A multicentre study of amphotericin B treatment for histoplasmosis: assessing mortality rates and adverse events.

BACKGROUND: Progressive disseminated histoplasmosis is a significant issue in Latin America, particularly in Brazil, contributing to high mortality rates. OBJECTIVES: Our objectives were to comprehensively describe histoplasmosis treatment with various amphotericin B (AmB) formulations, including mortality rates, adverse effects and risk factors for mortality. METHODS: This multicentre retrospective cohort study (January 2014-December 2019) evaluated medical records of patients with proven or probable histoplasmosis treated with at least two doses of AmB in seven tertiary medical centres in Brazil. We assessed risk factors associated with death during hospitalization using univariate and multivariate analyses. RESULTS: The study included 215 patients, mostly male (n = 158, 73%) with HIV infection (n = 187, 87%), and a median age of 40 years. Only 11 (5%) patients initiated treatment with liposomal amphotericin B (L-AmB). Amphotericin B deoxycholate (D-AmB) was administered to 159 (74%) patients without changes in the treatment. The overall mortality during hospitalization was 23% (50/215). Variables independently associated with mortality were use of D-AmB (OR 4.93) and hospitalization in ICU (OR 9.46). There was a high incidence of anaemia (n = 19, 90%), acute kidney injury (n = 96, 59%), hypokalaemia (n = 73, 55%) and infusion reactions (n = 44, 20%) during treatment. CONCLUSIONS: We found that D-AmB was the main formulation, which was also associated with a higher mortality rate. Lipid formulations of AmB have become more readily available in the public health system in Brazil. Further studies to evaluate the effectiveness of L-AmB will likely show improvements in the treatment outcomes for patients with disseminated histoplasmosis.

Proceedings of the second international meeting on endemic mycoses of the Americas (IMEMA) and first international symposium on implantation mycoses (ISIM).

The second international meeting on endemic mycoses of the Americas (IMEMA) and the first international symposium on implantation mycoses (ISIM) took place in Santiago del Estero, Argentina, on September 25-27, 2023. The conference provided a platform for researchers, clinicians, and experts to discuss the latest developments in the field of endemic and implantation mycoses. Topics included epidemiology, diagnostic advances, treatment strategies, and the impact of environmental factors on the spread of these fungal diseases. IMEMA and ISIM contributed to the regional discourse on the mycoses, emphasizing the importance of international cooperation in addressing these public health challenges.

IMEMA/ISIM, held in Santiago del Estero, Argentina, convened experts to discuss endemic and implantation mycoses, covering topics such as epidemiology, diagnostics, treatment, and advocacy. The event highlighted ongoing efforts in combating these diseases.

Effectiveness, Tolerability, and Safety of Different Amphotericin B Formulations in Invasive Fungal Infections: A Multicenter, Retrospective, Observational Study.

PURPOSE: Data on the real-life use of amphotericin B lipid complex (ABLC) compared with other available formulations are limited. This study aimed to evaluate the effectiveness, tolerability, and safety of different amphotericin B (AMB) intravenously administered in the context of hospital practice for the treatment of invasive fungal infections (IFI) and to provide new insights into the profile of ABLC. METHODS: This is a multicenter, retrospective, observational study conducted at 10 tertiary Brazilian hospitals. Patients first exposed to any formulation of AMB for treating endemic and opportunistic IFI who had received at least 2 intravenous doses were screened. Retrospective data (from January 2014 to December 2019) were extracted from the patients' medical records. Clinical parameters were examined pre- and post-treatment to determine effectiveness; acute infusion-related side effects (IRSE) and drug interruption to determine tolerability; and adverse events, toxicity, and treatment interruption were stated to analyze safety. FINDINGS: Overall, 1879 medical records of patients were identified. The median (interquartile rate) duration of treatment was 14 (7-21) days. The overall success rate (95% confidence interval [CI]) was 65% (95% CI 60-65). ABLC proved to be effective among AMB formulations with 59% (95% CI 55.6-62.5) within complete response. This was significantly higher in patients who received the drug for a longer period, ≥4 weeks compared to <1 week treatment (P < 0.001). IRSE was observed in 446 (23.7%) patients. Eight cases (1.4%) of severe IRSE in pediatrics and 14 (1.1%) in adults resulted in treatment discontinuation. Regarding safety, 637 (33.9%) patients presented some alteration in creatinine levels during AMB exposure, and 89 (4.74%) had to interrupt or discontinue the drug within the first 14 days of therapy because of renal dysfunction. Overall mortality was 34%. IMPLICATIONS: ABLC is an effective formulation for the treatment of invasive fungal infections, with few adverse events leading to drug discontinuation or lethal outcomes. Furthermore, this real-life study confirmed the comparative safety of AMB lipid formulations versus AMB deoxycholate.

