Paracoccidioidomycosis is a systemic fungal disease occurring in Latin America that is associated with rural environments and agricultural activities. However, the incidence and prevalence of paracoccidiodomycosis is underestimated because of the lack of compulsory notification. If paracoccidiodomycosis is not diagnosed and treated early and adequately, the endemic fungal infection could result in serious sequelae. While the Paracoccidioides brasiliensis (P. brasiliensis) complex has been known to be the causal agent of paracoccidiodomycosis, a new species, Paracoccidioides lutzii (P. lutzii), has been reported in Rondônia, where the disease has reached epidemic levels, and in the Central West and Pará. Accurate diagnoses and availability of antigens that are reactive with the patients' sera remain significant challenges. Therefore, the present guidelines aims to update the first Brazilian consensus on paracoccidioidomycosis by providing evidence-based recommendations for bedside patient management. This consensus summarizes etiological, ecoepidemiological, molecular epidemiological, and immunopathological data, with emphasis on clinical, microbiological, and serological diagnosis and management of clinical forms and sequelae, as well as in patients with comorbidities and immunosuppression. The consensus also includes discussion of outpatient treatments, severe disease forms, disease prevalence among special populations and resource-poor settings, a brief review of prevention and control measures, current challenges and recommendations.

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INTRODUÇÃOMicose sistêmica endêmica de grande interesse para os países da América Latina, a paracoccidioidomicose (PCM) é causada pelo fungo termo-dimórfico Paracoccidioides brasiliensis. Apresenta distribuição heterogênea, havendo áreas de baixa e alta endemicidade. No adulto, a forma clínica predominante é a crônica, mas quando acomete crianças ou adolescentes apresenta-se na forma aguda ou subaguda. Quando não diagnosticada e tratada oportunamente, pode levar a formas disseminadas graves e letais, com rápido e progressivo envolvimento dos pulmões, tegumento, gânglios, baço, fígado e órgãos linfóides do tubo digestivo.De acordo com dados de inquéritos epidemiológicos realizados com paracoccidioidina no Brasil, Venezuela, Colômbia e Argentina, acredita-se que em torno de 50% dos habitantes de zonas endêmicas tenham sido expostos ao agente desta micose. Felizmente, apenas uma proporção muito pequena de indivíduos expostos a P. brasiliensis desenvolve alguma manifestação clínica da micose. Esta micose representa um importante problema de Saúde Pública devido ao seu alto potencial incapacitante e à quantidade de mortes prematuras que provoca, principalmente para segmentos sociais específicos, como os trabalhadores rurais, que além de tudo isso apresentam grandes deficiências de acesso e suporte da rede dos serviços de saúde favorecendo o diagnóstico tardio. A faixa etária mais acometida situa-se entre 30 e 50 anos de idade e mais de 90% dos casos são do sexo masculino. Os indivíduos acometidos pela micose, usualmente encontram-se na fase mais produtiva da vida, sendo que a doença leva a impacto social e econômico.Este documento tem como objetivo estabelecer as diretrizes para o consenso da abordagem clínica, diagnóstica e tratamento da PCM, visando subsidiar os profissionais da saúde no atendimento primário e secundário da doença. ECOEPIDEMIOLOGIANa natureza, P. brasiliensis apresenta-se como estruturas filamentosas contendo propágulos infectantes chamados conídios. Uma vez inalados, os propágulos dão origem a formas leveduriformes do fungo que constituirão sua forma parasitária nos tecidos do hospedeiro. Até recentemente, os humanos eram tidos como os únicos hospedeiros naturalmente infectados por este fungo. Atualmente, alguns animais foram encontrados portadores da infecção, como o tatu.Ao longo das últimas décadas, têm sido observadas notáveis alterações na freqüência, nas características demográficas da população atingida e na distribuição geográfica da PCM. Dependendo da região, a incidência se alterou, sem que se possam justificar totalmente as suas causas. É possível que o aumento da urbanização e melhoria do diagnóstico expliquem, em parte, estas alterações. Além disto, fatores ambientais decorrentes da abertura de novas fronteiras agrícolas, com a derrubada de florestas, sobretudo nas regiões Centro-Oeste e Norte, atingindo marcadamente a Amazônia, também contribuíram para o atual panorama da micose. Como é adquirida a infecção por P. brasiliensis?O grande fator de risco para aquisição da infecção são as...

Chagas disease is now an active disease in the urban centers of countries of nonendemicity and endemicity because of congenital and blood and/or organ transplantation transmissions and the reactivation of the chronic disease in smaller scale than vectorial transmission, reported as controlled in countries of endemicity. Oral transmission of Chagas disease has emerged in unpredictable situations in the Amazon region and, more rarely, in areas of nonendemicity where the domiciliary triatomine cycle was under control because of exposition of the food to infected triatomine and contaminated secretions of reservoir hosts. Oral transmission of Chagas disease is considered when >1 acute case of febrile disease without other causes is linked to a suspected food and should be confirmed by the presence of the parasite after direct microscopic examination of the blood or other biological fluid sample from the patient.

