ABSTRACT A 34-year-old man presented with a history of 21-days of gait unsteadiness and diplopia. Ten days before presentation, he developed limb weakness and in the last three days reduced consciousness. HIV infection was diagnosed three months ago (CD4+ = 160 cells/ mm3; viral load HIV-1 = 144.000 copies/mL), and antiretroviral therapy was initiated. Impaired consciousness, ophthalmoplegia, limb weakness, ataxia, areflexia, and Babinskys sign were noted. At that moment, CD4+ count was 372 cells/mm 3 and viral load HIV-1 < 50 copies/mL. The clinical, laboratory and neurophysiological findings suggest overlapping Guillain-Barré syndrome (GBS) and Bickerstaff brainstem encephalitis as manifestation of HIV-related immune reconstitution inflammatory syndrome (IRIS). Here, we review and discuss 7 cases (including the present report) of GBS spectrum as manifestation of HIV-related IRIS.

ABSTRACT The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.

ABSTRACT Cryptococcal meningitis is the most common cause of opportunistic meningitis in HIV-infected patients in Brazil and causes unacceptable high mortality rates. In this study, HIV-infected patients with a first episode of culture-proven cryptococcal meningitis in cerebrospinal fluid (CSF) were prospectively included in order to evaluate sensitivity of cryptococcal antigen (CrAg) lateral flow assay (LFA) in serum, CSF, whole blood (fingerstick), and fresh urine. In addition, HIV-infected patients with other neurological confirmed diseases were included in order to evaluate the specificity of CrAg LFA in serum. Twenty patients with cryptococcal meningitis were included and in 19 of them, CrAg LFA in CSF, serum, and whole blood were positive (95% sensitivity). In 18 patients, India ink test was positive in CSF (90% sensitivity), and in 16 cases, CrAg LFA was positive in urine (80% sensitivity). Thirty-six HIV-infected patients with other neurological diseases had negative results of CrAg LFA in serum (100% specificity). In conclusion, CrAg LFA in serum, CSF, and whole blood showed high sensitivity and specificity. Whole blood CrAg LFA seems to be a good and reliable strategy to improve AIDS-related cryptococcal meningitis diagnosis in Brazil.

RESUMO Meningite meningocócica (MM) é um problema de saúde pública. Os objetivos deste estudo foram descrever características clinicas de pacientes com MM, e identificar fatores associados à mortalidade intra-hospitalar. Trata-se de um estudo retrospectivo, entre 2006 e 2011, em um centro de referência, São Paulo, Brasil. Análise de regressão logística multivariada foi usada para identificar fatores associados na admissão com mortalidade intra-hospitalar. Foram incluídos 316 casos. A média de idade foi 16 anos (IQR: 7–27) e 189 (60%) eram do sexo masculino. A tríade clínica: febre, cefaléia e rigidez de nuca foi observada em 89% dos casos. A tríade do exame de líquor: pleocitose, proteinorraquia elevada e hipoglicorraquia ocorreu em 79% dos casos. Fatores associados à mortalidade no modelo multivariado foram: idade acima de 50 anos, convulsões, taquicardia, hipotensão e rigidez de nuca. Tríades clínicas e laboratoriais clássicas de MM foram variáveis. Na admissão, idade, convulsões, taquicardia e hipotensão associaram-se independentemente com o desfecho.

ABSTRACT Meningococcal meningitis is a public health problem. The aim of this study was to describe the clinical characteristics of patients with meningococcal meningitis, and to identify associated factors with mortality. This was a retrospective study, between 2006 and 2011, at a referral center in São Paulo, Brazil. Logistic regression analysis was used to identify factors associated with mortality. We included 316 patients. The median age was 16 years (IQR: 7–27) and 60% were male. The clinical triad: fever, headache and neck stiffness was observed in 89% of the patients. The cerebrospinal triad: pleocytosis, elevated protein levels and low glucose levels was present in 79% of patients. Factors associated with mortality in the multivariate model were age above 50 years, seizures, tachycardia, hypotension and neck stiffness. The classic clinical and laboratory triads of meningococcal meningitis were variable. The fatality rate was low. Age, seizures and shock signs were independently associated with mortality.