Case report: First case of fungemia caused by Papiliotrema laurentii in a patient with SARS-CoV-2 infection.

Previously considered saprobe and non-pathogenic, the fungus Papiliotrema laurentii (formerly known as Cryptococcus laurentii), is rarely associated with human infection. Nevertheless, there has been an increase in reported infections by non-neoformans cryptococci. After a literature search on the Cochrane Library, LILACS, SciELO, MEDLINE, PubMed, and PMC (PubMed Central) databases, we conclude that this is the first case report of fungemia and probable meningitis caused by Papiliotrema laurentii in a previously immunocompetent host with associated COVID-19.

Skin innate immune response against fungal infections and the potential role of trained immunity.

Fungal skin infections are distributed worldwide and can be associated with economic and social traits. The immune response related to skin cells is complex and its understanding is essential to the comprehension of each cell's role and the discovery of treatment alternatives. The first studies of trained immunity (TI) described the ability of monocytes, macrophages and natural killer (NK) cells to develop a memory-like response. However, the duration of TI does not reflect the shorter lifespan of these cells. These conclusions supported later studies showing that TI can be observed in stem and haematopoietic cells and, more recently, also in non-immune skin cells such as fibroblasts, highlighting the importance of resident cells in response to skin disorders. Besides, the participation of less studied proinflammatory cytokines in the skin immune response, such as IL-36γ, shed light into a new possibility of inflammatory pathway blockade by drugs. In this review, we will discuss the skin immune response associated with fungal infections, the role of TI in skin and clinical evidence supporting opportunities and challenges of TI and other inflammatory responses in the pathogenesis of fungal skin infections.

Case report: First case of fungemia caused by Papiliotrema laurentii in a patient with SARS-CoV-2 infection

ABSTRACT Previously considered saprobe and non-pathogenic, the fungus Papiliotrema laurentii (formerly known as Cryptococcus laurentii), is rarely associated with human infection. Nevertheless, there has been an increase in reported infections by non-neoformans cryptococci. After a literature search on the Cochrane Library, LILACS, SciELO, MEDLINE, PubMed, and PMC (PubMed Central) databases, we conclude that this is the first case report of fungemia and probable meningitis caused by Papiliotrema laurentii in a previously immunocompetent host with associated COVID-19.

Case report: Mycetoma caused by Gordonia soli

ABSTRACT Mycetoma is a neglected tropical disease caused by fungi (eumycetoma) or bacteria (actinomycetoma), with high morbidity. Gordonia spp. are gram-positive bacteria that have previously been reported to cause mycetoma. Here, we report a case of Gordonia soli (initially misidentified as Nocardia spp.) as the etiological agent of actinomycetoma in a 64-year-old patient. After a literature search in the Cochrane Library, LILACS, SciELO, MEDLINE, PubMed, and PubMed Central databases, we concluded that this is the first case report of mycetoma caused by Gordonia soli. The current case highlights the importance of microbiological diagnosis of mycetoma and the challenges in its management.

Susceptibility and molecular characterization of Candida species from patients with vulvovaginitis

Abstract Vulvovaginal candidiasis affects women of reproductive age, which represents approximately 15–25% of vaginitis cases. The present study aimed to isolate and characterize yeast from the patients irrespective of the presentation of clinical symptoms. The isolates were subjected to in vitro susceptibility profile and characterization by molecular markers, which intended to assess the distribution of species. A total of 40 isolates were obtained and identified through the CHROMagar, API20aux and by ITS and D1/D2 regions sequencing of DNAr gene. Candida albicans strains were genotyped by the ABC system and the isolates were divided into two genotypic groups. The identity of the C. albicans, C. glabrata, C. guilliermondii, C. kefyr and Saccharomyces cerevisiae isolates was confirmed by the multilocus analysis. The strains of Candida, isolated from patients with complications, were found to be resistant to nystatin but sensitive to fluconazole, amphotericin B and ketoconazole, as observed by in vitro sensitivity profile. The isolates from asymptomatic patients, i.e., the colonized group, showed a dose-dependent sensitivity to the anti-fungal agents, fluconazole and amphotericin B. However, the isolates of C. albicans that belong to distinct genotypic groups showed the same in vitro susceptibility profile.

