Three new cases of reactivation of Chagas' disease in patients with AIDS, with central nervous system and/or cardiac involvement, are reported. One patient had histological evidence of acute esophageal and gastric Trypanosoma cruzi myositis, a previously unrecognized finding in patients with reactivated Chagas' disease. The patients had a low CD4 lymphocyte count and had other AIDS-defining opportunistic infections. One patient's condition improved with benznidazole therapy. Analysis of these three cases and review of the 13 others published in the literature revealed that the central nervous system is the most commonly involved site (75%), followed by the heart (44%). Early diagnosis and treatment with benznidazole or nifurtimox probably improve the survival rate. Long-term secondary prophylaxis should be recommended for patients who respond to therapy, although it is uncertain which drug to use for this purpose. T. cruzi should be included in the list of opportunistic pathogens causing infection in severely immunocompromised patients with AIDS.
Acquired immunodeficiency syndrome (AIDS) is one of the main causes of death in adults worldwide. More commonly than in the general population, in patients with AIDS there is substantial disagreement between causes of death which are clinically suspected and those established by postmortem examination. The findings of 52 postmortem examinations were compared to the premortem (clinical) diagnoses, and there was 46% agreement between them. Fifty two percent of the patients had more than one postmortem diagnosis, and 48% had at least one AIDS-related disease not suspected clinically. Cytomegalovirus infection was the commonest (30.7%) autopsy finding, but not a single case had been suspected premortem. Bacterial infection, tuberculosis, and histoplasmosis were also common, sometimes not previously suspected, postmortem findings. This study shows that multiple infections occur simultaneously in AIDS patients, and that many among them are never suspected before the postmortem examination. These findings suggest that an aggressive investigation of infections and cancers should be done in patients with AIDS, particularly in those who do not respond to therapy of an already recognized condition.
A paracoccidioidomicose é micose sistêmica de distribuição geográfica limitada à América Latina, com maior incidência no Brasil, Venezuela, Colômbia, Equador e Argentina. Causada pelo fungo dimórfico Paracoccidioides brasiliensis, é adquirida por via inalatória, resultando na formação de um complexo primário pulmonar ganglionar que, na maioria das vezes, regride espontaneamente com o estabelecimento de imunidade específica do hospedeiro. Antes do estabelecimento desta imunidade, porém, usualmente ocorre disseminação linfohematogênica, desenvolvendo-se focos secundários em qualquer sítio orgânico, que igualmente regridem com o surgimento da imunidade. Nas lesões residuais da primoinfecção, pulmonares ou extrapulmonares, o fungo pode permanecer viável, em latência, por muitos anos. Estes casos regressivos de infecção geralmente são assintomáticos ou com manifestações pouco expressivas e inespecíficas, sendo detectadas pela reação intradérmica à paracoccidioidina. As formas progressivas e disseminadas geralmente atingem os pulmões, mucosas, linfonodos, pele e adrenais; porém, ocasionalmente podem atingir qualquer órgão ou sistema. A apresentação clínica e o curso da doença variam de paciente para paciente 2 . Excepcionalmente, as lesões ósseas e/ou articulares apresentam-se como manifestações isoladas desta micose, sem qualquer evidência clínica de envolvimento de outros órgãos 1 . No presente trabalho relatamos um caso de paracoccidioidomicose articular, no qual a avaliação clínica e laboratorial não evidenciou da infecção em nenhum outro local do organismo. RELATO DE CASO
RESUMO -Linfomas não Hodgkin de alto grau são comumente relatados em pacientes com a síndrome da imunodeficiência adquirida (AIDS). Comprometendo com grande freqüência o sistema nervoso central, particularmente as leptomeninges e os hemisférios cerebrais. O acometimento epidural é pouco freqüente, variando de 3,5% a 8,3% de acordo com os registros da literatura. Os autores relatam o caso de um paciente de 27 anos de idade com AIDS, cuja manifestação clínica inicial da doença linfomatosa disseminada foi a mielite transversa associada à mielopatia vacuolar. Destaca-se a importância do diagnóstico diferencial precoce das mielopatias na AIDS, em virtude da alta malignidade da neoplasia e da evolução extremamente rápida nesses pacientes. PALAVRAS-CHAVE: mielite transversa, linfoma não Hodgkin, mielopatia vacuolar, AIDS.Transverse myelitis as initial symptom of disseminated non-Hodgkin lymphoma and HIV-associated vacuolar myelopathy: case report ABSTRACT -Non-Hodgkin lymphoma is frequently seen in AIDS patients usually affecting the central nervous system (CNS), especially the leptomeninges and the cerebral hemispheres. The epidural involvement is rarely described, ranging from 3.5% to 8.3% among the CNS sites. The authors present a case of disseminated non Hodgkin lymphoma associated to vacuolar myelopathy in a 27 years-old male patient with AIDS emphasizing the importance of this differential diagnosis in the myelopathies of AIDS.KEY WORDS: acute transverse myelitis, non-Hodgkin lymphoma, vacuolar myelopathy, AIDS.O comprometimento crônico da medula espinhal mais freqüente na síndrome da imunodeficiência adquirida (AIDS) é a mielopatia vacuolar, diferentemente registrado entre cerca de 30 e 90% dos pacientes com acometimento do sistema nervoso pelo HIV (vírus da imunodeficiência humana) 13 -24 . Os vacúolos que definem a patologia são caracterizados por alargamento dos espaços interlamelares e periaxonais, que geralmente contêm macrófagos. Topograficamente, as lesões se concentram nos funículos laterais e posteriores da medula espinhal e regionalmente, com maior freqüência, no segmento torácico 7 . A correlação entre a presença do HIV e a mielopatia tem sido
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