In the advanced stages of AIDS, characterized by severe immunodepression, tuberculosis (TB) may present with a clinical picture of septic shock, due to typical bacteremia. Hematogenic dissemination of mycobacteria is frequent in immunodepressed patients with TB or disseminated mycobacteriosis, leading to increased positivity in detection by automated blood culture. The objective of our study was to determine the prevalence of mycobacteremia in patients with AIDS and with prolonged fever seen at the Emilio Ribas Institute of Infectology. Patients with a history of daily fever (37.8ºC), lasting more than 30 days, and with CD4+ helper lymphocyte counts below 200 cells/mL, were selected from February 2001 to March 2002. A 5 mL peripheral blood sample was collected from each patient for mycobacterial blood culture by an automated method, using the BACTEC 9000 MB and MB/BACT techniques. Forty-five patients aged on average 35 years, most of them males, were included in the study. The mean T CD4+ lymphocyte count was 58 cells/mL. Among the samples submitted to blood culture, 30% gave M. tuberculosis growth, with 62% sensitivity. Among the patients with a negative blood culture, nine had received a diagnosis of TB by another method. Automated blood culture proved to be a technique of relevant diagnostic value for M. tuberculosis in patients with prolonged fever in advanced stages of AIDS. The method is simple, and it helps the physician to select the best therapeutic option.

Relata-se um caso de paciente com aids e imunodepressão severa que desenvolveu um quadro diarréico pela forma vacuolar do Blastocystis hominis. Utlizou-se da nitazoxanida, um 5 nitrotiazol, de amplo espectro parasitário, com remissão total da sintomatologia e erradicação da parasitose. A nitazoxanida se mostra como uma nova opção no tratamento da blastocistose em indivíduos com aids, porém estudos adicionais devem ser propostos.

We report a case of a patient with AIDS and severe immunosuppression who developed diarrhea due to a vacuolar stage of Blastocystis hominis. The patient was treated with nitazoxanide, a 5-nitrothiazole broad-spectrum antiparasitic agent. We obtained complete remission of symptoms and eradication of the parasite. Nitazoxanide is a new treatment option for blastocystosis in AIDS patients. Further studies to test its efficacy are needed.

Os abscessos tuberculosos cerebrais em pacientes com aids são raros, existindo apenas 8 casos publicados. Os autores relatam o caso de uma paciente de 34 anos com aids e antecedente de toxoplasmose cerebral, que foi admitida por cefaléia e convulsões. A tomografia computadorizada de crânio evidenciou lesão frontal única, grande, com realce anular e efeito expansivo. Diante da suspeita de abscesso cerebral foi submetida a trepanação, drenando material purulento e demonstrando presença de abundantes bacilos ácido-álcool resistentes. Abordagem cirúrgica e clínica oportuna determinaram uma boa evolução. Os abscessos tuberculosos devem ser considerados no diagnóstico diferencial das massas intracranianas em pacientes com aids. Excisão cirúrgica ou aspiração por estereotaxia e tuberculostáticos constituem as bases do tratamento destas lesões incomuns.

Tuberculous brain abscesses in AIDS patients are considered rare with only eight cases reported in the literature. We describe the case of a 34-year-old woman with AIDS and previous toxoplasmic encephalitis who was admitted due to headache and seizures. A brain computed tomography scan disclosed a frontal hypodense lesion with a contrast ring enhancement. Brain abscess was suspected and she underwent a lesion puncture through a trepanation. The material extracted was purulent and the acid-fast smear was markedly positive. Timely medical and surgical approaches allowed a good outcome. Tuberculous abscesses should be considered in the differential diagnosis of focal brain lesions in AIDS patients. Surgical excision or stereotactic aspiration, and antituberculous treatment are the mainstay in the management of these uncommon lesions.

Intestinal parasites in HIV infected patients are a compelling issue in epidemiological settings with high prevalence of these parasites. The present study reviewed frequencies of diagnosis for common intestinal parasites in HIV infected patients in association with sex, age, HIV risk behavior and CD4 lymphocyte count. Patients with confirmed HIV diagnosis and positive routine stool examination between January and December 2000 were selected. Diagnostic methods for Cyclospora cayetanensis and microsporidia were not included in the routine stool examination. A total of 146 patients had one or more positive samples (median 1.5) with age ranging between 2-75 years (mean: 34). Most of them were male (70.5%) and 53.6% had a CD4 count > 200 cells/mm³ (median: 158.5 cells/mm³). Endolimax nana (27.4%), Entamoeba coli (22.6%), Strongyloides stercoralis (21.9%), Giardia lamblia (13.0%), Isospora belli (12.3%), Ascaris lumbricoides (8.2%), Cryptosporidium parvum (6.8%) were the most frequent parasites diagnosed in this group. G. lamblia was more common in children with vertically transmitted HIV and men who have sex with men. No significant associations were found in relation to sex and age. Patients with CD4 count < 200 cells/mm³ presented lower prevalence of non-pathogenic parasites (e.g. E. nana OR 0.46 and E. coli OR 0.33) but had more pathogenic parasites diagnosed such as S. stercoralis (OR 3,9) and I. belli (OR 3,5) in relation to those HIV-infected individuals with CD4 count e•200 cells/mm³. These results underscore the importance of S. stercoralis in AIDS patients; the decrease in C. parvum prevalence in relation to previous reports from our institution before the routine use of HAART; local differences in parasite profiles in comparison to other epidemiological settings as well as changes in the proportion of diagnosis for pathogenic and non-pathogenic parasites according to the immune compromise due to HIV infection

