Priscila Maria de Oliveira Papaiordanou

Trichosporon species infection in bone marrow transplanted patients.

Trichosporon species are emerging as opportunistic agents that cause systemic diseases in immunocompromised patients. Patients undergoing bone marrow transplant are submitted to intense and prolonged periods of neutropenia and consequently to several risk factors to fungal infections as the use of broad spectrum antibiotics and invasive devices. Two cases of fungal infections caused by Trichosporon asahii var. asahii and T. inkin in patients with bone marrow transplant are described T. asahii var. asahii was responsible for fungemia and the identification of this microorganism was later performed. T. inkin caused vascular accesses infection and was recovered from an implanted Hickman-Broviac catheter. Both patients were under oral fluconazole prophylaxis. The patient with systemic infection died despite the therapy with amphotericin B and the patient with catheter-related infection recovered from the fungal infection after catheter removal. Difficulties in the identification of this microorganism lead to delays in treatment and post-mortem diagnosis.

Paracoccidioidomicose e infecção pelo virus da imunodeficiência humana

Sao apresentados dois casos de paracoccidioidomicose, um em paciente com a sindrome da imunodeficiencia adquirida e o outro em paciente com infeccao pelo HIV. Trata-se dos primeiros relatos em que esta associacao e descrita na literatura. No primeiro, a micose se evidenciou durante o acompanhamento de paciente com AIDS, que passou a apresentar hepato-esplenomegalia e febre elevada. A ecografia, radiografia simples e tomografia computadorizada do abdomen, demonstraram nodulos solidos, alguns calcificados, no parenquima esplenico. A puncao aspirativa da medula ossea confirmou o diagnostico; o conjunto dos achados caracterizou a forma aguda disseminada da paracoccidioidomicose, a qual levou o paciente ao obito. No segundo relato, em paciente com infeccao pelo HIV, a proposito de investigacao de tumoracao na regiao inguinal e fossa iliaca a direita, constatou-se a associacao de doenca de Hodgkin, tipo celularidade mista e paracoccidioidomicose. Avalia-se a importância destes relatos frente a expansao da infeccao pelo HIV e estima-se que mais casos venham a ser relatados em pacientes com AIDS, procedentes de areas endemicas desta micose. Propoe-se a inclusao da paracoccidioidomicose como infeccao oportunistica potencial em pacientes HIV positivos nestas areas.We present two cases of paracoccidioidomycosis, one occurring in an AIDS patient and the other in an HIV infected man. This is the first report of such association. The first patient, which was already followed for HIV infection (group IV-A) presented with high fever and hepatosplenomegaly. Plain X-ray, ultrasound and CT-scan of the abdomen showed solid nodules in the spleen, some of them with calcification. Both the direct smear and the culture of a bone marrow aspiration revealed Paracoccidioides brasiliensis. The patient died of acute disseminated Paracoccidioidomycosis. The second patient, a man anti-HIV seropositive presented with a mass on the right lower abdomen and inguinal region. A biopsy of the mass showed the association of Hodgkins disease of the mixed cellularity type and paracoccidioidomycosis. With the expanding AIDS epidemic we believe this report emphasizes the need to consider Paracoccidioidomycosis in HIV infected persons in countries where this mycosis is endemic. We also suggest the inclusion of Paracoccidioidomycosis as a potential opportunistic infection in these areas.We present two cases of paracoccidioidorrvycosis, one occurring in an AIDS patient and the other in an HIV infected man. This is the first report of such association. The first patient, which was already followed for HIV infection (group IV-A) presented with high fever and hepatosplenomegaly. Plain X-ray, ultrasound and CT-scan of the abdomen showed solid nodules in the spleen, some of them with calcification. Both the direct smear and the culture of a bone marrow aspiration revealed Paracoccidioides brasiliensis. The patient died of acute disseminated Paracoccidioidomycosis. The second patient, a man anti-HIV seropositive presented with a mass on the right lower abdomen and inguinal region. A biopsy of the mass showed the association of Hodgkins disease of the mixed cellularity type and paracoccidioidomycosis. With the expanding AIDS epidemic we believe this report emphasizes the need to consider Paracoccidioidomycosis in HIV infected persons in countries where this mycosis is endemic. We also suggest the inclusion of Paracoccidioidomycosis as a potential opportunistic infection in these areas.

