Recurrent meningitis associated to Strongyloides hyperinfection / Meningitis recurrente asociada a hiperinfección por Strongyloides

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An Unusual Case of CMV/EBV Ventriculoencephalitis with Evolution to Primary Central Nervous System Lymphoma in HIV-Positive Patient.

Epstein-Barr virus (EBV) is a well-known cause of different types of malignancies particularly Burkitt's lymphoma, nasopharyngeal carcinoma, Hodgkin's lymphomas, and non-Hodgkin's lymphomas including primary central nervous system lymphoma (PCNSL). A higher tendency of malignant transformation associated with EBV has been noticed in immunocompromised patients, such as human immunodeficiency virus (HIV) infected patients. The rapid and effective immune reconstitution is crucial to prevent PCNSL in HIV-positive patients. We present a clinical case of a young patient diagnosed with HIV infection and medicated with antiretroviral therapy (ART) with poor immunological recovery. After two weeks, he developed ventriculoencephalitis, observed in the cranial magnetic resonance imaging (MRI), caused by cytomegalovirus (CMV) and EBV, both with high serum viral load, rapidly evolving to PCNSL. With this unusual clinical case, the authors want to draw attention to the importance of rapid immunological reconstitution in preventing the progression of EBV infection to PCNSL, as well as encouraging the confirmation of the usefulness of early combination of chemotherapy and antiviral therapy, in order to reach a more effective treatment of this herpesvirus infection and associated malignancies.

A Classic Neurocysticercosis Case with an Unusual Complication.

Cysticercosis is triggered by infection with the larval form of the tapeworm Taenia solium. The usual sites for the development of cyscticerci are the central nervous system (neurocysticercosis - NCC), subcutaneous tissue, skeletal muscle, heart muscle, and the eye. Ocular cysticercosis is caused by the growth of the larvae within ocular tissues. The extraocular muscles form is the most common type of orbital cysticercosis. We report a case of a patient admitted with seizures secondary to NCC, who developed ocular symptoms after starting combined treatment with albendazole, praziquantel and dexamethasone. The investigation revealed a cystic lesion in the lateral rectus muscle. LEARNING POINTS: Neurocysticercosis (NCC) is the main cause of epilepsy in someone coming from an endemic area; therefore, it is imperative to have a high index of suspicion.Ocular cysticercosis can present at the time of diagnosis or can be triggered by the cysticidal treatment.Before starting cysticidal treatment, systemic corticosteroid should be used in order to reduce the inflammatory response secondary to the release of toxins following the death of the parasite.

[Klebsiella pneumoniae from K1 and Hypervirulent Clone ST23: First Documented Case in Portugal]. / Klebsiella pneumoniae do Serotipo K1 e do Clone Hipervirulento ST23: Primeiro Caso Documentado em Portugal.

The hypervirulent K1 serotype Klebsiella pneumoniae is responsible for a new invasive syndrome, typically associated to hepatic abscesses with extra-hepatic complications. Initially described in Taiwan, it has significantly spread to several Asian countries and more recently to Europe and North America, thus constituting an emerging and global problem. The authors describe a case report of a 64-years-old portuguese caucasian woman without any previous diseases or epidemiological risk factors such as trips or contact with Asian products or population, diagnosed with a pyogenic liver abscess with pleural effusion caused by this hyper-virulent strain. A successful clinical cure was achieved after the etiological identification and treatment with antimicrobial therapy combined with catheter drainage. This is the first identification of hypervirulent Klebsiella pneumonia ST 23 clone in Portugal in the context of an invasive syndrome.

A estirpe híper-virulenta Klebsiella pneumoniae serotipo K1 é responsável por uma síndrome invasiva infeciosa, caracterizada por abcessos hepáticos com manifestações extra-hepáticas. Inicialmente identificada em Taiwan, tem aumentado significativamente em vários países da Ásia, e mais recentemente na Europa e América do Norte, conferindo a esta entidade um caracter emergente e global. Os autores apresentam o caso clinico de uma mulher de 64 anos, caucasiana, portuguesa, sem antecedentes pessoais ou epidemiológicos como viagens ou exposição a produtos asiáticos, na qual foi diagnosticada, abcesso hepático piogénico complicado de derrame pleural por esta estirpe híper-virulenta. Após conhecimento do diagnóstico e instituição de terapêutica antibiótica combinada com drenagem percutânea, foi possível a resolução do caso clínico com sucesso. Este caso permitiu a identificação do primeiro caso de síndroma invasiva infeciosa, por Klebsiella pneumoniae do clone híper-virulento ST23 documentado em Portugal.

[Pneumocystis Pneumonia in 107 HIV Infected Patients Admitted to the Department of Infectious Diseases at Santa Maria Hospital, Lisbon (2002 - 2013)]. / Pneumonia por Pneumocystis em 107 Doentes com Infecção por VIH Internados no Serviço de Doenças Infecciosas, Hospital de Santa Maria, Lisboa (2002 - 2013).

