A histoplasmose à uma das micoses sistÃmicas oportunistas mais associada à aids na atualidade no Brasil e no mundo. O Cearà à o estado do Brasil com a maior casuÃstica na Ãltima dÃcada da coinfecÃÃo HD/aids. O objetivo deste estudo foi caracterizar a morbimortalidade e sobrevida de pacientes com coinfecÃÃo HD/aids, apÃs o 1 evento de HD,atendidos em unidades de referÃncia para HIV/aids em Fortaleza/CearÃ. Realizou-se uma coorte retrospectiva de pacientes com coinfecÃÃo HD/aids, tendo o 1 episÃdio de HD ocorrido no perÃodo de 2002-2008. Os dados foram coletadas a partir do diagnÃstico de HD atà 31/12/2010. AnÃlise estatÃstica foi realizada por meio do programa STATA 9.0. Foram incluÃdos no estudo 145 pacientes. A maioria era de adultos jovens, com mÃdia de idade de 34,6 anos (IC 95%= 33,2-36,0), do sexo masculino (83,5%), e sem atividade de risco definida para histoplasmose (80%). A prevalÃncia da coinfecÃÃo foi de 38 casos/ano. HD foi 1 infecÃÃo oportunista definidora de aids em 59% dos pacientes. Anfotericina B foi utilizada em 97% dos pacientes como droga de induÃÃo, e itraconazol em 92%, em dose de manutenÃÃo. O tempo mÃdio de seguimento clÃnico foi de 3,38 anos (dp = 2,2; IC 95% = 3,01-3,75); 55,2% dos pacientes necessitaram de novos internamentos; 23,3% apresentaram recidiva da histoplasmose; 31,4% interromperam o uso de antifÃngicos conforme orientaÃÃo mÃdica. A mÃdia do acompanhamento apÃs a interrupÃÃo foi de 2,85 anos (IC 95% = 2,24-3,46). Somente um paciente recidivou apÃs a interrupÃÃo do antifÃngico. Os fatores riscos relacionados à recidiva foram nÃo adesÃo à TARV (p = 0,000), uso irregular de antifÃngico (p= 0,000), nÃo recuperaÃÃo do CD4+ (p = 0,000) e ter aids antes do diagnÃstico de HD (p =0,025). Somente nÃo adesÃo à TARV (OR = 4,96; IC 95% = 1,26-30,10; p = 0,026) foi fator de risco independente para recidiva. Aos 60 meses a probabilidade de remissÃo foi de 67%(IC 95%= 55% -76%). AdesÃo à TARV (94% vs. 51% - p = 0,000), uso regular de antifÃngico (87% vs. 48% - p = 0,000), recuperaÃÃo do CD4+ (83% vs. 45% - p = 0,000) e nÃo ter aids antes da HD (76% vs. 55% - p = 0,035) foram os principais fatores que contribuÃram para manutenÃÃo da remissÃo. Ãbito ocorreu em 30,2% dos pacientes; os fatores relacionados à mortalidade foram nÃo adesÃo ao tratamento da aids (p = 0,000), uso irregular de antifÃngico (p = 0,000), nÃo recuperaÃÃo do CD4+ (p = 0,000), ter tido um novo episÃdio de histoplasmose (p = 0,000) e ter aids antes da HD (p = 0,009). NÃo adesÃo à TARV foi o Ãnico fator de risco independente associado à mortalidade na anÃlise multivariada (OR = 5,24; IC 95% = 1,28-21,38; p = 0,021). A sobrevida aos 60 meses foi de 68% (IC 95% = 57%-76%). Pacientes com adesÃo à TARV (92% vs. 54% - p = 0,000) e sem episÃdio de recidiva (77%vs. 32% - p = 0,000), tiveram melhor probabilidade de sobrevida. Uso regular de antifÃngico (84% vs. 50% - p = 0,000) , ter tido recuperaÃÃo do CD4+ (89% vs. 54% - p = 0,000) e nÃo ter tido aids antes da HD (75% vs. 57% - p = 0,021) tambÃm foram fatores associados a uma melhor sobrevida. Portanto, verificou-se nesse estudo, elevada prevalÃncia de HD em pacientes com aids nessa regiÃo do Brasil, com altas taxas de recidiva e Ãbito. AdesÃo à TARV foi o Ãnico fator de risco independente associado aos desfechos, recidiva e Ãbito. A melhor sobrevida ocorreu em pacientes aderentes à TARV / Histoplasmosis is one of the most opportunistic systemic mycoses associated with AIDS today in Brazil and worldwide. Cearà is the state of Brazil with the largest case in the last decade this co-infection. The objective of this study was to characterize the survival and morbimortality of patients with co-infection HD/AIDS after the 1st HD event, served in in units of a reference for HIV/AIDS in Fortaleza/CearÃ. Retrospective cohort study of patients with co-infection HD/AIDS, when the first HD episode occurred between 2002-2008. The data were collected from the diagnosis of HD until 12/31/2010. Statistical analysis was performed using STATA 9.0 program. The study included 145 patients. The majority were young adults with median age of 34.6 years (95%CI = 33.2-36.0), males (83.5%) and without risk activity associated with