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Paracoccidioidomycosis (PCM) is one of the main endemic systemic mycoses in Latin America, usually occurring in rural areas. When PCM occurs simultaneously with underlying immunosuppressive conditions, it can present as an opportunistic disease. Between 2000 and 2017, literature reported around 200 PCM cases in people living with HIV/AIDS (PLWHA). To address research gaps on this co-infection and to study its possible temporal changes in the last decade, we performed an active co-infection case search on the HIV/AIDS and PCM cohorts from a Brazilian reference center database from 1989 to 2019. We found 20 PLWHA among 684 PCM patients (2.92%), predominantly male (70.0%) and urban workers (80.0%). The median age of patients was higher in the 2010-2019 decade (p = 0.006). The occurrence of PCM in PLWHA was lower when compared with other fungal diseases. Although 50.0% of the patients had already been diagnosed with HIV infection and presented CD4+ T cell counts greater than 200/mm3 at the time of PCM diagnosis, the suspicion of immunosuppression in the context of atypical and more severe clinical forms of PCM revealed the diagnosis of HIV infection in 35.0% of the patients. Two (10.0%) patients had an evolution compatible with immune reconstitution inflammatory syndrome (IRIS) after starting antiretroviral therapy (ART).We highlight the importance of considering a PCM diagnosis in PLWHA to prevent a late-onset treatment and progression to severe manifestations and unfavorable outcomes. In addition, HIV investigation is recommended in PCM patients, especially those with atypical and more severe clinical presentations.

A Hanseníase é uma doença negligenciada com alto estigma e carga em países em desenvolvimento. Infecção crônica, granulomatosa, causada pelo M. leprae que afeta principalmente a pele e nervos periféricos. O Fenômeno de Lúcio (FL) é uma manifestação incomum com graves lesões cutâneas necróticas em pacientes com Hanseníase Lepromatosa. Dentre os fatores precipitantes, destacam-se infecções, uso de drogas e gravidez. JAFS, 17 anos, Nova Iguaçu, RJ, é admitida com lesões disseminadas, recebendo antibióticos sob suspeita de sepse cutânea. História pregressa de abortamento de 1º trimestre há 2 meses da internação; e Hanseníase com Poliquimioterapia (PQT-MB) por 1 ano com Rifampicina (RMP), Clofazimina (CFZ) e Dapsona. É transferida para serviço de referência após 7 dias, mantendo febre, taquicardia e astenia. Ao exame: regular estado, desidratada, com máculas hipercrômicas e purpúricas, placas eritematosas, bolhas serohemáticas e ulcerações necróticas nos membros, orelhas, nariz, palmas e plantas. Artrite do punho e 1º quirodáctilo esquerdos, além de amiotrofias, dor e espessamento dos nervos ulnares, parestesias em bota e em luva, bilaterais, mas assimétricas. Laboratório: Anemia (Hb 7.2 g/dL), trombocitose (624.000), leucocitose (28.040/mm3-0/0/3/5/17/59/12/4), e PCR elevada (29 mg/dL). Sorologias para HIV, Hepatites e Sífilis, hemoculturas para bactérias, fungos, e teste de gravidez foram negativos. Baciloscopia: BAAR e globias em todos os sítios (Índice Baciloscópico: 2.5+) e no aspirado das bolhas. A histopatologia da pele demonstrou inflamação superficial e profunda, perivascular, dermatite granulomatosa perianexial e depósitos fibrinoides vasculares. Com os achados clínicos, histopatológicos e baciloscópicos, foi feito o diagnóstico de Hanseníase Borderline-Lepromatosa em estado reacional - Fenômeno de Lúcio. Recebeu pulsoterapia com metilprednisolona por 3 dias, reduzindo as áreas hipercrômicas e maculares e resolvendo a febre, taquicardia e artrite. A PQT-MB foi reintroduzida com RMP, CFZ, Ofloxacino, Prednisona e Pentoxifilina. Teve alta hospitalar com acompanhamento mensal ambulatorial, com resolução das lesões após desbridamento cirúrgico do material necrótico em 3 meses de seguimento. O FL é raro e potencialmente fatal pela extensão e gravidade das lesões cutâneas, favorecendo complicações discrásicas ou infecciosas. A gravidez é descrita como deflagradora ou exacerbadora de quadros de Hanseníase devido às alterações hormonais e imunológicas.

