Strongyloides stercoralis en la médula ósea de una persona que vive con VIH: reporte de caso

Strongyloides stercoralis es un nemátodo que se caracteriza por causar infección intestinal, usualmente asintomática, en pacientes inmunocompetentes. Sin embargo, en aquellos que viven con VIH, y de acuerdo con su estado inmune, puede generar un síndrome de hiperinfección con complicaciones diversas por diseminación a diferentes órganos. Se presenta el caso de un paciente de 30 años con diagnóstico de novo de infección por el virus de la inmunodeficiencia humana, con documentación de enfermedad linfoproliferativa. En los estudios complementarios se documenta la presencia de Strongyloides stercoralis de manera inusual en la médula ósea. A pesar de contar con un recuento de linfocitos T CD4+ mayor a 400 células/ µL y de haberse iniciado el manejo para esta condición con ivermectina, el paciente fallece por un estado séptico asociado al síndrome de hiperinfección, por lo cual se considera que este es un caso inusitado que obliga al clínico a tener en cuenta la presencia del nemátodo en pacientes que viven con VIH.

Summary Strongyloides stercoralis is a nematode that is characterized by causing a usually asymptomatic intestinal infection in immunocompetent individuals. However, in patients living with HIV and depending on their immune status, it can generate a hyperinfection syndrome with various complications due to dissemination to different organs. We present the case of a 30-year-old patient with a de novo diagnosis of human immunodeficiency virus infection and lymphoproliferative disease. Within the laboratory workup, the presence of Strongyloides stercoralis was documented in the bone marrow. Despite having a CD4+ T lymphocyte count greater than 400 cells/microliter and having started treatment for this condition with ivermectin, the patient died due to a septic state associated with hyperinfection syndrome, which is why this is considered an unusual case that alerts the clinician to take into account the presence of the nematode in patients living with HIV.

Diagnostic accuracy of antigen detection in urine and molecular assays testing in different clinical samples for the diagnosis of progressive disseminated histoplasmosis in patients living with HIV/AIDS: A prospective multicenter study in Mexico.

BACKGROUND: The progressive disseminated histoplasmosis (PDH) has been associated with severe disease and high risk of death among people living with HIV (PLWHIV). Therefore, the purpose of this multicenter, prospective, double-blinded study done in ten Mexican hospitals was to determine the diagnostic accuracy of detecting Histoplasma capsulatum antigen in urine using the IMMY ALPHA Histoplasma EIA kit (IAHE), clarus Histoplasma GM Enzyme Immunoassay (cHGEI IMMY) and MiraVista Histoplasma Urine Antigen LFA (MVHUALFA); as well as the Hcp100 and 1281-1283220SCAR nested PCRs in blood, bone-marrow, tissue biopsies and urine. METHODOLOGY/PRINCIPAL FINDINGS: We included 415 PLWHIV older than 18 years of age with suspicion of PDH. Using as diagnostic standard recovery of H. capsulatum in blood, bone marrow or tissue cultures, or histopathological exam compatible, detected 108 patients (26%, [95%CI, 21.78-30.22]) with proven-PDH. We analyzed 391 urine samples by the IAHE, cHGEI IMMY and MVHUALFA; the sensitivity/specificity values obtained were 67.3% (95% CI, 57.4-76.2) / 96.2% (95% CI, 93.2-98.0) for IAHE, 91.3% (95% CI, 84.2-96.0) / 90.9% (95% CI, 87.0-94.0) for cHGEI IMMY and 90.4% (95% CI, 83.0-95.3) / 92.3% (95% CI, 88.6-95.1) for MVHUALFA. The Hcp100 nested PCR was performed on 393, 343, 75 and 297, blood, bone marrow, tissue and urine samples respectively; the sensitivity/specificity values obtained were 62.9% (95%CI, 53.3-72.5)/ 89.5% (95%CI, 86.0-93.0), 65.9% (95%CI, 56.0-75.8)/ 89.0% (95%CI, 85.2-92.9), 62.1% (95%CI, 44.4-79.7)/ 82.6% (95%CI, 71.7-93.6) and 34.9% (95%CI, 24.8-46.2)/ 67.3% (95%CI, 60.6-73.5) respectively; and 1281-1283220SCAR nested PCR was performed on 392, 344, 75 and 291, respectively; the sensitivity/specificity values obtained were 65.3% (95% CI, 55.9-74.7)/ 58.8% (95%CI, 53.2-64.5), 70.8% (95%CI, 61.3-80.2)/ 52.9% (95%CI, 46.8-59.1), 71.4% (95%CI, 54.7-88.2)/ 40.4% (95%CI, 26.4-54.5) and 18.1% (95%CI, 10.5-28.1)/ 90.4% (95%CI, 85.5-94.0), respectively. CONCLUSIONS/SIGNIFICANCE: The cHGEI IMMY and MVHUALFA tests showed excellent performance for the diagnosis of PDH in PLWHIV. The integration of these tests in clinical laboratories will certainly impact on early diagnosis and treatment.