histoplasmosis (80%). The prevalence of co-infection was of 38 cases/year. HD was first defining opportunistic infection of AIDS in 59% of the patients. Amphotericin B was used in 97% of patients as induction drug and itraconazole in 92% on maintenance dose. The average clinical follow-up was 3.38 years (sd=2.2,95%CI= 3.01 to 3.75); 55.2% of patients needed for new admissions; 23.3% presented relapse of histoplasmosis; 31.4% discontinued the use of antifungal as medical advice. The average follow-up after the interruption was 2.85 years (95%CI= 2.24 to 3.46). Only one patient relapsed after stopping the antifungal. Risk factors related to relapse were not adhering to ART (p 0.000), irregular use of antifungal (e.g. 0.000), non-recovery of CD4 (p 0.000) and have AIDS before diagnosis of HD (0.025). Non-adherence to ART (OR 4.96; 95% CI = 1.26- 30.10; p = 0.026) was the only independent risk factor for relapse. To 60 months the likelihood of remission was 67% (95%IC = 55% -76%). Join the ART (94% vs. 51% - p = 0.000), regular use of antifungal (87vs. 48 - p = 0.000), recovery of CD4+ (83% vs. 45% â p =0.000) and not having AIDS before the HD (76% vs.55% - p = 0.035) were the main factors that contributed to maintenance of remission. Death occurred in 30.2% of patients; mortalityrelated factors were not adherence to treatment of aids (p = 0.000), irregular use of antifungal medication (p = 0.000), non-recovery of CD4+ (p = 0.000), have had a new episode of histoplasmosis (p = 0.000) and have AIDS before the HD (p = 0.009). Patients with adherence to ART (92% vs. 54% - p = 0,000) and without relapse episode (77% vs. 32% - p = 0,000), had better chances of survival. Regular use of secondary prophylaxis as a maintenance therapy in HD was a factor associated with lower probability of progression to death (p=0.000). The survival at 60 months was of 68% (95%CI = 57%-76%). Regular use of antifungal (84% vs. 50% - p = 0.000), have had CD4+ recovery (89% vs. 54% - p = 0.000)and not have had AIDS before the HD (75% vs. 57% - p = 0.021) also were factors associated with better survival. Therefore, it was found in this study, high prevalence of HD in patients with AIDS in this region of Brazil, with high rates of relapse and death. Join the ART was the only independent risk factor associated with outcomes, relapse and death. The best survival occurred in patients adhering to ART.

Histoplasmosis is an endemic infection of the Ohio and Mississippi River valleys. Clinical presentation of infection in immunocompetent hosts ranges from asymptomatic to minor flu-like symptoms; however, disseminated infection can occur in immunocompromised patients. Esophageal involvement in the form of dysphagia secondary to mediastinal histoplasmosis is rarely reported in the literature. We present a young female who complained of dysphagia and was found to have an esophageal stricture on barium esophagogram. Endoscopy revealed a submucosal nodule stricture situated 29 cm from the incisors. She underwent thoracotomy for lymph node removal. Histologic findings of the removed lymph node showed caseating granuloma with macrophages. The clinical findings together with the laboratory evaluation and biopsy features were suggestive of mediastinal histoplasmosis as the cause of the dysphagia.

Histoplasmosis is an endemic infection of the Ohio and Mississippi River valleys. Clinical presentation of infection in immunocompetent hosts ranges from asymptomatic to minor flu-like symptoms; however, disseminated infection can occur in immunocompromised patients. Esophageal involvement in the form of dysphagia secondary to mediastinal histoplasmosis is rarely reported in the literature. We present a young female who complained of dysphagia and was found to have an esophageal stricture on barium esophagogram. Endoscopy revealed a submucosal nodule stricture situated 29 cm from the incisors. She underwent thoracotomy for lymph node removal. Histologic findings of the removed lymph node showed caseating granuloma with macrophages. The clinical findings together with the laboratory evaluation and biopsy features were suggestive of mediastinal histoplasmosis as the cause of the dysphagia.