Neuroparacoccidioidomycosis (NPCM) is a rare and severe clinical presentation of paracoccidioidomycosis (PCM). We performed a retrospective cohort study at the Evandro Chagas National Institute of Infectious Diseases (INI/Fiocruz), a reference center for PCM in the state of Rio de Janeiro, Brazil. All cases of PCM admitted to the INI/Fiocruz from January 2007 to December 2019 were reviewed. Eight (3.9%) among 207 patients met the diagnostic criteria for NPCM. The mean age was 44.6 years and the male:female ratio was 7:1. All cases presented multifocal disease, 5 (62.5%) the chronic form and 3 (37.5%) the acute/subacute form. All patients presented the pseudotumoral pattern and 6 (75.0%) had multiple lesions in the cerebral hemispheres. Seizures and motor symptoms were the most frequent clinical manifestations (50.0%, each). The treatment of choice was sulfamethoxazole/trimethoprim (SMZ-TMP) and fluconazole, in association (87.5%). Most patients responded well to the treatment. Sequela and death occurred in one (12.5%) patient, each.

Corynebacterium striatum is a potentially pathogenic microorganism with the ability to produce outbreaks of nosocomial infections. Here, we document a nosocomial outbreak caused by multidrug-resistant (MDR) C. striatum in Rio de Janeiro, Brazil. C. striatum identification was confirmed by 16S rRNA and rpoB gene sequencing. Fifteen C. striatum strains were isolated from adults (half of whom were 50 years of age and older). C. striatum was mostly isolated in pure culture from tracheal aspirates of patients undergoing endotracheal intubation procedures. The analysis by pulsed-field gel electrophoresis (PFGE) indicated the presence of four PFGE profiles, including two related clones of MDR strains (PFGE I and II). The data demonstrated the predominance of PFGE type I, comprising 11 MDR isolates that were mostly isolated from intensive care units and surgical wards. A potential causal link between death and MDR C. striatum (PFGE types I and II) infection was observed in five cases.

Aspergillosis is an opportunistic mycosis that generally affects the lungs. The fungus was cleared by the immune system of a healthy host. Extrapulmonary forms are very rare, and there are few reports of urinary aspergillosis. In this case report, we describe a 62-year-old woman with systemic lupus erythematosus (SLE) with complaints of fever and dysuria. The patient had recurrent episodes of urinary tract infection and several hospitalizations. A computed tomography revealed an amorphous mass in the left kidney and bladder. After partial resection of the material was referred for analysis, Aspergillus infection was suspected and confirmed by culture. Successful treatment with voriconazole was provided. Diagnosis of localized primary renal Aspergillus infection in a patient with SLE requires careful investigation due to its benign presentation and lack of associated systemic clinical features.

Objective: The stewardship strategy refers to a consistent practice to promoting responsible antimicrobial use. Optimizing the use of antibiotics is critical to mitigating adverse effects and combating bacterial resistance. The pillars of a stewardship program include: i) clinical pharmacist and infectologist with expertise; ii) educational measures for prescribers, nurses and pharmacists; iii) prophylaxis and therapeutic protocol; iv) monitoring of indicators. In this scenario of antimicrobial rational use, the older population are more susceptible to infection because immunocenescence and, therefore, greater use of antimicrobials is expected. Thus, the aim of the present study is to evaluate the prescription compliance of antimicrobial whose use is restricted in a hospitalized elderly population. Method: observational, controlled study in a Brazilian hospital, from January 2021 to January 2022. Based on the electrotonic antimicrobial form, the compliance of the prescriptions was evaluated. The definition used for elderly corresponded to individuals over 60 years old, according to the Brazilian Nation Principles for Older Persons, ordinance number 2528, of October 2006. Restricted drugs were considered: carbapenems, polymyxin, ceftazidime-avibactam, linezolid, tigecycline, ceftaroline, echinocandins and amphotericin. Results: A total of 1.688 requests for restricted use were received, of which 53% corresponded use in elderly group. Neutropenic fever was more common in young people and the inpatient unit was the sector with the highest percentage of antimicrobials. Furthermore, teicoplanin was the main drug that required intervention. Conclusion: Faced with the increase in bacterial resistance, the rational use of antimicrobials is extremely important, especially in older age group.