Diagnostic accuracy cohort study and clinical value of the Histoplasma urine antigen (ALPHA Histoplasma EIA) for disseminated histoplasmosis among HIV infected patients: A multicenter study.

BACKGROUND: The Histoplasma urine antigen (HUAg) is the preferred method to diagnose progressive disseminated histoplasmosis (PDH) in HIV patients. In 2007, IMMY ALPHA Histoplasma EIA was approved for clinical for on-site use, and therefore useful for regions outside the United States. However, ALPHA-HUAg is considered inferior to the MVista-HUAg which is only available on referral. We aim to evaluate the diagnostic accuracy of ALPHA-HUAg. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a multicenter, prospective, diagnostic test study in two secondary and eight tertiary-care facilities in Mexico. We included HIV patient with PDH suspicion and evaluated ALPHA-HUAg diagnostic accuracy using as reference standard the Histoplasma capsulatum growth on blood, bone marrow, and tissue cultures or compatible histopathologic exam (PDH-proven). We evaluated the results of 288 patients, 29.5% (85/288; 95% confidence interval [CI], 24.3-35.1) had PDH. The sensitivity of ALPHA-HUAg was 67.1% (95% CI, 56-76.8%) and the specificity was 97.5% (95% CI, 94.3%-99.1%). The positive likelihood ratio was 27.2 (95% CI; 11.6-74.4). In 10.5% of the PDH-proven patients, a co-existing opportunistic infection was diagnosed, mostly disseminated Mycobacterium avium complex infection. CONCLUSIONS/SIGNIFICANCE: We observed a high specificity but low sensitivity of IMMY-HUAg. The test may be useful to start early antifungals, but a culture-based approach is necessary since co-infections are frequent and a negative IMMY-HUAg result does not rule out PDH.

[Smoking and spirometric values in third year medical students: cross-sectional study]. / Estudio transversal sobre tabaquismo y su relación con valores espirométricos en estudiantes de tercer año de medicina.

OBJECTIVE: The aim of this study is to determine frequency of cigarette smoking and its relationship with indicators of lung function, as well as habits and attitudes towards smoking in third-year medical students of the Health Sciences Institute, Héctor A. Barceló Foundation, Santo Tomé, Corrientes, Argentina. METHODS: We performed a cross-sectional and analytic study in third-year medical students, during the first two weeks of October 2014. We divided the study group into smokers and non-smokers and we obtained spirometric values with a computerized Flowmax 2 spirometer following the protocols established by the American Thoracic Society. In addition, we applied a questionnaire to the study group with 36 questions including the Fagerström test. RESULTS: We obtained a mean age of 22.5 ± 3.81 years in 227 students; 52.9% were female and 47.1% male; 26.4% were smokers, predominantly male and with a larger consumption of cigarettes than women; 5% of smokers presented obstructive ventilatory spirometric patterns with a significant association (p = 0.017) with smoking. Twenty-five percent (25%) of male and 8.4% of female showed moderate to high tobacco physical dependence. In the non-smoker group, 18.6% had quit in the previous year or earlier, mostly to improve their health. CONCLUSION: It is important to encourage medical students to quit smoking, as well as to be aware of the harm that second-hand smoke produces. The future physician should be cognizant of the consequences associated with smoking and the importance of preventing and educating patients acting as a role model very early in their studies.

OBJETIVO: El presente estudio tiene por objetivo conocer la frecuencia de tabaquismo y su relación con los indicadores de la función respiratoria, además de los hábitos y las actitudes respecto al consumo de cigarrillos en estudiantes de tercer año de la carrera de Medicina del Instituto Universitario de Ciencias de la Salud, Fundación Héctor A. Barceló, sede Santo Tomé, Corrientes, Argentina. MÉTODOS: Estudio de corte transversal y analítico, con estudiantes de tercer año de la carrera de Medicina, durante las dos primeras semanas de octubre de 2014. Se agruparon en fumadores y no fumadores realizándose la espirometría mediante espirómetro computarizado Flowmax 2, según los parámetros de la Asociación Americana de Tórax. Se aplicó un cuestionario con 36 preguntas incluyendo el test de Fagerström. RESULTADOS: En los 227 alumnos se observó una edad promedio de 22,5 ± 3,81 años siendo el 52,9% mujeres y el 47,1% varones. El 26,4% eran fumadores con predominio de varones y con un mayor consumo de cigarrillos que las mujeres. Un 5% de los fumadores presentó patrón espirométrico obstructivo con una asociación significativa (p = 0,017) entre el fumar y la alteración espirométrica. El 25% de los varones y el 8,4% de las mujeres, presentaron un grado de dependencia física media o alta al tabaco. El 18,6% de los no fumadores habían dejado de fumar desde hace un año o más principalmente para mejorar su salud. CONCLUSIÓNES: Es importante incentivar a los estudiantes a dejar de fumar, así como la toma de conciencia de que fumar cerca de otras personas o estar cerca de fumadores es perjudicial para la salud. El futuro médico debe conocer las consecuencias asociadas al hábito de fumar y la importancia de prevenir y concientizar a los pacientes actuando como modelo a seguir desde los inicios en sus estudios de la Medicina.

