Evaluation of an enzyme immunoassay technique on detecting urinary Histoplasma capsulatum antigen in the diagnosis of disseminated histoplasmosis in Argentina.

INTRODUCTION: Histoplasmosis is a systemic mycosis of universal distribution, highly endemic in the Americas. It is caused by a dimorphic fungus Histoplasma capsulatum var. capsulatum. It affects both immunocompetent and immunocompromised individuals where progressive and disseminated forms are observed. A very important risk factor is HIV infection/AIDS, with a mortality rate of 20-40% in Latin America. The diagnosis of this mycosis is made by conventional and molecular methods or by antigen and antibody detection. METHODS: In this retrospective, longitudinal and analytical study, carried out over a period of 2 years, the sensitivity (S) and specificity (E) of a commercial kit for the detection of Histoplasma antigen by EIA technique (HC-Ag) was evaluated in 50 patients with AIDSassociated histoplasmosis. In addition, its performance was compared with that of other diagnostic techniques routinely used in our laboratory. RESULTS: HC-Ag had a S of 94%, E 96%, positive likelihood coefficient (CVP): 20.68 and negative likelihood coefficient (CVN): 0.06. The delay time of the results was 4 days, similar to that of antibody detection and n-PCR and much less than that of blood cultures. The combination of methods improved S to 100%; with similar values in E. CONCLUSION: The HC-Ag method demonstrated its usefulness in the diagnosis of progressive disseminated histoplasmosis and the combination of methods is a good option to increase sensitivity and decrease the time to reach the diagnosis of certainty. This allows improving the strategy in the management of the disease and decreasing its case-fatality rate.

Introducción: La histoplasmosis es una micosis sistémica de distribución universal, altamente endémica en las Américas. Es causada por un hongo dimórfico: Histoplasma capsulatum var. capsulatum. Afecta tanto a inmunocompetentes como a inmunocomprometidos, se observan formas progresivas y diseminadas. Un factor de riesgo muy importante es la infección por HIV/sida, con una tasa de mortalidad del 20-40% en América Latina. El diagnóstico de esta micosis se realiza por métodos convencionales y moleculares o por detección de antígenos y anticuerpos. Métodos: En este estudio retrospectivo, longitudinal y analítico, realizado en un periodo de 2 años, se evaluó la sensibilidad (S) y especificidad (E) de un kit comercial para la detección de antígeno de Histoplasma por técnica de EIA (HC-Ag) en 50 pacientes con histoplasmosis asociada a sida. Además, se comparó su rendimiento con el de otras técnicas diagnósticas utilizadas habitualmente en nuestro laboratorio. Resultados: HC-Ag tuvo una S del 94%, E del 96%, coeficiente de verosimilitud positiva (CVP) de 20.68 y coeficiente de verosimilitud negativa (CVN) de 0.06. El tiempo de demora de los resultados fue de 4 días, similar al de la detección de anticuerpos y n-PCR y mucho menor que el de los hemocultivos. La combinación de métodos mejoró la S a 100%; con valores similares en E. Conclusión: El método HC-Ag demostró su utilidad en el diagnóstico de histoplasmosis diseminada progresiva y la combinación de métodos es una buena opción para aumentar la sensibilidad y disminuir el tiempo para llegar al diagnóstico de certeza. Esto permite mejorar la estrategia en el manejo de la enfermedad y reducir su tasa de letalidad.

Sporotrichosis in Argentina: clinical and epidemiological analysis / Esporotricosis en Argentina: análisis clínico y epidemiológico

Introduction: Sporotrichosis is an implantation mycosis caused by Sporothrix spp. It is distributed worldwide and can be found in vegetation and soil. The most frequent route of infection is by trauma with elements contaminated with fungal propagules. Since domestic cats are the most affected animals and can transmit this infection to humans, sporotrichosis is considered a zoonosis. Clinical presentations include nodular lymphangitis, fixed cutaneous, pulmonary (rare), and disseminated (exceptional). Objectives: To analyze the epidemiology of sporotrichosis in Argentina during 2010 and 2022. To describe the clinical presentation, diagnostic methods, and treatment of cases diagnosed during this period. To know the circulating genotypes and to observe possible associations with the geographic location where the infection was acquired. Materials and methods: Analytical, retrospective, and observational study. We analyzed the medical records of patients with sporotrichosis from 12 health institutions in Argentina, between 2010 and 2022. Results: We present 54 cases in which the most frequent clinical form was nodular lymphangitis, and the treatment of choice was itraconazole. Conventional diagnosis was made in all cases. Culture of clinical samples was more sensitive than direct examination because it allowed the isolation of Sporothrix spp. in all 54 cases. Molecular identification was performed in 22 cases, with Sporothrix schenkii sensu stricto being the most frequently isolated species. Conclusions: This study allowed to know the epidemiology of this mycosis in Argentina, as well as the availability of diagnostic methods and the treatment of choice.

