Revista Portuguesa de Doenças Infecciosas (RPDI)
Revista Portuguesa de Doenças Infeciosas is an open-access, peer-reviewed medical scientific publication issued by the Portuguese Society of Infectious Diseases and Clinical Microbiology (SPDIMC). The journal’s mission is to promote, disseminate, and highlight high-quality scientific research in the field of infectious diseases, contributing to the advancement of knowledge, the updating of clinical practice, and the improvement of public health.
Introduction: Occupational human bites (OHB) associated with healthcare are an infrequent cause of occupational accidents (OA). However, they cause significant anxiety and medical care is heterogeneous. Scientific literature on its occurrence is scarce and they are commonly reported as an “aggression”, typically in psychiatric patients. Objectives: To characterize occupational accidents by occupational human bites (OA-OHB) to allow for planning of an appropriate intervention by the Occupational Health Department (OHD). Methods: Retrospective study performed by analyzing OA occurring in a large Portuguese hospital center over a period of 10 years (2013-2022). The number of OA-OHB, wound infections and transmission of bloodborne diseases were determined, and variables related to OA context, injuries and medical care were analyzed. Results: OA-OHB accounted for 1.5% of OA with exposure to potentially infectious organic fluids, in a total of 21 cases. The majority of OHB (78%) occurred in nonpsychiatric inpatient departments and emergency departments, when caring for patients with altered states of consciousness. In none of the cases was aggression reported. Medical care was heterogeneous. No wound infections or transmission of bloodborne diseases were recorded. A guideline was proposed. Conclusions: OHB are not deliberate aggressions to healthcare workers: they are mostly associated to providing care to patients with altered states of consciousness in non-psichiatric departments. There is a substantial risk of wound infection and risk of bloodborne diseases transmission, albeit low. Therefore, they should be considered true occupational accidents and merit the intervention of the responsible OHD and follow-up.
Copyright (c) 2023 Gonçalo Botelho Rodrigues, V. Pacheco, M. Beleza, L. Silva, C. Leitão, T. J. Rodrigues, R. Baptista-Silva, A. Afonso, I. Antunes (Autor) https://creativecommons.org/licenses/by/4.0
Extended-spectrum beta-lactamase producing Enterobacteriaceae
Introduction: Multi-resistant organisms, such as Extended-spectrum betalactamase producing Enterobacterales (ESBL), have emerged, which represents an important Public Health problem. The objective of this study is to characterize the patients in whom ESBL microorganisms were isolated, identify the isolated bacterial agents as well as their origin, identify the biological product and antibiotic therapy used, inferring the consequences on the average length of stay and mortality. Methods: Retrospective study, from January 1st to December 31st, 2022, which included isolations of ESBL-producing bacteria verified in the Internal Medicine Service of a District Hospital. Results: 340 isolates of ESBL-producing strains were included. The isolation of ESBL-producing bacteria occurred in patients who were mostly female and of advanced age. Klebsiella pneumoniae was the most frequently isolated agent (87,3%). Isolation mostly occurred through microbiological urine testing (70,7%). The average length of stay was 14,5 days and the most used antibiotics were carbapenems (82,6%). The mortality rate was 23,8%. Conclusion: The analysis of these data highlights the importance of quickly identifying ESBL-producing strains in order to institute antibiotic therapy early and adopt basic infection control precautions, as there are harmful consequences in terms of length of stay and mortality.
Extended-spectrum beta-lactamase producing Enterobacterales (ESBL)
Copyright (c) 2023 Marisa Brochado, J. Luís, B. V. Andrade, M. Jitari, I. A. Ambrioso, M. Sousa, P. Manata, M.M. Ramos, F.B. Rodrigues, M. I. Santos, G. Miranda, I. Cusnir, C. Nancassa, V. Baiherych, L. Siopa, P. Pinto (Autor) https://creativecommons.org/licenses/by/4.0
Detection of rpoB Gene Mutations Outside the Rifampicin Resistance- Determining Region of Mycobacterium tuberculosis
Pulmonary tuberculosis shlould be diagnosed as early as possible due to the risk of contagion. Although the tests and techniques used in the diagnostic approach have undergone great advances, namely in the laboratory, there are still many challenges being faced on a daily basis, especially regarding strains of the Mycobacterium tuberculosis complex that are resistant to antituberculosis drugs. Molecular tests are rapid and very important in the diagnosis and start of treatment of tuberculosis, but phenotypic tests are still mandatory. Culture isolation allows confirmation of the viability of the bacilli present in the sample and identification for subsequent phenotypic Drug-Susceptibility Testing, which, despite being a slow test, requires specialized infrastructure and highly qualified personnel. In the clinical case presented here, a discordance was identified between the molecular test and the phenotypic Drug-Susceptibility Testing, regarding rifampicin resistance, confirmed by genomic sequencing. Drug-Susceptibility Testing allowed the detection of a multidrug-resistant strain, alerting to the need to perform a second-line antibiogram and detection of the mutations involved through genomic sequencing.
