Cyclospora cayetanensis in sputum and stool samples

We report the observation of acid-fast Cyclospora cayetanensis oocysts in a sputum sample. The patient, a 60 year-old, HIV negative man, was successfully treated for pulmonary tuberculosis during 1997. On February 1998, he was admitted to our center due to loss of weight, cough with purulent expectoration, dysphonia and a radiological picture of pulmonary fibrosis. Bacilloscopic study of sputum (negative for acid-fast bacilli) stained with Ziehl-Neelsen technique showed large (8-10 µm) spherical, acid-fast Cyclospora cayetanensis oocysts. No other pathogens were isolated on cultures from this sample or from laryngeal biopsy. Serial parasitologic studies showed C. cayetanensis and also eggs of Trichuris trichiura, Ascaris lumbricoides and Hymenolepis nana and of Entamoeba coli cysts. The patient lives in the outskirts of Buenos Aires in a brick-made house with potable water and works as builder of sewers. He travelled in several occasions to the rural area of province of Tucumán which has poor sanitary conditions. C. cayetanensis is an emergent agent of diarrhea and as far as we know this is the first time the parasite is observed in respiratory samples.

A clinical, epidemological, laboratorial, histological and ultrasonographical evaluation of anti-HCV EIA-2 positive blood donors

Between 1992 and 1997, 790 blood donors with anti-HCV EIA-2 strongly reagent (relationship between the sample optical density/cut-off > 3) detected at the blood bank serological screening, were evaluated in ambulatory environment. They were all negative for Chagas disease, syphilis, hepatitis B (HBsAg) and AIDS. Blood samples were collected at the first ambulatorial evaluation, for hemogram, biochemical tests and new serological tests for HCV (anti-HCV EIA-2). In blood samples of 226 repeatedly reagent anti-HCV EIA-2 blood donors, supplementary "immunoblot" test for HCV (RIBA-2) was used. In 209 donors, the presence of HCV-RNA was investigated by the PCR test. The abdominal ultrasonography was realized in 366 donors. In 269 patients liver biopsy was performed for the histopathological study. The follow-up of blood donors showed that 95.6% were repeatedly EIA-2 reagent, 94% were symptomless and denied any hepatitis history, with only 2% mentioning previous jaundice. In 47% of this population at least one risk factor has been detected for the HCV transmission, the use of intravenous drugs being the main one (27.8%). Blood transfusion was the second factor for HCV transmission (27.2%). Hepatomegaly was detected in 54% of the cases. Splenomegaly and signs of portal hypertension have seldom been found in the physical examination, indicating a low degree of hepatic compromising in HCV. Abdominal ultrasound showed alterations in 65% of the subjects, being the steatosis the most frequent (50%). In 83.5% of the donors submitted to the liver biopsy, the histopathological exam showed the presence of chronic hepatitis, usually classified as active (89%) with mild or moderate grade in most of the cases (99.5%). The histopathological exam of the liver was normal in 1.5% of blood donors. The RIBA-2 test and the HCV-RNA investigation by PCR were positive in respectively 91.6 and 75% of the anti-HCV EIA-2 reagent donors. The HCV-RNA research was positive in 82% of the RIBA-2 positive subjects, in 37.5% of the indeterminate RIBA-2 donors and in 9% of the negative RIBA-2 donors. Chronic hepatitis has also been observed in 50% of the histopathological exams of the anti-HCV EIA-2 reagent donors which were indeterminate RIBA-2. Among 18 blood donors with minimal changes histopathological exam 11 (61%) were HCV-RNA positive. Our blood donors anti-HCV reagent generally had clinical, laboratorial and histopathological features observed in patients with chronic HCV hepatitis and a high proportion could be identified in interviews and medical evaluation realized in blood blanks. Generally, these HCV infected donors are identified and discharged only by the serological tests results.

The use of cyclosporine modifies the clinical and histopathological presentation of tuberculosis after renal transplantation

Tuberculosis is one of the most frequent opportunistic infections after renal transplantation and occurred in 30 of 1264 patients transplanted between 1976 and 1996 at Hospital São Paulo - UNIFESP and Hospital Dom Silvério, Brazil. The incidence of 2.4% is five times higher than the Brazilian general population. The disease occurred between 50 days to 18 years after the transplant, and had an earlier and worse development in patients receiving azathioprine, prednisone and cyclosporine, with 35% presenting as a disseminated disease, while all patients receiving azathioprine and prednisone had exclusively pulmonary disease. Ninety percent of those patients had fever as the major initial clinical manifestation. Diagnosis was made by biopsy of the lesion (50%), positivity to M. tuberculosis in the sputum (30%) and spinal cerebral fluid analysis (7%). Duration of treatment ranged from 6 to 13 months and hepatotoxicity occurred in 3 patients. The patients who died had a significant greater number of rejection episodes and received higher doses of corticosteroid. In conclusion, the administration of cyclosporine changed the clinical and histopathological pattern of tuberculosis occurring after renal transplantation.