In vitro susceptibility and molecular characterization of Candida spp. from candidemic patients / Sensibilidad in vitro y caracterización molecular de aislamientos de Candida procedentes de pacientes con candidemia

Background. Candida species are the main cause of hospital acquired fungal bloodstream infections. The main risk factors for candidemia include parenteral nutrition, long-term intensive care, neutropenia, diabetes, abdominal surgery and the use of central venous catheters. The antifungal drugs used to treat candidemia are mainly the echinocandins, however some isolates may be resistant to these drugs. Aims. This work aims to evaluate the in vitro susceptibility patterns of various Candida species isolated from blood samples and provide their identification by molecular characterization. Methods. Antifungal susceptibility testing was performed using the broth microdilution method. The sequencing of the ITS and D1/D2 regions of rDNA was used for molecular characterization. Results. Seventy-four of the 80 isolates were susceptible to anidulafungin, 5 were intermediate, and 1 was resistant. For micafungin 67 were susceptible, 8 were intermediate and 5 were resistant. All isolates were susceptible to amphotericin B. Lastly, 65 isolates were susceptible to fluconazole, 8 were dose-dependent and 4 were resistant. The molecular identification corroborated the phenotypic data in 91.3% of the isolates. Conclusions. Antifungal susceptibility data has an important role in the treatment of candidemia episodes. It was also concluded that the molecular analysis of isolates provides an accurate identification and identifies genetic variability within Candida species isolated from patients with candidemia (AU)

Antecedentes. Los hongos del género Candida son la causa principal de infección micótica del torrente sanguíneo adquirida en el hospital. Entre los factores de riesgo asociados a la candidemia destacan la nutrición parenteral, la estancia prolongada en una unidad de cuidados intensivos, la neutropenia, la diabetes, la cirugía abdominal y la utilización de catéter venoso central. Los agentes antifúngicos más utilizados para tratarla son las equinocandinas, pero determinados aislamientos son resistentes a dichos componentes, por lo que algunos pacientes no responden al tratamiento. Objetivos. Este trabajo tiene como objetivo evaluar la sensibilidad in vitro de varios aislamientos de Candida procedentes de muestras de sangre y realizar su caracterización molecular. Métodos. Se hicieron pruebas de sensibilidad a los antifúngicos mediante el método de microdilución en caldo. Para la caracterización molecular se utilizó la secuenciación de las regiones ITS y D1/D2 del DNAr. Resultados. De los 80 aislamientos evaluados, 74 fueron sensibles a la anidulafungina, 5 mostraron sensibilidad intermedia y solo uno era resistente. Cuando se utilizó la micafungina, 67 aislamientos resultaron sensibles, 8 presentaron sensibilidad intermedia y 5 fueron resistentes. Los 80 aislamientos fueron sensibles a la anfotericina B. Al menos 65 aislamientos eran sensibles al fluconazol, 8 presentaron sensibilidad dependiente de la dosis y 4 se mostraron resistentes. La identificación molecular confirmó la identificación fenotípica en un 91,3% de los aislamientos. Conclusiones. Teniendo en cuenta los resultados obtenidos con las pruebas de sensibilidad a los antifúngicos, estas resultan indispensables para el tratamiento adecuado de la candidemia. Se concluye además que la identificación molecular proporciona una identificación precisa y consigue identificar la variabilidad genética de las especies del género Candida aisladas en pacientes con candidemia (AU)

Chromoblastomycssis: a neglected tropical disease / Cromoblastomicose: doença tropical negligenciada

SUMMARYChromoblastomycosis (CMB) is a chronic fungal infection of the skin and the subcutaneous tissue caused by a transcutaneous traumatic inoculation of a specific group of dematiaceous fungi occurring mainly in tropical and subtropical zones worldwide. If not diagnosed at early stages, patients with CBM require long term therapy with systemic antifungals, sometimes associated with physical methods. Unlike other neglected endemic mycoses, comparative clinical trials have not been performed for this disease. Nowadays, therapy is based on a few open trials and on expert opinion. Itraconazole either as monotherapy or associated with other drugs, or with physical methods, is widely used. Recently, photodynamic therapy has been successfully employed in combination with antifungals in patients presenting with CBM. In the present revision the most used therapeutic options against CBM are reviewed as well as the several factors that may have impact on the patient's outcome.