São apresentados quatro casos de leishmaniose em pacientes com SIDA, sendo dois de leishmaniose visceral e dois com forma cutâneo-mucosa. Lesões cutâneas e de mucosa oral, disseminadas, estavam presentes nos pacientes com a forma tegumentar da doença. Febre prolongada, hepatoesplenomegalia e pancitopenia foram as manifestações principais da forma visceral. A contagem de linfócitos T CD4+ era baixa em todos os casos. A pesquisa de leishmanias foi positiva no aspirado de medula óssea e na biópsia de lesões cutâneas e mucosas. Os pacientes responderam ao tratamento com antimoniais pentavalentes e com a anfotericina B. Poucos casos de coinfecção leishmaniose e HIV têm sido descritos em nosso meio. Apesar da ampla expansão de ambas, até agora suas áreas de distribuição geográfica teve pouca superposição. Os autores recomendam a inclusão desta parasitose no diagnostico diferencial das doenças oportunistas que acometem indivíduos com SIDA.

Few cases of concurrent leishmaniasis and HIV infection have been reported in Brazil, despite both infections being in expansion. Two cases of visceral leishmaniasis and two cases of mucocutaneous leishmaniasis are discussed. Disseminated skin and oral lesions were found in the patients with the cutaneous form of the disease. Prolonged fever, hepatosplenomegaly and pancytopenia were the main manifestations of the visceral form. The CD4 T lymphocyte count was low in all cases. Direct examination of bone marrow aspirate for leishmania and biopsy of cutaneous lesions are the techniques of choice to confirm diagnosis. Pentavalent antimonials and amphotericin B are preferred drugs for the treatment of leishmaniasis, including patients with AIDS. The authors recommend the inclusion of this parasitosis in the differential diagnosis of opportunistic diseases in patients with AIDS.

OBJETIVO: Relatar a importância das parasitoses intestinais em pacientes com Aids, mostrando dados relevantes na literatura médica, com enfoque em especial, abordando a epidemiologia, diagnóstico e tratamento das enteroparasitoses, principalmente da criptosporidíase, isosporíase, microsporidíase e estrongiloidíase. TIPO DE ESTUDO: Revisão narrativa.

OBJECTIVE: To report on the importance of intestinal parasites in patients with AIDS, showing relevant data in the medical literature, with special emphasis on epidemiology, diagnosis and treatment of enteroparasitosis, especially cryptosporidiasis, isosporiasis, microsporidiasis and strongyloidiasis. DESIGN: Narrative review.

Estudo transversal em 200 pacientes portadores da síndrome da imunodeficiência adquirida (AIDS) na cidade de São Paulo, a fim de verificar se a presença de enteroparasitas está associada aos diversos fatores de risco para a infecção pelo HIV. Verificou-se que a diarréia foi mais freqüente no grupo que apresentou parasitose intestinal, sendo a diferença altamente significante (p < 0,0001). O parasita mais prevalente foi a Giardia lamblia em 32 (16%) casos. A associação entre a presença de parasitas nas fezes e os fatores de risco não revelou significado estatístico, principalmente para os patógenos Giardia lamblia e Cryptosporidium parvum (p = 0,99; p = 0,69, respectivamente). Devido à divergência na literatura, convém realizar estudos em outras áreas geográficas do país.

We conducted a cohort survey on 200 AIDS patients in São Paulo, SP, Brazil, to verify if the presence of enteroparasites is associated with the various risk factors for HIV infection. Diarrhea was significantly more frequent in the group of patients presenting enteroparasitosis (p < 0.00001). Giardia lamblia, found in 32 (16%) cases, was the most prevalent parasite. The presence of parasites in the stool samples was not significantly associated with risk factors for HIV infection, mainly when considering Giardia lamblia and Cryptosporidium parvum (p = 0.99 and 0.69, respectively). The controversy found in the literature indicates that additional studies should be done in the different geographical regions of the country.