Cecília Bittencourt Severo

Cryptococcosis in children

Cryptococcosis is a systemic-opportunistic mycosis caused by two species of the encapsulated yeast-like organism, Cryptococcus neoformans and C. gattii, which cause infection in immunocompromised individuals and in immunologically normal hosts, respectively. Most susceptible to infection are patients with T-cell deficiencies. The spectrum of disease ranges from asymptomatic pulmonary lesions to disseminated infection with meningoencephalitis. After the emergence of AIDS, cryptococcal infections have become much more common. The mycosis occurs less frequently in children than in adults. The purpose of this article is to discuss the aetiology, clinical presentation, predisposing conditions and outcomes in cases of cryptococcosis in children. Emphasis is placed upon paediatric cases occuring in Brazil and in particular to highlight the difference between cases diagnosed in Porto Alegre (South - subtropical climate) and in Belem (North - equatorial climate).

Nocardial infections: report of 22 cases

Twenty-two cases of nocardial infections were diagnosed in our city between 1977- 1998. All patients whose clinical specimens showed Nocardia spp. at Gram stain, which were further confirmed by culture, were selected to be included in the study. Data from patients who were cured were compared with those from patients who died by statistical tests using EPIINFO version 6.04 software. Six isolates were identified as Nocardia asteroides complex, one as Nocardia asteroides sensu stricto and other as Nocardia brasiliensis. We had 17 cases of lung nocardiosis, being one out of them also a systemic disease. Other four cases of systemic nocardiosis were diagnosed: nocardial brain abscesses (one); nocardiosis of the jejunum (one); multiple cutaneous abscesses (one); and a case of infective nocardial endocarditis of prosthetic aortic valve. One patient had a mycetoma by N. brasiliensis. Fifteen (68.2%) out of 22 patients were immunosuppressed, being most (93.3%) by high-doses corticotherapy. Mortality by nocardial infection was 41%; mortality of systemic nocardiosis was 60%. Nocardiosis has a bad prognosis in immunosuppressed patients and also in non-immunosuppressed patients if the diagnosis is delayed. We propose that the delay in diagnosis should be examined in larger series to document its influence in the prognosis of the disease.

Histoplasmosis in children

Histoplamosis is the most common primary systemic mycosis in the USA and is becoming more common as an opportunistic infection in HIV patients worldwide. In children the rate of asymptomatic infection is high. However, in infants with an immature immunological system, disseminated disease may occur. The clinical picture is variable depending on the immunological status. At the onset of the infection clinical manifestations are non specific (headache, fever, cough and nausea). Usually, these symptoms are self-limited and improve without treatment. However, patients with disseminated diseases present with prolonged fever, malaise, cough and weight loss. Hepatosplenomegaly is frequent in infants. Chest radiographs may be normal in 40 to 50% of patients with disseminated disease but findings such as lobar or diffuse infiltrates, cavitations, hilar adenopathy, or any combination of these may be found. Frequently, the clinical presentation is misdiagnosed as tuberculosis. Skin tests, serological reaction and specific cultures are used for diagnosis confirmation. Treatment indications and regimens are similar to those for adults, except that amphotericin B deoxycholate is usually well tolerated in children.

Associação entre paracoccidioidomicose e câncer

OBJECTIVE To analyze the association between paracoccidioidomycosis (Pcm) and cancer in a series of 25 cases and to review the literature on this topic. METHODS A retrospective review of 25 cases diagnosed with Pcm and cancer, retrieved from a series of 808 consecutive adult patients diagnosed with Pcm based on tests conducted in the Mycology Laboratory of the Santa Casa Complexo Hospitalar, in the city of Porto Alegre, Brazil, between 1972 and 2007. The diagnosis of Pcm was confirmed by means of direct microscopic examination, histopathological examination or immunodiffusion test. All cancer cases were confirmed by histopathological or cytopathological examination. RESULTS Respiratory symptoms were the principal complaints of the patients evaluated. Pulmonary involvement predominated, followed by skin and lymph node involvement. The most prevalent tumor was bronchial carcinoma, in 15 patients, followed by other types of carcinoma, and 1 patient had Hodgkins lymphoma. In 16 patients (64%), the site of the Pcm was the same as that of the tumor. In most cases, Pcm treatment consisted of the isolated administration of sulfanilamide, sulfamethoxazole-trimethoprim, ketoconazole, itraconazole or amphotericin B. The most common treatment for cancer was surgery, followed by radiotherapy and chemotherapy. Of the 25 patients, 12 were cured of Pcm, and 4 died. In 9 patients, the final outcome was unknown. In the general population of the area under study, the prevalence of lung cancer was significantly higher in smokers with Pcm than in smokers without Pcm (p < 0.001). CONCLUSIONS A diagnosis of Pcm appears to increase the risk of lung cancer.

