Human Q Fever on the Guiana Shield and Brazil: Recent Findings and Remaining Questions.

PURPOSE OF REVIEW: In this review, we report on the state of knowledge about human Q fever in Brazil and on the Guiana Shield, an Amazonian region located in northeastern South America. There is a contrast between French Guiana, where the incidence of this disease is the highest in the world, and other countries where this disease is practically non-existent. RECENT FINDINGS: Recent findings are essentially in French Guiana where a unique strain MST17 has been identified; it is probably more virulent than those usually found with a particularly marked pulmonary tropism, a mysterious animal reservoir, a geographical distribution that raises questions. SUMMARY: Q fever is a bacterial zoonosis due to Coxiella burnetii that has been reported worldwide. On the Guiana Shield, a region mostly covered by Amazonian forest, which encompasses the Venezuelan State of Bolivar, Guyana, Suriname, French Guiana, and the Brazilian State of Amapá, the situation is very heterogeneous. While French Guiana is the region reporting the highest incidence of this disease in the world, with a single infecting clone (MST 117) and a unique epidemiological cycle, it has hardly ever been reported in other countries in the region. This absence of cases raises many questions and is probably due to massive under-diagnosis. Studies should estimate comprehensively the true burden of this disease in the region.

Infecciones fúngicas en pacientes infectados por VIH en el Complejo Hospitalario Universitario "Ruiz y Páez"

Introducción: Las infecciones fúngicas constituyen una causa importante de morbilidad y mortalidad en individuos infectados con el VIH. Objetivo: Determinar la prevalencia de infecciones fúngicas, en pacientes hospitalizados con infección por VIH, en el Complejo Hospitalario "Ruiz y Páez", Ciudad Bolívar, Estado Bolívar, Venezuela. Métodos: Se realizó un estudio, descriptivo, transversal y prospectivo. Previo consentimiento informado, se recogieron los datos de interés epidemiológico y clínico. La muestra estuvo representada por aquellos sujetos con infección fúngica demostrada. Se tomaron muestras de sangre, esputo, médula ósea, mucosa oral, LCR, orina y heces. Se practicaron cultivos: bacterianos y micológicos; análisis coproparasitológico (examen directo de heces, métodos de concentración (Kato-Katz y formol-Éter), coloración de Kinyoun y Tricrómica modificada Ryan Blue). Además, coloraciones especiales: Giemsa, Grocott (metanamina argéntica) en muestras de aspirado de médula ósea y esputo así como inmunofluorescencia directa para P. jirovecii y estudio serológico para la demostración de antígenos (Cryptococcus) y anticuerpos específicos contra Aspergillus sp, Histoplasma y Paracoccidioides sp. Resultados: La prevalencia de infecciones fúngicas fue del 35,7 %, siendo la candidiasis orofaríngea (60 %), histoplasmosis (20 %), paracoccidioidomicosis (13,3 %) las predominantes. La neumocistosis y criptococosis fueron poco frecuentes (6,7 %). Las patologías asociadas fueron: tuberculosis (13,3 %), neumonía bacteriana (13,3 %), leishmaniasis (6,7 %), sarcoma de Kaposi (6,7 %) y toxoplasmosis (6,7 %). En 6,7 %, se demostró amebiasis, estrongiloidiasis, giardiasis y blastocistosis. Conclusiones: La prevalencia de infecciones fúngicas en los pacientes con infección por el VIH/SIDA en el Complejo Hospitalario Universitario "Ruiz y Páez" es elevada (35,7 %), siendo la candidiasis, histoplasmosis y paracoccidioidomicosis las micosis más frecuentes.

Introduction: Fungal infections are a major cause of morbidity and mortality in subjects with HIV. Objective: To determine the prevalence of fungal infections in hospitalized patients with HIV infection in the "Ruiz y Paez" Hospital Complex, Ciudad Bolivar, Bolívar State, Venezuela. Methods: A descriptive, cross-sectional and prospective study was conducted. Once written informed consent had been obtained, data of epidemiological and clinical interest was collected subjects with proven fungal infection were studied. Samples of blood, sputum, bone marrow, oral mucosa, urine and faeces were collected. Cultures and coproparasitologic analysis: direct examination of stool, concentration methods (Kato-Katz and formol-ether, Kinyoun stain, Trichromic stain and Ryan Blue modified Trichromic stain were performed. Special stains used like: Giemsa, Grocott (methenamine silver) in samples of bone marrow aspirate and sputum, as well as direct immunofluorescence for P. jirovecii were also used. Results: Prevalence of fungal infections was 35.7.%. Oropharyngeal candidiasis (60.%), histoplasmosis (20.%), paracoccidioidomycosis (13.3 %) and cryptococcosis were demonstrated. Pneumocystosis was uncommon (6.7 %). Among the diagnoses associated to fungal infection, tuberculosis (13.3 %), bacterial pneumonia (13.3 %), leishmaniasis (6.7 %), Kaposi sarcoma (6.7 %) and toxoplasmosis (6.7.%) were shown. Amoebiasis, strongyloidiasis, giardiasis and blastocystosis were demonstrated in 6.7 % of patients. Conclusions: Prevalence of fungal infections in patients with HIV/AIDS in the "Ruiz y Paez" University Hospital Complex was high (35.7 %). Candidiasis, histoplasmosis and paracoccidioidomycosis were the most frequent mycoses demonstrated.