Copyright (c) 2023 Carla Sofia da Costa Correia Amorim, Maria José Padre-Santo Janeiro, Marta Filomena Melo Ferreira Rijo, Tânia Isabel Dias Vermelhudo Batalha, Teresa Leonor Dimas Araújo (Autor) https://creativecommons.org/licenses/by/4.0
Urogenital tuberculosis in a teenager with congenital heart disease
An african migrant teenage girl with complex congenital heart disease, living in Portugal for two years, presents with intermittent haematuria and sterile pyuria with one month of evolution. She was diagnosed with urinary tuberculosis with extensive renal and urothelium involvement, conditioning a papilary necrosis, challyx dilation with caseum filling, uretheral stricture and bladder fibrosis. Urinary tuberculosis it is an insidious disease and a rare diagnosis in children. To reduce potential associated morbidity, urinary tuberculosis should be considered and excluded in patients with recurrent urinary symptoms, like haematuria and sterile pyuria, from countries with a high incidence.
Copyright (c) 2023 Maria do Rosário Stilwell, T. Milheiro Silva, D. Cardoso, G. Neto, M.J. Brito (Autor) https://creativecommons.org/licenses/by/4.0
The diagnostic and treatment challenge of cystoisosporiasis in patients with human immunodeficiency virus infection
Cystoisosporiasis is a human intestinal disease whose etiology is the parasite Cystoisospora belli with infection frequent in immunocompromised subjects, principally HIV-infected and AIDS patients. An 18-year-old female, born in Guinea-Bissau, presented to the Emergency Room with abdominal pain, chronic diarrhea, and weight loss. She had an HIV infection with TCD4+ > 200cells/uL. Voluminous ovarian masses seen on computerized tomography scan conditioned intestinal subocclusion. Although parasitological stools were negative, duodenal biopsies detected infection by Cystoisospora belli. She was treated with trimethoprim-sulfamethoxazole (TMP/SMX) for seven days, and a laparotomy was performed with confirmation of a cystic teratoma. She returned two months later due to the persistence of the previous symptoms with the recurring detection of Cystoisospora belli. Assuming therapy failure, TMP/SMX was started for 30 days with complete resolution. Treatment of Cystoisosporiasis in HIV patients is challenging; there are no clear recommendations for dosage or duration of treatment. Histological detection of infection can favor the diagnosis when clinical suspicion is high but parasitological stools exams are negative.
Copyright (c) 2023 Ana Catarina Rodrigues Gonçalves, G. Cristóvão, V. Almeida, C. Cruz, M. Leal, A Fernandes, J. Santos, D. Seixas, F. Ramirez, F. Maltez (Autor) https://creativecommons.org/licenses/by/4.0
Chronic Chagas Disease with cardiac and gastrointestinal complication
Chagas disease is an infection caused by the protozoa Trypanossoma cruzi. Most infected patients remain in an asymptomatic stage, but 20 to 40% develop symptoms secondary to hearth and gastrointestinal involvement. A female patient, born in Brazil, started follow-up at the Infectious Diseases department at Hospital Beatriz Ângelo. She presented with atrial fibrillation, repeated syncope episodes and chronic dysphagia. After complementary exams the diagnosis of chronic Chagas Disease with dilated cardiomyopathy with depressed ejection fraction, achalasia and megaoesophagus was made. A cardiac resynchronization therapy pacemaker was implanted and a Heller myotomy was performed, with symptomatic improvement. She had no indication to start antiparasitic therapy. It is estimated that the rate of underdiagnosed cases of Chagas Diseases in Portugal can be as high as 99%. This clinical case is presented not only to report on a rare disease in Portugal, but also to raise awareness to this sometimes-forgotten diagnosis amongst clinicians.
Copyright (c) 2023 Salomão Fernandes, Rita Sérvio, Jorge Seixas, Ana Rita Silva, Raquel Tavares, Paulo Rodrigues (Autor) https://creativecommons.org/licenses/by/4.0
Mycobacterium gordonae, an improbable infection on an immunocompetent patient
Introduction: Mycobacterium gordonae, one of the least pathogenic mycobacteria, is in most cases considered a contaminant. Its infection occurs most often in immunocompromised individuals. Clinical case: Male, caucasian 71 years old. In May 2019 he started with nausea, fever and abdominal bar pain. Medicated with Piperacillin/Tazobactam and clindamycin with symptomatic improvement. The imagiologic study showed near the celiac trunk a formation compatible with adenopathic conglomerate that extended to the hepatic hilar region, pancreatic head and isthmus. Laparoscopic biopsy and aspiration cytology of retroperitoneal adenopathic conglomerate and of pancreatic tissue was performed. It showed negative results for malignant cells, fungi and resistant acid-alcohol bacilli. The polimerase chain reaction (PCR) for Mycobacterium gordonae was positive. On 2 of October 2019, he performed another upper digestive endoscopy, that showed a bulging of the gastric antrum by an extra-gastric mass and biopsies were made. Direct examination and culture were negative for bacteria, fungi and mycobacteria. PCR for M. tuberculosis and Nontuberculous mycobacteria were negative. He started therapy with rifabutin, ethambutol and levofloxacin. Abdominal computed tomography (CT) in May 2021, showed that the adenopathic conglomerate had almost disappeared. Discussion: The treatment for M.gordonae is not yet defined. In this case rifambutin, ethambutol and levofloxacin provided effectiveness.
