Retinal hemorrhages and intermediate uveitis in a patient with drug reaction with eosinophilia and systemic symptoms syndrome: a case report.

PURPOSE: To report a case of drug reaction (or rash) with eosinophilia and systemic symptoms syndrome in association with intraretinal hemorrhages and intermediate uveitis. METHODS: Single case report. RESULTS: A 22-year-old Hispanic woman developed a facial rash and blurry vision after the use of oral trimethoprim-sulfamethoxazole for a urinary tract infection. Fundus examination revealed bilateral +2 vitritis and intraretinal hemorrhages in all four quadrants. An oral mucosal biopsy revealed V-shaped coagulative necrosis, intraepithelial and superficial acute and lymphoplasmacytic inflammation, consistent with drug hypersensitivity reaction. CONCLUSION: Drug reaction (or rash) with eosinophilia and systemic symptoms syndrome can present as cutaneous rash, mucosal lesions, eosinophilia, intermediate uveitis, and intraretinal hemorrhages. In such cases, vitreoretinal manifestations may be considered as diagnostic criteria instead visceral involvement.

Cholestatic hepatitis with severe systemic reactions induced by trimethoprim-sulfamethoxazole.

Trimethoprim-Sulfomethoxazole (TMP-SMX) related hepatotoxicity and associated severe systemic reaction are not frequent and documented only in case reports. We report a case of a 30-year-old man, who underwent a 15-day therapy with TMP-SMX for urinary tract infection and two weeks later developed acute cholestatic hepatitis, fever and a skin rash followed by severe systemic reaction. He was admitted in Intensive Care unit and with supportive therapy and prednisolone administration, he showed subsequent improvement over a period of few days. He had fully recovered months later. All tests for other causes of liver disease were negative and his liver biopsy showed evidence of drug-induced hepatic injury.

Absence of dihydropteroate synthase mutations in Pneumocystis jirovecii from Brazilian AIDS patients.

Several studies from developed countries have documented the association between trimethoprim-sulfamethoxazole prophylaxis failure and mutations in the Pneumocystis jirovecii gene coding for dihydropteroate synthase (DHPS). DNA was extracted from Giemsa-stained smears of 70 patients with P. jirovecii pneumonia seen in Porto Alegre, Brazil, from 1997 to 2004. Successful PCR amplification of the DHPS locus was obtained in 57 of 70 cases (81.4%), including five cases (8.7%) that had used sulfa prophylaxis. No DHPS gene mutations were seen. These results suggest that DHPS mutations are currently as rare in Brazil as in other developing countries.

Resistance of uropathogens in symptomatic urinary tract infections in León, Nicaragua.

Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is complicated by the lack of knowledge about the antibiotic resistance of uropathogens. We conducted a prevalence study to gain more insight into the aetiology, bacterial resistance and risk factors for symptomatic UTI in the region of León, Nicaragua. In 2002, all consecutive patients with UTI symptoms and pyuria >/=10 WBC/hpf were admitted to the study. Positive cultures from midstream urine specimens were defined as >/=10(5) cfu/ml of a single uropathogen. Susceptibility tests were performed with disc diffusion tests using the Kirby-Bauer method and broth microdilution using National Committee for Clinical Laboratory Standards criteria both in León and a reference laboratory in Utrecht. A positive culture was present in 62 of 208 study subjects (30%). Escherichia coli (56%), Klebsiella spp. (18%) and Enterobacter spp. (11%) were the most frequent pathogens isolated. Presence of cystocele, incontinence and increasing age were risk factors for bacterial UTI. E. coli was least resistant to ceftriaxone, amikacin and nitrofurantoin (>90% susceptible). We observed high resistance rates in E. coli to amoxicillin (82%, MIC(90) 128 mg/l), trimethoprim-sulphamethoxazole (TMP-SMX) (64%, MIC(90) 32 mg/l), cephalothin (58%, MIC(90), 32 mg/l), ciprofloxacin (30%; MIC(90), 32 mg/l), amoxicillin/clavulanate (21%, MIC(90) 8 mg/l) and gentamicin (12%, MIC(90) 2 mg/l). Our results suggests that community acquired uropathogens in Nicaragua are highly resistant to many antimicrobial agents. The use of amoxicillin, trimethoprim-sulphamethoxazole and cephalothin against uropathogens needs to be reconsidered. High quinolone resistance rates among E. coli in Nicaragua gives cause for great concern.

