RESUMO
Hematologic patients with superficial skin lesions on admission growing Fusarium spp. are at a high risk for developing invasive fusariosis during neutropenia. We evaluated the impact of primary prophylaxis with a mold-active azole in preventing invasive fusariosis in these patients. Between August 2008 and December 2014, patients with acute leukemia or aplastic anemia and recipients of hematopoietic cell transplants were screened on admission with dermatologic and direct exams and fungal cultures of superficial skin lesions. Until November 2009, no interventions were made. Beginning in December 2009, patients with baseline skin lesions and a direct exam and/or culture suggestive of the presence of Fusarium spp. received prophylaxis with voriconazole or posaconazole. Skin lesions in the extremities (mostly onychomycosis and interdigital intertrigo) were present on admission in 88 of 239 episodes (36.8%); 44 lesions had hyaline septate hyphae identified by direct exam, and cultures from 11 lesions grew Fusarium spp. Antimold prophylaxis was given for 20 episodes (voriconazole for 17 and posaconazole for 3). Invasive fusariosis was diagnosed in 14 episodes (5.8%). Among patients with baseline skin lesions with positive cultures for Fusarium spp., 4 of 5 without antimold prophylaxis developed invasive fusariosis versus 0 of 6 with antimold prophylaxis (P = 0.01; 95% confidence interval for the difference between proportions, 22% to 96%). Primary antifungal prophylaxis with an antimold azole may prevent the occurrence of invasive fusariosis in high-risk hematologic patients with superficial skin lesions on admission growing Fusarium spp.
Assuntos
Antifúngicos/uso terapêutico , Fusariose/tratamento farmacológico , Fusariose/prevenção & controle , Fusarium/efeitos dos fármacos , Triazóis/uso terapêutico , Voriconazol/uso terapêutico , Adolescente , Adulto , Idoso , Anemia Aplástica/microbiologia , Feminino , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Hospedeiro Imunocomprometido , Intertrigo/tratamento farmacológico , Leucemia/microbiologia , Masculino , Pessoa de Meia-Idade , Onicomicose/tratamento farmacológico , Estudos Prospectivos , Pele/microbiologia , Adulto JovemRESUMO
Invasive fusariosis (IF) is an infection with Fusarium spp. fungi that primarily affects patients with hematologic malignancies and hematopoietic cell transplant recipients. A cutaneous portal of entry is occasionally reported. We reviewed all cases of IF in Brazil during 2000-2010, divided into 2 periods: 2000-2005 (period 1) and 2006-2010 (period 2). We calculated incidence rates of IF and of superficial infections with Fusarium spp. fungi identified in patients at a dermatology outpatient unit. IF incidence for periods 1 and 2 was 0.86 cases versus 10.23 cases per 1,000 admissions (p<0.001), respectively; superficial fusarial infection incidence was 7.23 versus 16.26 positive cultures per 1,000 superficial cultures (p<0.001), respectively. Of 21 cases of IF, 14 showed a primary cutaneous portal of entry. Further studies are needed to identify reservoirs of these fungi in the community and to implement preventive measures for patients at risk.
Assuntos
Dermatomicoses/mortalidade , Fusariose/mortalidade , Fusarium , Leucemia Mieloide Aguda/imunologia , Brasil/epidemiologia , Dermatomicoses/imunologia , Dermatomicoses/microbiologia , Fusariose/imunologia , Fusariose/microbiologia , Humanos , Hospedeiro Imunocomprometido , IncidênciaRESUMO
Meningeal sporotrichosis is rare and occurs predominantly in immunosuppressed individuals. This retrospective study explored clinical and laboratory characteristics, treatment, and prognosis of patients with disseminated sporotrichosis who underwent lumbar puncture (LP) at a Brazilian reference center from 1999 to 2020. Kaplan-Meier and Cox regression models were used to estimate overall survival and hazard ratios. Among 57 enrolled patients, 17 had meningitis. Fifteen (88.2%) had HIV infection, and in 6 of them, neurological manifestations occurred because of the immune reconstitution inflammatory syndrome (IRIS). The most frequent symptom was headache (88.2%). Meningeal symptoms at first LP were absent in 7/17 (41.2%) patients. Sporothrix was diagnosed in cerebrospinal fluid either by culture or by polymerase chain reaction in seven and four patients, respectively. All but one patient received prolonged courses of amphotericin B formulations, and seven received posaconazole, but relapses were frequent. Lethality among patients with meningitis was 64.7%, with a higher chance of death compared to those without meningitis (HR = 3.87; IC95% = 1.23;12.17). Meningeal sporotrichosis occurs mostly in people with HIV and can be associated with IRIS. Screening LP is indicated in patients with disseminated disease despite the absence of neurological complaints. Meningitis is associated with poor prognosis, and better treatment strategies are needed.