Central nervous system paracoccidioidomycosis. Report of a case successfully treated with Itraconazol

Paracoccidioidomycosis (PCM) is a primary pulmonary infection that often disseminates to other organs and systems. Involvement of the central nervous system (CNS) is rare and due to the fact that both clinical alertness and establishment of the diagnosis are delayed, the disease progresses causing serious problems. We report here a case of neuroparacoccidioidomycosis (NPCM), observed in a 55 year-old male, who consulted due to neurological symptoms (left hemiparesis, paresthesias, right palpebral ptosis, headache, vomiting and tonic clonic seizures) of a month duration. Upon physical examination, an ulcerated granulomatous lesion was observed in the abdomen. To confirm the diagnosis a stereotactic biopsy was taken; additionally, mycological tests from the ulcerated lesion and a bronchoalveolar lavage were performed. In the latter specimens, P. brasiliensis yeast cells were visualized and later on, the brain biopsy revealed the presence of the fungus. Treatment with itraconazole (ITZ) was initiated but clinical improvement was unremarkable; due to the fact that the patient was taking sodium valproate for seizure control, drug interactions were suspected and confirmed by absence of ITZ plasma levels. The latter medication was changed to clonazepam and after several weeks, clinical improvement began to be noticed and was accompanied by diminishing P. brasiliensis antigen and antibody titers. In the PCM endemic areas, CNS involvement should be considered more often and the efficacy of itraconazole therapy should also be taken into consideration.

Inoculation of BALB/c mice with Lacazia loboi

In a previous study, the authors inoculated Swiss mice with Lacazia loboi (L. loboi) and succeeded in maintaining a granulomatous infiltrate and viable fungal cells up to one year and six months after inoculation. Considering the experimental work on paracoccidioidomycosis, 0.03 ml of a fungal suspension obtained from a biopsy of a Jorge Lobo's Disease patient were inoculated into both hind foot pads of 32 six week-old BALB/c mice of both sexes. The animals were sacrificed 1, 4, 7 and 10 months post inoculation. The suspension contained 1.3 x 10(6) fungi/ml and presented 38% viability. Seven months after inoculation, most of the animals presented profuse infiltrates consisting of isolated histiocytes, foreign body and Langhans' giant cells and a large number of fungi, most of them viable. Emergence of macroscopic lesions was observed during the 8th month. Based on fungal count, viability index before and after inoculation, presence of macroscopic lesions and histopathological findings similar to the findings in humans, the authors believe that BALB/c mice may be a good experimental model to study Jorge Lobo's Disease, mainly regarding therapeutic evaluation.

Clinical and diagnostic aspects of intestinal microsporidiosis in HIV-infected patients with chronic diarrhea in Rio de Janeiro, Brazil

The objectives of this study were to determine both the prevalence of microsporidial intestinal infection and the clinical outcome of the disease in a cohort of 40 HIV-infected patients presenting with chronic diarrhea in Rio de Janeiro, Brazil. Each patient, after clinical evaluation, had stools and intestinal fragments examined for viral, bacterial and parasitic pathogens. Microsporidia were found in 11 patients (27.5%) either in stools or in duodenal or ileal biopsies. Microsporidial spores were found more frequently in stools than in biopsy fragments. Samples examined using transmission electron microscopy (n=3) or polymerase chain reaction (n=6) confirmed Enterocytozoon bieneusi as the causative agent. Microsporidia were the only potential enteric pathogens found in 5 of the 11 patients. Other pathogens were also detected in the intestinal tract of 21 patients, but diarrhea remained unexplained in 8. We concluded that microsporidial infection is frequently found in HIV infected persons in Rio de Janeiro, and it seems to be a marker of advanced stage of AIDS.

