Beatriz Prista-Leão

O presente protocolo clínico foi desenhado para servir como um guia hospitalar na abordagem diagnóstica, terapêutica e de monitorização da neurossífilis, tendo em conta a positividade ou não para o vírus de imunodeficiência humana. A sífilis é uma doença sexualmente transmissível, de notificação obrigatória, conhecida como a grande imitadora nosológica. Em cerca de 30% dos casos de doença não tratada ocorre infeção persistente do sistema nervoso central. A neurossífilis é uma forma grave e progressiva de sífilis, que pode ocorrer em qualquer estádio da doença, com frequente atraso no diagnóstico e tratamento. Classifica-se como neurossífilis precoce (meningite sifilítica, neurossífilis meningovascular ou gomas sifilíticas) e neurossífilis tardia (gomas sifilíticas, demência sifilítica ou tabes dorsalis). A importância da punção lombar prende-se não só com questões diagnósticas, mas também com a avaliação da eficácia do tratamento. O tratamento desta patologia em todos os estádios consiste em penicilina por via parentérica. Com este protocolo pretende-se facilitar a decisão clínica nos casos de suspeita de neurossífilis através de uma conduta sistematizada, individualizada e multidisciplinar.

Introduction: Hepatitis E virus (HEV) infection causes zoonotic hepatitis in Europe, with a higher risk of complications in immunocompromised hosts. HEV natural history in human immunodeficiency virus (HIV) positive patients is not fully understood, and its prevalence is unknown.Objectives: To study the seroprevalence of HEV and prevalence of chronic HEV in HIV‐positive patients from Porto, Portugal.Methods: We randomly selected patients from the cohort of HIV‐positive patients followed in our hospital. We performed an enzyme‐linked immunosorbent assay to search for immunoglobulin G for HEV. When the absorbance/cut‐off was inferior to 3.5, the test was repeated, and a confirmatory test executed in that sample. For reactive tests and for immunosuppressed patients (CD4 count < 200/mm³) with nonreactive test, a polymerase chain reaction (PCR) test was also performed.Results: We included 299 patients. The mean age was 48 and 75.3% were men. Regarding HIV infection, the median follow‐up time was 10 years, the acquisition was mainly heterosexual contact, and 94% were on antiretroviral therapy. Seventy‐six patients (25.4%) had reactive immunoglobulin G (IgG) hepatitis E serology. Patients with a reactive test were older (statistically significant difference). Otherwise, there was no difference between groups concerning birthplace, rural residence, chronic viral hepatitis coinfection, or cirrhosis. Nadir and actual T_CD4+ lymphocyte counts did not differ significantly from patients with HEV reactive and nonreactive serology. Gamma‐glutamyl‐transferase (GGT) was higher in patients with reactive IgG HEV. All serum HEV PCR tests were negative.Conclusions: Seroprevalence of HEV was 25.4% in HIV‐positive patients. Older age and higher GGT correlated to HEV reactive IgG test. No cases of current hepatitis E were found.

Background and Purpose: Prevalence of mucormycosis is growing with the increase of the population at risk. Current recommendations for its management are mostly based on retrospective studies. 3 study aimed to present the cumulative experience of an Infectious Diseases Department from a Portuguese hospital in the management of mucormycosis and discuss the potential gaps in the diagnostic and therapeutic approaches of this infection. Materials and Methods: For the purposes of the study, the electronic hospital database was searched for adult patients with mucormycosis from 1996 to 2019 based on the definition provided by the Consensus Definitions of Invasive Fungal Disease. Demographic, clinical, treatment, and outcome data were collected and compared to what had been described in the related literature. Results: In total, 15 cases of mucormycosis were found, including 11 cases with sinus involvement (10 with central nervous system involvement), two pulmonary, and two gastrointestinal infections. Diabetes mellitus (n=7) and corticosteroid therapy (n=7) were frequent risk factors. Median duration of symptoms before the suspicion of diagnosis was 26 days (3-158). The diagnosis was confirmed in 12 patients mostly by histopathology (n=9); the culture was positive only once. Systemic antifungals and surgical debridement were the backbones of treatment; however, side effects, the need for therapeutic drug monitoring, and the anatomical location of lesions added complexity to management. Overall, seven patients died, two of them before the consideration of clinical suspicion. Conclusion: More medications are becoming available for the treatment of mucormycosis. Nevertheless, we believe that its prognosis will only significantly change through the increase of awareness and reduction of the time to diagnosis. An effective multidisciplinary approach among surgeons, infectious diseases specialists, radiologists, microbiologists, and anatomopathologists is critical to the achievement of this goal.

Background: Multiple sclerosis treatment has changed in the last years with the emergence of new disease-modifying therapies (DMTs). Despite a better efficacy profile, these drugs raise concerns about infectious risk, which needs to be mitigated. Objective: To analyze the results of a systematic collaborative approach between Neurology and Infectious Diseases (ID) Departments in the management of infectious risk and complications in MS patients treated with DMT. Methods: Retrospective collection of MS patients’ demographic and clinical data from clinical records of MS and ID outpatient clinics (2011–2017). Results: We included 149 patients: most had evidence of previous contact with Herpesviridae, and half of them were not immune to hepatitis A and B viruses (HAV and HBV). Vaccines for HAV, HBV, and Streptococcus pneumoniae were administered in 91%, 78%, and 88% of non-immune patients, respectively. JC virus serology monitoring prevented natalizumab (NTZ) initiation or prompted its switch in 34/122 patients. Forty patients had latent tuberculosis, in which 88% were treated. Infectious events occurred in 33 patients, mostly mild urinary, respiratory, and herpes virus group infections. Only three patients required inpatient care. Conclusion: Facing the expansion of the new DMT, we highlight the benefits of an interdisciplinary approach for safer use of the chosen treatment.

Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-SA) is associated with relapsing multifocal skin and soft tissue infections (SSTI), necrotizing pneumonia (NP) and severe musculoskeletal infections. Epidemiology is underknown and underdiagnosis is likely. Recent travel abroad, case clustering and relapsing disease are often reported. We reviewed all cases of PVL-SA infection diagnosed at our center, and found 21 cases over a 43-month period. Most patients were adult males, had relevant travel history, reported recurrent disease and presented with SSTI. Etiologic diagnosis took up to five years; meanwhile, 42% of patients had antibiotic treatments. Draining procedures were required in 43% of patients and intensive care support in 19%. All patients recovered. Methicillin-resistance prevalence was 24%. Only 2/13 decolonized patients had posterior relapsing SSTI, both with likely infected contacts. PVL-SA infection’s severity and impact are clear, even in small case series as ours. Physician awareness and active PVL-gene search are crucial for an adequate management.

Case: We present a case of azole and partial caspofungin-resistant Candida albicans spondylodiscitis, after bariatric surgery with bowel perforation. Treatment included debridement and several months of anidulafungin, complemented with antibacterial therapy because of relapse for bacterial superinfection. After treatment, the infection did not recur clinically or radiologically during one and half years follow-up. Conclusion: Although C. albicans spondylodiscitis is rare, fungi should be suspected as a causative agent. Adequate history, imaging and laboratory testing, and medical and surgical treatment should be performed to successfully eradicate the infection and resolve potential neurological deficits.