Introdução: Pessoas com AIDS estão vulneráveis a infecções oportunistas oculares resultando em sequelas visuais e apresentações atípicas desafiadoras. Descrição do caso: Homem, 33 anos, com HIV há 9 anos em abandono de terapia antirretroviral (TAR) há 6 anos, apresentou em março/2021 cefaleia e redução súbita da acuidade visual (AV) em ambos os olhos (AO). Relatou episódio de herpes-zoster dorsal três meses antes, tratado com aciclovir. Os exames realizados à internação evidenciaram na ressonância magnética do crânio aumento do diâmetro do nervo óptico direito, carga viral (CV-HIV) igual a 87.118 cópias/mL, CD4 igual a 28 células/mm3 e antígeno criptocócico (CrAg) positivo no soro. As sorologias revelaram IgG reagente para varicela-zoster (VZV), herpes simplex vírus e citomegalovírus (CMV). O exame do líquido cefalorraquiadiano (LCR) revelou proteinorraquia de 73,7 mg/dL, glicorraquia de 53 mg%, 14 células (98% mononucleares) e CrAg negativo. A fundoscopia foi normal em AO. Foi aventada a hipótese de neurite retrobulbar por criptococose, tratada com anfotericina B deoxicolato e fluconazol por 14 dias, com melhora parcial da AV e dos parâmetros liquóricos. Recebeu alta em tratamento de consolidação com fluconazol e introdução de TAR (esquema de primeira linha). Porém, reinternou em maio/2021 com queda do estado geral, febre, cefaleia e redução da AV. À ocasião, o LCR revelou celularidade de 5 (100% mononucleares), proteinorraquia de 109,3 mg/dL, CV-HIV sérica de 180 cópias/mL e CD4 de 100 células/mm3 (6,48%). Exame oftalmológico revelou midríase fixa no olho direito e fundoscopia sugestiva de retinite por CMV. O exame neurológico foi compatível com meningoencefalite herpética e após introdução do ganciclovir, ocorreu melhora parcial da midríase e AV, possivelmente por melhora da encefalite. No entanto, o PCR multiplex no LCR foi positivo para VZV, confirmando necrose retiniana aguda por VZV, com modificação da terapia para aciclovir. Em setembro/2021, mantém supressão viral em recuperação imunológica e déficit visual grave. Comentários: Múltiplas infecções oportunistas impactam a qualidade de vida dos pacientes. Neste caso, o paciente apresentou uma forma grave de retinite por VZV, possivelmente associada a um componente de reconstituição imunológica, precedida por neurite retrobulbar criptocócica. A investigação por técnicas moleculares associada ao exame oftalmológico podem antecipar o diagnóstico e evitar a progressão da perda visual.

The acute form of histoplasmosis usually occurs after the exposition of more than one individual to a common environmental source harboring Histoplasma capsulatum. Here, we present two cases of acute pulmonary histoplasmosis seen within two weeks at a reference center for infectious diseases at Rio de Janeiro, Brazil. The patients did not present a common epidemiologic history for histoplasmosis, however both presented COVID-19 before the onset of histoplasmosis symptoms. Due to the difficulties in the diagnosis of acute histoplasmosis, novel laboratory methods such as Western Blot and PCR were included in the investigation of these cases. Both patients presented negative cultures for H. capsulatum and negative urinary galactomannan. However, they presented H and M bands in the Western blot as well as a positive H. capsulatum DNA detection in sputum. These results were available approximately 36 h after sample collection, fastening the beginning of treatment of one patient. Both patients progressed well with itraconazole treatment. These cases suggest that COVID-19 may facilitate the development of acute pulmonary histoplasmosis and, therefore, clinicians must be aware of this differential diagnosis in patients from endemic areas with fever and coughing after recovery from COVID-19.

PURPOSE: To evaluate the minimum inhibitory concentration (MIC) of GTA against these microorganisms and alternative disinfectants for high-level disinfection (HLD). METHODS: Reference mycobacteria and clinical M. massiliense strains were included in this study. Active cultures were submitted to susceptibility qualitative tests with GTA dilutions (ranging from 1.5% to 8%), and commercial orthophthaldehyde (OPA) and peracetic acid (PA) - based solutions, during the period of exposure as recommended by National Agency of Sanitary Surveillance for HLD. RESULTS: All reference and M. massiliense non-BRA100 strains, recovered from sputum, were susceptible to any GTA concentration, OPA and PA solutions. M. massiliense BRA100 strains presented MIC of 8% GTA and were susceptible to OPA and PA. CONCLUSION: M. massiliense BRA100 strain is resistant to high GTA concentrations (up to 7%), which proves that this product is non-effective against specific rapidly growing mycobacteria and should be substituted by OPA or PA - based solutions for HLD.OBJETIVO: Avaliar a concentração mínima inibitória (CMI) de GTA frente a M. massiliense e a susceptibilidade a produtos alternativos para desinfecção de alto nível (DAN). MÉTODOS: Cepas de M. massiliense de origem clínica e de referência foram incluídas no estudo. As culturas ativadas foram submetidas a testes qualitativos com diluições de GTA (de 1,5% a 8%) e com soluções comerciais de ortoftaldeído (OPA) ou ácido peracético (PA), utilizando os tempos de exposição recomendados pela Agência Nacional de Vigilância Sanitária para DAN. RESULTADOS: Todas as cepas de referência e M. massiliense não-BRA100, obtida de escarro, foram susceptíveis às concentrações de GTA, e soluções de OPA e PA. As cepas de M. massiliense BRA100 apresentaram CMI de 8% para GTA e foram susceptíveis a OPA e PA. CONCLUSÃO: M. massiliense BRA100 é resistente a altas concentrações de GTA (até 7%), o que demonstra que esse composto não é eficaz, e deve ser substituído por OPA ou PA nos processos de DAN.