ABSTRACT Um aumento expressivo da incidência de alterações cognitivas em pacientes com AIDS/HIV vem ocorrendo, assim três categorias de acometimento cognitivo foram propostas: comprometimento cognitivo assintomático (ANI) e alteração cognitiva leve/moderada (MND) que correspondem às formas leves e intermediárias; e demência associada ao HIV (HAD), a forma mais grave. O termo HIV-associated neurocognitive disorders (HAND) é uma denominação genérica que engloba as três categorias de acometimento. A aplicação de métodos de neuroimagem agregou grande avanço no entendimento das alterações neurológicas do HIV, promovendo maior confiabilidade na exclusão de patologias associadas e diagnóstico mais precoce. Diante disso, as alterações ou características específicas de neuroimagem podem ser em breve incorporadas aos critérios de classificação da HAND, o que será de grande valor no seu manejo, inclusive no auxílio para a otimização de esquemas antirretrovirais de alta penetração no SNC.

ABSTRACT A significant increase in the incidence of cognitive impairment in HIV/AIDS patients has been continuously observed. Consequently, three classification categories of cognitive impairment have been proposed: asymptomatic neurocognitive impairment (ANI) and mild neurocognitive disorder (MND), that correspond to the mild and intermediate forms, and HIV-associated dementia (HAD) for the most severe cases. HIV-associated neurocognitive disorders (HAND) is a broad term that encompasses these three categories. Moreover, the application of neuroimaging methods has led to a major breakthrough in understanding of the neurological changes in HIV, providing greater reliability in the exclusion of associated diseases and allowing earlier diagnosis. Therefore, abnormalities and/or specific neuroimaging elements may soon be incorporated into the HAND classification criteria, which will be of great value in the management of these diseases, including in the optimization of high CNS penetration antiretroviral regimens.

A reativação da doença de Chagas em pacientes com a infecção pelo HIV apresenta uma alta morbidade e mortalidade. Neste relato, apresentamos caso confirmado de meningoencefalite chagásica, como doença definidora de aids, em paciente com 318 linfócitos T-CD4+/mm3. Após 2 meses de tratamento seguido de um ano de profilaxia secundária com benzonidazol e início precoce de terapia antirretroviral (HAART), a paciente apresentou boa evolução clínica, parasitológica e radiológica. Utilizamos a reação em cadeia da polimerase qualitativa do T. cruzi, para monitorização da parasitemia por T. cruzi durante e após o tratamento. Ressaltamos o valor potencial das técnicas moleculares associadas aos parâmetros clínicos e radiológicos nos pacientes com doença de Chagas e infecção pelo HIV. A introdução precoce da terapia antirretroviral, a terapia antiparasitária prolongada, manutenção e descontinuação da mesma, são desafios atuais, embora possíveis, no manejo da reativação da doença de Chagas na era das terapias antirretrovirais de alta eficácia.

The reactivation of Chagas disease in HIV infected patients presents high mortality and morbidity. We present the case of a female patient with confirmed Chagasic meningoencephalitis as AIDS-defining illness. Interestingly, her TCD4+ lymphocyte cell count was 318 cells/mm3. After two months of induction therapy, one year of maintenance with benznidazol, and early introduction of highly active antiretroviral therapy (HAART), the patient had good clinical, parasitological and radiological evolution. We used a qualitative polymerase chain reaction for the monitoring of T. cruzi parasitemia during and after the treatment. We emphasize the potential value of molecular techniques along with clinical and radiological parameters in the follow-up of patients with Chagas disease and HIV infection. Early introduction of HAART, prolonged induction and maintenance of antiparasitic therapy, and its discontinuation are feasible, in the current management of reactivation of Chagas disease.

