Luis Aliaga

Localized mucosal leishmaniasis due to Leishmania (Leishmania) infantum clinical and microbiologic findings in 31 patients

The clinical and microbiologic characteristics of 31 patients with mucosal leishmaniasis due to Leishmania (Leishmania) infantum are described. Twenty-eight (90%) patients were male. Mean age at presentation was 48 ± 14 years. Thirteen (42%) patients had no underlying disease, while 18 (58%) patients had several other medical conditions. Fifteen (48%) patients were immunocompromised, 7 patients were infected with human immunodeficiency virus (HIV), and 3 were graft recipients. The primary location of lesions was the larynx in 11 (35%) patients, oral mucosa in 10 (32%) patients, and the nose in 5 (16%) patients. Mucosal lesions were painless in all patients but 2 and consisted of whitish, red, or violaceous nodular swelling or tumorlike masses. Ulceration was reported in 6 patients. Pathologically, the lesions showed a chronic inflammatory infiltrate. Granuloma may be seen.The localization of the lesions determined the symptomatology of the disease. Symptoms included hoarseness, difficulty swallowing, and nasal obstruction. The disease presentation was usually protracted, with a mean time from the onset of symptoms to diagnosis of 13 months (range, 3 wk-4.5 yr), and the clinical diagnosis was usually mistaken for neoplasia of the upper aerodigestive tract. No laboratory abnormalities were found in these patients due to the localized disease, apart from those attributed to underlying diseases.Parasites were easily identified in smears or sections by Giemsa stain or hematoxylin-eosin stain. Leishmania was grown in culture in 12 (60%) patients; culture was negative in 8 (40%) patients. Leishmania (Leishmania) infantum was identified in only 9 instances. The following zymodemes were reported: MON-1 (2 patients), MON-24 (2 patients), MON-27 (1 patient), and MON-34 (1 patient). Serologic test results were known in 25 patients. Serology was usually positive at low titer; 6 (24%) patients had negative serologic test results.Twenty patients were treated with antimonial compounds for between 3 and 36 days. Three patients were given drugs other than antimonial drugs. Five patients were treated only locally, by surgery (3 patients) or topical medical therapy. One patient received no therapy, and treatment was not reported in 2 cases. Patients were cured in 25 (89%) cases, and sequelae were uncommon (14%). Relapse was detected in 2 individuals and 1 patient developed visceral leishmaniasis after treatment. Two HIV-coinfected patients died of causes unrelated to leishmaniasis.The results of the present report stress the clinical importance of searching for the presence of Leishmania in patients with suspected neoplasia of the upper respiratory tract if they have visited or resided in zones endemic for Leishmania (Leishmania) infantum. The treatment of choice for these patients is not established yet, but most patients respond to antimonial compounds given for 28 days or less.

A clinical index predicting mortality with Pseudomonas aeruginosa bacteraemia.

The aim of this study was to define risk factors associated with mortality in Pseudomonas aeruginosa bactaeremia and to combine them in a clinical index predicting the risk of death. The study investigated 125 consecutive episodes of P. aeruginosa bacteraemia at this hospital. Crude mortality was 34%, corresponding to 43 patients who died, with 67% of deaths, directly attributable to bacteraemia. A regression logistic model identified five variables that were independently and significantly associated with an increased risk of death: 1) hospitalisation in the intensive care unit; 2) coagulopathy; 3) septic shock; 4) age > or = 65 years; and 5) the clinical condition of the patient. These variables were as recorded at the time that the first positive blood culture was obtained. The sensitivity and specificity of a prediction of death based on the model were 84% and 85%, respectively. An index score, calculated from these variables, divided patients into three groups with increasing likelihood of mortality resulting from P. aeruginosa bacteraemia.

Nontyphoidal Salmonella Intracranial Infections in HIV-Infected Patients

Salmonella focal intracranial infections are unusual in human immunodeficiency virus (HIV)-infected patients. Six such infections have been reported in the world literature. We report a case of salmonella subdural and epidural cerebral empyema with concomitant osteomyelitis of the frontal bone. Such a complication in the course of salmonellosis is reported for the first time. In previously published case reports, four patients had brain abscess and two had subdural empyema. Salmonella typhimurium was isolated from two patients, and different serotypes were recovered from the others. All patients had advanced HIV disease, and all but two had had opportunistic infections before the diagnosis of salmonella intracranial infection. Surgical drainage combined with systemic antibiotic therapy resulted in the recovery of four of five patients. No regression of the lesions occurred in one patient treated only with antibiotics for multiple cerebral abscesses.

