Dapsone hypersensitivity syndrome in an adolescent during treatment during of leprosy

A 12 y old girl was admitted 24 days after start a WHO multidrug therapy scheme for multibacillary leprosy (dapsone, clofazimine and rifampicin) with intense jaundice, generalized lymphadenopathy, hepatoesplenomegaly, oral erosions, conjunctivitis, morbiliform rash and edema of face, ankles and hands. The main laboratory data on admission included: hemoglobin, 8.4 g/dL; WBC, 15,710 cells/mm³; platelet count, 100,000 cells/mm³; INR = 1.49; increased serum levels of aspartate and alanine aminotransferases, gamma-glutamyl transpeptidase, alkaline phosphatase, direct and indirect bilirubin. Following, the clinical conditions had deteriorated, developing exfoliative dermatitis, shock, generalized edema, acute renal and hepatic failure, pancytopenia, intestinal bleeding, pneumonia, urinary tract infection and bacteremia, needing adrenergic drugs, replacement of fluids and blood product components, and antibiotics. Ten days after admission she started to improve, and was discharged to home at day 39th, after start new supervised treatment for leprosy with clofazimine and rifampicin, without adverse effects. This presentation fulfils the criteria for the diagnosis of dapsone hypersensitivity syndrome (fever, generalized lymphadenopathy, exfoliative rash, anemia and liver involvement with mixed hepatocellular and cholestatic features). Physicians, mainly in geographical areas with high prevalence rates of leprosy, should be aware to this severe, and probably not so rare, hypersensitivity reaction to dapsone.

Incidence of respiratory viruses in preterm infants submitted to mechanical ventilation

The objectives of this study were to determine the incidence of infection by respiratory viruses in preterm infants submitted to mechanical ventilation, and to evaluate the clinical, laboratory and radiological patterns of viral infections among hospitalized infants in the neonatal intensive care unit (NICU) with any kind of acute respiratory failure. Seventy-eight preterm infants were studied from November 2000 to September 2002. The newborns were classified into two groups: with viral infection (Group I) and without viral infection (Group II). Respiratory viruses were diagnosed in 23 preterm infants (29.5%); the most frequent was respiratory syncytial virus (RSV) (14.1%), followed by influenza A virus (10.2%). Rhinorrhea, wheezing, vomiting and diarrhea, pneumonia, atelectasis, and interstitial infiltrate were significantly more frequent in newborns with nosocomial viral infection. There was a correlation between nosocomial viral infection and low values of C-reactive protein. Two patients with mixed infection from Group I died during the hospital stay. In conclusion, RSV was the most frequent virus in these patients. It was observed that, although the majority of viral lower respiratory tract infections had a favorable course, some patients presented a serious and prolonged clinical manifestation, especially when there was concomitant bacterial or fungal infection.

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.

Clinical guideline for diagnosis and management of melioidosis

Melioidosis is an emerging infection in Brazil and neighbouring South American countries. The wide range of clinical presentations include severe community-acquired pneumonia, septicaemia, central nervous system infection and less severe soft tissue infection. Diagnosis depends heavily on the clinical microbiology laboratory for culture. Burkholderia pseudomallei, the bacterial cause of melioidosis, is easily cultured from blood, sputum and other clinical samples. However, B. pseudomallei can be difficult to identify reliably, and can be confused with closely related bacteria, some of which may be dismissed as insignificant culture contaminants. Serological tests can help to support a diagnosis of melioidosis, but by themselves do not provide a definitive diagnosis. The use of a laboratory discovery pathway can help reduce the risk of missing atypical B. pseudomallei isolates. Recommended antibiotic treatment for severe infection is either intravenous Ceftazidime or Meropenem for several weeks, followed by up to 20 weeks oral treatment with a combination of trimethoprim-sulphamethoxazole and doxycycline. Consistent use of diagnostic microbiology to confirm the diagnosis, and rigorous treatment of severe infection with the correct antibiotics in two stages; acute and eradication, will contribute to a reduction in mortality from melioidosis.

