Infectologia

Introduction: tetanus is a disease caused by a toxin produced by the bacterium Clostridium tetani. It is characterized clinically by generalized stiffness and muscle spasms capable of causing respiratory arrest and death. The high-risk population includes older adults, diabetics, injection drug users, and the unvaccinated. The diagnosis of tetanus is increasingly rare, with the implementation of compulsory vaccination programs it has been possible to reduce the incidence of this disease worldwide; however, it continues to have significant morbidity and mortality.
Objective: to describe the case of a male patient with generalized tetanus in order to reinforce the relevance of vaccination, prophylaxis, early diagnosis and timely treatment.
Clinic case: 18-year-old male patient admitted to the emergency department of a primary care center 10 days after wounding his lower right limb, which progressed to fever, trismus, hypertonia and generalized muscle contractions. His immunization schedule was unknown and he lacked tetanus prophylaxis; Therefore, based on the history and the clinical picture, a diagnosis of accidental generalized tetanus was made, treatment was instituted, and the patient was admitted to the Intensive Care Unit. The neurological manifestations were graves; however, he progressed satisfactorily until complete resolution of the condition and was subsequently discharged.
Conclusions: despite the fact that tetanus is a pathology that doctors do not usually see in their clinical practice, it is a serious infection that still represents an important diagnostic and therapeutic challenge. The disease can be completely prevented by vaccination and proper wound care.

RESUMEN
Introducción: el tétanos es una enfermedad causada por una toxina producida por la bacteria Clostridium tetani. Se caracteriza clínicamente por rigidez generalizada y espasmos musculares capaces de causar paro respiratorio y muerte. La población de alto riesgo incluye a los adultos mayores, los diabéticos, los usuarios de drogas inyectables y las personas no vacunadas. El diagnóstico de tétanos es cada vez más raro, con la implementación de programas de vacunación obligatoria se ha logrado disminuir la incidencia de esta enfermedad a nivel mundial; no obstante, sigue teniendo una morbimortalidad significativa.
Objetivo: describir el caso de un paciente masculino con tétanos generalizado con el fin de reforzar la relevancia de la vacunación, profilaxis, su diagnóstico precoz y tratamiento oportuno.
Caso clínico: paciente masculino de 18 años de edad que ingresa al servicio de urgencias remitido centro de atención primaria 10 días después de hacerse herida en miembro inferior derecho, que evolucionó hasta presentar fiebre, trismo, hipertonía y contracciones musculares generalizadas. Su esquema de inmunizaciones era desconocido y carecía de profilaxis antitetánica; por lo tanto, con base a los antecedentes y el cuadro clínico se hizo diagnóstico de tétanos generalizado accidental, se instauró tratamiento y se trasladó a la Unidad de Cuidados Intensivos. Las manifestaciones neurológicas fueron graves; sin embargo, evolucionó satisfactoriamente hasta la resolución completa del cuadro y fue dado de alta posteriormente.
Conclusión: a pesar de que el tétanos es una patología que los médicos no ven usualmente en su práctica clínica, es una infección grave que todavía representa un importante desafío diagnóstico y terapéutico. La enfermedad se puede prevenir completamente mediante la vacunación y el cuidado adecuado de las heridas.

O estudo tem como objetivo analisar pesquisas sobre as infecções hospitalares neonatais prevalentes em unidades de terapia intensiva. Trata-se de uma revisão integrativa da literatura realizada nas bases de dados Medline e ScienceDirect. Foram selecionados 20 artigos que atenderam aos critérios de inclusão da pesquisa: estudos primários, disponíveis na integra de forma eletrônica e publicados no período de 2011 a 2015. Os dados foram processados no software IRAMUTEC e analisados pela
classificação hierárquica descendente, análise de similitude e nuvem de palavras. Os resultados foram apresentados em 04 classes, a saber: 1-O Staphylococcus aureus resistente a meticilina em infecções na Unidade de Terapia Intensiva Neonatal - UTIN; 2- Vigilância
aos casos de infecção em UTIN; 3- Distribuição topográfica das infecções neonatais em UTI; 4- Fatores de risco para
desenvolvimento de infecções em UTIN e 5- Medidas de Prevenção e controle de infecções neonatais em UTI. A prevalência de
infecção em unidade de terapia intensiva é elevada e possui relação com fatores intrínsecos ao neonato, bem como ao ambiente hospitalar. Concluiu-se que há necessidade da adoção de uma política efetiva de prevenção e controle das infecções hospitalares para diminuir os índices de infecções neonatais em unidades de terapia intensiva. Descritores: Unidade de terapia intensiva. Infecção hospitalar. Fatores de risco. Neonatal.