Leucotrienos e prostaglandinas são metabólitos do ácido araquidônico que, além de mediadores da inflamação são importantes imunomoduladores da liberação de citocinas, nas respostas imune inata e adquirida. Embora estes mediadores apresentem potencial para serem utilizados como adjuvantes ou imunomoduladores da resposta imune, eles são altamente instáveis, dificultando o uso in vivo. Por esta razão, estas substâncias foram incorporadas em um sistema polimérico microestruturado. Este foi constituído de microesferas de quatro a seis micrômetros de diâmetro, contendo leucotrieno B4 (LTB4) ou prostaglandina E2 (PGE2) incorporados na matriz polimérica (PLGA). A caracterização in vitro das microesferas de PLGA, contendo LTB4 ou PGE2, foi feita através da determinação da morfologia e medida dos diâmetros médios, taxa de encapsulação e perfil de liberação in vitro dos mediadores. Além disso, foi avaliada a preservação da atividade biológica do LTB4 liberado das microesferas, através do efeito do mesmo sobre a expressão de moléculas de adesão Mac-1 por citometria de fluxo. Também foram avaliadas a preservação da atividade biológica do LTB4 e da PGE2 liberados do interior das microesferas, através de estudos com microscopia intravital e a ativação de células endoteliais humanas (HUVECs e HUAECs). Realizamos ainda, ensaio de fagocitose com as microesferas contendo os dois mediadores encapsulados, utilizando macrófagos peritoneais murinos, além da avaliação da sobrevivência dos animais tratados intranasalmente com microesferas contendo LTB4 ou PGE2 durante a infecção pelo H. capulatum. Nestes animais, avaliamos a reação inflamatória pulmonar, o número de UFCs recuperadas dos pulmões e a modulação da resposta imune, através da quantificação de citocinas inflamatórias. Os estudos abordados neste trabalho revelaram achados interessantes e importantes quanto ao uso de microesferas biodegradáveis contendo mediadores lipídicos em situação de terapia, especialmente quando estes estão envolvidos em processos inflamatórios e/ou infecciosos. / Leukotrienes and prostaglandins are arachidonic acid metabolites, which participate in the inflammatory response and modulate cytokines release in both adaptive and innate immune responses. However, some physicochemical characteristics of these mediators, such as poor solubility in water and chemical instability, make them difficult to administer in vivo. In this sudy, we developed a polymeric microparticulate system for the encapsulation of lipid mediators. Regarding the in vitro characterization of the microspheres, we determined their diameters, evaluated the in vitro release of the mediators and the microspheres uptake by peritoneal macrophages. To assess the preservation of the biological activities of these mediators, we conducted intravital microscopy studies and determined the effect of LTB4 and PGE2-loaded biodegradable microspheres on inflammatory mediators release by murine peritoneal macrophages and human endothelial cells. In mice infected by H. capsulatum, we investigated the effects of intranasal administration of the microspheres on pulmonary inflammatory response. In this context, we analyzed the inflammatory cells recruited to the bronchoalveolar space, the mice survival and the number of CFUs recovered from the lungs after the administrations. We also assessed the cytokines release by the lung cells after the treatment with microspheres during the course of the infection. In conclusion, our findings showed that biodegradable microspheres could preserve the biological activity of the encapsulated mediators indicating their use as a new strategy to modulate cell activation, especially in the innate immune response.