Questing one Brazilian query: reporting 16 cases of Q fever from Minas Gerais, Brazil

Q fever has been considered non-existing in Brazil where reports of clinical cases still cannot be found. This case-series of 16 patients is a result of a systematic search for such illness by means of clinical and serologic criteria. Serologic testing was performed by the indirect microimmunofluorescence technique using phase I/II C. burnetii antigens. Influenza-like syndrome was the most frequent clinical form (eight cases - 50%), followed by pneumonia, FUO (fever of unknown origin), mono-like syndrome (two cases - 12.5% each), lymphadenitis (one case - 6.3%) and spondylodiscitis associated with osteomyelitis (one case - 6.3%). The ages varied from four to 67 years old with a median of 43.5. All but one patient had positive serologic tests for phase II IgG whether or not associated with IgM positivity compatible with acute infection. One patient had both phase I and phase II IgG antibodies compatible with chronic Q fever. Seroconvertion was detected in 10 patients. Despite the known limitations of serologic diagnosis, the cases here reported should encourage Brazilian doctors to include Q fever as an indigenous cause of febrile illness.

Toxicodependentes Internados numa Enfermaria de Medicina Interna: Relato de uma Experiência

Contexto: Nos últimos anos tem-se verificado um aumento da patologia médica associada à toxicodependência, em particular infecciosa, condicionando internamento hospitalar. O próprio internamento, por seu lado, é muitas vezes complicado por problemas directamente associados ao estado de dependência física e psíquica, nomeadamente síndrome de abstinência, comportamento indisciplinado e alta precoce por abandono. Os autores pretenderam caracterizar o impacto desta população numa enfermaria de Medicina Interna durante um ano (1998). Métodos: Foram revistos todos os processos dos doentes internados durante o ano de 1998 numa enfermaria de Medicina Interna. Foram identificados dois grupos: o primeiro constituído por todos os toxicodependentes (definido como doentes com consumo activo de substâncias ilícitas na altura da admissão hospitalar - grupo TD); o segundo pela restante população internada (grupo controlo). Foram identificados para todos os doentes: motivos do internamento, duração do mesmo, e mortalidade; dados demográficos (sexo e idade); todos os episódios infecciosos (na admissão e nosocomiais) e serologias positivas para os vírus da imunodeficiência humana, hepatite B e hepatite C. No grupo TD foram ainda caracterizados os hábitos de consumo e as complicações do mesmo em internamento (em particular síndrome de privação). Resultados: Foram identificados 80 toxicodependentes(5,8% do total de internamentos): 50 homens (7,1 %) e 30 mulheres (4,5%). A idade média no grupo TD foi de 31 anos (no grupo controlo foi de 68,5 anos). Em 70% do grupo TD foi identificada serologia positiva para o VIH e em 48,7% para o VHC (no grupo controlo essa prevalência foi de 2,4% e 1,2%, respectivamente). A mortalidade foi de 11,3% e de 12,7 % respectivamente nos grupos TD e controlo, sendo a demora média de 18,7 e de 16,0 dias. Foram identificados 46 casos de tuberculose (18,8% em doentes TD e 2,4 % nos restantes), 293 de pneumonia (28,7% e 21%) e 54 casos de infecção dos tecidos moles (27,5% e 1,5% respectivamente). Só foram identificados 4 casos de endocardite (2 em cada grupo) e 6 de hepatite aguda (todos no grupo TD). No grupo TD verificaram-se 33 casos de síndrome de privação (41,3%). 16 das altas (20%) foram precoces; destes doentes, 4 tinham diagnóstico de tuberculose. Desta população 10 doentes (12,5%) eram sem abrigo (9 homens, 1 mulher) e 66 (82,5%) eram consumidores de drogas endovenosas. Conclusões: No ano de 1998 os doentes toxicodependentes constituíram uma percentagem significativa da população internada, tendo tido demora média e mortalidade semelhantes às da restante população, embora fossem significativamente mais jovens. A maioria foi internada por patologia infecciosa, sendo de assinalar a alta prevalência de tuberculose e de infecção pelo VIH e VHC. É igualmente relevante o elevado número de altas precoces nesta população, algumas das quais de doentes com patologia potencialmente contagiosa.