Embolização das artérias prostáticas no tratamento da hiperplasia benigna da próstata : estudo anátomo-clínico

Resumo: A hiperplasia benigna da próstata (HBP) tem elevada prevalência nos homens entre os 50 e 79 anos de idade, sendo ubiquitária com o envelhecimento. Devido à significativa morbi-mortalidade associada aos tratamentos médicos e cirúrgicos currentemente disponíveis, são necessárias novas tecnologias para melhorar os resultados e minimizar o desconforto dos doentes. Recentemente, estudos preliminares de experimentação animal e em 3 doentes tratados, sugeriram a embolização arterial prostática selectiva (EAPS) como hipótese terapêutica para a HBP. Decidimos investigar se a EAPS poderia ser um procedimento bem sucedido no tratamento da HBP gravemente sintomática. Para tal realizámos um estudo anátomo-radiológico e clínico em 63 doentes com recurso a uma terapêutica inovadora minimamente invasiva guiada pela imagem. Avaliámos 126 hemipélvis com recurso a Angio-RM, Angio-TC e Angiografia Digital de Subtracção, com o intuito de definir os padrões básicos de bifurcação das artérias ilíacas internas até agora apenas descritos em estudos cadavéricos. Estudámos ainda o suprimento vascular arterial prostático, identificando: 1 as artérias prostáticas; 2 origem e direcção; 3 os ramos intra-prostáticos; 4 anastomoses com outras artérias. Em relação aos resultados anatómicos, identificámos 181 artérias prostáticas, já que em 43.7% das hemipélvis existiam dois pedículos arteriais prostáticos com origens independentes. A origem mais frequente foi a artéria pudenda interna (39.7%), seguida do tronco comum glúteo-pudendo (21%) e da artéria vesical superior (18.2%). Origens menos frequentes foram a artéria obturadora (12.1%), as artérias glúteas inferior (3.9%)ou superior (1.7%), ramos rectais provenientes da artéria mesentérica inferior (1.7%) e a artéria pudenda acessória (1.7%). Identificaram-se anastomoses com as artérias adjacentes em 57.9% dos casos: com a terminação da artéria pudenda interna (41.6%),artérias prostáticas contra-laterais (18.2%) e homo-laterais (11.7%), com ramos rectais (15.6%) e com artérias vesicais (12.9%). Em relação ao estudo clínico tratámos 63 doentes (idades compreendidas entre 52 - 82 anos, média 69.5 anos) com HBP gravemente sintomática refractária à terapêutica médica há mais de 6 meses. Foi possível avaliação após o tratamento em 37 doentes: média de seguimento de 4.7 meses (variando entre 1 e 12 meses). A EAPS unilateral foi possível em todos os doentes, com embolização bilateral em 73% dos casos. A embolização bilateral não foi possível em 27% dos casos devido a tortuosidade, alterações ateroescleróticas e pequeno calibre das artérias ilíacas e/ou prostáticas. Em média houve uma melhoria do International Prostate Symptom Score (IPSS) de 10.8 pontos, da QoL de 1.5 pontos e do Internationl Index of Erectile Function (IIEF) de 2.1 pontos. Houve uma redução média do PSA de 30% (2.4 ng/mL), um aumento do pico de fluxo urinário (Qmax) de 3.1 - 3.85 mL/s e uma redução média do volume prostático de 21% (18.5 mL). Registou-se uma complicação major: pequena área de isquémia da parede vesical tratada cirurgicamente. Em 75% dos doentes tratados obteve-se sucesso clínico com franca melhoria dos sintomas, enquanto 25% dos doentes foram considerados insucesso clínico por se ter registado uma fraca ou ausente melhoria sintomática após a embolização. Os restantes doentes tratados estão sob controlo evolutivo, pararam toda a medicação prostática, sem qualquer caso de disfunção sexual associada com o tratamento. Este trabalho constitui o primeiro estudo anatómico descritivo in vivo das artérias prostáticas, conseguido devido à utilização de técnicas de imagem nunca usadas para este fim. O uso clínico dos dados anatómicos acima referidos permitiu a implementação de técnicas de Radiologia de Intervenção no tratatamento de uma doença de elevada prevalência. ------------------------------- ABSTRACT: Benign prostatic hyperplasia (BPH) has high prevalence in men aged 50–79 years being ubiquitous with aging. Due to significant morbi-mortality associated with currently available medical and surgical treatments, there is the need for innovative technologies to continue to improve outcomes and minimize patient discomfort and morbidity. Recently, prostatic arterial embolization (PAE) was suggested as a treatmentoption for BPH based on preliminary results from animal studies and 3 treated patients. We decided to investigate if PAE might be a successful treatment option for severely symptomatic BPH patients. We performed a clinical and anatomical-radiological study in 63 patients with the use of an inovative image-guided minimally invasive technique. We evaluated 126 pelvic sides using Angio-MR or Angio-CT and Catheter Angiography before embolisation to treat symptomatic BPH. We aimed to define the main branching patterns of the male internal iliac arteries, so far only studied in the cadaver. We also evaluated the prostatic arterial supply, identifying: 1 the prostatic arteries; 2 origin and direction; 3 intra-prostatic branches; 4 anastomoses with surrounding arteries. Regarding the anatomical study we identified 181 prostatic arteries, because in 43.7% of pelvic sides 2 separate prostatic vascular pedicles were found. The most frequent origin was the internal pudendal artery (39.7%) with the common glutealpudendal trunk (21%) and superior vesical arteries (18.2%) the next commonest. Less frequent origins were the obturator artery (12.1%), the inferior (3.9%) or superior (1.7%) gluteal arteries, rectal branches from the inferior mesenteric artery (1.7%) and the accessory pudendal artery (1.7%). There were anastomoses with the surrounding arteries in 57.9% of cases: termination of the internal pudendal artery (41.6%), contralateral prostatic arteries (18.2%), same-side prostatic arteries (11.7%), rectal branches (15.6%), and vesical arteries (12.9%).Regarding the clinical study, we treated 63 patients aged 52–82 years (mean 69.5 years) who presented with symptomatic BPH refractory to medical treatment for at least 6 months. Follow-up evaluation (mean 4.7 months, range 1-12 months) was possible in 37 patients. PAE was achieved in all patients with bilateral embolization in 73%. In 27% PAE was performed unilaterally due to tortuosity, atherosclerotic changes and small size of iliac and prostatic arteries. There was a mean decrease in the IPSS of 10.8 points, a mean improvement in QoL of 1.5 points, and a mean increase in the sexual function score of 2.1 points. There was a mean PSA reduction of 30% (2.4 ng/mL), a Qmax increase of 3.1 to 3.85 mL/sec, and a mean prostate volume decrease of 21% (18.5 mL). There was one major complication: a small area of bladder wall ischemia treated by surgery. Overall, 75% of patients were considered clinical success with major improvement after PAE, while 25% of patients were considered clinical failure with little or no improvement after PAE. All remaining patients are under follow-up, stopped all prostatic medication, and reported no sexual dysfunction. This study is the first one to describe the radiological anatomy of the prostatic arteries, with the use of imaging techniques never used for this purpose before. The clinical use of the anatomical findings allowed the implementation of Interventional Radiology tehniques in the treatment of a disease with a high prevalence.