Introducción: La esporotricosis es una micosis de implantación causada por Sporothrix spp. Este se encuentra distribuido mundialmente y se puede encontrar en la vegetación y en el suelo. La ruta más frecuente de adquisición de la infección es por traumatismos con elementos contaminados con propágulos del hongo. Los gatos domésticos son los animales más afectados y pueden transmitirla a los humanos, por lo que es considerada una zoonosis. Las formas clínicas incluyen: la linfangítica nodular, la cutánea fija, la pulmonar (poco habitual) y la diseminada (excepcional). Objetivo: Analizar la epidemiología de la esporotricosis en Argentina entre los años 2010 y 2022. Describir la presentación clínica, los métodos de diagnóstico y el tratamiento de los casos diagnosticados en este período. Conocer los genotipos circulantes y observar su relación con el lugar geográfico de adquisición de la infección. Materiales y métodos. Se llevó a cabo un estudio analítico, retrospectivo y observacional, en el que se analizaron las historias clínicas de los pacientes con esporotricosis de 12 instituciones de salud de Argentina, entre los años 2010 y 2022. Resultados: Se presentan 54 casos en los que la forma clínica más frecuente fue la linfangítica nodular y el tratamiento de elección fue el itraconazol. En todos los casos se realizó diagnóstico convencional. El cultivo de las muestras clínicas resultó más sensible que el examen directo, ya que permitió el desarrollo de Sporothrix spp. en los 54 casos. En 22 casos se hizo identificación molecular y Sporothrix schenkii sensu stricto fue la especie más frecuentemente aislada. Conclusiones: Este estudio permitió conocer la epidemiología de esta micosis en Argentina, así como la disponibilidad de métodos diagnósticos y el tratamiento de elección.

Esporotricosis en Argentina: análisis clínico y epidemiológico / Sporotrichosis in Argentina: clinical and epidemiological analysis

Introducción. La esporotricosis es una micosis de implantación causada por Sporothrix spp. Este se encuentra distribuido mundialmente y se puede encontrar en la vegetación y en el suelo. La ruta más frecuente de adquisición de la infección es por traumatismos con elementos contaminados con propágulos del hongo. Los gatos domésticos son los animales más afectados y pueden transmitirla a los humanos, por lo que es considerada una zoonosis. Las formas clínicas incluyen: la linfangítica nodular, la cutánea fija, la pulmonar (poco habitual) y la diseminada (excepcional). Objetivo. Analizar la epidemiología de la esporotricosis en Argentina entre los años 2010 y 2022. Describir la presentación clínica, los métodos de diagnóstico y el tratamiento de los casos diagnosticados en este período. Conocer los genotipos circulantes y observar su relación con el lugar geográfico de adquisición de la infección. Materiales y métodos. Se llevó a cabo un estudio analítico, retrospectivo y observacional, en el que se analizaron las historias clínicas de los pacientes con esporotricosis de 12 instituciones de salud de Argentina, entre los años 2010 y 2022. Resultados. Se presentan 54 casos en los que la forma clínica más frecuente fue la linfangítica nodular y el tratamiento de elección fue el itraconazol. En todos los casos se realizó diagnóstico convencional. El cultivo de las muestras clínicas resultó más sensible que el examen directo, ya que permitió el desarrollo de Sporothrix spp. en los 54 casos. En 22 casos se hizo identificación molecular y Sporothrix schenkii sensu stricto fue la especie más frecuentemente aislada. Conclusiones. Este estudio permitió conocer la epidemiología de esta micosis en Argentina, así como la disponibilidad de métodos diagnósticos y el tratamiento de elección.

