Catalina de Bedout

Treatment of Chromoblastomycosis with Itraconazole

The results of long-term itraconazole therapy in 10 patients with active chromoblastomycosis due to F. pedrosoi were reported. Therapy consisted of 100 or 200 mg/day of itraconazole, the length of therapy depending on the patients response (12 to 24 months). This new triazole proved effective in reducing the number, size, and severity of the lesions in nine of the patients. Those patients with minor involvement profited more from therapy and were cured; patients with moderate involvement achieved either minor or major improvement. In most cases, signs and symptoms began to improve after 6 months of therapy. Mycological tests (in which tissue samples were treated with potassium hydroxide and cultured) became negative in six patients, but the fungus was eradicated in only three patients. Itraconazole produced no side effects. In spite of the need for long-term therapy, this new azole derivative effectively controls the disease.

Histoplasmosis: results of the Colombian National Survey, 1992-2008

INTRODUCTION Histoplasmosis, a fungal disorder characterized by a wide spectrum of manifestations that range from subclinical infections to disseminated processes, affects both immunocompetent and immunosuppressed individuals. Histoplasmosis is not a reportable disease in Colombia and consequently, a survey was designed to collect histoplasmosis cases diagnosed in the country. OBJECTIVE The aim of this work was to analyze the data collected from 1992 to 2008. Materials and methods. The survey included demographic data, risk factors, clinical manifestations, imaging data, diagnostic methods and antifungal treatment. Patients were grouped according to risk factors and comparisons of the various findings were done. RESULTS A total of 434 surveys were gathered from 20 of the countrys Departments. Most patients (96.1%) were adults, 77% were males with a mean age of 38.4 years. Only 3.9% were children less than 15 years of age. In the adult population, AIDS was reported in 70.5% of the cases; additionally, in 7.0% patients other immunosuppressive conditions were informed. The most frequent clinical manifestations were fever (76.1%), cough (54.8%) and constitutional symptoms (56.8%). X rays abnormalities were represented mainly by infiltrates (65.9%) and nodules (17.1%). Diagnosis was made by microscopic observation of H. capsulatum in 49.6% patients, by culture in 58.0% and by serological test in 14.6% cases. Antifungal use was recorded in 52.5% cases. CONCLUSIONS Histoplasmosis is frequent in Colombia, especially in certain risk factor groups such as the HIV-infected population. Data collected from this large number of cases has allowed valid comparisons on various aspects of histoplasmosis in Colombia.

Histoplasmosis en Colombia: resultados de la encuesta nacional, 1992-2008

Introduccion. La histoplasmosis esta caracterizada por variadas manifestaciones que van desde la afeccion subclinica a la enfermedad diseminada, y suele presentarse tanto en huespedes inmunocompetentes como inmunosuprimidos. Como la enfermedad no es de notificacion obligatoria en Colombia, se diseno una encuesta para recolectar informacion de los casos diagnosticados en el pais. Objetivo. El objetivo de este trabajo fue analizar los datos recolectados desde 1992 hasta 2008. Materiales y metodos. La encuesta incluyo datos demograficos, factores de riesgo, manifestaciones clinicas, estudios de imagenes, metodos diagnosticos y tratamiento antifungico. Los pacientes se agruparon de acuerdo con los factores de riesgo y se compararon los correspondientes hallazgos. Resultados. Se examinaron 434 encuestas provenientes de 20 de los departamentos colombianos. La mayoria (96,1 %) correspondian a adultos, 77 % eran hombres con edad promedio de 38,4 anos, y solo 3,9 % eran ninos o adolescentes. En los adultos, 70,5 % tenian sida y 7 % presentaban otra inmunosupresion. Las manifestaciones predominantes fueron fiebre (76,1 %), tos (54,8 %) y sintomas constitucionales (56,8 %). En las radiografias, las anormalidades fueron principalmente infiltrados (65,9 %) y nodulos (17,1 %). El diagnostico se establecio por observacion microscopica de H. capsulatum en 49,6 % casos, por cultivo en 58 % y por pruebas serologicas en 14,6 %. El tratamiento se informo solo en 52,5 % casos. Conclusiones. Se demostro que la histoplasmosis es frecuente en Colombia, especialmente en grupos de riesgo como son los pacientes infectados con el VIH. El analisis de este numero relevante de pacientes permitio establecer comparaciones validas sobre aspectos de la histoplasmosis en nuestro pais.

In vitro susceptibility testing of Fonsecaea pedrosoi to antifungals

Based on the difficulties experienced in the treatment of chromoblastomycosis, 12 primary human isolates of F. pedrosoi, were tested for their in vitro susceptibility to various antimycotics. We adapted the recommendations of the NCCLS for yeasts and followed the indications for mold testing from other authors in order to determine their MICs and the MLCs. It was found that a significant proportion of the isolates were resistant to 3 of the 4 antimycotics tested, as revealed by high MIC values, as follows: 33% were resistant to amphotericin B (AMB), 58.3% to 5 fluocytosine (5 FC) and 66.7% to fluconazole (FLU). Contrarywise, none of the isolates proved resistant to itraconazole (ITZ). Determination of the MLCs revealed that a larger proportion of the isolates were not killed by AMB, 5 FC (91.7%), FLU (100%) or even, ITZ (41.7%). These data indicate that it would be desirable to determine the susceptibility of F. pedrosoi before initiating therapy, in order to choose the more effective antifungal and avoid clinical failure.