Liver histology in co-infection of hepatitis C virus (HCV) and Hepatitis G virus (HGV)

As little is known about liver histology in the co-infection of hepatitis C virus (HCV) and hepatitis G virus (HGV), HGV RNA was investigated in 46 blood donors with hepatitis C, 22 of them with liver biopsy: co-infection HCV / HGV (n = 6) and HCV isolated infection (n = 16). Besides staging and grading of inflammation at portal, peri-portal and lobular areas (Brazilian Consensus), the fibrosis progression index was also calculated. All patients had no symptoms or signs of liver disease and prevalence of HGV / HCV co-infection was 15.2%. Most patients had mild liver disease and fibrosis progression index, calculated only in patients with known duration of infection, was 0.110 for co-infection and 0.130 for isolated HCV infection, characterizing these patients as "slow fibrosers". No statistical differences could be found between the groups, although a lesser degree of inflammation was always present in co-infection. In conclusion co-infection HCV / HGV does not induce a more aggressive liver disease, supporting the hypothesis that HGV is not pathogenic.

Leishmaniasis in the genital area

Two patients from the gold mines of Bolivar State, Venezuela, presenting cutaneous leishmaniasis in the genital region, an unusual location, are described. The first patient showed an ulcerated lesion of the glans penis. Leishmanin skin test was positive. A biopsy specimen revealed a granulomatous infiltrate containing Leishmania parasites. In the second patient, Leishmanin skin test was positive, HIV and VDRL were negative. Leishmania parasites were present in a biopsy of an ulcerated lesion in the scrotum, with an indurated base, infiltrative borders with an yellowish exudate. Patients were treated with meglumine antimoniate and the lesions healed.

Confluent peripheral multiple mononeuropathy associated to acute hepatitis B: a case report

A thirty three year-old, male patient was admitted at the Hospital of the São Paulo University School of Medicine, at the city of São Paulo, Brazil, with complaint of pains, tingling and decreased sensibility in the right hand for the last four months. This had progressed to the left hand, left foot and right foot, in addition to a difficulty of flexing and stretching in the left foot. Tests were positive for HBeAg, IgM anti-HBc and HBsAg, thus characterizing the condition of acute hepatitis B. The ALT serum level was 15 times above the upper normal limit. Blood glucose, cerebral spinal fluid, antinuclear antibodies (ANA) and anti-HIV and anti-HCV serum tests were either normal or negative. Electroneuromyography disclosed severe peripheral neuropathy with an axon prevalence and signs of denervation; nerve biopsy disclosed intense vasculitis. The diagnosis of multiple confluent mononeuropathy associated to acute hepatitis B was done. This association is not often reported in international literature and its probable cause is the direct action of the hepatitis B virus on the nerves or a vasculitis of the vasa nervorum brought about by deposits of immune complexes.