O Histoplasma capsulatum é um fungo dimórfico responsável por infecções pulmonares graves caracterizadas por reação granulomatosa. Sua incidência vem aumentando nos últimos anos devido principalmente às alterações imunológicas relacionadas ao comprometimento da imunidade celular. Anteriormente, nosso grupo de pesquisa demonstrou o envolvimento dos leucotrienos (LTs) nos mecanismos de defesa do hospedeiro durante a histoplasmose. Além disso, demonstrou que antígenos livres de células (CFAgs, do inglês cell-free antigens), derivados de H. capsulatum, quando empregados na imunização de animais, conferem proteção eficiente aos mesmos e controle da infecção, uma vez que ativam a imunidade celular, e aumento da produção de LTs nos pulmões dos animais imunizados. Assim, nosso grupo desenvolveu microesferas (MS) biodegradáveis, constituídas de ésteres derivados dos ácidos láctico e glicólico (PLGA), contendo LTB4. Estas MS foram avidamente fagocitadas por macrófagos in vitro e aumentaram o recrutamento de leucócitos para os pulmões, quando administradas intratraquealmente. Diante do papel dos LTs na histoplasmose e dos potenciais terapêutico e profilático dos CFAgs, o objetivo deste estudo foi avaliar as atividades biológicas in vitro e in vivo de MS contendo LTB4 e/ou CFAgs. Assim, foram desenvolvidas MS (PLGA) contendo LTB4 e/ou CFAgs através do processo de simples ou dupla emulsão seguido pela extração do solvente. Este método permitiu uma eficiente encapsulação tanto do mediador lipídico quanto dos antígenos protéicos e um perfil de liberação sustentada ao longo dos dias avaliados. O potencial zeta e a morfologia das MS não foram alterados com o processo de microencapsulação; da mesma forma, a integridade dos CFAgs não foi interferida. Para estudos in vitro, empregamos macrófagos diferenciados de medula óssea murina (BMDM). O tamanho adequado das MS contribuiu para sua eficiente fagocitose pelos BMDM e as MS contendo LTB4 e/ou CFAgs modularam a produção de TNF-, IL-1, IL-6 e IL-12, quimiocinas (KC, MCP-1 e RANTES), e nitrito, sendo que as MS-CFAgs mostraram-se mais potentes. O estímulo com as diferentes MS induziu discreto aumento na expressão de CD86 na superfície de BMDM. Neste contexto, verificamos o envolvimento do fator de transcrição NF-B durante a ativação de BMDM induzida pelas MS. Apesar da eficiente ativação dos BMDM induzida pelas MS, não foi possível evidenciar uma resposta imune celular em animais imunizados com as MS-LTB4+CFAgs ou MS-CFAgs. Portanto, futuros experimentos deverão ser realizados a fim de investigar o potencial profilático das MS contendo LTB4 e/ou CFAgs na histoplasmose. / Histoplasma capsulatum is a dimorphic pathogenic fungus that causes a pulmonary disease characterized by chronic granulomatous reaction. In the last years, the incidence of histoplasmosis has increased, mainly as a result of the immunological alterations involved with deficiency of the cellular immunity. Previously, our research group demonstrated the involvement of leukotrienes (LTs) on host defense mechanisms during the histoplasmosis. Cell-free antigens (CFAgs) derived from H. capsulatum, when employed for animals´ immunization, can confer efficient protection and control of the infection, since they activate the cellular immunity. Furthermore, the protection of CFAgs-immunized mice was associated with increased LTB4 generation in the lungs. Based on these results, our group developed biodegradable microspheres (MS) based on PLGA containing LTB4. We showed that these MS were phagocytosed by macrophages in vitro and increased the leukocyte recruitment into the lungs, when administrated via intratracheal. Because the role of leukotrienes in the histoplasmosis and therapeutic and profilatic effects of CFAgs, the aim of this study was evaluate the in vitro and in vivo biological activities of MS containing LTB4 and/or CFAgs. Then, MS (PLGA) containing LTB4 and/or CFAgs were developed through simple or double emulsion/extraction process. This method allowed an efficient encapsulation of the lipid mediator and CFAgs, and a sustained release profile during the evaluated days. Zeta potential and morphology of MS were not altered with the microencapsulation process; CFAgs integrity was not interfered. For in vitro studies, we employed bone marrow-derived macrophages (BMDM). The appropriate size of MS contributed for efficient uptake by BMDM. MS containing LTB4 and/or CFAgs modulated the TNF-, IL-1, IL-6 and IL-12, chemokines (KC, MCP-1 and RANTES), and nitrite production by BMDM, since the MS-CFAgs showed potent immunostimulant effect. Moreover, the stimulus with different MS provoked a discreet increase in the CD86 cell expression. Also we verified an involvement of the transcription factor NF-B during the BMDM activation induced by MS. Even though the in vitro biological activities on BMDM, it was not possible to evidence a cellular immune response in immunized mice with the MS-LTB4+CFAgs or MS-CFAgs. Therefore, future experiments should be conducted in order to investigate the profilatic potential of MS containing LTB4 and/or CFAgs in the histoplasmosis.

