ABSTRACT Background: Bothrops envenomations can often lead to complications, such as secondary infections. Methods: This cross-sectional study analyzed the medical records of all patients diagnosed with snakebite. Results: A total of 127 patients were included. Clindamycin was the most commonly prescribed antibiotic, with 105 patients (82.7%) receiving it as the primary antibiotic regimen. In 31 (24.4%) individuals, the first-choice antibiotic did not cease the infection. Conclusions: Secondary infection is an important complication resulting from snakebites, and evidence-based management of this complication can contribute to better clinical outcomes.

Abstract Tuberculosis is one of the most common infections worldwide with particularly high incidence rates in countries with unfavorable socioeconomic conditions and among persons with impaired immune systems. While most patients with this disease will present with pulmonary tuberculosis, immunocompromised individuals also commonly present with extrapulmonary manifestations. We report the case of a 28-year-old male patient with end-stage renal disease who presented with long-standing systemic symptoms and genitourinary manifestations, who was diagnosed with urogenital tuberculosis both by clinical and microbiologic criteria. Clinicians should always suspect tuberculosis in patients with chronic symptoms, especially in those with immunosuppression.

Abstract INTRODUCTION: Immunological control of Mycobacterium tuberculosis infection is dependent on the cellular immune response, mediated predominantly by Th1 type CD4+ T cells. Polarization of the immune response to Th2 can inhibit the host immune protection against pathogens. Patients with tuberculosis coinfected with helminths demonstrate more severe pulmonary symptoms, a deficiency in the immune response against tuberculosis, and an impaired response to anti-tuberculosis therapy. METHODS: We evaluated the cellular immune response and the impact of the presence of Ascaris lumbricoides on the immune and clinical response in pulmonary tuberculosis patients. Ninety-one individuals were included in the study: 38 tuberculosis patients, 11 tuberculosis patients coinfected with Ascaris lumbricoides and other helminths, 10 Ascaris lumbricoides patients, and 34 non-infected control individuals. Clinical evolution of pulmonary tuberculosis was studied on 0, 30, 60, and 90 days post-diagnosis of Mycobacterium tuberculosis and Ascaris lumbricoides. Furthermore, immune cells and plasma cytokine profiles were examined in mono/coinfection by Mycobacterium tuberculosis and Ascaris lumbricoides using flow cytometry. RESULTS: There were no statistical differences in any of the evaluated parameters and the results indicated that Ascaris lumbricoides infection does not lead to significant clinical repercussions in the presentation and evolution of pulmonary tuberculosis. CONCLUSIONS: The association with Ascaris lumbricoides did not influence the Th1, Th2, and Th17 type responses, or the proportions of T lymphocyte subpopulations. However, higher serum levels of IL-6 in tuberculosis patients may explain the pulmonary parenchymal damage.

RESUMO Objetivo: Identificar fatores preditores de mortalidade em pacientes da UTI coinfectados por tuberculose (TB)/HIV em Manaus (AM). Métodos: Estudo retrospectivo de coorte com pacientes coinfectados por TB/HIV, com mais de 18 anos de idade e admitidos na UTI entre janeiro de 2011 e dezembro de 2014. Foram avaliadas variáveis sociodemográficas, clínicas e laboratoriais. Para identificar fatores preditores de mortalidade, foi empregado um modelo de riscos proporcionais de Cox. Resultados: Durante o período estudado, 120 pacientes com coinfecção por TB/HIV foram admitidos na UTI. A média de idade foi de 37,0 ± 11,7 anos. Dos 120 pacientes avaliados, 94 (78,3%) morreram; dos 94 óbitos, 62 (66,0%) ocorreram na primeira semana após a admissão. Havia dados sobre ventilação mecânica invasiva (VMI) e SARA referentes a 86 e 67 pacientes, respectivamente. Dos 86, 75 (87,2%) foram submetidos a VMI, e, dos 67, 48 (71,6%) apresentaram SARA. Os fatores que se relacionaram independentemente com a mortalidade foram VMI (p = 0,002), hipoalbuminemia (p = 0,013) e contagem de CD4 < 200 células/mm3 (p = 0,002). Conclusões: Elevada mortalidade precoce foi observada em pacientes com coinfecção por TB/HIV admitidos na UTI. Os fatores preditores de mortalidade nessa população foram VMI, hipoalbuminemia e imunodepressão grave.