RESUMOCromoblastomicose (CMB) é uma infecção fúngica crônica da pele e tecido subcutâneo causada pela inoculação transcutânea traumática de um grupo específico de fungos dermatiáceos que ocorrem principalmente em zonas tropicais e subtropicais do mundo. Quando não são diagnosticados nas fases iniciais, pacientes com CBM necessitam de tratamentos prolongados com antifúngicos sistêmicos, por vezes associados a métodos físicos. Diferentemente de outras micoses endêmicas negligenciadas, não foram realizados ensaios clínicos comparativos para esta doença. Atualmente a terapia é baseada em alguns poucos ensaios abertos e em opiniões de especialistas. Itraconazol é amplamente utilizado como monoterapia ou em associação com outras drogas, ou com métodos físicos. Recentemente, a terapia fotodinâmica foi empregada com sucesso combinada a antifúngicos em pacientes com CBM. Neste manuscrito as opções terapêuticas mais utilizadas contra CBM foram revistas, assim como os diversos fatores que podem influenciar a evolução dos pacientes.

Recomendaciones para el diagnóstico de la candidemia en América Latina / Recommendations for the diagnosis of candidemia in Latin America

La candidemia es una de las micosis oportunistas más frecuentes en todo el mundo. El escaso número de estudios epidemiológicos llevados a cabo en América Latina indica que las tasas de incidencia en esta región son mayores que las descritas en el hemisferio norte. A menudo el diagnóstico de la infección se establece tardíamente, lo que afecta al inicio del tratamiento antimicótico. Por esta razón, para el diagnóstico y el manejo de la candidemia está justificada una estrategia más científica, basada en parámetros específicos. Recomendaciones para el diagnóstico y manejo de la candidemia constituye una serie de artículos preparados por miembros del grupo Latin America Invasive Mycosis Network. Su objetivo es proporcionar las mejores evidencias disponibles para el diagnóstico y el manejo de la candidemia. El presente artículo, Recomendaciones para el diagnóstico de la candidemia en América Latina, ha sido redactado con el objetivo de brindar asesoramiento a los profesionales de la salud en lo referente al diagnóstico de la candidemia en pacientes que la padecen o están en riesgo de padecerla. Mediante la base de datos PubMed se emprendió una búsqueda informatizada de los estudios publicados. Los miembros del grupo revisaron y analizaron exhaustivamente los datos. El grupo también se reunió en 2 ocasiones para proponer preguntas, abordar los puntos de vista conflictivos y deliberar sobre las recomendaciones terapéuticas. Recomendaciones para el diagnóstico de la candidemia en América Latina incluye diversas recomendaciones sobre aspectos relacionados con los métodos diagnósticos para la detección de la candidemia, la identificación de las especies de Candida y las pruebas de sensibilidad antifúngica. Se expone también la disponibilidad de los métodos, sus costes y el marco en el que se aplican los tratamientos. Este manuscrito es el primero de los artículos de esta serie dedicada al diagnóstico y tratamiento de las candidiasis invasoras. Otras publicaciones de esta serie son Recomendaciones para el diagnóstico de la candidemia en adultos en América Latina, Recomendaciones para el manejo de la candidemia en niños en América Latina, y Recomendaciones para el manejo de la candidemia en neonatos en América Lat (AU)

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. ‘Recommendations for the diagnosis and management of candidemia’ are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, ‘Recommendations for the diagnosis of candidemia in Latin America’, was written to provide guidance to healthcare professionals on the diagnosis of candidemia, as well as on the usefulness and application of susceptibility testing in patients who have a confirmed diagnosis of candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. ‘Recommendations for the diagnosis of candidemia in Latin America’ includes diagnostic methods used to detect candidemia, Candida species identification, and susceptibility testing. The availability of methods, their costs and treatment settings are considered. This manuscript is the first of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: ‘Recommendations for the management of candidemia in adults in Latin America’, ‘Recommendations for the management of candidemia in children in Latin America’, and ‘Recommendations for the management of candidemia in neonates in Latin America’ (AU)

Recomendaciones para el manejo de la candidemia en neonatos en América Latina / Recommendations for the management of candidemia in neonates in Latin America