Cryptococcus gattii fungemia: report of a case with lung and brain lesions mimicking radiological features of malignancy

A 64-year-old apparently immunocompetent white man developed lung and brain lesions of disseminated cryptococcosis. The radiologic features mimicked those of lung cancer metastatic to the central nervous system. C. gattii was recovered from cultures of bronchoalveolar lavage fluid, brain biopsy, and blood. The same fungus was recovered from pulmonary and brain specimens at autopsy. Serum and cerebrospinal fluid cryptococcal antigen tests were diagnostic in our case and should be included in the diagnostic evaluation of unexplained pulmonary and cerebral lesions. A literature search showed few reports of fungemia by this species of Cryptococcus, contrasting to C. neoformans.

Invasive pulmonary aspergillosis due to a mixed infection caused by Aspergillus flavus and Aspergillus fumigatus

Invasive pulmonary aspergillosis is typically caused by a single Aspergillus species, most frequently Aspergillus fumigatus. Here we report that a lung transplant recipient developed invasive aspergillosis due to a mixed infection caused by Aspergillus flavus and A. fumigatus. The implications for this unusual finding are discussed.

Histopathology, serology and cultures in the diagnosis of cryptococcosis

Cryptococcosis is one of the most common opportunistic fungal infections in patients with acquired immunodeficiency syndrome (AIDS). We report 13 cases of cryptococcal infection based on histopathology, serology and cultures. Epidemiological analysis, histochemical techniques of hematoxilin and eosin (HE) and Grocots silver (GMS), as well special histochemical techniques such as Mayers mucicarmine (MM) and Fontana-Masson (FM), cryptococcal antigen test (CrAg) and isolation on fungal media: Sabourauds (SAB), brain-heart infusion agar (BHI) and canavanine-glycine-bromothymol blue (CGB) agar were analyzed. Unsatisfactory staining results by MM stain associated to negative titers by CrAg test, which FM stain confirmed that capsule-deficient Cryptococcus infections were observed in four cases. Eight isolated cases were identified as follows: six cases were infection with Cryptococcus neoformans and two cases were Cryptococcus gattii.

Atypical micromorphology and uncommon location of cryptococcosis: a histopathologic study using special histochemical techniques (one case report).

Here we report an unusual case of disseminated cryptococcosis in a patient with AIDS. Although typical Cryptococcus neoformans micromorphology was observed in tongue biopsy, cervical lymph node examination revealed atypical histopathologic findings. These included pseudohyphae, chains of budding yeasts and structures resembling germ tubes. Cryptococcus neoformans infection in supraclavicular lymph nodes was also confirmed by culture. The importance of using special histochemical techniques—Mayer’s mucicarmine stain for mucicarminophilic capsule and Grocott’s silver stain—in the diagnosis of cryptococcosis is reinforced.

Capítulo 3: criptococose pulmonar

Cryptococcosis is a systemic mycosis caused by two species of the encapsulated basidiomycetes, Cryptococcus neoformans and C. gattii, which, respectively, cause infection in immunocompromised individuals and in immunologically normal hosts. Patients with T-cell deficiencies are more susceptible to this infection. The spectrum of the disease ranges from asymptomatic pulmonary lesions to disseminated infection with meningoencephalitis. The medical relevance of cryptococcosis increased dramatically as a consequence of the AIDS epidemic and organ transplants.

Determination of germ tube, phospholipase, and proteinase production by bloodstream isolates of Candida albicans

INTRODUCTION Candida albicans is a commensal and opportunistic agent that causes infection in immunocompromised individuals. Several attributes contribute to the virulence and pathogenicity of this yeast, including the production of germ tubes (GTs) and extracellular hydrolytic enzymes, particularly phospholipase and proteinase. This study aimed to investigate GT production and phospholipase and proteinase activities in bloodstream isolates of C. albicans. METHODS One hundred fifty-three C. albicans isolates were obtained from blood samples and analyzed for GT, phospholipase, and proteinase production. The assays were performed in duplicate in egg yolk medium containing bovine serum albumin and human serum. RESULTS Detectable amounts of proteinase were produced by 97% of the isolates, and 78% of the isolates produced phospholipase. GTs were produced by 95% of the isolates. A majority of the isolates exhibited low levels of phospholipase production and high levels of proteinase production. CONCLUSIONS Bloodstream isolates of C. albicans produce virulence factors such as GT and hydrolytic enzymes that enable them to cause infection under favorable conditions.