RESUMO
Although rare, disseminated sporotrichosis is increasing in several countries. Despite its limiting toxic potential, amphotericin B is the only intravenous antifungal available to treat severe sporotrichosis. We aimed to describe the effectiveness and safety of amphotericin B treatment for severe sporotrichosis. Clinical records of patients with disseminated sporotrichosis at a reference center were reviewed. This study included 73 patients. Most (53.4%) were men and non-white. HIV coinfection was the main comorbidity (52.1%). Most reported contact with cats (76.7%). Sporothrix brasiliensis was the causative species. Affected sites were skin (98.6%), osteoarticular system (64.4%), upper airway (42.5%), central nervous system (20.5%), eyes (12.3%), and lungs (8.2%). Median doses of amphotericin B used were 750 mg and 4500 mg for deoxycholate and lipid complex formulations, respectively. Amphotericin B discontinuation occurred in 20.5% due to adverse events, mainly azotemia. The outcomes included cure (52.1%), death due to sporotrichosis (21.9%), death due to other causes (9.6%), and loss to follow-up (8.2%). Survival analysis showed an association between cure and the absence of bone, upper airway, and central nervous system involvement. Amphotericin B is the first-choice treatment for disseminated sporotrichosis; however, the severity of systemic dissemination might predict its response. Favorable clinical results depend on prompt diagnosis, investigation of fungal dissemination, and early therapy initiation.
RESUMO
BACKGROUND: Paracoccidioidomycosis (PCM) is a systemic mycosis caused by pathogenic dimorphic fungi of the genus Paracoccidioides. It is the most important systemic mycosis in Latin America and the leading cause of hospitalizations and death among them in Brazil. Acute PCM is less frequent but relevant because vulnerable young patients are affected and the severity is usually higher than that of the chronic type. METHODS: The authors performed a retrospective cohort study from 2001 to 2009 including acute juvenile PCM patients from a reference center in Rio de Janeiro, Brazil. Clinical, epidemiological, diagnostic, therapeutic, and prognostic data were reported. RESULTS: Twenty-nine patients were included. The average age was 23 years old and the male to female ratio was 1:1.07. All cases were referred from 3 of 9 existing health areas in the state of Rio de Janeiro, predominantly from urban areas (96.5%). Lymph nodes were the most affected organs (100%), followed by the skin and the spleen (31% each). Twenty-eight patients completed treatment (median 25 months) and progressed to clinical and serological cure; 1 death occurred. Twenty-four patients completed 48-month median follow-up. Four patients abandoned follow-up after the end of treatment. The most frequent sequela was low adrenal reserve. Paracoccidioides brasiliensis S1 was identified by partial sequencing of the arf and gp43 genes from 4 patients who presented a viable fungal culture. CONCLUSION: Acute juvenile PCM is a severe disease with a high rate of complications. There are few cohort clinical studies of acute PCM in the literature. More studies should be developed to promote improvement in patients' healthcare.
Assuntos
Doenças Endêmicas , Paracoccidioides/isolamento & purificação , Paracoccidioidomicose/epidemiologia , Adolescente , Adulto , Antifúngicos/uso terapêutico , Brasil/epidemiologia , Criança , Estudos de Coortes , Feminino , Proteínas Fúngicas/genética , Genótipo , Humanos , Masculino , Paracoccidioides/classificação , Paracoccidioides/genética , Paracoccidioidomicose/diagnóstico , Paracoccidioidomicose/tratamento farmacológico , Paracoccidioidomicose/patologia , Estudos Retrospectivos , Análise de Sequência de DNA , Resultado do Tratamento , Adulto JovemRESUMO
Angionvasive mucormycosis is an emerging fungal disease known to affect mainly diabetics or subjects with profound neutropenia. Infection usually occurs through the inhalation route, but cutaneous inoculation may occur after trauma or burns. However, mucormycosis remains unusual in HIV infection. We report a fatal case of cutaneous mucormycosis due to Rhizopus arrhizus involving the scalp following herpes zoster infection. The patient was a 42-year-old man with advanced AIDS failing on salvage antiretroviral therapy. The fungus was diagnosed on the basis of histopathology and culture. Our case emphasizes the need to consider mucormycosis in the differential diagnosis of necrotic cutaneous lesions in patients with late-stage HIV disease.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Mucormicose/diagnóstico , Rhizopus/isolamento & purificação , Adulto , Humanos , Masculino , Mucormicose/tratamento farmacológicoRESUMO
