Infecções fúngicas disseminadas com acometimento das supra-renais: descrição de dois pacientes brasileiros HIV-negativos

A paracoccidioidomicose e a histoplasmose são infecções fúngicas sistêmicas endêmicas no Brasil. As formas clínicas disseminadas são incomuns em pacientes imunocompetentes. Nós descrevemos dois pacientes HIV-negativos com infecções fúngicas disseminadas, paracoccidioidomicose e histoplasmose, que foram diagnosticadas por biópsias de lesões de supra-renal. Ambos foram tratados por períodos prolongados com antifúngicos orais, evoluindo com boa resposta terapêutica.Paracoccidioidomycosis and histoplasmosis are systemic fungal infections endemic in Brazil. Disseminated clinical forms are uncommon in immunocompetent individuals. We describe two HIV-negative patients with disseminated fungal infections, paracoccidioidomycosis and histoplasmosis, who were diagnosed by biopsies of suprarenal lesions. Both were treated for a prolonged period with oral antifungal agents, and both showed favorable outcomes

Antifungal drug susceptibility profile of Pichia anomala isolates from patients presenting with nosocomial fungemia

In vitro susceptibility of 58 isolates of Pichia anomala to five antifungal drugs using two broth microdilution methods (CLSI and EUCAST) was analyzed. Low susceptibility to itraconazole was observed. Fluconazole, voriconazole, amphotericin B, and caspofungin showed good antifungal activity, although relatively high drug concentrations were necessary to inhibit the isolates.Inst Adolfo Lutz Registro, São Paulo, BrazilUniversidade Federal de São Paulo, Div Infect Dis, São Paulo, BrazilUniv Estadual Campinas, Fac Med Sci, Div Infect Dis, Campinas, SP, BrazilUniv Catolica Argentina, Fac Med, Buenos Aires, DF, ArgentinaUniv São Paulo, Hosp Clin, Lab Clin Micorbiol, São Paulo, BrazilUniv São Paulo, Hosp Clin, Hosp Infect Control Dept, LIM 54, São Paulo, BrazilHosp Sirio Libanes, São Paulo, BrazilUniv Fed Rio de Janeiro, Dept Internal Med, Rio de Janeiro, BrazilUniv São Paulo, Hosp Clin, Dept Infect Dis, São Paulo, BrazilUniversidade Federal de São Paulo, Div Infect Dis, São Paulo, BrazilWeb of Scienc

Perfil clínico-epidemiológico da criptococose associada e não associada à infecção pelo HIV na região Centro-Oeste do Brasil / Clinical and epidemiological aspects of cryptococcosis associated and non-associated to HIV infection in Central Western region of Brazil

Objetivo: Analisar as características clínicas-epidemiológicas, segundo a infecção pelo HIV, dos casos de criptococose no estado de Goiás. Métodos: Estudo transversal dos casos de criptococose no período de 2011 a 2014. Utilizou-se registros laboratoriais e prontuários médicos de unidades de saúde referência para a doença. Aplicou testes estatísticos para comparar o grupo HIV positivos e HIV negativos com as variáveis estudadas. Resultados: Identificou 130 casos de criptococose, 116(89,2%) HIV positivos e 14(10,8%) negativos. A meningoencefalite foi a forma clínica predominante em ambos os grupos, assim como a espécie Cryptococcus neoformans. Entre os casos HIV negativos (64,3%) usavam medicamentos imunossupressores. A média da contagem de células TCD4 dos casos HIV positivos foi 58,7 células/mm3e 60,8% foram a óbito, entre os sobreviventes, 43,1% ficaram com sequelas, sendo o déficit visual o mais frequente. Conclusões:  A criptococose é uma doença grave, dada a elevada letalidade e potencial de provocar danos funcionais

