Validation of the Global Leadership Initiative on Malnutrition criteria for diagnosis of malnutrition and mortality prediction for people living with HIV or AIDS.

OBJECTIVES: To validate the Global Leadership Initiative on Malnutrition (GLIM) criteria to diagnose malnutrition in hospitalized people living with HIV or AIDS (HA) considering different combinations, using the Subjective Global Assessment (SGA) as the semi-gold standard, and to assess the predictive effects of malnutrition according to the GLIM criteria on hospital length of stay and mortality. METHODS: Retrospective observational study including hospitalized people living with HA aged >18 y. Forty GLIM combinations were obtained by combining the different phenotypic and etiologic criteria. The concurrent validity was assessed according to the sensitivity and specificity values, and the agreement with the SGA was tested using κ values. Multivariate logistic and Cox regression models were used to test the independent predictors for longer length of stay (LOS) and mortality, respectively. RESULTS: The sample comprised 320 patients (mean age, 44.6 ± 12.1 y; 69.1% were men, and 68.4% were malnourished, according to the SGA). The prevalence of malnutrition, according to GLIM, varied from 10.3% to 69.1%. The combination of any phenotypic criteria with the etiologic criteria of low food intake and the combination of any phenotypic criteria with the etiologic criteria of disease severity were independent predictors for mortality (Hazard Ratio: 2.09 [95% CI, 1.15-3.77] and 2.09 [95% CI, 1.25-3.51], respectively). The combination of low body mass index and reduced absorption was independently associated with LOS higher than the median value (Oodds Ratio; 2.57; 95% CI, 1.21-5.45). CONCLUSIONS: Nine GLIM combinations had satisfactory sensitivity and specificity values to determine concurrent validity, all of them including weight loss and low weight; two combinations were independent predictors of mortality (any phenotypic criteria and low food intake or opportunistic infections), and one combination predicted longer LOS. Combining any phenotypic criteria with low food intake resulted in adequate concurrent and predictive validity.

Aureobasidium pullulans infection in a patient with chronic lymphocytic leukemia.

Saprophytic fungi are being increasingly recognized as etiologic agents of mycoses in immunosuppressed patients. We report a case of subcutaneous infiltration by Aureobasidium pullulans, likely due to traumatic inoculation, in a neutropenic patient during chemotherapy for chronic lymphocytic leukemia. The patient was treated with amphotericin B deoxycholate but was subsequently switched to itraconazole, which improved the lesion. This case highlights the importance of considering unusual fungal infections in critically ill patients such as those who are immunosuppressed due to chemotherapy. Diagnostic techniques and effective antifungal therapy have improved the prognosis of these cases.

Aureobasidium pullulans infection in a patient with chronic lymphocytic leukemia

Saprophytic fungi are being increasingly recognized as etiologic agents of mycoses in immunosuppressed patients. We report a case of subcutaneous infiltration by Aureobasidium pullulans, likely due to traumatic inoculation, in a neutropenic patient during chemotherapy for chronic lymphocytic leukemia. The patient was treated with amphotericin B deoxycholate but was subsequently switched to itraconazole, which improved the lesion. This case highlights the importance of considering unusual fungal infections in critically ill patients such as those who are immunosuppressed due to chemotherapy. Diagnostic techniques and effective antifungal therapy have improved the prognosis of these cases.

Disseminated Sporothrix brasiliensis infection with endocardial and ocular involvement in an HIV-infected patient.

Disseminated sporotrichosis occurs in individuals with impaired cellular immunity, such as in cases of neoplasia, transplantation, diabetes, and especially, acquired immunodeficiency syndrome. This report presents a 32-year-old Brazilian human immunodeficiency virus (HIV)-infected patient who developed a protracted condition of disseminated sporotrichosis with endocarditis, bilateral endophthalmitis, and lymphatic involvement. He needed cardiac surgery to replace the mitral valve. Sporothrix brasiliensis isolates were recovered from cultures of subcutaneous nodules and mitral valve fragments. Species identification was based on classical and molecular methods. The patient received amphotericin B for 52 days and subsequently, oral itraconazole. He remains asymptomatic, and he is on maintenance therapy with itraconazole. Despite his positive clinical outcome, he developed bilateral blindness. To our knowledge, this case is the first report of endocarditis and endophthalmitis caused by S. brasiliensis.