Preventing opportunistic infections in human immunodeficiency virus-infected persons: implications for the developing world

More than 18 million persons in the the world are estimated to have been infected with human immunodefeiciency virus (HIV), the cause of the acquired immunodeficiency syndrome (AIDS). As immunodeficiency progresses, these persons become susceptible to a wide variety of opportunistic infections (OIs). The spectrum of OIs varies among regions of the world. Tuberculosis is the most common serious OI in sub-Saharan Africa and is also more common in Latin America and in Asia than in the United States. Bacterial infections such as toxoplasmosis, cryptosporidiosis, and isosporaisis are also common in Latin America. Fungal infections, including cryptococcosis and Penicillium marneffei infection, appear to be prevalent in Southeast Asia. Despite limited health resources in these regions, some measures that are recommended to prevent OIs in the United States may be useful for prolonging and improving the quality of life of HIV-infected persons. These include trimethoprim-sulfamethoxazole to prevent Pneumocystis carinii pneumonia, toxoplasmosis, and bacterial infections; isoniazid to prevent tuberculosis; and 23-valent pnemococcal vaccine to prevent disease due to Streptococcus pneumoniae. Research is needed to determine the spectrum of OIs and the efficacy of various prevention measures in resource-poor nations, and health officials need to determine a minimum standard of care for HIV-infected persons. An increasing problem in the developing world, HIV/AIDS should receive attention comparable to other tropical diseases (AU).

Profilaxia da bacteriúria e/ou infecçäo urinária na cirurgia de incontinência urinária de esforço pela via vaginal / Prophylaxis of bacteriura and/or urinary infection in stress urinary incontinence treated by the vaginal route

Em um estudo comparativo envolvendo 62 pacientes com Incontinência: Urinária de Esforço, corrigida pela cirurgia de Kelly, pela via vaginal e requerendo o emprego de drenagem vesical no pós-operatório, foram administradas por instilaçäo vesical uma soluçäo de uso tópico e uma medicaçäo oral, para a profilaxia de bacteriúrias e/ou infecçöes urinárias no pós-operatório. Trinta e duas pacientes usaram a medicaçäo oral (cada comprimido contendo 410 mg de sulfadiazina mais 90 mg de trimetoprim), resultando em 37,5% de infecçäo (20 pacientes) e em paenas 3,1% de retençäo urinária (uma paciente). Nas 30 pacientes que usaram a soluçäo tópica (cada frasco contendo 30 ml de soluçäo estéril de neomicina a 1% e sulfametizol a 8%), 20% apresentaram infeçäo urinária (6 pacientes). A análise dos resultados demonstrou, em nossa populaçäo, um número duas vezes maior de infecçäo nas pacientes que fizeram o uso da medicaçäo por via oral, o que nos permite concluir favoravelmente, em relaçäo ao medicamento de uso tópico

Efficacy of trimethoprim-sulfamethoxazole in treatment of acute diarrhea in a Mexican pediatric population.

The efficacy of trimethoprim-sulfamethoxazole (TMP-SMX) and placebo were compared in a randomized double-blind study of 141 Mexican children with acute diarrhea. Patients who met specific entry criteria received TMP-SMX or an identical appearing placebo for 5 days. Stools were examined for bacterial, viral, and parasitic pathogens. Enterotoxigenic Escherichia coli were the most commonly isolated pathogens (22% of total). Patients given TMP-SMX had a significantly shorter time to "last illness stool" than did those given placebo, but no difference in number of unformed stools in 5 days was found between treatment groups. However, TMP-SMX significantly shortened the illness in patients with fever or many fecal leukocytes. When stool cultures positive for any bacterial pathogen or for enterotoxigenic E. coli were analyzed as separate groups, a significantly faster recovery was observed in patients given TMP-SMX. TMP-SMX is efficacious in the treatment of Mexican children with diarrhea and culture-proved bacterial infection or when the clinical signs and symptoms suggest bacterial enteritis.

Increasing resistance to trimethoprim-sulfamethoxazole among isolates of Escherichia coli in developing countries.

Resistance of Escherichia coli to trimethoprim (TMP)-sulfamethoxazole remains at 3%-8% at many medical centers within the United States. In this study a 44% resistance rate was observed among E. coli isolated at a pediatric hospital in Santiago, Chile, and a 40% resistance rate at a general teaching hospital in Bangkok, Thailand. Most isolates were from urinary tract infections and showed high-level resistance (minimal inhibitory concentration of TMP greater than 1,000 micrograms/ml). Nineteen of 35 isolates tested transferred resistance to TMP; most cotransferred resistance to streptomycin and sulfonamides. Dihydrofolate reductase type I was detected by gene probing in 14 of 35 strains. Subsequent investigations in Brazil, Honduras, and Costa Rica revealed that this high rate of resistance was not an isolated phenomenon.