Copyright (c) 2023 Sara Pocinho, Lia Bastos, João Domingos, Sara Casanova, Susana Peres (Autor) https://creativecommons.org/licenses/by/4.0
Mpox virus infection associated with the multi-country 2022 outbreak
In the past, mpox infection was typically characterised by a centrifugal distribution of lesions, with preference for the face and extremities. However, in the 2022 global outbreak, skin lesions have been more likely to appear in the anogenital area and do not always evolve simultaneously throughout the course of infection. The authors describe the case of a 33-year-old male presenting with a 2-week history of an exanthematous rash, which began with two vesicular lesions on the right gluteus. A PCR swab of both lesions tested positive for mpox virus and after signs of inflammation ensued, bacterial cellulitis was admitted, secondary to infection of both swabbed lesions. Empiric treatment with oral amoxicillin/clavulanate was initiated and the patient had a favorable outcome. This clinical case provides insights into the presentation of Mpox infection. Healthcare providers should be cognisant of the variability in the clinical course to ensure accurate diagnosis and management.
Copyright (c) 2023 Miguel Póvoas, Diana Póvoas (Autor) https://creativecommons.org/licenses/by/4.0
Hepatocellular carcinoma related to Hepatitis B Virus infection in the absence of cirrhosis
Introduction: Chronic hepatitis B infection is associated with a risk of developing cirrhosis and hepatocellular carcinoma. Most tumors occur in the presence of cirrhosis, but non-cirrhotic patients appear to maintain an increased risk of hepatocellular carcinoma. Case description: We describe a 58-year-old woman with chronic hepatitis B infection (HBe antigen-negative), with a viral load of less than 2,000 IU/mL. She has normal levels of liver enzymes and doesn’t have any evidence of liver disease. In November 2020, she presents with an elevation of alpha-fetoprotein serum levels, with identification of a solid hepatic nodule on computed tomography scan. The lesion was surgically resected and a histological diagnosis of moderately differentiated hepatocellular carcinoma was established. There was no need for adjuvant therapy. Antiviral treatment for Hepatitis B infection was initiated. She’s in a surveillance program, with no evidence of tumor recurrence. Discussion: Chronic hepatitis B infection, even under virological control, is a risk factor for the development of hepatocellular carcinoma. Multiple host factors contribute to such risk, whose individual role is still being studied. This case is a rare phenomenon and demonstrates the importance of an early diagnosis, which has an important impact on the prognosis of these patients.
Copyright (c) 2023 Ana Carolina Martins Silva, A. P. Tavares, A. L. Vasconcelos (Autor) https://creativecommons.org/licenses/by/4.0
Epidemiological surveillance requires management by gathering, storage and analysing on accurate and reliable information. Our goal was to describe the implementation and adoption of digital technologies to support and enhance integrative care and evidence-based decision-making for epidemiological surveillance. Data was collected at the Northern Portuguese Regional Administration Coordination Group of the Program for the Prevention and Control of Infection and Antimicrobial Resistance until saturation. This is a qualitative study with a descriptive design component using focus group discussions. It was divided in accordance with technology lifecycle stages to describe implementation of digital technology. Crucial activities were identified and executed for each framework step (i) Description on information flow; (ii) Selecting a system; (iii) Planning; (iv) Maintenance and evolution. Continuous Integrated Care Units was selected as a priority area for improvement and introducing new tools to tailor the local needs. Efficient information systems are the cornerstone for infectious disease surveillance. Our work met the proposed aims and highlighted the necessity to adequately implement information systems that meet user needs. The methodological framework adopted in this study could be used as a reference for studies relying on similar situations. Future research will be required to determine the impact of such intervention.
Copyright (c) 2023 Diana Portela, Paula Baptista, Elvira Silva, Pedro Almeida, Victor Freire, António Amorim, Fernando Tavares, Lucas Ribeiro, Bernardo Gomes, Hugo Monteiro (Autor) https://creativecommons.org/licenses/by/4.0
Carbapenem Resistant Enterobacteriaceae screening, impact assessment
Introduction: Screening programs for Carbapenem Resistant Enterobacteriaceae/ Carbapenemase Producers Enterobacteriaceae (CRE/CPE) must take into account costs and consequences, to document their impact and support decision-makers. Aim: Identifying the epidemiological, clinical and economic impact of screening as a strategy to prevent transmission and reducing CRE/CPE. Method: integrative review. Results: Screening prevented colonization and reduced infections and death. Regarding the assessment of the cost-effectiveness of CRE/CPE screening, for a colonization prevalence of 0.05%, the difference in effectiveness between screening and non-screening was not significant, but the low cost of screening made it costeffective. For a prevalence greater than 0.3%, screening generates cost savings compared to no screening, however, when CPE colonization showed a prevalence >60%, screening had higher cost than no screening. Regarding economics and infections avoided per year, some strategies that proved to be effective were: [culture + PCR] algorithm and the implementation of a CRE/CPE computer record. Conclusion: Screening decision can be justified based on cost-effectiveness, CRE/ CPE infections morbidity and mortality, and early intervention potential by the ULPPCIRA and Health Organizations decision makers to prevent outbreaks.