La candidemia es una de las micosis oportunistas más frecuentes en todo el mundo. El escaso número de estudios epidemiológicos llevados a cabo en América Latina indica que las tasas de incidencia en esta región son mayores que las descritas en el hemisferio norte. A menudo el diagnóstico de la infección se establece tardíamente, lo que afecta el inicio del tratamiento antimicótico. Por esta razón, para el diagnóstico y el manejo de la candidemia está justificada una estrategia más científica, basada en parámetros específicos. Recomendaciones para el diagnóstico y manejo de la candidemia constituye una serie de artículos preparados por miembros del grupo Latin America Invasive Mycosis Network. Su objetivo es proporcionar las mejores evidencias disponibles para el diagnóstico y el manejo de la candidemia. El presente artículo, Recomendaciones para el manejo de la candidemia en neonatos en América Latina, ha sido redactado con el objetivo de orientar a los profesionales de la salud en el manejo de los neonatos que padecen, o pueden padecer, candidemia. Mediante la base de datos PubMed se emprendió una búsqueda informatizada de los estudios publicados. Los miembros del grupo revisaron y analizaron exhaustivamente los datos. El grupo también se reunió en dos ocasiones para proponer preguntas, abordar los puntos de vista conflictivos y deliberar sobre las recomendaciones terapéuticas. Recomendaciones para el manejo de la candidemia en neonatos en América Latina incluye aspectos sobre profilaxis, terapia empírica, tratamiento de la candidemia demostrada, evaluación y seguimiento del paciente después del diagnóstico de candidemia, manejo de los recién nacidos con infección por Candida del catéter venoso central y manejo de otras complicaciones. Este manuscrito es el cuarto de los artículos de esta serie dedicada al diagnóstico y tratamiento de las candidiasis invasoras. Otras publicaciones de esta serie son Recomendaciones para el diagnóstico de la candidemia en América Latina, Recomendaciones para el manejo de la candidemia en adultos en América Latina, y Recomendaciones para el manejo de la candidemia en niños en América Latina (AU)

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. ‘Recommendations for the diagnosis and management of candidemia’ are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, ‘Recommendations for the management of candidemia in neonates in Latin America’, was written to provide guidance to healthcare professionals on the management of neonates who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. ‘Recommendations for the management of candidemia in neonates in Latin America’ includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, central venous catheter management, and management of complications. This manuscript is the fourth of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: ‘Recommendations for the diagnosis of candidemia in Latin America’, ‘Recommendations for the management of candidemia in adults in Latin America’, and ‘Recommendations for the management of candidemia in children in Latin America’ (AU)

Recomendaciones para el manejo de la candidemia en niños en América Latina / Recommendations for the management of candidemia in children in Latin America

La candidemia es una de las micosis oportunistas más frecuentes en todo el mundo. El escaso número de estudios epidemiológicos llevados a cabo en América Latina indica que las tasas de incidencia en esta región son mayores que las descritas en el hemisferio norte. A menudo el diagnóstico de la infección se establece tardíamente, lo que afecta al inicio del tratamiento antimicótico. Por esta razón, para el diagnóstico y el manejo de la candidemia está justificada una estrategia más científica, basada en parámetros específicos. Recomendaciones para el diagnóstico y manejo de la candidemia constituye una serie de artículos preparados por miembros del grupo Latin America Invasive Mycosis Network. Su objetivo es proporcionar las mejores evidencias disponibles para el diagnóstico y el manejo de la candidemia. El presente artículo, Recomendaciones para el manejo de la candidemia en adultos en América Latina, ha sido redactado con el objetivo de orientar a los profesionales de la salud en el manejo de los pacientes adultos que padecen, o pueden padecer, candidemia. Mediante la base de datos PubMed se emprendió una búsqueda informatizada de los estudios publicados. Los miembros del grupo revisaron y analizaron exhaustivamente los datos. El grupo también se reunió en dos ocasiones para proponer preguntas, abordar los puntos de vista conflictivos y deliberar sobre las recomendaciones terapéuticas. Recomendaciones para el manejo de la candidemia en adultos en América Latina está orientado al tratamiento de pacientes neutropénicos y no neutropénicos, e incluye aspectos sobre la profilaxis, el tratamiento empírico, el tratamiento de la candidemia confirmada, el seguimiento del paciente después del diagnóstico de la candidemia, la duración del tratamiento y el manejo del catéter venoso central. Esta publicación es la segunda de los artículos de esta serie dedicada al diagnóstico y tratamiento de las candidiasis invasoras. Otras publicaciones de esta serie son Recomendaciones para el diagnóstico de la candidemia en América Latina, Recomendaciones para el manejo de la candidemia en ni˜nos en América Latina, y Recomendaciones para el manejo de la candidemia en neonatos en América Latina (AU)