Introduction. Sporotrichosis is an implantation mycosis caused by Sporothrix spp. It is distributed worldwide and can be found in vegetation and soil. The most frequent route of infection is by trauma with elements contaminated with fungal propagules. Since domestic cats are the most affected animals and can transmit this infection to humans, sporotrichosis is considered a zoonosis. Clinical presentations include nodular lymphangitis, fixed cutaneous, pulmonary (rare), and disseminated (exceptional). Objective. To analyze the epidemiology of sporotrichosis in Argentina during 2010 and 2022. To describe the clinical presentation, diagnostic methods, and treatment of cases diagnosed during this period. To know the circulating genotypes and to observe possible associations with the geographic location where the infection was acquired. Materials and methods. Analytical, retrospective, and observational study. We analyzed the medical records of patients with sporotrichosis from 12 health institutions in Argentina, between 2010 and 2022. Results. We present 54 cases in which the most frequent clinical form was nodular lymphangitis, and the treatment of choice was itraconazole. Conventional diagnosis was made in all cases. Culture of clinical samples was more sensitive than direct examination because it allowed the isolation of Sporothrix spp. in all 54 cases. Molecular identification was performed in 22 cases, with Sporothrix schenkii sensu stricto being the most frequently isolated species. Conclusions. This study allowed to know the epidemiology of this mycosis in Argentina, as well as the availability of diagnostic methods and the treatment of choice.

Preemptive Therapy in Cryptococcosis Adjusted for Outcomes.

Cryptococcosis is one of the most serious opportunistic diseases in patients living with HIV. For this reason, early diagnosis and appropriate treatment are important. OBJECTIVES: The aim of the study was to understand the development of patients diagnosed with cryptococcosis by detection of Cryptococcus antigen in serum by lateral flow assay (CrAg LFA) without nervous system involvement and with treatment in accordance with the results. MATERIALS AND METHODS: A retrospective, longitudinal, analytical study was performed. Seventy patients with cryptococcosis initially diagnosed by serum CrAg LFA without meningeal involvement between January 2019 and April 2022 were analyzed for medical records. The treatment regimen was adapted to the results of blood culture, respiratory material, and pulmonary tomography imaging. RESULTS: Seventy patients were included, 13 had probable pulmonary cryptococcosis, 4 had proven pulmonary cryptococcosis, 3 had fungemia, and 50 had preemptive therapy without microbiological or imaging findings compatible with cryptococcosis. Among the 50 patients with preemptive therapy, none had meningeal involvement or cryptococcosis recurrences to date. CONCLUSION: Preemptive therapy avoided progression to meningitis in CrAg LFA-positive patients. Preemptive therapy with dose adjustment of fluconazole in patients with the mentioned characteristics was useful despite the use of lower doses than recommended.

Aspergilosis invasiva: definiciones, diagnóstico y tratamiento / Invasive aspergillosis: definitions, diagnosis, and treatment

Resumen La aspergilosis invasiva (AI) es una enfermedad grave y con alta mortalidad. Existen factores de riesgo y se describen brotes intrahospitalarios relacionados con construcciones. También se des cribe una entidad relacionada con la infección por COVID-19, conocida como aspergilosis pulmonar asociada a COVID-19 (APAC). Es de vital importancia implementar un tratamiento adecuado y precoz, especialmente en pacientes inmunocomprometidos y críticamente enfermos. El diagnóstico se basa en reconocer los factores predisponentes, la clínica, la obtención de imágenes, exámenes directos, cultivos, histopatología y biomarca dores como el galactomanano. La droga de elección es el voriconazol, pero se deben conocer las alternativas terapéuticas dada la creciente presencia de aislamientos resistentes.

Abstract Invasive aspergillosis (IA) is a serious disease with high mortality. There are several risk factors and in-hospital outbreaks related with construction have been described. An entity related to COVID-19 infection, known as COVID-19 associated pulmonary aspergillosis (CAPA), has recently appeared. Early and appropriate treatment is of paramount importance, especially in immunocompromised and critically ill patients. Diagnosis is based on recognition of predisposing factors, clinical signs, imaging, direct examination, culture, histopathology, and biomarkers such as galactomannan. The drug of choice is voriconazole, but alternative therapies must be taken into account given the increasing presence of resistant isolates.

[Invasive aspergillosis: definitions, diagnosis, and treatment]. / Aspergilosis invasiva: definiciones, diagnóstico y tratamiento.

Invasive aspergillosis (IA) is a serious disease with high mortality. There are several risk factors and in-hospital outbreaks related with construction have been described. An entity related to COVID-19 infection, known as COVID-19 associated pulmonary aspergillosis (CAPA), has recently appeared. Early and appropriate treatment is of paramount importance, especially in immunocompromised and critically ill patients. Diagnosis is based on recognition of predisposing factors, clinical signs, imaging, direct examination, culture, histopathology, and biomarkers such as galactomannan. The drug of choice is voriconazole, but alternative therapies must be taken into account given the increasing presence of resistant isolates.

