the most unusual yeasts exhibit resistance profiles to the few available antifungals.

First report of sporadic cases of Candida auris in Colombia.

BACKGROUND: Candida auris is a recently reported Candida species that is phenotypically similar to Candida haemulonii and related to hospital outbreaks. This organism can be misidentified as Candida haemulonii, Candida famata, Candida catenulata, or Rhodotorula glutinis by phenotypic approaches. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and DNA sequence analysis using internal transcribed spacer rDNA bar-coding provide an accurate identification. CASE REPORTS: Three cases of C. auris infection in patients with risk factors for fungal infection (one admitted to the intensive care unit, one with lymphoma, and one with HIV; all three with previous antibiotic use) are reported; these infections were not epidemiologically related. Yeast isolates were recovered from blood, ocular secretion, and bronchoalveolar lavage and were misidentified as C. catenulata and Candida albicans by the phenotypic MicroScan method. The isolates were confirmed to be C. auris by means of MALDI-TOF MS and DNA sequence analysis. Antifungal susceptibility testing was performed on these C. auris isolates, which exhibited high minimum inhibitory concentrations to triazoles and amphotericin B. One patient survived and the other two died. Only one of these deaths was related to fungemia. CONCLUSIONS: C. auris is an emerging and opportunistic multidrug-resistant human pathogen. It is necessary to strengthen measures to achieve an accurate and quick identification and also to avoid its dissemination. This will require improvements in health and infection control measures, as well as the promotion of antifungal stewardship in healthcare facilities.

Estrategias de prevención de mediastinitis / Prevention strategies for mediastinitis

La cirugía cardiovascular en pacientes con enfermedad coronaria tiene beneficios clínicos que no requieren mayor ilustración; sin embargo, una de las complicaciones más temidas es el desarrollo de mediastinitis. En esta edición de la Revista Colombiana de Cardiología y Cirugía Cardiovascular se presenta un estudio interesante acerca de los factores de riesgo de mediastinitis en pacientes con revascularización miocárdica, que indica que la diabetes mellitus OR 2,3 (1,1-4,9), el uso de circulación extracorpórea OR 2,4 (1,1-5,5), el tiempo de perfusión OR 1,1 (1,1-1,3) y la edad mayor a 70 años OR 1,1 (1,2-1,4) favorecen el desarrollo de infección. Pese a que la relevancia de todos estos factores ha sido reportada previamente en la literatura, la diabetes y la edad son inmodificables y los dos restantes se relacionan con el procedimiento pues dependen en gran medida de la complejidad del mismo. De otra parte, entre los factores modificables que se han asociado con menor riesgo de mediastinitis están el uso de profilaxis antibiótica, el cual se ha empleado de manera general en toda la población estudiada y debe constituir un estándar de calidad en el manejo de estos pacientes, y evitar la remoción del pelo antes de la intervención quirúrgica o en caso de ser necesario realizarlo con recortadora ("clipper"), actividad rutinaria en la mayoría de instituciones en las que se realiza cirugía cardiovascular en Colombia. Así mismo, un aspecto que también se ha relacionado con menor riesgo de infección es el control rutinario de la glicemia luego de 24 y 48 horas del posoperatorio, la cual debe ser menor a 200 mg en las mañanas. Por último, vale mencionar dos estrategias enfocadas al control de las infecciones por Staphylococcus aureus que no se utilizan de forma rutina en el país. Este microorganismo es uno de los agentes etiológicos que más se ha relacionado con mediastinits. En el estudio de Parada y colaboradores, llevado a cabo en la Fundación Cardioinfantil, fue el más aislado y el que más se relacionó con alta virulencia, tasas de complicaciones y mortalidad.

Polineuropatia desmielinizante aguda en SIDA: presentación de dos casos / Atypical acute inflammatory demyelinating polyneuropathy in the setting of HIV infection: Report of two cases

La polineuropatia desmielinizante aguda (AIDP) es un desorden inmune que afecta el nervio periférico produciendolesión axonal o mielínica. las infecciones respiratorias altas, gastrointestinales o los cuadros febriles inespecíficosusualmente preceden este caudro clínico caracterizado por debilidad progresiva y disminución de reflejos miotendinosos.En el paciente con infección VIH la AIDP usulamnete aparece en el periodo de seroconversión cuandoel conteo de CD4 es mayor a 500 células/uL. Se presume origen infecciosos a pesar de no existir un anticuerpoespecífico. reportamos dos casos de paciente con VIH y ADPI con presentación atípica. El primero con un conteode CD4 menos a 100 células/uL, el segundo en el contexto de síndrome de reconstitución inmunológica (IRIS).Ambos pacientes tuvieron recuperación satisfactoria luego de tratamiento con inmunoglobulina intravenosa ysuspensión temporal del tratamiento antiretroviral respectivamente.

Chagasic encephalitis in HIV patients: common presentation of an evolving epidemiological and clinical association.

We present a case of chagasic meningoencephalitis reactivation in an HIV-infected woman with advanced immunosuppression. Prolonged survival was attained with antiparasitic therapy and secondary prophylaxis, in conjunction with the use of highly-active antiretroviral therapy. The geographic expansion of the HIV epidemic around the world coupled with global migration and international travel have created a favourable situation for Trypanosoma cruzi and HIV coinfection. The clinical manifestations of Chagas disease in HIV-positive people usually represent reactivation and not acute infection with T cruzi (coinfection). Symptomatic reactivation of chronic latent T cruzi infection can be triggered by severe immunosuppression associated with HIV infection. In this setting, Chagas disease reactivation often presents as meningoencephalitis resembling toxoplasma encephalitis. We review, in this Grand Round, the clinical manifestations, diagnostic approach, pathogenesis, natural history, treatment, prognosis, and prevention of Chagas disease reactivation among HIV-infected people with an emphasis on CNS manifestations.