Miltefosine is the first effective oral drug against visceral leishmaniasis. However, there are few data about its role against the increasing problem of HIV-associated visceral leishmaniasis. It is necessary to establish a treatment and secondary prophylaxis approach with miltefosine in this population, particularly for those in whom standard treatment was unsuccessful. We report our experience with miltefosine in 5 HIV-infected patients. Miltefosine was used in relapse treatments (50 mg, b.i.d.) in 3 patients and as maintenance therapy (50 mg, 3 times/week) in all of them. Miltefosine was discontinued after full recovery of immune function in 4 patients. The median disease-free period has been 20 months since miltefosine discontinuation. One patient was lost to follow-up. Miltefosine dosage regimens for the treatment of relapses and for maintenance treatment in HIV-infected patients should be established in prospective studies.

Objective. Laser-treated surfaces for ventricular assist devices. Impact Statement. This work has scientific impact since it proposes a biofunctional surface created with laser processing in bioinert titanium. Introduction. Cardiovascular diseases are the world’s leading cause of death. An especially debilitating heart disease is congestive heart failure. Among the possible therapies, heart transplantation and mechanical circulatory assistance are the main treatments for its severe form at a more advanced stage. The development of biomaterials for ventricular assist devices is still being carried out. Although polished titanium is currently employed in several devices, its performance could be improved by enhancing the bioactivity of its surface. Methods. Aiming to improve the titanium without using coatings that can be detached, this work presents the formation of laser-induced periodic surface structures with a topology suitable for cell adhesion and neointimal tissue formation. The surface was modified by femtosecond laser ablation and cell adhesion was evaluated in vitro by using fibroblast cells. Results. The results indicate the formation of the desired topology, since the cells showed the appropriate adhesion compared to the control group. Scanning electron microscopy showed several positive characteristics in the cells shape and their surface distribution. The in vitro results obtained with different topologies point that the proposed LIPSS would provide enhanced cell adhesion and proliferation. Conclusion. The laser processes studied can create new interactions in biomaterials already known and improve the performance of biomaterials for use in ventricular assist devices.

Ochrobactrum anthropi is a Gram-negative bacillus widely distributed in nature. It is a low virulence and low pathogenic microorganism and human infection by this agent is considered rare. This microorganism can cause bacteremia and in some cases can lead to osteomyelitis and endocarditis. Included in Brucellaceae family, this bacterium is phenotypically and genetically closely related to the Brucella genus and may be misidentified by rapid identification systems. The authors describe a patient admitted to the Infectious Diseases Department with vertebral osteomyelitis initially identified as Ochrobactrum anthropi. Despite appropriate antimicrobial therapy, the blood cultures remained positive and there were no signs of clinical improvement. This raised suspicion of a possible misidentification. It was decided to initiate antimicrobial therapy to include the Brucella genus, with slow but progressive clinical improvement. Samples were sent to Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA) for genotyping, confirming the initial suspicion of misidentification and identifying Brucella melitensis as the causal agent. Timely diagnosis of brucellosis is essential for the correct management and prevention of its consequences for the patient and for safe handling of the laboratory samples, preventing laboratory-acquired infection

The incidence and prevalence of nontuberculous mycobacterial disease is increasing due to enhanced clinician awareness and improved detection methods. The species identification using molecular microbiology techniques allows a better understanding of the differences in pathogenicity and treatment response. A 57-year-old man with a history of B-cell lymphoma in remission was transferred from the hematology department due to fever of unknown origin, night sweats and asthenia. The empirical antibiotic therapy was initiated with no clinical response, and he developed a subacute pneumonia, severe anemia and hepatosplenomegaly. After positive blood, bronchoalveolar lavage and bone marrow cultures, a disseminated Mycobacterium avium-intracellulare complex infection was diagnosed, and the patient began treatment with clarithromycin, rifabutin and ethambutol. Two weeks later, a fourth antibiotic was added, amikacin at first and then linezolid, with slow but gradual improvement. Due to amikacin-related severe kidney injury and linezolid-related severe myelosuppression, the fourth antibiotic was changed to moxifloxacin, which the patient tolerated. After 6 months of therapy, the sensitivity to the regimen was confirmed and the species was identified as Mycobacterium chimaera (MC), using the molecular genetic test GenoType NTM-DR. The blood and tissue cultures were negative after 4 months of therapy, and treatment was continued for 12 months. Although the infection was being treated successfully, the patient's B-cell lymphoma relapsed after 12 months and the patient died. This is a case report of a confirmed severe and disseminated MC infection in an immunocompromised patient using a molecular genetic test, successfully treated using a four-drug regimen.

