RESUMEN

Aim: We aimed to verify the frequency of CD8+ T cell subsets in patients with acute form and chronic form of paracoccidioidomycosis. Material & Methods: Mononuclear cells from paracoccidioidomycosis patients and healthy donors were isolated and phenotyped by flow cytometry. Dendritic cells were pulsed with Paracoccidioides brasiliensis yeast and co-cultures with lymphocytes. Cytokine production was measured by ELISA. Results: Acute form patients present a higher frequency of Tc1 and Tc10 cells, while chronic form patients have more Tc1 and Tc21 cells, compared with healthy controls. In vitro assays showed that P. brasiliensis induced polarization to the Tc17/Tc22 subsets. Conclusion: Our results suggest that CD8+ T cells can respond in a similar way to P. brasiliensis infection, regardless of the clinical presentation of the disease.

Asunto(s)

Linfocitos T CD8-positivos/inmunología , Paracoccidioidomicosis , Humanos , Paracoccidioides , Paracoccidioidomicosis/inmunología , Subgrupos de Linfocitos T/inmunología

RESUMEN

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak is an unprecedented global public health challenge, leading to thousands of deaths every day worldwide. Despite the epidemiological importance, clinical patterns of children with COVID-19 remain unclear. The aim of this study was to describe the clinical, laboratorial, and radiological characteristics of children with COVID-19. METHODS: The Medline database was searched between December 1st 2019 and April 6th 2020. No language restrictions were applied. Inclusion criteria were (a) studied patients younger than 18 years old; (b) presented original data from cases of COVID-19 confirmed by reverse-transcription polymerase chain reaction; and (c) contained descriptions of clinical manifestations, laboratory tests, or radiological examinations. RESULTS: A total of 38 studies (1124 cases) were included. From all the cases, 1117 had their severity classified: 14.2% were asymptomatic, 36.3% were mild, 46.0% were moderate, 2.1% were severe, and 1.2% were critical. The most prevalent symptom was fever (47.5%), followed by cough (41.5%), nasal symptoms (11.2%), diarrhea (8.1%), and nausea/vomiting (7.1%). One hundred forty-five (36.9%) children were diagnosed with pneumonia and 43 (10.9%) upper airway infections were reported. Reduced lymphocyte count was reported in 12.9% of cases. Abnormalities in computed tomography were reported in 63.0% of cases. The most prevalent abnormalities reported were ground-glass opacities, patchy shadows, and consolidations. Only one death was reported. CONCLUSIONS: Clinical manifestations of children with COVID-19 differ widely from adult cases. Fever and respiratory symptoms should not be considered a hallmark of COVID-19 in children.

Asunto(s)

Infecciones por Coronavirus/diagnóstico , Tos/etiología , Fiebre/etiología , Neumonía Viral/diagnóstico , Adolescente , Betacoronavirus , COVID-19 , Prueba de COVID-19 , Niño , Preescolar , Técnicas de Laboratorio Clínico , Infecciones por Coronavirus/diagnóstico por imagen , Infecciones por Coronavirus/epidemiología , Eritema/etiología , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Pandemias , Neumonía Viral/diagnóstico por imagen , Neumonía Viral/epidemiología , Pronóstico , Infecciones del Sistema Respiratorio/etiología , SARS-CoV-2 , Taquicardia/etiología , Taquipnea/etiología , Tomografía Computarizada por Rayos X , Vómitos/etiología