INTRODUCTION: Pneumocystis jirovecii pneumonia remains one of the most common opportunistic illnesses in patients infected with the human immunodeficiency virus. It is currently the most reported AIDS-defining infection in Portugal. The aims of this study were to analyze the features of a human immunodeficiency virus /Pneumocystis jirovecii pneumonia coinfected population, to compare it with the current literature, and to evaluate comparatively subpopulations of patients based on the previous knowledge of the human immunodeficiency virus infection, Pneumocystis jirovecii pneumonia diagnostic method and discharge results. MATERIAL AND METHODS: A retrospective, observational, non-controlled study was conducted. The 107 patients admitted to the Department of Infectious Diseases at Santa Maria Hospital, in Lisbon, between the 1st of January 2002 and the 31st of December 2013, that presented the simultaneous diagnosis of human immunodeficiency virus infection and Pneumocystis jirovecii pneumonia were included. We studied epidemiologic and clinical data collected from the patient files, including immunity status, human immunodeficiency virus viral load and treatment options. The variables were analyzed using the Chi-Squared and Mann-Whitney tests. RESULTS: Data from this population evidenced male predominance (81.3%), patient age between 20 - 39 years old in 59.2% and heterossexual human immunodeficiency virus transmission in 48.6%; 24.3% were immigrants. Human immunodeficiency virus infection was previously known in 62.6% patients, but 76.2% were not engaged in medical care. A TCD4+ cell count ≤ 200 cells/mm3, high viral load and oropharyngeal candidiasis (72%) were prevalent risk factors associated with the Pneumocystis jirovecii pneumonia infection; hypoxaemia (78.5%) and LDH (82.2%), which are markers of Pneumocystis jirovecii pneumonia severity, did not translate into a worse prognosis. Pneumocystis jirovecii was only identified in 55.1% patients, pointing out the hardship involved in achieving a definite diagnosis. The inicial drug of choice was TMP-SMX (91.6%), and corticosteroid adjuvant therapy was added in 75.7%. The in-hospital mortality was 13.1%. DISCUSSION: The comparative analysis between groups of patients showed that injection drug users knew more frequently their human immunodeficiency virus seropositivity before the current hospitalization, which could be explained by the presence of specific programs aiming the early human immunodeficiency virus diagnosis in this population. However, there is lack of adhesion to the treatment and follow up consultations, putting them at a higher risk of Pneumocystis jirovecii pneumonia infection and other AIDS related diseases. Besides showing the classic Pneumocystis jirovecii pneumonia presentation, healthcare seeking was delayed, especially amongst patients with newly diagnosed human immunodeficiency virus infection. Moreover, the Pneumocystis jirovecii pneumonia diagnosis was difficult to obtain, mainly because of the current limitations of Pneumocystis jirovecii pneumonia diagnostic techniques, the simultaneous presence of other respiratory diseases, and the need of a high degree of clinical suspicion. CONCLUSION: This population of human immunodeficiency virus and Pneumocystis jirovecii pneumonia coinfected patients shows similarities with the data from previous studies, particularly considering Portuguese epidemiological data. The main differences found were the Pneumocystis jirovecii pneumonia diagnostic frequence in injection drug users, the importance of previous/recurrent episodes of Pneumocystis jirovecii pneumonia as a risk factor and the frequency of concurrent pulmonary diseases. The deceased patients showed less imagiologic features suggestive of Pneumocystis jirovecii pneumonia, and advanced age was found to be an indicative of worst prognosis.