La Enfermedad de Chagas es una condición crónica descuidada con elevada carga de morbilidad y mortalidad e impacto desde los puntos de vista psicológico, social y económico. Representa un importante problema de salud pública en Brasil, con diferentes escenarios regionales. Este documento traduce la sistematización de las evidencias que compone el Consenso Brasileño de Enfermedad de Chagas. El objetivo fue sistematizar estrategias de diagnóstico, tratamiento, prevención y control de la Enfermedad de Chagas en el país, de modo a reflexionar sobre las evidencias científicas disponibles. Su construcción se fundamentó en la articulación y contribución estratégica de expertos brasileños con conocimiento, experiencia y actualización sobre diferentes aspectos de la enfermedad. Representa el resultado de la estrecha colaboración entre la Sociedad Brasileña de Medicina Tropical y el Ministerio de Salud. Se espera, con este documento, fortalecer el desarrollo de acciones integradas para el enfrentamiento de la enfermedad en el país con enfoque en epidemiología, gestión, atención integral (incluyendo familias y comunidades), comunicación, información, educación e investigaciones.

Foot-and-mouth disease (FMD) is a highly contagious viral disease that severely impacts global food security and is one of the greatest constraints on international trade of animal products. Extensive viral population diversity and rapid, continuous mutation of circulating FMD viruses (FMDVs) pose significant obstacles to the control and ultimate eradication of this important transboundary pathogen. The current study investigated mechanisms contributing to within-host evolution of FMDV in a natural host species (cattle). Specifically, vaccinated and non-vaccinated cattle were infected with FMDV under controlled, experimental conditions and subsequently sampled for up to 35 days to monitor viral genomic changes as related to phases of disease and experimental cohorts. Consensus-level genomic changes across the entire FMDV coding region were characterized through three previously defined stages of infection: early, transitional, and persistent. The overall conclusion was that viral evolution occurred via a combination of two mechanisms: emergence of full-genomic minority haplotypes from within the inoculum super-swarm, and concurrent continuous point mutations. Phylogenetic analysis indicated that individuals were infected with multiple distinct haplogroups that were pre-existent within the ancestral inoculum used to infect all animals. Multiple shifts of dominant viral haplotype took place during the early and transitional phases of infection, whereas few shifts occurred during persistent infection. Overall, this work suggests that the establishment of the carrier state is not associated with specific viral genomic characteristics. These insights into FMDV population dynamics have important implications for virus sampling methodology and molecular epidemiology.

La endocarditis infecciosa es una enfermedad que afecta a múltiples sistemas y resulta de una infección, generalmente bacteriana, de la superficie endocárdica del corazón, siendo una causa importante de morbilidad y mortalidad en pacientes que reciben hemodiálisis por enfermedad renal crónica (ERC) establecida. En el presente artículo se expone una revisión bibliográfica a propósito del caso de un paciente masculino de 28 años de edad con endocarditis asociada a ERC en tratamiento sustitutivo renal modalidad hemodiálisis y bacteriemia por angiacceso, ya que el riesgo es significativamente más común que en la población general debido al uso de vías intravasculares, siendo una infección en aumento en estos pacientes, generando ingresos prolongados y un mal pronóstico con hasta 37% de mortalidad durante la hospitalización y 50% al año. Debido a las estadísticas en nuestro país acerca de la mortalidad en la ERC que posiciona a las enfermedades cardiovasculares en primer lugar y en segundo a las infecciosas, es de suma importancia reconocer a la endocarditis infecciosa como un factor que contribuye a la mortalidad, ya que en muchas ocasiones existe un subdiagnóstico debido a la gran variedad de presentaciones clínicas no reconocidas y a que la mayoría de estos pacientes se diagnostican cuando se presentan cuadros severos y posterior a la exclusión de otras entidades, con un incremento en la mor-talidad de los pacientes. En todos los pacientes con ERC en hemodiálisis con respuesta inflamatoria se debe realizar escrutinio y aplicar los criterios diagnósticos ya establecidos para endocarditis.

