Revista Do Instituto De Medicina Tropical De Sao Paulo最新文献

Neurological manifestations remain a significant cause of hospitalization and in-hospital mortality among people living with HIV (PLWH), even in the era of antiretroviral therapy (ART). This study aims to describe the clinical and epidemiological profile of PLWH with neurological opportunistic infections (nOIs) and to identify factors associated with in-hospital mortality. We conducted a retrospective cohort study with PLWH aged >18 years hospitalized due to nOIs between November 2017 and December 2021 at a tertiary hospital in Brazil. Demographic, clinical, and laboratory data were extracted from electronic medical records. Logistic regression was used to evaluate associations between patient characteristics and in-hospital mortality. Among 237 hospitalized PLWH, 89 (37.6%) had nOIs. The median CD4 count at admission was 55 cells/mm³ (IQR 22.5-149), and 91.7% had previously used ART (only 22.7% used it regularly). The most frequent infections were cerebral toxoplasmosis (50.6%), cryptococcal meningitis (10.1%), and progressive multifocal leukoencephalopathy (9%). A total of 19 in-hospital deaths occurred. In the multivariate analysis, undefined neurological infections (aOR: 8.67; 95%CI: 1.23-61.17) and ICU admission (aOR: 58.61; 95% CI: 10.24-335.49) were independently associated with mortality. In conclusion, severe immunosuppression and low ART adherence were common in this cohort. Cerebral toxoplasmosis was the most prevalent neurological infection. ICU admission and undefined neurological syndromes were strong predictors of in-hospital mortality. Early diagnosis, prompt treatment, and strategies to improve ART adherence are essential to reduce fatal outcomes in this population.

Paracoccidioidomycosis (PCM) is a neglected tropical disease classified as acute/subacute and chronic. In people living with HIV/AIDS (PLWHA), coinfection can lead to severe clinical manifestations. We report the case of a 30-year-old immunosuppressed male presenting fever, weight loss, polymorphic skin lesions, diffuse lymphadenopathy, hepatosplenomegaly, and joint effusion. Histopathological analysis revealed fungal structures compatible with Paracoccidioides spp., and serology was positive at a titer of 1:16. Despite initial Amphotericin B and antiretroviral therapy, the patient developed a productive cough and persistent systemic symptoms. Initial sputum tests were negative for Mycobacterium tuberculosis, but subsequent bronchoalveolar lavage detected rifampin-resistant tuberculosis (TB). The remarkable overlap of clinical and radiological features of TB and PCM can significantly delay diagnosis, highlighting the need for high clinical suspicion and prompt investigation with bronchoalveolar lavage (BAL) testing. After one-month outpatient follow-up, the patient showed significant cutaneous improvement, undetectable HIV viral load, and a marked increase in CD4+ T-cell count. This report highlights the importance of recognizing the acute/subacute form of PCM as an AIDS-defining illness in endemic areas, enabling early treatment and improved outcomes.

Pediatric tuberculosis (TB) remains a diagnostic challenge in Brazil and worldwide. The Brazilian Ministry of Health recommends a clinical scoring system (S-MoH) for children and adolescents with suspected TB. Interpretation of radiographs within this scoring system may require specialist input. AI-based systems, such as CAD4TB (Delft Imaging Systems B.V.), approved by the WHO for adults, are not yet recommended for standalone use in children under 15 years of age. A retrospective study was conducted at a pediatric institute from January 31, 2017, to January 29, 2025, including 179 patients aged 0-14 years with pulmonary TB or other diseases. CAD4TBv7.1 analyzed chest radiographs using two cutoff points established by Youden's index: 53.48 for analyses against the S-MoH score and 53.89 for analyses against microbiological confirmation. Results were compared with both microbiological confirmation and S-MoH score. Among the 179 participants, 61 (34.1%) had TB, 25 of which were microbiologically confirmed. CAD4TBv7.1 showed an area under the ROC curve (AUROC) of 0.71, with a sensitivity of 52% and a specificity of 86.3% compared with microbiological diagnosis. Against S-MoH, AUROC was 0.59, with a sensitivity of 34.43% and a specificity of 86.44%. CAD4TBv7.1 demonstrated low sensitivity and high specificity, particularly regarding its overall discriminative capacity. Thus, CAD4TBv7.1 emerges as a promising complementary screening tool for pediatric TB. Although its standalone use is not yet recommended, it may complement S-MoH in settings lacking radiologists. Investments in AI must be accompanied by consistent pediatric validation and strategies that combine technological innovation with traditional and cost-effective clinical approach.