RESUMEN

OBJECTIVES: Inferior vena cava ultrasound has been used as a predictor of fluid responsiveness in children. Two ultrasonographic modes can be used to measure the respiratory variation of inferior vena cava diameter: M-mode and B-mode. Inconsistencies in measurements between the modes can result in inaccuracies in commonly used indices that assess fluid responsiveness. Our primary objective was to determine whether there are differences in the ultrasound-based measurements between these two modes of evaluation, which would impact respiratory variation of inferior vena cava diameter calculation. Our secondary objective was to assess inferior vena cava displacements during the respiratory cycle as a possible mechanism for measurement differences between the modes. DESIGN: Prospective observational study. SETTING: PICU of a tertiary care teaching hospital. PATIENTS: Seventy-three children under controlled ventilation (median age of 16 mo and weight of 10 kg). INTERVENTIONS: The inferior vena cava diameters were measured using a longitudinal view using B- and M-mode ultrasound. Two respiratory variation of inferior vena cava diameter indices were evaluated: distensibility and respiratory variation. Maximum craniocaudal and mediolateral displacements of the inferior vena cava were measured using the B-mode ultrasound. MEASUREMENTS AND MAIN RESULTS: Maximum diameters of the inferior vena cava were similar between the B- and M-modes (7.90 vs 7.90 mm, respectively; p = 0.326), but minimum diameters were smaller when measured by M-mode (6.36 vs 5.00 mm; p = 0.003). When calculated by data obtained from M-mode, respiratory variation of inferior vena cava diameter indices presented significantly higher values compared to B-mode measures (p ≤ 0.001, for both). Median inferior vena cava displacements were 5.00 mm (interquartile range, 3.68-6.26 mm) in the craniocaudal and 0.80 mm (interquartile range, 0.12-1.23 mm) in the mediolateral directions. CONCLUSIONS: There is a significant difference between measurements of the minimum inferior vena cava diameter observed in M- and B-mode ultrasound during the respiratory cycle in children under controlled ventilation. This results in imprecise respiratory variation of inferior vena cava diameter indices. Displacements of the inferior vena cava during the respiratory cycle may influence the reliability of ultrasonographic measurements, particularly in M-mode.

Asunto(s)

Ecocardiografía , Vena Cava Inferior , Niño , Humanos , Estudios Prospectivos , Reproducibilidad de los Resultados , Ultrasonografía , Vena Cava Inferior/diagnóstico por imagen

RESUMEN

OBJECTIVE: To compare the expression of stem cell-related genes in the endometrium (END), superficial endometriosis (SE), and deep infiltrating endometriosis (DIE). STUDY DESIGN: We performed a prospective pilot study of six women suffering from SE and DIE who gave consent for laparoscopy surgery, endometrial biopsies, and participation in this study. Quantitative RT-PCR analysis of 84 stem cell-related genes was performed in 18 biopsy samples. RESULTS: A total of 40 of 84 genes were expressed in SE and DIE, but were different from END as follows. Seven genes were over-expressed in SE and 33 genes were under-expressed in DIE compared with END. Two genes were only over-expressed in SE and three genes were only over-expressed in DIE. Six under-expressed genes were exclusively located in SE and one was only located in DIE. The remaining 31 genes were not different among the groups. There was no significant difference in gene expression between SE and DIE samples. CONCLUSION: Tissue of DIE and SE appears to have similar stem cell-related genes. Nevertheless, there are differences in gene expression between SE and DIE.

Asunto(s)

Endometriosis/genética , Endometrio/metabolismo , ARN Mensajero/metabolismo , Células Madre/metabolismo , Adulto , Biopsia , Endometriosis/metabolismo , Endometriosis/patología , Femenino , Expresión Génica , Humanos , Laparoscopía , Proyectos Piloto , Estudios Prospectivos , Adulto Joven

Asunto(s)

Endometriosis/cirugía , Miometrio/cirugía , Complicaciones Posoperatorias/etiología , Enfermedades Uterinas/cirugía , Rotura Uterina/etiología , Adulto , Endometriosis/patología , Femenino , Fertilización In Vitro/métodos , Humanos , Inicio del Trabajo de Parto , Miometrio/patología , Embarazo , Enfermedades Uterinas/patología

RESUMEN

This report describes the clinical features and outcome of 61 pediatric hospitalized patients with influenza-like infection. Fever, cough and respiratory distress were the most common symptoms of the infection. Fifteen patients presented positive RT-PCR results for influenza A (H1N1). The group with positive results was compared with the negative one. The main significant difference was antibiotic usage and the need of mechanical ventilation in the patients with H1N1-virus infection. Among the 11 patients who required intensive care due to respiratory failure, 3 from the positive group died and none from the negative group.