La aspergilosis invasiva (AI) es una enfermedad grave y con alta mortalidad. Existen factores de riesgo y se describen brotes intrahospitalarios relacionados con construcciones. También se describe una entidad relacionada con la infección por COVID-19, conocida como aspergilosis pulmonar asociada a COVID-19 (APAC). Es de vital importancia implementar un tratamiento adecuado y precoz, especialmente en pacientes inmunocomprometidos y críticamente enfermos. El diagnóstico se basa en reconocer los factores predisponentes, la clínica, la obtención de imágenes, exámenes directos, cultivos, histopatología y biomarcadores como el galactomanano. La droga de elección es el voriconazol, pero se deben conocer las alternativas terapéuticas dada la creciente presencia de aislamientos resistentes.

Utilidad del recuento de unidades formadoras de colonia de Cryptococcus sp. en líquido cefalorraquídeo de pacientes con criptococosis meníngea asociada al sida / Cryptococcus' colony forming unit count usefulness

Antecedentes: El recuento de unidades formadoras de colonia (UFC) de Cryptococcus en el líquido cefalorraquídeo (LCR) sería un marcador fiable para el pronóstico del paciente y una herramienta simple y económica. Objetivo: Evaluar la utilidad del recuento de UFC de Cryptococcus spp. y compararlo con las variaciones de antígeno capsular de Cryptococcus (AgCr) en LCR.Materiales y métodos: Se realizó la revisión de historias clínicas de pacientes con meningoencefalitis por Cryptococcus asociada con el sida en nuestro centro, entre febrero de 2016 y julio de 2020. Se evaluaron los valores de UFC y AgCr en LCR durante la evolución de la micosis. Resultados y discusión: Se analizaron datos de 94 episodios clínicos de 85 pacientes, con un total de 297 observaciones de muestras de LCR. Se evidenció el valor del recuento de UFC por ser un marcador de viabilidad y de carga fúngica. El recuento de UFC bajo no necesariamente coexistió con un nivel bajo de AgCr. Con respecto a la evolución en el tiempo, la mayoría de los pacientes fueron diagnosticados con una alta carga fúngica y su descenso ocurrió más rápido que el del AgCr, por lo que reflejaría la mejora del paciente, permitiendo tomar conductas al respecto.Palabras clave: Criptococosis, carga fúngica, ufc/mL.

Background. The Cryptococcus' colony-forming unit (CFU) count in cerebrospinal fluid (CSF) would be a reliable marker for patient prognosis and a simple and inexpensive tool. Objectives: To evaluate the usefulness of the CFU count of Cryptococcus spp. And to compare it with the variations of Cryptococcus' capsular antigen (CrAg) in CSF.Materials and methods. Clinical records of patients with aids-related meningoencephalitis caused by Cryptococcusassisted in our center between February 2016 and July 2020 were reviewed. CFU count and CrAg values in CSF were evaluated during the evolution of the mycosis.Results and Discussion. Data from 94 clinical episodes of 85 patients with a total of 297 observations of CSF samples were analyzed.The importance of using the CFU count was evidenced as it is a viability and fungal load marker.Low CFU count did not necessarily coexist with low CrAg.Regarding the evolution over time, most of the patients were diagnosed with a high fungal load and its decrease occurred faster than that the one of AgCr. This would reflect the improvement of the patient, allowing behaviors to be taken in this regard

Características clínicas, métodos diagnósticos y evolución de la criptococosis extrameníngea en personas viviendo con VIH / Clinical features, diagnosis methods and evolution in non meningeal cryptococcosis in people living with VIH

La criptococosis es una micosis grave que se manifiesta, en el 90% de los casos, como una meningoencefalitis, especialmente en las personas con VIH. El objetivo de este estudio es describir los casos de criptococosis extrameníngea en personas viviendo con VIH y conocer cuántas de estas padecen compromiso meníngeo concomitante. Además, determinar la relación con el título de antígeno polisacárido capsular de Cryptococcus en suero. Se realizó un estudio retrospectivo, observacional y analítico. Se incluyeron personas viviendo con VIH cuyo diagnóstico inicial de criptococosis se había realizado a partir de muestras extrameníngeas en el período comprendido entre 2012 y 2019. Los pacientes se dividieron en dos grupos. Grupo 1, pacientes sin compromiso meníngeo; Grupo 2, aquellos que finalmente tenían compromiso del SNC. De un total de 531 criptococosis registradas en ese período, se incluyeron 113 pacientes (21%), de los cuales en 58 se comprobó el compromiso meníngeo. No se observaron diferencias significativas en cuanto a la mortalidad entre ambos grupos.Ninguno de los pacientes con antigenemia por LFA (antígeno capsular en suero por inmunocromatografía) positiva, pero con antigenemia por aglutinación de partículas de látex (AL) negativa, tuvo compromiso meníngeo. Se observó que títulos de antígeno para Cryptococcus en suero por AL mayor o igual a 1/100 se correlacionaron con un aumento de 30 veces en la posibilidad de padecer meningitis. En todos los casos se debe descartar el compromiso del SNC. La AL sigue siendo una prueba útil y complementaria, debido a que en los casos con AL negativa no se observó compromiso meníngeo

