[Brazilian guidelines for the clinical management of paracoccidioidomycosis]. / II Consenso Brasileiro em Paracoccidioidomicose - 2017.

Paracoccidioidomycosis is a systemic fungal disease associated with agricultural activities. Its incidence and prevalence are underestimated because of the lack of reporting in several Brazilian states. If paracoccidiodomycosis is not diagnosed and treated early and adequately, endemic fungal infection may result in serious sequelae. In addition to the Paracoccidioides brasiliensis (P. brasiliensis) complex, the appearance of a new species, Paracoccidioides lutzii (P. lutzii), in Rondônia state, where the disease has reached epidemic levels, and in the country's Midwest region and Pará state, are challenges to diagnosis and to the urgent availability of antigens that are reactive with patients' sera. These guidelines aim to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. The guidelines provide data on etiology, epidemiology, immunopathogenesis, diagnosis, treatment and sequelae, with emphasis on diagnosis and treatment, as well as current recommendations and challenges in this field of knowledge.

A paracoccidioidomicose (PCM) é uma micose sistêmica, relacionada às atividades agrícolas, com incidência e prevalência subestimadas, pela ausência de notificação em várias Unidades da Federação (UFs). A evolução insidiosa do quadro clínico pode ter como consequência sequelas graves se o diagnóstico e o tratamento não forem instituídos precoce e adequadamente. Ao lado do complexo Paracoccidioides brasiliensis (P. brasiliensis), a descrição de nova espécie, Paracoccidioides lutzii (P. lutzii), em Rondônia, onde a doença alcançou níveis epidêmicos, bem como na região Centro-Oeste e no Pará, constituem-se em desafios para a instituição do diagnóstico e a urgente disponibilização de antígenos que tenham reatividade com os soros dos pacientes. Este consenso visa atualizar o primeiro consenso brasileiro em PCM, estabelecendo recomendações para o manejo clínico do paciente, com base nas evidências conhecidas. São apresentados dados de etiologia, epidemiologia, imunopatogenia, diagnóstico, terapêutica e sequelas, enfatizando-se o diagnóstico e a terapêutica, bem como recomendações e desafios atuais nessa área do conhecimento.

La paracoccidioidomicosis es una micosis sistémica, relacionada con las actividades agrícolas, con incidencia y prevalencia subestimadas por la ausencia de notificación en varios estados. La evolución insidiosa del cuadro clínico puede tener como consecuencia secuelas graves si el diagnóstico y el tratamiento no se establecen precoz y adecuadamente. Al lado del complejo Paracoccidioides brasiliensis (P. brasiliensis), la descripción de nueva especie, Paracoccidioides lutzii (P. lutzii) en Rondonia, donde la enfermedad alcanzó niveles epidémicos, y en la región Centro Oeste y en Pará, se constituyen en desafíos para la institución del diagnóstico y la urgente puesta a disposición de antígenos que tengan reactividad con los sueros de los pacientes. El presente consenso tiene por objeto actualizar el primer consenso brasileño en paracoccidioidomicosis, estableciendo recomendaciones para el manejo del paciente al borde del lecho, con base en las evidencias conocidas. Se presentan datos de etiología, epidemiología, inmunopatogenia, diagnóstico, terapéutica y secuelas, enfatizando el diagnóstico y terapéutica, así como recomendaciones desafíos y actuales en esta área del conocimiento.

II Consenso Brasileiro em Paracoccidioidomicose ­ 2017 / Brazilian guidelines for the clinical management of paracoccidioidomycosis / Brazilian guidelines for the clinical management of paracoccidioidomycosis / II Consenso Brasileño en la paracoccidioidomicosis, 2017

A paracoccidioidomicose (PCM) é uma micose sistêmica, relacionada às atividades agrícolas, com incidência e prevalência subestimadas, pela ausência de notificação em várias Unidades da Federação (UFs). A evolução insidiosa do quadro clínico pode ter como consequência sequelas graves se o diagnóstico e o tratamento não forem instituídos precoce e adequadamente. Ao lado do complexo Paracoccidioides brasiliensis (P. brasiliensis), a descrição de nova espécie, Paracoccidioides lutzii (P. lutzii), em Rondônia, onde a doença alcançou níveis epidêmicos, bem como na região Centro-Oeste e no Pará, constituem-se em desafios para a instituição do diagnóstico e a urgente disponibilização de antígenos que tenham reatividade com os soros dos pacientes. Este consenso visa atualizar o primeiro consenso brasileiro em PCM, estabelecendo recomendações para o manejo clínico do paciente, com base nas evidências conhecidas. São apresentados dados de etiologia, epidemiologia, imunopatogenia, diagnóstico, terapêutica e sequelas, enfatizando-se o diagnóstico e a terapêutica, bem como recomendações e desafios atuais nessa área do conhecimento