Asunto(s)

Subtipo H1N1 del Virus de la Influenza A/aislamiento & purificación , Gripe Humana , Antibacterianos/uso terapéutico , Antivirales/uso terapéutico , Niño , Preescolar , Cuidados Críticos , Femenino , Humanos , Lactante , Gripe Humana/diagnóstico , Gripe Humana/mortalidad , Gripe Humana/terapia , Tiempo de Internación , Masculino , Oseltamivir/uso terapéutico , Respiración Artificial , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/mortalidad , Infecciones del Sistema Respiratorio/terapia , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Resultado del Tratamiento

RESUMEN

PURPOSE: endometriosis and its associated infertility have been the object of continuous research for over a century. To understand the molecular mechanisms underlying the disease, it has become necessary to determine the aspects of its etiology that are not explained by the retrograde menstruation theory. This could in turn elucidate how various clinical and surgical treatments might affect the evolution and remission of the disease. METHODS: this review is focused on the most recent clinical and laboratory findings regarding the association of HOXA10 with endometriosis and infertility. RESULT: the homebox (Hox/HOX) proteins are highly conserved transcription factors that determine segmental body identities in multiple species, including humans. Hoxa10/HOXA10 is directly involved in the embryogenesis of the uterus and embryo implantation via regulation of downstream genes. Cyclical endometrial expression of Hoxa10/HOXA10, with a peak of expression occurring during the window of implantation, is observed in the adult in response to estrogen and progesterone. Women with endometriosis do not demonstrate the expected mid-luteal rise of HOXA10 expression, which might partially explain the infertility observed in many of these patients. Recent studies also demonstrated HOXA10 expression in endometriotic foci outside the Müllerian tract. CONCLUSIONS: multiple lines of evidence suggest that the actions of the homeobox A10 (Hoxa10/HOXA10) gene could account for some aspects of endometriosis.

Asunto(s)

Endometriosis/etiología , Endometriosis/genética , Proteínas de Homeodominio/efectos adversos , Infertilidad Femenina/etiología , Infertilidad Femenina/genética , Adulto , Implantación del Embrión , Endometrio/metabolismo , Estrógenos/metabolismo , Femenino , Regulación del Desarrollo de la Expresión Génica , Genes Homeobox , Proteínas Homeobox A10 , Proteínas de Homeodominio/genética , Humanos , Embarazo , Progesterona/metabolismo , Factores de Transcripción/genética

RESUMEN

Paradoxical reactions have never been described in patients with paracoccidioidomycosis or other deep endemic mycoses out of the context of human immunodeficiency virus infection. We describe 2 patients with an acute form of paracoccidioidomycosis who presented with a worsening of their clinical manifestations while on appropriate antifungal treatment. These manifestations were severe and required adjunct corticosteroid therapy.

Asunto(s)

Corticoesteroides/uso terapéutico , Antifúngicos/efectos adversos , Antifúngicos/uso terapéutico , Factores Inmunológicos/uso terapéutico , Granulomatosis Linfomatoide/inducido químicamente , Paracoccidioidomicosis/complicaciones , Paracoccidioidomicosis/tratamiento farmacológico , Adolescente , Niño , Histocitoquímica , Humanos , Inmunohistoquímica , Ganglios Linfáticos/patología , Granulomatosis Linfomatoide/patología , Masculino , Microscopía , Cuello/patología , Piel/patología

RESUMEN

STUDY OBJECTIVE: We sought to compare the outcomes of in vitro fertilization (IVF) treatments in women with infertility-associated deep infiltrative endometriosis (DIE) who underwent extensive laparoscopic excision of endometriosis before IVF with those who underwent IVF only. DESIGN: Prospective cohort study. SETTING: Infertility clinic and private hospital in São Paulo, Brazil. PATIENTS: A total of 179 infertile patients younger than 38 years had symptoms and/or signs of endometriosis and sonographic images suggestive of DIE. INTERVENTIONS: After thorough counseling, 179 women were invited to participate in a prospective cohort study with 2 treatment options: IVF without undergoing laparoscopic surgery (group A, n = 105) and extensive laparoscopic excision of DIE before IVF (group B, n = 64). Ten women were lost to follow-up. The IVF outcomes were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS: In group B, patients had 5 +/- 2 (mean +/- SD) DIE lesions excised during laparoscopy. Patient characteristics in groups A and B, respectively, were: age (32 +/- 3 vs 32 +/- 3 years, p = .94), infertility duration (29 +/- 20 vs 27 +/- 17 months, p = .45), day-3 serum follicle-stimulating hormone levels (5.6 +/- 2.5 vs 5.9 +/- 2.5 IU/L, p = .50), and previous IVF attempts (1 +/- 1 vs 2 +/- 1, p = .01). The IVF outcomes differed between groups A and B, respectively, with regard to total dose of recombinant follicle-stimulating hormone required to accomplish ovulation induction (2380 +/- 911 vs 2542 +/- 1012 IU, p = .01), number of oocytes retrieved (10 +/- 5 vs 9 +/- 5, p = .04), and pregnancy rates (24% vs 41%, p = .004), but not number of embryos transferred (3 +/- 1 vs 3 +/- 1, p = 1). The odds ratio of achieving a pregnancy were 2.45 times greater in group B than in group A. CONCLUSION: Extensive laparoscopic excision of DIE significantly improved IVF pregnancy rates of women with infertility-associated DIE.