Spotted fever is a tick-borne rickettsiosis caused by several Rickettsia species-including R. rickettsii, R. parkeri, and others-with varying degrees of pathogenicity. Its nonspecific symptoms often lead to misdiagnosis such as dengue. This study investigated anti-R. rickettsii and R. parkeri antibodies in 152 patients with acute febrile illness who tested negative for dengue. Serological analysis using immunofluorescence assay found 29 reactive samples (19%) at a 1:64 dilution. Among them, 20.6% were male and 58.6% female, with an average age of 42.6 years. The average sample collection time totaled 14.6 days. Reactive samples included 13.1% for R. rickettsii and 5.9% for R. parkeri. These results suggest possible rickettsial infections in patients initially suspected of dengue.

Osteoarticular sporotrichosis is the most common extracutaneous type of the disease and may occur either concomitantly with cutaneous lesions or as isolated musculoskeletal disease, the latter frequently resulting in delayed diagnosis. We describe five confirmed cases of osteoarticular sporotrichosis diagnosed between 2002 and 2023 at a university hospital in Brazil. Diagnosis was confirmed by fungal culture, with serology and histopathology used as complementary methods. Clinical and epidemiological data, radiologic findings, treatment, and outcomes were analyzed. Patients were 39 to 67 years of age and all had chronic conditions or alcoholism. Joint involvement most frequently affected the knee (four cases), followed by the wrist (three cases), and small joint of the hands (two cases), often with bone and periarticular tissue involvement. Three patients had concomitant cutaneous involvement. Diagnostic delays were frequent, reflecting the nonspecific clinical presentation and the tendency to misattribute symptoms to other musculoskeletal conditions. All patients received antifungal therapy with itraconazole and/or amphotericin B. Relapses were recorded in two patients, and there were irreversible sequelae such as chronic arthritis, joint stiffness, or deformity in all cases. Osteoarticular sporotrichosis should be considered in the differential diagnosis of chronic musculoskeletal conditions, including arthritis, osteomyelitis, synovitis, bursitis, and tenosynovitis, particularly in endemic regions. Early recognition and prolonged antifungal therapy are essential to achieve cure and prevent complications.

Cerebral myiasis is an exceptionally rare condition caused by infestation with dipteran larvae, with only 20 cases reported in the literature to date. A 78-year-old man presented with anorexia, vomiting, and fever. Physical examination revealed a 7 × 8 cm ulcerated scalp lesion with a necrotic base, purulent discharge, a foul odor, and numerous larvae. Computed tomography demonstrated an osteolytic frontal bone defect accompanied by pneumocephalus and subcutaneous emphysema. The larvae were manually removed, an iodoform dressing was applied, and intravenous ceftriaxone therapy was initiated. Progressive neurological decline prompted repeat imaging, which revealed frontal and parietal cerebritis with abscess formation. Surgical debridement was performed to remove necrotic tissue. Histopathological analysis showed moderately differentiated squamous cell carcinoma with acute osteomyelitis, and cultures yielded multidrug-resistant Pseudomonas aeruginosa. Despite targeted antibiotic therapy and intensive supportive care, the patient died. This case highlights the significant morbidity and mortality associated with cerebral myiasis, particularly when complicated by underlying malignancy and multidrug-resistant infection. Early recognition, prompt surgical intervention, and pathogen-directed antimicrobial therapy are crucial, while comprehensive multidisciplinary management remains essential to optimize outcomes in this life-threatening condition.

Panstrongylus megistus is the most important autochthonous vector of Trypanosom cruzi, the etiological agent of Chagas disease, in the midwest region of the Minas Gerais State, Brazil. This study investigates the vectorial roles of Triatoma infestans and P. megistus in Chagas disease in this geographical area during the late 1970s. A retrospective analysis of entomological and serological surveys from 1975-1983 was conducted, comparing the presence of T. infestans and P. megistus with the seroprevalence of T. cruzi infection in the human population within the Divinopolis Regional Health Superintendency. Panstrongylus megistus was recorded in all surveyed municipalities (52/52), whereas T. infestans co-occurrence with P. megistus was recorded in only 19.2% (10/52) of them. In the 41 municipalities where only P. megistus was found and relevant data were available, the mean seroprevalence of human T. cruzi infection was 17.8% ranging from 1.0% to 41.9%. In the municipalities where T. infestans occurred, the mean seroprevalence was higher, at 25.8%, ranging from 9.8% to 40.8%. Among the municipalities where only P. megistus was present, 19.5% had a low, 29.3% an intermediate, and 51.2% a high seroprevalence of human T. cruzi infection. In the ten municipalities where both T. infestans and P. megitus were found, 80% showed high seroprevalence, whereas only one municipality each showed low or intermediate levels. The findings highlight the significant role of P. megistus in T. cruzi transmission, even in the absence of T. infestans. The wide distribution of P. megistus increased the risk of transmission. P. megistus was the main household vector in the region in the 1970s. Nowadays, continuous surveillance remains essential for monitoring triatomine infestations and evaluating the current risk of T. cruzi transmission.

