André Silva-Pinto

Candida parapsilosis prosthetic valve endocarditis

Candida endocarditis is a rare infection associated with high mortality and morbidity. There are still some controversies about Candida endocarditis treatment, especially about the treatment duration. We report a case of a Candida parapsilosis endocarditis that presented as a lower limb ischemia. The patient was surgically treated with a cryopreserved homograft aortic replacement. We used intravenous fluconazole 800 mg as initial treatment, followed with 12 months of 400 mg fluconazole per os. The patient outcome was good.

Tick-borne lymphadenopathy, an emerging disease

Tick-borne lymphadenopathy (TIBOLA) is a spotted fever group disease characterized by an eschar and pronounced enlarged lymph nodes after a scalp tick bite. The goal of this synopsis is to review the TIBOLA literature published until May 2013: Forty-one articles (reporting 537 cases) were included. There was a predominance of cases in females and young people. Spain, France, and Hungary reported the majority of cases, and they were mainly reported in the colder seasons. The involved tick bite was frequently on the scalp. Rickettsia slovaca was the most frequent identified bacterium and Dermacentor marginatus the most frequently identified vector. The most prescribed antibiotic was doxycycline. TIBOLA has the potential to emerge outside Europe: improving knowledge of TIBOLA may promote early symptoms recognition and may allow early treatment.

Visceral adipose tissue and carotid intima-media thickness in HIV-infected patients undergoing cART: a prospective cohort study

BackgroundCombined antiretroviral therapy (cART) in HIV-infected patients has been associated with lipodystrophy, metabolic abnormalities, and an increased risk of cardiovascular disease. Ultrasound measures of carotid artery intima-media thickness (cIMT) have been used as a valid measure of subclinical atherosclerosis and as a tool to predict the risk of cardiovascular events. Our aim was to evaluate the progression of cIMT in HIV-infected patients subjected to cART, with and without lipodystrophy, over a one-year period.MethodsWe performed a one-year prospective cohort study to compare changes in cIMT, metabolic and inflammation markers in HIV-infected patients undergoing cART. Body composition was assessed by dual-energy X-ray absorptiometry (DXA) and abdominal computed tomography (CT). Levels of blood pressure, lipids and inflammatory markers were evaluated, as well as ultrasound measures of cIMT. Lipodystrophy defined by Fat Mass Ratio (L-FMR) is measured as the ratio of the percentage of trunk fat mass to the percentage of lower limb fat mass by DXA. Categorical variables were compared, using the chi-square or Fisher’s exact test. Wilcoxon ranks tests and the McNemar chi-square tests were used to compare results of selected variables, from the first to the second year of evaluation. Means of cIMT, adjusted for age, glucose, triglycerides levels, systolic blood pressure (SBP), and waist to hip ratio were calculated, using generalised linear models for repeated measures.ResultsL-FMR was present in 44.3% of patients, and the mean of cIMT increased significantly in this group [0.82 (0.26) vs 0.92 (0.33); pu2009=u20090.037], as well as in patients without lipodystrophy [0.73 (0.20) vs 0.84 (0.30); pu2009=u20090.012]. In the overall sample, the progression of cIMT was statistically significant after the adjustment for age, glucose, triglycerides, and SBP, but the significance of the progression ceased after the adjustment for waist/hip ratio [0.770 (0.737–0.803) vs 0.874 (0.815–0.933); pu2009=u20090.514].ConclusionsCarotid IMT progressed significantly in both groups of this HIV-infected cohort, however no association between the progression of cIMT and the presence of lipodystrophy defined by FMR was found. Visceral adipose tissue had an impact on the increment of cIMT, both in patients with, and without lipodystrophy defined by FMR.

Artemether-lumefantrine and liver enzyme abnormalities in non-severe Plasmodium falciparum malaria in returned travellers: a retrospective comparative study with quinine-doxycycline in a Portuguese centre.

