BackgroundIn view of the close relationship of Portugal with African countries, particularly former Portuguese colonies, the diagnosis of malaria is not a rare thing. When a traveller returns ill from endemic areas, malaria should be the number one suspect. World Health Organization treatment guidelines recommend that adults with severe malaria should be admitted to an intensive care unit (ICU).MethodsSevere cases of malaria in patients admitted to an ICU were reviewed retrospectively (1990-2011) and identification of variables associated with in-ICU mortality performed. Malaria prediction score (MPS), malaria score for adults (MSA), simplified acute physiology score (SAPSII) and a score based on WHO's malaria severe criteria were applied. Statistical analysis was performed using StataV12.ResultsFifty nine patients were included in the study, all but three were adults; 47 (79,6%) were male; parasitaemia on admission, quantified in 48/59 (81.3%) patients, was equal or greater than 2% in 47 of them (97.9%); the most common complications were thrombocytopaenia in 54 (91.5%) patients, associated with disseminated intravascular coagulation (DIC) in seven (11.8%), renal failure in 31 (52.5%) patients, 18 of which (30.5%) oliguric, shock in 29 (49.1%) patients, liver dysfunction in 27 (45.7%) patients, acidaemia in 23 (38.9%) patients, cerebral dysfunction in 22 (37.2%) patients, 11 of whom with unrousable coma, pulmonary oedema/ARDS in 22 (37.2%) patients, hypoglycaemia in 18 (30.5%) patients; 29 (49.1%) patients presented five or more dysfunctions. The case fatality rate was 15.2%. Comparing the four scores, the SAPS II and the WHO score were the most sensitive to death prediction. In the univariate analysis, death was associated with the SAPS II score, cerebral malaria, acute renal and respiratory failure, DIC, spontaneous bleeding, acidosis and hypoglycaemia. Age, partial immunity to malaria, delay in malaria diagnosis and the level of parasitaemia were not associated with death in this cohort.ConclusionSevere malaria cases should be continued monitored in the ICUs. SAPS II and the WHO score are good predictors of mortality in malaria patients, but other specific scores deserve to be studied prospectively.

BackgroundIn HIV-infected patients, combination antiretroviral therapy (cART) is associated with clinical lipodystrophy (CL) and metabolic abnormalities (MA). This study aimed to evaluate the prevalence of the metabolic syndrome (MS) and its components, and to determine whether patients with or without CL had a different prevalence of MA.MethodsWe evaluated 345 HIV-infected patients on cART using two different MS definitions (NCEP-ATPIII-2005 and IDF-2005) and the Framingham risk score.ResultsCL was present in 58.7% of the patients. The prevalence of the MS was 52.2% (ATPIII) and 43.2% (IDF), and it was not significantly different between patients with (W) or without (WT) CL, regardless of the definition used (ATPIII WCL 52.9% vs WT CL 51.1%; p = 0.738; IDF WCL 41.3% vs WTCL 46.0%; p = 0.379). Moderate concordance was observed between the 2 definitions (kappa = 0.484; p < 0.001) and after gender stratification there was good concordance in women (kappa = 0.759; p < 0.001). Patients with CL had lower waist circumference and HDL-C and higher triglycerides levels. In women, CL was significantly associated with MS, hypertriglyceridemia and low HDL cholesterol independently of age, cART and BMI. Patients with CL had a significantly higher risk of coronary heart disease at 10 years, measured by the Framingham risk score, than patients without CL. Those with CL and with MS had higher frequencies of moderate and high risk categories than those without MS.ConclusionsThe prevalence of the MS was high in these HIV-infected patients with an age average of 40 years and this finding could explain why HIV patients have an increased risk for cardiovascular disease (CVD).

Background. This study aims to describe the characteristics of tuberculosis (TB) patients requiring intensive care and to determine the in-hospital mortality and the associated predictive factors. Methods. Retrospective cohort study of all TB patients admitted to the ICU of the Infectious Diseases Department of Centro Hospitalar de São João (Porto, Portugal) between January 2007 and July 2014. Comorbid diagnoses, clinical features, radiological and laboratory investigations, and outcomes were reviewed. Univariate analysis was performed to identify risk factors for death. Results. We included 39 patients: median age was 52.0 years and 74.4% were male. Twenty-one patients (53.8%) died during hospital stay (15 in the ICU). The diagnosis of isolated pulmonary TB, a positive smear for acid-fast-bacilli and a positive PCR for Mycobacterium tuberculosis in patients of pulmonary disease, severe sepsis/septic shock, acute renal failure and Multiple Organ Dysfunction Syndrome on admission, the need for mechanical ventilation or vasopressor support, hospital acquired infection, use of adjunctive corticotherapy, smoking, and alcohol abuse were significantly associated with mortality (p < 0.05). Conclusion. This cohort of TB patients requiring intensive care presented a high mortality rate. Most risk factors for mortality were related to organ failure, but others could be attributed to delay in the diagnostic and therapeutic approach, important targets for intervention.

