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.

[Clinical problems in Medical Mycology: Problem number 56]. / Problemas clínicos en Micología Médica: problema número 56.

We present the case of a twenty six year-old woman with rheumatoid arthritis, treated with certolizumab. She sought medical attention due to cough, fever and night sweats. X-ray exam showed a miliary pneumonia. She was treated for tuberculosis and 50days later she presented with aphasia. Magnetic nuclear resonance revealed brain lesions. Histoplasma capsulatum PCR test and urinary antigen were positive, so an antifungal treatment with voriconazole was started. Visual adverse effects forced to change the antifungal schedule in both the length of treatment and the antifungal drug. With this measure the patient progressed favorably. The test of urinary Histoplasma capsulatum antigen and PCR amplification were key to make a diagnosis and also for a follow-up.

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.

Problemas clínicos en Micología Médica: problema número 56 / Clinical problems in Medical Mycology: Problem number 56

We present the case of a twenty six year-old woman with rheumatoid arthritis, treated with certolizumab. She sought medical attention due to cough, fever and night sweats. X-ray exam showed a miliary pneumonia. She was treated for tuberculosis and 50days later she presented with aphasia. Magnetic nuclear resonance revealed brain lesions. Histoplasma capsulatum PCR test and urinary antigen were positive, so an antifungal treatment with voriconazole was started. Visual adverse effects forced to change the antifungal schedule in both the length of treatment and the antifungal drug. With this measure the patient progressed favorably. The test of urinary Histoplasma capsulatum antigen and PCR amplification were key to make a diagnosis and also for a follow-up.(AU)

Se presenta el caso de una paciente de 26años de edad, profesora de educación física. Nació y vive en Burzaco, conurbano sur de la Provincia de Buenos Aires, República Argentina. Debido a su trabajo había realizado diversos viajes y acampado en diferentes provincias de nuestro país (Misiones, Corrientes, San Juan y Mendoza). En el extranjero solo había visitado Orlando (EE.UU.). Desde hacía 10años padecía artritis reumatoide juvenil. Por esta patología recibió metotrexato 15mg/semana, prednisona 5mg/día e hidroxicloroquina 400mg/día durante 7años. Posteriormente le fue prescrito certolizumab 200mg cada dos semanas y, posteriormente, 400mg cada cuatro semanas. Tras dos años con esta medicación le fue suspendida por la aparición de tos seca, fiebre, astenia, adinamia y sudores nocturnos. Debido a estas manifestaciones se le realizó una radiografía de tórax (fig. 1) y se suspendió inmediatamente el tratamiento con el inmunomodulador (certolizumab).(AU)

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

Infecciones fúngicas en pacientes con COVID-19 / Fungal infections in patients with COVID-19

En diciembre de 2019 se identificó en Wuhan, China, un nuevo coronavirus denominado SARS-CoV-2, agente causal de la epidemia de neumonía atípica COVID-2019, que el 11 de marzo de 2020 fue declarada pandemia por la OMS.Hasta el 30 de septiembre de 2020, en Argentina fueron confirmados 751.001 casos y más de 16.937 muertes.La frecuencia y el impacto de las coinfecciones que afectan a los pacientes infectados por SARS-Cov-2 se ha estudiado junto con el avance de la pandemia. Entre las debidas a hongos se encuentran las fungemias por Candida sp, la aspergilosis invasora, las micosis sistémicas endémicas y la neumocistosis. Presentamos las distintas coinfecciones micosis-COVID-19 que fueron asistidas en nuestra institución entre abril y septiembre de 2020, y se realiza un análisis de las características de estas infecciones en pacientes con y sin sida. En este período se internaron 2837 pacientes, 2287 tuvieron diagnóstico confirmado de COVID-19. La coinfección de COVID-19 con micosis pulmonares o sistémicas fue menor al 1%.Dieciocho pacientes presentaron infecciones fúngicas pulmonares o sistémicas. Ocho padecieron candidemias, cinco criptococosis meningeas, dos histoplasmosis, dos aspergilosis invasoras agudas probables y una aspergilosis pulmonar crónica. La estadía prolongada en terapia intensiva facilitó las fungemias por Candida sp, los casos de histoplasmosis y criptococosis parecen relacionarse con la enfermedad avanzada por VIH y no con COVID-19. Los enfermos con un componente inflamatorio basal alto con neumonía grave por coronavirus se relacionan más con micosis invasoras que los enfermos VIH positivos con niveles bajos de LTCD4+