Background Artemisinin-based therapy is the current standard treatment for non-severe malaria due to Plasmodium falciparum. The potential for asymptomatic liver toxicity of this therapy and its implication in clinical practice is currently unknown. The aim of this study is to assess the hepatic function in patients treated with a standard three-day artemisinin-based regimen and to compare it with the quinine-doxycycline regimen.MethodsRetrospective and comparative study of returned adult travellers admitted with non-severe P. falciparum malaria. Fifty-seven patients were included: 19 treated with artemisinin-based therapy and 38 with quinine-doxycycline therapy.ResultsDuring treatment, when compared with quinine-doxycycline group, the artemisinin-lumefantrine group presented a higher proportion of significant liver enzyme abnormalities (42 vs. 5%, pxa0<xa00.01) and a higher peak value of aspartate aminotransferase (131 vs. 64 U/L, pxa0<xa00.01) and alanine aminotransferase (99 vs. 75xa0U/L, pxa0=xa00.05). None of the patients was symptomatic, there were no treatment interruptions and all patients achieved clinical cure.ConclusionsTreatment of uncomplicated falciparum malaria with artemisinin-based therapy might cause asymptomatic liver enzyme abnormalities in the first days of treatment. Nevertheless, these liver enzyme abnormalities seem to be harmless, asymptomatic and self-limited.

Imported dengue from 2013 Angola outbreak: Not just serotype 1 was detected

BACKGROUNDnAll the reports from Angolas 2013 dengue outbreak revealed serotype 1. However, previously dengue serotypes 1-4 have been reported in Africa and in 2014 serotype 4 was reported in Angola.nnnOBJECTIVESnTo report dengue serotypes in patients returning from Angola during 2013 outbreak.nnnSTUDY DESIGNnRetrospective, cross-sectional study. We serotyped the dengue by an in house Polymerase Chain Reaction technique in randomly selected cases.nnnRESULTSnFrom the 2013 Angolas dengue outbreak we treated 47 adult patients. None had history of past dengue. A combo kit test for dengue revealed positive NS1 antigen in 39 and IgM antibodies in 8. From 17 randomly patients tested by RNA Real Time-PCR, 11 were positive: 7 for DENV-1, 2 for DENV-2, 1 for DENV-3 (co-infected with DENV-1) and 1 for DENV-4. None had a complicated or fatal evolution.nnnCONCLUSIONnUnlike previous reports the 4 serotypes were detected, and this resulted in a different epidemiological situation, raising the risk of future outbreaks of severe dengue.

Prediction of unfavorable outcomes in cryptococcal meningitis: results of the multicenter Infectious Diseases International Research Initiative (ID-IRI) cryptococcal meningitis study

Cryptococcal meningitis (CM) is mostly seen in immunocompromised patients, particularly human immunodeficiency virus (HIV)-positive patients, but CM may also occur in apparently immunocompetent individuals. Outcome analyses have been performed in such patients but, due to the high prevalence of HIV infection worldwide, CM patients today may be admitted to hospitals with unknown HIV status, particularly in underdeveloped countries. The objective of this multicenter study was to analyze all types of CM cases in an aggregate cohort to disclose unfavorable outcomes. We retrospectively reviewed the hospitalized CM patients from 2000 to 2015 in 26 medical centers from 11 countries. Demographics, clinical, microbiological, radiological, therapeutic data, and outcomes were included. Death, neurological sequelae, or relapse were unfavorable outcomes. Seventy (43.8%) out of 160 study cases were identified as unfavorable and 104 (65%) were HIV infected. On multivariate analysis, the higher Glasgow Coma Scale (GCS) scores (pu2009=u20090.021), cerebrospinal fluid (CSF) leukocyte counts >xa020 (pu2009=u20090.038), and higher CSF glucose levels (pu2009=u20090.048) were associated with favorable outcomes. On the other hand, malignancy (pu2009=u20090.026) was associated with poor outcomes. Although all CM patients require prompt and rational fungal management, those with significant risks for poor outcomes need to be closely monitored.