BACKGROUND: Cerebral toxoplasmosis (CT) continues to cause significant morbidity and mortality in human immunodeficiency virus (HIV)-infected patients in Brazil. In clinical practice, the initial diagnosis is usually presumptive and alternative diagnosis tools are necessary. Our objective was to evaluate whether the detection of high titers of IgG anti-Toxoplasma gondii and T. gondii DNA in blood samples are associated with the diagnosis of CT. METHODS: In this case-control study we included 192 patients with HIV-1 infection: 64 patients with presumptive CT (cases) and 128 patients with other diseases (controls). Blood samples to perform indirect immunofluorescense reaction (IFI) to detect anti-T. gondii IgG antibodies and polymerase chain reaction (PCR) were collected before or within the first three days of anti-Toxoplasma therapy. Two multivariate logistic regression models were performed: one including the variable qualitative serology and another including quantitative serology. RESULTS: In the first model, positive IgG anti-T. gondii (OR 4.7, 95% CI 1.2-18.3; p = 0.027) and a positive T. gondii PCR result (OR 132, 95% CI 35-505; p < 0.001) were associated with the diagnosis. In the second model, IgG anti-T. gondii titres > 1:1024 (OR 7.6, 95% CI 2.3-25.1; p = 0.001) and a positive T. gondii PCR result (OR 147, 95% CI 35-613; p < 0.001) were associated with the diagnosis. CONCLUSIONS: Quantitative serology and molecular diagnosis in peripheral blood samples were independently associated with the diagnosis of CT in HIV-infected patients. These diagnostic tools can contribute to a timely diagnosis of CT in settings where Toxoplasma infection is common in the general population.

As complicações neurológicas causadas pelo Citomegalovírus (CMV) em pacientes com aids são raramente relatadas na era HAART. O objetivo deste estudo foi descrever as principais características clínicas e laboratoriais de pacientes com complicações neurológicas associadas ao CMV em pacientes com aids admitidos em centro de referência em Sao Paulo, Brasil. A doença citomegálica precisou da identificação do vírus no líquor mediante a reação em cadeia da polimerase (PCR). Treze casos foram identificados entre janeiro de 2004 e dezembro de 2008. A mediana da idade foi 38 anos e nove (69%) eram homens. Na admissão, todos os pacientes sabiam do seu status sorológico para o HIV e apenas quatro (31%) pacientes usavam HAART. A doença citomegálica foi a primeira doença definidora de aids em oito (62%) pacientes. As síndromes neurológicas identificadas foram: encefalite difusa (n = 7; 62%), polirradiculopatia (n = 7; 54%), encefalite focal (romboencefalite) (n = 1; 8%), e ventrículo-encefalite (n = 1; 8%). Sete (54%) pacientes apresentaram doença citomegálica fora do sistema nervoso e quatro (31%) tiveram retinite. A mediana da contagem de células CD4+ foi 13 células/µL. A mortalidade global durante a internação foi 38%. Oito pacientes usaram ganciclovir ou foscarnet (mortalidade: 50%) e cinco pacientes usaram ganciclovir e foscarnet (mortalidade: 20%). Nenhum paciente apresentou critérios diagnósticos da síndrome inflamatória de reconstituição imunológica. Quatro pacientes foram perdidos do acompanhamento ambulatorial e três pacientes apresentaram reconstituição imunológica e descontinuaram as profilaxias secundárias. Embora raras, as particulares síndromes neurológicas causadas pelo CMV continuam causando elevada mortalidade em pacientes com aids. A sobrevida depende do uso de terapia antiviral efetiva contra o CMV e a introdução oportuna do HAART.

Neurological disorders caused by Cytomegalovirus (CMV) in patients with Acquired Immunodeficiency Syndrome (AIDS) are rarely reported in the Highly Active Antiretroviral Therapy (HAART) period. The objective of this study was to describe the main clinical and laboratory features of patients with CMV-related neurological complications in HIV-infected patients admitted to a referral center in São Paulo, Brazil. CMV disease requires the identification of the virus in the cerebrospinal fluid (CSF) using Polymerase Chain Reaction (PCR). Thirteen cases were identified between January, 2004 and December, 2008. The median age of patients was 38 years and nine (69%) were men. At admission all patients were aware of their HIV status and only four (31%) patients were on HAART. Patients who were not on antiretroviral therapy before admission received HAART while inpatients. CMV disease was the first AIDS-defining illness in eight (62%) patients. The neurologic syndromes identified were diffuse encephalitis (n = 7; 62%), polyradiculopathy (n = 7; 54%), focal encephalitis (rhombencephalitis) (n = 1; 8%), and ventriculo-encephalitis (n = 1; 8%). Seven (54%) patients presented extra-neural CMV disease and four (31%) had retinitis. The median of CD4+ T-cell count was 13 cells/µL (range: 1-124 cells/µL). Overall in-hospital mortality was 38%. Eight patients used ganciclovir or foscarnet (in-hospital mortality: 50%) and five patients used ganciclovir and foscarnet (in-hospital mortality: 20%). None of the patients fulfilled the diagnosis criteria of immune reconstitution inflammatory syndrome. Four patients were lost to follow-up, and three patients presented immune recovery and discontinued secondary prophylaxis. Although infrequent, distinct neurological syndromes caused by CMV continue to cause high mortality among AIDS patients. Survival depends upon the use of effective antiviral therapy against CMV and the early introduction of HAART.