Sensibilidad in vitro a fluconazol y voriconazol de especies de Candida aisladas de las manos de trabajadores de salud y pacientes / In vitro susceptibility to fluconazole and voriconazole of Candida species isolated from the hands of health care workers and patients

Las manos del personal de salud se consideran importantes para la colonización e infección por Candida spp. El objetivo del estudio fue determinar la prevalencia y distribución de levaduras aisladas en las manos de trabajadores de salud y algunos pacientes, así como su sensibilidad in vitro frente al fluconazol y voriconazol. El estudio se realizó en tres servicios del Complejo Hospitalario Universitario “Ruíz y Páez”: unidad de cuidados intensivos, retén patológico y retén sano. El estudio de sensibilidad se realizó mediante el método de difusión con discos (Documento M44-A2). Se obtuvieron 79 aislamientos, de los cuales el 50,6% fue Candida albicans y el 49,4% especies no albicans. Las especies no albicans predominantes fueron C. tropicalis (n=25; 31,6%) seguidas del Complejo C. parapsilosis (n=13; 16,5%). El 87,3% y 91,1% de los aislados fue sensible al fluconazol y voriconazol, respectivamente. El 11,4% y 6,3% fue resistente al fluconazol y al voriconazol. Los resultados de este estudio demuestran que el estado de portador de levaduras en las manos del personal de salud es importante, por lo tanto es indispensable educarlos sobre el lavado adecuado de las manos, uso de guantes y uso de antisépticos para evitar o minimizar la posibilidad de transmisión de estos agentes.

The hands of health care workers are considered important for colonization and infection by Candida spp. The aim of the study was to determine the prevalence and distribution of yeasts isolated from the hands of health personnel and some patients and their in vitro susceptibility to fluconazole and voriconazole. The study was conducted in three services of the Hospital Universitario “Ruiz y Páez”: Neonatal Intensive Care Unit and Healthy and Pathologic Newborn Units. The susceptibility tests were performed by the disk diffusion method (document M44-A2). A total of 79 isolates were obtained, of which 50.6% were Candida albicans and 49.4% non-albicans species. Among the non-albicans species were C. tropicalis (n = 25; 31.6%) followed by C. parapsilosis complex (n = 13; 16.5%). 87.3% and 91.1% of isolates were sensitive to fluconazole and voriconazole, respectively. 11.4% and 6.3% were resistant to fluconazole and voriconazole. The results of this study demonstrate the importance of the carriage of yeasts in the hands of health personnel; therefore it is essential to educate them about proper hand washing, use of gloves and antiseptic products to prevent or minimize the transmission of these agents.

Sensibilidad in vitro de aislados del complejo Paracoccidioides spp a antifúngicos sistémicos utilizando el método de microdilución / In vitro susceptibility of isolates of Paracoccidioides spp complex to systemic antifungals using the microdilution method

El método de referencia, microdilución en caldo, recomendado por el Instituto de Estándares Clínicos y de Laboratorios (CLSI), no está disponible para hongos dimórficos, como los del género Paracoccidioides. En este trabajo se evaluó la sensibilidad in vitro del Complejo Paracoccidoides (n=19) frente a los antifúngicos sistémicos: anfotericina B, 5-fluorocitosina, ketoconazol, itraconazol, fluconazol, voriconazol y caspofungina empleando el método de microdilución (Documento M27-A3 y M27-S3), con algunas modificaciones: tiempo de cultivo en medio de Sabouraud dextrosa agar (7-10 días), medio RPMI 1640 suplementado con glucosa al 2%, tiempo de incubación (7, 8 y 18 días). La sensibilidad in vitro fue variable; la mayoría de los aislados de Paracoccidioides fueron sensibles a ketoconazol (73,7%), seguido de voriconazol (68,4%), itraconazol (63,1%), anfotericina B (52,6%), fluconazol (47,4%), 5-fluorocitosina (42,1%) y caspofungina (5%). La resistencia global fue mayor ante caspofungina (94,7%), seguido de 5-fluorocitocina (52,6%) and anfotericina B (47,4%). El 53% de los aislados fue sensible dosis dependiente a fluconazol, 15,7%, itraconazol y 5,3% a 5-fluorocitosina. Anfotericina B, itraconazol y voriconazol fueron los antifúngicos más potentes contra Paracoccidioides spp (CMI: 0,03-1µg/mL). Basándose en estos resultados, se propone tentativamente un protocolo de ensayo de microdilución para las pruebas de sensibilidad de Paracoccidioides spp frente a fármacos antimicóticos. Esta metodología podría ser clínicamente útil para predecir el desarrollo de resistencias, aunque son necesarios más estudios.

