Stanley de Almeida Araújo

Combined use of Paracoccidioides brasiliensis recombinant rPb27 and rPb40 antigens in an enzyme-linked immunosorbent assay for immunodiagnosis of paracoccidioidomycosis.

Paracoccidioidomycosis (PCM) is one of the most important endemic mycoses in Latin America; its usually diagnosed by observation and/or isolation of the etiologic agent, Paracoccidioides brasiliensis, as well as by a variety of immunological methods, such as complement fixation and immunodiffusion. Although these approaches are useful, historically their sensitivity and specificity have often been compromised by the use of complex mixtures of undefined antigens. The use of combinations of purified, well-characterized antigens appears preferable and may yield good results. In the present study combinations of the previously described 27-kDa recombinant antigen (rPb27) and a recombinant 40-kDa-molecular-mass antigen (rPb40) from this fungus, that was identified by Goes et al. (2005) through the AST strategy as a homolog of Neurospora crassa calcineurin B, were used in an indirect enzyme linked immunosorbent assay (ELISA) for diagnosis and follow-up of patients with PCM. The complete coding cDNA of rPb40 and rPb27 were cloned into a pET-21a and a pET-DEST 42 plasmid, respectively, expressed in E. coli with a his-tag and purified by affinity chromatography. Among 109 PCM serum samples analyzed, a homogeneous IgG response to these proteins was observed. 62 serum samples from patients with other diseases, 18 from patients with other mycosis and 23 from healthy individuals were also studied. Detection of anti-rPb27 and anti-rPb40 antibodies in sera of patients with PCM by ELISA using a combination of the two purified proteins showed a sensitivity of 96% with a specificity of 100% in relation to control normal human sera and to sera from patients with other systemic mycosis and 93.5% to sera from patients with diverse infections. The use of this two proteins combination provided an excellent immunodiagnosis assay with great values of sensitivity and specificity, even in relation to sera from patients with other mycosis, making possible the standardization of a new methodology to diagnose this important mycosis, with a good confiability and reprodutibility.

Coronary Giant Cell Arteritis and Acute Myocardial Infarction

Giant cell arteritis (GCA) is a systemic immune-mediated granulomatous vasculitis of large- and medium-sized arteries mainly affecting elderly people. Death from GCA alone is rare and usually results of ruptured aorta. In this paper is reported a case of a 83-year-old woman who unexpectedly died during treatment of GCA. Necropsy revealed inflammatory involvement of the coronary arteries with left descendent anterior artery thrombosis, myocardial infarct and rupture of the anterior wall of the left ventricle, as well as hemopericardium and cardiac tamponade. Myocardial infarction leading to sudden death is an exceptional complication of GCA.

Fatal Staphylococcal infection following classic Dengue fever.

Dengue represents an important public health issue in many tropical areas, leading to high morbidity and the employment of substantial health resources. Even though the number of fatalities related to dengue is unknown, several reports warn about the potential occurrence of severe infections and even death. The clinical spectrum of dengue is highly variable, ranging from a mild flu-like syndrome to severe disease, with shock and hemorrhage. The occurrence of bacterial superinfection, or coinfection, in patients with dengue has been noted by some authors, but the available information comes from anecdotic reports. In this study, we show the clinical and anatomopathological data of a patient infected with dengue, who subsequently died of acute multi-organic failure related to Staphylococcus aureus infection. The autopsy revealed a severe disseminated staphylococcal disease and confirmed dengue infection.

Serum levels of sTNF-R1, sTNF-R2 and CXCL9 correlate with disease activity in adult type paracoccidioidomycosis.