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. ‘Recommendations for the diagnosis and management of candidemia’ are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, ‘Recommendations for the management of candidemia in children in Latin America’, was written to provide guidance to healthcare professionals on the management of children who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. ‘Recommendations for the management of candidemia in children in Latin America’ includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, duration of candidemia treatment, and central venous catheter management in children with candidemia. This manuscript is the third of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: ‘Recommendations for the diagnosis of candidemia in Latin America’, ‘Recommendations for the management of candidemia in adults in Latin America’, and ‘Recommendations for the management of candidemia in neonates in Latin America’ (AU)

Recommendations for the management of candidemia in adults in Latin America

La candidemia es una de las micosis oportunistas más frecuentes en todo el mundo. El escaso número de estudios epidemiológicos llevados a cabo en América Latina indica que las tasas de incidencia en esta región son mayores que las descritas en el hemisferio norte. A menudo el diagnóstico de la infección se establece tardíamente, lo que afecta al inicio del tratamiento antimicótico. Por esta razón, para el diagnóstico y el manejo de la candidemia está justificada una estrategia más científica, basada en parámetros específicos. Recomendaciones para el diagnóstico y manejo de la candidemia constituye una serie de artículos preparados por miembros del grupo Latin America Invasive Mycosis Network. Su objetivo es proporcionar las mejores evidencias disponibles para el diagnóstico y el manejo de la candidemia. El presente artículo, Recomendaciones para el manejo de la candidemia en adultos en América Latina, ha sido redactado con el objetivo de orientar a los profesionales de la salud en el manejo de los pacientes adultos que padecen, o pueden padecer, candidemia. Mediante la base de datos PubMed se emprendió una búsqueda informatizada de los estudios publicados. Los miembros del grupo revisaron y analizaron exhaustivamente los datos. El grupo también se reunió en dos ocasiones para proponer preguntas, abordar los puntos de vista conflictivos y deliberar sobre las recomendaciones terapéuticas. Recomendaciones para el manejo de la candidemia en adultos en América Latina está orientado al tratamiento de pacientes neutropénicos y no neutropénicos, e incluye aspectos sobre la profilaxis, el tratamiento empírico, el tratamiento de la candidemia confirmada, el seguimiento del paciente después del diagnóstico de la candidemia, la duración del tratamiento y el manejo del catéter venoso central. Esta publicación es la segunda de los artículos de esta serie dedicada al diagnóstico y tratamiento de las candidiasis invasoras. Otras publicaciones de esta serie son Recomendaciones para el diagnóstico de la candidemia en América Latina, Recomendaciones para el manejo de la candidemia en ni˜nos en América Latina, y Recomendaciones para el manejo de la candidemia en neonatos en América Latina (AU)

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. ‘Recommendations for the diagnosis and management of candidemia’ are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, ‘Recommendations for the management of candidemia in adults in Latin America’, was written to provide guidance to healthcare professionals on the management of adults who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. ‘Recommendations for the management of candidemia in adults in Latin America’ includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, duration of candidemia treatment, and central venous catheter management in patients with candidemia. This manuscript is the second of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: ‘Recommendations for the diagnosis of candidemia in Latin America’, ‘Recommendations for the management of candidemia in children in Latin America’, and ‘Recommendations for the management of candidemia in neonates in Latin America’ (AU)

Brazilian guidelines for the management of candidiasis - a joint meeting report of three medical societies: Sociedade Brasileira de Infectologia, Sociedade Paulista de Infectologia and Sociedade Brasileira de Medicina Tropical

Candida infections account for 80% of all fungal infections in the hospital environment, including bloodstream, urinary tract and surgical site infections. Bloodstream infections are now a major challenge for tertiary hospitals worldwide due to their high prevalence and mortality rates. The incidence of candidemia in tertiary public hospitals in Brazil is approximately 2.5 cases per 1000 hospital admissions. Due to the importance of this infection, the authors provide a review of the diversity of the genus Candida and its clinical relevance, the therapeutic options and discuss the treatment of major infections caused by Candida. Each topography is discussed with regard to epidemiological, clinical and laboratory diagnostic and therapeutic recommendations based on levels of evidence.