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Miliary tuberculosis results from the lymphohematogenous spread of Mycobacterium tuberculosis and it is a rare form of this disease. The most affected places are the lymph nodes, pleura, and osteoarticular system, but any organ can be involved. Currently the disease is still endemic in developing countries by its close association with poor living conditions and malnutrition. Other comorbidities, particularly infection by human immunodeficiency virus (HIV), diabetes mellitus, smoking and alcoholism are of great importance in the epidemiology of this disease.The authors describe the case of an adult man from Guinea-Bissau that has been residing in Portugal for the last few months, admitted with complaints of headache. He was submitted to a computerized tomography (CT) scan of the brain which showed multiple lesions. This led to further study and the diagnosis of a disseminated tuberculosis with cerebral, liver, prostate and retroesophageal involvement. He was started on anti-tuberculosis therapy, achieving good results.

We report a case of spondylodiscitis caused by multiresistant Serratia marcescens in a cirrhotic patient who had several Serratia bacteremias after the placement of a transjugular intrahepatic portosystemic shunt (TIPS) device. We concluded that an endovascular stent that can not be removed makes management of recurrent bacteremia difficult. Furthermore, back pain due to bacteremia is indicative of spondylodiscitis. Serratia marcescens can be an aggressive pathogen, causing spinal infection. Key-Words: Serratia marcescens, recurrent bacteremia, spondylodiscitis, TIPS. Case ReportA 59-year-old Caucasian man had liver cirrhosis due to alcohol abuse, which was complicated by portal hypertension and esophageal varices. Because of acute upper gastroenterological bleeding and transesophageal sclerosis of varices, he underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure performed at our hospital. As he also had aspiration pneumonia, intravenous antibiotic therapy with cefoxitin was done for four days. There was gradual clinical improvement, and he was transferred to his local hospital. However, blood cultures collected seven days after TIPS revealed Serratia marcescens, which was only susceptible to cefotaxime, ceftazidime and imipenem. Imipenem was administered during seven days.Three weeks after TIPS, the patient developed low-back pain and fever (38.5ºC), without neurological involvement. Lumbar radiography and computed tomography were compatible with degenerative processes. The blood cultures showed S. marcescens, which was susceptible to the previously-mentioned antibiotics. Imipenem was reinitiated for another seven days. Ten weeks after TIPS, he was transferred to our department to determine the source of the bacteremia. On admission, he complained of worsening lowback pain, and he was febrile (38.3ºC). Laboratory blood examination showed C-reactive protein to be 5.7 mg/dL (normal values: 0.0-0.5 mg/dL), erythrocyte sedimentation rate 48 mm/ hr and white blood cell counts 8.8x10 9 /L, with 75% segmented neutrophils. The blood cultures revealed S. marcescens, which was only susceptible to imipenem.A gallium-67 citrate scan revealed an increased uptake at D9-D11, probably due to spondylodiscitis, which was confirmed by bone scanning with technetium-99m and magnetic resonance imaging. He had no central line devices, and the urine cultures were negative. The abdominal Doppler ultrasound showed a TIPS stent with a normal-direction blood flow. Abdominal ultrasound and chest X-rays, as well as transthoracic echocardiography, were normal.The patient could only walk with the aid of a thoracolumbar brace, and imipenem was administered from the 10 th until the 45 th week after TIPS, with substantial clinical improvement and discrete imaging symptom stabilization. His next presentation was 48 weeks after TIPS, with a recrudescence of fever, despite 36 weeks of antibiotic therapy. He had a satisfactory clinical condition, no longer wore a lumbar support, and the lab data (ESR, CRP, WBC) showed a good re...

Background Mycobacterium malmoense is a nontuberculous mycobacteria seen mainly in two age groups and with different clinical presentations. Most patients are male adults presenting clinical symptoms and signs similar to those of pulmonary tuberculosis. The second group is formed by immunocompetent children with localized cervical lymphadenitis. Although cervical adenitis is the main extrapulmonary manifestation of M. malmoense, virtually all cases of cervical disease were documented in children. Disseminated disease is rare and has been reported in patients with severely impaired immunity. Case report We report a case of a 47-year-old immunocompetent man with a cervical abscess, in whom we identified a M. malmoense pulmonary disease with multiple cervical, thoracic and abdominal adenopathies. Conclusion Extrapulmonary infection due to M. Malmoense needs to be considered on the differential diagnosis of cervical masses and adenopathies, not only in pediatric patients but also in adults with no impaired immunity. A high index of suspicion for nontuberculous mycobacteria is essential for the diagnosis and prognosis.