Paracoccidioidomycosis is a systemic fungal disease associated with agricultural activities. Its incidence and prevalence are underestimated because of the lack of reporting in several Brazilian states. If paracoccidiodomycosis is not diagnosed and treated early and adequately, endemic fungal infection may result in serious sequelae. In addition to the Paracoccidioides brasiliensis (P. brasiliensis) complex, the appearance of a new species, Paracoccidioides lutzii (P. lutzii), in Rondônia state, where the disease has reached epidemic levels, and in the country's Midwest region and Pará state, are challenges to diagnosis and to the urgent availability of antigens that are reactive with patients' sera. These guidelines aim to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. The guidelines provide data on etiology, epidemiology, immunopathogenesis, diagnosis, treatment and sequelae, with emphasis on diagnosis and treatment, as well as current recommendations and challenges in this field of knowledge

La paracoccidioidomicosis es una micosis sistémica, relacionada con las actividades agrícolas, con incidencia y prevalencia subestimadas por la ausencia de notificación en varios estados. La evolución insidiosa del cuadro clínico puede tener como consecuencia secuelas graves si el diagnóstico y el tratamiento no se establecen precoz y adecuadamente. Al lado del complejo Paracoccidioides brasiliensis (P. brasiliensis), la descripción de nueva especie, Paracoccidioides lutzii (P. lutzii) en Rondonia, donde la enfermedad alcanzó niveles epidémicos, y en la región Centro Oeste y en Pará, se constituyen en desafíos para la institución del diagnóstico y la urgente puesta a disposición de antígenos que tengan reactividad con los sueros de los pacientes. El presente consenso tiene por objeto actualizar el primer consenso brasileño en paracoccidioidomicosis, estableciendo recomendaciones para el manejo del paciente al borde del lecho, con base en las evidencias conocidas. Se presentan datos de etiología, epidemiología, inmunopatogenia, diagnóstico, terapéutica y secuelas, enfatizando el diagnóstico y terapéutica, así como recomendaciones desafíos y actuales en esta área del conocimiento

Brazilian guidelines for the clinical management of paracoccidioidomycosis

Abstract Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America that is associated with rural environments and agricultural activities. However, the incidence and prevalence of paracoccidiodomycosis is underestimated because of the lack of compulsory notification. If paracoccidiodomycosis is not diagnosed and treated early and adequately, the endemic fungal infection could result in serious sequelae. While the Paracoccidioides brasiliensis ( P. brasiliensis ) complex has been known to be the causal agent of paracoccidiodomycosis, a new species, Paracoccidioides lutzii ( P. lutzii ), has been reported in Rondônia, where the disease has reached epidemic levels, and in the Central West and Pará. Accurate diagnoses and availability of antigens that are reactive with the patients' sera remain significant challenges. Therefore, the present guidelines aims to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. This consensus summarizes etiological, ecoepidemiological, molecular epidemiological, and immunopathological data, with emphasis on clinical, microbiological, and serological diagnosis and management of clinical forms and sequelae, as well as in patients with comorbidities and immunosuppression. The consensus also includes discussion of outpatient treatments, severe disease forms, disease prevalence among special populations and resource-poor settings, a brief review of prevention and control measures, current challenges and recommendations.

Brazilian guidelines for the clinical management of paracoccidioidomycosis.

Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America that is associated with rural environments and agricultural activities. However, the incidence and prevalence of paracoccidiodomycosis is underestimated because of the lack of compulsory notification. If paracoccidiodomycosis is not diagnosed and treated early and adequately, the endemic fungal infection could result in serious sequelae. While the Paracoccidioides brasiliensis ( P. brasiliensis ) complex has been known to be the causal agent of paracoccidiodomycosis, a new species, Paracoccidioides lutzii ( P. lutzii ), has been reported in Rondônia, where the disease has reached epidemic levels, and in the Central West and Pará. Accurate diagnoses and availability of antigens that are reactive with the patients' sera remain significant challenges. Therefore, the present guidelines aims to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. This consensus summarizes etiological, ecoepidemiological, molecular epidemiological, and immunopathological data, with emphasis on clinical, microbiological, and serological diagnosis and management of clinical forms and sequelae, as well as in patients with comorbidities and immunosuppression. The consensus also includes discussion of outpatient treatments, severe disease forms, disease prevalence among special populations and resource-poor settings, a brief review of prevention and control measures, current challenges and recommendations.

Prevalence and factors associated with Chlamydia trachomatis infection among women with HIV in São Paulo.

INTRODUCTION: This study aimed to estimate the prevalence and risk factors associated with Chlamydia trachomatis (CT) infection among women with HIV in São Paulo. METHODS: This cross-sectional study included women with HIV who were receiving care from sixteen public health services in São Paulo (October 2013 to March 2014). All participants answered a questionnaire regarding their sociodemographic, behavioral, and clinical characteristics. A urine sample was tested for CT and Neisseria gonorrhoeae (NG) using the polymerase chain reaction. The chi-square test and a logistic regression model were used to test the associations with CT or NG infections. RESULTS: We evaluated 853 women and ultimately included 836 (98%) women. The mean age was 40.5 ± 0.34 years, and the prevalences of CT and NG infections were 1.8% and 0.5%, respectively. CT infection was associated with CD4+ T-cell counts of <350 cells/mm3 [adjusted odds ratio (ORadj): 24.5], age of 18-25 years (ORadj: 23.2), the non-use of condoms during the last 6 months (ORadj: 10.2), a self-reported history of a sexually transmitted infection (ORadj: 9.4), and having two or more sexual partners during the last year (ORadj: 6.1). CONCLUSIONS: Although we observed a low prevalence of CT infection among women with HIV, younger age was associated with a high risk of infection. Therefore, it may be appropriate to include screening for CT as part of the routine care for this population.

Prevalence and factors associated with Chlamydia trachomatis infection among women with HIV in São Paulo

Abstract: INTRODUCTION: This study aimed to estimate the prevalence and risk factors associated with Chlamydia trachomatis (CT) infection among women with HIV in São Paulo. METHODS: This cross-sectional study included women with HIV who were receiving care from sixteen public health services in São Paulo (October 2013 to March 2014). All participants answered a questionnaire regarding their sociodemographic, behavioral, and clinical characteristics. A urine sample was tested for CT and Neisseria gonorrhoeae (NG) using the polymerase chain reaction. The chi-square test and a logistic regression model were used to test the associations with CT or NG infections. RESULTS: We evaluated 853 women and ultimately included 836 (98%) women. The mean age was 40.5 ± 0.34 years, and the prevalences of CT and NG infections were 1.8% and 0.5%, respectively. CT infection was associated with CD4+ T-cell counts of <350 cells/mm3 [adjusted odds ratio (ORadj): 24.5], age of 18-25 years (ORadj: 23.2), the non-use of condoms during the last 6 months (ORadj: 10.2), a self-reported history of a sexually transmitted infection (ORadj: 9.4), and having two or more sexual partners during the last year (ORadj: 6.1). CONCLUSIONS: Although we observed a low prevalence of CT infection among women with HIV, younger age was associated with a high risk of infection. Therefore, it may be appropriate to include screening for CT as part of the routine care for this population.

Incubation period and early natural history events of the acute form of paracoccidioidomycosis: Lessons from patients with a single paracoccidioides spp. exposure

Several aspects of the natural history of paracoccidioidomycosis are still poorly understood. Different from the most prevalent, chronic form of the disease, the acute form represents a continuum from the initial respiratory infection to the full-blown disease, thus providing an opportunity to elucidate the pathogenesis of the early phase of this mycosis. We describe, for the first time, two patients with a single time point exposure to Paracoccidioides spp., for whom we were able to determine the time lapsed between exposure to the fungus Paracoccidioides spp. and the onset of signs and symptoms. In case 1, the pulmonary infection was unapparent, and the first manifestations of the acute/subacute form of the disease presented 4 months after Paracoccidioides spp. exposure. In case 2, self-limited, non-specific respiratory and systemic symptoms presented 45 days after infection. Thus, our patients confirm that, within a few weeks of infection, Paracoccidioides spp. affects the pulmonary lymphatic system and initially causes no or mild-to-moderate self-limited symptoms, eventually causing abnormalities on a chest X-ray, all of which spontaneously subside. These cases provide some insight into the natural history of this mycosis, the extent of the host exposure to the fungus, and the determination of its incubation period

Incubation Period and Early Natural History Events of the Acute Form of Paracoccidioidomycosis: Lessons from Patients with a Single Paracoccidioides spp. Exposure.

