Isolated oral histoplasmosis presenting as Fever of unknown origin in a Portuguese hemodialysis patient.

The authors report a clinical case of an isolated oral histoplasmosis in a hemodialysis patient that presented with fever of unknown origin and had an unremarkable physical examination. During the investigation, a Gallium scan showed uptake in the oral cavity and soon after the oral cavity examination revealed a granulomatous lesion on the tooth 26. Histopathologic findings were compatible with histoplasmosis. The treatment regimen included liposomal amphotericin B followed by itraconazole consolidation therapy, and side effects did not occur. Both clinical evolution and outcome were favorable. Oral histoplasmosis in a non-immunosuppressed patient is extremely rare.

Surveillance of surgical site infection after colorectal surgery: comprehensiveness and impact of risk factors.

OBJECTIVE: The incidence of surgical site infection (SSI) is highest after colorectal surgery. We assessed the impact of risk factors for SSI using the population attributable fraction (PAF). DESIGN: Retrospective cohort study. SETTING: Portuguese hospitals performing regular surveillance. PATIENTS: We identified patients who underwent colorectal procedures in hospitals that reported colorectal surgeries every year between 2015 and 2019. Among 42 reporting hospitals, 18 hospitals were included. METHODS: Risk-factor incidence was estimated using the National Epidemiological Surveillance platform from 2015 to 2019. This platform follows the methodology recommended by the European Centre for Disease Prevention and Control. American Society of Anaesthesiologists (ASA) physical classification, wound classification, open surgery, urgent operation, antibiotic prophylaxis, operation time, and male sex were included as risk factors. Measures of association were retrieved from published meta-analyses. PAFs were calculated using the Levin formula. To account for interaction between risk factors, communality of risk factors was used in a weighted-sum approach, providing a combined value that serves as a measure of the comprehensiveness of surveillance. RESULTS: Among 11,219 reported procedures, the cumulative SSI incidence was 16.8%. The proportion of SSI attributed to all risk factors was 61%. Modifiable variables accounted for 31% of procedures; the highest was laparotomy (16.8%), and urgent operations (2.7%) had the lowest value. Nonmodifiable factors accounted for 28.7%; the highest was wound classification (14.3%). CONCLUSIONS: A relevant proportion (39%) of SSI remains unaccounted for by current surveillance. Almost one-third of SSI cases have potentially modifiable factors. Interventions focusing on shorter, less invasive procedures may be optimally effective in reducing the SSI incidence.

Disseminated Saprochaete capitata fungal infection in a patient with acute myeloid leukemia.

The case highlights the importance of actively obtaining informative samples at an early stage and of prompt initiation of combination therapy with antifungal drugs.

[Consensus on HPV of the Portuguese Society of Andrology, Sexual Medicine and Reproduction: Treatment]. / Consensos em HPV Masculino da Sociedade Portuguesa de Andrologia, Medicina Sexual e Reprodução: Tratamento.

The treatment of condyloma is generally a challenge in clinical practice. Although the spontaneous resolution rate is high, a significant proportion of patients seek treatment, not because of symptomatology, but mainly for aesthetic issues and concerns related to the transmission or worsening of existing lesions. The available treatments should be applied only for clinically evident macroscopic lesions. Ideally, available therapies should have rapid action onset and clearance, resolve symptoms, reduce recurrence rate and viral load, be effective in treating small lesions, and be well tolerated. However, none of the currently available treatments is clearly more effective than the others and there is no ideal treatment for all patients or for all condyloma. Therefore, the therapeutic decision should be based on the clinician's experience, available resources, lesion morphology, size, number and location, primary or recurrent lesions, disease severity, patient preference and expectations, patient's immune competence, convenience, tolerance, cost of treatment and results of previous therapies. The available treatments are divided into three groups: applied by the patient himself (imiquimod 3.75 or 5%, podophyllotoxin .5%, synecatekines 10% or 15%), applied by the health care provider (bi- and tricloacetic acids 80%-90%, intralesional interferon alpha, cryotherapy, surgical removal, electrofulguration, laser ablation) and experimental or alternative therapies (topical cidofovir, intralesional bleomycin, photodynamic therapy). Treatment methodologies can be further divided into their action - ablative or destructive treatment (cryotherapy, electrofulguration, laser ablation, surgical excision), cytotoxic or proapoptotic treatments (podophyllotoxin .5%, 5-fluoruracil, bleomycin) and immunomodulatory treatments (imiquimod 3.75% or 5%, synecatekines 10% or 15%, intralesional interferon alpha). The overall success rate of the various treatments available ranges from 23% to 94%. Only treatments that include cryotherapy or surgical excision are suitable in condyloma with any anatomical location and that have the highest success rate in monotherapy. Recurrences are common regardless of the treatment received. In contrast, immunomodulatory therapies despite having lower initial clearance rates appear to have higher probabilities of cure in the medium term, with low recurrence rates. Some treatments may be combined with each other and the effectiveness of combined therapies appears to be superior to monotherapy (proactive sequential treatment). The consensuses for the treatment of HPV also consider special situations: immunocompromised patients, meatus and intraurethral lesions and treatment of the partner.