Asunto(s)

Endometriosis/cirugía , Fertilización In Vitro , Infertilidad Femenina/terapia , Laparoscopía/métodos , Adulto , Estudios de Casos y Controles , Endometriosis/complicaciones , Endometriosis/patología , Femenino , Humanos , Infertilidad Femenina/complicaciones , Proyectos Piloto , Embarazo , Índice de Embarazo , Adulto Joven

RESUMEN

The objective of this study was to assess the feasibility and safety of laparoscopic rectosigmoid anterior wall discoid resection for endometriosis using the circular stapler. A retrospective analysis was conducted of nine consecutive patients undergoing laparoscopic radical excision of pelvic endometriosis, including bowel anterior wall discoid excision, at the Fertility and Pelvic Surgery Clinic and private hospitals in São Paulo, Brazil. The selected intervention was a radical laparoscopic endometriosis resection, including rectosigmoid anterior wall excision with the circular stapler. For certain types of bowel endometriosis, the anterior wall discoid stapler excision proved a suitable option that diminishes the chances of serious complications such as bowel fistula or anastomosis dehiscence.

Asunto(s)

Colon Sigmoide/cirugía , Endometriosis/cirugía , Procedimientos Quirúrgicos Ginecológicos/métodos , Laparoscopios , Engrapadoras Quirúrgicas , Adulto , Endometriosis/patología , Diseño de Equipo , Análisis de Falla de Equipo , Estudios de Factibilidad , Femenino , Humanos , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

OBJETIVO: Descrever o caso de uma criança com endocardite infecciosa causada por Haemophilus aphrophilus. DESCRIÇÃO: Menino com febre e calafrios há 20 dias. À internação, apresentava-se febril, descorado e sem sinais de instabilidade hemodinâmica; à ausculta cardíaca, tinha sopro holosistólico em foco mitral. Os exames laboratoriais identificaram anemia (hemoglobina = 9,14 g/dL), leucócitos totais de 11.920 mm³, plaquetas de 250.000 mm³, velocidade de sedimentação das hemácias e proteína C reativa elevadas. O ecocardiograma revelou imagem em válvula mitral, sugestiva de vegetação. Com a hipótese de endocardite, foi iniciada antibioticoterapia com penicilina cristalina (200.000 UI/kg/dia) associada à gentamicina (4 mg/kg/dia). No terceiro dia de tratamento, foi identificado Haemophilus aphrophilus em hemoculturas, sendo então trocado o esquema antibiótico para ceftriaxona (100 mg/kg/dia). No 20º dia de internação, encontrava-se pálido, mas sem febre e sem outras queixas. Os exames mostravam hemoglobina = 7,0 g/dL, leucócitos = 2.190 mm³, plaquetas = 98.000 mm³, razão normatizada internacional = 1,95 e R = 1,89. Foi feita hipótese de reação adversa ao ceftriaxona, que foi substituído por ciprofloxacina, 20 mg/kg/dia, até completar 6 semanas de tratamento. Após 72 horas da troca, houve normalização dos exames. Durante seguimento ambulatorial, apresentou insuficiência mitral grave, sendo submetido a troca de válvula por prótese metálica 9 meses após quadro agudo. Há 3 anos encontra-se bem, em acompanhamento ambulatorial. COMENTÁRIOS: É rara a identificação de agentes do grupo HACEK (Haemophilus ssp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens e Kingella kingae) em crianças com endocardite infecciosa. O caso apresentado, sem fatores de risco relacionados a esses agentes, reafirma a necessidade de tentar sempre identificar o agente etiológico das endocardites para adequação do tratamento.

