Esporotricose pulmonar em paciente imunocompetente: relato de caso / Pulmonary sporotrichosis in immunocompetent patient: case report

A forma extracutânea pulmonar da esporotricose, uma infecção causada por espécies geneticamente distintas de um fungo dimórfico do gênero Sporothrix, é rara, com poucos casos relatados na literatura. Trata-se de um caso de uma mulher de 55 anos, residente da região do Barreiro de Belo Horizonte/Minas Gerais, que buscou o serviço de infectologia de um hospital público de Belo Horizonte com história de emagrecimento, dispneia aos pequenos esforços, tosse crônica e calafrios vespertinos de três anos de evolução. Foi tratada para pneumonia bacteriana, em cinco ocasiões, sem melhora clínica. Apresentou tomografia computadorizada de tórax com cavitação residual e lesões escavadas pulmonares. A paciente foi internada com quadro de dispneia aos pequenos esforços, tosse e expectoração purulenta, sendo sua cultura de escarro positiva para Sporothrix spp. Foi instituído o tratamento padrão ouro para esporotricose pulmonar, inicialmente, com itraconazol, 200 mg, duas vezes ao dia, entretanto, após 10 meses, a melhora clínica e radiológica não foi satisfatória e optou-se pela internação a administração de anfotericina B complexo lipídico endovenosa 4 mg/kg/dia. Em menos de 1 mês a paciente apresentou piora do quadro e evoluiu a óbito, apesar de ter recebido 2g de dose acumulada de anfotericina

The pulmonary extracutaneous form of sporotrichosis, an infection caused by genetically distinct species of a dimorphic fungus of the genus Sporothrix, is rare, with few cases reported in the literature. This is a case of a 55-year-old woman, resident of the Barreiro region in Belo Horizonte/ Minas Gerais, who sought the infectious disease service of a public hospital in Belo Horizonte with a history of weight loss, dyspnea at small efforts, chronic cough and three-year-old vespertinus chills. She was treated for bacterial pneumonia on five occasions without clinical improvement. He presented computed tomography of the chest with residual cavitation and excavated pulmonary lesions. The patient was hospitalized with dyspnea on small efforts, cough and purulent sputum, and her sputum culture was positive for Sporothrix spp. The gold standard treatment for pulmonary sporotrichosis was instituted, initially with itraconazole, 200 mg twice a day, however, after 10 months, the clinical and radiological improvement was not satisfactory and the administration of intravenous amphotericin B lipid complex 4 mg/kg/day was chosen. In less than 1 month the patient presented worsening of the condition and died, despite receiving 2g of accumulated dose of amphotericin B lipid complex.

Endoscopic third ventriculostomy in patients with myelomeningocele after shunt failure.

PURPOSE: Myelomeningocele (MMC) is the most frequent form of spina bifida. Moreover, 90% of patients with MMC have hydrocephalus and require shunt placement. However, shunt failure management in such patients typically involves several shunt revisions, increasing the risk for morbidity and mortality. In this study, we report our experience with endoscopic third ventriculostomy (ETV) in MMC patients with shunts in a Brazilian institution. METHODS: Patients with MMC who presented with shunt failure and underwent ETV alone between January 1996 and December 2016 were included in this study. Patients who had undergone endoscopic choroid plexus cauterization (CPC) or had non-shunted MMC hydrocephalus were excluded. Various data related to the ETV procedure were collected for each patient, including features, operative characteristics, complications, and ETV success. The follow-up period for the patients was 6-12 months. ETV success scores (ETVSSs) were calculated retrospectively for each patient to compare the predicted success of the procedure with the actual success at 6 months after ETV. RESULTS: Forty-three MMC patients with shunt failure were included in this study. Of them, 16 (37.2%) had a previous central nervous system (CNS) infection and 4 (9.3%) had complications. Two neuroendoscopies were interrupted, one because of anatomic impossibility due to thickening of the interthalamic adhesion, obliterating the floor of the third ventricle, and another because of intraoperative hemorrhage. One patient developed hyponatremia during the postoperative period, whereas another developed reversible paresis of the oculomotor nerve. The ETVSS predicted a success rate of 49.6% compared with the actual ETV success rate of 53.48% (23 patients) at 6 months. At 12 months, the actual success rate was 41.9% (18 patients). All patients survived the procedure. CONCLUSION: Our findings indicate that ETV is an effective procedure for managing MMC-related hydrocephalus after shunt failure. The expertise of the neurosurgeon in neuroendoscopy procedures is often the deciding factor when choosing a management option. Accordingly, less experienced neurosurgeons should be warned of the risks of this procedure.