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Purpose of reviewto review recent advances in the epidemiology, diagnosis, and treatment of deep fungal infectionsRecent findingsMycetoma and chromoblastomycosis are the only deep fungal infections incorporated in the list of neglected tropical diseases. These infections start in the skin but progress to deep tissues if not recognized early. A wide array of fungal pathogens are the causative agents. Molecular methods allow for early and accurate identification of the pathogens, but are unfortunately not available in endemic areas. Treatment options are mostly based upon clinical experience rather than on well-designed clinical trialsSummaryDeep fungal infections of the skin and soft tissues are rare conditions of wide world distribution but mostly reported from tropical countries. Urgent need for affordable and easily accessible molecular methods and well-conducted studies to allow for accurate diagnosis and to provide evidence to guide proper therapy are urgently needed.

Se presenta el caso de una mujer de 19 años con 29 semanas de gestación, procedente de Llumpe (Ancash) con antecedentes de viajes a las localidades de Chanchamayo (Junín) y Rinconada (Ancash). Ingresó al Hospital de Chacas (Ancash) por presentar mal estado general, deshidratación, dificultad respiratoria, ictericia, sensación de alza térmica y dolor abdominal, tuvo reporte de: hemoparásitos 60% en frotis sanguíneo. Fue transferida al Hospital Ramos Guardia (Huaraz) donde presentó mayor dificultad respiratoria, coluria, hematuria, disminución del débito urinario y reporte de Plasmodium (+), luego fue transferida al Hospital Cayetano Heredia (Lima) donde ingresó a la Unidad de Cuidados Intensivos (UCI), con evolución a falla multiorgánica, óbito fetal y muerte materna. Se confirmó infección por Plasmodium vivax. Destacamos la importancia de mejorar nuestras capacidades de diagnóstico y manejo para brindar un tratamiento adecuado y oportuno. Here we describe the case of a 19-year-old woman, in her 29th week of gestation, who was from Llumpe (Ancash, Peru) and had a history of traveling to Chanchamayo (Junín, Peru) and Rinconada (Ancash, Peru). The patient presented at Chacas Hospital (Chacas, Ancash, Peru) with general malaise, dehydration, respiratory distress, jaundice, the sensation of thermal rise, and abdominal pain. Analysis of blood smears revealed 60% hemoparasites. She was transferred to Ramos Guardia Hospital (Huaraz, Peru) where she presented increasing respiratory distress, choluria, hematuria, and decreased urine output, moreover she was positive for Plasmodium. From there she was transferred to Cayetano Heredia Hospital (Lima, Peru), where she was admitted to the intensive care unit (ICU) with multiple organ failure, stillbirth, and leading to death. She underwent mechanical ventilation, was administered clindamycin, and was prescribed quinine, which she did not received due a lack by availability. The evolution of the illness was torpid, and she ultimately developed multiple organ failure and died. Plasmodium vivax infection was confirmed. Accordingly, we emphasize the importance of improving our diagnostic capabilities and management techniques to enable clinicians to provide adequate and timely treatment.

This is the case of a 19-year-old woman, with 29 weeks of pregnancy, from Llumpe (Ancash, Peru) with a history of traveling to the towns of Chanchamayo (Junín, Peru) and Rinconada (Ancash, Peru). She was admitted to the Chacas Hospital (Chacas, Ancash, Peru) with a general poor condition, dehydration, respiratory distress, jaundice, apparent elevation of body temperature, and abdominal pain. A microscopic examination of blood films revealed a 60% of hemoparasites. She was transferred to the Ramos Guardia Hospital (Huaraz, Peru) where presented more difficulty to breath, choluria, haematuria and decreased urine output, also a positive test for Malaria parasites (Plasmodium). Then, she was transferred to the Cayetano Heredia Hospital (Lima, Peru), admitted to the intensive care unit (ICU) where she suffered multiple organ failure and death. The product was stillborn. She had indication of mechanical ventilation, and antibiotic treatment with clindamycin and quinine which did not received by unavailability. The disease evolution was torpid. Plasmodium vivax infection was confirmed. We emphasize the importance of improving our diagnostic capabilities and management to provide adequate and timely treatment. Este proyecto fue financiado por el Instituto Nacional de Salud. Revisión por pares

