Cutaneous Tuberculosis in Heart Transplant.

Tuberculosis is a disease with a significant global burden in terms of morbidity and mortality. It usually presents as a pulmonary disease but can occasionally have extrapulmonary presentations. Immunosuppressed people are at an increased risk of tuberculosis and more frequently have atypical manifestations of the disease. Cutaneous involvement is estimated to occur in only 2% of extrapulmonary presentations. We report a case of a heart transplant recipient with disseminated tuberculosis who initially presented with cutaneous manifestations in the form of multiple abscesses that were mistaken for a community-acquired bacterial infection. The diagnosis was made after positive nucleic acid amplification testing and cultures for Mycobacterium tuberculosis from the drainage of the abscesses. After initiating antituberculous treatment, the patient had 2 instances of immune reconstitution inflammatory syndrome. A combination of diminished immunosuppression due to discontinuation of mycophenolate mofetil in the setting of acute infection, rifampin drug interactions with cyclosporine, and the beginning of treatment of tuberculosis all contributed to this paradoxical worsening. The patient responded favorably to increased glucocorticoid therapy and showed no signs of treatment failure after 6 months of antituberculous therapy.

Mononeuritis multiplex: an uncommon neurological manifestation of cytomegalovirus reactivation in an HIV-infected patient.

BACKGROUND: Cytomegalovirus (CMV) reactivation with neurological involvement in patients with acquired immunodeficiency syndrome (AIDS) is increasingly rare since the introduction of antiretroviral therapy (ART). Manifestations include encephalitis, myelitis, polyradiculopathy and, less commonly, mononeuritis multiplex (MNM). We report a case of disseminated CMV disease with gastrointestinal and peripheral and central nervous system involvement in a patient with AIDS, manifesting primarily as MNM. CASE PRESENTATION: A 31-year old woman with AIDS presented with a clinical picture of MNM. Electromyography confirmed the clinical findings. CMV DNA was detected in cerebrospinal fluid (CSF) and blood. Gastrointestinal involvement was histologically documented. HIV RNA was also detected in CSF and brain MRI was consistent with HIV encephalopathy. A diagnosis of disseminated CMV disease (with esophagitis, colitis, encephalitis and MNM) and HIV encephalopathy was made. Treatment consisted of ganciclovir and foscarnet, followed by maintenance therapy with valganciclovir. Evolution was favorable and valganciclovir was stopped after sustained immune recovery following ART initiation. CONCLUSION: We discuss the diagnostic approach to CMV neurological disease, with a focus on MNM and CMV encephalitis. Combination therapy with ganciclovir and foscarnet should be considered for all forms of neurological involvement, although available data are scarce. Since there is significant overlap between CMV encephalitis and HIV encephalopathy, ART drugs with higher CSF penetration may have to be considered. ART and immune recovery are essential to improve outcomes.

Plasmodium spp. and Borrelia burgdorferi co-infection associated with antiphospholipid syndrome in a returned traveler: a case report.

The differential diagnosis of fever in a returned traveler is wide and challenging. We present a case of a patient working in Africa, who returned with fever, constitutional symptoms, headache, and blurred vision. An initial diagnosis of malaria was made, and additional workup revealed Borrelia burgdorferi co-infection and antiphospholipid syndrome.

Clinical and Radiological Characterization of Progressive Multifocal Leukoencephalopathy in HIV-Infected Patients: A Retrospective Analysis and Review of the Literature.

INTRODUCTION: Progressive multifocal leukoencephalopathy is a demyelinating disease of the central nervous system caused by John Cunningham virus, mostly associated with immunodeficiency conditions, such as the human immunodeficiency virus infection. Progressive multifocal leukoencephalopathy can have multiple clinical features and usually presents a typical lesion pattern on brain magnetic resonance imaging. Its course may be rapidly progressive, although immunological responsiveness can be associated with an improved prognosis. MATERIAL AND METHODS: We performed a retrospective analysis of the clinical and radiological data from patients admitted in our institution between January 2005 and April 2014 with the diagnosis of definitive progressive multifocal leukoencephalopathy (ICD10:A81.2) in the setting of human immunodeficiency virus infection. RESULTS: Twenty-one patients were included in our study, mostly men (n = 20, 95.2%). Mean age at diagnosis was 39 years. Motor deficits were the most common clinical finding. John Cunningham virus-DNA was detected in the cerebral spinal fluid in 20 patients (95.2%). Brain imaging studies most commonly disclosed bilateral supratentorial, asymmetric lesions. Four (19%) patients developed immune reconstitution inflammatory syndrome in the follow-up. Therapeutic approach included initiation and continuation/optimization of antiretroviral therapy, with adjunctive therapy with corticosteroids in four patients. Seventeen (81%) patients died during the study period; median survival time following progressive multifocal leukoencephalopathy diagnosis was 3 months (range 1 - 13). DISCUSSION: The results of our study are in accordance with the data previously published on progressive multifocal leukoencephalopathy in human immunodeficiency virus patients. Progressive multifocal leukoencephalopathy is predominantly associated with severe immunosuppression, particularly in patients who are not under anti-retroviral therapy, and usually presents with motor and cognitive symptoms and signs. A typical bilateral asymmetric pattern in conventional magnetic resonance imaging is present in the majority of the patients. There is no specific therapy for progressive multifocal leukoencephalopathy and it is usually fatal, although outcomes can improve with highly active anti-retroviral therapy. Immune reconstitution inflammatory syndrome is also an important complication related with progressive multifocal leukoencephalopathy, usually associated with anti-retroviral therapy. Progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome presents with different imaging characteristics from progressive multifocal leukoencephalopathy and treatment with steroids can improve survival. CONCLUSION: The mortality rate and long-term neurological morbidity associated with progressive multifocal leukoencephalopathy are quite high. These data should increase clinician awareness to the occurrence of progressive multifocal leukoencephalopathy among human immunodeficiency virus patients and highlight the important role of magnetic resonance imaging, as early diagnosis may beassociated with better outcome.