Comparative study of survivor and nonsurvivor sepsis patients in a university hospital.

To determine parameters associated with the evolution of sepsis, a five-year retrospective study was conducted in a university hospital. One hundred and four consecutive sepsis patients were evaluated, of whom 55.8% were men. The mortality was 68.3% and was associated with older age (p<0.05). Chronic comorbidities and infection site were not associated with prognosis. Gram-positive bacteria were more frequently identified in survivors (p<0.05), while non-detection of the germ was associated with mortality (p<0.01). Appropriate use of antibiotics (germ sensitive to at least one drug administered) was associated with survival (p<0.0001) while inappropriate use (p<0.05) or empirical use (p<0.01) were more frequent in nonsurvivors. Leukocytosis was the main abnormality (54.8%) detected on diagnosis, from the leukocyte count. During the evolution, normal leukocyte count was associated with survival (p<0.01) and leukocytosis with mortality (p<0.05). In conclusion, mortality was associated with nondetection of the pathogen, leukocytosis during the evolution of the sepsis and inappropriate or empirical use of antimicrobials. Evidence-based treatment that is directed towards modifiable risk factors might improve the prognosis for sepsis patients.

Comparative study of survivor and nonsurvivor sepsis patients in a university hospital

To determine parameters associated with the evolution of sepsis, a five-year retrospective study was conducted in a university hospital. One hundred and four consecutive sepsis patients were evaluated, of whom 55.8 percent were men. The mortality was 68.3 percent and was associated with older age (p<0.05). Chronic comorbidities and infection site were not associated with prognosis. Gram-positive bacteria were more frequently identified in survivors (p<0.05), while non-detection of the germ was associated with mortality (p<0.01). Appropriate use of antibiotics (germ sensitive to at least one drug administered) was associated with survival (p<0.0001) while inappropriate use (p<0.05) or empirical use (p<0.01) were more frequent in nonsurvivors. Leukocytosis was the main abnormality (54.8 percent) detected on diagnosis, from the leukocyte count. During the evolution, normal leukocyte count was associated with survival (p<0.01) and leukocytosis with mortality (p<0.05). In conclusion, mortality was associated with nondetection of the pathogen, leukocytosis during the evolution of the sepsis and inappropriate or empirical use of antimicrobials. Evidence-based treatment that is directed towards modifiable risk factors might improve the prognosis for sepsis patients.

Para determinar parâmetros associados à evolução da sepse, foi realizado estudo retrospectivo de 5 anos em um hospital universitário. Foram avaliados 104 pacientes consecutivos com sepse, sendo 55,8 por cento homens. A mortalidade foi de 68,3 por cento, associada à idade elevada (p<0,05). Doenças crônicas associadas e sítio de infecção não relacionados ao prognóstico. Identificação de bactérias gram-positivos foi mais frequente em sobreviventes (p<0,05) e não detecção do germe foi associada à mortalidade (p<0,01). O uso apropriado de antibióticos (germe sensível a pelo menos uma droga administrada) foi associado à sobrevida (p<0,0001) enquanto uso inapropriado (p<0,05) ou empírico (p<0,01) foi mais freqüente em não sobreviventes. No diagnóstico, leucocitose foi a principal (54,8 por cento) alteração no leucograma. Na evolução, leucograma normal foi associado à sobrevida (p<0,01) e leucocitose à mortalidade (p<0,05). Em conclusão, a mortalidade foi associada à ausência de detecção do germe, leucocitose na evolução da sepse e uso inapropriado ou empírico de antibióticos. O tratamento baseado em evidências e direcionado para fatores de risco que podem ser modificados deve melhorar o prognóstico do paciente com sepse.

