Problemas clínicos en micología médica: problema número 48 / Clinical problems in medical mycology: Problem number 48

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We present the case of a 42-year-old man, HIV-positive, with low CD4+ T cell count (31 cells/μl), who was admitted to Hospital de Infecciosas F. J. Muñiz in Buenos Aires (Argentina) due to a severe lower back pain. He had a history of several highly active antiretroviral therapy treatments and he also had diabetes and chronic B and C viral hepatitis. A spinal cord CT scan showed two lytic bone lesions in L2 and L3. A bone biopsy was carried out and its microbiological study allowed the isolation of a methicillin-resistant Staphylococcus aureus. Intravenous vancomycin was prescribed, together with a corset and physical rest. A few days later the patient presented with acute dermatitis with papules, vesicles, scales and erythema, which spread over the whole lumbar region. The mycological study of the scales led to the isolation in culture of Candida albicans and Candida parapsilosis. With the diagnosis of decubitus candidiasis he was initially treated with a topical ointment containing 3% salicylic acid and 6% benzoic acid, but only slow, partial improvement was observed. The treatment was changed to oral fluconazole at a daily dose of 200 mg. With the latter the patient showed a rapid, complete clinical response (AU)

[Clinical problems in medical mycology: Problem number 48]. / Problemas clínicos en micología médica: problema número 48.

We present the case of a 42-year-old man, HIV-positive, with low CD4(+) T cell count (31 cells/µl), who was admitted to Hospital de Infecciosas F. J. Muñiz in Buenos Aires (Argentina) due to a severe lower back pain. He had a history of several highly active antiretroviral therapy treatments and he also had diabetes and chronic B and C viral hepatitis. A spinal cord CT scan showed two lytic bone lesions in L2 and L3. A bone biopsy was carried out and its microbiological study allowed the isolation of a methicillin-resistant Staphylococcus aureus. Intravenous vancomycin was prescribed, together with a corset and physical rest. A few days later the patient presented with acute dermatitis with papules, vesicles, scales and erythema, which spread over the whole lumbar region. The mycological study of the scales led to the isolation in culture of Candida albicans and Candida parapsilosis. With the diagnosis of decubitus candidiasis he was initially treated with a topical ointment containing 3% salicylic acid and 6% benzoic acid, but only slow, partial improvement was observed. The treatment was changed to oral fluconazole at a daily dose of 200mg. With the latter the patient showed a rapid, complete clinical response.

Linfoma de Burkitt primario de la cavidad oral en una paciente con sida. Reporte de un caso y revisión de la literatura / Burkitt's lymphoma of the oral cavity in a female with AIDS. Case report and literature review

Los linfomas no Hodgkin (LNH) son un grupo heterogéneo de enfermedades linfoproliferativas con elevada prevalencia en pacientes infectados por el virus de la inmunodeficiencia humana (VIH). La inmunodeficiencia asociada al sida predispone al desarrollo de LNH, incluyendo el linfoma de Burkitt (LB). El LB es un subtipo infrecuente y agresivo de LNH con elevada frecuencia en pacientes con sida. Se asocia a una alta tasa de replicación celular (determinada por el índice Ki67) y con alta frecuencia de compromiso extranodal como forma de presentación clínica de la neoplasia. Se presenta una paciente con sida que desarrolló un LB primario de la cavidad oral y se realiza una revisión de la literatura sobre el tema (AU)

Non-Hodgkin lymphomas (NHL) are a heterogeneous group of diseases with a high prevalence in human immunodeficiency virus (HIV) infected patients. The immunosuppression associated with AIDS predisposes to develop NHL, including Burkitt's lymphoma (BL). BL is an uncommon and aggressive subtype of NHL that occurs with increased frequency among patients with AIDS. BL is associated with a high proliferative rate (Ki67 index) and compromises extranodal sites as the clinical presentation of the disease. Here we report a case of a primary BL of the oral cavity in an AIDS female patient, and a review the literature on the characteristics of oral cavity lymphomas in AIDS patients (AU)

Criptococosis meníngea en pacientes con diabetes y sida / Cryptococcal meningitis in patients with diabetes and AIDS