Clinical aspects and relevance of molecular diagnosis in late mucocutaneous leishmaniasis patients in Paraná, Brazil

The aim of the present work was to study the clinical aspects and relevance of molecular diagnosis in late mucocutaneous leishmaniasis patients in Parana, Brazil. Twenty one suspected cases of mucocutaneous leishmaniasis (MCL) in patients from the endemic areas of leishmaniasis were assessed. Different methods used in diagnosing the disease and the polymerase chain reaction (PCR) technique were compared in order to establish the sensitivity of each method. Out of the 21 patients analyzed, 14.3 percent presented other etiologies such as vasculitis, syphilis, and paracoccidioidomycosis, with all tests negative for leishmaniasis. Out of the remaining 15 patients, 6.7 percent cases were confirmed for leishmaniasis by direct examination; 46.67 percent were positive for culture, which allowed isolating and identifying the parasite and - with the PCR technique - it was possible to diagnose 100 percent MCL patients for all the three repetitions of exams. The PCR optimized for the present work proved to be an auxiliary method for diagnosing leishmaniasis applicable in the patients carrying MCL due to Leishmania (Viannia) braziliensis and did not need culture to be performed, resulting in a faster diagnosis.

Infecções causadas por fungos demácios e suas correlações anátomo-clinicas / Infections caused by dematiaceous fungi and their anatomoclinical correlations

O gênero Exophiala é composto por fungos melanizados dimórficos, responsáveis por um espectro de doenças, incluindo feohifomicoses, micetomas, cromoblastomicoses e fungemia. A espécie E. jeanselmei é a predominante nestas infecções, seguida de E. dermatitidis. Este trabalho tem como objetivo relatar quatro casos e discutir aspectos clínicos, histológicos, micológicos e epidemiológicos para o seu diagnóstico.

The Exophiala genus comprises dimorphic melanized fungi responsible for a spectrum of diseases including phaeohyphomycosis, mycetoma, chromoblastomycosis and fungemia. The E. jeanselmei species is predominant in such infections, followed by E. dermatitidis. This paper aims at reporting four cases and at discussing clinical, histologycal, mycologycal and epidemiologycal aspects for its diagnosis.

Análise das alterações radiográficas pulmonares durante a terapêutica da paracoccidioidomicose / Review of lung radiographic findings during treatment of patients with chronic paracoccidioidomycosis

OBJETIVO: Foram analisadas as alterações radiográficas pulmonares em pacientes com paracoccidioidomicose crônica de modo evolutivo, verificando-se as diferenças entre os tratados com um novo agente antifúngico triazólico, o voriconazol, em relação aos que utilizaram a atual droga de escolha para o tratamento, o itraconazol. MATERIAIS E MÉTODOS: Realizou-se estudo comparativo, randomizado, com avaliação das radiografias do tórax obtidas antes, durante e após o tratamento de 39 pacientes, divididos em dois grupos: um recebendo o voriconazol e o outro, itraconazol. A avaliação das radiografias teve como parâmetro uma adaptação do método já estabelecido para a análise de outra doença pulmonar difusa, o esquema ILO (International Labour Office) de classificação das pneumoconioses, classificando-se as lesões em pequenas ou grandes opacidades. RESULTADOS: Os resultados obtidos coincidiram com as descrições prévias existentes em relação à apresentação das alterações radiográficas pulmonares, e a evolução destas ao longo do tratamento foi semelhante nos dois grupos. As pequenas opacidades regrediram parcialmente, ao passo que as grandes opacidades mostraram tendência à regressão completa. CONCLUSÃO: O uso da adaptação do modelo ILO de classificação das pneumoconioses revelou-se útil para o acompanhamento dos pacientes com paracoccidioidomicose crônica ao longo do tratamento, do ponto de vista radiográfico.

OBJECTIVE: Lung radiographic findings were reviewed to evaluate the differences in the progression of findings along the follow-up of patients with chronic paracoccidioidomycosis treated with a novel second-generation triazole antifungal agent (voriconazole) as compared with patients treated with the drug of choice for treatment of such disease (itraconazole). MATERIALS AND METHODS: A comparative, randomized study involved the review of chest radiographic images acquired before, during and after treatment of 39 patients divided into two groups: one receiving voriconazole and the other receiving itraconazole. The parameters adopted to describe and to measure lesions present on the radiographic images were based on an adaptation of the method used in cases of another diffuse pulmonary disease, the ILO (International Labour Office) classification of pneumoconioses, dividing the lesions into small and large opacities. RESULTS: The results coincided with previous descriptions regarding lung radiographic findings, and the progression of such findings along the treatment was similar for both groups. Partial regression was observed in the small opacities while large opacities showed a tendency towards complete regression. CONCLUSION: The adapted ILO classification demonstrated to be useful in the radiographic follow-up along treatment of patients with chronic paracoccidioidomycosis.