UNLABELLED: Several aspects of the natural history of paracoccidioidomycosis are still poorly understood. Different from the most prevalent, chronic form of the disease, the acute form represents a continuum from the initial respiratory infection to the full-blown disease, thus providing an opportunity to elucidate the pathogenesis of the early phase of this mycosis. We describe, for the first time, two patients with a single time point exposure to Paracoccidioides spp., for whom we were able to determine the time lapsed between exposure to the fungus Paracoccidioides spp. and the onset of signs and symptoms. In case 1, the pulmonary infection was unapparent, and the first manifestations of the acute/subacute form of the disease presented 4 months after Paracoccidioides spp. EXPOSURE: In case 2, self-limited, non-specific respiratory and systemic symptoms presented 45 days after infection. Thus, our patients confirm that, within a few weeks of infection, Paracoccidioides spp. affects the pulmonary lymphatic system and initially causes no or mild-to-moderate self-limited symptoms, eventually causing abnormalities on a chest X-ray, all of which spontaneously subside. These cases provide some insight into the natural history of this mycosis, the extent of the host exposure to the fungus, and the determination of its incubation period.

CHAGASIC MENINGOENCEPHALITIS IN AN HIV INFECTED PATIENT WITH MODERATE IMMUNOSUPPRESSION: PROLONGED SURVIVAL AND CHALLENGES IN THE HAART ERA / Meningoencefalite chagásica em paciente infectada pelo HIV com imunodepressão moderada: desafios na era HAART e sobrevida prolongada

The reactivation of Chagas disease in HIV infected patients presents high mortality and morbidity. We present the case of a female patient with confirmed Chagasic meningoencephalitis as AIDS-defining illness. Interestingly, her TCD4+ lymphocyte cell count was 318 cells/mm3. After two months of induction therapy, one year of maintenance with benznidazol, and early introduction of highly active antiretroviral therapy (HAART), the patient had good clinical, parasitological and radiological evolution. We used a qualitative polymerase chain reaction for the monitoring of T. cruzi parasitemia during and after the treatment. We emphasize the potential value of molecular techniques along with clinical and radiological parameters in the follow-up of patients with Chagas disease and HIV infection. Early introduction of HAART, prolonged induction and maintenance of antiparasitic therapy, and its discontinuation are feasible, in the current management of reactivation of Chagas disease.

A reativação da doença de Chagas em pacientes com a infecção pelo HIV apresenta uma alta morbidade e mortalidade. Neste relato, apresentamos caso confirmado de meningoencefalite chagásica, como doença definidora de aids, em paciente com 318 linfócitos T-CD4+/mm3. Após 2 meses de tratamento seguido de um ano de profilaxia secundária com benzonidazol e início precoce de terapia antirretroviral (HAART), a paciente apresentou boa evolução clínica, parasitológica e radiológica. Utilizamos a reação em cadeia da polimerase qualitativa do T. cruzi, para monitorização da parasitemia por T. cruzi durante e após o tratamento. Ressaltamos o valor potencial das técnicas moleculares associadas aos parâmetros clínicos e radiológicos nos pacientes com doença de Chagas e infecção pelo HIV. A introdução precoce da terapia antirretroviral, a terapia antiparasitária prolongada, manutenção e descontinuação da mesma, são desafios atuais, embora possíveis, no manejo da reativação da doença de Chagas na era das terapias antirretrovirais de alta eficácia.

Abdominal alterations in disseminated paracoccidioidomycosis: computed tomography findings.