Profilaxia da infecçäo urinária conseqüente à manipulaçäo endoscópica com o emprego local da soluçäo de neomicina a 1% e sulfametizol a 8% / Prophylaxis of urinary infection following endoscopic manipulation by the local use of a solution of neomycin 1% and sulfamethizole 8%

Os autores referem-se aos resultados do estudo realizado para avaliar a açäo profilática de uma soluçäo de neomicina a 1% e sulfametizol a 8% sobre a infecçäo urinária em pacientes manipulados por citoscopia. O estudo envolveu 73 pacientes divididos em três grupos: Grupo I - Placebo, Grupo II e Grupo III. Os pacientes do grupo I - Placebo, utilizados como controle, receberam água destilada na bexiga, logo depois de praticada a endoscopía e 24 horas mais tarde. Aos pacientes do Grupo II foi administrada, por instilaçäo vesical, a soluçäo antibacteriana, logo depois da endoscopia e 24 horas após; e aos do Grupo III, foi feita uma instilaçäo vesical pré-endoscópica, uma logo depois da endoscopia e outra 24 horas após. Controles clínico e laboratoriais (citobacterioscopia do sedimento urinário e urinocultura) foram feitos entre e depois da realizaçäo da citoscopia. Os resultados observados foram analisados estatisticamente, chegando-se à conclusäo de que a soluçäo de neomicina a 1% e sulfametizol a 8%, instilada na bexiga, é um protetor eficaz contra infecçöes urinárias de pacientes submetidos a citoscopia diagnóstica. Evidenciou-se, também uma tendência de melhores resultados nos pacientes do Grupo III. A medicaçäo isenta de risco, é de boa tolerabilidade local

Tratamento local de uretrites inespecíficas e de cistites persistentes, com a soluçäo de neomicina a 1% e sulfametizol a 8% / Local treatment of unspecific urethritis and persistent cystitis with 1% neomicina solution and an 8% sulfametizol solution

O Autor estudou o emprego da terapêutica local das infecçöes urinárias baixas, em esquema de curto prazo, através da instilaçäo uretral e/ou vesical de uma soluçäo de neomicina a 1% e sulfametizol a 8%, pronta para uso. Para tanto, utilizou dois grupos de pacientes: Grupo I, de 20 homens entre 18 e 42 anos de idade, com uretrite inespecífica e Grupo II, de 5 homens entre 24 e 70 anos e 15 mulheres entre 18 e 65 anos, portadores de uretro-trigonites persistentes. Os pacientes dos dois grupos receberam a medicaçäo tópica, ainda que a uma parte deles tivesse sido permitida uma terapêutica concomitante, de patologias associadas, que näo interferisse na avaliaçäo dos resultados do tratamento local. Utilizaram-se critérios diagnósticos e do controle clínico e laboratorial para proceder-se à avaliaçäo da eficácia e tolerabilidade ao tratamento local. O produto mostrou-se eficaz nos portadores de uretrite inespecífica do Grupo I bem como nos casos de cistite crônica do Grupo II. Quanto à tolerabilidade, foi 100% Boa no Grupo II e de 95% Boa no Grupo I, no qual houve um abandono de tratamento por intolerância à medicaçäo. conclui o autor que os resultados obtidos como emprego de uma instilaçäo diária da soluçäo de neomicina a 1% e sulfametizol a 8%, durante 5 dias em média, foram comprobatórios da reduçäo e do desaparecimento dos sintomas/sinais predominantes nas infecçöes das vias urinárias inferiores, eliminando os germes em elevada porcentagem dos casos

Emprego de solucao de neomicina a 1% e sulfametizol a 8% no tratamento das infeccoes urinarias baixas. / The use of solution of neomycin 1% and sulfamethizol 8% in the treatment of urinary infections

Em 30 pacientes que nao respondiam bem ao tratamento por via oral de quadro infeccioso urinario baixo, empregou-se como coadjuvante terapeutico, instilacoes vesicais de uma solucao pronta para uso, esteril, de neomicina a 1% e sulfametizol a 8% com o intuito de obter e eliminacao do processo infeccioso. Em 80% dos pacientes alcancou-se a cura da infeccao e, em 93, 33%, melhora ou cura. Os resultados foram melhores no grupo de pacientes que nao usava sonda de demora. A tolerabilidade ao metodo terapeutico e a solucao instilada foi considerada boa. Em funcao dos bons resultados obtidos como o emprego concomitante de terapeutica antimicrobiana geral e local, atraves de instilacoes vesicais, os autores opinam que este esquema deve voltar a cogitacao dos urologistas, uma vez que tal procedimento representa um util recurso terapeutico ao paciente com infeccao urinaria baixa