Caso Clínico 3 Micosis

Les dejo otro caso, espero tengamos una buena discusión. :)


Caso 3

A 34 year old Brazilian male, HIV-positive since 1989, with past history of disseminated tuberculosis and a

suspected neurotoxoplasmosis, was admitted to the hospital in October 2004 with frequent vomiting, nausea, sleepiness, fever, oral candidiasis, and a count of T-CD4  lymphocytes = 91 cell/mm3. During physical examination numerous skin nodular lesions, some of them ulcerated,  through out his body, especially on his arms, were noted.

The ulcerated nodules were characterized by the secretion of a serosanguineous discharge. The formation of enlarged lymph nodes in chains was also observed, especially on the limbs. Because the clinical aspects of the lesions a tentative diagnosis of bacterial dermatitis was suspected. However, samples collected from multiple nodules and a set of blood cultures sent to the  laboratory did not reveal the etiologic agent. One week after admission, a collected biopsy of the infected nodules showed a granulomatous reaction with fibrosis and an intense infiltrate of inflammatory mononuclear and giant cells. Edema and vascular neoformation was also noted. Despite the use of especial stains for fungi and other etiologic agents (Wade, Giemsa, and Grocott), the detection of the pathogen was not possible. Thus, a clinical diagnosis of atypical mycobacteriosis was presented. Due to the granulomatous nature of the multicentric (multifocal) nodules new samples, collected from several enlarged lymph nodes, and a spinal fluid were sent to the Mycology section to rule out fungal pathogens. After one week of incubation at room temperature, S. schenckii was isolated from the inoculated plates, including those cultures plates inoculated with the patient’s spinal fluid. Amphotericin B (1.0 mg/kg/day) was prescribed to a total dose of 650 mg. The skin lesions and his neurological condition improved one week after treatment. However, two weeks later the patient clinical condition worsened, apparently not related to the sporotrichosis or to the antifungal therapy, and later the patient died. Unfortunately, a necropsy was not possible.