Comparison of users of an HIV/syphilis screening community-based mobile van and traditional voluntary counselling and testing sites in Guatemala.

OBJECTIVES: The use of a mobile van (MV) for screening for HIV and other sexually transmitted infections (STIs) is effective at reaching at-risk populations. The aim of this study was to compare behaviour characteristics and HIV and syphilis prevalence between subjects tested at a MV offering voluntary counselling and testing and those tested at three STI clinics in Guatemala. METHODS: Over 28 months, female sex workers (FSWs), men who have sex with men/transgenders (MSM/TG), and people not reporting being a member of a risk group (NR) were offered HIV and syphilis rapid tests and interviewed about their sociodemographic and risk behaviour. RESULTS: 2874 subjects were tested (MV, 1336 (46%); clinics, 1538 (54%)). The MV screened 73% of FSWs and 73% of the MSM/TG, and detected 19% of HIV and 69% of syphilis cases. HIV prevalence was significantly higher (p<0.001) at the STI clinics than at the MV for both NR and MSM/TG groups (NR, 7% vs 1%; MSM/TG, 8% vs 1%, respectively). A significantly higher proportion of MSM/TG screened at the STI clinic reported having had a prior HIV test (MV, 21%; clinics, 41%; p<0.001), whereas more FSWs tested in the MV reported having multiple partners and using condoms during their last sexual intercourse. CONCLUSIONS: The higher prevalence of HIV and syphilis at the STI clinics suggests that they successfully identified high-risk subjects. In particular, the NR group showed higher than expected HIV and syphilis prevalence. Innovative approaches such as the use of a MV helped to increase access to other hard-to-reach groups such as MSM/TG and FSWs.

The UALE Project: decline in the incidence of HIV and sexually transmitted infections and increase in the use of condoms among sex workers in Guatemala.

OBJECTIVES: To assess the impact of a multilevel sexually transmitted infections (STI)/HIV prevention and treatment intervention on the incidence of STIs and HIV, the use of condoms, and HIV knowledge among sex workers (SWs). METHODS: An open-enrolment cohort of 1554 SWs attending STI clinics integrated within the primary health care system of Escuintla, Guatemala. They were offered 6 monthly STI/HIV screening, condom promotion, education, and community-based interventions. We evaluated trends in condom use, HIV-related knowledge, and STI/HIV incidence using generalized estimating equations. RESULTS: For over three and a half years, there was a significant increase in the proportion of consistent condom use from the baseline visit through the third follow-up visit (94.29%-99.11% with new clients and 90.36%-97.22% with regular clients) and in HIV-related knowledge (95.99%-97.22%). Except for syphilis, we observed a significant decline in gonorrhoea, chlamydia, trichomoniasis, and candidiasis in each follow-up visit, from 11.30 per 100 person-years, 10.71 per 100 person-years, 6.88 per 100 person-years, and 8.23 per 100 person-years in the first follow-up visit to 6.44 per 100 person-years, 6.21 per 100 person-years, 4.81 per 100 person-years, and 6.17 per 100 person-years in the third follow-up visit, for each STI, respectively. HIV global incidence was 0.41 per 100 person-years, and it significantly declined from 1.85 per 100 person-years (2005) to 0.42 per 100 person-years (2008). CONCLUSIONS: Although a longer follow-up would be needed, the results suggest that the intervention was feasible and has been shown to be effective in reducing STI and HIV incidence and in increasing condom use with clients and HIV-related knowledge.

Reproductive health and healthcare among sex workers in Escuintla, Guatemala.

This study examines understandings of sexual and reproductive health and healthcare, and perceptions of health services among women who regularly or occasionally sell or transact sex in Escuintla, Guatemala. Using an approach informed by grounded theory, 35 individual interviews were analysed. Results suggest that sex workers face multiple forms of vulnerability due to their level of education, economic situation and unequal gender relations. Many feel dissatisfied with the quality of health services received, specifically with the lack of medicines, poor personal treatment by health workers and scanty information. Condoms were widely acknowledged as the means of preventing STI/HIV; however, many of the women do not use them with regular clients and regular partners. An effective STI/HIV-prevention strategy that addresses sex workers' circumstances and needs, requires a comprehensive approach, which includes a combination of individual and community-based interventions. These interventions must involve clients, sex establishment owners and health personnel.

Estudio multicéntrico centroamericano de prevalencia de VIH/ITS y comportamiento en trabajadoras comerciales del sexo en Panamá: EMC: Equipo multidisciplinario en salud sexual y reproductiva: EMESSAR / Central American study of cities of prevalence of VIH/ITS and behavior in commercial workers of sex in Panama

En el estudio se aplicó a una muestra de 432 trabajadoras comerciales del sexo para determinar la prevalencia de VIH e ITS (sífilis, gonorrea, herpes y clamidia); identificar características sociodemográficas y determinar patrones de comportamiento de riesgos