ABSTRACT Objective: To identify factors predictive of mortality in patients admitted to the ICU with tuberculosis (TB)/HIV coinfection in the Manaus, Amazon Region. Methods: This was a retrospective cohort study of TB/HIV coinfected patients over 18 years of age who were admitted to an ICU in the city of Manaus, Brazil, between January of 2011 and December of 2014. Sociodemographic, clinical, and laboratory variables were assessed. To identify factors predictive of mortality, we employed a Cox proportional hazards model. Results: During the study period, 120 patients with TB/HIV coinfection were admitted to the ICU. The mean age was 37.0 ± 11.7 years. Of the 120 patients evaluated, 94 (78.3%) died and 62 (66.0%) of those deaths having occurred within the first week after admission. Data on invasive mechanical ventilation (IMV) and ARDS were available for 86 and 67 patients, respectively Of those 86, 75 (87.2%) underwent IMV, and, of those 67, 48 (71.6%) presented with ARDS. The factors found to be independently associated with mortality were IMV (p = 0.002), hypoalbuminemia (p = 0.013), and CD4 count < 200 cells/mm3 (p = 0.002). Conclusions: A high early mortality rate was observed among TB/HIV coinfected ICU patients. The factors predictive of mortality in this population were IMV, hypoalbuminemia, and severe immunosuppression.

Abstract This article reviews tuberculosis control actions performed over the last decade, at a global level. The perspectives for the fulfillment of the goals of the new Global Tuberculosis Elimination Plan are described, where the insertion of social protection (Pillar 2) and research (Pillar 3) will play an innovative and strategic role, especially in high-burden countries, like Brazil.

Tuberculosis (TB) is one of the infectious diseases that contributes most to the morbidity and mortality of millions of people worldwide. Brazil is one of 22 countries that accounts for 80% of the tuberculosis global burden. The highest incidence rates in Brazil occur in the States of Amazonas and Rio de Janeiro. The aim of this study was to describe the temporal distribution of TB in the State of Amazonas. Between 2001 and 2011, 28,198 cases of tuberculosis were reported in Amazonas, distributed among 62 municipalities, with the capital Manaus reporting the highest (68.7%) concentration of cases. Tuberculosis was more prevalent among males (59.3%) aged 15 to 34 years old (45.5%), whose race/color was predominantly pardo (64.7%) and who had pulmonary TB (84.3%). During this period, 81 cases of multidrug-resistant TB were registered, of which the highest concentration was reported from 2008 onward (p = 0.002). The municipalities with the largest numbers of indigenous individuals affected were São Gabriel da Cachoeira (93%), Itamarati (78.1%), and Santa Isabel do Rio Negro (70.1%). The future outlook for this region includes strengthening the TB control at the primary care level, by expanding diagnostic capabilities, access to treatment, research projects developed in collaboration with the Dr. Heitor Vieira Dourado Tropical Medicine Foundation .;Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD).; and financing institutions, such as the project for the expansion of the Clinical Research Center and the creation of a hospital ward for individuals with transmissible respiratory diseases, including TB.

Problem The World Health Organization has endorsed the Xpert MTB/RIF (Xpert), an automated polymerase-chain-reaction-based assay, for the rapid diagnosis of tuberculosis. However, large-scale use of a new technology calls for preparation and adaptation. Approach A pilot implementation study was conducted in two Brazilian cities to explore the replacement of sputum smear microscopy with Xpert. The laboratories included covered 70% of the tuberculosis cases diagnosed, had no overlap in population catchment areas, handled different workloads and were randomly shifted to Xpert. Sputum samples were collected through the same routine procedures. Before the study the medical information system was prepared for the recording of Xpert results. Laboratory technicians were trained to operate Xpert machines and health workers were taught how to interpret the results. Local setting The average annual tuberculosis incidence in Brazil is around 90 cases per 100 000 population. However, co-infection with the human immunodeficiency virus and multidrug resistance are relatively infrequent (10% and < 2%, respectively). Relevant changes Of the tested sputum samples, 7.3% were too scanty for Xpert and had to be examined microscopically. Ten per cent of Xpert equipment needed replacement, but spare parts were not readily available in the country. Absence of patient identification numbers led to the introduction of errors in the medical information system. Lessons learnt For nationwide scale-up, a local service provider is needed to maintain the Xpert system. Ensuring cartridge availability is also essential. The capacity to perform smear microscopy should be retained. The medical information system needs updating to allow efficient use of Xpert.

