Álvaro A. Faccini-Martínez

Probable case of spotted fever group rickettsial infection in a new suspected endemic area, Colombia

Spoted fever group (SFG) rickettsioses are actually considered as emerging and re-emerging zoonotic diseases, caused by pathogenic bacteria of the spotted fever group rickettsiae (SFGR). Recently, serologic studies in human and animals conducted in Colombian Orinoquia, showed a high seroprevalence against SFGR. In June 2015, a 50-year-old male was admitted to a hospital in Bogotá, Colombia, with two days of malaise and temperature of 39°C, associated to generalized rash 24h after the onset of fever. He referred a work visit and outdoor activities in rural area of the Department of Meta 15days prior the onset of symptoms. The patient was transferred to the intensive care unit with supplementary oxygen, inotropic support and was assessed by the infectious diseases department, indicating the addition of Doxycycline. After seven days of antibiotic treatment the patient was discharged with no evidence of new symptoms or sequels. Retrospectively, two serum samples collected during the acute and convalescent phase were evaluated; there was four fold rise in titer against SFGR. With the foregoing, associated with the recent serological evidence that suggests the circulation of SFGR species in the Colombian Orinoquia, we consider to recognize this region as a new endemic area for SFG Rickettsioses.

Isolation and molecular characterization of a relapsing fever Borrelia recovered from Ornithodoros rudis in Brazil

In South America, early reports from more than 50 years ago incriminated Ornithodoros rudis as vector of Borrelia venezuelensis, an agent of tick-borne relapsing fever (TBRF). Herein we report the rediscovery of O. rudis by means of morphological, biological and molecular analyses, which also comprise the first report of this tick species in Brazil. Phylogenetic analysis using partial fragments of mitochondrial 16S rRNA gene suggested that O. rudis forms a monophyletic group with Ornithodoros erraticus. By using laboratory rodents as hosts, we isolated a relapsing fever Borrelia from an infected O. rudis female. Phylogenetic analysis inferred from the rrs, flaB, and glpQ genes of Borrelia spp. placed the spirochete harbored by O. rudis closely related to Borrelia turicatae. Until further genetic evidence is not obtained we are referring to this O. rudis spirochete as B. venezuelensis. This is the first in vitro isolation of a TBRF Borrelia from South America. The presence of O. rudis in Brazil should not be overlooked, since this tick has been historically implicated in human cases of TBRF in Colombia, Panama, and Venezuela. This study provides new reports of O. rudis and B. venezuelensis after decades of scientific silence on these agents.

Confirming Rickettsia rickettsii as the etiological agent of lethal spotted fever group rickettsiosis in human patients from Espírito Santo state, Brazil

Although Espírito Santo state is considered an endemic area for Brazilian spotted fever (BSF) with related lethal cases, it also constitutes the only state of southeastern Brazil that currently lacks a specific confirmation of the specific rickettsial agent. In an attempt to a species level confirmation of the etiological agent of fatal rickettsiosis cases in Espírito Santo state, in this study we tested human sera obtained between 2015 to 2017 by means of qPCR and subsequent conventional PCR protocols targeting gltA (citrate synthase) and ompA (190-kDA outer membrane protein) rickettsial genes. All samples were found to contain rickettsial DNA through the citrate synthase qPCR protocol. By conventional PCR, rickettsial gltA and ompA specific DNA fragments were detected in 25% (one sample) and 50% (2 samples) of the screened sera, respectively. Obtained consensuses for each gene partial sequences were 100% identical to Rickettsia rickettsii gltA and ompA genes. The present study confirms for the first time R. rickettsii as the etiological agent of a lethal spotted fever group rickettsiosis in human patients from Espírito Santo state.

Infections with biological therapy: strategies for risk minimization in tropical and developing countries.

In recent decades, biological therapy has enabled disease activity control and improved quality of life in patients with autoimmune diseases. These therapies that are involved in immune response modifications and change multiple immunological pathways induce an incremental risk for certain infectious diseases. Though there have been recent advances in risk assessment for biological therapy, there is a lack of data and recommendations for assessing risks in populations with high prevalence of infectious diseases, such as those located in tropical areas and developing countries. We performed a review on infections with biological therapy as well strategies for risk minimization in areas with a high prevalence of tropical diseases.

A case of paracoccidioidomycosis due to Paracoccidioides lutzii presenting sarcoid-like form

Paracoccidioidomycosis (PCM) is a fungal disease caused by Paracoccidioides spp., which can cause a systemic granulomatous infection with tegumentary and visceral involvement. Sarcoid-like skin lesions are uncommon and can be misdiagnosed due to similarities with other granulomatous diseases. We report a case of a women presenting with erythematous infiltrated plaques on her face that was treated for leprosy and rosacea with no response and was later diagnosed with PCM, presenting positive serology for Paracoccidioides lutzii.