INTRODUCCIÓN: La criptococosis meníngea es una de las patologías con mayor mortalidad en pacientes con sida. La diabetes mellitus (DM) comprende un grupo de enfermedades metabólicas que afecta a gran parte de la población mundial. La evolución de las infecciones en pacientes diabéticos ha demostrado ser siempre más grave. El objetivo de este trabajo fue analizar la evolución de pacientes con criptococosis meníngea, DM e infección por VIH, comparándola con la de enfermos VIH-positivos con criptococosis meníngea de similar gravedad, pero no diabéticos. MATERIALES Y MÉTODOS: Se analizaron las historias clínicas de 182 pacientes con diagnóstico de criptococosis meníngea. Fueron seleccionados 28 pacientes con características clinicoepidemiológicas similares, se los dividió en 2 grupos, 14 pacientes con DM (grupo A) y los restantes sin alteraciones en el metabolismo de los glúcidos (grupo B). RESULTADOS: Solo 3/14 pacientes del grupo A (21,4%) lograron la negativización del cultivo de LCR, antes de las 10 semanas de tratamiento. Con respecto al grupo B, esto sucedió en 11/14 enfermos (78,5%). La mortalidad global para el grupo A fue del 85,7% (12/14 pacientes), para el grupo B del 21,4% (3/14 pacientes). En todos los casos los aislamientos de Cryptococcus neoformans resultaron sensibles in vitro a la anfotericina B y al fluconazol. CONCLUSIONES: La vinculación de DM y meningitis por Cryptococcus spp. se asoció a la evolución desfavorable en la gran mayoría de los casos; esto plantea la posibilidad de extender el tratamiento de inducción

INTRODUCTION: Cryptococcal meningitis is a severe AIDS-related infectious disease, with a high mortality rate. Diabetes mellitus (DM) is a metabolic disorder very common worldwide. Infectious diseases in diabetic patients are always more severe than in non-diabetic ones. The aim of this study was to compare the outcome of a group of HIV-positive patients with DM and cryptococcal meningitis with a similar group HIV-positive patients with cryptococcal meningitis, but without DM. MATERIAL AND METHODS: A total of 182 clinical records of HIV-positive patients suffering cryptococcal meningitis were reviewed, and 28 of them with similar clinical and epidemiological characteristics, were chosen. They included 14 patients with DM (group A) and the remaining 14 who did not suffer this metabolic disorder (group B). RESULTS: Only 21.4% (3/14 cases) of group A patients had negative CSF cultures after 10 weeks of treatment. In group B patients, 78.5% (11/14 cases) achieved negative CSF cultures before 10 weeks. A higher overall mortality rate was observed in the diabetic patients (85.7%, 12/14 cases) than in the non-diabetic group (21.4%, 3/14 cases). All CSF isolates were identified as Cryptococcus neoformans, and all strains were susceptible in vitro to amphotericin B and fluconazole. CONCLUSIONS: Cryptococcal meningitis in diabetic patients was associated with a poor clinical outcome and a high mortality rate. A longer treatment induction period is suggested in order to improve the outcome of cryptococcal meningitis in diabetic patients

[Cryptococcal meningitis in patients with diabetes and AIDS]. / Criptococosis meníngea en pacientes con diabetes y sida.

INTRODUCTION: Cryptococcal meningitis is a severe AIDS-related infectious disease, with a high mortality rate. Diabetes mellitus (DM) is a metabolic disorder very common worldwide. Infectious diseases in diabetic patients are always more severe than in non-diabetic ones. The aim of this study was to compare the outcome of a group of HIV-positive patients with DM and cryptococcal meningitis with a similar group HIV-positive patients with cryptococcal meningitis, but without DM. MATERIAL AND METHODS: A total of 182 clinical records of HIV-positive patients suffering cryptococcal meningitis were reviewed, and 28 of them with similar clinical and epidemiological characteristics, were chosen. They included 14 patients with DM (group A) and the remaining 14 who did not suffer this metabolic disorder (group B). RESULTS: Only 21.4% (3/14 cases) of group A patients had negative CSF cultures after 10 weeks of treatment. In group B patients, 78.5% (11/14 cases) achieved negative CSF cultures before 10 weeks. A higher overall mortality rate was observed in the diabetic patients (85.7%, 12/14 cases) than in the non-diabetic group (21.4%, 3/14 cases). All CSF isolates were identified as Cryptococcus neoformans, and all strains were susceptible in vitro to amphotericin B and fluconazole. CONCLUSIONS: Cryptococcal meningitis in diabetic patients was associated with a poor clinical outcome and a high mortality rate. A longer treatment induction period is suggested in order to improve the outcome of cryptococcal meningitis in diabetic patients.

Soft-tissue masses as presentation of non-Hodgkin's lymphoma in AIDS patients.