Treatment by splenectomy of a portal vein aneurysm in hepatosplenic schistosomiasis

Portal vein aneurysm is a rare medical entity that can be caused by chronic hepatic diseases with portal hypertension. We describe a 45-year-old man with variceal bleeding from hepatosplenic schistosomiasis and an incidentally found intrahepatic aneurysm. Diagnosis was confirmed with non-invasive imaging exams, arteriography and liver biopsy. Following splenectomy, the aneurysm diameter decreased substantially.

Sarcosine oxidase composite screen-printed electrode for sarcosine determination in biological samples

XIX Meeting of the Portuguese Electrochemical Society - XVI Iberic Meeting of Electrochemistry

Fonsecaea pedrosoi cerebral phaeohyphomycosis ("chromoblastomycosis"): first human culture-proven case reported in Brazil

Cerebral phaeohyphomycosis ("chromoblastomycosis") is a rare intracranial lesion. We report the first human culture-proven case of brain abscesses due to Fonsecaea pedrosoi in Brazil. The patient, a 28 year-old immunocompetent white male, had ocular manifestations and a hypertensive intracranial syndrome. Magnetic resonance imaging (MRI) of the brain revealed a main tumoral mass involving the right temporo-occipital area and another smaller apparently healed lesion at the left occipital lobe. A cerebral biopsy was performed and the pathological report was cerebral chromoblastomycosis. The main lesion was enucleated surgically and culture of the necrotic and suppurative mass grew a fungus identified as Fonsecaea pedrosoi. The patient had received a knife wound sixteen years prior to his hospitalization and, more recently, manifested a pulmonary granulomatous lesion in the right lung with a single non-pigmented form of a fungus present. It was speculated that the fungus might have gained entrance to the host through the skin lesion, although a primary respiratory lesion was not excluded. The patient was discharged from the hospital still with ocular manifestations and on antimycotic therapy and was followed for eight months without disease recurrence. Few months after he had complications of the previous neuro-surgery and died. A complete autopsy was performed and no residual fungal disease was found.

Cerebral mass lesion due to cytomegalovirus in a patient with AIDS: case report and literature review

Cytomegalovirus (CMV) disease in acquired immunodeficiency syndrome (AIDS) patients most commonly presents as chorioretinitis and gastro-intestinal infection. Neurological involvement due to CMV may cause several clinical presentations: polyradiculitis, myelitis, encephalitis, ventriculo-encephalitis, and mononeuritis multiplex. Rarely, cerebral mass lesion is described. We report a 39 year-old woman with AIDS and previous cerebral toxoplasmosis. She presented with fever, seizures, and vulval ulcers. Her chest X-ray showed multiple lung nodules, and a large frontal lobe lesion was seen in a brain computed tomography scan. She underwent a brain biopsy through a frontal craniotomy, but her condition deteriorated and she died in the first postoperative day. Histopathological studies and immunohistochemistry disclosed CMV disease, and there was no evidence of cerebral toxoplasmosis, bacterial, mycobacterial or fungal infection. CMV disease should be considered in the differential diagnosis of cerebral mass lesion in AIDS patients. High suspicion index, timely diagnostic procedures (surgical or minimally invasive), and proper utilization of prophylactic and therapeutic medication could improve outcome of these patients.

Transformation of a Cutaneous Follicle Center Lymphoma to a Diffuse Large B-Cell Lymphoma - An Unusual Presentation

Primary cutaneous follicle center lymphoma (PCFCL) is characterized by a proliferation of follicle center cells in the skin. A definitive diagnosis is frequently delayed because of difficulties in interpretation of the histopathologic findings. It has an excellent prognosis with a 5-year survival over 95% and its risk of transformation has not been established. We describe a case report of man with a gastric diffuse large B-cell lymphoma (DLBCL) referred to our clinic because of nodules in the back that had gradually developed over a period of 10 years. A biopsy performed 3 years before was interpreted as reactive follicular hyperplasia. A new skin biopsy revealed a diffuse large B-cell lymphoma and immunoglobulin heavy chain gene rearrangements from the initial skin biopsy (PCBCL) and the DLBCL gastric biopsy were studied by polymerase chain reaction and an identical clonal rearrangement was detected which was highly suggestive of a transformation lymphoma.