Broth microdilution, the reference method recommended by the Clinical Laboratory Standards Institute (CLSI), is not available for use with dimorphic fungi, such as those of the Paracoccidioides genus. In this work, in vitro susceptibility of the Paracoccidioides complex (n=19) to systemic antifungals: amphotericin B, 5-flucytosine, ketoconazole, itraconazole, fluconazole, voriconazole and caspofungin, was evaluated using the microdilution method (Document M27-A3, M27-S3), with some modifications such as: culture time in Sabouraud dextrose agar (7-10 days), RPMI 1640 medium supplemented with 2% glucose and the incubation time (7, 8 and 18 days). The sensitivity in vitro was variable; the majority of Paracoccidioides isolates was susceptible to ketoconazol (73.7%), followed by voriconazole (68.4%), itraconazole (63.1%), amphotericin B (52.6%), fluconazole (47.4%), 5-flucytosine (42.1%) and caspofungin (5%). The overall resistance was mainly to caspofungin (94.7%), followed by 5-flucytosine (52.6%) and amphotericin B (47.4%). Fifty-three percent of the isolates were susceptible-dose dependent to fluconazole followed by itraconazole (15.7%) and 5-fluorocytosine (5.3%). Amphotericin B, itraconazole and voriconazole were the most potent antifungal drugs against Paracoccidioides spp (CMI: 0.03-1µg/mL). Based on these results, we tentatively propose a microdilution assay protocol for susceptibility testing of Paracoccidioides spp to antifungal drugs. This method may be clinically useful to predict resistance, even though further studies are needed.

Tuberculosis y micosis sistémicas en indígenas del Municipio Cedeño Estado Bolívar Venezuela / Tuberculosis and systemic mycoses in indigenous Cedeño Municipality Bolivar State Venezuela

Determinar la prevalencia de tuberculosis y micosis sistémicas endémicas, Paracoccidioidomicosis e Histoplasmosis, en poblaciones indígenas. Se realizó un estudio transversal en pacientes sintomáticos respiratorios de 3 comunidades indígenas del municipio Cedeño del estado Bolívar, Venezuela. Se obtuvieron muestras de esputo y secreción ganglionar para la búsqueda de bacilos ácido-resistentes, el complejo Paracoccidioides sppe Histoplasma capsulatum; se realizó cultivo en medio Lowëstein Jensen y medios selectivos para hongos, además estudio molecular para micobacterias. Se estudiaron muestras de suero para la demostración de anticuerpos específicos contra el Complejo Paracoccidioides sppe H. capsulatum. Se evaluaron 60 pacientes sintomáticos respiratorios. Se demostraron bacilos ácido-resistentes por baciloscopia en 26 casos (43,3%) y 29 cultivos positivos para Mycobacterium tuberculosis (48,3%) resultando un total de 33 pacientes con diagnóstico de tuberculosis; hubo correlación significativa entre los hallazgos en el Ziehl-Nielsen y el crecimiento de M. tuberculosis en cultivo (p=0,013). Se demostró la presencia del Complejo Paracoccidioides spp en 2 casos (3,3%), con coexistencia de bacilos ácido-resistentes. No se evidenció la presencia de H. capsulatum. La tuberculosis constituye la principal causa de infección respiratoria crónica en estas comunidades indígenas y obliga a que se revisen de forma urgente los programas regionales para la atención de estas poblaciones vulnerables, así como a realizar estudios en otras poblaciones.

To determine prevalence of tuberculosis and endemic systemic mycoses, Paracoccidiodomycosis (PCM) and Hystoplasmosis in native populations. A transversal study in individuals with respiratory symptoms from 3 native populations from Cedeño County from Bolivar state, Venezuela, was realized. Sputum and spontaneous lymphatic node secretion samples were obtained to look for acid-resistant bacilli, Paracoccidioides spp complex and Histoplasma capsulatum. Culture in Lowëstein-Jensen and selective media to fungi, andmolecular study formycobacteria were realized. Serum samples were studied to demonstrate specific antibodies against Paracoccidioides spp complex and H. capsulatum. Sixty individuals had respiratory symptoms. Acid-resistant bacilli were demonstrated in 26 cases by bacilloscopy (43.3%) and 29 positive cultures for Mycobacterium tuberculosis (48.3%), resulting 33 patients with diagnosis of tuberculosis; there was significative correlation between features in bacilloscopy and growing of M. Tuberculosis in Lowëstein-Jensen media (p=0.013). Presence of the characteristic yeastlike forms of Paracoccidioides spp complex was found in 2 cases (3.3%) with coexistence of acidresistant bacilli in both. There was no evidence of H. capsulatum. Tuberculosis constitutes the principal origin of chronic respiratory infection in these native populations and it should conduce to revise urgently the regional programs attending to these vulnerable populations.

Seroprevalencia de citomegalovirus (CMV) en pacientes infectados con el virus de inmunodeficiencia humana (VIH) en el estado Bolívar, Venezuela / Cytomegalovirus (CMV) seroprevalence in patients infected with human immunodeficiency virus (HIV) at Bolivar State, Venezuela

El citomegalovirus (CMV) es un agente patógeno ampliamente distribuido en la naturaleza que puede causar infecciones primarias, latentes, crónicas y persistentes. Con el objetivo de determinar la seroprevalencia de CMV en pacientes infectados con el virus de la inmunodeficiencia humana y/o con el síndrome de inmunodeficiencia adquirida, en el estado Bolívar (Venezuela), se realizó un estudio de corte transversal, donde se detectaron anticuerpos IgG contra CMV mediante ensayo inmunoenzimático en 83 pacientes. Ningún paciente presentó hallazgo clínico de infección del sistema nervioso central. El 94% (n=78) de los pacientes presentó anticuerpos de tipo IgG contra CMV, predominando en el grupo de 20-29 años (n=28; 36,1%) y en el sexo masculino (n=42; 53,8%). Se demostró una seroprevalencia mayor en los pacientes con contaje de linfocitos CD4+ entre 100-200 células/mm³. Se observó asociación estadísticamente significativa entre el incremento de la edad con los títulos de anticuerpos IgG-CMV (p=0,009). La infección por CMV tiene una prevalencia elevada en los pacientes infectados por el virus de inmunodeficiencia humana del estado Bolívar (Venezuela), incrementándose proporcionalmente con la edad.

