ABSTRACT Introduction Influenza is an important cause of morbimortality worldwide. Although people at the extremes of age have a greater risk of complications, influenza has been more frequently investigated in the elderly than in children, and inpatients than outpatients. Yearly vaccination with trivalent or quadrivalent vaccines is the main strategy to control influenza. Objectives Determine the clinical and molecular characteristics of influenza A and B infections in children and adolescents with influenza-like illness (ILI). Methods: A cohort of outpatient children and adolescents with ILI was followed for 20 months. Influenza was diagnosed with commercial multiplex PCR platforms. Results: 179 patients had 277 episodes of ILI, being 79 episodes of influenza A and 20 episodes of influenza B. Influenza A and B cases were mild and had similar presentation. Phylogenetic tree of influenza B viruses showed that 91.6% belonged to the B/Yamagata lineage, which is not included in trivalent vaccines. Conclusions: Influenza A and B are often detected in children and adolescents with ILI episodes, with similar and mild presentation in outpatients. The mismatch between the circulating influenza viruses and the trivalent vaccine offered in Brazil may have contributed to the high frequency of influenza A and B in this population.

Pacientes submetidos ao transplante de medula óssea, alogênico ou autogênico, perdem sua memória imunológica de exposição a agentes infecciosos e a vacinas adquiridas durante sua vida e necessitam eventualmente serem revacinados. Toxóide difteriano, tetânico e pertussis (crianças < de 7 anos), Haemophilus influenza do tipo B (Hib) conjugada, polissacáride pneumocócica -- valência 23, vacina inativada de influenza, vacina de pólio inativada e vacinas vivas atenuadas de sarampo-caxumba- rubéola são as vacinas comumente recomendadas em um programa de vacinação de TMO. No entanto, o momento, número de doses e/ou o tempo de duração da imunidade após a vacinação ainda não se encontram estabelecidos. Os protocolos de vacinação entre os vários centros de TMO variam e inexistem dados que propiciem sólidas recomendações. O uso de outras vacinas e perspectivas de diferentes protocolos de vacinação são discutidos nesta revisão.

Autologous and allogeneic BMT recipients lose immune memory of exposition to infectious agents and vaccines accumulated throughout lifetime and therefore need to be revaccinated. Diphtheria toxoid, tetanus toxoid, pertussis vaccine (children < 7 years old), Haemophilus influenza type B (Hib) conjugate, 23-valent pneumococcal polysaccharide, inactivated influenza vaccine, inactivated polio vaccine and live-attenuated measles-mumps-rubella vaccine are the currently recommended vaccines to be included in a vaccination program after BMT. For most of them, the best time of vaccination, the number of vaccine doses and/or the duration of immunity after vaccination have not been established. Vaccination protocols vary greatly among BMT centers suggesting that the lack of sufficient data has not permitted the establishment of solid recommendations. The use of other vaccines and the perspectives for different vaccination protocols are discussed in this review.

We report a case of cutaneous infection caused by Phialemonium curvatum GAMS et COOKE, 1983, after bone marrow transplantation. The genus Phialemonium was created by GAMS & MCGINNIS in 1983 including three new species: Ph. obovatum, Ph. curvatum and Ph. dimorphosporum, and represents an intermediate genus between Acremonium and Phialophora. Nowadays, the genus Phialemonium is considered to be a pheoid fungus which may cause the eventual lesions observed in pheo- and hyalohyphomycosis. Species of this genus have been described as opportunistic agents in humans and animals, mainly as a result of immunosuppression. In the present case, the patient had multiple myeloma and received an allogenic bone marrow transplant from his HLA-compatible brother. Two months after transplantation, he developed purplish and painful nodular lesions on the right ankle. Some of these lesions drained spontaneously and apparently hyaline mycelial filaments were observed, whose culture was initially identified as Acremonium sp. Subsequent studies showed that the fungus was Phialemonium curvatum. The infection was treated with amphotericin B, followed by ketoconazole. The patient was submitted to surgical debridement followed by two skin grafts to repair the bloody area. The duration of the treatment was 4 months and secondary prophylaxis with ketoconazole alone was maintained for one additional month. No recurrence was observed after discontinuation of treatment. The authors comment on the pathogenicity of the genus Phialemonium.

Paciente portador de leucemia mielóide crônica, com irmã HLA-compatível foi submetido a transplante alogênico de medula óssea. No dia +90 pós-TMO foi diagnosticado doença do enxerto contra o hospedeiro (DECH) extensa e iniciado protocolo alternado de imunossupressão com altas doses de ciclosporina A e prednisona. O seguimento ambulatorial foi complicado, com granulocitopenia intermitente e quadros frequentes de sinusite e pneumonia. Um ano após o transplante, o paciente apresentou rouquidão e voz anasalada. Foi realizada uma biópsia de corda vocal mas nenhum agente infeccioso pode ser identificado. Na diminuição das doses das drogas imunossupressoras, houve piora da DECH crônica e foi reiniciado esquema de doses altas no dia +550. Três meses após, permanecendo o quadro de DECH fora do controle, foi tentado imunossupressão com azatioprina sem sucesso. Novo episódio de rouquidão foi observado no dia +700, mas nenhum agente pode ser identificado em nova biópsia de corda vocal. Após um mês, o paciente apresentou secreção nasal sanguinolenta e foi realizada uma raspagem cirúrgica dos seios maxilares. Scedosporium apiospermum foi identificado nas culturas iniciando-se itraconazol na dose de 800 mg/dia. O paciente desenvolveu falência respiratória progressiva e foi a óbito em 15 dias.

A forty-year-old man underwent an allogeneic BMT from his HLA identical sister. GvHD prophylaxis was done with cyclosporine (CyA), methotrexate and prednisone (PDN). On day +90 extensive GvHD was noted and higher doses of immunosuppressive drugs alternating CyA with PDN were initiated. Patient's follow-up was complicated by intermittent episodes of leukopenia and monthly episodes of sinusitis or pneumonia. One year after BMT, the patient developed hoarseness and nasal voice. No etiologic agent could be identified on a biopsy sample of the vocal chord. Upon tapering the doses of immunosuppressive drugs, the patient had worsening of chronic GvHD and was reintroduced on high doses of cyclosporine alternating with prednisone on day +550. Three months later, GvHD remained out of control and the patient was started on azathioprine. On day +700, hoarseness and nasal voice recurred. Another biopsy of the left vocal chord failed to demonstrate infection. Episodes of sinusitis became more frequent and azathioprine was withheld 3 months after it was started. One month later, the patient had bloody nasal discharge and surgical drainage of maxillary sinuses was performed. Histopathology showed hyphae and cultures grew Scedosporium apiospermum. ltraconazole 800 mg/day was initiated. The patient developed progressive respiratory failure and died 15 days later.