Cytokine serum levels in patients infected by human immunodeficiency virus with and without Trypanosoma cruzi coinfection

Neste estudo foi avaliado o número de linfócitos TCD4, a parasitemia e os níveis séricos de interferon gama (IFN-g), fator de necrose tumoral alfa (TNF-a), interleucina-1 (IL-1), IL-4 e IL-10 em pacientes infectados pelo vírus da imunodeficiência adquirida ou apresentavam co-infeccão pelo HIV/Trypanosoma cruzi. O número de linfócitos T CD4 estava baixo nos dois grupos de pacientes, embora significativamente menor nos pacientes sem a doenca de Chagas. Os níveis séricos de IFN-g, IL-4 e TNF-a foram significativamente maiores nos pacientes com a co-infeccão pelo HIV/Trypanosoma cruzi. A razão IL-4/IFN-g foi maior nos pacientes com a co-infeccão pelo HIV/T. cruzi, que sugere um balanco favorável para perfil Th2 nesse grupo de pacientes. Este balanco Th2 foi maior nos pacientes com parasitemia detectável. Conclui-se que, embora tenha sido observado imunossupressão, na maioria com linfócitos T CD4 abaixo de 200/µm3, esses pacientes não reativaram a infeccão pelo T. cruzi e que o balanco favorável a Th2 estava associado à presenca de parasitemia.

Cytokine serum levels in patients infected by human immunodeficiency virus with and without Trypanosoma cruzi coinfection.

This study assessed the number of CD4 T lymphocytes, the parasitemia and serum levels of interferon gamma (IFN-gamma), tumor necrosis factor alpha (TNF-alpha), interleukin-1 (IL-1), IL-4 and IL-10 of patients infected by human immunodeficiency virus (HIV) and human immunodeficiency virus/Chagas' disease coinfection. CD4 T lymphocytes were low in the two groups of patients, although significantly lower in patients without Chagas' disease. Serum levels of IFN-gamma, IL-4 and TNF-alpha were significantly higher in patients with HIV/Chagas' disease. IL-4/IFN-gamma ratios were higher in patients with HIV/Chagas' disease, which showed a clear balance in favor of Th2-like cytokines in this group of patients. This Th2 balance was higher in patients with detectable parasitemia. We conclude that, although immunosuppression was observed, with CD4 T lymphocytes below 200/microm3, these patients did not display reactivation of T. cruzi infection and that a balance favorable to Th2 was associated with the presence of parasitemia.

Avaliação do uso e monitorização de aminoglicosídeos em pacientes internados em um Hospital Universitário / Evaluation of use and monitoring of aminoglycosides in patients from an universitary hospital

Avaliar o uso e monitorização de aminoglicosídeos em pacientes internados em um hospital universitário. Estudo prospectivo e observacional, em que foram avaliadas as fichas de prescrição de antibióticos e os prontuários de pacientes internados no HE/FMTM, que receberam aminoglicosídeo, durante o período de maio/2002 a abril/2003. Foram avaliados 325 pacientes (65,2 por cento homens e 34,8 por cento mulheres) recebendo gentamicina (77,2 por cento) ou amicacina (22,8 por cento), no total de 376 ciclos. As culturas foram realizadas em 81 (21,5 por cento) ciclos, sendo negativas em 45,7 por cento e positivas em 54,3 por cento casos, com crescimento de Gram-negativos em 52,3 por cento das culturas. A principal bactéria isolada foi Escherichia coli (39,2 por cento), seguida de Enterobacter cloacae (17,4 por cento) e Klebsiella pneumoniae (17,4 por cento). O antibiograma mostrou que as amostras foram sensíveis a outros antibióticos. A monitorização dos níveis séricos de creatinina foi feita antes e após (ou durante) o tratamento em 68 (18,1 por cento) ciclos. Aumento de creatinina sérica foi detectado em 22 (32,2 por cento) ciclos; em 21 (95,4 por cento) o aumento foi menor que 0,5 mg/dL e em um (4,6 por cento) caso foi indicativo de nefrotoxicidade (³0,5 mg/dL acima do basal). Dentre esses pacientes, seis (27,3 por cento) tiveram redução do clearance da creatinina abaixo do limite inferior de normalidade, considerando sexo, idade e peso. A gentamicina foi o principal aminoglicosídeo utilizado, principalmente de forma empírica. O antibiograma mostrou que existem alternativas eficazes aos aminoglicosídeos em pacientes com fatores de risco para toxicidade renal. Comparado à creatinina sérica, o clearance da creatinina foi um parâmetro mais útil para avaliar possível nefrotoxicidade.