Cryptococcosis is a serious mycosis that manifests itself, in 90% of cases, as meningoencephalitis, especially in AIDS patients. The objective of this study is to describe the extra-meningeal cases of cryptococcosis in people living with HIV and to know how many of them suffer from concomitant meningeal involvement. Also, to determine its relationship with the Cryptococcus capsular polysaccharide antigen titer in serum.A retrospective, observational and analytical study was carried out. HIV-positive patients whose initial diagnosis had been made from extrameningeal samples in the period between 2012 and 2019 were included. The patients were divided into 2 groups. Group 1: patients without meningeal involvement; group 2: those who finally had CNS involvement.Of a total of 531 cryptococcosis registered in this period, 113 patients (21%) were included, of whom meningeal involvement was confirmed in 58. No significant differences were observed in terms of mortality in both groups.None of the patients with positive LFA antigenemia (Capsular antigen detection by lateral Flow assay) but negative latex particle agglutination (LA) antigenemia had meningeal involvement. LFA was found to be highly sensitive and allows early diagnosis, but it does not replace other diagnostic procedures.Serum Cryptococcus antigen titers for by LA greater than or equal to 1/100 were found to correlate with a 30-fold increase in the likelihood of meningitis.In all cases, CNS involvement must be ruled out. LA continues to be a useful and complementary test, because in cases with negative LA, no meningeal involvement was observed

Chronic recurrent vulvovaginitis is not only due to Candida.

BACKGROUND: Recurrent vulvovaginitis is a growing problem that affects millions of women worldwide. In many cases it is treated as vulvovaginal candidiasis, but there is not always microbiological confirmation. AIMS: To determine the etiology of vulvovaginitis in a group of patients. METHODS: This is a cross-sectional study in which the data from the medical records of 316 adult patients who consulted for vulvovaginitis were analyzed. Eighty nine percent of the cases had already suffered previous episodes. RESULTS: The median age was 34 (265 patients were between 16 and 45 years old). Yeasts were isolated in culture from 211 (66.8%) patients, although pseudo-hyphae and yeasts were observed in only 166 samples (52.5%) in the direct microscopic examination. Multiple predisposing factors were found, among which the use of contraceptives or previous antibiotics stand out. Most of the patients (almost 90%) had been treated with antifungals, with or without microbiological confirmation. Candida albicans was isolated in 187 (88.6%) patients, followed by Candida glabrata in 6 (2.8%) patients. Association with bacterial vaginosis was found in 35.1% and with intermediate bacterial microbiota in 33.2% of the cases. A remarkably high proportion of C. albicans isolates resistant to fluconazole (80.1%) and itraconazole (58.8%) was found. CONCLUSIONS: A microbiological analysis is essential to confirm the diagnosis of vulvovaginal candidiasis, whether simple, complicated, or recurrent. Identifying the isolated yeast species and determining its susceptibility to antifungal agents are particularly important.

Problemas clínicos en Micología Médica: problema número 55 / Clinical problems in Medical Mycology: problem number 55

Paciente de 31 años y sexo femenino que nació y vivió en la Ciudad Autónoma de Buenos Aires, Argentina, en vivienda con sanitarios completos y necesidades básicas satisfechas. Refirió haber realizado viajes a la costa atlántica (provincia de Buenos Aires). Fue fumadora de 10 cigarrillos al día desde los 18 hasta los 30 años. No consumía alcohol. Como antecedentes acerca de su estado de salud solo dijo haber padecido varicela en la infancia. Acudió a la consulta por disnea clase funcional II/III de 3 semanas de evolución y fiebre durante los últimos 3 días

A 31-year-old woman, with signs of HIV infection (oral thrush, weight loss, asthenia) presented to our hospital with dyspnea and fever. A rapid HIV test yielded a positive result, and cryptococcal capsular antigen was detected in serum. In the mycological study of the clinical respiratory samples, yeasts compatible with Cryptococcus were observed under light microscope in a wet mount; structures compatible with Pneumocystis jirovecii were also observed in Giemsa stain. Treatment for both pathologies was prescribed but, unfortunately, the patient died 7 days after. The finding of two etiologic agents in the same clinical picture is rare but not exceptional, and it always must be considered in immunocompromised hosts