Copyright (c) 2023 Florbela Maria Campos Pereira, G. Monteiro, A. Pereira, F. Salema (Autor) https://creativecommons.org/licenses/by/4.0
Osteomyelitis caused by Clostridium perfringens in a patient with Rheumatoid Arthritis
Osteomyelitis caused by anaerobic bacteria is very rare and the authors are not aware of any previous reports of osteomyelitis caused by this bacterium affecting femur and acetabulum. The authors describe the case of a 48-year-old male with rheumatoid arthritis under intravenous tocilizumab and bilateral hip osteoarthritis, presenting with new onset severe left hip pain and fatigue. After the diagnostic workup, including bone culture, he was diagnosed with osteomyelitis, caused by Clostridium perfringens, affecting femur and acetabulum. The patient initiated treatment with intravenous G penicillin and cotrimoxazole, which were then shifted to oral amoxicillin and clavulanic acid that was maintained continuously. The followup magnetic resonance imaging demonstrated reduction of bone marrow oedema and joint effusion and, despite the functional limitation, the patient has controlled pain and refuses surgery.
Copyright (c) 2022 Rita N. Cunha, Catarina Ambrósio, Nuno Neves, Renata Aguiar, Anabela Barcelos (Autor) https://creativecommons.org/licenses/by/4.0
Infectious Panniculitis caused by Streptococcus pyogenes
Panniculitis refers to disorders with the inflammation of the subcutaneous tissue. Infectious panniculitis is rare in childhood and an unusual presentation of Group A b-haemolytic streptococcus (GABHS) infection. A 13-month-old, previously healthy girl, presented with a three-day fever (> 39°C) and erythematous, non pruriginous rash on her thorax, abdomen, back, and left armpit, which progressed to palpable, non-painful, subcutaneous, nodules with an erythematopurpuric halo. Physical examination revealed an irritable infant, with tachycardia. Laboratory testing showed anaemia, leukocytosis with neutrophilia, and CRP 171 mg/L. Soft tissue ultrasound was compatible with panniculitis with no abscessed areas. Streptococcus pyogenes was isolated from a blood culture. Penicillin and clindamycin were started, with sustained apyrexia starting from the fourth day of treatment. The lesions progressively regressed. Due to the refusal of right plantar support, an MRI was performed revealing the osteomyelitis of the right astragalus. She maintained antibiotic treatment with amoxicillin after discharge for 4 weeks, with the complete resolution of the complaints. Conclusion: Infectious panniculitis is a rare condition in childhood especially without immunodeficiency. GABHS may be the cause of infectious panniculitis, but is not a frequent agent, making this specific case particularly interesting.
Copyright (c) 2022 Inês Fidalgo Martins, Tiago Milheiro Silva, Maria João Brito (Autor) https://creativecommons.org/licenses/by/4.0
Spontaneous retroperitoneal hemorrhage in hypocoagulated patients with SARS-CoV-2 infection
Retroperitoneal hemorrhage is usually associated with trauma or local interventions. Although rare, it can also occur spontaneously. It is known that SARS-CoV-2 infection is related with coagulation disturbances. Despite the higher prevalence of thrombotic phenomena, it is described in the literature the existence of hemorrhagic phenomena, mainly in critical patients. We present a series of 4 patients admitted with SARS-CoV-2 infection in an Infectious disease department, between March 2020 and August 2021, that have developed spontaneous retroperitoneal hemorrhage during their hospital stay. All patients were treated with enoxaparin in therapeutic dose, being one of them also under platelet antiagregation. The cases presented differ in several factor, as hemorrhage presenting symptoms, COVID-19 severity, and the timing between the hemorrhage and the beginning of the infection. Despite all patients having risk factors for spontaneous retroperitoneal hemorrhage, as for anticoagulation, we cannot exclude the possible contribution for the clinical scenario, neither as a causative agent, nor for its severity.