J Clin Hypertens (Greenwich). 2012; 14:593–600. © 2012 Wiley Periodicals, Inc. The data on the risk of hypertension in human immunodeficiency virus (HIV)–infected patients, particularly in those with lipodystrophy, are controversial. The authors assessed the impact of lipodystrophy on hypertension in a cohort of HIV‐infected adults receiving combination antiretroviral therapy. This was a cross‐sectional study in which lipodystrophy (clinically and fat mass ratio [FMR]–defined), blood pressure, and body composition (dual‐energy x‐ray absorptiometry and computed tomography) were evaluated in 368 HIV adults. The prevalence of hypertension in HIV patients with or without clinically or FMR‐defined lipodystrophy was similar (with clinical lipodystrophy 35.3% vs without 32.9%, not significant; with FMR lipodystrophy 41.7% vs without 32.2%, not significant). When HIV‐infected patients were classified into 4 categories of fat distribution (based on the presence or absence of lipoatrophy and abdominal prominence), isolated lipoatrophy was not significantly associated with hypertension, but patients with isolated central fat accumulation and mixed forms of lipodystrophy had a significantly higher prevalence of hypertension. Hypertensive HIV patients had significantly higher total fat, central, and central/peripheral fat mass ratio than normotensive ones. After adjustment for age, sex, smoking, and body mass index, hypertension remains significantly associated with central/peripheral fat mass ratio (odds ratio, 1.258; 95% confidence interval, 1.008–1.569). Hypertension was not more prevalent in lipodystrophic HIV‐infected patients, but was significantly associated with central/peripheral fat mass ratio.

BackgroundCryptococcal meningoencephalitis is an opportunistic infection that predominantly affects immunocompromised patients. Hyper immunoglobulin M syndrome is a primary immunodeficiency syndrome that increases susceptibility to several opportunistic infections. Here, we report a case of cryptococcal meningoencephalitis in the context of hyper immunoglobulin M syndrome, a situation that has been reported very few times and whose management is not clearly defined. We describe our management of this case and the outcome of the patient to help in future similar situations.Case presentationThe patient is a 19-year-old Caucasian male student diagnosed with X-linked hyper immunoglobulin M syndrome and treated chronically with weekly intravenous immunoglobulin and daily sulfamethoxazole-trimethoprim. He was admitted to the infectious diseases ward because of headache, diplopia and a cerebral-spinal fluid analysis revealing cryptococcal meningoencephalitis. The patient was treated with liposomal amphotericin and flucytosine with a favorable outcome. Maintenance therapy with fluconazole has continued and will be sustained for 6 months following his upcoming bone marrow transplantation.ConclusionMonitoring for cryptococcal meningoencephalitis should be considered in patients with primary immunodeficiencies, as clinical manifestations may go unnoticed. In these patients, it is expected that chronic treatment with fluconazole will be the only treatment that will prevent reinfection or reactivation, and therefore should be kept at least until bone marrow transplant, the only curative treatment, is performed. It may, however, lead to intolerable side effects and hepatic toxicity.

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Streptococcus dysgalactiae subspecies equisimilis (SDSE) is a β-hemolytic Streptococcus that possesses genetic and clinical similarities to Streptococcus pyogenes. It is increasingly recognized as the etiological microorganism of invasive diseases. We report a case of a 74-year-old male who was admitted to this hospital with lower back and neck pain and infected with leg ulcer. The diagnosis of spondylodiscitis C2-C3 and L1-L3 caused by Streptococcus dysgalactiae subsp. equisimilis was made. The present case demonstrates the risk of older patients of developing invasive disease upon skin infection with Streptococcus dysgalactiae subsp. equisimilis, even when risk factors are absent or well controlled (as was diabetes mellitus in this case), suggesting that the pathogenic potential of SDSE should not be underestimated.

Introduction: Current guidelines recommend the start of antiretroviral therapy before advanced immunosuppression, which is not always possible. The purpose of this study is to evaluate factors associated with the degree of immunosuppression at the diagnosis of HIV infection. Methods: We evaluated demographic and epidemiological data of HIV-infected patients observed at the Department of Infectious Diseases diagnosed between 2006–2011, and analyzed the relationship between these data and the immune status at diagnosis. Statistical analysis was performed using SPSS version 20.0 for Windows. Results: Data from 600 new patients were analyzed. 584 (97.3%) infected by HIV-1. 426 (71%) male. Mean age=42 years (SD=14). Risk factor for HIV infection: sexual in 548 patients (91.3%) (22.8% homo/bisexual). 153 (25.5%) patients had AIDS -defining illness. Origin of patients: general practitioner - 153 (25.5%), hospitalization in the Department of Infectious Diseases - 110 (18.3%), diagnostic screening after partner's diagnosis - 69 (11.5%), hospital consultation - 68 (11 3%), emergency room - 61 (10.2%), anonymous diagnostic testing center - 46 (7.7%), other hospital inpatient services - 31 (5.2%), hospitalization in another hospital - 30 (5%), attempted blood donation - 15 (2.5%), drug addiction treatment center - 8 (1.3%), pregnancy screening - 3 (0.5%) and patient's own initiative - 6 (1%). The mean CD4+ cell count was 319 cells/cmm (SD=274; range: 2–1416). Women were diagnosed at significantly higher CD4+ cell count levels (p=0.005), as well as younger patients (p<0.001). Homo/bisexual patients had CD4+ cell counts significantly higher than the other groups (p<0.001). There were differences in CD4+ cell count depending on the origin of the patients (p<0.001): patients diagnosed at anonymous diagnostic center, drug addiction treatment center, blood donors, pregnant women and coming on their own initiative, had higher CD4+ cell count levels (p<0.001). Patients admitted in the Department of Infectious Diseases were those with the lower CD4+ cell counts. No relationship was found between CD4+ cell count level and year of diagnosis. Conclusion: These results indicate the importance of early HIV screening even in individuals without a perceived risk of acquisition of this infection, so they can benefit from antiretroviral treatment before having advanced immunosuppression