Infective endocarditis is a disease that affects multiple systems and results from an infection, usually bacterial, of the endocardial surface of the heart, being an important cause of morbidity and mortality in patients receiving hemodialysis for established chronic kidney disease (CKD). This article presents a bibliographic review on the case of a 28-year-old male patient with infective endocarditis secondary to CKD undergoing renal replacement therapy (hemodialysis modality), since the risk is significantly more common than in the general population due to the use of intravas-cular routes, with an increasing infection in these patients, generating prolonged admissions and a poor prognosis with up to 37% mortality during hospitalization and 50% per year.
Due to the statistics in our country about mortality in CKD that place cardio-vascular diseases in first place and infectious diseases second, it is extremely impor-tant to recognize infective endocarditis as a factor that contributes to mortality, since in many times, there is an underdiagnosis due to the great variety of unrecognized clinical presentations, since most of these patients are diagnosed when they present severe conditions and after the exclusion of other entities, with an increase in the mortality of the patients.
In all CKD patients on hemodialysis who present evidence of infection, fever with no apparent source, or embolic phenomena, infective endocarditis should be considered as an initial diagnostic suspicion.

Spinal epidural abscess (SEA) is a rare infectious disorder that often has delayed diagnosis and is associated with significant morbidity and mortality rates. We present a case of an AIDS patient with a SEA due to Mycobacterium tuberculosis. This type of SEA in AIDS patients is characterized by localized spinal pain and prolonged fever. Magnetic resonance imaging is the method of choice in the diagnostic process. Early diagnosis, followed by specific therapy (surgical decompression combined with antituberculous drugs), is necessary to improve the prognosis of these kinds of patients.

Prion protein (PrP) of mammals and avians has several putative Cu-binding sites. The generation of superoxide anion is catalyzed by Cu-binding motifs in mammal PrPs in the presence of certain co-factors such as H2O2 and phenolics or monoamines such as catecholamine-type neurotransmitters and related compounds [1]. Our previous study concerning the action of prion protein has revealed that the copper-binding regions in prion protein (e.g. –VNITKQHTVTTTT-) interacts with tyramine or free tyrosine in the presence of H2O2, fi nally leading to robust generation of superoxide[2]. Moreover, tyrosine-containing peptides (including tyrosine-rich sequence within prion protein) could be a target of the reaction. We found that tyrosine-residues on peptide sequences contribute as a substrate for this peroxidative ROS generating reaction [3]. In this study, we synthesized six peptides corresponding to Cu-binding region (hexa-repeat) of chicken PrP and examined its catalytic activity for the generation of superoxide. Each peptide contains both histidine residue anchoring copper ion and tyrosine residue behaving as a substrate (Fig. 1). The activity for superoxide generation was assessed with the superoxidespecific chemiluminescence of Cypridina luciferin analog. As a result, the generation of superoxide was observed in the presence of hexapeptide, copper and H2O2 without addition of any phenolic substrate since tyrosine-residue on the hexapeptide possibly behaves as a substrate for the reaction. We conclude that requirement of tyrosine residue on the peptides and certain positions of histidine binding copper are the key factors of the catalytic reaction of the PrP-mediated generation of superoxide.