Copyright (c) 2022 Catarina Carreira da Costa, R. J. Gonçalves, J. Cabo, S. Betkova, M. Pinto, B. Mendes, M. Torres, E. Leal, A. Dias, I. Duarte, S. Lino, M. J. Manata, F. Maltez (Autor) https://creativecommons.org/licenses/by/4.0
Comparison between Tuberculinic Test records in the past and current “Interferon Gamma Release Assay” in health professionals exposed in hospital settings
Introduction: Tuberculosis is one of the oldest infectious diseases and is a major cause of death worldwide. Portugal is currently classified a low incidence country (< 20 cases / 100,000 habitants). Nevertheless, healthcare workers have an increased risk of exposure to tuberculosis. Whenever there is a high-risk exposure, contacts should be screened to exclude active disease, followed by an evaluation of latent tuberculosis. For this evaluation, the most available tests are the tuberculin sensitivity test (TST) and the Interferon Gamma Release Assay (IGRA). Objectives: Perform a retrospective and concordance analysis between the results of the IGRA test (QuantiFERON-TB Gold®) and the previous registration of TST in a Tertiary Hospital Center. Conduct an epidemiological assessment of latent tuberculosis among health professionals. Material and methods: Healthcare workers who had high risk exposure according to the definition adopted by the DGS were recruited. Those who had evidence of having had a TST prior to the exposure in question and who were evaluated with IGRA were eligible. Results: In 2017 and 2018, 344 healthcare workers were evaluated and 92 met inclusion criteria. The average age was 42.85 +/- 9.16, with the majority being female (75%). In 60.9% of the cases, the previous TST result were positive, however when the immune response with IGRA was evaluated, only 15.2% were positive. We performed statistical concordance tests that found a low relationship between TST and IGRA, when considering positive TST if the diameter of the induration is greater than 10 mm and when considering with a diameter greater than 15 mm. The same low relationship occurred when considering the temporal distance between the tests. Conclusions: No studies have been found that have followed this methodology. In our study, both with IGRA and TST, the prevalence of positive tests was higher than expected for a country with a low incidence. The agreement between the two tests was weak, and there is no relationship between the results in this light.
Copyright (c) 2022 Alexandre Afonso, J. Silva, V. Pinheiro, R. Silva, V. Pacheco, T. Rodrigues, I. Antunes, A. Ferreira (Autor) https://creativecommons.org/licenses/by/4.0
Aqui chegados, fazemos notar que o quadro clínico de neuro-sífilis – diagnóstico que quer epidemiologicamente, quer clinicamente, é plausível formular em Vincent – é, em muitos aspectos, bastante semelhante ao da neuroborreliose de Lyme na sua fase de disseminação tardia. E evocamos a neuroborreliose de Lyme – inicialmente designada ‘doença de Lyme’ – porque ela, só por si, poderia determinar toda a sintomatologia que Vincent manifestou na sua evolução para a “loucura”.
Copyright (c) 2021 J. A. David de Morais (Autor) https://creativecommons.org/licenses/by/4.0
Clinical management of comorbidities in the aging population living with HIV
Introduction: The number of people living with HIV with 50 years or older has been increasing. This is mainly due to the implementation of combination antiretroviral therapies which allowed the increase in longevity and quality of life of this population. However, most of the aging population living with HIV has at least one comorbidity and thus need a personalized treatment. Aims: This work is the second part of a specialized review. The main goal is to highlight the most relevant issues on prevention, diagnosis and treatment of the comorbidities commonly observed in the Portuguese population living with HIV. Methods: An independent scientific committee coordinated specialized panels, where specialists of different clinical areas analyzed the main comorbidities associated with HIV infection in the Portuguese population. Results: The most common comorbidities associated with HIV infection were identified and the main recommendations for their prevention, diagnosis and treatment are summarized in this paper. Conclusions: Aging of the population living with HIV led to an increase in the emergence of comorbidities belonging to different clinical specialties. Specific recommendations for each one of these areas were compiled in this document with the goal of improving the quality of life of people living with HIV.
Copyright (c) 2021 N. Marques, A. Horta, A. Ferreira, F. Carneiro, J. Massano, J. Ferreira, M. Bragança, N. Tomada, P. Freitas, F. Maltez, J. Saraiva da Cunha, R. Sarmento e Castro, Ana Rita Silva (Autor) https://creativecommons.org/licenses/by/4.0
Prevention of HIV transmission and other infectious diseases in the era of antiretroviral therapy
Introduction: Antiretroviral therapy allowed not only the increase in longevity, but also an improvement of the quality of life of people living with HIV. Implementation of this therapeutic approach had a significative impact in public health, causing a reduction of mother-to-child transmission and allowing indetectable levels of HIV, indicative of protection against its transmission, to be reached. Utilization of this therapeutic approach as pre-exposure prophylaxis (PrEP) has the potential to alter the evolution of this pandemic. Aims: This work aims to approach the use of PrEP and the sexuality, pregnancy and vaccination of people living with HIV with the goal of improving their quality of life. Methods: In October 2020, three specialists of different clinical areas discussed the key strategies for prevention of HIV transmission and of infectious comorbidities. Results: PrEP and precautions during preconception, pregnancy and childbirth were approached as strategies to prevent transmission of HIV-infection. Vaccination and management of sexually transmitted infections were approached as strategies to prevent transmission of certain infectious comorbidities. Conclusions: The recommendations reported in this document, are essential for the improvement of the quality of life of the Portuguese population living with HIV.