Cytomegalovirus (CMV) is a pathogenic agent widely distributed in nature which can produce primary, latent, chronic and persistent infections. With the purpose of determining CMV seroprevalence in patients infected with human immunodeficiency virus and/or with acquired immunodeficiency syndrome at Bolivar State in Venezuela, we carried out a transversal section study where we detected anti-CMV IgG antibodies by an immunoenzymatic assay in 83 patients. None of the patients presented clinical findings indicating central nervous system infection. Of the 83 patients, 94% (n=78) showed anti-CMV IgG type antibodies, predominating in the 20-29 years group (n=28, 36.1%), and in male sex (n=42, 53.8%). A higher seroprevalence was demonstrated in patients with CD4+ lymphocyte counts between 100-200 cells/mm³. A statistically significant association between age increase and IgG-CMV antibody titers (p=0.009) was observed.. CMV infection has a high prevalence in human immunodeficiency virus infected patients at Bolivar State (Venezuela), which increases proportionally to age.

Casuística de cromomicosis en el estado Bolívar (1987-2010) y evaluación de la sensibilidad in vitro de dos aislados de Fonsecaea pedrosoi / Chromomycosis cases in Bolivar State (1987-2010) and evaluation of the in vitro sensitivity of two Fonseca pedrosoi isolates

El objetivo de este estudio fue determinar la prevalencia de cromomicosis en un período de 23 años en dos hospitales de referencia del estado Bolívar. Se realizó un estudio retrospectivo, mediante la revisión de historias clínicas de pacientes con diagnóstico de cromomicosis, registrándose catorce casos de la enfermedad. El 78,6% correspondieron al sexo masculino, en su mayoría agricultores provenientes de zonas rurales; el 28,6% presentaron lesiones verrugosas. El tiempo de evolución de las lesiones osciló entre 5 meses y 35 años. Fonsecaea pedrosoi fue el agente etiológico aislado en tres (21,4%) de los cuatro pacientes en que las muestras fueron cultivadas. Sólo a dos aislados conservados de F. pedrosoi se les evaluó la sensibilidad in vitro mediante E-test®, demostrándose resistencia a los antifúngicos sistémicos: anfotericina B, 5-fluorocitosina, ketoconazol, fluconazol e itraconazol. Dos pacientes fueron tratados con itraconazol: uno de ellos mejoró; el otro presentó comorbilidad con micetoma eumicótico y falleció. La prevalencia de cromomicosis durante el período estudiado fue baja (0,6 casos/año), sin embargo esta infección representa un problema de salud en el personal de riesgo, principalmente agricultores y mineros del estado Bolívar, que presentan lesiones verrugosas de evolución crónica.

The purpose of this study was to determine chromomycosis prevalence during a 23-year period at two reference hospitals of Bolivar State. A retrospective study was carried out through the revision of clinical case histories of patients with a chromomycosis diagnosis, registering fourteen cases of this disease. Of these cases, 78.6% corresponded to males, most of them agricultural workers from rural areas; 28.6% presented verrucous lesions. The period of evaluation of the lesions varied between 5 months and 35 years. Fonsecae pedrosoi was the etiologic agent isolated in three (21.4%) of the four patients whose samples were cultured. Sensitivity was evaluated in vitro in only two cases through E-test®, showing resistance to systemic antifungals agents: amphotericine-B, 5-fluorocytosine, ketoconazole, fluconazole and itraconazole. Two patients were treated with itraconazol, one of them improved and the other presented co-morbility with eumycotic mycetoma and died. Chromomycosis prevalence during the period studied was low (0.6 cases/year); nevertheless, this infection constitutes a health problem for risk populations, mainly agricultural and mining workers at Bolivar State who present verrucous lesions with a chronic evolution.

Dermatomicosis en ancianos institucionalizados y estudios de sensibilidad in vitro a los antifúngicos sistémicos / Dermatomycosis in institutionalized elderly patients and in vitro sensitivity study to systemic antifungus