[Acute bacterial meningitis as an occupational disease]. / Meningite bacteriana aguda como doença ocupacional.

Streptococcus suis is a zoonotic pathogen with worldwide distribution, responsible for more than 700 human cases globally reported. This infection affects mostly men, exposed to pig or pork, which leads to its usual classification as an occupational disease. We report a case of acute bacterial meningitis in a 44 years old male. According to his past medical history, the patient had chronic alcoholism and worked in a restaurant as a piglet roaster. Microbiological examination of blood and CSF revealed S. suis. After 14 days of ceftriaxone the patient fully recovered. The authors review the clinical reports previously described in Portugal. In all of them was possible to identify risk exposition to pork. We alert to this microorganism's importance in Portugal where it is probably underdiagnosed.

Streptococcus suis é um agente zoonótico com distribuição mundial, atualmente responsável por mais de 700 casos reportados em humanos. Atinge quase em exclusivo indivíduos do sexo masculino com exposição a suínos ou à sua carne, classificando-se neste contexto como uma doença ocupacional. Os autores apresentam um caso de meningite bacteriana aguda por este agente infeccioso, num homem de 44 anos com antecedentes de etilismo crónico cuja atividade profissional consistia em assar leitões num restaurante. A análise microbiológica do sangue e do LCR revelou S. suis, agente etiológico desta infecção. Foi tratado empiricamente com ceftriaxona, completando 14 dias de antibioterapia com resolução total do quadro. Reveem-se os casos previamente descritos em Portugal. Em todos foi possível identificar exposição a carne de porco crua. Alerta-se para a importância deste agente infeccioso em Portugal, onde possivelmente se encontrará sub-diagnosticado.

Severe hyponatremia in older patients at admission in an internal medicine department.

Hyponatremia is common in older people, most often of multifactorial origin, and can be associated with poor clinical outcomes. The aim was to analyze the frequency of severe hyponatremia (sodium concentration below 125 mmol/L), risk factors and mortality association in hospitalized older patients. A retrospective study was performed in older patients (over 65 years) with hyponatremia, diagnosed at admission in an Internal Medicine Department during one year. A control group of 127 older patients without hyponatremia was considered. Statistical analysis of the data gathered was made with SPSS Statistics 20. The main results were: a group of 1060 patients with age superior to 65 years was identified (representing 72.26% of total admissions); incidence of hyponatremia in those patients was 27.55% and severe hyponatremia was 5.94%; diagnosis of hyponatremia was mentioned in the discharge note in 66.67% of cases; mortality was 27.0%, against 16.0% in the control group (p=0.057, Odds Ratio (OR)=1.940); drugs were a significant risk factor (p<0.001), specially thiazide diuretics (p=0.029, OR=2.774), angiotensin receptor blockers (ARB) (p=0.001, OR=4.097), proton-pump inhibitors (PPI) (p=0.007, OR=2.561) and spironolactone (p=0.011, OR=4.473); other relevant risk factors were: increased water intake (p=0.004), tube feeding (p<0.001), vomiting (p=0.032, OR=2.492), cirrhosis (p=0.008, OR=10.862) and hyperhidrosis (p=0.017, OR=2.542). We conclude that, although this group of patients had a high mortality, hyponatremia is often not investigated and not always mentioned as a diagnosis. Clinicians should have a clear appreciation of the roles that iatrogenic interventions and lapses in nutrition frequently play in upsetting the homeostatic balance in older patients.