Os tuberculomas cerebrais constituem diagnóstico diferencial importante da toxoplasmose cerebral em pacientes infectados pelo vírus da imunodeficiência humana (HIV) de países em desenvolvimento. Os autores relatam o caso de uma mulher HIV positiva de 34 anos de idade, que apresentou provável tuberculose disseminada (hepatite, adenomegalia, e derrame pleural) associada à lesão expansiva cerebral única e gigante. Apesar dos esforços diagnósticos realizados, incluindo biópsia cerebral, ganglionar e hepática, o diagnóstico etiológico não foi confirmado. Porém, a resposta clínico-radiológica ao tratamento tuberculostático permitiu definir o diagnóstico de tuberculoma cerebral e a paciente teve alta hospitalar. Apresentações atípicas de tuberculomas cerebrais devem ser sempre consideradas no diagnóstico diferencial das lesões expansivas cerebrais em pacientes infectados pelo HIV e o uso do tratamento tuberculostático constitui ferramenta útil na definição diagnóstica em um sub-grupo de pacientes

Cerebral tuberculomas constitute a major differential diagnosis of cerebral toxoplasmosis in human immunodeficiency virus (HIV)-infected patients in developing countries. We report the case of a 34-year old woman co-infected with HIV and possible disseminated tuberculosis (hepatitis, lymphadenopathy, and pleural effusion) who presented a large and solitary intracranial mass lesion. Despite extensive diagnostic efforts, including brain, ganglionar, and liver biopsies, no definitive diagnosis was reached. However, a trial with first-line antituberculous drugs led to a significant clinical and radiological improvement. Atypical presentations of cerebral tuberculomas should always be considered in the differential diagnosis of intracranial mass lesions in HIV-infected patients and a trial with antituberculous drugs is a valuable strategy to infer the diagnosis in a subset of patients.

Existe informação limitada sobre a presença da leucoencefalopatia multifocal progressiva (LEMP) em pacientes com aids no Brasil. Os objetivos do presente estudo foram descrever as principais características dos pacientes com LEMP e estimar a freqüência desta doença em pacientes com aids e doenças oportunistas do sistema nervoso central (SNC) internados em um centro de referência de São Paulo, Brasil. Neste estudo retrospectivo e descritivo, identificamos 12 (6%) casos de LEMP entre 219 pacientes com doenças neurológicas oportunistas do SNC. A idade média dos pacientes com LEMP foi 36 anos e 9 (75%) eram do sexo masculino. As manifestações clínicas mais freqüentes foram: déficits focais (75%), alterações da fala (58%), alterações visuais (42%), alterações cognitivas (42%), e problemas de coordenação (42%). A média da contagem de células T-CD4+ foi 45 células/µL. Oito (67%) dos 12 pacientes com LEMP tiveram diagnóstico confirmado laboratorialmente e em quatro (33%) casos o diagnóstico foi possível. Onze (92%) pacientes apresentaram LEMP clássica e um caso teve LEMP associada à síndrome de reconstituição imune. Em quatro (33%) pacientes, a LEMP foi a primeira doença definidora de aids. Durante a internação, três pacientes (25%) faleceram devido a pneumonia hospitalar e nove (75%) tiveram alta. A LEMP foi apenas ultrapassada em freqüência pela toxoplasmose cerebral, a meningoencefalite criptococócica e a neurotuberculose, as três mais freqüentes doenças neurológicas oportunistas no Brasil. Os resultados deste estudo sugerem que a LEMP não é uma complicação neurológica incomum em pacientes com infecção pelo HIV no nosso meio.