Se determinó la prevalencia de dermatomicosis en ancianos institucionalizados de Ciudad Bilívar, Estado Bolívar, Venezuela, y se evaluó la sensibilidad in vitro de los aislamientos clínicos a los antifúngicos itraconazol, fluconazol y terbinafina mediante el método de microdilución en medio líquido, recomendado por el Comité Internacional de Laboratorios Clínicos (M38-P), con algunas modificicaciones. Los hongos fueron identificados mediante métodos tradicionales. Las levaduras se identificaron mediante pruebas bioquímicas, sistema Api 20 C AUX (Biomérieux SA®, France) y crecimiento en medio de Staib. Se estudiaron 74 ancianos, todos recluidos en el Asilo "San Vicente de Paúl" y el Geriátrico "Carlos Fragachán" quienes dieron consentimiento por escrito para participar en el estudio. La edad de los pacientes estuvo comprendida entre 63 y 98 años (80 ± 8,4 años), la mayoría eran hombres (73%). Todos los pacientes tenían lesiones sugestivas de onicomicosis en los pies. El único dermatofito aislado fue Trichophyton rubrum (n=2) el cual resultó sensible al Itraconazol, terbinafina y sensibilidad variable a flucozazol. Asimismo se logró aislar Aspergillus niger (n=5; 6,7%) demostrándose sensible a terbinafina y fluconazol con sensibilidad variable a itraconazol. Candida albicans (n=3; 4,1%) fue sensible a fluconazol, resistentes a itraconazol y variable a la terbinafina. Aspergillus flavus fue aislado en dos casos (2,7%). Además de Geomyces sp, Fusarium oxysporum y Pseudeurotium ovale. Se concluye que existe una prevalencia baja de dermatomicosis en los ancianos institucionalizados de Ciudad Bolívar y que las lesiones clinicamente observadas son debidas a los cambios degenerativos propios de la edad.

A study determine prevalence of dermatomycosis in 74 institutionalized elderly patients was conductted in Ciudad Bolivar, state of Bolivar, Venezuela. Clinical isolates were assayed for in vitro sensitivity to itraconazole, fluconazole, and terbinafine using a slightly modified version of the microdilution method in liquid medium recommended by the International Committee of Clinical Laboratory (M38-P). Traditional methods were used to identify the fungi. The yeasts were identified by Api 20C AUX biochemical testing (bioMérieux SA®, France) and growth on Staib media. The elders, mostly men (73%), from the "San Vicente de Paúl" Nursing Home and the "Carlos Fragachan" Geriatric Hospital, were aged between 63 and 98 (80 ± 8.4 years). All the patients, whose written consent was secured, had lesions suggestive of onychomycosis. Trichophyton rubrum was the only isolated dermatophyte (n=2), which resulted sensitive to itraconazole and terbinafine, with variable sensitivity to fluconazole. Aspergillus niger (n=5;6.7%) was sensitive to terbinafine and fluconazole with variable itraconazole sensitivity. Candida albicans (n=3; 4.1%) was fluconazole sensitive, resistant to itraconazole, and variable to terbinafine. Aspergillus flavus was isolated in two cases 2.7%). Geomyces sp., Fusarium oxysporum, and Pseudeurotium ovale were also isolated. It is concluded that there is a low prevalence of dermatomycosis among institutionalized elders in Ciudad Bolivar, and that the lesions clinically observed were due to degenerative changes naturally occurring with aging.

Epidemiological study of paracoccidioidomycosis and histoplasmosis in a suburb of San Félix city, Bolívar state, Venezuela.

Epidemiologic studies of deep mycosis have been scarce in Bolivar state, where paracoccidioidomycosis and histoplasmosis are considered as endemic diseases. The aim of this study was to determine paracoccidioidomycosis and histoplasmosis prevalences in people from a suburb of San Féix, Bolívar state, Venezuela. Three-hundred volunteers agreed to participate in this study and they were inoculated with paracoccidioidine and histoplasmine. Identification and epidemiologic data were registered. Reading of skin tests after 24 hours was performed in 275 persons. Paracoccidioidine test was positive in 10.2% (n=28). A higher percentage of positive reactions in the age group of 40-50 years old (n=10; 35.7%) was observed. Bricklayers, farmers and miners were positive in 27.3% (3 out of 11), a higher percentage than in people with other occupations. Histoplasmine test was positive in 7.6% of cases (n=21). The higher percentage of reactivity was observed in the age group of 40-50 years old (n=9; 42.9%). There was a direct proportional relationship between staying time in the locality and H. capsulatum infection mainly in persons staying in the area for more than 30 years (p < 0.05). These results showed low prevalences of P. brasiliensis and H. capsulatum infection in this area.

Epidemiological study of paracoccidioidomycosis and histoplasmosis in a suburb of San Félix city Bolívar state Venezuela

Epidemiologic studies of deep mycosis have been scarce in Bolívar state, where paracoccidioidomycosis and histoplasmosis are considered as endemic diseases. The aim of this study was to determine paracoccidioidomycosis and histoplasmosis prevalences in people from a suburb of San Félix, Bolívar state, Venezuela. Three-hundred volunteers agreed to participate in this study and they were inoculated with paracoccidioidine and histoplasmine. Identification and epidemiologic data were registered. Reading of skin tests after 24 hours was performed in 275 persons. Paracoccidioidine test was positive in 10.2% (n=28). A higher percentage of positive reactions in the age group of 40-50 years old (n=10; 35.7%) was observed. Bricklayers, farmers and miners were positive in 27.3% (3 out of 11), a higher percentage than in people with other occupations. Histoplasmine test was positive in 7.6 percent of cases (n= 21). The higher percentage of reactivity was observed in the age group of 40-50 years old (n=9; 42.9%). There was a direct proportional relationship between staying time in the locality and H. capsulatum infection mainly in persons staying in the area for more than 30 years (p<0.05). These results showed low prevalences of P. brasiliensis and H. capsulatum infection in this area.