Resumen Situación La Organización Mundial de la Salud ha aprobado Xpert MTB/RIF (Xpert), un ensayo automatizado basado en la reacción en cadena de la polimerasa para el diagnóstico rápido de la tuberculosis (TB). Sin embargo, el uso a gran escala de una tecnología nueva requiere una preparación y adaptación. Enfoque Con objeto de examinar la sustitución de la microscopia de frotis de esputo con Xpert, se llevó a cabo un estudio piloto de implementación en dos ciudades brasileñas. Los laboratorios participantes incluyeron el 70 % de los casos de tuberculosis diagnosticados, no se produjo ningún solapamiento en las zonas de captación de población, manejaron cargas de trabajo distintas y se asignaron a Xpert de forma aleatoria. Las muestras de esputo se recogieron a través de los mismos procedimientos rutinarios. Antes del estudio, se preparó el sistema de información médica con objeto de registrar los resultados de Xpert. Se capacitó a los técnicos de laboratorio para operar máquinas Xpert y se enseñó a los trabajadores sanitarios cómo interpretar los resultados. Marco regional La tasa de incidencia anual media de la tuberculosis en Brasil es de unos 90 casos por cada 100 000 habitantes. Sin embargo, la coinfección con el virus de la inmunodeficiencia humana y la multirresistencia son relativamente poco frecuentes (10 % y < 2 %, respectivamente). Cambios importantes De las muestras de esputo sometidas a prueba, el 7,3 % fueron demasiado escasas para Xpert y tuvieron que ser examinadas con microscopio. El diez por ciento de los equipos Xpert necesitó piezas de repuesto, pero estas no estaban disponibles en el país. La ausencia de números de identificación de pacientes dio lugar a la introducción de errores en el sistema de información médica. Lecciones aprendidas La expansión nacional del sistema Xpert necesita un proveedor de servicios local que se haga cargo del mantenimiento del sistema. También es fundamental garantizar la disponibilidad de los cartuchos, y debería conservarse la capacidad de realizar microscopias de frotis. El sistema de información médica debe mantenerse actualizado para permitir un uso eficiente de Xpert.

Résumé Problème L'Organisation mondiale de la Santé a approuvé Xpert MTB/RIF (Xpert), un test automatisé basé sur l'amplification en chaîne par polymérase, pour le diagnostic rapide de la tuberculose (TB). Cependant, l'utilisation à grande échelle d'une nouvelle technologie exige une préparation et une adaptation préalables. Approche Une étude de mise en œuvre pilote a été menée dans deux villes du Brésil pour étudier le remplacement de l'examen au microscope des frottis d'expectoration par Xpert. Les laboratoires inclus couvraient 70% des cas de TB diagnostiqués, ne présentaient pas de chevauchement dans les bassins de vie des populations, traitaient différentes charges de travail et basculaient aléatoirement vers l’utilisation de Xpert. Les échantillons d'expectoration étaient recueillis avec les mêmes procédures de routine. Avant l'étude, le système d'informations médicales a été préparé pour l'enregistrement des résultats Xpert. Les techniciens de laboratoire ont été formés à l'utilisation des machines Xpert, et le personnel de santé a appris à interpréter les résultats. Environnement local Le taux moyen annuel d'incidence de la TB au Brésil est d'environ 90 cas pour 100 000 habitants. Cependant, la co-infection avec le virus de l'immunodéficience humaine et la multirésistance aux médicaments sont relativement peu fréquentes (10% et > 2%, respectivement). Changements significatifs Parmi les échantillons d'expectoration testés, 7,3% étaient insuffisants pour Xpert et ont dû être examinés par microscope. Dix pour cent de l'équipement Xpert a dû être remplacé, mais les pièces de rechange n'étaient pas facilement disponibles dans le pays. L'absence de numéros d'identification des patients a conduit à l'apparition d'erreurs dans le système d'informations médicales. Leçons tirées Pour un déploiement à l'échelle du pays, un prestataire de service local est nécessaire pour la maintenance du système Xpert. Assurer la disponibilité des cartouches est également indispensable. La capacité à effectuer les examens des frottis par microscope doit être maintenue. Le système d'informations médicales doit être mis à jour pour permettre l'utilisation efficace de Xpert.

We present a patient with Paracoccidioidomycosis/HIV coinfection which has been investigated because of chronic monoarthritis and mucocutaneous lesions. A biopsy of the synovial membrane and skin revealed structures consistent with Paracoccidioides brasiliensis. At diagnosis, the count of CD4 + T cells was 44 cells/mm3. We emphasize the importance of clinical suspicion of Paracoccidioidomycosis in patients with HIV/AIDS who live in or are from risk areas.