[Extraintestinal finding of Isospora belli unizoic cysts in a patient with AIDS: case report]. / Presença extra-intestinal de cistos unizóicos de Isospora belli em paciente com SIDA: relato de caso.

This report describes the presence of Isospora belli unizoic cysts in mesenteric lymph nodes and of gametocytes in the gallbladder epitelium of a 26 year-old Brazilian male patient with Acquired Immune Deficiency Syndrome. This patient had received treatment for several times with sulfamethoxazole-trimethoprim. It is discussed the significance of I. belli tissue cysts as possible foci of resistance of the parasite and their association with the infection relapse even post-treatment with anticoccidian medication.

Presença extra-intestinal de cistos unizóicos de Isospora belli em paciente com SIDA: relato de caso / Extraintestinal finding of Isospora belli unizoic cysts in a patient with AIDS: case report

Descreve-se a presença de cistos unizóicos de Isospora belli em linfonodos mesentéricos e de gametócitos no epitélio da vesícula biliar de um paciente brasileiro de 26 anos de idade, com a Síndrome da Imunodeficiência Adquirida que recebeu tratamento, por diversas vezes, com sulfametoxazol-trimetoprim. Discute-se a importância dos cistos teciduais de I. belli como possíveis focos de resistência do parasita e a associaçäo destes a episódios de recidivas da infecçäo mesmo após tratamento com medicaçäo anticoccídios

Isospora belli infection: observation of unicellular cysts in mesenteric lymphoid tissues of a Brazilian patient with AIDS and animal inoculation.

We describe the finding of unizoic cysts of Isospora belli in lymphoid tissues of a Brazilian patient with AIDS, and discuss the possibilities of their drug resistance, they being the cause of relapses, and of being an indication for the existence of intermediary or paratenic animal hosts.

Hantavirus pulmonary syndrome in Uberaba, Minas Gerais, Brazil.

This report describes the epidemiological and clinical-evolutive characteristics of eight patients with hantavirus pulmonary syndrome (HPS) in Uberaba, Minas Gerais, Brazil. A positive history of contact with rodents was present in 100% of the cases. The time between the onset of symptoms and hospital care was, on average, 3.6 days. All patients showed clinical and laboratory findings suggestive of HPS. Elevated urea and creatinine levels were observed in 6 (75%) cases, PO2 was < 60 mmHg in 100% of the cases, and a chest X-ray demonstrated a bilateral interstitial-alveolar infiltrate. The diagnosis was confirmed by the detection of IgM antibodies against Sin Nombre virus by ELISA. Three patients died as a direct consequence of HPS.

Hantavirus pulmonary syndrome in Uberaba, Minas Gerais, Brazil

This report describes the epidemiological and clinical-evolutive characteristics of eight patients with hantavirus pulmonary syndrome (HPS) in Uberaba, Minas Gerais, Brazil. A positive history of contact with rodents was present in 100 percent of the cases. The time between the onset of symptoms and hospital care was, on average, 3.6 days. All patients showed clinical and laboratory findings suggestive of HPS. Elevated urea and creatinine levels were observed in 6 (75 percent) cases, PO2 was < 60 mmHg in 100 percent of the cases, and a chest X-ray demonstrated a bilateral interstitial-alveolar infiltrate. The diagnosis was confirmed by the detection of IgM antibodies against Sin Nombre virus by ELISA. Three patients died as a direct consequence of HPS

Abscesso cerebral por Nocardia sp em paciente imunossuprimido / Brain abscess by Nocardia sp in immunocompromised patient

Paciente portadora de anemia hemolitica autoimune e púrpura trombocitopenica idiopatica (Sindrome de Evans) em uso de terapia imunossupressora (predinisona e azatioprina), desenvolveu quadro de abscesso cerebral nao responsivo a 23 dias de terapia antimicrobiana. O diagnostico de nocardiose foi possivel apos coleta de material de abscesso peribulbar e observacao deste material por periodo superior ha uma semana