Isolamento de Cryptococcus neoformans de amostras ambientais de Curitiba e região metropolitana (Paraná, Brasil) e testes de suscetibilidade frente a drogas antifúngicas / Isolation of Cryptococcus neoformans from environmental samples of Curitiba and metropolitan region (Paraná, Brazil), and susceptibility antifungal testing

Criptococose é uma doença causada pela levedura encapsulada Cryptococcus neoformans, está intimamente ligada a pessoas imunodeprimidas, quer seja por drogas imunossupressoras administradas pós-transplantes ou por doenças imunodepressorascomo a SIDA. A doença origina-se pela penetração do fungo através das vias aéreas superiores, seguindo para os pulmões, acometendo o paciente com uma pneumonia criptocócica, com posterior disseminação do microrganismo pela via hematogênica,chegando ao sistema nervoso central e até as meninges, originando uma meningite criptocócica. As amostras analisadas neste estudo são provenientes de restos vegetais, areia de galinheiros, fezes de morcegos, restos vegetais de eucaliptos como folhas e caules, e, principalmente, fezes de pombos. A análise de 88 amostras de diferentes materiais orgânicos resultou em 11 amostras positivas para o desenvolvimento da levedura. Os 11 isolados foram testados quanto à sensibilidade frente aos antifúngicos anfotericina B, fluconazol e itraconazol. C. neoformans não apresentou resistência às drogas testadas e as concentrações mínimas inibitóriasencontradas foram: CIM de 0,03 a 1 μg/mL para anfotericina B (média de 0,515 μg/mL), CIM de 0,125 μg/mL para fluconazol e CIM de 0,03 μg/mL para itraconazol.

Cryptococcosis is a fungal disease caused by Cryptococcus neoformans is closely with the imunodepressed people, as for imunodeletion drugs managed after-transplants as mmunosuppressives diseases, the illness where originates for the inoculation of fungus through the superior airways, in the lung causes the patient with a cryptococcal pneumonia, and follow dissemination of themicroorganism for the hematogênic way arriving at the central nervous system and until meninges, originating a cryptococcal meningitis. The samples analyzed in this study are proceeding from vegetal remaining portions, sand of poulterer, excrements of bats, vegetal remaining portions of eucalyptus as leaves and stem. The analysis of 88 samples of different organic materialsresulted in 11 positive samples for the development of the yeast. The 11 isolated ones had been tested to sensitivity antifungal for amphotericin B, fluconazole and itraconazole. C. neoformans did not present resistance to the tested drugs: the minimum inhibitory concentrations was founded: MIC of 0,03 to 1 μg/mL for amphotericin B (average of 0,515 μg/mL), CIM of 0,125 μg/mL for fluconazole and CIM of 0,03 μg/mL for itraconazole.

Treatment of severe chromoblastomycosis with itraconazole and 5-flucytosine association / Tratamento de cromoblastomicose severa com a associação itraconazole e 5-flucitosina

Chromoblastomycosis is a chronic human melanized fungi infection of the subcutaneous tissue caused by traumatic inoculation of a specific group of dematiaceous fungi through the skin, often found in barefooted agricultural workers, in tropical and subtropical climate countries. We report the case of a male patient presenting a slow-growing pruriginous lesion on the limbs for 20 years, mistreated over that time, which was diagnosed and successfully treated as chromoblastomycosis. Besides the prevalence of this disease, treatment is still a clinical challenge.

Cromoblastomicose é uma infecção fúngica crônica do tecido subcutâneo causada pela inoculação traumática de um grupo específico de fungos através da pele, encontrados eventualmente em trabalhadores do campo descalços em países de clima tropical e subtropical. Relatamos aqui o caso de um paciente do sexo masculino com uma lesão dermatológica de crescimento lento e pruriginosa nos membros inferiores por 20 anos, diagnosticada e tratada com sucesso para cromoblastomicose. Apesar da prevalência desta doença em nossa região, o tratamento ainda é um desafio.