OBJECTIVES: Mucormycosis is an invasive fungal infection afflicting immunocompromised patients, causing a significant degree of morbidity and mortality. The purpose of the study was to provide a comprehensive analysis describing the epidemiology and outcome of mucormycosis in the scenario of HIV infection. METHODS: We systematically searched PubMed for reports about mucormycosis associated with HIV. Eligible studies describe the predisposing factor, clinical form, treatment, and survival outcome. RESULTS: We included 61 articles from 212 reviewed abstracts, corresponding to 67 cases. Patients were mostly men (68.2%) with a median CD4(+) count of 47 [IQR 17-100] cells/mm(3). Intravenous drug use (50%), neutropenia (29.7%) and corticosteroid use (25%) were the predominant associated factors. The main clinical forms were disseminated (20.9%), renal (19.4%), and rhino-cerebral (17.9%). Rhizopus (45.5%) and Lichtheimia spp (30.3%) were the main fungal isolates. Treatment consisted of antifungal therapy and surgery in 38.8%. Overall mortality rate was 52.2%, and varied with the site of infection: 92.9% for disseminated disease, 62.5% for cerebral disease, 60% for pulmonary infection, and 36.4% for cutaneous infection. Survival was worse for those who did not initiate antifungals (p = .04), who were antiretroviral naïve (p = .01), who were admitted to ICU (p = .003) or had disseminated disease (p = .007). CONCLUSIONS: Mucormycosis is a life-threatening infection in HIV patients and clinician should be aware of this co-infection in the differential diagnosis of HIV opportunistic infections.
Assuntos
Coinfecção , Efeitos Psicossociais da Doença , Infecções por HIV/complicações , Mucormicose/complicações , Mucormicose/epidemiologia , Adulto , Antifúngicos/uso terapêutico , Coinfecção/tratamento farmacológico , Coinfecção/microbiologia , Coinfecção/mortalidade , Coinfecção/virologia , Feminino , Infecções por HIV/virologia , Humanos , Hospedeiro Imunocomprometido/imunologia , Pneumopatias/complicações , Pneumopatias/microbiologia , Masculino , Pessoa de Meia-Idade , Mucormicose/tratamento farmacológico , Mucormicose/mortalidade , Neutropenia/complicações , Neutropenia/microbiologia , Neutropenia/virologia , Rhizopus/isolamento & purificação , Fatores de RiscoAssuntos
Hospedeiro Imunocomprometido , Linfoma/complicações , Micetoma/complicações , Adulto , Antibacterianos/uso terapêutico , Antineoplásicos/uso terapêutico , Humanos , Linfoma/tratamento farmacológico , Masculino , Micetoma/tratamento farmacológico , Micetoma/microbiologia , Nocardia/isolamento & purificação , Combinação Trimetoprima e Sulfametoxazol/uso terapêuticoAssuntos
Betacoronavirus , Coinfecção , Infecções por Coronavirus/complicações , Infecção Hospitalar/complicações , Paracoccidioidomicose/complicações , Pneumonia Viral/complicações , Doença Aguda , COVID-19 , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/transmissão , Humanos , Masculino , Pandemias , Paracoccidioidomicose/diagnóstico , Paracoccidioidomicose/imunologia , Pneumonia Viral/diagnóstico , Pneumonia Viral/transmissão , Radiografia Torácica , SARS-CoV-2 , Adulto JovemRESUMO
OBJECTIVES: To evaluate the frequency of skin colonization by Fusarium spp. in high-risk hematologic patients and its impact on the subsequent development of invasive fusariosis. METHODS: We screened all high-risk hematologic patients from August 2008 to December 2009 with cultures of 6 pre-defined areas in the feet and hands on admission and at discharge. In addition, cultures of any skin lesion present on admission were performed. RESULTS: Among 61 patients screened, alterations in the skin and/or nails were present in 32 patients (52%) on admission, mostly represented by abnormal appearing nails and intertrigo. Four patients (7.2%) presented positive baseline cultures for Fusarium spp., all in existing lesions of onychomycosis, intertrigo or both. Invasive fusariosis was diagnosed in six patients. The presence of a skin lesion at baseline that grew Fusarium spp. was associated with the subsequent development of invasive fusariosis (p = 0.04). CONCLUSIONS: Our data suggest that: 1) baseline cultures in patients without alterations in the skin and/or nails seems not justifiable; 2) cultures of pre-existing lesions may help to identify a group of patients at higher risk to develop invasive fusariosis. The use of anti-mould prophylaxis in this setting should be explored in future studies.