Plasmodium spp. and Borrelia burgdorferi co-infection associated with antiphospholipid syndrome in a returned traveler: a case report

The differential diagnosis of fever in a returned traveler is wide and challenging. We present a case of a patient working in Africa, who returned with fever, constitutional symptoms, headache, and blurred vision. An initial diagnosis of malaria was made, and additional workup revealed Borrelia burgdorferi co‐infection and antiphospholipid syndrome.

Reactivation of Hepatitis B Virus without Core Antibody

ABSTRACT We present the case of a male patient not vaccinated against hepatitis B virus (HBV) and with reactivity to a surface antibody who, after immunosuppression for a multiple myeloma, had HBV reactivation. Pharmacological HBV suppression was tried, but viremia could not be suppressed. Production-detection core mutations or immunity issues can explain this clinical phenomenon.

Abdominal cause of asymmetric lower limb oedema

A 94 year-old Caucasian woman presented to the Emergency Department with right inferior limb oedema. Erythema, pallor and pain were not present neither other signs nor symptoms. The patient had multiple comorbidities namely hypertension, atrial fibrillation, heart failure, dementia and chronic obstipation. She was on furosemide, irbesartan, digoxin, clopidogrel and laxatives. The venous Doppler ultrasound showed no signs of deep venous thrombosis. However, it suggested indirect signs of upstream venous compression. The abdominal CT scan is presented here. (See Fig. 1.)

Diabetes mellitus in HIV-infected patients: fasting glucose, A1c, or oral glucose tolerance test – which method to choose for the diagnosis?

BackgroundAntiretroviral therapy dramatically reduced HIV-related morbidity and mortality, prolonging the lifespan of HIV-infected patients. Greater duration of infection and exposure to antiretroviral therapy makes these patients susceptible to traditional cardio-metabolic risk factors and pathologies. The optimal diagnostic protocol for Diabetes Mellitus in these patients is still controversial. Haemoglobin A1c (HbA1c) has been shown to underestimate glycaemia levels and the oral glucose tolerance test (OGTT) has been shown to reveal cases of glucose metabolism disturbances in patients with normal fasting glucose. Thus, this study aimed to determine the prevalence of prediabetes and diabetes in a population of HIV-infected patients undergoing combined antiretroviral therapy, using three different diagnostic methods (fasting glucose, OGTT and HbA1c), to determine the agreement between the different methods and the characteristics associated with each one.MethodsThis study analyzed 220 HIV-infected patients on antiretroviral therapy. Patient characteristics were collected using a standardized protocol. Disturbances of glucose homeostasis were defined by the ADA 2017 criteria. Patients were characterized according to the presence or absence of clinical lipodystrophy, and distributed into four different categories, according to the presence, or absence of either clinical lipoatrophy, or abdominal prominence. Insulin resistance was assessed by HOMA-IR and QUICKI indexes. Agreement between the diagnostic methods was assessed by Cohen’s kappa coefficient.ResultsThere were no patients diagnosed with diabetes with HbA1c. 5.9% prevalence was obtained when OGTT was used, and 3.2% prevalence when fasting glucose was used. Prediabetes had a prevalence of 14.1% when using HbA1c, 24.1% when using OGTT, and 20% when using fasting glucose. In all three methods, glucose homeostasis disturbances were associated with older age and higher resistance to insulin. Regarding other characteristics, associations varied between the three methods. The agreement between them was fair, or slight.ConclusionsWe observed that HbA1c was the method that diagnosed the least amount of cases and that OGTT was the one that diagnosed the most cases. Accordingly, our results indicate that HbA1c underestimated glycaemia levels in this population and that the use of OGTT might allow an earlier diagnosis of glucose homeostasis disturbances, potentially making it possible to avoid severe complications of DM.