Paracoccidioidomycosis (PCM) is the most common systemic mycosis in Latin America. A major problem in the management of PCM is to determine the best time to discontinue therapy due to the high relapse rate among patients. Soluble TNF receptors (sTNF-R) levels and chemokines are associated with disease activity in several infectious, inflammatory and autoimmune disorders. The aim of the present work was to evaluate levels of sTNF-R1, sTNF-R2 and chemokines in serum of patients with adult type of PCM, before and after antifungal therapy, and to correlate those levels to disease activity. Concentrations of sTNF-R1, sTNF-R2 and CXCL9 were higher in untreated patients and decreased progressively with treatment. The serum marker with the best accuracy to discriminate PCM cases from controls was sTNF-R2. sTNF-R1 did not drop to control levels before 36 months of treatment. CCL2 and CCL3 levels were low at baseline in PCM patients, raised significantly after 12 months of treatment and diminished thereafter. CCL24 levels were higher after 36 months of antifungal therapy in PCM patients. CCL11 levels were not statistically different from control subjects. sTNF-R1, sTNF-R2 and CXCL9 may be useful as laboratory parameters to assess disease activity in PCM patients.

Colonic Leishmaniasis Followed by Liver Transplantation

A 17-year-old, 37-kg Brazilian man was diagnosed with autoimmune hepatitis at the age of 7 years and underwent liver transplant (cadaveric) at the age of 14. Immunosuppressants included tacrolimus and prednisone. He had lost 3 kg over the previous year and had diarrhea with blood streaks in the previous 3 months but no history of fever. Laboratory tests showed pancytopenia (hemoglobin = 8.1 g/dL; leukocytes = 1,300/mm3; platelets = 79,000/mm3; albumin = 2.7 g/dL). Physical examination showed enlarged liver and spleen. Unrevealing imaging included upper gastroenterointestinal endoscopy, abdominal ultrasound, and computerized tomography of the chest and abdomen (Figure 1) but showed hepatosplenomegaly. Viral serologies were negative. Colonoscopy showed gross nodularity, hyperemia, and friability of the colonic mucosa (Figure 2). Biopsy of terminal ileum region showed amastigote forms of Leishmania inside macrophages (Figure 3A and ​andB).B). The nature of the agent was confirmed by immunohistochemistry (Figure 3C) and polymerase chain reaction (PCR), which showed L. chagasi infection.1 Examination of a bone-marrow biopsy showed innumerable Leishmania amastigotes (Figure 3D). Serology for leishmaniasis was negative. Treatment with amphotericin B desoxycholate was initiated; renal function deteriorated, and treatment with liposomal amphotericin was substituted (3 mg/kg for 7 days).2 The patient clinically responded with resolution of diarrhea, weight gain, and normalization of spleen size. Two months later, hemoglobin was 11.3 g/dL, leukocytes were 3,670/mm3, platelets were 164,000/mm3, and albumin was 3.8 g/dL.1,2 Figure 1. Computerized tomography of the abdomen showing hepatosplenomegaly. Figure 2. Colonoscopic view—irregular nodularity and hyperemia of the mucosa. This figure appears in color at www.ajtmh.org. Figure 3. Biopsy of colon and bone marrow. (A) Increased cellularity of the colon because of mononuclear inflammatory infiltrate. (B) Detail shows macrophages filled with amastigote forms of Leishmania chagasi

Paracoccidioidomycosis case series with and without central nervous system involvement

INTRODUCTION Paracoccidioidomycosis (PCM) is the most important systemic mycosis in South America. Central nervous system involvement is potentially fatal and can occur in 12.5% of cases. This paper aims to contribute to the literature describing eight cases of neuroparacoccidioidomycosis (NPMC) and compare their characteristics with patients without neurological involvement, to identify unique characteristics of NPCM. METHODS A cohort of 213 PCM cases was evaluated at the Infectious Diseases Clinic of the University Hospital, Federal University of Minas Gerais, Brazil, from October 1976 to August 2008. Epidemiological, clinical, laboratory, therapeutic and follow-up data were registered. RESULTS Eight patients presented NPCM. The observed NPCM prevalence was 3.8%. One patient presented the subacute form of PCM and the other seven presented the chronic form of the disease. The parenchymatous form of NPCM occurred in all patients. 60% of the patients who proceeded from the north/ northeast region of Minas Gerais State developed NPCM. The neurological involvement of a mother and her son was observed. NPCM patients exhibited demographical and clinical profiles similar to what is described in the literature. When NPCM cases were compared to PCM patients, there were differences in relation to origin and positive PCM family history. CONCLUSIONS The results corroborate the clinical view that the neurological findings are extremely important in the evaluation of PCM patients. Despite the limitations of this study, the differences in relation to patients origins and family history point to the need of further studies to determine the susceptibility factors involved in the neurological compromise.