Assuntos
Fusariose/microbiologia , Fusarium/isolamento & purificação , Pele/microbiologia , Adolescente , Adulto , Idoso , Antifúngicos/uso terapêutico , Feminino , Fusariose/diagnóstico , Fusariose/tratamento farmacológico , Transplante de Células-Tronco Hematopoéticas , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Adulto JovemRESUMO
Cross-reactivity of Fusarium species with serum galactomannan antigen (GMI) test has been observed. We sought to evaluate if GMI could help to early diagnose invasive fusariosis and to monitor treatment response. We reviewed the records of all patients with invasive fusariosis between 2008 and 2012 in three Brazilian hospitals. We selected patients who had at least 1 GMI test within 2 days before or after the date of the first clinical manifestation of fusariosis, and analyzed the temporal relationship between the first positive GMI test and the date of the diagnosis of invasive fusariosis, and the kinetics of GMI in relation to patients' response to treatment. We also selected 18 controls to determine the sensitivity and specificity of the test. Among 18 patients, 15 (83%) had at least one positive GMI (median 4, range 1-15). The sensitivity and specificity of was 83% and 67%, respectively. GMI was positive before the diagnosis of invasive fusariosis in 11 of the 15 cases (73%), at a median of 10 days (range 3-39), and after the diagnosis in 4 cases. GMI became negative in 8 of the 15 patients; 3 of these 8 patients (37.5%) were alive 90 days after the diagnosis of fusariosis compared with 2 of 7 (29%) who did not normalize GMI (p = 1.0). GMI is frequently positive in invasive fusariosis, and becomes positive before diagnosis in most patients. These findings may have important implications for the choice of antifungal therapy in settings with high prevalence of invasive fusariosis.
Assuntos
Fusariose/diagnóstico , Antifúngicos/uso terapêutico , Aspergillus , Biomarcadores/sangue , Brasil , Reações Cruzadas , Diagnóstico Precoce , Fusariose/tratamento farmacológico , Galactose/análogos & derivados , Humanos , Cinética , Mananas/imunologia , Prognóstico , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
We report 2 cases of patients with immune reconstitution inflammatory syndrome (IRIS) associated with cutaneous disseminated sporotrichosis and human immunodeficiency virus (HIV) coinfection. The patients received specific treatment for sporotrichosis. However, after 4 and 5 weeks from the beginning of antiretroviral therapy, both patients experienced clinical exacerbation of skin lesions despite increased T CD4+ cells (T cells cluster of differentiation 4 positive) count and decreased viral load. Despite this exacerbation, subsequent mycological examination after systemic corticosteroid administration did not reveal fungal growth. Accordingly, they were diagnosed with IRIS. However, the sudden withdrawal of the corticosteroids resulted in the recurrence of IRIS symptoms. No serious adverse effects could be attributed to prednisone. We recommend corticosteroid treatment for mild-to-moderate cases of IRIS in sporotrichosis and HIV coinfection with close follow-up.
Assuntos
Infecções por HIV/complicações , Síndrome Inflamatória da Reconstituição Imune/complicações , Esporotricose/etiologia , Adulto , Contagem de Linfócito CD4 , Coinfecção , Infecções por HIV/imunologia , Humanos , Síndrome Inflamatória da Reconstituição Imune/imunologia , Masculino , Esporotricose/imunologia , Carga Viral , Adulto JovemRESUMO
Bartonella henselae is associated with a wide spectrum of clinical manifestations, including cat scratch disease, endocarditis and meningoencephalitis, in immunocompetent and immunocompromised patients. We report the first molecularly confirmed case of B. henselae infection in an AIDS patient in state of Rio de Janeiro, Brazil. Although DNA sequence of B. henselae has been detected by polymerase chain reaction in a lymph node biopsy, acute and convalescent sera were nonreactive.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Bartonella henselae/isolamento & purificação , Doença da Arranhadura de Gato/diagnóstico , Adulto , Animais , Bartonella henselae/genética , Gatos , DNA Bacteriano/análise , Humanos , Masculino , Reação em Cadeia da PolimeraseRESUMO