Objetivo: Análise do conhecimento de idosos acerca da síndrome e do vírus da imunodeficiência humana.
Métodos: Estudo descritivo, transversal e quantitativo envolvendo 457 idosos da Unidade de Atenção ao Idoso de Uberaba, Minas
Gerais, durante 3 meses. Foram aplicados os instrumentos Mini Exame do Estado Mental e o questionário sobre o vírus da imunodeficiência humana para terceira idade e, para a análise, foram usadas medidas de frequência.
Resultados: A maioria dos participantes eram mulheres (74%), entre 60 a 69 anos (51%). O maior índice de acertos obteve a transmissão por agulhas 96,2% e o menor (45,3%), a transmissão pela picada de mosquito e se a pessoa com o vírus da imunodeficiência
humana sempre apresenta sintomas (49,6%). 88,2% deles relataram nunca usar camisinha.
Conclusões: O nível geral de conhecimento pode ser considerado bom, respondendo ao nosso objetivo. No entanto, foram identificadas
lacunas decorrentes da falta de campanhas voltadas exclusivamente para tal público, bem como na conscientização de profissionais.

Background: Malaria in Cameroon was previously known to be caused solely by Plasmodium falciparum but today, evidence points to other Plasmodium species including P. vivax, P. ovale and P. malariae. The purpose of this study was to identify the Plasmodium species in clinical samples from children residing in five epidemiological strata of malaria in Cameroon, so as to advise control policies.
Methods: One thousand six hundred nine febrile children (≤15 years) were recruited from five epidemiological strata of malaria including the Sudano-sahelian (SS) strata, the High inland plateau (HIP) strata, the South Cameroonian Equatorial forest (SCEF) strata, the High western plateau (HWP) strata and the Coastal (C) strata. Malaria parasites were detected by Giemsa microscopy (GM) while a multiplex polymerase chain reaction (PCR) was used to identify the Plasmodium species. Statistical analysis performed included the Pearson chi-square test, and statistical significance was set at p < 0.05.
Results: The PCR-adjusted prevalence of malaria was 17.6%. The detection rate of PCR was higher than GM (p = 0.05). However, GM demonstrated a high sensitivity (85.5%) and specificity (100%) and, overall, a perfectly correlated agreement with PCR (97.5%). The prevalence of malaria was significantly higher in children between 60 and 119 months (p < 0.001) and in Limbe (in the Coastal strata) (p < 0.001). Contrariwise, the prevalence of malaria was not associated with gender (p = 0.239). P. falciparum was identified in all (100%) the cases of malaria; P. ovale, P. vivax, P. malariae and P. knowlesi were all absent. No case of mixed infection was identified.
Conclusions: P. falciparum was the only species causing clinical malaria in the target population, which is contrary to studies that have reported P. vivax, P. malariae and P. ovale as causing clinical malaria in Cameroon.

Primary gastric non-Hodgkin lymphoma is a severe complication during the clinical course of human immunodeficiency virus infection. Clinical presentation includes symptoms associated with the upper digestive tract and "B" symptoms (fever, night sweats and weight loss). Endoscopic findings can reveal polypoid, ulcero-infiltrative or ulcer lesions. Multiple biopsy smears are necessary to determine histopathological subtypes. Diffuse large B cell lymphoma (DLBCL) is the most common histopathological subtype in HIV/AIDS patients followed by Burkitt's lymphoma and plasmablastic lymphoma. Chemotherapy plus highly active antiretroviral therapy is the best treatment to achieve a complete remission with prolonged survival in this kind of patients. Here we present an HIV seropositive patient who developed a primary gastric DLBCL as second AIDS-defining neoplasm during HAART therapy and after three years of successfully controlling HIV-viral load. Patient presented with a past history of anal squamous cell carcinoma several years before and gastro esophageal reflux disease treated for a long time with omeprazole. He presented with epigastric pain, nausea and dyspepsia. Upper gastrointestinal endoscopy showed erosive gastritis and a large gastric ulcer at the minor gastric curvature. Microscopy examination and immunohistochemistry of the biopsy smears of the large ulcer biopsy confirm the diagnosis of primary gastric DLBCL. He was treated with HAART plus chemotherapy with a complete remission for a time of three years.