El estudio epidemiológico de las micosis profundas ha sido escaso en el estado Bolívar donde la paracoccidioidomicosis e histoplasmosis son endémicas. El objetivo de este estudio fue determinar la prevalencia de infecciones por Paracoccidioides brasiliensis e Histoplasma capsulatum en individuos residenciados en una población suburbana de San Félix, estado Bolívar, Venezuela. Se administró paracoccidioidina e histoplasmina a 300 personas voluntarias. Se realizó lectura de las pruebas a las 24 horas. La paracoccidioidina fue positiva en el 10,2% (n=28). Se observó mayor porcentaje de positividad en el grupo de 40-50 años (n=10; 35,7%). Las ocupaciones de riesgo: albañiles, agricultores y mineros, presentaron un porcentaje de positividad de 27,3% (3 de 11), mayor que el de los individuos sin riesgo aparente: mecánicos, oficios del hogar y estudiantes (25 de 264; 9,5 %) (p=0,04). La histoplasmina fue positiva en el 7,6% (n=21). El mayor porcentaje de intradermorreacción positiva se observó entre los 40-50 años (n=9; 42,9%). Hubo relación significativa entre el tiempo de residencia en la localidad y la infección por H. capsulatum, demostrándose en los individuos con más de 30 años en esa localidad (p<0,05). Estos resultados muestran una prevalencia relativamente baja de infecciones por P. brasiliensis y de H. capsulatum en el área estudiada.

Zigomicosis en el Complejo Hospitalario Universitario “Ruiz y Páez”, Ciudad Bolívar, período 1984-2007 / Zygomycosis at the “Ruiz y Paez” University Hospital Complex, Ciudad Bolivar, during the 1984-2007 period

La zigomicosis es una infección grave en pacientes inmunocomprometidos. El objetivo de este estudio fue presentar los casos de zigomicosis registrados en un período de 23 años en el hospital de referencia del estado Bolívar. Se realizó una investigación retrospectiva de las historias clínicas de pacientes en el hospital de referencia del estado Bolívar. Todos los pacientes a quienes se les realizó diagnóstico de zigomicosis por biopsia entre enero 1984 y enero 2007 fueron incluidos en este estudio. Se identificaron 6 casos de pacientes con zigomicosis. Todos los casos tuvieron como factor predisponente la diabetes mellitus. Tres casos correspondieron a la forma rinosinusal, de los cuales uno tuvo complicación cerebral y los otros 3 casos presentaron compromiso cutáneo. Hubo 2 casos de mortalidad. El tratamiento agresivo de la enfermedad localmente invasiva es importante para prevenir la diseminación rápida y fatal de esta micosis. Los pacientes con diabetes mellitus descompensada están en riesgo de desarrollarla.

Zygomycosis is a serious infection in immunocompromised patients. The purpose of this study was to present the zygomycosis cases registered during a 23 year period at the reference hospital in Bolivar State. A retrospective analysis of all the clinical case histories was done at the mentioned hospital in Bolivar State. All patients who were diagnosed with zygomycosis through a biopsy between January 1984 and January 2007 were included in the study. Six patients were identified with zygomycosis. All cases had diabetes mellitus as predisposing factor. Three cases corresponded to the rinosinusidal form, one of which had a cerebral complication, and the other 3 presented cutaneous compromise. There were 2 deaths. Aggressive treatment of the locally invasive disease is important to prevent a fast and fatal dissemination of this mycosis. Patients with uncompensated diabetes mellitus are under risk of developing it.

Etiología de diarrea aguda en niños menores de 5 años Ciudad Bolívar, Venezuela / Etiology of acute diarrhea in children under five years of age in Ciudad Bolivar, Venezuela

Se determinó la etiología infecciosa de la diarrea aguda en niños menores de 5 años en Ciudad Bolívar, Estado Bolívar. Para ello, se procesaron 110 muestras de heces. Se realizó un examen directo de heces, métodos de concentración Kato-Katz, formol-éter y Kinyoun para identificación de parásitos; detección de antígenos virales de Adenovirus y Rotavirus mediante Látex Diarlex®, coprocultivo y Tricrómica modificada de Ryan-Blue para Microsporidium spp. La prevalencia de parasitosis intestinal fue 27,3%, siendo Blastocystis hominis y Giardia lamblia las más frecuentes (11,8% y 9,2% respectivamente). Once muestras resultaron positivas para Rotavirus (10,0%) y 3 para Adenovirus (2,7%). Las enterobacterias diagnosticadas fueron Escherichia coli enteropatógena (2,7%; 3/110), Salmonella spp (1,8%; 2/110) y Shigella spp (0,9%; 1/110). Los síntomas más frecuentes fueron: fiebre (40,1%) y dolor abdominal (27,3%). No se observó Microsporidium spp. No hubo asociación significativa entre la presencia de enteropatógenos y los síntomas (p>0,05). Se concluye que la etiología de las diarreas agudas en niños menores de 5 años en Ciudad Bolívar, durante el período de estudio, fue principalmente de origen parasitario y viral.