Chronic hepatitis C virus (HCV) infection is a major cause of liver cirrhosis and hepatocellular carcinoma, which may lead to liver transplantation. Co-infection with HIV may accelerate liver disease and impact treatment response. Monitoring liver fibrosis involves non-invasive methods such as transient hepatic elastography (THE), AST to Platelet Ratio Index (APRI), and Fibrosis-4 (FIB-4). This study compared changes in THE, APRI, and FIB-4 among patients with HCV alone and those with HIV-HCV co-infection before and after direct-acting antiviral (DAA) therapy. We conducted a retrospective cohort study using medical records from patients treated at a reference clinic in Sao Paulo, Brazil, between January 2015 and February 2019. Fibrosis assessments (THE, APRI, FIB-4) were performed pre-treatment and six months post-treatment. APRI and FIB-4 were also evaluated at 12 months. Among 148 participants, 105 (70%) had HCV mono-infection and 43 (30%) had HIV-HCV co-infection. Genotype 1 was most prevalent (86%). At six months post-treatment, greater reductions in THE, APRI, and FIB-4 were observed in the HCV mono-infection group. Pre-treatment THE values positively correlated with subsequent reductions. However, multivariable analysis showed no significant differences between groups in THE reductions, and no significant group differences in APRI or FIB-4 at six and 12 months. DAA treatment led to fibrosis regression in most participants. HIV co-infection did not significantly alter fibrosis outcomes following successful HCV treatment.

Paracoccidioidomycosis (PCM) is a neglected fungal disease with a rising incidence in Brazil, including increasing hospitalizations in previously non-endemic regions outside the Amazon. This study analyzed the spatiotemporal patterns of acute PCM hospitalizations and their relationship with deforestation. We carried out a retrospective ecological analysis of all PCM-related hospitalizations that were registered in the Brazilian Hospital Information System from 2014 to 2023. Acute and subacute cases were defined using ICD-10 codes (B40.0, B40.7, B40.8, B40.9, B41.0, B41.7, B41.8, and B41.9), whereas chronic forms were excluded. Rates were calculated with census population data and stabilized by Spatial Empirical Bayes smoothing. Space-time cube analysis was applied to detect clusters, which were then compared with deforestation alerts from the DETER-B satellite monitoring system. This study found 4,232 acute PCM hospitalizations, predominantly in men (80%), with a median age of 49 years. Cases were reported in 1,292 municipalities (23%), of which 78% were outside the Amazon. This study also found four significant hotspot clusters, including a newly emergent area in the Cerrado region along the Tocantins-Goias border near Brasilia. Hotspot municipalities showed the largest deforested areas (1,178 km2) when compared to coldspots (24 km2), suggesting a strong spatial association. The spatiotemporal dynamics of acute PCM indicate expansion into deforested areas of the Cerrado, highlighting the role of environmental disruption in shaping disease risk. Mitigating PCM spread in Brazil urgently requires strengthened surveillance and integrated health-environmental policies.

Dengue fever is an acute, systemic, and debilitating febrile illness that poses a significant global public health threat. Vaccination is important in combating the virus in highly prevalent countries, as it reduces the risk of symptomatic infection, hospitalizations, morbidity, and mortality. We report a unique case of atypical dengue fever in a previously healthy 42-year-old Brazilian woman. She developed dengue without the characteristic fever or elevated inflammatory markers 15 days after her initial TAK-003 (Q-denga) vaccine dose, setting her case apart from typical manifestations. 'Whether the mildness of the case was due to the vaccine's protective effect or if it was caused by the vaccine virus itself, as genetic sequencing of DENV-2 was not possible, is unclear. In regions where the vaccine is being introduced, atypical cases, particularly those without fever, require thorough investigation, so dengue can be excluded.