Primary soft tissue Non-Hodgkin lymphomas are very rare and account only for 0.1 % of the cases. Generally, Non-Hodgkin lymphomas of the soft tissue present as large subcutaneous masses without evidence of nodal or skin involvement. We describe four cases of primary Non-Hodgkin lymphomas of the soft tissue in patients infected with the human immunodeficiency virus. The most common site of involvement was the chest wall in all the patients; histopathological and immunophenotypic examination of the biopsy smears revealed two cases of plasmablastic lymphomas, one Burkitt and one diffuse large B-cell lymphoma. Non-Hodgkin lymphomas should be included in the differential diagnosis of soft tissue masses in human immunodeficiency virus - seropositive patients.

Soft-tissue masses as presentation of non-Hodgkin's lymphoma in AIDS patients / Massas de tecidos moles como apresentacao do linfoma nao-Hodgkin em pacientes com AIDS

Primary soft tissue Non-Hodgkin lymphomas are very rare and account only for 0.1 % of the cases. Generally, Non-Hodgkin lymphomas of the soft tissue present as large subcutaneous masses without evidence of nodal or skin involvement. We describe four cases of primary Non-Hodgkin lymphomas of the soft tissue in patients infected with the human immunodeficiency virus. The most common site of involvement was the chest wall in all the patients; histopathological and immunophenotypic examination of the biopsy smears revealed two cases of plasmablastic lymphomas, one Burkitt and one diffuse large B-cell lymphoma. Non-Hodgkin lymphomas should be included in the differential diagnosis of soft tissue masses in human immunodeficiency virus - seropositive patients.

Os linfomas Não-Hodgkin primários de tecidos moles são muito raros e responsáveis por somente 0,1% dos casos. Geralmente, os linfomas Não-Hodgkin de tecidos moles se apresentam como massas subcutâneas sem evidência de comprometimento dos nódulos ou da pele. Descrevemos aqui quatro casos de linfomas Não-Hodgkin primário de tecidos moles em pacientes infectados pelo vírus da imunodeficiência humana. O local mais comum de comprometimento foi a parede torácica em todos os pacientes; os exames histopatológico e imunofenotípico do esfregaço da biópsia revelaram dois casos de linfoma plasmablástico, um linfoma de Burkitt e um linfoma difuso de grandes células B. O linfoma Não-Hodgkin deve ser incluído no diagnóstico diferencial de massas de tecidos moles nos pacientes soropositivos para vírus da imunodeficiência humana.

[Clinical problems in medical mycology: Problem number 47]. / Problemas clínicos en micología médica: problema número 47.

A 66 year-old man, who had lived in Paraguay and was a rural worker, was admitted to Infectious Diseases Hospital F. J. Muñiz in Buenos Aires. He presented fever, loss of body weight, cough, mucopurulent expectoration, wide perianal ulceration, paresthesia and paresis of both legs as well as vesical and anal sphincter dysfunction. He was a heavy smoker and drinker. Thorax X-ray examination showed bilateral micronodular interstitial lesions. With a NMR of the dorsolumbar spine region a nodular lesion outside the spinal cord (which produced compression of this organ) was shown. The diagnosis of disseminated paracoccidiodomycosis was based on the finding of Paracoccidioides brasiliensis in the skin ulcer in histopathology and mycology studies, and on the positive results of serologic tests with paracoccidioidin antigen. The patient was treated with trimethoprim-sulfamethoxazole with good clinical outcome.

Acute meningoencephalomyelitis due to varicella-zoster virus in an AIDS patient: report of a case and review of the literature / Meningoencefalomielite aguda pelo vírus varicela-zoster em um paciente com AIDS: relato de um caso e revisão da literatura

Varicella-zoster virus (VZV) meningoencephalomyelitis is a rare but severe neurological complication of VZV reactivation in immunocompromised patients. We report the case of an HIV-infected individual who developed an acute and severe meningoencephalomyelitis accompanied by a disseminated cutaneous eruption due to VZV. The presence of VZV DNA in cerebrospinal fluid was confirmed by polymerase chain reaction (PCR) technique. The patient started undergoing an intravenous acyclovir therapy with a mild recovery of neurological manifestations. Varicella-zoster virus should be included as a cause of acute meningoencephalomyelitis in patients with AIDS. Early diagnosis followed by specific therapy should modify the rapid and fulminant course for this kind of patients.