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OBJECTIVE: To report the case of a child with infective endocarditis caused by Haemophilus aphrophilus. DESCRIPTION: Boy with 20 days of fever and chills. On admission, he was febrile, pale and with no signs of hemodynamic instability; on cardiac auscultation, a mitral-related holosystolic murmur was observed. Laboratory examination identified anemia (hemoglobin = 9.14 g/dL), total leukocytes of 11,920 mm³, platelets of 250,000 mm³, elevated sedimentation velocity of red cells and elevated C-reactive protein. The echocardiogram revealed image on mitral valve, resembling vegetation. Considering endocarditis, antibiotic therapy was started with crystalline penicillin (200,000 UI/kg/day) in association with gentamicin (4 mg/kg/day). On the third day of treatment, Haemophilus aphrophilus was identified in the blood cultures and the antibiotic scheme was replaced with ceftriaxone (100 mg/kg/day). On the 20th day of evolution, the patient was pale but with no fever or other complaints. Examinations showed hemoglobin = 7.0 g/dL, leukocytes = 2,190 mm³, platelets = 98,000 mm³, international normalized ratio = 1.95 and R = 1.89. Considering the hypothesis of adverse reaction to ceftriaxone, a 6-week replacement treatment with ciprofloxacin (20 mg/kg/day) was started. Examination results normalized after 72 hours of the replacement therapy. During ambulatory follow-up, patient presented with severe mitral regurgitation, undergoing a valve replacement with a metallic prosthetic valve 9 months after acute event. Patient has done well throughout the 3-year ambulatory follow-up. COMMENTS: Identification of agents of the HACEK group (Haemophilus ssp, Actinobacillus actinomycetemcomitans,Cardiobacterium hominis, Eikenella corrodens and Kingella kingae) in children with infective endocarditis is rare. This case report, with no HACEK agent-related risk factors, reinforces the need for identification of the etiological agent of endocarditis to ensure adequate treatment.

Asunto(s)

Niño , Humanos , Masculino , Endocarditis Bacteriana/microbiología , Haemophilus , Infecciones por Haemophilus/microbiología , Antibacterianos/uso terapéutico , Endocarditis Bacteriana/tratamiento farmacológico , Estudios de Seguimiento , Infecciones por Haemophilus/tratamiento farmacológico , Haemophilus/clasificación , Insuficiencia de la Válvula Mitral/microbiología , Índice de Severidad de la Enfermedad

RESUMEN

OBJECTIVE: To report the case of a child with infective endocarditis caused by Haemophilus aphrophilus. DESCRIPTION: Boy with 20 days of fever and chills. On admission, he was febrile, pale and with no signs of hemodynamic instability; on cardiac auscultation, a mitral-related holosystolic murmur was observed. Laboratory examination identified anemia (hemoglobin = 9.14 g/dL), total leukocytes of 11,920 mm3, platelets of 250,000 mm3, elevated sedimentation velocity of red cells and elevated C-reactive protein. The echocardiogram revealed image on mitral valve, resembling vegetation. Considering endocarditis, antibiotic therapy was started with crystalline penicillin (200,000 UI/kg/day) in association with gentamicin (4 mg/kg/day). On the third day of treatment, Haemophilus aphrophilus was identified in the blood cultures and the antibiotic scheme was replaced with ceftriaxone (100 mg/kg/day). On the 20th day of evolution, the patient was pale but with no fever or other complaints. Examinations showed hemoglobin = 7.0 g/dL, leukocytes = 2,190 mm3, platelets = 98,000 mm3, international normalized ratio = 1.95 and R = 1.89. Considering the hypothesis of adverse reaction to ceftriaxone, a 6-week replacement treatment with ciprofloxacin (20 mg/kg/day) was started. Examination results normalized after 72 hours of the replacement therapy. During ambulatory follow-up, patient presented with severe mitral regurgitation, undergoing a valve replacement with a metallic prosthetic valve 9 months after acute event. Patient has done well throughout the 3-year ambulatory follow-up. COMMENTS: Identification of agents of the HACEK group (Haemophilus ssp, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae) in children with infective endocarditis is rare. This case report, with no HACEK agent-related risk factors, reinforces the need for identification of the etiological agent of endocarditis to ensure adequate treatment.

