Browsing by Author "Toscano, C."
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- Disseminated mucormycosis in a 6 month old infant following congenital heart defect corrective surgery: case reportPublication . Brogueira, P.; Carvalho, N.; Batista, J.; Gonçalves, E.; Sabino, Raquel; Veríssimo, Cristina; Mansinho, K.; Anjos, R.; Toscano, C.This abstract reports a case of a disseminated fungal infection caused by Mucor velutinosus in a 6 month old infant admitted to a intensive care unit and under several risk factors. The species was isolated from urine and 4 days later it was also detected from several tracheal aspirates.Molecular identification of the fungal isolate was performed in order to identify correctly the species.
- Imported African histoplasmosis by Histoplasma capsulatum var. duboisii in an HIV-2 infected patientPublication . Toscano, C.; Batista, J.; Carvalho, R.; Espírito-Santo, C.E.; Marcos, R.; Sabino, R.; Verissimo, C.; Viana, I.; Marques, T.Objectives: African histoplasmosis caused by the fungus Histoplasma capsulatum var. duboisii, is a rare endemic mycosis occuring in western and central regions of sub-Saharian Africa. For unknown reasons, although HIV infection and H. capsulatum var. duboisii coexist in Africa, this coinfection remains rare. In Europe, diagnosed cases of African histoplasmosis are all imported. We describe a case of African histoplasmosis on a Portuguese war veteran co-infected with HIV-2 who fought in Guiné-Bissau in 1963-65 and Angola in 1972. Methods: We report a case of a 76-year-old man, diagnosed with HIV-2 infection in the previous year (under combined antiretroviral therapy) presenting an ulcerated skin lesion on the right tight (image 1), just above the knee. He was diagnosed pulmonary tuberculosis the year before and was finishing one year treatment. The solitary skin lesion begun as a small non-pruriginous eritematous papule, evolving in 6 month to a painless 3-4cm ulcer with raised borders surrounded by a hiperpigmented halo. There were no adenopathies or bone lesions. Respiratory samples and blood cultures were systematically negative for Histoplasma capsulatum. He was treated with IV liposomal Amphotericin-B for one month, followed by oral itraconazol (now on the first month), with a favourable clinical outcome. Results: Histopathology of skin biopsy revealed a superficial ulceration with underlying granulomatous infiltrate with many giant cells, where numerous round mononucleated yeasts measuring 7-8µm were evident and highlighted with PAS and Grocott stain (image 2, left side). Skin biopsy was observed on a wet mount with KOH and revealed numerous round yeasts that were also seen on Gram stain, measuring 7-8µm. Culture of skin biopsy on two Sabouraud dextrose agar (with and without cicloheximide) showed growth of a filamentous fungus compatible with Histoplasma capsulatum (image 2, right side), with large thick-walled spherical macroconidia with finger-like projections (tuberculate conidia) that arise from short conidiophores, and small oval microconidia arising on short stalks from undifferentiated hyphae. Reversion to the yeast fase has not been succeed yet. Identification was further confirmed by sequencing of genomic DNA fragments using the universal fungal primers ITS1 and ITS4. The sequences obtained were compared with sequences deposited in the GenBank and the result was: Histoplasma capsulatum var. duboisii (99% homology). Conclusion: With banalization of business or leisure trips, endemic mycosis are becoming frequently diagnosed in countries outside their natural geographic endemic areas and only a high index of suspicion makes the diagnosis possible. Apart from trips, nowadays in Portugal 4% of the resident population is immigrant, mostly from Brasil (25.5%) but also from Angola and Guiné-Bissau (9.2%), being the former an endemic country of American histoplasmosis and the later of both American and African histoplasmosis. We consider histoplasmosis a probable underdiagnosed disease that should be suspected mainly in immunodeficient HIV positive individuals with a past history of travel or residence in an endemic area.