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O objetivo do trabalho foi estudar a variação de subtipos e suscetibilidade a fármacos antifúngicos de amostras de Candida albicans isoladas de 25 pacientes com candidíase bucal associada à AIDS. Foram coletadas três amostras seriadas de cada paciente, sendo a primeira antes do tratamento, a segunda após o início da terapia com fármaco antifúngico e a terceira durante esta e após remissão clínica da lesão bucal. As 75 amostras, assim obtidas, foram submetidas à prova fenotípica de biotipagem de ODDS & ABBOTT (1980), morfotipagem e cariotipagem por eletroforese em campo pulsátil (CHEF-DR II, Bio-Rad, USA). O padrão de peso molecular de Sacharomyces cerevisiae foi usado como controle de qualidade da corrida eletroforética e para cálculo do peso molecular. O DNA das cepas foi contido em blocos de agarose para a eletroforese em gel. A corrida eletroforética ocorreu a 150 V e 13°C com intervalos de pulso de 120 s durante 24 h e a 240 s por 36 h. Após a corrida, as bandas de DNA contidos no gel foram coradas com brometo de etídio, fotografadas sob luz ultra-violeta e analisadas a \"olho nú\". Provas de suscetibilidade a fluconazol, cetoconazol, itraconazol c anfotericina B foram realizadas por técnica de microdiluição em caldo com todas as amostras. Para a prova foi utilizado meio RPMI com L-glutamina e inóculo final de 0,9-4,5 x 10 -4 cel. ml-1 padronizado em espectrofotômetro a 530 nm. Candida parapsilosis (ATCC 22019) foi incluída como controle de qualidade dos testes. Estes foram realizados em placas de microtitulação e incubadas à 30°C por 24 horas. A leitura de IC 50 para os fármacos azólicos e IC100 para antotericina B foi feita em espectrofotômetro a 460 nm. A tipagem das amostras revelou 14 morfotipos, 13 biótipos de ODDS &ABBOTT e 11 cariótipos. A maioria dos pacientes apresentavam um só biótipo (68,0%) ou um só cariótipo (72,0%) nas três amostras analisadas. Todos os cariótipos apresentaram bandas de DNA entre 850 kb e 2200 kb e um deles, agrupando 8 (10,7 %) cepas, também mostrou bandas em 680 kb Os fármacos apresentaram boa atividade antifúngica in vitro contra as amostras estudadas, com valores de concentração inibitória mínima (CIM) para antotericina B situados entre 0,31 µg ml-1 a 2,50 µg ml-1. De 1 (4,0%) paciente foram isoladas cepas de mesmo cariótipo, consideradas resistentes in vitro para anfotericina B, desde que o CIM para o fármaco toi 2,5 µg ml-1 nas tres amostras analisadas. Para as 75 amostras o CIM de fluconazol situou-se entre =0,09 µg ml-1 e 12,5 µg ml-1, para cetoconazol entre =0,02 µg ml-1 e 0,62 µg ml-1 e para itraconazol entre =0,02 µg ml-1e 1,25 µg ml-1. Três (12,0%) pacientes apresentavam cepas resistentes in vitro ao fluconazol, sendo 2 (8,0 %) casos após terapia com fármacos azólicos (resistência adquirida) e l (4,0 %) com provável resistência natural ao medicamento. Para 2 (8,0 %) pacientes houve falta de correlação de resistência in vivo e in vitro ao tluconazol. Em I ( 4 %) paciente foi verificada também resistência in vitro para cetoconazol e itraconazol.The objective of this longitudinal study was to confirm strain biotyping, karyotyping and variation besides antifungal susceptibility patterns in 75 C. albicans isolates from 25 AIDS patients with oropharyngeal candidiasis. Three isolates were obtained from each patient. The first sample was taken before treatment, the second one was obtained during therapy course and the last one was taken after resolution of the lesion but undergoing therapy. All isolates were characterized by morphotyping and biotyping method (ODDS & ABBOTT, 1980) before the molecular kariotype analysis using PFGE. S.cerevisiae chromosome size markers were included in the gels as standards. Each gel was electrophoresed in a CHEF-DR II system with pulse intervals of 120 s for 24 h and 240 s for 36 h at 13°C 150 volts. Photographs of ethidium bromide-stained gels were examined visually and the electrophoretic karyotype (Ek) patterns were compared by examining each DNA band present. The susceptibilities of isolates to amphotericin B, itraconazole, ketoconazole, and fluconazole were performed by using broth microdilution method with RPMI 1640 medium with 1-glutamina, and final inoculum of O.9-4.5x10 4 cel./ml (spectrophotometric method) C.parapsilosis (ATCC 22019) was included as quality control of drug activity. In 96-flat bottom well culture plates 10 antifungal concentrations were mixed with yeast suspension, and incubated at 30°C for 24 h. The turbidity in each well was measured at 460 nm with a microdilution plate reader. The MIC end points were defined for the azoles as reduction of 50% of the drug-free control value [IC50]. For amphotericin B the MIC end points were determined by IC 100. Biotyping showed 13 subtypes and DNA subtyping of the isolates revealed 11 different Eks. Eighteen (72.0 %) patients were infected with a single DNA subtype throughout the course of infection and 17 (68.0 %) patients harbored the same biotype. All Eks showed bands of 850 kb to 2200kb and only one subtype (8 strains)had an additional 680 kb-band. All the drugs showed good in vitro antifungal activity for the 75 isolates. The amphotcricin B MICs ranged trom 0.3 to µg ml. In 1 (4.0%) patient the 3 isolates had the same DNA pattern and showed relatively high amphotericin B MICs (2.5 µg/ml) suggesting a natural resistance to this drug. The fluconazole MICs for the 75 strains ranged from =0.09 to 12.5 µg/ml. For itraconazole and ketoconazole the MICs ranged from <0.02 to 1.25µg/ml and from <0.02 to 0.62µg/ml, respectively. Three (12.0%) patients harbored fluconazole resistant strains including 2 (8.0%) patients undergoing azole therapy (acquired resistance) and 1 (4.0%) patient with a probable intrinsic fluconazole-resistant strain. One fluconazole- resistant strain showed resistance to the other two azoles tested (ketoconazole and itraconazole). Of particular interest were 2 (8.0%) patients with clinicail but not in vitro resistance to itraconazole and ketoconazole