Asunto(s)

Endocarditis Bacteriana/microbiología , Infecciones por Haemophilus/microbiología , Haemophilus , Antibacterianos/uso terapéutico , Niño , Endocarditis Bacteriana/tratamiento farmacológico , Estudios de Seguimiento , Haemophilus/clasificación , Infecciones por Haemophilus/tratamiento farmacológico , Humanos , Masculino , Insuficiencia de la Válvula Mitral/microbiología , Índice de Severidad de la Enfermedad

RESUMEN

Vancomycin-resistant enterococci (VRE) are important pathogens involved in nosocomial infections. Colonization precedes infection and the number of colonized individuals is about 10 times higher than the number of infected patients. We examined VRE colonization in two intensive care units from October 2003 to June 2004. Perirectal swab specimens were obtained from all patients, starting on the 5th day after admission, and then weekly. A total of 249 swabs were obtained from 112 patients. Nine patients had VRE-positive swabs, giving a positive rate of 8.0 percent. The rate of patients colonized by V-R E. faecalis was 1.8 percent (n=2), 4.5 percent by V-R E. gallinarun (n=5) and 1.8 percent by V-R E. casseliflavus (n=2). No V-R E. faeciun was isolated. None of the patients that had been colonized by VRE were found to be infected by these pathogens. In summary, a low prevalence of colonization by VRE was found in our institution. Only a structured surveillance program, based on active searching, was able to detect this low number of cases.

Asunto(s)

Preescolar , Humanos , Persona de Mediana Edad , Antibacterianos/farmacología , Infección Hospitalaria/microbiología , Enterococcus/efectos de los fármacos , Infecciones por Bacterias Grampositivas/microbiología , Resistencia a la Vancomicina , Brasil/epidemiología , Infección Hospitalaria/epidemiología , Enterococcus/clasificación , Enterococcus/aislamiento & purificación , Infecciones por Bacterias Grampositivas/epidemiología , Hospitales de Enseñanza/estadística & datos numéricos , Unidades de Cuidados Intensivos , Prevalencia , Factores de Riesgo

RESUMEN

Vancomycin-resistant enterococci (VRE) are important pathogens involved in nosocomial infections. Colonization precedes infection and the number of colonized individuals is about 10 times higher than the number of infected patients. We examined VRE colonization in two intensive care units from October 2003 to June 2004. Perirectal swab specimens were obtained from all patients, starting on the 5th day after admission, and then weekly. A total of 249 swabs were obtained from 112 patients. Nine patients had VRE-positive swabs, giving a positive rate of 8.0%. The rate of patients colonized by V-R E. faecalis was 1.8% (n=2), 4.5% by V-R E. gallinarun (n=5) and 1.8% by V-R E. casseliflavus (n=2). No V-R E. faeciun was isolated. None of the patients that had been colonized by VRE were found to be infected by these pathogens. In summary, a low prevalence of colonization by VRE was found in our institution. Only a structured surveillance program, based on active searching, was able to detect this low number of cases.

Asunto(s)

Antibacterianos/farmacología , Infección Hospitalaria/microbiología , Enterococcus/efectos de los fármacos , Infecciones por Bacterias Grampositivas/microbiología , Resistencia a la Vancomicina , Brasil/epidemiología , Preescolar , Infección Hospitalaria/epidemiología , Enterococcus/clasificación , Enterococcus/aislamiento & purificación , Infecciones por Bacterias Grampositivas/epidemiología , Hospitales de Enseñanza/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos , Persona de Mediana Edad , Prevalencia , Factores de Riesgo

RESUMEN

OBJECTIVE: To describe the case of a child with paracoccidioidomycosis who presented hypercalcemia with multiple osteolytic lesions. DESCRIPTION: A 6-year-old boy was admitted with a one-month history of fever and hepatosplenomegaly. On admission, he looked sick, pale, and had disseminated lymphadenopathy and hepatosplenomegaly. The laboratory findings included anemia (hemoglobin = 6.8 g/dl), eosinophilia (1,222/mm3), thrombocytopenia (102,000/mm3), and hypoalbuminemia (serum albumin = 2.2 g/dl). Paracoccidioides brasiliensis was identified in bone marrow examination. In the second week after admission, the patient presented joint pain, poor activity and difficulty in walking. He presented hypercalcemia (maximum value = 14.9 mg%) and reduction in renal function, which lasted for two weeks. On the 42nd day after admission, his chest X-ray showed lytic lesions in clavicle, scapula, ribs, and humerus, with bilateral slipped capital humeral epiphysis. The patient presented nephrocalcinosis and nephrolithiasis, reduction in creatinine clearance and evidence of tubular lesions. At the end of the second month after admission, Mycobacterium tuberculosis was isolated in gastric washing. The child received treatment for paracoccidioidomycosis and tuberculosis and has not had any sequelae for 3 years. COMMENTS: The development of symptomatic hypercalcemia leading to renal lesion, associated with multiple osteolytic lesions, had never been described in paracoccidioidomycosis. Although pulmonary tuberculosis was diagnosed and could be related to hypercalcemia, the sudden onset of hypercalcemia and its normalization without specific treatment for tuberculosis suggests that bone lysis was the most important factor in the genesis of hypercalcemia.