Mediterranean spotted fever with encephalitis.

Rickettsia conorii infection is endemic in the Mediterranean basin, where it is known as Mediterranean spotted fever, also known as Boutonneuse fever and Marseilles fever. We report the case of a 66-year-old diabetic man who presented a severe form of the disease, complicated by acute renal failure, thrombocytopenia and encephalitis. Diagnosis was confirmed by indirect immunofluorescence assay. Despite appropriate treatment, severe neurological sequelae have remained. Medical literature on encephalitis caused by R. conorii is also reviewed.

Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC)

Most urinary tract infections (UTI) are uncomplicated infections occurring in young women. An extensive evaluation is not required in the majority of cases, and they can be safely managed as outpatients with oral antibiotics. Escherichia coli is by far the most common uropathogen, accounting for >80% of all cases. Other major clinical problems associated with UTI include asymptomatic bacteriuria, and patients with complicated UTI. Complicated UTIs are a heterogeneous group associated with conditions that increase the risk of acquiring infection or treatment failure. Distinguishing between complicated and uncomplicated UTI is important, as it influences the initial evaluation, choice, and duration of antimicrobial therapy. Diagnosis is especially challenging in the elderly and in patients with in-dwelling catheters. The increasing prevalence of resistant uropathogens, including extended-spectrum β-lactamases and carbapenemase-producing Enterobacteriaceae, and other multidrug-resistant Gram-negative organisms further compromises treatment of both complicated and uncomplicated UTIs. The aim of these Clinical Guidelines is to provide a set of recommendations for improving the diagnosis and treatment of UTI.

Distribución de la actividad, tipos de anestesia y recursos humanos en Cataluña en 2003

BACKGROUND AND OBJECTIVE The aim of this arm of the ANESCAT 2003 study was to describe the temporal distribution and types of anesthesia used in Catalonia, Spain, in 2003, along with the associated human resources used. PATIENTS AND METHOD Data were used from a survey of 23,136 anesthetic procedures collected on 14 randomly selected days in 2003 and an individual questionnaire was completed by 765 anesthesiologists working in Catalonia. RESULTS Anesthesia practice was divided into that associated with surgery (78.4%), obstetrics (11.3%), and other nonsurgical procedures (10.4%). Of all anesthetic procedures performed, 84.3% took place in operating theaters and 7.0% in obstetric areas. Emergency procedures accounted for 20.3% of the total. Most procedures (71.2%) were undertaken within 08:00 and 16:00 h, and the lowest number of procedures performed on workdays took place on Fridays. The median duration of anesthesia was 60 minutes. The most common technique was regional anesthesia (41.4%), with spinal block being the most widely used. There were an estimated 12.5 anesthesiologists per 100,000 inhabitants, with a median (10th-90th percentile) age of 45 (34-57) years; women made up 47.2% of that group. The mean number of standard working hours was 46 hours per week and 65% of anesthesiologists also undertook on duty shifts. Anesthesiologists spent 77% of their time performing anesthesia and the remainder in postoperative recovery and critical care units and pain clinics. CONCLUSIONS Emergency anesthesia represents 20% of the total workload and obstetrics and nonsurgical procedures another 20%. The use of regional anesthesia was very widespread. The population density of anesthesiologists is comparable to that of other European countries, but with a higher proportion of women.Fundamento y objetivo Describir la distribucion temporal y los tipos de anestesia administrada en Cataluna en el ano 2003, asi como los recursos humanos para su realizacion. Pacientes y metodo Para ello se utilizaron datos del estudio epidemiologico ANESCAT sobre 23.136 anestesias recogidas en 14 dias aleatorios del ano 2003 y de un cuestionario individual contestado por 765 anestesiologos que trabajaban en Cataluna (Espana). Resultado La actividad anestesica se repartio en un 78,4% para procedimientos quirurgicos, en un 11,3% para obstetricia y en un 10,4% para tecnicas y exploraciones. El 84,3% de todas las anestesias se realize en quirofano y el 7,0%, en las salas de partos. El 20,3% de toda la actividad fue urgente. El 71,2% de la actividad se realizo de las 8 a las 16 h y entre los dias laborables fue menor los viernes. La duracion mediana de la anestesia fue de 60 min. El tipo de anestesia mas frecuente fue la regional (41,4%), y el bloqueo subaracnoideo fue el mas utilizado.La densidad de anestesiologos se estimo en 12,5 por 100.000 habitantes,con edad mediana (percentiles 10-90) de 45 (34-57) anos; el 47,2% eran mujeres. El promedio de horas de trabajo en horario regular fue de 46 h semanales y ademas el 65% hacia guardias. El 77% del tiempo global de los anestesiologos estuvo dedicado a la anestesia y el resto, a reanimacion y dolor. Conclusiones La actividad anestesica urgente supone el 20% de toda la actividad y tambien el 20% de toda esta se realiza para procedimientos no quirurgicos. El uso de anestesia regional es muy elevado.La densidad de anestesiologos es comparable con la del entorno europeo,con un porcentaje mayor de mujeres.