- Majocchi’s Granuloma by Trichophytum rubrum in a kidney transplant patient - A case reportPublication . Matos Cruz, S.; Silva, L.; Catorze, G.; Sabino, R.; Verissimo, C.; Toscano, C.Introduction: Trichophytum rubrum is a filamentous fungus, with worldwide distribution, that usually causes superficial infections of skin and nails, namely tinea pedis, tinea corporis, tinea cruris and onychomycosis. Rarely, severe dermatophytosis can occur, presenting as deep dermatophytosis, Majocchi’s Granuloma or extensive dermatophytosis. Objectives and Methods: Case report of Majocchi’s Granuloma in a kidney transplant patient. Results: A case of a 55-year-old woman who underwent a kidney transplant 7 months before, under immunosuppressive therapy with tacrolimus and mycophenolate mofetil. She attended a Dermatology consultation to clarify skin lesions that appeared 6 months earlier. The skin exam revealed hard and painful plaque lesions on both legs, with an ulcer on the left leg lesion, violaceous papular lesions on the dorsum of the left foot and toes and a hard consistency nodule on the left leg. Some of the toe nails presented dystrophy or onycholysis. The patient denied any previous trauma or contact with plants or soil. Biopsies of lesions of the left leg and foot dorsum where sent for histology and mycological culture and toe nails for mycological culture. The histological examinations showed, in the reticular dermis and reaching the hypodermis, suppurative granulomas with multinucleated giant cells and areas of necrosis. PAS (Periodic Acid- Schiff) and GMS (Grocott’s Methenamine Silver) staining revealed multiple spores and septate hypha within the granulomas but not in the stratum corneum. No remnants of hair follicles where found. Culture of skin biopsies were positive for Tricophytum rubrum but nails´ culture was negative. Identification was further confirmed by sequencing of ITS region of ribosomal DNA (GenBank accession number MK967277). Oral Itraconazole 100mg bid and topic Sertoconazole where initiated. The patient was observed one month after and reported general malaise, tiredness, exertional dyspnea, whitish stools and increased abdominal volume. The physician chose to discontinue itraconazole and initiate oral terbinafine 250mg id. After two months on oral terbinafine, there was regression of the legs´ and left foot lesions with ulcer healing and disappearance of the left leg nodule. Conclusion: Diagnosis of deeper dermatophytosis is difficult, in part because there is no specific clinical presentation and, in many cases, it is even polymorphic. However, especially in patients with immunodeficiency, this hypothesis should be weighed. Confirmation is achieved by finding hyphae compatible with dermatophytes in the dermis and a positive culture for a dermatophyte. Treatment should include systemic antifungal agents, to which topical medication may be associated. Multiple therapeutic regimens have been proposed, but randomized trials or large case series are lacking. Antifungal therapy should be continued until the lesions are completely resolved. Surgical treatment has been reported as an option for highly localized lesions.
- Molecular and epidemiologic study of Clostridium difficile reveals unusual heterogeneity in clinical strains circulating in different regions in PortugalPublication . Santos, A.; Isidro, J.; Silva, C.; Boaventura, L.; Diogo, J.; Faustino, A.; Toscano, C.; Oleastro, M.Clostridium difficile infection (CDI) represents a great healthcare burden in developed countries. The emergence of the epidemic PCR ribotype (RT) 027 and its acquired fluoroquinolones resistance have accentuated the need for an active surveillance of CDI. Here we report the first countrywide study of CDI in Portugal with the characterization of 498 C. difficile clinical isolates from 20 hospitals in four regions in Portugal regarding RT, virulence factors and antimicrobial susceptibility. We identified 96 RTs with marked variations between and within regions, as only six RTs appeared in all four regions. RT027 was the most frequent RT overall (18.5%) and among healthcare facility-associated isolates (19.6%), while RT014 was the most common among community-associated isolates (12%). The north showed a high RT diversity among isolates and a low moxifloxacin (MXF) resistance rate (11.9%), being the only region in which RT027 was not predominant. In contrast, the isolates from the centre presented the highest RT027 frequency, and 53.4% were resistant to MXF. Overall, MXF resistance (33.2%) was associated (p <0.001) with the presence of binary toxin genes and mutations in tcdC regardless of the RT. Both traits appeared in almost 30% of the strains. RT027 showed a reduced susceptibility to metronidazole (p <0.01), and RT126 had higher minimum inhibitory concentrations to vancomycin (p = 0.03) compared to other RTs. The present study highlights an unusual heterogeneity of RTs in Portugal, with a high frequency of hypervirulent RTs and the emergence of virulence factors in non-027 RTs, emphasizing the need for a surveillance system for CDI in Portugal.