Standardization of Semi-Quantitative Dot Blotting Assay—Application in the Diagnosis, Follow-Up, and Relapse of Paracoccidioidomycosis

Introduction: This study standardized a semi-quantitative dot blotting assay (DB) and a quantitative real-time polymerase chain reaction (qPCR) to detect specific antibodies for Paracoccidioides brasiliensis and its DNA in PCM patients. Methodology: We evaluated 42 confirmed PCM patients upon admission using a serological double agar gel immunodiffusion test (DID), DB, and molecular tests (qPCR in total blood). The control groups included 42 healthy individuals and 37 patients with other infectious diseases. The serological progress during treatment was evaluated in eight patients, and there was a relapse diagnosis in ten patients using the Pb B.339 strain antigen. The cut-off points for the serological tests were determined by a receiver operator characteristic curve. Results: The DB and DID tests showed similar accuracy, but the DB identified lower antibody concentrations. Cross-reactions were absent in the DB assay. In the relapse diagnoses, DB exhibited much higher sensitivity (90%) than DID (30%). Conclusions: A DB assay is easier and faster than a DID test to be performed; DB and DID tests show the same accuracy, while blood qPCR is not recommended in the diagnosis at the time of admission; cross-reactions were not observed with other systemic diseases; DB and DID tests are useful for treatment monitoring PCM patients; and a DB assay is the choice for diagnosing relapse. These findings support the introduction of semi-quantitative DB assays in clinical laboratories

Nosocomial candidiasis in Rio de Janeiro State: Distribution and fluconazole susceptibility profile

One hundred and forty-one Candida species isolated from clinical specimens of hospitalized patients in Rio de Janeiro, Brazil, during 2002 to 2007, were analized in order to evaluate the distribution and susceptibility of these species to fluconazole. Candida albicans was the most frequent species (45.4%), followed by C. parapsilosis sensu lato (28.4%), C. tropicalis (14.2%), C. guilliermondii (6.4%), C. famata (2.8%), C. glabrata (1.4%), C. krusei (0.7%) and C. lambica (0.7%). The sources of fungal isolates were blood (47.5%), respiratory tract (17.7%), urinary tract (16.3%), skin and mucous membrane (7.1%), catheter (5.6%), feces (2.1%) and mitral valve tissue (0.7%). The susceptibility test was performed using the methodology of disk-diffusion in agar as recommended in the M44-A2 Document of the Clinical and Laboratory Standards Institute (CLSI). The majority of the clinical isolates (97.2%) was susceptible (S) to fluconazole, although three isolates (2.1%) were susceptible-dose dependent (S-DD) and one of them (0.7%) was resistant (R). The S-DD isolates were C. albicans, C. parapsilosis sensu lato and C. tropicalis. One isolate of C. krusei was resistant to fluconazole. This work documents the high susceptibility to fluconazole by Candida species isolated in Rio de Janeiro, Brazil

Report of filamentous forms in a mating type VNI clinical sequential isolates of Cryptococcus neoformans from an HIV virus-infected patient

We reported a cryptococcal meningitis Aids-patient infected with a mating type VNI isolate showing filamentous cells in direct examination of cerebrospinal fluid. Clinical data, outcome, treatment features and microbiological findings were discussed

Disseminated Amphotericin-Resistant Fusariosis in Acute Leukemia Patients: Report of Two Cases

Disseminated fusariosis has emerged as a significant, usually fatal infection in immunocompromised hosts despite antifungal treatment. We describe here two patients with acute leukemia who developed disseminated amphotericin-resistant fusariosis, and review of six studies of cases series in the literature. Two Fusarium solani strains were isolated from blood and skin cultures of one patient, and one strain from the blood culture of the second patient. Both patients died despite antifungal treatment. Strains were identified by sequencing of ITS1 and ITS4 regions. Random amplified polymorphic DNA analysis of the three F. solani isolates showed a low degree of similarity. Screening for Fusarium spp. contaminants within our facility was negative. Using the CLSI M-38-A2 broth dilution method and E tests®, we found that the MICs were low for voriconazole (0. 12 and 0. 5 mg/L, respectively), unexpectedly high for amphotericin B (≥8 and ≥32 μg/mL, respectively) and itraconazole (≥16 mg/ml). Patients with leukemia or persistent neutropenia should be assessed for disseminated fungal infections, including biopsy and skin cultures. Antifungal susceptibility tests are important due to the possibility of the strains being amphotericin resistant. Treatments must be aggressive, with high doses of antifungals or combined therapy. © 2012 Springer Science+Business Media Dordrecht