OBJECTIVE: To evaluate the incidence and spectrum of abdominal computed tomography imaging findings in patients with paracoccidioidomycosis. MATERIALS AND METHODS: Retrospective analysis of abdominal computed tomography images of 26 patients with disseminated paracoccidioidomycosis. RESULTS: Abnormal abdominal tomographic findings were observed in 18 patients (69.2%), while no significant finding was observed in the other 8 (30.8%) patients. CONCLUSION: Computed tomography has demonstrated to play a relevant role in the screening and detection of abdominal abnormalities in patients with disseminated paracoccidioidomycosis.

OBJETIVO: Avaliar a frequência e variedade de achados de imagem por exames de tomografia computadorizada de abdome em indivíduos com paracoccidioidomicose disseminada. MATERIAIS E MÉTODOS: Estudo retrospectivo dos exames de tomografia computadorizada de abdome de 26 pacientes com paracoccidioidomicose disseminada. RESULTADOS: Foram encontradas alterações tomográficas abdominais em 18 pacientes (69,2%) dos casos analisados e 8 pacientes (30,8%) apresentaram exames normais. CONCLUSÃO: A tomografia computadorizada de abdome mostrou grande importância no rastreamento e identificação de alterações abdominais nos pacientes com paracoccidioidomicose disseminada.

Factors associated with a delay in seeking HIV/AIDS treatment in São Paulo, Brazil

This quantitative cross-sectional study of HIV/AIDS patients (N = 1,520) in São Paulo evaluated factors associated with a delay in seeking care. Analysis included Chi square tests and multiple logistic regression. Care was sought at the AIDS stage in 56.7 % (861) of patients, and 48.2 % (732) had a CD4 count ≤350 cells/mm(3); 9 % (136) delayed seeking care for 6 months or more after a positive HIV test. Women sought medical care earlier after testing (odds ratio (OR) = 1.79; P = 0.0227), but were already symptomatic (OR = 1.90; P = 0.0004). Partners of seropositive patients (OR = 3.92; P = 0.0000) also sought care symptomatic. Reasons for late presentation for care were non-acceptance of HIV diagnosis (OR = 24.56; P = 0.0000), treatment refusal (OR = 55.34; P = 0.0000), and physical disability (OR = 1.90; P = 0.0414). Necessary strategies for HIV treatment and prevention include improved education and access to services

Abdominal alterations in disseminated paracoccidioidomycosis: computed tomography findings / Alterações abdominais da paracoccidioidomicose disseminada: achados por tomografia computadorizada

Objective: To evaluate the incidence and spectrum of abdominal computed tomography imaging findings in patients with paracoccidioidomycosis. Materials and Methods: Retrospective analysis of abdominal computed tomography images of 26 patients with disseminated paracoccidioidomycosis. Results: Abnormal abdominal tomographic findings were observed in 18 patients (69.2%), while no significant finding was observed in the other 8 (30.8%) patients. Conclusion: Computed tomography has demonstrated to play a relevant role in the screening and detection of abdominal abnormalities in patients with disseminated paracoccidioidomycosis. .

Objetivo: Avaliar a frequência e variedade de achados de imagem por exames de tomografia computadorizada de abdome em indivíduos com paracoccidioidomicose disseminada. Materiais e Métodos: Estudo retrospectivo dos exames de tomografia computadorizada de abdome de 26 pacientes com paracoccidioidomicose disseminada. Resultados: Foram encontradas alterações tomográficas abdominais em 18 pacientes (69,2%) dos casos analisados e 8 pacientes (30,8%) apresentaram exames normais. Conclusão: A tomografia computadorizada de abdome mostrou grande importância no rastreamento e identificação de alterações abdominais nos pacientes com paracoccidioidomicose disseminada. .

Factors associated with a delay in seeking HIV/AIDS treatment in São Paulo, Brazil.

This quantitative cross-sectional study of HIV/AIDS patients (N = 1,520) in São Paulo evaluated factors associated with a delay in seeking care. Analysis included Chi square tests and multiple logistic regression. Care was sought at the AIDS stage in 56.7 % (861) of patients, and 48.2 % (732) had a CD4 count ≤350 cells/mm(3); 9 % (136) delayed seeking care for 6 months or more after a positive HIV test. Women sought medical care earlier after testing (odds ratio (OR) = 1.79; P = 0.0227), but were already symptomatic (OR = 1.90; P = 0.0004). Partners of seropositive patients (OR = 3.92; P = 0.0000) also sought care symptomatic. Reasons for late presentation for care were non-acceptance of HIV diagnosis (OR = 24.56; P = 0.0000), treatment refusal (OR = 55.34; P = 0.0000), and physical disability (OR = 1.90; P = 0.0414). Necessary strategies for HIV treatment and prevention include improved education and access to services.