On December 2019 a new coronavirus (SARS-CoV2) result in atypical pneumonía epidemic, it was identified in Wuhan China and it was called COVID-19. Then on March 11 was declared pandemic by the WHO.Until September 30, 2020 in Argentina 751,001 cases and more than 16,937 deaths have been confirmed. The frequency and impact of co-infections affecting SARS-Cov2 infected patients has been studied with the advance of the pandemic. Among those due to fungi are Candida sp fungemias, invasive aspergillosis, endemic systemic mycoses, and pneumocystosis.We present the different mycosis-COVID-19 co-infections that were assisted in F. J. Muñiz Hospital between April and September of this year and review the characteristics of these infections in patients with and without AIDS is carried out.In this period, 2,837 patients were admitted in the Muñiz hospital, 2,287 had a confirmed diagnosis of COVID-19.Co-infection of COVID-19 with pulmonary or systemic mycoses was less than 1%.Eighteen patients had pulmonary or systemic fungal infections. Eight suffered from candidemia, five meningeal cryptococcosis, two histoplasmosis, two probable acute invasive aspergillosis, and one chronic pulmonary aspergillosis.Prolonged stay in intensive care facilitated fungemia due to Candida sp. Histoplasmosis and cryptococcosis cases seem to be related to advanced HIV disease and not to COVID-19.Patients with a high baseline inflammatory component with severe coronavirus pneumonia are more associated with invasive mycoses than HIV-positive patients with low levels of LTCD4 +

[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.

Coronavirus Disease 2019 (COVID-19) in a Patient with Disseminated Histoplasmosis and HIV-A Case Report from Argentina and Literature Review.

The disease caused by the new SARS-CoV-2, known as Coronavirus disease 2019 (COVID-19), was first identified in China in December 2019 and rapidly spread around the world. Coinfections with fungal pathogens in patients with COVID-19 add challenges to patient care. We conducted a literature review on fungal coinfections in patients with COVID-19. We describe a report of a patient with disseminated histoplasmosis who was likely infected with SARS-CoV-2 and experienced COVID-19 during hospital care in Buenos Aires, Argentina. This patient presented with advanced HIV disease, a well-known factor for disseminated histoplasmosis; on the other hand, we suspected that COVID-19 was acquired during hospitalization but there is not enough evidence to support this hypothesis. Clinical correlation and the use of specific Histoplasma and COVID-19 rapid diagnostics assays were key to the timely diagnosis of both infections, permitting appropriate treatment and patient care.

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

Antifungal Resistance in Clinical Isolates of Aspergillus spp.: When Local Epidemiology Breaks the Norm.

Aspergillosis is a set of very frequent and widely distributed opportunistic diseases. Azoles are the first choice for most clinical forms. However, the distribution of azole-resistant strains is not well known around the world, especially in developing countries. The aim of our study was to determine the proportion of non-wild type strains among the clinical isolates of Aspergillus spp. To this end, the minimum inhibitory concentration of three azoles and amphotericin B (used occasionally in severe forms) was studied by broth microdilution. Unexpectedly, it was found that 8.1% of the isolates studied have a diminished susceptibility to itraconazole. This value turned out to be similar to the highest azole resistance rate reported in different countries across the world.

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

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 2different clinical pictures on a single patient is extremely rare.

Cryptococcosis in an Infectious Diseases Hospital of Buenos Aires, Argentina. Revision of 2041 cases: diagnosis, clinical features and therapeutics / Criptococosis en un hospital de enfermedades infecciosas de Buenos Aires, Argentina. Revisión de 2.041 casos: aspectos diagnósticos, clínicos y terapéuticos

Background. Cryptococcosis is still a life-threatening mycosis that continues to be of serious concern in Latin American countries, especially among HIV+positive population. However, there is not any reliable information about the prevalence of this disease in this region. Aims. The aim of this study is to report data of 2041 patients with cryptococcosis that were attended at the Infectious Diseases Hospital F. J. Muñiz over a 30 year-period. Methods. Information about demographic and clinical data, survival time and the applied treatment, was taken from the Mycology Unit database. Mycological exams from different clinical samples were performed. Cryptococcal capsular antigen in serum and cerebrospinal fluid was detected through the latex agglutination technique. Cryptococcus isolates were phenotypically identified and the genotype was determined in some of them. Susceptibility tests were carried out following M27-A3 document. Results. Seventy five percent of HIV+positive patients and 50% of the HIV-negative population were males. Mean ages were 34.1 in HIV+positive patients and 44.8 in the HIV-negative. Cryptococcosis was associated with AIDS in 98% of the cases. Meningeal compromise was seen in 90% of the patients. Although cerebrospinal fluid rendered more positive results, blood culture was the first diagnostic finding in some cases. Cryptococcal antigen showed positive results in 96.2% of the sera samples and in the 93.1% of the cerebrospinal fluid samples. Most of the isolates were Cryptococcus neoformans and belonged to genotype VNI. Minimal inhibitory concentration values were mostly below the epidemiological cutoff values. Conclusions. We observed that thanks to a high level of clinical suspicion, early diagnosis, combined therapy and intracranial pressure control by daily lumbar punctures, the global mortality rate has markedly decreased through the years in the analyzed period (AU)