Few data are available about progressive multifocal leukoencephalopathy (PML) in patients with acquired immunodeficiency syndrome (AIDS) from Brazil. The objectives of this study were to describe the main features of patients with PML and estimate its frequency among AIDS patients with central nervous system (CNS) opportunistic diseases admitted to the Instituto de Infectologia Emílio Ribas, São Paulo, Brazil, from April 2003 to April 2004. A retrospective and descriptive study was performed. Twelve (6%) cases of PML were identified among 219 patients with neurological diseases. The median age of patients with PML was 36 years and nine (75%) were men. Nine (75%) patients were not on antiretroviral therapy at admission. The most common clinical manifestations were: focal weakness (75%), speech disturbances (58%), visual disturbances (42%), cognitive dysfunction (42%), and impaired coordination (42%). The median CD4+ T-cell count was 45 cells/µL. Eight (67%) of 12 patients were laboratory-confirmed with PML and four (33%) were possible cases. Eleven (92%) presented classic PML and only one case had immune reconstitution inflammatory syndrome (IRIS)-related PML. In four (33%) patients, PML was the first AIDS-defining illness. During hospitalization, three patients (25%) died as a result of nosocomial pneumonia and nine (75%) were discharged to home. Cases of PML were only exceeded by cases of cerebral toxoplasmosis, cryptococcal meningoencephalitis, and CNS tuberculosis, the three more frequent neurologic opportunistic infections in Brazil. The results of this study suggest that PML is not an uncommon HIV-related neurologic disorder in a referral center in Brazil.

Os autores descrevem dois pacientes brasileiros com a síndrome da fraqueza neuromuscular associada ao HIV, uma síndrome tóxica, clínicamente particular, que foi recentemente relatada em países desenvolvidos. Ambas pacientes eram do sexo feminino, usavam estavudina e apresentaram hiperlactatemia, uma delas com acidose láctica. Os exames electrofisiológicos foram consistentes com neuropatia axonal. As pacientes melhoraram significativamente das alterações neurológicas, assim como normalizaram os níveis de lactato, após descontinuar o uso dos antiretrovirais. Até onde sabemos, este é o primeiro relato da síndrome de fraqueza neuromuscular associada ao HIV em países em desenvolvimento. Nesse contexto, o uso crescente de antiretrovirais, particularmente a estavudina, possibilitarão que casos similares sejam observados.

We describe two Brazilian patients with HIV-associated neuromuscular weakness syndrome (HANWS), a unique clinical toxic syndrome that was recently reported in developed countries. Both patients were women, used stavudine and had hyperlactatemia, one of them with lactic acidosis. Eletrophysiological studies were consistent with axonal neuropathy. After discontinuation of antiretroviral therapy the patients had significant improvement in neurologic manifestations, and normalization of lactate levels. To our knowledge, this is the first report of HANWS in developing countries. Growing use of antiretroviral therapy in this setting, particularly stavudine, make it likely that similar cases will be observed.

Severe pulmonary involvement in malaria has been frequently reported in cases of Plasmodium falciparum infection, but rarely in vivax malaria. Among the 11 previous cases of vivax-related severe respiratory involvement described in the literature, all except one developed it after the beginning of anti-malarial treatment; these appear to correspond to an exacerbation of the inflammatory response. We report the case of a 43-year-old Brazilian woman living in a malaria-endemic area, who presented acute respiratory distress syndrome (ARDS) caused by P. vivax before starting anti-malarial treatment. The diagnosis was made based on microscopic methods. A negative rapid immunochromatographic assay, based on the detection of Histidine Rich Protein-2 (HRP-2) of P. falciparum, indicated that falciparum malaria was unlikely. After specific anti-plasmodial therapy and intensive supportive care, the patient was discharged from the hospital. We conclude that vivax malaria-associated ARDS can develop before anti-malarial therapy.

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.

