Clinical and epidemiological aspects of Candidemia in eight medical centers in the state of Parana, Brazil: Parana Candidemia Network

Objectives

Candida spp. has been reported as one of the common agents of nosocomial bloodstream infections and is associated with a high mortality. Therefore, this study evaluated the clinical findings, local epidemiology, and microbiological aspects of candidemia in eight tertiary medical centers in the state of Parana, South of Brazil.

Methods

In this study, we reported 100 episodes of candidemia in patients admitted to eight different hospitals in five cities of the state of Parana, Brazil, using data collected locally (2016 and 2017) and tabulated online.

Results

The incidence was found to be 2.7 / 1000 patients / day and 1.2 / 1000 admissions. C. albicans was responsible for 49% of all candidemia episodes. Cancer and surgery were the two most common underlying conditions associated with candidemia. The mortality rate within 30 days was 48%, and removal of the central venous catheter (p = 0.029) as well as empirical or prophylactic exposure to antifungals were both related to improved survival (p = 0.033).

Conclusions

This study highlights the high burden and mortality rates of candidemia in hospitals from Parana as well as the need to enhance antifungal stewardship program in the enrolled medical centers.

Nail clipping in onychomycosis and comparison with normal nails and ungual psoriasis

BACKGROUND

Of all nail disorders seen in dermatology offices, half of them are due to onychomycosis. The main differential diagnosis is nail psoriasis. The objective of this study was to compare the microscopic findings, other than the presence of fungi, in the clipping of onychomycosis versus normal nails and nail psoriasis.

METHODS

Cross-sectional study of onychomycosis cases, analyzed by clipping and compared with data on normal nails and those with nail psoriasis.

RESULTS

Sixty-two onychomycosis samples were compared with 30 normal nails and 50 nails with psoriasis. In onychomycosis, measurement of subungual region, serous lakes, neutrophils and number of layers of parakeratosis are more intense than in psoriasis. Onychocariosis is less common in psoriasis, while bacteria are more frequent. The nail transition zone is more commonly blurred and irregular in onychomycosis.

CONCLUSION

Clipping helps in the differential diagnosis of onychomycosis and nail psoriasis and may be useful even when fungi are not found.

Chronic Meningitis and Hydrocephalus due to Sporothrix brasiliensis in Immunocompetent Adults: A Challenging Entity

Chronic meningitis caused by Sporothrix sp. is occasionally described in immunosuppressed patients. We report the challenges in diagnosing and managing 2 nonimmunocompromised patients with hydrocephalus and chronic meningitis caused by Sporothrix brasiliensis. This more virulent species appears to contribute more atypical and severe cases than other related species.

Molecular characterization and antifungal susceptibility testing of Cryptococcus neoformans sensu stricto from southern Brazil

PURPOSE

Cryptococcosis is acquired from the environment by the inhalation of Cryptococcus cells and may establish from an asymptomatic latent infection into pneumonia or meningoencephalitis. The genetic diversity of a Cryptococcus neoformans species complex has been investigated by several molecular tools, such as multi-locus sequence typing, amplified fragment length polymorphism (AFLP), restriction fragment length polymorphism and microsatellite analysis. This study aimed to investigate the genotype distributions and antifungal susceptibility profiles of C. neoformans sensu lato isolates from southern Brazil.

METHODOLOGY

We studied 219 C. neoformans sensu lato isolates with mating- and serotyping, AFLP fingerprinting, microsatellite typing and antifungal susceptibility testing.Results/Key findings. Among the isolates, 136 (69 %) were from HIV-positive patients. Only C. neoformans mating-type α and serotype A were observed. AFLP fingerprinting analysis divided the isolates into AFLP1/VNI (n=172; 78.5 %), AFLP1A/VNII (n=19; 8.7 %), AFLP1B/VNII (n=4; 1.8 %) and a new AFLP pattern AFLP1C (n=23; 10.5 %). All isolates were susceptible to tested antifungals and no correlation between antifungal susceptibility and genotypes was observed. Through microsatellite analysis, most isolates clustered in a major microsatellite complex and Simpson's diversity index of this population was D=0.9856.

CONCLUSION

The majority of C. neoformans sensu stricto infections occurred in HIV-positive patients. C. neoformans AFLP1/VNI was the most frequent genotype and all antifungal drugs had high in vitro activity against this species. Microsatellite analyses showed a high genetic diversity within the regional C. neoformans sensu stricto population, and correlation between environmental and clinical isolates, as well as a temporal and geographic relationship.