The infectious etiology of acute diarrhea in children under five years of age in Ciudad Bolivar, Bolivar State was determined. One hundred and ten stool samples were processed. The tests included direct examination, the Kato-Katz concentration method, the formol-ether method and the Kinyoun method for parasite identification, detection of viral Adenovirus and Rotavirus antigens through Latex Diarlex ®, stool culture, and modified Ryan-Blue trichromic stain for Microsporidium spp. Prevalence of intestinal parasitosis was 27.3% and Blastocytis hominis and Giardia lamblia were the most frequent parasites (11.8% and 9.2% respectively). Eleven samples were positive for Rotavirus (10.0%) and 3 for Adenovirus (2.7%). The enterobacteria diagnosed were enteropathogenic Escherichia coli (2.7%; 3/110), Salmonella spp (1.8%; 2/110) and Shigella spp (0.9%; 1/110). The most frequent symptoms were: fever (40.1%) and abdominal pain (27.3%). Microsporidium spp was not observed. There was no significant association between presence of enteropathogens and symptoms (p>0.05). It is concluded that the etiology of acute diarrhea in children under five years of age in Ciudad Bolivar during the study period was mainly of parasite and viral origin.

Sistemic mycosis associated to tuberculosis in Bolívar state Venezuela

Se determinó la frecuencia y características clínicas de las micosis sistémicas endémicas asociadas a tuberculosis en el estado Bolívar. Se revisaron las historias clínicas de los casos con diagnóstico confirmado de micosis sistémicas y tuberculosis en un período de cinco años. Se detectaron 7 casos de las micosis sistémicas endémicas en la región, Paracoccidioidomicosis e Histoplasmosis, asociadas a tuberculosis. Todos los pacientes procedían del estado Bolívar, sólo uno era del sexo femenino y ninguno tenía serología positiva para la infección por el Virus de Inmunodeficiencia Humana. Todos presentaron manifestaciones pulmonares, la mayoría sintomáticos y con pérdida de peso (6 de 7). En todos los casos, se evidenciaron alteraciones en el estudio radiológico del tórax, con diferentes patrones, predominando el compromiso alveolar difuso bilateral. En 6 de los 7 pacientes, se observaron bacilos ácidos resistentes en muestras de esputo. La micosis más frecuentemente asociada a tuberculosis fue Paracoccidioidomicosis (6 de 7). Todos los pacientes recibieron tratamiento antimicótico y tratamiento antituberculoso con cuatro drogas y todos mostraron mejoría. La asociación de micosis sistémicas endémicas con tuberculosis no es rara en el estado Bolívar, por tanto, la asociación de estas infecciones deberían investigarse sistemáticamente.

The frequency and clinical characteristics of endemic systemic mycosis associated with tuberculosis were determined in Bolívar State. Clinical case records with confirmed diagnoses of systemic mycosis and tuberculosis were reviewed for a 5-year period. Seven cases of systemic mycoses endemic to the region were detected: Paracoccidioidomycosis and Histoplasmosis, associated with tuberculosis. All patients came from Bolívar state; only one was feminine and no one was seropositive for the Human Immunodeficiency Virus. All presented pulmonary compromise, mostly symptomatic, accompanied by weight loss (6 of 7). In all cases, alterations appeared on the radiological study of the thorax, mainly diffuse bilateral alveolar compromise. In 6 of the 7 patients, acid-resistant bacilli were observed in sputum samples. The mycosis most frequently associated with tuberculosis was Paracoccidioidomycosis (6 of 7); the other associated mycosis was Histoplasmosis (1 of 7). All patients received antimycotic and 4-drug anti-tuberculosis treatments and all of them improved. The association of endemic systemic mycosis with tuberculosis is not unusual in Bolívar state and therefore, the association of these infections should be systematically investigated.

[Adrenocortical function in patients with systemic mycoses]. / Función adrenocortical en pacientes con micosis sistémica.

The systemic mycoses like paracoccidioidomycosis and histoplasmosis, are the main cause of adrenal insufficiency in the countries where they arc endemic. In Venezuela an elevated frequency of these mycoses has been registered. The objective of this study was to evaluate the glucocorticoid adrenal function in patients with paracoccidioidomycosis and histoplasmosis hospitalized in the University Hospital "Ruiz y Pácz" of Ciudad Bolivar (Bolivar state) and in the Hospital "Luis Felipe Rojas Guevara", of El Tigre (Anzoátegui state), Venezuela, between January 2003 and January 2004. The test of fast stimulation with synthetic adrenocorticotrophin hormone (ACTH) was applied to a total of 12 patients with diagnosis of some of these mycoses and data of epidemiologic interest were taken. The proportion men:women was of 5:1, the average age was 35.1 +/- 0.37 years, similar to the control group. Basal plasmatic cortisol levels were within the normal rank in all the patients. After the injection of synthetic ACTH, an increase of plasmatic cortisol values in the same rank for patients with a normal adrenal function was observed, but it was significantly lower than the observed for the control group. These results suggest that there is an adrenal gland functional reserve diminution in patients with either Paracoccidioidomycosis or Histoplasmosis. In patients with systemic mycoses, it is important to evaluate the response to the test of fast stimulation with ACTH due to the frequency of impairment of the glucocorticoid adrenal function in our location.