Asunto(s)

Hipercalcemia/etiología , Osteólisis/etiología , Paracoccidioidomicosis/complicaciones , Tuberculosis Pulmonar/complicaciones , Niño , Humanos , Hipercalcemia/diagnóstico por imagen , Masculino , Osteólisis/diagnóstico por imagen , Paracoccidioidomicosis/diagnóstico por imagen , Radiografía , Tuberculosis Pulmonar/diagnóstico por imagen

RESUMEN

OBJETIVO: Descrever o caso de uma crianca com paracoccidioidomicose, que apresentou hipercalcemia associada a múltiplas lesões osteolíticas. DESCRIÇAO: Menino de 6 anos, internado com história de febre e hepatoesplenomegalia há 1 mês. A internacão, apresentava-se em regular estado geral, descorado, com linfonodomegalia generalizada e hepatoesplenomegalia. Os exames laboratoriais identificaram anemia (hemoglobina = 6,8 g/dl), eosinofilia (1.222/mm ), plaquetopenia (102.000/mm ) e hipoalbuminemia (albumina = 2,2 g/dl). Paracoccidioides brasiliensis foi identificado no mielograma. A partir da segunda semana de internacão, apresentou artralgia, hipoatividade e dificuldade à deambulacão, sendo constatada hipercalcemia (dosagem máxima de 14,9 mg por cento) e reducão da funcão renal, que duraram pouco mais de 2 semanas. No 42º dia de internacão, foram vistas, na radiografia de tórax, múltiplas lesões líticas em clavículas, escápulas, costelas e úmeros, com escorregamento epifisário de úmero bilateral. Apresentou nefrocalcinose e nefrolitíase, com reducão no clearance de creatinina e evidências de lesão tubular. No final do segundo mês de internacão, na cultura do lavado gástrico, foi identificado Mycobacterium tuberculosis. Recebeu tratamento para paracoccidioidomicose e tuberculose e está há mais de 3 anos em acompanhamento, sem nenhuma seqüela. COMENTARIOS: O desenvolvimento da hipercalcemia sintomática, levando à lesão renal e associada a lesões ósseas múltiplas e disseminadas, nunca foi descrito em paracoccidioidomicose. Embora tenha sido diagnosticada tuberculose pulmonar, que pode estar relacionada à hipercalcemia, a forma abrupta como se instalou e como se normalizou sem o tratamento específico para tuberculose sugere que a lise óssea foi o fator mais importante na gênese da hipercalcemia.

Asunto(s)

Niño , Humanos , Masculino , Hipercalcemia , Osteólisis , Paracoccidioidomicosis/patología , Tuberculosis Pulmonar/patología , Hipercalcemia/etiología , Osteólisis/etiología , Paracoccidioidomicosis/complicaciones , Paracoccidioidomicosis , Tuberculosis Pulmonar/complicaciones , Tuberculosis Pulmonar

RESUMEN

Menina, 12 anos, foi admitida referindo o uso de esquema de poliquimioterapia preconizado pela OMS para tratamento de hanseníase forma multicibacilar (dapsona, rifampicina e clofazimina) há 24 dias, apresentando icterícia, linfadenomegalia generalizada, hepatoesplenomegalia, conjuntivite, úlceras orais, exantema morbiliforme e edema de face, mãos e tornozelo. Os principais achados laboratoriais à admissão incluíam: hemoglobina, 8,4 g/dl; leucograma, 15.710 céls/mm3; contagem de plaquetas, 100.000 céls/mm3; RNI = 1,49; aumento dos níveis séricos da alanino e aspartato aminotransferases, gama-glutamil transpeptidase, fosfatase alcalina e bilirrubinas. Em seqüência, ocorreu piora do quadro, desenvolvendo dermatite esfoliativa, choque, edema generalizado, insuficiências renal e hepática, pancitopenia, sangramento intestinal, pneumonia, infecção urinária e bacteremia, necessitando de drogas adrenérgicas, antibióticos, infusão de líquidos e hemoderivados. Iniciou melhora no 10º dia de internação, recebendo alta hospitalar no 39º dia, tendo iniciado novo tratamento supervisionado para hanseníase com rifampicina e clofazimina, sem efeitos adversos. O caso relatado preenche os critérios para o diagnóstico de síndrome de hipersensibilidade à dapsona (febre, dermatite esfoliativa, linfadenopatia, anemia e acometimento hepático com necrose hepatocítica e colestase). Os médicos, principalmente em regiões com alta prevalência de hanseníase, devem estar atentos para esta grave, e provavelmente não tão rara, reação de hipersensibilidade à dapsona.