Tongue lesion due to Cryptococcus neoformans as the first finding in an HIV-positive patient / Lesión lingual por Cryptococcus neoformans como primer hallazgo clínico en una paciente VIH positiva

BACKGROUND: Cryptococcosis is a severe universally distributed mycosis which mainly affects immunocompromised hosts. This mycosis is caused by yeasts of two species complex of the genus Cryptococcus: Cryptococcus neoformans and Cryptococcus gattii. Meningeal cryptococcosis is the most frequent clinical presentation of this disseminated mycosis. The oral mucosa involvement is extremely unusual. CASE REPORT: We present a case of cryptococcosis with an unusual clinical form. The patient was assisted because she had an ulcerated lesion on the lingual mucosa. Encapsulated yeasts compatible with Cryptococcus were found in microscopic exams of wet preparations from lingual ulcer clinical samples obtained for cytodiagnosis and mycological studies. Cryptococcus neoformans (C. neoformans var. grubii VNI) was isolated in culture. This patient did not know her condition of HIV seropositive before the appearance of the tongue lesion. CONCLUSIONS: The involvement of the oral mucosa is uncommon in this fungal infection, but is important to include it in the differential diagnosis in HIV positive patients

ANTECEDENTES: La criptococosis es una micosis grave de distribución universal que afecta principalmente a los huéspedes inmunodeficientes. Se han definido dos complejos de especies patógenas: Cryptococcus neoformans y Cryptococcus gattii. La meningoencefalitis es la presentación clínica más frecuente de esta micosis sistémica. La afectación de la mucosa oral es extremadamente rara. CASO CLÍNICO: Presentamos el caso de una paciente VIH positiva con una forma clínica inusual de criptococosis. La enferma presentaba una lesión ulcerada en la punta de la lengua. El examen microscópico en fresco de la escarificación y de la biopsia de esta lesión mostraron levaduras capsuladas compatibles con Cryptococcus. Se obtuvo Cryptococcus neoformans (C. neoformans var. grubii VNI) en los cultivos. La paciente conoció su estado inmunológico (infección por VIH) en el contexto de esta enfermedad oportunista. CONCLUSIONES: La afectación de la mucosa oral es poco común en esta infección fúngica, pero es importante incluirla en el diagnóstico diferencial en pacientes VIH positivos

[Tinea capitis: clinical features and therapeutic alternatives]. / Tinea capitis: aspectos clínicos y alternativas terapéuticas.

A descriptive observational and cross-sectional study was carried out. The clinical characteristics, etiologic agents, treatments and outcome of 33 cases of tinea capitis in the Mycology Unit at Francisco J. Muñiz Hospital of Buenos Aires City between January 2015 and December 2019 were analyzed. The median age of the patients was 7 years, 21 of whom were male, 3 were HIV-positive and 22 had pets. The isolated etiologic agents were the following: Microsporum canis in 22 cases, Trichophyton tonsurans in 8, Nannizzia gypsea in 2 and Trichophyton mentagrophytes in one patient. Suppurative tinea capitis (krion Celsi) was detected in 10 cases and the same number of patients presented other skin locations of their dermatophytosis in addition to those in the scalp. Twenty-one cases were orally treated with griseofulvin and 12 with terbinafine. Those patients with suppurative tinea capitis received drops of betamethasone by mouth besides the antifungal drugs. All patients had good clinical and mycological response to the treatments, all lesions disappeared, and mycological studies turned negative by the end of the treatments. We conclude that both drugs were effective for the treatment of tinea capitis; however, lesions in those cases receiving terbinafine involuted more slowly.

[Clinical problems in Medical Mycology: problem number 55]. / Problemas clínicos en Micología Médica: problema número 55.

A 31-year-old woman, with signs of HIV infection (oral thrush, weight loss, asthenia) presented to our hospital with dyspnea and fever. A rapid HIV test yielded a positive result, and cryptococcal capsular antigen was detected in serum. In the mycological study of the clinical respiratory samples, yeasts compatible with Cryptococcus were observed under light microscope in a wet mount; structures compatible with Pneumocystis jirovecii were also observed in Giemsa stain. Treatment for both pathologies was prescribed but, unfortunately, the patient died 7 days after. The finding of two etiologic agents in the same clinical picture is rare but not exceptional, and it always must be considered in immunocompromised hosts.