Copyright (c) 2021 C. Guerreiro, C. Abreu, A. C. Miranda, F. Maltez, J. Saraiva da Cunha, R. Sarmento e Castro, Ana Rita Silva (Autor) https://creativecommons.org/licenses/by/4.0
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the aetiological agent of the respiratory tract infection called COVID-19, is at the origin of a pandemic with millions of cases diagnosed worldwide. Fast genomic sequencing of this RNA virus allowed the development of diverse diagnostic tests, of which the RT-PCR is the gold standard. During the past year, other diagnostic methods were developed and implemented, thus it is essential for the clinician to be familiar with their advantages and limitations. The correct use of the different methods may allow a better interpretation of the cases identified in hospital settings, namely in the evaluation of transmissibility and in infection control strategies in healthcare institutions.
Copyright (c) 2021 R. Patrocínio de Jesus, C. Rodrigues, S. Gomes, P. Freitas, P. Pacheco (Autor) https://creativecommons.org/licenses/by/4.0
HIV infection in migrant populations in Lisbon
Introduction: Migrants differ in HIV-related health determinants and outcomes and they may also differ in uptake of and response to antiretroviral therapy and subsequent survival. Objectives/ Methods: The aim of this study was to characterise the migrant population under follow-up at our centre by retrospectively analysing clinical records. Results: We identified 541 migrants, mostly men (68%), from Portuguese speaking countries, mainly Brazil (40%) and African Portuguese Speaking Countries (42%). HIV infection was diagnosed the same year they entered in Portugal in 24% of these patients. HIV-1 infection was preponderant (95%) and of probable heterosexual transmission (83.4%). On admission, 39.9% were late diagnosis, 18.5% presenting with opportunistic infections, more frequently active tuberculosis (29%). Most frequently we identified subtype B infections, 56.5% showing no resistance mutations. The majority (85%) are compliant with therapy having undetectable viral loads. Most significant coinfection is hepatitis B, accounting for 82.6% (n=130) of all coinfections. Conclusions: Migrants represent an important percentage of patients attending our centre (18%), and compared to other cohorts we have a significant proportion of Sub-Saharan African patients. Characteristics of infection are determinant for the evolution of the disease and associated comorbidities. Understanding populationspecific differences is vital in order to enhance and adapt health strategies.
Copyright (c) 2021 Marta Leal-dos-Santos, C. Cruz, A. Ferreira Dias, H. Pinheiro, A. Caeiro, M. Torres, E. Leal, A. R. Pinto, P. Simões, S. Betkova, A. R. Garrote, F. Ramirez, D. Póvoas, D. Seixas, J. Sousa Ribeiro, S. Lino, O. Cardoso, T. Martins, M.J. Manata, F. Maltez (Autor) https://creativecommons.org/licenses/by/4.0
Intestinal parasitosis in a pediatric population of the Hospital Professor Doutor Fernando Fonseca
Introduction: Although there has been a progressive and significant decrease in intestinal parasites, certain regions of the country due to the characteristics of their population, such as high immigration rate, population concentration or poverty, may deserve specific considerations. Objectives: To determine the frequency of intestinal parasites in a population of children assisted at the Professor Doutor Fernando Fonseca Hospital, in the metropolitan area of Lisbon, and analyze clinical, sociodemographic and epidemiological variables. Methods: Observational, descriptive study, between March and July 2015, which involved an epidemiological survey and parasitological examination of faeces of 65 children. Results: Pathogenic intestinal parasites were identified in 9% (n=6/65): 6% (n=4/6) with Giardia lambdia, 1.5% (n=1/6) with Hymenolepis nana and 1.5% (n=1/6) with Ascaris lumbricoides. Abdominal pain was the most frequent symptom in 83% (n=5/6) of the cases. An epidemiological context of interest was found in 67% of cases (n=4/6), namely travel abroad, birthplace or residence in an endemic country. Conclusions: A higher rate of parasitism was found in comparison to previous studies, with Giardia lambdia being the most frequent parasite. Results suggest that the search for intestinal parasites remains relevant in the study of children with gastrointestinal symptoms and/or suggestive epidemiological history, even in developed countries.
Copyright (c) 2021 Inês Pinto Ferreira, E. Rocha, M. L. Torre, H. Carreiro, A. Vasconcelos (Autor) https://creativecommons.org/licenses/by/4.0
Many diagnoses have been suggested for Vincent van Gogh’s disease(s). However, it is important to recognize that most of the diagnoses were made by non-doctors, based on equivocal clinical data and did not consider the epidemiological context. Thus, combining epidemiology and clinic, the author, a medical specialist in infectious diseases, admits as possible the diagnosis of Lyme borreliosis, in the late disseminated phase with ‘pseudotumor cerebri’.
Introduction: Tuberculous meningitis is a rare but serious illness, and its diagnosis is very challenging. Clinical case: Male, 86 years old, with arterial hypertension, type 2 diabetes mellitus and polymyalgia rheumatica, treated with corticosteroid and methotrexate. He was admitted to the emergency service with visual hallucinations. The examination and blood tests performed had no significant changes, and the cranial computed tomography revealed cortical atrophy, so the patient was discharged and sent to Neurology query for dementia screening. Due to the persistence of symptoms associated with fever and increase of inflammatory parameters, 2 days later, he was hospitalized and Mycobacterium tuberculosis was detected in the cerebrospinal fluid. He started on a 4-drug regimen associated with dexamethasone and stopped methotrexate, with positive clinical evolution. Discussion: In this case, the presence of multiple risk factors were crucial to the clinical suspicion and the diagnosis, allowing early initiation of the treatment, which is essential for a good prognosis. The diagnosis of latent tuberculosis previous to the initiation of immunosuppressive treatment is essential to avoid potentially fatal complications of the reactivation of the Mycobacterium tuberculosis.