La aspergilosis cerebral es una causa rara de lesión expansiva cerebral en pacientes con SIDA. Presentamos el primer reporte de un absceso cerebral causado por Aspergillus fumigatus en un paciente brasileño con SIDA. El paciente, de 26 años de edad, presentaba antecedentes de infección por el virus de la inmunodeficiencia humana (VIH), tuberculosis pulmonar y toxoplasmosis cerebral. Manifestó fiebre, tos, disnea y dos episódios de convulsiones. La tomografía computadorizada (TC) demostró una lesión hipodensa parasagital y bi-parietal con realce periférico e importante efecto de masa. Se inició tratamiento anti-Toxoplasma. Tres semanas después, el paciente evidenció confusión mental y una nueva TC de cráneo mostró aumento de la lesión. Se realizó biopsia cerebral con drenaje de 10 mL de material purulento. El examen micológico directo reveló hifas hialinas septadas. Se inició anfotericina B deoxicolato. La cultura del material demostró presencia de Aspergillus fumigatus. En los siguientes dos meses el paciente fue sometido a otras tres cirugías, insertándose un catéter de drenaje y administrándose anfotericina B intralesional. Tres meses después de la admisión hospitalaria, la condición neurológica del paciente sufrió discretos cambios. Sin embargo, falleció debido a neumonia intrahospitalaria. Aunque muy raros, los abscesos cerebrales causados por Aspergillus fumigatus deben ser considerados en el diagnóstico diferencial de las lesiones expansivas cerebrales en pacientes con SIDA.

Anthrax is a zoonosis produced by Bacillus anthracis, and as an human infection is endemic in several areas in the world, including Peru. More than 95% of the reported naturally acquired infections are cutaneous, and approximately 5% of them can progress to meningoencephalitis. In this study we review the clinical and epidemiological characteristics of the patients with diagnosis of cutaneous anthrax evaluated between 1969 and 2002 at the Hospital Nacional Cayetano Heredia (HNCH) and the Instituto de Medicina Tropical Alexander von Humboldt in Lima, Peru. Seventy one patients were included [49/71 (69%) of them men], with a mean age of 37 years. The diagnoses were classified as definitive (44%) or probable (56%). The most common occupation of the patients was agriculture (39%). The source of infection was found in 63 (88.7%) patients. All the patients had ulcerative lesions, with a central necrosis. Most of the patients (65%) had several lesions, mainly located in the upper limbs (80%). Four patients (5.6%) developed meningoencephalitis, and three of them eventually died. In conclusion, considering its clinical and epidemiological characteristics, cutaneous anthrax must be included in the differential diagnosis of skin ulcers. A patient with clinical suspicion of the disease should receive effective treatment soon, in order to avoid neurological complications which carry a high fatality rate.

El ántrax es una zoonosis producida por el Bacillus anthracis y la infección humana es endémica en diversas partes del mundo, incluyendo el Perú. Más del 95% de las infecciones adquiridas naturalmente son cutáneas y aproximadamente 5% de ellas pueden evolucionar para meningoencefalitis. En este estudio revisamos las características clínicas y epidemiológicas de los pacientes con diagnóstico de ántrax cutáneo evaluados entre 1969 y 2002 en el Hospital Nacional Cayetano Heredia (HNCH) y en el Instituto de Medicina Tropical Alexander von Humboldt, en Lima, Perú. Se incluyeron 71 pacientes [49/71 (69%) del sexo masculino], con edad media de 37 años. Los diagnósticos fueron clasificados como definitivos (44%) o probables (56%). La ocupación más frecuente fue la agricultura (39%). La fuente de infección fue identificada en 63 (88.7%) pacientes. Todos presentaron lesiones ulcerativas con necrosis central. La mayoría de ellos (65%) tuvieron lesiones múltiples, principalmente localizadas en miembros superiores (80%). Cuatro pacientes (5.6%) desarrollaron meningoencefalitis y tres de ellos fallecieron. En conclusión, considerando sus particulares características clínicas y epidemiológicas, el ántrax cutáneo debe ser siempre incluido en el diagnóstico diferencial de las lesiones cutáneas ulcerativas. Los pacientes con sospecha clínica de la enfermedad deben recibir tratamiento precoz con el objetivo de evitar complicaciones neurológicas, las cuales presentan elevados índices de fatalidad.