Hiperaldosteronismo primario: análisis de una serie de 54 pacientes

Fundamento y objetivo La prevalencia del hiperaldosteronismo primario (HAP) ha aumentado notablemente en los ultimos anos y algunos autores lo consideran la principal causa de hypertension arterial secundaria. Pacientes y metodo Estudio retrospectivo de 54 pacientes con HAP estudiados en nuestra unidad entre 1999 y 2003. Resultados La prevalencia de HAP fue del 5,1%. Hubo 13 casos de adenoma productores de aldosterona (APA), 30 casos de hiperplasia bilateral suprarrenal (HBS), un caso de hyperplasia nodular bilateral y otro caso de hiperplasia nodular unilateral. En 9 casos no se llego a ningun diagnostico etiologico. Los APA se diagnosticaron mas en mujeres y las HBS mas en varones; no hubo diferencias en cuanto al sexo. La presion arterial en los casos de APA fue significativamente superior a la encontrada en los pacientes con HBS. La potasemia en los casos de APA fue significativamente menor que en las HBS. La tomografia computarizada identifico el 90% de los APA y la gammagrafia el 100% de las HBS. El tratamiento con espironolactona redujo la presion arterial significativamente en todos los grupos, pero de manera mas acusada en los APA. Conclusiones La prevalencia de HAP en nuestra serie fue del 5,1%. Aunque existe controversia respecto a los metodos de cribado y diagnosticos, el HAP debe investigarse en pacientes con hipertension arterial resistente, con o sin hipopotasemia mantenida. La espironolactona fue eficaz para el tratamiento de la HBS y es un tratamiento alternativo adecuado para los APA cuando estos no pueden intervenirse quirurgicamente.

Nocardia paucivorans brain abscess. Clinical and microbiological characteristics

Highlights • Brain abscess caused by Nocardia paucivorans is an infrequent infection in humans.• Molecular speciation has revolutionized the study of Nocardia spp. infections.• N. paucivorans brain abscess has a favourable prognosis with long-term antimicrobial therapy.• Antimcirobial susceptibility testing is a useful guide to therapy.

Respuesta inmunológica, virológica y clínica en pacientes infectados por el VIH tras terapia antirretroviral de gran eficacia con nelfinavir: estudio sobre una cohorte prospectiva

INTRODUCTION: To assess the long-term effectiveness, safety and response-related factors in a cohort of HIV-infected persons receiving antiretroviral therapy containing nelfinavir. Design and setting. Prospective, non-randomized multicenter study. METHOD: A total of 792 patients were included: 254 (32.1%) treatment-naive patients and 538 (67.9%) patients previously treated with protease inhibitors who were switched to a nelfinavir-containing regimen due to virological failure or intolerance. Factors related to virological response and to treatment failure were assessed by standard survival techniques and Cox proportional risk models. RESULTS: Nelfinavir was well tolerated; treatment had to be interrupted in only 57 patients (7.1%) because of toxicity. During a median follow-up of 12 months, 31 patients (3.9%) experienced a new AIDS-defining event or death, and 463 (58.4%) showed immunological response. Overall, 52% patients achieved plasma HIV-1 RNA levels below 500 copies/mL (57% of naive and 49% of previously treated patients), but a high rate of virological rebound (24% and 49%, respectively) was observed. Low baseline viral load and few prior treatments were factors related to virological response. Naive treatment status and a high increase in CD4 cell count were predictive of longer viral response. CONCLUSIONS: Highly active antiretroviral therapy with a nelfinavir-containing regimen was associated with favorable virological response in nearly half of previously treated patients, and most experienced clinical and immunological benefits. Nevertheless, the limited duration of virological response indicates the need for new alternative drugs.