Copyright (c) 2021 Filipa Bacalhau Lima, P. Costa, F. Carreiro, M. Rocha, A. Prisca, L. Dias (Autor) https://creativecommons.org/licenses/by/4.0
Nocardiosis in a renal transplant recipient with HIV infection
The bacteria from the genus Nocardia are Gram-negative fastidious bacilli. Nocardia farcinica seems to be the most virulent within this group, showing a specific antimicrobial resistance profile. Infection by these agents is rare, but immunocompromised patients are a risk group. Clinical and radiological manifestations are non-specific. Pulmonary disease is the most common presentation, and fast progression into disseminated disease can occur in some cases. The diagnosis is often difficult but can be made by microbial cultures and by molecular biology techniques. Here we present a patient with a history of human immunodeficiency virus infection, with good immune and virologic control, treated hepatitis C virus infection and end-stage renal disease submitted to a kidney transplant and being immunosuppressed. Three years post-transplant, he was admitted for fever and diarrhoea, progressing to respiratory failure. Nocardia farcinica was isolated in bronchoalveolar lavage cultures. After literature review, the patient started therapy with intravenous imipenem and oral trimethoprim/ sulfamethoxazole, extending the last for 6 months, with clinical and imagiologic improvement.
Copyright (c) 2021 Margarida Torres, Joana Marques, Luís Falcão, Luísa Pereira, Sara Pereira, João Ribeiro, Patrícia Cotovio, Cecília Silva, Francisco Remédio, Maria José Manata, Fernando Maltez (Autor) https://creativecommons.org/licenses/by/4.0
Cohabitants increase the persistence of SARS-CoV-2 RNA detection in healthcare professionals with COVID-19
Background: Healthcare workers are at increased risk of infection with COVID-19, due to their greater exposure. In the beginning, those who tested positive, were asked to stay in isolation, and were only allowed to return to work after two consecutive negative RT-PCR tests from a respiratory sample with a minimum 24 hours interval. Prolonged RNA detection has been associated with disease severity, age gender and immune response. Objective: We aim to evaluate the impact of isolation measures in prolonged RNA detection. We also aim to study health care workers characteristics. Methods: We performed a retrospective analysis based on the healthcare workers records, from a large hospital in the Center Region of Portugal, who tested positive for COVID-19. During the follow up we collected demographic data, comorbidities, professional category, the existence of cohabitants and isolation measurements. Results: We found an average isolation period of 35 days. Women took longer than men to be discharged. We also found that healthcare workers who did not isolate themselves from their cohabitants took longer than those who did and those who lived alone. Conclusions: Isolation measurements may have an important impact on the reduction of RNA detection period.
Copyright (c) 2021 Joana Oliveira e Silva, A. Afonso, D. Gomes, M. J. Cavaco, R. B. Silva, V. Pacheco, T. Rodrigues, V. Pinheiro, I. Antunes (Autor) https://creativecommons.org/licenses/by/4.0
Infection by Extended- Spectrum Betalactamase producing Bacteria in Patients with Acute Cholecystitis Treated with Surgery
Introduction: Acute cholecystitis can lead to a retrograde infection of the biliary tree. Its treatment is primarily surgical, but early antibiotic therapy is recommended for every degree of severity. Increasingly, bacteria that are resistant to the most common antibiotics, are isolated from these patients making microbiological information in this pathology essential. Methods: The clinical files of patients submitted to urgent cholecystectomy for acute cholecystitis in the General Surgery Department of Bragança Hospital, from 01 January of 2015 to 31 Decembr of 2017, where retrospectively analyzed. Results: In the study period 259 cholecystectomies were performed in patients with acute cholecystitis. The majority of patients were male (~60%) with a median age of 73 years old (variation: 19-98 years old). As for comorbidities, 21,4% presented diabetes mellitus and more than half high blood pressure. The Charlson Comorbidities Index was high, with more than 45% of patients presenting values greater than 4. Biliary samples were collected in 45,4% of operated patients. Of these 51,7% presented positive microbial isolation. Twenty-four different strains of bacteria were isolated, the majority of which Gram-negative (80,3%), namely Escherichia coli (45,5%) and Enterobacter cloacae (10,6%) and Klebsiella pneumoniae (10,6%). In four patients (6,6%), there was a positive isolation of extended-spectrum beta-lactamase (ESBL+) producing bacteria, and in only one of these a healthcare associated infection was clearly present. Additionally, six strains of resistant bacteria were isolated, namely to fluoroquinolones and 3rd generation cephalosporins (non-ESBL+). The presence of a strain with increased antibiotic resistance (ESBL+ or non-ESBL+) was associated to a prolonged in-hospital time or to complication in the postoperative period. Conclusion: The is a high prevalence of acute cholecystitis in our institution, with a low incidence of microbiological isolates of ESBL+ bacterial strains. This low incidence does not allow for the recommendation of empiric coverage of these bacteria for all patients. Nonetheless, the presence of resistant bacteria strains was associated with increased in-hospital time and postoperative complications.