A meningoencefalomielite pelo vírus varicela-zoster (VVZ) é uma complicação neurológica rara mas grave da reativação do VVZ em pacientes imunocomprometidos. Nós relatamos o caso de um indivíduo infectado por HIV que desenvolveu uma meningoencefalomielite aguda e grave acompanhada por uma erupção cutânea por causa do VVZ. A presença do DNA do VVZ no líquor foi confirmada pela técnica de reação em cadeia da polimerase (PCR). O paciente iniciou uma terapia intravenosa com aciclovir com uma leve recuperação das manifestações neurológicas. O vírus varicela-zoster deve ser incluído como uma causa de meningoencefalomielite nos pacientes com AIDS. O diagnóstico precoce seguido por terapia específica pode modificar o curso rápido e fulminante deste tipo de pacientes.

Human herpesvirus 6: report of emerging pathogen in five patients with HIV/AIDS and review of the literature.

The reactivation of human herpesvirus 6 (HHV-6) in patients with AIDS can result in an acute and severe diffuse meningoencephalitis. We describe the epidemiological, clinical and outcome findings of five patients with diagnosis of HIV/AIDS and central nervous system involvement (CNS) due to HHV-6. Fever was present in all the patients. Meningeal compromise, seizures and encephalitis were present in some of the patients. Polymerase chain reaction (PCR) of cerebrospinal fluid (CSF) specimens was positive for HHV-6 in all the patients. HHV-6 should be included among opportunistic and emerging pathogens that involve the CNS in patients with AIDS.

Human herpesvirus 6: report of emerging pathogen in five patients with HIV/AIDS and review of the literature / Herpes virus humano 6: relato de patógenos emergentes em cinco pacientes com HIV/AIDS e revisão da literatura

The reactivation of human herpesvirus 6 (HHV-6) in patients with AIDS can result in an acute and severe diffuse meningoencephalitis. We describe the epidemiological, clinical and outcome findings of five patients with diagnosis of HIV/AIDS and central nervous system involvement (CNS) due to HHV-6. Fever was present in all the patients. Meningeal compromise, seizures and encephalitis were present in some of the patients. Polymerase chain reaction (PCR) of cerebrospinal fluid (CSF) specimens was positive for HHV-6 in all the patients. HHV-6 should be included among opportunistic and emerging pathogens that involve the CNS in patients with AIDS.

A reativação do herpesvírus humano 6 (HHV-6), em um hospedeiro com AIDS, pode resultar em meningoencefalite aguda difusa. Nós descrevemos a epidemiologia, a clínica e resultados encontrados em cinco pacientes com diagnóstico de HIV/AIDS e comprometimento do sistema nervoso central (SNC) devido ao HHV-6. Todos os pacientes apresentaram febre. Sinais e sintomas de comprometimento meníngeo, convulsões e encefalite podem ser encontrados. A reação em cadeia da polimerase (PCR) de amostras do líquor foi positiva para HHV-6 em todos os pacientes. O HHV-6 deve ser incluído entre os patógenos emergentes oportunistas que comprometem o SNC de pacientes com AIDS.

Acute meningoencephalomyelitis due to varicella-zoster virus in an AIDS patient: report of a case and review of the literature.

Varicella-zoster virus (VZV) meningoencephalomyelitis is a rare but severe neurological complication of VZV reactivation in immunocompromised patients. We report the case of an HIV-infected individual who developed an acute and severe meningoencephalomyelitis accompanied by a disseminated cutaneous eruption due to VZV. The presence of VZV DNA in cerebrospinal fluid was confirmed by polymerase chain reaction (PCR) technique. The patient started undergoing an intravenous acyclovir therapy with a mild recovery of neurological manifestations. Varicella-zoster virus should be included as a cause of acute meningoencephalomyelitis in patients with AIDS. Early diagnosis followed by specific therapy should modify the rapid and fulminant course for this kind of patients.

Non-Hodgkin lymphomas of the oral cavity in AIDS patients in a reference hospital of infectious diseases in Argentina: report of eleven cases and review of the literature.

INTRODUCTION: Extranodal non-Hodgkin lymphoma (NHL) were commonly described in AIDS patients and are related with an atypical morphology and aggressive clinical course. MATERIALS AND METHODS: In this single institutional study we evaluated the epidemiological, clinical, immunological, virological, histopathological and the outcome of eleven HIV/AIDS patients with oral cavity lymphomas (OCL). RESULTS: Nine were males and seven intravenous drug abusers. The median of age was 33 years and the median of CD4 T cell counts at the time of diagnosis was 97 cell/µL. The majority of tumors presented as large and ulcerated masses involving the gingiva, the palate and the jaw. Six of these tumors were diffuse large B-cell lymphomas (DLBCL); three were Burkitt's lymphomas and the final case was a plasmablastic lymphoma. An association with Epstein-Barr virus (EBV) was found in three of the ten tested cases by in situ hybridization (EBER 1 and 2 probes) and immunohistochemistry (LMP-1). Human herpes virus-8 (HHV-8) was detected by polymerase chain reaction (PCR) in only one neoplasm. Six patients died without specific treatment; four received chemotherapy and highly active antiretroviral therapy (HAART) and three of them presented a prolonged survival. DISCUSSION: Combination of HAART and chemotherapy should modify the poor prognosis of AIDS patients with OCL.