Prostatic paracoccidioidomycosis : differential diagnosis of prostate cancer

Symptomatic prostatic paracoccidioidomycosis (PCM) is a very rare condition; however, it may express as a typical benign prostatic hyperplasia or a simulating prostatic adenocarcinoma. This case report presents PCM mimicking prostatic adenocarcinoma. The purpose of this paper is to call the general physicians attention to this important differential diagnosis.

Case of recurrent Paracoccidioidomycosis: 25 years after initial treatment.

Figure 1. Cervical lymph node enlargement. Figure 2. Nasal mucosa lesion. A 43 year-old man, farmer, born in Santo Antonio do Norte, Minas Gerais, Brazil, developed Paracoccidioidomycosis (PCM) in 1983, when he was eighteen. He presented cervical, submandibular, supraclavicular, axillary and inguinal lymph node enlargement, and also involvement of the oral mucosa, lungs and guts. The diagnosis was made through the finding of Paracoccidioides brasiliensis in lymph node secretion and phlegm. He was admitted to the Hospital das Clinicas of the Universidade Federal de Minas Gerais and treated with Sulfadiazine, Sulfamethoxazole/ Trimethoprim and Ketoconazole for two months. After discharged from hospital he had no ambulatorial follow up or took any medicine. He revealed moderate tabagism and alcohol intake. In 1991 moved out to the metropolitan area of Belo Horizonte and became a doorman. He had no contact with any endemic area of PCM ever since. In 2004 he quitted tobacco smoking and alcohol drinking. In January of 2008 he started loosing weight and showed dysphonia, odynophagia, vomiting, abdominal pain, low gastrointestinal hemorrhage, dyspnea, cough with expectoration and enlargement of cervical (Figure 1), axillary, navel and inguinal lymph node with suppuration. He also exhibited plaques and papules on the face and neck; ulcerated-vegetative lesions in the

Cutaneous Disseminated Paracoccidioidomycosis

A 46-year-old male farmer born in Minas Gerais State, Brazil, presented with disseminated plaque-like, ulcerated skin lesions (Figure 1A–D). Laryngoscopy showed lesions on the pharyngeal, nasal, and laryngeal mucosa (Figure 1E). He was a heavy tobacco smoker and drank 1–2 L of rum daily.

Impacto do uso da solução reveladora de linfonodos no estadiamento do câncer colorretal

INTRODUCTION: Accurate pathological study of colorectal cancer (CRC) specimens is of paramount importance to prognosis and indication of adjuvant therapies. Despite the minimum of 12 lymph nodes has been considered adequate to correctly establish the stage of disease, a bigger harvest of lymph nodes would increase the number of metastatic lymph nodes obtained. AIMS: To evaluate the harvest of lymph nodes from mesocolic fat before and after the introduction of routine use of a revealing solution of lymph nodes. Methods: We evaluated a total of 706 pathological reports of CRC, 582 without use of revealing solution and 124 with use of this solution. RESULTS: most of patients were females (57.6%) with mean age of 61.36 years. Sixty per cent of tumors were located distally to splenic flexure. The average of lymph nodes obtained was 16.73 and 28.97 before and after use of revealing solution, respectively (p < 0,001). Percentage of specimens with eleven or less lymph nodes (Nx) decreased significantly after use of revealing solution (32.7 to 3.2%; p < 0,0001). In opposite, there was a significative increase in number of cases sorted as pN0, pN1, pN2 e pN3 after use of revealing solution. CONCLUSION: The use of revealing solution of lymph nodes causes great impact in the pathological study of CRC and its routine use is strongly recommended in the surgical pathology services.