Postexposure prophylaxis after sexual assaults: a prospective cohort study.

Objective: The objective of this study was to evaluate HIV postexposure prophylaxis (PEP) protocol in rape victims. Study: The victims were assigned to 1 of 3 categories, according to the severity of exposure (I—low, II—moderate, III—high). HIV PEP was provided to victims in groups II (Zdv + 3TC) and III (Zdv + 3TC + PI) until 72 hours after exposure. The follow-up was 6 months. Results: From May 1997 to October 2001, 347 victims were attended. PEP was offered to 278 victims (141 in group II and 137 in group III). Side effects were more common in group III (P <0.01). No seroconversion was diagnosed in the 180 victims that completed the follow-up. Univariate analysis showed that the schooling level, knowledge of the aggressors HIV status, and the use of PEP were associated with compliance. Conclusions: Triple therapy was associated with side effects, which suggested that drug regimes should be reviewed. The variables related to a high risk of HIV transmission were also significant for compliance.

Tétano acidental: análise do perfil clínico e epidemiológico de casos internados em hospital universitário

INTRODUCAO: O numero de casos notificados de tetano acidental no Estado de Sao Paulo sofreu reducao. O declinio do numero de casos de qualquer doenca sempre traz transformacoes no seu perfil epidemiologico, que devem sempre ser analisadas para aprimorar as medidas preventivas. Assim, foi analisado o perfil clinico e epidemiologico dos casos de tetano internados em hospital universitario de Campinas de 1989 a 1996. MATERIAL E METODO: Estudo descritivo e retrospectivo (serie de casos). Todos os pacientes com diagnostico de tetano de janeiro de 1989 a marco de 1996, internados no hospital universitario, foram analisados. RESULTADOS: Catorze (28%) eram da zona rural e 36 (72%) da zona urbana. A idade media foi de 47,6 anos e a mediana de 49,5. Dos pacientes da zona rural, 42,8% tinham ate 30 anos e 21,42% tinham mais de 50 anos, sendo a media 36,21 e a mediana 34,5; dos pacientes da zona urbana, 13,9% tinham ate 30 anos e 58,3% mais de 50 anos, sendo a media de 52,2 e a mediana de 54,5. A letalidade foi de 20%, mais elevada nos pacientes curarizados (60%). CONCLUSAO: Na regiao estudada existem dois padroes epidemiologicos: o rural, com maior numero de jovens, refletindo uma vacinacao inadequada, e o urbano, semelhante ao dos paises desenvolvidos, com predominio das faixas etarias mais altas.INTRODUCTION Notwithstanding its substantial decline over the last two decades, acquired tetanus is still a serious health problem in most developing countries. Epidemiological transition is often cited as an explanation for this decline, the increase in vaccination coverage of children being the most obvious cause. Few studies have looked carefully at the current epidemiological patterns of acquired tetanus in developing countries. METHODOLOGY A descriptive, retrospective (series of cases). An acute care 400 - bed university referral hospital situated in a densely populated and highly urbanized area in Southeastern Brazil (Campinas, SP). Patient records the data-base analysed were from the Epidemiological Surveillance Unit of the hospital. RESULTS In the 57 month period from January 1989 to March 1996 fifty-three patients were admitted with a diagnosis of acquired tetanus. Fifty patients had clinical confirmation, 3 were otherwise diagnosed. Thirty-two (64%) were male and 18 (36%) female. Fourteen (28%) were from rural areas and 36 (72%) from urban. Mean age was 47.6 years, with a median of 49.5. Of the rural patients, 42.85% were under 30 years and 21.42% were over 50, mean age was 36.21 with a median of 34.5. Fewer urban patients were under 30 (13.88%) than over 50 (58.33%), mean age was 52.19 with a median of 54.5. Trismus was the most frequent (92.0%) clinical sign on admittance, followed by abdominal muscular rigidity (84.0%). Treatment measures were uniform and included tetanus immune globulin, antibiotics, surgical debridement of the wound when feasible, diazepan or curare depending on the intensity of spasms. In the second half of the study period, penicillin was replaced by metronidazol. Overall case fatality rate was 20%, in patients that had to receive curare, it was 60%. Hospitalization exceeded 21 days in 56% (28) of the cases, only 10% (5) had a hospital stay of less than 7 days. CONCLUSION A high proportion of patients were from rural areas, despite an urbanization rate of more than 90%. In the Campinas region there are two different epidemiological patterns of acquired tetanus: a rural pattern, with a higher proportion of younger patients, determined by an inadequate immunization rate and an urban pattern, similar to that found in industrialized countries, with a higher proportion of older patients. RECOMMENDATIONS There is an obvious need to immunize older individuals in urban areas and young adults in rural areas. The elimination of acquired tetanus will only be achieved with a wider and more intensive adult vaccination program.