Importância do problema: Relatar um caso de hipersensibilidade à lamivudina, droga considerada segura e antirretroviral indicado como de primeira linha para início de tratamento para pacientes infectados pelo HIV. Comentários: É relatado o caso de paciente infectada pelo HIV que evoluiu com farmacodermia associada à terapia antirretroviral (TARV) utilizando tenofovir, lamivudina e efavirenz. Inicialmente, a hipersensibilidade foi atribuída ao efavirenz, pela maior incidência de eventos desta natureza com este medicamento e este foi substituído por fosamprenavir/ ritonavir. Apesar da substituição, paciente desenvolveu síndrome de Stevens-Johnson. Foi hospitalizada e iniciou novo esquema, com introdução de droga a droga, com atazanavir/ritonavir, seguido de zidovudina e lamivudina, desenvolvendo manifestação de eritema multiforme após a última droga, sendo esta considerada a responsá- vel pela hipersensibilidade. (AU)
Relevance: To report a case of hypersensitivity to lamivudine, a medicine that is considered safe and is indicated as part of the initial therapy for HIV infected patients. Comments: It is reported the evolution of an HIV patient who developed a drug eruption due to the following antirretroviral therapy: tenofovir, lamivudine and efavirenz. It initially was attributed to efavirenz, due to its higher incidence in these adverse reactions and it was replaced by fosamprenavir/ritonavir. In spite of the replacement, the patient developed Stevens-Johnson's Syndrome. She was hospitalized and began a new therapy with atazanavir/ritonavir, followed by zidovudine and lamivudine and presented a drug reaction with the last one, which was considered to be the responsible for the hypersensitivity. (AU)
Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , Síndrome da Imunodeficiência Adquirida , HIV , Lamivudina/efeitos adversos , Terapia Antirretroviral de Alta Atividade , HipersensibilidadeRESUMO
ABSTRACT Angionvasive mucormycosis is an emerging fungal disease known to affect mainly diabetics or subjects with profound neutropenia. Infection usually occurs through the inhalation route, but cutaneous inoculation may occur after trauma or burns. However, mucormycosis remains unusual in HIV infection. We report a fatal case of cutaneous mucormycosis due to Rhizopus arrhizus involving the scalp following herpes zoster infection. The patient was a 42-year-old man with advanced AIDS failing on salvage antiretroviral therapy. The fungus was diagnosed on the basis of histopathology and culture. Our case emphasizes the need to consider mucormycosis in the differential diagnosis of necrotic cutaneous lesions in patients with late-stage HIV disease.
Assuntos
Humanos , Masculino , Adulto , Rhizopus/isolamento & purificação , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Mucormicose/diagnóstico , Mucormicose/tratamento farmacológicoRESUMO
Bartonella henselae is associated with a wide spectrum of clinical manifestations, including cat scratch disease, endocarditis and meningoencephalitis, in immunocompetent and immunocompromised patients. We report the first molecularly confirmed case of B. henselae infection in an AIDS patient in state of Rio de Janeiro, Brazil. Although DNA sequence of B. henselae has been detected by polymerase chain reaction in a lymph node biopsy, acute and convalescent sera were nonreactive.
Bartonella henselae está associada a um amplo espectro de manifestações clínicas, incluindo a doença da arranhadura de gato, endocardite, e meningoencefalite, em pacientes imunocompetentes e imunocomprometidos. Relatamos o primeiro caso confirmado por método molecular de B. henselae em um paciente com SIDA no estado do Rio de Janeiro, Brasil. Apesar da sequência de DNA de B. henselae ser detectada pela reação em cadeia da polimerase em uma biópsia do linfonodo, soros das fases aguda e convalescente foram não reativos.
Assuntos
Adulto , Animais , Gatos , Humanos , Masculino , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Bartonella henselae/isolamento & purificação , Doença da Arranhadura de Gato/diagnóstico , Bartonella henselae/genética , DNA Bacteriano/análise , Reação em Cadeia da PolimeraseRESUMO
We report 2 cases of patients with immune reconstitution inflammatory syndrome (IRIS) associated with cutaneous disseminated sporotrichosis and human immunodeficiency virus (HIV) coinfection. The patients received specific treatment for sporotrichosis. However, after 4 and 5 weeks from the beginning of antiretroviral therapy, both patients experienced clinical exacerbation of skin lesions despite increased T CD4+ cells (T cells cluster of differentiation 4 positive) count and decreased viral load. Despite this exacerbation, subsequent mycological examination after systemic corticosteroid administration did not reveal fungal growth. Accordingly, they were diagnosed with IRIS. However, the sudden withdrawal of the corticosteroids resulted in the recurrence of IRIS symptoms. No serious adverse effects could be attributed to prednisone. We recommend corticosteroid treatment for mild-to-moderate cases of IRIS in sporotrichosis and HIV coinfection with close follow-up.