Introdução: A pneumonia por Pneumocystis jirovecii é das doenças infecciosas oportunistas mais comuns em infectados por vírus da imunodeficiência humana, sendo, actualmente, em Portugal a infecção definidora de sida mais reportada. Os objectivos deste estudo foram, analisar as características de uma população co-infectada por vírus da imunodeficiência humana e pneumonia por Pneumocystis jirovecii, comparando-a com as referências disponíveis, e avaliar comparativamente subpopulações de doentes, consoante o conhecimento prévio da infecção por vírus da imunodeficiência humana, o método de diagnóstico de pneumonia por Pneumocystis jirovecii e o resultado na alta. Material e Métodos: Realizámos um estudo restrospectivo pela análise dos registos clínicos de 107 doentes internados no Serviço de Doenças Infecciosas do Hospital de Santa Maria, entre 1 de janeiro de 2002 e 31 de dezembro de 2013, com o diagnóstico de pneumonia por Pneumocystis jirovecii e vírus da imunodeficiência humana. As características epidemiológicas e clínicas foram avaliadas, incluindo o estado imunitário, a carga vírica e a terapêutica instituída e foi realizado um estudo estatístico das variáveis.Resultados: Nesta população, os resultados demonstraram predomínio do sexo masculino (81,3%), idade entre 20 - 39 anos (59,2%), transmissão de vírus da imunodeficiência humana por via heterossexual (48,6%), e que 24,3% eram imigrantes. Apesar do conhecimento da infecção por vírus da imunodeficiência humana (62,6%), 76,2% destes doentes não apresentava seguimento médico sustentado. A contagem de linfócitos TCD4+ ≤ 200 células/mm3 (96,3%), carga vírica elevada e candidose orofaríngea (72%) foram os principais factores de risco para o desenvolvimento de pneumonia por Pneumocystis jirovecii, e os marcadores de gravidade, como a hipoxemia (78,5%) e a elevação da LDH (82,2%) não traduziram pior prognóstico. Apenas foi possível isolar Pneumocystis jirovecii (e portanto, confirmar definitivamente o diagnóstico) em 55,1% dos doentes. A terapêutica etiotrópica mais utilizada foi o trimetoprimsulfametoxazol (91,6%), associado a corticóides (75,7%). A mortalidade foi de 13,1%. Discussão: Na análise comparativa entre grupos, constantou-se que os doentes utilizadores de drogas injectáveis conhecem com maior frequência o estado de seropositividade para o vírus da imunodeficiência humana, previamente ao internamento, o que poderá ser explicado pela maior implementação de programas de proximidade e de rastreio oportunista junto das populações de utilizadores de drogas injectáveis. No entanto, o seguimento e tratamento não são mantidos devido à má adesão aos mesmos, pelo que os doentes apresentam um risco aumentado para o desenvolvimento de pneumonia por Pneumocystis jirovecii e de outras doenças relacionadas com a sida. Apesar de a apresentação clínica da pneumonia por Pneumocystis jirovecii, no grupo de doentes avaliado, ser coincidente com o quadro mais comum desta patologia, o recurso aos cuidados de saúde foi tardio, sobretudo nos doentes com apresentação inaugural da infecção por vírus da imunodeficiência humana, e o diagnóstico difícil, quer pelas características inerentes às técnicas de diagnóstico de pneumonia por Pneumocystis, à presença de infecção respiratória concomitante e ao grau de suspeição clínica. Conclusão: Neste grupo de doentes, as características estudadas são semelhantes às descritas na literatura, particularmente considerandoo padrão epidemiológico da infecção por vírus da imunodeficiência humana e Pneumocystis jirovecii em Portugal, sendo as principais diferenças encontradas a maior frequência de diagnóstico de pneumonia por Pneumocystis jirovecii em utilizadores de drogas injectáveis, comparativamente ao grupo de homens que têm relações sexuais com homens, a importância de episódios prévios/recorrentes de pneumonia por Pneumocystis jirovecii como factor de risco, e a frequência em que está presente patologia pulmonar concomitante. Os doentes falecidos apresentaram menos achados imagiológicos sugestivos de Pneumocystis jirovecii, e a idade avançada constituiu um factor pior prognóstico nesta população.

Cutaneous and Skeletal Simultaneous Locations as a Rare Clinical Presentation of Tuberculosis.

Tuberculosis is a resurgent disease in most regions of the world, infecting one-third of the world's population and having a multisystemic involvement. Incidence of extra-pulmonary tuberculosis has increased in the last few decades as a result of the Human Immunodeficiency Virus (HIV) infection. The authors report a clinical case of the rare concomitant cutaneous and skeletal tuberculosis in an immunocompetent patient transferred from endemic area.

Clinical experience in invasive fungal infections: multiple fungal infection as the first presentation of HIV.

Fungal infections constitute an important cause of morbidity and mortality in HIV-infected patients. The authors describe the case of a 40-year-old healthy male patient with a 2-month history of fever, shivers, asthenia and anorexia, who had lost weight during the past 6 months. Laboratory investigations revealed a positive HIV screening. Computed tomography scans of the chest and abdomen showed thoracic and lumbo-aortic adenopathies. Cryptococcus neoformans was isolated from cultures of blood, bone marrow, cerebrospinal fluid and from material obtained by transbronchial biopsy. Moreover, Cryptococcus spp. were seen in the lymph node biopsy. Pneumocystis jirovecii was isolated from bronchoalveolar lavage, whereas Aspergillus fumigatus and Aspergillus flavus were detected in material from a transbronchial biopsy. The patient initially received treatment with sulfamethoxazole plus trimethoprim and amphotericin B, which resulted in a substantial clinical improvement. After the diagnosis of invasive aspergillosis, amphotericin B was replaced by voriconazole as antifungal therapy and antiretroviral therapy was added. The simultaneous occurrence of three different infectious diseases-disseminated cryptococcosis, invasive pulmonary aspergillosis and Pneumocystis jirovecii pneumonitis-in a HIV-infected patient is extremely rare and there is no doubt that both early diagnosis and treatment are crucial for the patient's chances of survival.