Murine (endemic) typhus in Brazil: case report and review

Murine typhus has been increasingly recognized worldwide and is becoming a relevant differential diagnosis in febrile conditions. In Brazil, murine typhus has never received much attention. We present a recently diagnosed case and a literature review that suggests that the disease could be more prevalent in Southeastern Brazil than acknowledged until now.

Situação da febre maculosa na Região Administrativa de Campinas, São Paulo, Brasil

Brazilian spotted fever was detected for the first time in the State of S o Paulo in 1929. However, there is no systematic reporting of the disease in the State. In 1985, three cases of the disease occurred in the municipality of Pedreira, located in the Campinas Region, belonging to the 5th Administrative Region, in the Northeast part of the State, including 88 municipalities. An investigation was conducted at the time, but the lack of case registry limited its scope. The present study was undertaken with the aim of recovering the history of the disease in the Region. Data recovered from several public health services for 1985-2000 were used to analyze incidence patterns. It was observed that the transmission area expanded and the number of suspected cases increased, especially after 1996, when mandatory reporting was established. Deaths due to spotted fever were observed in most of the years under study. The study concluded that spotted fever incidence is increasing in the Campinas Region. Complementary bio-ecological studies are currently under way to better understand the epidemiology of this disease, recognized worldwide as an emerging public health problem.

Indicadores relacionados ao retardo no diagnóstico e na instituição das precauções para aerossóis entre pacientes com tuberculose pulmonar bacilífera em um hospital terciário

BACKGROUND: The risk for nosocomial transmission of tuberculosis exists in health care institutions. OBJECTIVE: To evaluate indicators of transmission risk among patients with pulmonary tuberculosis treated at a university hospital. METHOD: A retrospective study covering the January 1997 to September of 1999 period and evaluating patients admitted to the Hospital de Clinicas of the Universidade Estadual de Campinas with pulmonary tuberculosis. Three intervals were determined: from admission to collection of sputum for acid-fast bacilli microscopy; from admission to implementation of airborne infection control measures; from sputum collection to the initiation of treatment. RESULTS: The final sample included 63 cases. Concomitant human immunodeficiency virus-positivity was found in 31.7%. Forty patients (63.5%) were admitted through the emergency room. In 42 (66.7%) patients, TB was suspected at admission. The interval between admission and sputum collection exceeded 12 hours in 27.5% of cases admitted through the emergency room and in 30.4% of those admitted directly to wards (p = 0.803). Delayed respiratory isolation occurred in 31 cases (49.2%). The delay in isolation was correlated to no diagnosis of tuberculosis at admission (p < 0.000) and lower bacillary load in the sputum (p = 0.032). Co-infection with human immunodeficiency virus (p = 0.530), hospitalization ward (p = 0.284) and underlying diseases (p = 0.541) were not correlated with delayed isolation. The interval between sputum collection and initiation of treatment was greater than 24 hours in 15.9% of the cases. CONCLUSION: Delayed isolation was observed in many cases. Policies of continuing education are called for, especially in high-risk areas.