Tongue lesion due to Cryptococcus neoformans as the first finding in an HIV-positive patient.

BACKGROUND: Cryptococcosis is a severe universally distributed mycosis which mainly affects immunocompromised hosts. This mycosis is caused by yeasts of two species complex of the genus Cryptococcus: Cryptococcus neoformans and Cryptococcus gattii. Meningeal cryptococcosis is the most frequent clinical presentation of this disseminated mycosis. The oral mucosa involvement is extremely unusual. CASE REPORT: We present a case of cryptococcosis with an unusual clinical form. The patient was assisted because she had an ulcerated lesion on the lingual mucosa. Encapsulated yeasts compatible with Cryptococcus were found in microscopic exams of wet preparations from lingual ulcer clinical samples obtained for cytodiagnosis and mycological studies. Cryptococcus neoformans (C. neoformans var. grubii VNI) was isolated in culture. This patient did not know her condition of HIV seropositive before the appearance of the tongue lesion. CONCLUSIONS: The involvement of the oral mucosa is uncommon in this fungal infection, but is important to include it in the differential diagnosis in HIV positive patients.

Problemas clínicos en micología médica: problema número 54 / Clinical problems in medical mycology: problem number 54

No disponible

A 26 year_old woman, who had been submmited to a classic cholecystectomy for a lithic cholecystitis, was admitted in the Hepathology Unit of the F. J. Muniz Hospital of Buenos Aires City, due to persistent jaundice, weight loss, asthenia, arterial hypotension, ascites and periumbilical ulcer. These skin lesions were located under an adhesive tape which was around a Kehr tube. Laboratory studies showed anemia, hyperbilirrubinemia, increased level of hepatic enzymes and a positive anti-mitochondrial antibodies test 1/80. The diagnosis of her liver disease was autoimmune hepatitis and the patient received corticosteroid treatment by oral route. The microbiological study of the skin lesions showed hyaline, wide, non_septate hyphae in the microscopic study, and Rhizopus arrhizus was isolated in cultures. Colloidal dispersion of amphotericin B at a daily dose of 5 mg/kg intravenously was administered and a surgical debridement of the cutaneous lesions was done. Skin lesions improved with this treatment, but her hepatic condition turned worse and evolved to a fatal hepatic insufficiency. She could not receive a liver transplant due to the lack of a compatible donor

Onicomicosis en paciente inmunocompetente por Aspergillus sección Candidi / Onychomycosis in immunocompetent patient by Aspergillus section Candidi

Introducción: los hongos miceliales no dermatofitos (HMND) pueden causar un gran número de infecciones, entre ellas, la onicomicosis. Su implicancia como agentes patógenos y su significado clínico en esta afección, se encuentran sujetos al cumplimiento de los criterios de Walshe y Mary P. English. Presentamos un caso de onicomicosis causada por un hongo hifomiceto poco frecuente, del género Asper-gillus sección Candidi, en una paciente inmunocompetente y su estrategia terapéutica. Materiales y métodos: se estudió una paciente inmunocompetente, de 43 años de edad, con lesión en uña de primer dedo del pie derecho, de 10 años de evolución. Se realizó toma de muestra para examen micológico. Resultados: el examen directo reveló la presencia de hifas hialinas irregulares, ramificadas y tabica-das, compatibles con HMND. En muestras seriadas, desarrollaron colonias blanco algodonosas, cuya micromorfología fue concordante con Aspergillus sección Candidi. La identificación fue confirmada en la Unidad de Micología del Hospital de Infecciosas Francisco Javier Muñiz de la Ciudad Autónoma de Buenos Aires, Argentina. Allí también se realizaron pruebas de sensibilidad a antifúngicos, resultando sensible a itraconazol y terbinafina. Conclusión: exponemos un caso de onicomicosis causada por Aspergillus sección Candidi, HMND no queratinolítico, de escasa frecuencia de aparición, siendo el primer caso descripto y publicado en Argentina. También se planteó una estrategia terapéutica efectiva, que condujera a la cura clínica y microbiológica, de la uña de la paciente.