Función adrenocortical en pacientes con micosis sistémica / Adreno cortical function in patients with systemic mycoses

Las micosis sistémicas como paracoccidioidomicosis e histoplasmosis, son la principal causa de insuficiencia suprarrenal en los países donde éstas son endémicas. Venezuela es un país que registra una frecuencia elevada de estas micosis. El objetivo de este estudio fue evaluar la función adrenal glucocorticoide en pacientes hospitalizados con paracoccidioidomicosis e histoplasmosis. Se realizó la prueba de estimulación rápida con ACTH sintética a 12 pacientes con diagnóstico de alguna de estas micosis y a 12 sujetos control, y se recogieron datos de interés epidemiológico. La relación hombre:mujer de los pacientes fue de 5:1 y la edad media fue 35,214,4 años, similar al grupo control. El cortisol plasmático basal estuvo dentro del rango normal en todos los pacientes y fue similar a los del grupo control. Posterior a la administración de ACTH sintética se observó un incremento del cortisol plasmático, dentro del rango considerado normal pero significativamente menor que el del grupo control. Estos resultados sugieren una disminución de la reserva funcional de las glándulas suprarrenales en los pacientes con paracoccidioidomicosis e histoplasmosis. En nuestro medio, es importante evaluar la respuesta a la prueba de estimulación rápida con ACTH en los pacientes con micosis sistémica dada la frecuencia de su afectación.

Isolation of arcanobacterium haemolyticum in semen of an infertile patient

This is the report of a genital tract infection caused by Arcanobacterium haemolyticum in an infertile man from Venezuela. This 29 year-old patient was evaluated for primary infertility, without symptoms of seminal infection. Laboratory analysis showed leukocytospermia, low sperm count, motility and vitality, without abnormalities in hormonal profile. Sperm culture was positive for A. haemolyticum. After erythromycin therapy an improvement in some sperm parameters was observed. A. haemolyticum could be considered as a cause for silent seminal infection

Meningoencephalitis by Naegleria fowleri: epidemiological study in Anzoategui state, Venezuela.

A case of primary amoebic meningoencephalitis produced by Naegleria fowleri was diagnosed in the Independencia county of Anzoategui State, Venezuela. This case motivated the realization of the present epidemiological study with the aim of identifying free-living amoebae in this area. Representative water samples were taken and physicochemical and microbiologic analyses were carried out. Trophozoites and cysts of Naegleria spp, were detected in 44.4% (n=4). An excellent concordance was found among the observations of free-living amoebae in smears and those of monoxenic cultures in non-nourishing agar with Klebsiella pneumoniae (Kappa=1; p= 0.003). A variable load of aerobic mesophils was obtained. Moulds and yeast averages presented 3.0 CFU/ml (SD +/- 2.0) and 102.9 CFU/ml (SD +/- 32.2), respectively. One hundred per cent of the samples presented a most probable number of total and fecal coliforms of 240,000 NMP/100mL. Naegleria spp was present in waters of the Independence county of Anzoategui state, which constitutes a risk for people that use these sources.

Meningoencephalitis by Naegleria fowleri: epidemiological study in Anzoategui state, Venezuela

Um caso de meningoencefalite amebiana primária, causada por Naegleria fowleri, foi diagnosticada no município de Independência no Estado de Anzoategui, Venezuela. Este caso motivou a realização deste estudo epidemiológico com o objetivo de identificar amebas de vida livre nessa área. Foram colhidas amostras representativas de água e realizadas análises fisicoquímicas e microbiológicas. Trofozoítos e cistos de Naegleria spp foram detectados em 44,4% (n=4). Verificou-se excelente concordância entre a observação das amebas de vida livre em esfregaços e aquelas de culturas monoxênicas em ágar não nutriente com Klebsiella pneumoniae (Kappa=1; p=0,003). Obteve-se uma carga variável de microrganismos mesófilos aeróbicos. As médias de mofos e leveduras foram de 3,0 CFU/ml (SD+2,0) e 102,9 CFU/ml(SD+32,2), respectivamente. Cem por cento das amostras apresentaram um número maior provável de coliformes totais e fecais de 240.000 NMP/100ml. Naegleria spp estava presente nas águas do município de Independência no Estado de Anzoategui, o que constitui um risco para a população que usa essas fontes.

Isolation of Arcanobacterium haemolyticum in semen of an infertile patient.

This is the report of a genital tract infection caused by Arcanobacterium haemolyticum in an infertile man from Venezuela. This 29 year-old patient was evaluated for primary infertility, without symptoms of seminal infection. Laboratory analysis showed leukocytospermia, low sperm count, motility and vitality, without abnormalities in hormonal profile. Sperm culture was positive for A. haemolyticum. After erythromycin therapy an improvement in some sperm parameters was observed. A. haemolyticum could be considered as a cause for silent seminal infection.

Cryptococcus neoformans and Histoplasma capsulatum in dove's (Columbia livia) excreta in Bolívar state, Venezuela.

Dove's excreta samples from state Bolívar several places in Venezuela, were evaluated to determine the presence of primary pathogen fungi in dove's excreta. Filamentous fungi such as: Aspergillus spp (31.1%), Mucor spp (20.2%), Penicillium spp (9.5%) and Fusarium spp (6.7%) were the most frequently isolated strains. Species such as Candida albicans (4.1%), Cryptococcus albidus and Rhodotorula spp (2.7%), C. neoformans var neoformans (1.4%), Trichosporum asahii (1.4%), Curvularia, Microsporum and Phoma as well as Histoplasma capsulatum (1.3%) were less frecuently isolated. This study shows the presence of C. neoformans and H. capsulatum in dove's excreta from Bolívar state, it remarks infection risk with these pathogens fungi and the necessity to avoid accumulation of dove's excreta.