ELEVATED ALANINE AMINOTRANSFERASE (ALT) IN BLOOD DONORS: AN ASSESSMENT OF THE MAIN ASSOCIATED CONDITIONS AND ITS RELATIONSHIP TO THE DEVELOPMENT OF HEPATITIS C

The determination of aminotranferases levels is very useful in the diagnosis of hepatopathies. In recent years, an elevated serum ALT level in blood donors has been associated with an increased risk of post-transfusion hepatitis (PTH). The purpose of the study was to research the factors associated with elevated ALT levels in a cohort of voluntary blood donors and to evaluate the relationship between increased ALT levels and the development of hepatitis C (HCV) infection. 166 volunteer blood donors with elevated ALT at the time of their first donation were studied. All of the donors were questioned about previous hepatopathies, exposure to hepatitis, exposure to chemicals, use of medication or drugs, sexual behaviour, contact with blood or secretions and their intake of alcohol. Every three months, the serum levels of AST, ALT, alkaline phosphatase, gamma glutamyl transpeptidase, cholesterol, triglyceride and glycemia are assessed over a two year follow-up. The serum thyroid hormone levels as well as the presence of auto-antibodies were also measured. Abdominal ultrasound was performed in all patients with persistently elevated ALT or AST levels. A needle biopsy of liver was performed in 9 donors without definite diagnostic after medical investigation. The presence of anti-HCV antibodies in 116 donors were assayed again the first clinical evaluation. At the end of follow-up period (2 years later) 71 donors were tested again for the presence of anti-HCV antibodies. None of donors resulted positive for hepatitis B or hepatitis C markers during the follow-up. Of the 116 donors, 101 (87%) had persistently elevated ALT serum levels during the follow-up. Obesity and alcoholism were the principal conditions related to elevated ALT serum levels in 91/101 (90.1%) donors. Hypertriglyceridemia, hypercholesterolemia, hypothyroidism and diabetes mellitus also were associated with increased ALT levels. Only 1/101 (0.9%) had mild chronic active non A-G viral hepatitis and 3/101 (2.9%) had liver biopsy with non-specific reactive hepatitis. The determination of ALT levels was not useful to detect donors infected with HCV at donation in Brazil, including the initial seronegative anti-HCV phase.

Listeriosis and AIDS: case report and literature review

Listeriosis is a not uncommon infection in humans, usually associated with immunodeficient states and with newborns. However, relatively few cases have been reported in HIV-infected patients. This scarcity of reported cases has aroused interest in the association of listeriosis and AIDS. In this paper we present a case of meningitis and septicemia caused by Listeria monocytogenes in a female patient with AIDS. A review of recent medical literature indicates that association of listeriosis and AIDS may be more common than it seems. Recent research in host-parasite interaction in listerial infection suggests an important role for tumor necrosis factor (TNF) and for integralin, a bacterial protein, in modulating listerial disease in AIDS patients. Inadequate diagnosis may be in part responsible for the scarcity of reports.

Efeito adverso do uso intermitente de rifampicina para tratamento de hanseníase

The authors present a case of acute renal failure, acute hemolysis and thrombocytopenia due to intermittent use of Rifampin for leprosy. These adverse reactions have rarely been discribed in the medical literature. During follow up there was recovery of renal function and complete remission of the hematological alterations. To our knowledge, this has been the first report of such adverse effects of Rifampin during leprosy therapy in Brazil. Pathogenetic aspects are discussed and current literature is reviewed.Os autores apresentam um caso de insuficiencia renal aguda, hemolise aguda e trombocitopenia relacionada ao uso intermitente de Rifampicina para tratamento da Hanseniase. Estas reacoes adversas sao observadas com extrema raridade na literatura mundial. A evolucao da paciente foi benigna havendo recuperacao total da funcao renal e regressao completa das alteracoes hematologicas. Este foi o primeiro registro no Brasil dos efeitos adversos da Rifampicina no tratamento de Hanseniase. Sao discutidos os principais aspectos patogenicos das alteracoes apresentadas e fez-se revisao da literatura existente sobre o assunto.