Asunto(s)

Humanos , Femenino , Niño , Clofazimina , Dapsona , Hipersensibilidad a las Drogas , Leprostáticos , Lepra , Rifampin , Síndrome

RESUMEN

A two year-old female child was admitted at the Pediatric Intensive Care Unit in a septic shock associated with a lymphoproliferative syndrome, with history of fever, adynamia and weight loss during the last two months. On admission, the main clinical and laboratory manifestations were: pallor, jaundice, disseminated enlarged lymph nodes, hepatosplenomegaly, crusted warts on face, anemia, eosinophilia, thrombocytopenia, increased direct and indirect bilirubin, alkaline phosphatase, and gammaglutamyl transpeptidase. A parenteral administration of fluids, dobutamine and mechanical ventilation was started, without improvement of the clinical conditions. A direct examination of exsudate collected from cervical lymph node revealed numerous oval-to-around cells with multiple budding, like a "pilot wheel" cell, suggesting Paracoccidioides brasiliensis. Even though treatment with intravenous sulfamethoxazole-trimethoprine was soon started, the child died 36 hours after hospital admission. Disseminated paracoccidioidomycosis was confirmed in the autopsy. This is the youngest case of paracoccidioidomycosis in children reported in the literature.

Asunto(s)

Paracoccidioides/aislamiento & purificación , Paracoccidioidomicosis/microbiología , Niño , Resultado Fatal , Femenino , Humanos , Trastornos Linfoproliferativos/microbiología , Paracoccidioidomicosis/complicaciones , Choque Séptico/microbiología

RESUMEN

Uma menina de dois anos foi internada em Unidade de Terapia Intensiva com o diagnóstico de choque séptico associado a sindrome linfoproliferativa febril, adinamia e perda de peso nos últimos dois meses. Na admissão, as principais manifestações clínicas e laboratoriais eram: palidez, icterícia, aumento ganglionar em todas as cadeias superficiais, hepatoesplenomegalia, lesões crostosas em face, anemia, eosinofilia, plaquetopenia, elevação de bilirrubina indireta e direta, de fosfatase alcalina e de gama glutamil transferase. A terapêutica instituída foi infusão de fluidos, dobutamina e ventilação mecânica, sem melhora das condições clínicas, seguido da introdução de sulfametoxazol-trimetoprina. O exame direto do linfonodo revelou numerosas estruturas ovaladas, com múltiplos brotamentos, como "roda de leme" sugerindo Paracoccidioides brasiliensis. A paciente evoluiu para o óbito 36 horas após a internação. Paracoccidioidomicose disseminada foi confirmada na necropsia. Trata-se do caso mais jovem de paracoccidioidomicose reportado na literatura consultada.

Asunto(s)

Niño , Femenino , Humanos , Paracoccidioides/aislamiento & purificación , Paracoccidioidomicosis/microbiología , Resultado Fatal , Trastornos Linfoproliferativos/microbiología , Paracoccidioidomicosis/complicaciones , Choque Séptico/microbiología

RESUMEN

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.

Asunto(s)

Dapsona/efectos adversos , Hipersensibilidad a las Drogas/etiología , Leprostáticos/efectos adversos , Lepra/tratamiento farmacológico , Niño , Clofazimina/administración & dosificación , Dapsona/administración & dosificación , Hipersensibilidad a las Drogas/diagnóstico , Quimioterapia Combinada , Femenino , Humanos , Leprostáticos/administración & dosificación , Rifampin/administración & dosificación , Síndrome