Magnetic resonance imaging findings in AIDS patients with central nervous system cryptococcosis.

Cryptococcosis is an opportunistic fungal infection caused by Cryptococcus neoformans. Generally, the disease affects the central nervous system, especially in patients with human immunodeficiency virus infection. Central nervous system involvement can be either meningeal or parenchymal. As the infection spreads along the Virchow-Robin spaces these structures may dilate with the mucoid and gelatinous material produced by the organism's capsule. The lesions associated with the dilatation of Virchow-Robin spaces are referred to as gelatinous pseudocysts. Bigger lesions are known as cryptococcomas. In this article we describe five patients with neurocryptococcosis associated with AIDS and parenchymal lesions compatible with gelatinous pseudocysts and cryptococcomas.

Apendicitis aguda con peritonitis como única manifestación de unahistoplasmosis diseminada en un paciente con sida / No disponible

Las lesiones gastrointestinales de la histoplasmosis diseminada pueden presentar diversas manifestaciones clínicas. Se presenta un paciente con enfermedad VIH/sida avanzada que ingresa por neumopatía bilateral por Pneumocystis jirovecii, y que desarrolló durante la internación un cuadro de abdomen agudo con peritonitis por Histoplasma capsulatum, como primera y única manifestación de enfermedad diseminada por este agente. La histoplasmosis debe incluirse en el diagnóstico diferencial del abdomen agudo en los pacientes con sida. Se trata de una complicación poco frecuente de la enfermedad cuya sospecha resulta sumamente difícil cuando no existen otras localizaciones orientadoras (AU)

Gastrointestinal compromise of disseminated histoplasmosis can present as several clinical manifestations. We describe HIV/aids patients that consult for a bilateral pneumonia caused by Pneumocystis jiroveci. Later, but during the same admission to our hospital, he developed abdominal pain with signs of peritoneal involvement. Exploratory laparotomy was made; histopathology examination of the appendix and peritoneum smears revealed the presence of poor defined granulomas containing Histoplasma-like organisms. In this patient, appendicitis and peritonitis were the first and the only manifestation of the disease caused by Histoplasma capsulatum. Histoplasmosis should be included in the differential diagnosis of acute abdominal pain inaids patients. Is a less frequently complication and is very difficult to suspect when there are no other localizations of the disease (AU)

Lesión ulcerocostrosa en el brazo derecho en paciente VIH positivo / 9009 Ulcerous lesion on the right arm of an HIV-positive patient

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Magnetic resonance imaging findings in AIDS patients with central nervous system cryptococcosis

La criptococosis es una micosis oportunista causada porCryptococcus neoformans. Por lo general compromete el sistema nerviosocentral de individuos inmunodeprimidos, en especial aquellos con infecciónpor el virus de la inmunodeficiencia humana. A nivel del sistema nerviosocentral puede comprometer las meninges o el parénquima encefálico.Como la infección se disemina a través de los espacios de Virchow-Robin,éstos pueden dilatarse por efecto del material gelatinoso que produce lacápsula del microorganismo. Estas lesiones se denominan “seudoquistesgelatinosos” y aquellas de mayor tamaño reciben el nombre de“criptococomas”. En este trabajo, se presentan cinco pacientes condiagnóstico de neurocriptococosis asociada a sida, y presencia de lesionescerebrales parenquimatosas compatibles con seudoquistes gelatinosos ocriptococomas(AU)

Cryptococcosis is an opportunistic fungal infection caused byCryptococcus neoformans. Generally, the disease affects the central nervoussystem, especially in patients with human immunodeficiency virus infection.Central nervous system involvement can be either meningeal or parenchymal.As the infection spreads along the Virchow-Robin spaces these structures maydilate with the mucoid and gelatinous material produced by the organism’scapsule. The lesions associated with the dilatation of Virchow-Robin spacesare referred to as gelatinous pseudocysts. Bigger lesions are known ascryptococcomas. In this article we describe five patients withneurocryptococcosis associated with AIDS and parenchymal lesionscompatible with gelatinous pseudocysts and cryptococcomas(AU)