[Brucellar spondylodiscitis: case series of the last 25 years]. / Espondilodiscite Brucélica: Casuística dos Últimos 25 Anos.

INTRODUCTION: Brucellosis is an endemic zoonosis in Portugal. Brucellar spondylodiscitis is one of the most frequent focal manifestations which may cause severe sequelae despite appropriate therapy. MATERIAL AND METHODS: Retrospective study of patients with diagnosis of brucellar spondylodiscitis admitted to the Infectious Diseases Department of Centro Hospitalar e Universitário de Coimbra, over a 25-year period (1988-2012). RESULTS: We identified 54 patients, 55.6% male, mean age of 54.8 years. In 81.5% an epidemiological context was identified, mostly contact with sheep and goats. The duration of symptoms prior to diagnosis was 5.5 months. The most common signs and symptoms were pain (98.1%), fever (46.3%) and neurological deficits (25.9%). Spinal magnetic resonance imaging was the most used imaging method (77.8%) showing abscesses in 29.6% of patients. Lumbar location predominated (77.7%). Diagnosis was attained in 47 patients (87.0%): positive blood cultures (3 patients), positive serology (32 patients) or by both methods (12 patients). Combined regimens of doxycycline and rifampicin (64.8%), or streptomycin (24.1%) were most used, for an average duration of 4.4 months. A patient was referred for surgery for abscess drainage. Evolution was mostly favorable (92.6%), no deaths occurring. DISCUSSION: Research of the epidemiologic context turned out to be a major key leading to the diagnosis. Treatment of osteoarticular brucellosis is still controversial. CONCLUSIONS: Brucellar spondylodiscitis should be considered in the differential diagnosis of patients with low back pain, even in the absence of fever, particularly in regions where the disease is endemic. Antibiotic regimen, its' duration and the need for surgery should be individualized to achieve a better prognosis. Cases have declined over the years, a fact related to better control of animal endemic.

Introdução: A brucelose é uma zoonose endémica em Portugal, sendo a espondilodiscite brucélica uma das manifestações focaismais frequentes. Pode provocar sequelas graves, apesar da terapêutica dirigida.Material e Métodos: Estudo retrospectivo dos processos dos doentes com espondilodiscite brucélica, internados no Serviço de Doenças Infecciosas do Centro Hospitalar e Universitário de Coimbra, num período de 25 anos (1988-2012).Resultados: Foram identificados 54 doentes, 55,6% do sexo masculino, com idade média de 54,8 anos. Em 81,5% identificou-se contexto epidemiológico, maioritariamente contacto com gado ovino e caprino. A duração da sintomatologia prévia ao diagnóstico foi de 5,5 meses. Os sinais e sintomas mais frequentes foram: dor (98,1%), febre (46,3%) e défices neurológicos (25,9%). A ressonância magnética nuclear da coluna foi o exame imagiológico mais usado (77,8%) evidenciando abcessos em 29,6% dos doentes. A localizaçãolombar predominou (77,7%). O diagnóstico etiológico foi confirmado em 47 doentes (87,0%): microbiologicamente (3 doentes), serologicamente (32 doentes) ou por ambos (12 doentes). As associações de doxiciclina com rifampicina (64,8%), ou estreptomicina (24,1%) foram as mais utilizadas, com duração média de 4,4 meses de tratamento. Um doente teve indicação cirúrgica para drenar abcesso. A evolução foi maioritariamente favorável (92,6%), sem óbitos.Discussão: A investigação de contexto epidemiológico revelou ser uma peça importante na suspeita do diagnóstico. O tratamento da brucelose osteoarticular ainda é controverso.Conclusões: A espondilodiscite brucélica deve ser considerada no diagnóstico diferencial dos doentes com lombalgia, mesmo naausência de febre, particularmente em regiões onde a doença é endémica. O esquema antibiótico, sua duração e a necessidade de cirurgia deverão ser individualizados, com vista a um melhor prognóstico. O número de casos tem diminuído ao longo dos anos, facto relacionado com melhor controlo da endemia animal.