CHAGASIC MENINGOENCEPHALITIS IN AN HIV INFECTED PATIENT WITH MODERATE IMMUNOSUPPRESSION: PROLONGED SURVIVAL AND CHALLENGES IN THE HAART ERA.

The reactivation of Chagas disease in HIV infected patients presents high mortality and morbidity. We present the case of a female patient with confirmed Chagasic meningoencephalitis as AIDS-defining illness. Interestingly, her TCD4+ lymphocyte cell count was 318 cells/mm3. After two months of induction therapy, one year of maintenance with benznidazol, and early introduction of highly active antiretroviral therapy (HAART), the patient had good clinical, parasitological and radiological evolution. We used a qualitative polymerase chain reaction for the monitoring of T. cruzi parasitemia during and after the treatment. We emphasize the potential value of molecular techniques along with clinical and radiological parameters in the follow-up of patients with Chagas disease and HIV infection. Early introduction of HAART, prolonged induction and maintenance of antiparasitic therapy, and its discontinuation are feasible, in the current management of reactivation of Chagas disease.

Toxoplasmose gástrica em paciente infectado pelo vírus da imunodeficiência humana. Relato de caso / Gastric toxoplasmosis in patient infected with human immunodeficiency virus. Case report

A toxoplasmose é uma zoonose altamente disseminada. A maio­ria das infecções em imunocompetentes é assintomática. Porém, em pacientes imunodeprimidos, a infecção adquire um curso variável. Em pacientes com contagem de CD4 abaixo de 100 e que foram previamente expostos ao Toxoplasma gondii, pode haver reativação da doença em diversos tecidos. Envolvimento do trato gastrintestinal por Toxoplasma gondii é raramente relatado. Embora os sintomas gastrintestinais sejam comuns entre os pacientes com síndrome da imunodeficiência adquirida, a maioria é causada por infecções entéricas que não o Toxoplasma gondii. O objetivo deste estudo foi relatar um caso raro de toxoplasmose gástrica. Paciente do gênero feminino, 38 anos, com diagnóstico recente de vírus da imunodeficiência humana, iniciou sintomas gástricos inespecíficos como: epigastralgia, náuseas, vômitos e perda ponderal. O diagnóstico definitivo foi fechado com o estudo anatomopatológico da lesão na mucosa gástrica. Foi instituído tratamento para a toxoplasmose com clindamicina, pirimetamina e ácido folínico (devido à mielotoxicidade), com melhora parcial dos sintomas. Embora raro, a toxoplasmose gástrica deve entrar no diagnóstico diferencial de dor epigástrica em pacientes portadores da síndrome da imunodeficiência adquirida com contagem de CD4 baixa. Seu diagnóstico pre­suntivo pode ser dado pelo quadro clínico, mas o diagnóstico definitivo é obtido pela biópsia da lesão...

Toxoplasmosis is a highly disseminated zoonosis. Most infections are asymptomatic in immunocompetent patients. However, in immunocompromised patients, infection acquires a variable course. In patients with CD4 counts lower than 100 and who have been previously exposed to Toxoplasma gondii, there may be reactivation of the disease in various tissues. Involvement of the gastrointestinal tract by Toxoplasma gondii is rarely reported. Although gastrointestinal symptoms are common among patients with acquired immunodeficiency syndrome, most are caused by enteric infections other than Toxoplasma gondii. The aim of this study was to report a rare case of gastric toxoplasmosis. A 38-year-­old female patient, recently diagnosed with immunodeficiency human virus, presented with nonspecific gastric symptoms such as epigastric pain, nausea, vomiting and weight loss. The definitive diagnosis was reached with anatomopathological examination of gastric mucosa damage. She was treated for toxoplasmosis with clindamycin, pyrimethamine and folinic acid (due to myelotoxicity), with partial improvement of symptoms. Although rare, gastric toxoplasmosis should enter the differential diagnosis of epigastric pain in patients with acquired immunodeficiency syndrome with low CD4 count. Its presumptive diagnosis can be made on a clinical basis, but the definitive diagnosis is reached with biopsy...