Um Caso de Esófago Negro em Doente Alcoólico

A necrose esofágica aguda é uma entidade raramente descrita na literatura, caracterizada endoscopicamente por uma coloração negra da mucosa do esófago. Tem sido associada à ingestão de cáusticos, à hipersensibilidade a fármacos, a infecções locais da mucosa e, mais frequentemente, a fenómenos da isquémia por instabilidade hemodinâmica. Recentemente, foram detectados alguns casos em doentes com ingestão alcoólica aguda e crónica e suas complicações, admitindo-se uma relação entre as duas entidades. Os autores descrevem um caso de esófago negro num doente internado por intoxicação alcoólica aguda, hematemeses, choque hipovolémico e pneumonia de aspiração. Atribui-se uma etiopatogénese multifactorial, que inclui a lesão directa e indirecta do álcool sobre a mucosa esofágica, assim como fenómenos de isquémia secundários ao choque hipovolémico e à pneumonia.

Metastização Pulmonar na Apresentação de Angiossarcoma Cardíaco. Caso Clínico e Discussão

Apresenta-se um caso clínico referente a doente de 35 anos, do sexo masculino sem antecedentes pessoais relevantes, admitido no serviço de urgência por quadro de toracalgia e tosse produtiva com alterações electrocardiográficas sugestivas de pericardite. Inicialmente admitido pelo Serviço de Cardiologia, com melhoria do quadro clínico após terapêutica anti- -inflamatória; contudo, no internamento houve como intercorrência pneumonia de provável etiologia bacteriana, complicada por derrame pleural. Após a alta,foi referenciado à consulta de pneumologia, onde se manteve o estudo etiológico do derrame persistente, tendo vindo a complicar-se o seu quadro com alterações das cavidades cardíacas e múltiplos nódulos pulmonares, sugestivos de endocardite subaguda com embolização séptica pulmonar. Internado no serviço de Pneumologia e submetido a videotoracoscopia, foi-lhe diagnosticado angiossarcoma cardíaco com metastização pulmonar. Assistiu-se a uma rápida evolução do quadro clínico, quase fulminante, com falência cardíaca e óbito do doente sem ter iniciado radioterapia ou quimioterapia adjuvante.

Frequency of toxocara infection in children attended by the health public service of Maringá, south Brazil

The lack of specific laboratorial diagnosis methods and precise symptoms makes the toxocariasis a neglected disease in Public Health Services. This study aims to determine the frequency of Toxocara spp. infection in children attended by the Health Public Service of Hospital Municipal de Maringá, South Brazil. To evaluate the association of epidemiological and clinical data, an observational and cross-section study was carried out. From 14,690 attended children/year aged from seven month to 12 years old, 450 serum samples were randomly collected from September/2004 to September/2005. A questionnaire was used to evaluate epidemiological, clinical and hematological data. An ELISA using Toxocara canis larval excretory-secretory products as antigen detected 130 (28.8%) positive sera, mainly between children from seven month to five years old (p = 0.0016). Significant correlation was observed between positive serology for Toxocara, and frequent playing in sandbox at school or daycare center (p = 0.011) and the presence of a cat at home (p = 0.056). From the families, 50% were dog owners which exposed soil backyards. Eosinophilia (p = 0.776), and signs and symptoms analyzed (fever p = 0.992, pneumonia p = 0.289, cold-like symptoms p = 0.277, cough p = 0.783, gastrointestinal problems p = 0.877, migraine p = 0.979, abdominal pain p = 0.965, joint pain p = 0.686 and skin rash p = 0.105) could not be related to the presence of anti-Toxocara antibodies. Therefore, two asthmatics children showed titles of 1:10,240 and accentuated eosinophilia (p = 0.0001). The authors emphasize the needs of prevention activities.