Susceptibility and molecular characterization of Candida species from patients with vulvovaginitis

Vulvovaginal candidiasis affects women of reproductive age, which represents approximately 15–25% of vaginitis cases. The present study aimed to isolate and characterize yeast from the patients irrespective of the presentation of clinical symptoms. The isolates were subjected to in vitro susceptibility profile and characterization by molecular markers, which intended to assess the distribution of species. A total of 40 isolates were obtained and identified through the CHROMagar, API20aux and by ITS and D1/D2 regions sequencing of DNAr gene. Candida albicans strains were genotyped by the ABC system and the isolates were divided into two genotypic groups. The identity of the C. albicans, C. glabrata, C. guilliermondii, C. kefyr and Saccharomyces cerevisiae isolates was confirmed by the multilocus analysis. The strains of Candida, isolated from patients with complications, were found to be resistant to nystatin but sensitive to fluconazole, amphotericin B and ketoconazole, as observed by in vitro sensitivity profile. The isolates from asymptomatic patients, i.e., the colonized group, showed a dose-dependent sensitivity to the anti-fungal agents, fluconazole and amphotericin B. However, the isolates of C. albicans that belong to distinct genotypic groups showed the same in vitro susceptibility profile.

Occurrence of Candida orthopsilosis in Brazilian tomato fruits (Lycopersicum esculentum Mill.)

We aimed to isolate and identify yeasts found in the tomato fruit in order to obtain isolates with biotechnological potential, such as in control of fungal diseases that damage postharvest fruits. We identified Candida orthopsilosis strains LT18 and LT24. This is the first report of this yeast on Lycopersicum esculentum fruits in Brazil.

Central nervous system Aspergillus fumigatus infection after near drowning

AIMS

To report the case of a 26 year old white man, who developed chronic meningitis and intracerebral granulomata 15 days after an episode of near drowning in a swamp.

METHODS

Aspergillus fumigatus was isolated from cerebrospinal fluid cultures.

RESULTS

The patient died 70 days after the symptoms were first noticed, and seven days after a subarachnoid haemorrhage. Aspergillus has never been reported before as a cause of intracranial infection after near drowning.

CONCLUSIONS

Physicians must be aware of this possibility when confronted with such a situation, because there are now effective therapeutic options for systemic aspergillosis.

Infection of the CNS by Scedosporium apiospermum after near drowning. Report of a fatal case and analysis of its confounding factors

This report describes a fatal case of central nervous system pseudallescheriasis. A 32 year old white man presented with headache and meningismus 15 days after nearly drowning in a swine sewage reservoir. Computerised tomography and magnetic resonance imaging of the head revealed multiple brain granulomata, which vanished when steroid and broad spectrum antimicrobial and antifungal agents, in addition to dexamethasone, were started. Cerebrospinal fluid analysis disclosed a neutrophilic meningitis. Treatment with antibiotics and amphotericin B, together with fluconazole and later itraconazole, was ineffective. Miconazole was added through an Ommaya reservoir, but was insufficient to halt the infection. Pseudallescheria boydii was finally isolated and identified in cerebrospinal fluid cultures, a few days before death, three and a half months after the symptoms began. Diagnosis was delayed because of a reduction in the lesions after partial treatment, which prevented a stereotactic biopsy. Physicians should be aware of this condition, and provide prompt stereotactic biopsy. Confirmed cases should perhaps be treated with voriconazole, probably the most effective, currently available treatment for this agent.

[Preservation of the liver using a new solution of phosphate-buffered saccharose]

The efficacy of the new phosphate-buffered sucrose solution (PBS), was compared with the conventional Euro-Collins (EC) and the lactated Ringer solution (LR), in its capacity to preserve the canine liver in cold storage. Three groups of 6 canine livers, each group in one of those solutions, were put in cold storage for 24 h at 4 degrees centigrade. At the end of this period the effect of warm hepatic reperfusion was studied in relationship with the following parameters: weight of the liver, bile excretion, hepatic biopsy, Na, K, Ca, P and some tests used to evaluate the hepatic function. The results obtained confirm, that PBS has an important impermeant effect over the hepatocyte, simulating that described recently by Lam et al to the kidney. Contrary to the EC and LR, the PBS inhibits hypothermic cell swelling, is more effective in the preservation of the liver histology, and has an opposed effect to the weight gain tendency induced by cold storage. During the period of warm reperfusion, high volumes of bile excretion and lesser levels of K depletion were observed in the PBS model. PBS is easy to prepare, and it is not expensive. For these reasons PBS could be an advantageous substitute of the EC in liver preservation.

[Hyponatremia--new concepts and therapy. Apropos of a clinical case]

The therapeutic approach of hyponatremia is reviewed, and the authors describe their recent experience of a clinical case of a woman with acute hyponatremia. After analysing the main publications of the last years, they conclude that the way of correcting hyponatremia largely depends of its acute or chronic character. Chronic hyponatremia must be corrected with slow rate infusion of sodium chloride (0.5 mmol/l/h), and acute hyponatremia with a rapid (2 mmol/l/h) or intermediate (1-1.5 mmol/l/h) rate of infusion of the same solution. This is the current advisable approach, until a new better orientation will virtually be clarified by further prospective studies.