Introdução: A leucoencefalopatia multifocal progressiva é uma patologia desmielinizante causada pelo vírus John Cunningham, geralmente associada a estados de imunodepressão, em particular a infeção pelo vírus da imunodeficiência humana. Pode apresentar múltiplas manifestações clínicas e tem habitualmente um padrão imagiológico típico. A evolução clínica é geralmente progressiva, podendo ocorrer uma melhoria do prognóstico associada à recuperação imunológica.Material e Métodos: Foi conduzida uma análise retrospetiva dos dados clínicos e imagiológicos de doentes admitidos no nosso Hospital entre janeiro de 2005 e abril de 2014 com o diagnóstico de leucoencefalopatia multifocal progressiva (ICD10:A81.2) associado a infeção por vírus da imunodeficiência humana.Resultados: Vinte e um doentes foram incluídos, sendo 20 do sexo masculino (95,2%). A idade média na altura do diagnóstico foi 39 anos. A forma de apresentação mais frequente foi défice motor. O vírus John Cunningham foi identificado no líquido cefalorraquidiano em 20 doentes (95,2%). Nos estudos de imagem verificou-se um predomínio de lesões supratentoriais, assimétricas e bilaterais. Quatro doentes (19%) desenvolveram síndrome inflamatória de resposta imunológica. A abordagem terapêutica incluiu início ou otimização de terapêutica anti-retrovirica, associada a corticoterapia em quatro casos. Dezassete (81%) doentes morreram no período do estudo, sendo a sobrevida mediana após diagnóstico de três meses (intervalo 1 a13).Discussão: Os resultados do nosso estudo são concordantes com os dados previamente publicados relativamente à leucoencefalopatia multifocal progressiva, evidenciando a sua associação à infecção pelo vírus da imunodeficiência humana, particularmente nos doentes com imunossupressão grave, o predomínio de sinais e sintomas motores e cognitivos, e a existência de um atingimento bilateral e assimétrico evidente nas sequências convencionais dos estudos de ressonância magnética. Não existe terapêutica específica e esta patologia é normalmente fatal, apesar de se verificar um aumento da sobrevida associado à terapêutica anti-retrovírica. A síndrome inflamatória de reconstituição imunológica é uma complicação associada a leucoencefalopatia multifocal progressiva, habitualmente ocorrendo após início de terapêutica anti-retrovírica, apresentando caraterísticas imagiológicas diferentes da leucoencefalopatia multifocal progressiva. A instituição de corticoterapia pode melhorar o prognóstico dos doentes que desenvolvem síndrome inflamatória de reconstituição imunológica associada a leucoencefalopatia multifocal progressiva.Conclusão: A mortalidade e morbilidade associadas à leucoencefalopatia multifocal progressiva são elevadas, com sequelas neurológicas importantes a longo-prazo. Os dados apresentados deverão alertar os clínicos para a ocorrência desta patologia nos doentes com infecção vírus da imunodeficiência humana, evidenciando o papel cada vez mais determinante da Ressonância Magnética no diagnóstico precoce da leucoencefalopatia multifocal progressiva e consequente melhoria do prognóstico.

Candida albicans brain abscesses in an injection drug user patient: a case report.

BACKGROUND: Fungal brain abscess is an uncommon disease, mostly associated with immunocompromised states and poorly controlled diabetes. Its incidence, however, is rising as a result of the increasing use of immunosuppressive agents, corticosteroids and broad-spectrum antimicrobial therapy. Candida species have emerged as the most prevalent etiologic agents of brain abscesses in autopsy studies. CASE PRESENTATION: A 46-year-old male with a history of injection drug abuse, chronic hepatitis C and diabetes mellitus presented to the Emergency Department of our hospital following a generalized tonic-clonic seizure without recovery of mental status. On admission, the patient was in coma, febrile, with severe acidemia with respiratory and metabolic acidosis, requiring invasive mechanical ventilation. Brain imaging revealed multiple ring-enhancing lesions with oedema and mass effect. Microbiologic studies, including cerebrospinal fluid, blood, sputum and urine cultures, were all negative. A stereotactic brain biopsy was performed and culture of brain specimens revealed Candida albicans. The patient was successfully treated with fluconazole therapy for 48 weeks presenting a good clinical response and a complete radiological resolution of brain abscesses. CONCLUSION: Despite advances in diagnostic and therapeutic procedures, fungal brain abscess remains a life-threatening disease with a poor outcome. Successful treatment requires an early diagnosis and usually a combined medical and surgical approach. A long-term antibiotic regimen is a cornerstone of fungal brain abscesses treatment, with the endpoint determined by clinical and neuroimaging response. The authors report an uncommon case of successfully treated Candida albicans brain abscesses with anti-fungal therapy consisting of fluconazole alone. This case illustrates the importance of early recognition of predisposing factors and multidisciplinary approach in timely therapeutic intervention, in order to prevent neurologic sequelae and improve the outcome of the patients with this severe and challenging form of central nervous system infection.