Purpose of review: The present review focuses on recent epidemiological and diagnostic advances in cystoisosporiasis and cyclosporiasis. Recent findings: Continuous outbreaks of these parasites occur worldwide. Sporadic cases in the United States are travel acquired, but also domestically acquired. New molecular diagnostic Methods: allow for accurate early diagnosis in humans, and might potentially decrease the burden of disease by detecting these parasites in vehicles of transmission. Summary: Better understanding of the epidemiology of Cyclospora cayetanensis and to a less extent to Cystoisospora belli has been gained recently. However, several gaps still remain in knowledge on the transmission and on mechanisms of persistent infection in immunosuppressed patients and prevention. New molecular Methods: might help in filling these gaps and in controlling transmission.

Anthrax is a zoonosis produced by Bacillus anthracis, and as an human infection is endemic in several areas in the world, including Peru. More than 95% of the reported naturally acquired infections are cutaneous, and approximately 5% of them can progress to meningoencephalitis. In this study we review the clinical and epidemiological characteristics of the patients with diagnosis of cutaneous anthrax evaluated between 1969 and 2002 at the Hospital Nacional Cayetano Heredia (HNCH) and the Instituto de Medicina Tropical Alexander von Humboldt in Lima, Peru. Seventy one patients were included [49/71 (69%) of them men], with a mean age of 37 years. The diagnoses were classified as definitive (44%) or probable (56%). The most common occupation of the patients was agriculture (39%). The source of infection was found in 63 (88.7%) patients. All the patients had ulcerative lesions, with a central necrosis. Most of the patients (65%) had several lesions, mainly located in the upper limbs (80%). Four patients (5.6%) developed meningoencephalitis, and three of them eventually died. In conclusion, considering its clinical and epidemiological characteristics, cutaneous anthrax must be included in the differential diagnosis of skin ulcers. A patient with clinical suspicion of the disease should receive effective treatment soon, in order to avoid neurological complications which carry a high fatality rate. El ántrax es una zoonosis producida por el Bacillus anthracis y la infección humana es endémica en diversas partes del mundo, incluyendo el Perú. Más del 95% de las infecciones adquiridas naturalmente son cutáneas y aproximadamente 5% de ellas pueden evolucionar para meningoencefalitis. En este estudio revisamos las características clínicas y epidemiológicas de los pacientes con diagnóstico de ántrax cutáneo evaluados entre 1969 y 2002 en el Hospital Nacional Cayetano Heredia (HNCH) y en el Instituto de Medicina Tropical Alexander von Humboldt, en Lima, Perú. Se incluyeron 71 pacientes [49/71 (69%) del sexo masculino], con edad media de 37 años. Los diagnósticos fueron clasificados como definitivos (44%) o probables (56%). La ocupación más frecuente fue la agricultura (39%). La fuente de infección fue identificada en 63 (88.7%) pacientes. Todos presentaron lesiones ulcerativas con necrosis central. La mayoría de ellos (65%) tuvieron lesiones múltiples, principalmente localizadas en miembros superiores (80%). Cuatro pacientes (5.6%) desarrollaron meningoencefalitis y tres de ellos fallecieron. En conclusión, considerando sus particulares características clínicas y epidemiológicas, el ántrax cutáneo debe ser siempre incluido en el diagnóstico diferencial de las lesiones cutáneas ulcerativas. Los pacientes con sospecha clínica de la enfermedad deben recibir tratamiento precoz con el objetivo de evitar complicaciones neurológicas, las cuales presentan elevados índices de fatalidad.