Copyright (c) 2021 João Miguel Carvas, Ana Rodrigues, Júlia Granda, Diego Perez, Madalena Alves, Cristina Nunes, Pelicano Borges (Autor) https://creativecommons.org/licenses/by/4.0
Mono and dual therapies in human immunodeficiency virus infection
Introduction: Mono/dual therapies have gained relevance in the treatment of human immunodeficiency virus infection, whether due to adverse effects, drug interactions, resistance, simplification or toxicity prevention. Objectives: Our goal was to characterize the human immunodeficiency virus infected population, followed in our center, currently undergoing such regimens. Methods: Descriptive retrospective study based on the analysis of clinical files of patients currently on follow-up. Results: Amongst the patients followed, 11% (83) were under monotherapy (8) or bitherapy (75), with median age of 52 [38-80] years and predominantly (61) male. Amongst the comorbidities found, we highlight chronic kidney disease (n=55, 67.3%) and dyslipidemia (n=50, 60.2%), followed by psychiatric pathology and arterial hypertension (n=25, 30.1% each). The most commonly used regimens consisted of boosted protease inhibitors with nucleoside reverse transcriptase analogues (34) or integrase inhibitors (18). All patients started these therapies on switch, 38 previously under mono/dual therapy(s). Main reasons for switching were simplification (43.3%) or adverse effects (25.3%). When changing was due to adverse effects, there was an improvement/resolution in approximately two-thirds. At the last laboratory workup, median CD4+ T lymphocyte count was 625/mm3 and 94.0% were undetectable. Conclusions: After switch, mainly due to therapeutic simplification, patients maintained good tolerance and good immune-virological control.
Copyright (c) 2021 Margarida Martins Mouro, A. Martins, C. Soeiro, D. Coutinho, J. Velez, F. Freitas, C. Oliveira (Autor) https://creativecommons.org/licenses/by/4.0
Introduction: Dengue is a systemic viral infection, whose etiologic agent is an arbovirus, called the Dengue virus (DENV). Dengue is the most widespread viral infection worldwide and represents a threat to Public Health. Aim: This study aims to address the Dengue epidemic that hit Madeira in 2012 and to assess the island’s endemic potential. Methods: The methodology used consisted of a literature search and literature review based on reference articles published in the PubMed database. Results: The occurrence of the first Dengue epidemic in Madeira in 2012 resulted from the increase in the population of Aedes aegypti mosquitoes, as well as the introduction of the DENV-1 serotype. In addition, there is a risk of the introduction and spread of other DENV serotypes in the coming years. In a study carried out to assess the risk of the occurrence of a Dengue epidemic in Madeira, the results showed that both populations of Aedes aegypti are very susceptible to infections by the DENV-2 virus. Discussion: Due to the global threat posed by Dengue, which is expanding its area of activity and reaching areas that were previously free of this arbovirus, it is necessary to explore the feasibility of mosquito control strategies.
Copyright (c) 2021 Débora Nicole Pina Serrano (Autor) https://creativecommons.org/licenses/by/4.0
Central Nervous System Histoplasmosis in a patient living with Acquired Immunodeficiency Syndrome
This report describes a difficult diagnosis of neurohistoplamosis in a patient living with Human Immunodeficiency Virus (HIV). Neurological involvement in cases of histoplasmosis is rare and usually happens when the immune system is compromised. This disease has high morbidity and mortality, and as such is an important differential diagnosis in HIV patients with neurological symptoms, especially in areas where the fungus Histoplasma capsulatum is endemic.
Copyright (c) 2021 João Victor Soares Coriolano Coutinho, Ana Tomé, André Mendonça, Ailton José Soares, Lísia Tomich (Autor) https://creativecommons.org/licenses/by/4.0
Neurosyphilis presenting as acute meningitis
Neurosyphilis is defined as the infection of the central nervous system at any stage of the disease by Treponema pallidum. In the pre-penicillin era the disease was ubiquitous and a major cause of disability and death. Since 2001 there has been a resurgence of syphilis, with high prevalence among individuals coinfected with human immunodeficiency virus. Although neurosyphilis is now uncommon, its prevalence may be increasing and often with atypical manifestations. Here we present a case of a 52-year-old male that presented in the emergency department with acute presentation of meningitis: the sexual history evoked the diagnosis of neurosyphilis that was confirmed with a reactive Venereal Disease Research Laboratories (VDRL) in the cerebrospinal fluid.
Copyright (c) 2021 Filipa Nunes, Marina Vitorino, Beatriz Porteiro, Mariana Costa, Alexys Reis Borges, João Machado (Autor) https://creativecommons.org/licenses/by/4.0