Fatal septicemia caused by Chromobacterium violaceum in a child from Colombia

A 4-year old child living in Colombia presented with a history of fever and severe abdominal pain for four days. The patient developed pneumonia, septic shock, multiple organ failure and died on the fifth day of hospitalization. Chromobacterium violaceum was isolated from admission blood cultures and was resistant to ampicillin, cephalosporins, carbapenems and aminoglycosides.

Empiema Torácico. Revisão Baseada em Três Casos Clínicos

O derrame parapneumónico caracteriza-se pela necessidade de um processo invasivo para a sua resolução e o empiema pela presença de pus na cavidade pleural. Em ambos os casos, o diagnóstico por TAC e o tratamento precoces resultando em menores morbilidade e mortalidade. São indicação para um tratamento invasivo os derrames loculados, os que ocupam mais de 50% do tórax, os que revelam coloração por Gram e exame cultural positivos, ou derrames com pH inferior a 7,20, glucose inferior a 60 mg/dl, e nível de DHL superior a três vezes o limite normal no soro. Estas características resultam da evolução através de três estádios dos derrames incorrectamente tratados: 1) exsudativo; 2) fibrino-purulento; 3) fibrótico. Dependendo do estádio evolutivo, a abordagem terapêutica varia entra toracentese terapêutica, colocação de drenagem torácica com ou sem instilação de fibrinolíticos, cirurgia toracoscópica vídeo-assistida e decorticação pulmonar. Os autores fazem uma revisão do estudo destas situações baseados em três casos clínicos com apresentações muito díspares: uma doente com empiema por Streptococcus pyogenes que faleceu rapidamente por hemoptise maciça; um doente com empiema resultante de pneumonia aguda ocorrida durante um voo de avião; uma doente com empiema e bacteriemia por Streptococcus pneumoniae conduzindo a diagnóstico até então desconhecido de infecção por VIH.

Nocardiosis: an overview and additional report of 28 cases in cattle and dogs

Phenotypic characteristics, antimicrobial susceptibility profile, and clinical-epidemiological features of 28 Nocardia strains isolated from 19 cases of bovine mastitis, eight cutaneous-subcutaneous lesions and one case of pneumonia in dogs were evaluated. Microbiological, biochemical, cytological and scanning electron microscopy methods were used in diagnosis. Nocardia asteroides type IV, Nocardia otitidiscaviarum,Nocardia nova (type III) and Nocardia farcinica (type V) were isolated from bovine milk, bronchial lavage and/or cutaneous-subcutaneous abscesses in dogs. Nocardial bovine mastitis was diagnosed predominantly in clinical cases, in dairy herds with poor environmental hygienic conditions between milking and inappropriate intramammary therapy. Canine nocardiosis was observed commonly in animals co-infected with distemper virus. Sulphamethoxazole-trimethoprim (92.8%), amikacin (92.8%) and ceftiofur (92.8%) were the most effective drugs in 28 isolates. Multiple drug resistance to three or more and five or more antimicrobials was observed in ten (35.7%) and three (10.7%) strains, respectively, predominantly with use of cloxaxillin, cefoperazone and ampicillin. The species (type) classification, clinical-epidemiological characteristics, diagnosis, multiple-drug resistance and public health considerations in Nocardia strains isolated from cattle and dogs in Brazil are discussed, with special reference to report of bovine mastitis by N. otitidiscaviarum by first time in Brazil and the similarity between Nocardia species isolated from human and animal origin.