Chagas disease reactivation in HIV-positive people is an opportunistic infection with 79 to 100% mortality. It commonly involves the central nervous system (CNS). Early treatment with trypanocidal drugs such as benznidazole (BNZ) is crucial for this severe manifestation of Trypanosoma cruzi infection. However, limited BNZ clinical pharmacology data are available, especially its concentration in the CNS. We report a series of HIV-positive patients undergoing treatment for T. cruzi meningoencephalitis, their clinical response, and cerebrospinal fluid (CSF) and plasma BNZ concentrations. Measurements were carried out using leftover samples originally obtained for routine medical care. A high-performance liquid chromatography/tandem mass spectrometry bioanalytical method designed for BNZ plasma measurements
was adapted and validated for CSF samples. Six patients were enrolled in this study from 2015 to 2019. A total of 6 CSF and 19 plasma samples were obtained. Only three of the CSF samples had detectable BNZ levels, all under 1mg/ml. Fifteen plasma samples had detectable BNZ, and 13 were above 2mg/ml, which is the putative trypanocidal level. We observed BNZ concentrations in human CSF and plasma.
CSF BNZ concentrations were low or not measurable in all patients, suggesting that the usual BNZ doses may be suboptimal in HIV-positive patients with T. cruzi meningoencephalitis. While drug-drug and drug-disease interactions may be in part responsible, the factors leading to low CSF BNZ levels remain to be studied in detail. These findings highlight the potential of therapeutic drug monitoring in BNZ treatment and suggest that the use of higher doses may be useful for Chagas disease CNS reactivations.

A hanseníase é uma doença infectocontagiosa com
evolução lenta e de natureza crônica, causando impacto no cotidiano dos sujeitos, como sofrimento,
abandono, deformidades físicas e problemas psicossociais. Objetivos: Descrever o perfil clínico e socioeconômico, avaliar a qualidade de vida (QV), ocorrência
de transtornos depressivos e o grau de incapacidade
física de pessoas com hanseníase e suas correlações.
Métodos: Estudo transversal, quantitativo, descritivo
e analítico, desenvolvido no município de Uberaba
(MG), em um centro de saúde especializado. Após o
consentimento dos participantes foram realizadas entrevistas com aplicação dos questionários: Clínico e Socioeconômico; Inventário de depressão de Beck- BDI
para avaliação dos graus de depressão; Questionário
WHOQOL-bref para avaliação da QV. Posteriormente,
o Formulário de Classificação de Incapacidades Físicas
(IFH) foi preenchido por meio da revisão de prontuários. O estudo foi aprovado pelo comitê de ética local
nº 2173/2014. Análises estatísticas descritivas foram
realizadas. Resultados: 32 pacientes participaram do
estudo, destes 59,4% eram do sexo masculino; manchas na pele ocorreram em 43,8% da amostra. Em relação ao IFH, 37,5% eram de grau I; a QV obteve menor escore no domínio físico do WHOQOL-bref (11,54
±2,22). O BDI evidenciou que 68,7 % dos pacientes não apresentavam sintomas depressivos. As correlações
entre QV e IFH foram negativas e significantes (p<0,01)
nos domínios físico, psicológico e relações sociais.
Conclusão: Os resultados possibilitaram conhecer melhor a população e sua realidade. A hanseníase atinge
homens e mulheres, a QV e o indicativo de depressão
têm correlação com a idade mais avançada, com o
maior grau de incapacidade, com a menor renda familar, com a escolaridade mais baixa e com a capacidade
produtiva dos indivíduos. A avaliação dos pacientes
deve ser feita de maneira rotineira e humanizada, para
que ocorra o diagnóstico precoce com a busca ativa de
casos, recursos que devem ser priorizados pelas equipes multidisciplinares de sáude.

Mucormycosis is an opportunistic fungal infection that is associated with states of immunosuppression, among which uncontrolled diabetes mellitus (ketoacidosis) and the use of corticosteroids stand out. Both conditions are interwoven between the comorbidities and the treatments most used in patients with COVID-19. That is why its presence must be taken into account as a complication to be ruled out, and highlights the need to incorporate the Diabetologist into the Multidisciplinary Team for COVID management.