Introduction: non-dermatophyte mycelial fungi (HMND) can cause a large number of infections, including onychomycosis. Its implica-tion as pathogens and its clinical significance in this condition are subject to compliance with Walshe's and Mary P. English's criteria. We present a case of onychomycosis caused by hyphomycete rare fungus, of the genus Aspergillus section Candidi, in an immunocompetent patient and its therapeutic strategy. Materials and methods: a 43-year-old immunocompetent patient with a 10-year-old right-toe nail lesion was studied. Samples were taken for mycological examination. Results: the direct examination revealed the presence of irregu-lar, branched and tabulated hyaline hyphae, compatible with HMND. In serial samples, they developed white cotton colonies, whose micromorphology was consistent with Aspergillus, section Candidi. The identification was confirmed at the Mycology Unit of Francisco Javier Muñiz Infectious Hospital in the Autonomous City of Buenos Aires, Argentina. Susceptibility to antifungals was also tested there, resulting in susceptibility to itraconazole and terbinafine. Conclusion: we present a case of onychomycosis caused by Aspergillus section Candidi, non-keratinolytic HMND, of rare occurrence, being the first case described and published in Argentina. An effective therapeutic strategy was also proposed that led to the patient's toenail's clinical and microbiological cure.

Genomic diversity of the human pathogen Paracoccidioides across the South American continent.

Paracoccidioidomycosis (PCM) is a life-threatening systemic mycosis widely reported in the Gran Chaco ecosystem. The disease is caused by different species from the genus Paracoccidioides, which are all endemic to South and Central America. Here, we sequenced and analyzed 31 isolates of Paracoccidioides across South America, with particular focus on isolates from Argentina and Paraguay. The de novo sequenced isolates were compared with publicly available genomes. Phylogenetics and population genomics revealed that PCM in Argentina and Paraguay is caused by three distinct Paracoccidioides genotypes, P. brasiliensis (S1a and S1b) and P. restrepiensis (PS3). P. brasiliensis S1a isolates from Argentina are frequently associated with chronic forms of the disease. Our results suggest the existence of extensive molecular polymorphism among Paracoccidioides species, and provide a framework to begin to dissect the connection between genotypic differences in the pathogen and the clinical outcomes of the disease.

Inherited CARD9 Deficiency in a Patient with Both Exophiala spinifera and Aspergillus nomius Severe Infections.

PURPOSE: Caspase-associated recruitment domain-9 (CARD9) deficiency is an inborn error of immunity that typically predisposes otherwise healthy patients to single fungal infections and the occurrence of multiple invasive fungal infections is rare. It has been described as the first known condition that predisposes to extrapulmonary Aspergillus infection with preserved lungs. We present a patient that expands the clinical variability of CARD9 deficiency. MATERIALS AND METHODS: Genetic analysis was performed by Sanger sequencing. Neutrophils and mononuclear phagocyte response to fungal stimulation were evaluated through luminol-enhanced chemiluminescence and whole blood production of the proinflammatory mediator interleukin (IL)-6, respectively. RESULTS: We report a 56-year-old Argentinean woman, whose invasive Exophiala spinifera infection at the age of 32 years was unexplained and reported in year 2004. At the age of 49 years, she presented with chronic pulmonary disease due to Aspergillus nomius. After partial improvement following treatment with caspofungin and posaconazole, right pulmonary bilobectomy was performed. Despite administration of multiple courses of antifungals, sustained clinical remission could not be achieved. We recently found that the patient's blood showed an impaired production of IL-6 when stimulated with zymosan. We also found that she is homozygous for a previously reported CARD9 loss-of-function mutation (Q289*). CONCLUSIONS: This is the first report of a patient with inherited CARD9 deficiency and chronic invasive pulmonary aspergillosis (IPA) due to A. nomius. Inherited CARD9 deficiency should be considered in otherwise healthy children and adults with one or more invasive fungal diseases.

Problemas clínicos en micología médica: problema número 53 / Clinical problems in medical mycology: problem number 53

Paciente de 21 años, de sexo masculino, infectado por el VIH y que no sigue adecuadamente el tratamiento antirretroviral, que acude a consulta debido a una erupción papular en el tronco y las extremidades, acompañada de manera simultánea por manchas hipocrómicas en la espalda. El paciente estaba afebril y hemodinámicamente estable. En el estudio micológico de las muestras clínicas de diferentes lesiones se observaron levaduras compatibles con Malassezia. Se prescribió itraconazol por vía oral, con una excelente respuesta clínica. El hallazgo del mismo agente etiológico con 2 presentaciones clínicas diferentes en un solo paciente es poco habitual

A 21 year-old man, HIV infected, and with poor adherence to antiretroviral treatment, consulted us due to a papular rash on trunk and extremities, showing simultaneously hypochromic stains on his back. He was afebrile and hemodynamically stable. In the mycological study of the clinical samples taken from different lesions, yeasts compatible with Malassezia were observed. Oral itraconazole was prescribed, with an excellent clinical response. Finding the same etiolologic agent in 2 different clinical pictures on a single patient is extremely rare