Aids-related progressive multifocal leukoencephalopathy: a retrospective study in a referral center in São Paulo, Brazil

Few data are available about progressive multifocal leukoencephalopathy (PML) in patients with acquired immunodeficiency syndrome (AIDS) from Brazil. The objectives of this study were to describe the main features of patients with PML and estimate its frequency among AIDS patients with central nervous system (CNS) opportunistic diseases admitted to the Instituto de Infectologia Emílio Ribas, São Paulo, Brazil, from April 2003 to April 2004. A retrospective and descriptive study was performed. Twelve (6%) cases of PML were identified among 219 patients with neurological diseases. The median age of patients with PML was 36 years and nine (75%) were men. Nine (75%) patients were not on antiretroviral therapy at admission. The most common clinical manifestations were: focal weakness (75%), speech disturbances (58%), visual disturbances (42%), cognitive dysfunction (42%), and impaired coordination (42%). The median CD4+ T-cell count was 45 cells/µL. Eight (67%) of 12 patients were laboratory-confirmed with PML and four (33%) were possible cases. Eleven (92%) presented classic PML and only one case had immune reconstitution inflammatory syndrome (IRIS)-related PML. In four (33%) patients, PML was the first AIDS-defining illness. During hospitalization, three patients (25%) died as a result of nosocomial pneumonia and nine (75%) were discharged to home. Cases of PML were only exceeded by cases of cerebral toxoplasmosis, cryptococcal meningoencephalitis, and CNS tuberculosis, the three more frequent neurologic opportunistic infections in Brazil. The results of this study suggest that PML is not an uncommon HIV-related neurologic disorder in a referral center in Brazil.

Clinical and epidemiological analysis of patients with HIV/AIDS admitted to a reference hospital in the northeast region of Brazil

The AIDS epidemic has become a worldwide phenomenon of enormous magnitude and extension, deeply transforming medical practices and public health initiatives. This retrospective survey aimed to analyze clinical and epidemiological characteristics of patients with HIV/AIDS admitted to the Institute of Tropical Diseases Natan Portella, Teresina, Piauí, Brazil, from January, 2001 through December, 2004. Of the 828 patients, 43% were from other states and 71.3% were men. Average patient age was 35.4 ± 11.5 years-old and 85.5% were illiterate or had primary education. The main form of exposure to HIV was heterosexual behavior (54.1%), while injectable drug use was confirmed by only 2.7% of registered cases. The most frequent infectious complications were candidiasis (42.4%) and pneumocystosis (22.2%). Sixty-eight cases (8.2%) of visceral leishmaniasis were registered. Using multivariate analysis, individuals aged over 40 years-old, patients with active tuberculosis, Pneumocystis carinii pneumonia and central nervous system cryptococcosis showed increased risk of death. In this study, young male adults with low educational levels predominated and the most frequent opportunistic infections were candidiasis and pneumocystosis.

Lúpus Eritematoso Sistémico

O Lúpus Eritematoso Sistémico (LES) é uma doença multissistémica, auto-imune, caracterizada por inflamação vascular e do tecido conjuntivo, com anticorpos antinucleares. As manifestações clínicas são variáveis, com uma história natural progressiva e imprevisível. Apresentamos o caso de uma adolescente, com antecedentes de artrite dos joelhos, febre e astenia de etiologia não esclarecida, com um ano de evolução. Internada na Unidade de Cuidados Intensivos Pediátricos por pneumonia bilateral a Streptococcus pneumoniae complicada com derrame pleural, anasarca e hematúria macroscópica. Iniciou antibioticoterapia, com evolução favorável, após o que se verifica agravamento clínico, com reaparecimento do derrame pleural, lesões vesiculares disseminadas sugestivas de etiologia herpética, hipertensão arterial sintomática e convulsão tónico-clónica generalizada. Da investigação, destaca-se estudo imunológico compatível com LES em actividade, poliserosite, proteinúria nefrótica, nefrite lúpica classe IV e anemia grave.