Epididymo-orchitis caused by Histoplasma capsulatumin a Colombian patient

Although histoplasmosis is generally a self-limited disease, disseminated infection can occur in patients lacking effective cell-mediated immunity, reaching virtually every organ, even the genitourinary tract in rare cases. We report a case of epididymo-orchitis in an immunocompetent 38-year-old bricklayer from the rural area of Villeta, Cundinamarca, Colombia. The patient presented with testicular pain and macroscopic scrotal changes requiring a left orchiectomy, with microbiological isolation and molecular confirmation of Histoplasma capsulatum.

Nodular Lymphangitis Syndrome

On August 19, 2016, a 36-year-old man from an urban area of Cariacica town, an electricity worker, presented with refractory cellulitis involving his right thumb and extending up his arm. Two months before, he had pricked his thumb with a wood splinter. Within 10 days, a painless papule appeared at the inoculation site, and over the next weeks, tender lymphangitis developed. Despite the use of oral cephalexin and amoxicillin-clavulanate, lymphangitis involving the forearm progressed. He was afebrile, and there were no systemic symptoms or signs. An ulcerated lesion on the affected finger and subcutaneous erythematous nodules in a lymphangitic streak were observed (Figure 1). Right axillary lymphadenitis was noted. Taking into account the epidemiological exposure history, nodular lymphangitis byNocardia spp. was suspected and oral therapy with trimethoprim-sulfamethoxazole was indicated (160–800 mg po twice a day) for a total of 3 months, with complete resolution of lesions.

Leishmaniasis Recidiva Cutis

A 39-year-old man from a rural area of Brazil (Linhares town, Espiríto Santo State) was referred to our institution for an 8-month history of pruritic lesions on the left side of his face. The lesions started as a single erythematous papule, which progressively grew, became ulcerated and associated with satellite lesions. The patient reported no local purulent discharge, no fever, or other systemic symptoms. One month before referral, he received, without clinical improvement, several courses of empirical antibiotics (gentamicin, azithromycin), topical corticosteroids (betamethasone), and drugs for leprosy (rifampin, dapsone, clofazimine). He had an unremarkable medical history. Physical examination revealed infiltrative plaques with a central atrophic area in his left temporomandibular region (Figure 1) and ipsilateral cervical and occipital lymph nodes measuring 1 by 2 cm. Tests for human immunodeficiency virus type 1/2 (HIV 1/2 rapid test; Alere, Belo Horizonte, MG, Brazil), syphilis (syphilis ultra rapid test; Alere), and viral hepatitis (surface antigen of the hepatitis B virus [HBsAg] [VIKIA HBsAg rapid test; Biomérieux, Jacarepaguá, RJ, Brazil], anti-hepatitis C virus (HCV) [ImmunoComb HCV; AlereTM]) were negative. The results of routine laboratory testing, including a complete blood count and a metabolic panel with liver function tests, were normal. Antinuclear antibodies were positive (1/80). Histologic examination of the skin lesions revealed an epidermis with ulceration and pseudoepitheliomatous hyperplasia, an accentuated lymphohistiocytic inflammatory infiltrate with numerous plasma cells and eosinophils, superficial and deep perivascular and interstitial distribution in the superficial dermis. An intradermal leishmanin test (Leishmania amazonensis MHOM/BR/73/M2269 strain) showed 11 mm of induration (read at 48 hours). A diagnosis of leishmaniasis recidiva cutis (LRC) was made. The patient was treated with intravenous meglumine antimoniate (Glucantime; Sanofi Aventis, Buenos Aires, Argentina) (15 mg Sb(V)/kg/day for 20 days) resulting in a marked clinical improvement (Figure 2). The patient remained in the improved state on the medical follow-up. Cutaneous leishmaniasis is a vector-borne tropical infection of high prevalence in Latin America, mainly caused by the parasites Leishmania (Viannia) braziliensis, Leishmania (Viannia) amazonensis, Leishmania (Viannia) panamensis, and Leishmania (Viannia) guyanensis; the former is the predominant species in Brazil, and the only detected species in Espiríto Santo State. Localized cutaneous leishmaniasis (LCL) is the most common clinical form. The disease is characterized by ulcers which commonly start as a nodule at the site of the sandfly vector’s bite, the nodule becoming an ulcer with an indurated raised outer border. LCL lesions vary in severity, clinical appearance, and time to cure. LRC is an infrequent variant of cutaneous leishmaniasis; histologically, diffuse infiltration of lymphocytes, plasma cell, and macrophages are observed, but the parasites are scarce or absent. At the same time, LRC is comparatively rare in Latin America (approximately 34 cases have been reported in Brazil in the period of 1993–2011), and such unusual *Address correspondence to Álvaro A. Faccini-Martínez, Centro de Ciências da Saúde, Universidade Federal do Espírito Santo, Avenida Marechal Campos, 1468, Maruípe, Vitória 29043-900, Brazil. E-mail afaccini@gmail.com FIGURE 1. Infiltrative plaques with a central atrophic area in his left temporomandibular region. FIGURE 2. Marked clinical improvement after treatment with intravenous meglumine antimoniate.