Antecedentes. La criptococosis es una micosis grave y un motivo de preocupación en América Latina, en especial en los pacientes positivos para el VIH. Sin embargo, no existen aún datos regionales fiables acerca de la prevalencia de la enfermedad. Objetivos. Presentar los datos de 2.041 pacientes con criptococosis atendidos en la Unidad de Micología del Hospital de Infecciosas F. J. Muñiz de Buenos Aires, recogidos en un período de 30 años. Métodos. Se presentan datos demográficos, diagnósticos, clínicos y el tiempo de supervivencia de los pacientes, obtenidos de la base de datos de la Unidad de Micología. Se realizaron exámenes micológicos de diversas muestras clínicas, además de antigenemia y antigenorraquia por aglutinación de látex para Cryptococcus en el momento del diagnóstico y durante el seguimiento. Se llevó a cabo la identificación fenotípica de los aislamientos y en numerosos casos también se efectuó la genotipificación. La determinación de los valores de concentración mínima inhibitoria frente a diversos antifúngicos se realizó según el documento M27-A3 (CLSI). Resultados. El 75% de los pacientes positivos para el VIH y el 50% de los no portadores eran varones; la media de edad fue 34,1 años para los positivos para el VIH y 44,8 para los no portadores. La criptococosis se asoció con el sida en el 98% de los casos y el 90% de ellos presentó compromiso meníngeo. Aunque la muestra clínica con mayor porcentaje de resultados positivos fue el LCR, en numerosas ocasiones el hemocultivo fue el primer elemento diagnóstico. La antigenemia fue positiva en el 96,2% de los casos y la antigenorraquia en el 93,1%. La mayor parte de las cepas era Cryptococcus neoformans y pertenecía al genotipo VNI, y la concentración mínima inhibitoria en las pruebas de sensibilidad a los antifúngicos de la mayoría de ellos mostró valores inferiores al punto de corte epidemiológico. Conclusiones. Observamos que un alto nivel de sospecha clínica, el diagnóstico temprano, el tratamiento combinado y el control de la presión intracraneal mediante punciones lumbares diarias han permitido disminuir la mortalidad global a lo largo de los años en el período analizado (AU)

Problemas clínicos en micología médica: problema número 51 / Clinical problems in medical mycology: problem number 51

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A 48 year-old immunocompetent woman, who had a nodular lesion in the neck and a dense infiltrate at the lower lobe of the left lung, presented at the Mycology Unit of Muñiz Hospital of Buenos Aires City. The pulmonary infiltrate disappeared spontaneously 3 months later. The histopathological study of the nodular lesion showed capsulated yeasts (mucicarmin and alcian blue positive stains) compatible with Cryptococcus. The mycological study of a new sample, obtained by a nodular puncture, allowed the isolation of yeasts, identified as Cryptococcus gattii (VGII). Latex test for Cryptococcus capsular antigen in serum was positive (1/100). CSF cultures rendered negative results. Fluconazole at a daily dose of 800mg was given during 45 days with partial improvement; as cultures from a new clinical sample were positive for Cryptococcus, the antimycotic was changed to itraconazole 400mg/day for 5 months, with an excellent clinical response (AU)

Problemas clínicos en micología médica: problema número 52 / Clinical problems in medical mycology: problem number 52

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The case of a 60 year old woman with hemoptysis and a thin-walled cavitary lesion at the upper lobe of the right lung is presented. The woman presented at the Mycology Unit of the Muñiz Hospital in Buenos Aires City 3 months after the beginning of her clinical manifestations. A hyaline micelial fungus with chlamido-arthroconidias was isolated from the bronchoalveolar lavage. Immunodiffusion and counter-immnunoelectrophoresis with coccidioidin and histoplasmin rendered positive results against both antigents, and skin tests with coccidioidin and histoplasmin were also positive with strong reactions. The isolated fungus was identified as Coccidioides posadasii at the National Microbiology Institute Carlos Malbrán, by means of a molecular technique. The patient was treated with itraconazole by oral route at a daily dose of 200mg with good clinical response, but due to the persistence of the lung cavity, a surgical removal of the upper lobe of the right lung had to be scheduled (AU)