Introduction: tetanus is a disease caused by a toxin produced by the bacterium Clostridium tetani. It is characterized clinically by generalized stiffness and muscle spasms capable of causing respiratory arrest and death. The high-risk population includes older adults, diabetics, injection drug users, and the unvaccinated. The diagnosis of tetanus is increasingly rare, with the implementation of compulsory vaccination programs it has been possible to reduce the incidence of this disease worldwide; however, it continues to have significant morbidity and mortality. Objective: to describe the case of a male patient with generalized tetanus in order to reinforce the relevance of vaccination, prophylaxis, early diagnosis and timely treatment. Clinic case: 18-year-old male patient admitted to the emergency department of a primary care center 10 days after wounding his lower right limb, which progressed to fever, trismus, hypertonia and generalized muscle contractions. His immunization sch...

Central nervous system involvement due to herpesvirus reactivation in AIDS patients. Herpesviruses have a markedly tropism
to the peripheral and central nervous system (CNS). The reactivation of latent infections due to Herpesviridae is associated with a serious compromise of the nervous system in HIV/AIDS patients. We retrospectively analyzed the epidemiological, clinical, microbiological, immunological, the outcome and the survival of 56 patients
with AIDS and nervous system infections due to Herpesvirus. CNS involvement was confirmed by the lumbar puncture and the cerebrospinal fluid (CSF) examination by the polymerase chain reaction (PCR) to the detection of Herpesvirus DNA. Cytomegalovirus
(HHV-5) was the most frequent pathogen isolated in CSF. The time
until reactivation of Herpesvirus infections was significative longer in patients treated with highly active antiretroviral therapy (HAART). There was no statistically significant difference in outcomes between the different therapeutics schemes, but patients treated with foscarnet as single or combined therapy showed a best outcome despite no statistically significant difference was found. Global survival was not significantly different between patients with different herpesvirus reactivation. Early diagnosis followed by specific antiherpetic
therapy and the immune reconstitution associated with HAART can improve the prognosis of these kind of patients.

Visceral leishmaniasis is a tropical parasitic disease caused by the species of the genus Leishmania infantum. The clinical picture includes fever, splenomegaly, leucopenia, anaemia and hypergammaglobulinaemia. There may also be a drop in plasma fibrinogen levels or an increase in plasma fibrinolytic activity. Furthermore, visceral leishmaniasis may be the trigger for secondary haemophagocytic lymphohistiocytosis. On the other hand, disseminated intravascular coagulation may also result. The International Society of Thrombosis and Hemostasis has recommended the use of a scoring system for disseminated intravascular coagulation. An association between visceral leishmaniasis and consumption coagulopathy is not frequent. Our systematic literature review from 1967 to 2019 pointed to the report of only 16 cases. Our case demonstrates that it is necessary to be aware of the existence of this association.

Objectives: Trypanosoma cruzi reactivation in HIV patients is considered an opportunistic infection, usually with a fatal outcome. The aim of this study was to describe the epidemiological and clinical features of T. cruzi infection in HIV patients and to compare these findings between patients with and without Chagas disease reactivation. Methods: The medical records of T. cruzi-HIV co-infected patients treated at the Muñiz Infectious Diseases Hospital from January 2005 to December 2014 were reviewed retrospectively. Epidemiological and clinical features were assessed and compared between patients with and without Chagas disease reactivation. Results: The medical records of 80 T. cruzi-HIV co-infected patients were reviewed. The most likely route of T. cruzi infection was vector-borne (32/80 patients), followed by intravenous drug use (12/80). Nine of 80 patients had reactivation. Patients without reactivation had a significantly higher CD4 T-cell count at diagnosis of T. cruzi infection (144 cells/ml vs. 30 cells/ml, p = 0.026). Chagas disease serology was negative in two of nine patients with reactivation. Conclusions: Serological assays for T. cruzi infection may be negative in severely immunocompromised patients. Direct parasitological techniques should be performed in the diagnosis of patients for whom there is a suspicion of T. cruzi reactivation. HIV patients with a lower CD4 count are at higher risk of reactivation.

Paciente asmática quien ingresa por cuadro respiratorio compatible con proceso bronconeumónico, asociado a obstrucción intestinal complicada con sangrado gastrointestinal masivo. Se encontró en la biopsia duodenal larva de S. Stercoralis se maneja con Ivermectina con lenta mejoría. Lo anterior pone en evidencia un caso de estrogiloidiasis diseminada en un paciente aparentemente inmunocompetente.