PARACOCCIDIOIDOMYCOSIS AND AIDS: REPORT OF THE FIRST TWO COLOMBIAN CASES

The records of the first two Colombian patients with AIDS and paracoccidioidomycosis are presented. Both patients were males and had no known risk factors for HIV although in the past they had worked in the field where they could have been infected with the fungus. They exhibited the juvenile type of disease with multiple organ system involvement and symptoms of short duration. They were deeply immunodepressed as indicated by less than 100 CD4 T lymphocytes per mL; however, serologic tests revealed circulating anti-Paracoccidioides brasiliensis antibodies and in one patient the first diagnostic clue came from such tests. In one case, the mycosis preceded the AIDS diagnosis while in the other, both pathologies were discovered simultaneously. Antimycotic therapy with itraconazole was administered for over 10 months, with an initial dose of 200 mg/day followed by 100 mg/day; marked improvement of the mycotic signs and symptoms was soon noticed an there have been no signs of relapse. The patients improvement was also due to the combined retroviral treatment that was instituted. In spite of the rarity of the AIDS-paracoccidioidomycosis association, physicians practicing in endemic areas should consider the presence of the mycosis in immunosuppressed patients, since a prompt diagnosis and institution of combined antimycotic-anti-retroviral treatments would result in patient improvement and survival. It appears possible that the longer survival time of todays AIDS patients would give the quiescent fungus the opportunity to revive, multiply and cause overt disease.

Recovery of Paracoccidioides brasiliensis from a partially calcified lymph node lesion by microaerophilic incubation of liquid media.

Surgical specimens were obtained from a patient who had had life-threatening paracoccidioidomycosis 5 years previously. Residual lesions were found in the mesenteric lymph nodes; there were areas of caseous necrosis separated from the surrounding tissue by a fibrous capsule made of connective tissue. Abundant P. brasiliensis cells, many of which appeared degenerated, were observed in the necrotic material. Primary isolation was possible only under the microaerophilic conditions offered by fluid media kept stationary at 36 degrees C. Cultures in solid media were obtained after serial passages and gradual accommodation of the strain to aerobic incubation. It is apparent that P. brasiliensis yeast cells can become accustomed to reduced oxygen tension in the tissues. In this way, they are able to withstand the passing of time without completely losing their viability.

Whole-Genome Sequencing to Determine Origin of Multinational Outbreak of Sarocladium kiliense Bloodstream Infections.

Next-generation technologies and bioinformatics enabled source attribution and implementation of effective control strategies.

Implementation of a Training Course Increased the Diagnosis of Histoplasmosis in Colombia

Histoplasmosis causes a significant mortality, especially persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) from developing countries where access to both appropriate diagnostic methods and antiretroviral therapy are limited. A total of 81 physicians assigned to 17 Colombian departments (states) received training in the clinical, epidemiological, and diagnostic aspects of histoplasmosis. Once this training was received and during the period of October 2009-November 2012, these physicians sent biological samples for immunodiagnostic, mycological, and molecular tests from their patients with suspicion of histoplasmosis. A total of 1,536 samples from 768 patients were evaluated. Of the 768 patients studied, 463 (60%) were HIV positive, 214 (28%) HIV negative, and in 91 (12%) this diagnosis was unknown, and 538 (70%) were males. The 1,536 specimens studied comprised 722 sera, 439 blood samples, and 241 urines, which were tested by immunodiffusion (ID), culture, and antigenuria, respectively; in addition, 134 specimens were tested by performing a molecular assay. Histoplasmosis was diagnosed in 133 patients (17%). After the training, we observed more diagnoses from 27 to 44 cases per year. In this study, a significantly increased number of histoplasmosis cases reported by year were observed after implementing an educational training program.

Association of clinical and demographic factors in invasive candidiasis caused by fluconazole-resistant Candida species: a study in 15 hospitals, Medellín, Colombia 2010-2011.

Candida is the most important agent of fungal infections. Several risk factors have been described associated with invasive infection by fluconazole-resistant Candida spp. A prospective cross-sectional study with case-control analysis was conducted. Case group patients with fluconazole-resistant Candida isolate were included; control group were patients with fluconazole-susceptible Candida spp. A multivariate logistic regression model was performed. Three hundred isolates of Candida spp. were analyzed. Most frequent species were Candida albicans/Candida dubliniensis (48.3%) and Candida tropicalis (22.3%). Posaconazole susceptibility was 93.7%; voriconazole, 84%; and fluconazole, 78.7%. Susceptibility to anidulafungin and caspofungin was 92.7% and 92.3%, respectively. Neutropenia (adjusted odds ratio [aOR] 6.5, 95% confidence interval [CI] 1.0-43.1), antifungal exposure (aOR 5.1, 95% CI 2.3-11.2), and antituberculosis therapy (aOR 7.7, 95% CI 1.4-43.2) were associated to fluconazole resistance. Susceptibility results are useful to guide the selection of empiric antifungal treatment and the design of local therapeutic guidelines. Previous antifungal exposure suggests possible resistance to fluconazole, pointing towards the selection of a different class of antifungal agents.

Candida y candidiasis invasora: un reto continuo para su diagnóstico temprano

Invasive candidiasis represents 75% of fungal infections in hospitalized patients, with reported mortalities up to 78%. The frequency of these infections varies according to the hospital services and the risk factors of the patients. In parallel, changes in the epidemiology of the Candida species have been observed, in particular variations in their prevalence and in their resistance to antifungals according to geographic location. For these reasons it is crucial to establish an early diagnosis that identifies the pathogen to the species level in order to allow an appropriate therapeutic decision. The diagnosis of invasive candidiasis continues to be a challenge, where combining the different available methods (microbiologic, immunologic and new molecular approaches) is the best strategy to achieve a prompt and accurate diagnosis. We review the currently available assays for conventional and molecular diagnosis, their limitations, and the perspectives for assays that are now in development and validation. In the last decade, well established reference methods have become available for testing antifungal susceptibility and this has allowed worldwide and regional sensitivity profiles to be established for the different Candida species.