Between June 1989 and December 2005, an observational study of adults co-infected with HIV and Trypanosoma cruzi was conducted, to investigate the spectrum of manifestations of chronic Chagas disease (American trypanosomiasis) in the HIV-positive. The 31 men and 22 women investigated were aged 23-59 years. Each subject was investigated by ambulatory (Holter) and non-ambulatory electrocardiography, chest X-ray, oesophagography and echocardiography (to determine the clinical form of trypanosomiasis), by xenodiagnosis, blood culture and the microscopical examination of blood (to explore their T. cruzi parasitaemia), and by counting their CD4 T cells (to stage their HIV infection). The subjects were followed-up for 1-190 months (median = 58 months) and checked for re-activation of their Chagas disease, which was usually defined by the occurrence of unusual clinical manifestations and/or the detection, by microscopical examination, of trypanosomes in the blood or cerebrospinal fluid. Eleven (20.8%) of the subjects showed re-activation, another nine (17.0%) were found to have developed high T. cruzi parasitaemias but these were only detected by xenodiagnosis or culture, and 15 (28.3%) had illnesses typical of chronic Chagas disease in HIV-negative individuals, with low parasitaemias. Anti-T. cruzi therapy (benznidazole), recommended for 17 patients, resulted in the sustained reduction of parasitaemia in 11 of the 12 subjects who completed treatment. Chagas disease was the cause of death of eight of the 14 subjects who died during the study. Four of the women investigated gave birth, each to a single child, during follow-up, and three of the four babies showed evidence of the congenital transmission of T. cruzi.

Cytomegalovirus infection is a frequent complication after transplantation. This infection occurs due to transmission from the transplanted organ, due to reactivation of latent infection, or after a primary infection in seronegative patients and can be defined as follows: latent infection, active infection, viral syndrome or invasive disease. This condition occurs mainly between 30 and 90 days after transplantation. In hematopoietic stem cell transplantation in particular, infection usually occurs within the first 30 days after transplantation and in the presence of graft-versus-host disease. The major risk factors are when the recipient is cytomegalovirus seronegative and the donor is seropositive as well as when lymphocyte-depleting antibodies are used.There are two methods for the diagnosis of cytomegalovirus infection: the pp65 antigenemia assay and polymerase chain reaction. Serology has no value for the diagnosis of active disease, whereas histology of the affected tissue and bronchoalveolar lavage analysis are useful in the diagnosis of invasive disease.Cytomegalovirus disease can be prevented by prophylaxis (the administration of antiviral drugs to all or to a subgroup of patients who are at higher risk of viral replication) or by preemptive therapy (the early diagnosis of viral replication before development of the disease and prescription of antiviral treatment to prevent the appearance of clinical disease). The drug used is intravenous or oral ganciclovir; oral valganciclovir; or, less frequently, valacyclovir. Prophylaxis should continue for 90 to 180 days. Treatment is always indicated in cytomegalovirus disease, and the gold-standard drug is intravenous ganciclovir. Treatment should be given for 2 to 3 weeks and should be continued for an additional 7 days after the first negative result for viremia.

Acquired by inhalation of the thermal dimorphic fungi Paracoccidioides spp. conidia, paracoccidioidomycosis ranges from symptomatic to severe and potentially fatal disseminated disease. The main focus of this review is to highlight clinical aspects of paracoccidioidomycosis and, its pathogens' diversity ecology and particularities. In addition, we present strategies for therapy, including DNA vaccines and nanostructured drugs. Molecular and morphological data supported the split of the Paracoccidioides genus into two species, Paracoccidioides brasiliensis and Paracoccidioides lutzii. An acute form of the disease affects approximately 5% of cases and involves the phagocytic mononuclear system, resulting in progressive lymphadenopathy. The chronic form affects adult men and frequently involves lungs, skin and mucous membranes, lymph nodes, and adrenal glands. The clinical manifestations depend on the ability of the host to control the fungal multiplication and dissemination. The long survival time of the fungus in the host tissues allows it to evade immune responses; therefore, successful treatment often requires long-time therapy. The consensus for treatment must consider the severity of the disease and includes sulfone derivatives, amphotericin B and azoles. Novel strategies for therapy, based on DNA vaccines and nanostructured drugs are also presented and discussed in this review.

Introduction:The co-infection Trypanosoma cruzi/HIV has been described as a clinical event of great relevance. The objective of this study was to describe clinical and epidemiological aspects published in literature. Methods: It is a systematic review of a descriptive nature from the databases Medline, Lilacs, SciELO, Scopus, from 1980 to 2010. Results: There were 83 articles (2.8 articles/year) with a total of 291 cases. The co-infection was described in 1980 and this situation has become the defining AIDS clinical event in Brazil. This is the country with the highest number of publication (51.8%) followed by Argentina (27.7%). The majority of cases are amongst adult men (65.3%) native or from endemic regions with serological diagnosis in the chronic stage (97.9%) and indeterminate form (50.8%). Both diseases follow the normal course, but in 41% the reactivation of the Chagas disease occurs. The most severe form is the meningoencephalitis, with 100% of mortality without specific and early treatment of the T. cruzi. The medication of choice was the benznidazole on doses and duration normally used for the acute phase. The high parasitemia detected by direct or indirect quantitative methods indicated reactivation and its elevation is the most important predictive factor. The lower survival rate was related to the reactivation of the Chagas disease and the natural complications of both diseases. The role of the antiretroviral treatment on the co-infection cannot yet be defined by the knowledge currently existent. Conclusions: Despite the relevance of this clinical event there are still gaps to be filled.