O Histoplasma capsulatum é um fungo dimórfico responsável por infecções pulmonares graves caracterizadas por reação granulomatosa. Sua incidência vem aumentando nos últimos anos devido principalmente às alterações imunológicas relacionadas ao comprometimento da imunidade celular. Anteriormente, nosso grupo de pesquisa demonstrou o envolvimento dos leucotrienos (LTs) nos mecanismos de defesa do hospedeiro durante a histoplasmose. Além disso, demonstrou que antígenos livres de células (CFAgs, do inglês cell-free antigens), derivados de H. capsulatum, quando empregados na imunização de animais, conferem proteção eficiente aos mesmos e controle da infecção, uma vez que ativam a imunidade celular, e aumento da produção de LTs nos pulmões dos animais imunizados. Assim, nosso grupo desenvolveu microesferas (MS) biodegradáveis, constituídas de ésteres derivados dos ácidos láctico e glicólico (PLGA), contendo LTB4. Estas MS foram avidamente fagocitadas por macrófagos in vitro e aumentaram o recrutamento de leucócitos para os pulmões, quando administradas intratraquealmente. Diante do papel dos LTs na histoplasmose e dos potenciais terapêutico e profilático dos CFAgs, o objetivo deste estudo foi avaliar as atividades biológicas in vitro e in vivo de MS contendo LTB4 e/ou CFAgs. Assim, foram desenvolvidas MS (PLGA) contendo LTB4 e/ou CFAgs através do processo de simples ou dupla emulsão seguido pela extração do solvente. Este método permitiu uma eficiente encapsulação tanto do mediador lipídico quanto dos antígenos protéicos e um perfil de liberação sustentada ao longo dos dias avaliados. O potencial zeta e a morfologia das MS não foram alterados com o processo de microencapsulação; da mesma forma, a integridade dos CFAgs não foi interferida. Para estudos in vitro, empregamos macrófagos diferenciados de medula óssea murina (BMDM). O tamanho adequado das MS contribuiu para sua eficiente fagocitose pelos BMDM e as MS contendo LTB4 e/ou CFAgs modularam a produção de TNF-, IL-1, IL-6 e IL-12, quimiocinas (KC, MCP-1 e RANTES), e nitrito, sendo que as MS-CFAgs mostraram-se mais potentes. O estímulo com as diferentes MS induziu discreto aumento na expressão de CD86 na superfície de BMDM. Neste contexto, verificamos o envolvimento do fator de transcrição NF-B durante a ativação de BMDM induzida pelas MS. Apesar da eficiente ativação dos BMDM induzida pelas MS, não foi possível evidenciar uma resposta imune celular em animais imunizados com as MS-LTB4+CFAgs ou MS-CFAgs. Portanto, futuros experimentos deverão ser realizados a fim de investigar o potencial profilático das MS contendo LTB4 e/ou CFAgs na histoplasmose. / Histoplasma capsulatum is a dimorphic pathogenic fungus that causes a pulmonary disease characterized by chronic granulomatous reaction. In the last years, the incidence of histoplasmosis has increased, mainly as a result of the immunological alterations involved with deficiency of the cellular immunity. Previously, our research group demonstrated the involvement of leukotrienes (LTs) on host defense mechanisms during the histoplasmosis. Cell-free antigens (CFAgs) derived from H. capsulatum, when employed for animals´ immunization, can confer efficient protection and control of the infection, since they activate the cellular immunity. Furthermore, the protection of CFAgs-immunized mice was associated with increased LTB4 generation in the lungs. Based on these results, our group developed biodegradable microspheres (MS) based on PLGA containing LTB4. We showed that these MS were phagocytosed by macrophages in vitro and increased the leukocyte recruitment into the lungs, when administrated via intratracheal. Because the role of leukotrienes in the histoplasmosis and therapeutic and profilatic effects of CFAgs, the aim of this study was evaluate the in vitro and in vivo biological activities of MS containing LTB4 and/or CFAgs. Then, MS (PLGA) containing LTB4 and/or CFAgs were developed through simple or double emulsion/extraction process. This method allowed an efficient encapsulation of the lipid mediator and CFAgs, and a sustained release profile during the evaluated days. Zeta potential and morphology of MS were not altered with the microencapsulation process; CFAgs integrity was not interfered. For in vitro studies, we employed bone marrow-derived macrophages (BMDM). The appropriate size of MS contributed for efficient uptake by BMDM. MS containing LTB4 and/or CFAgs modulated the TNF-, IL-1, IL-6 and IL-12, chemokines (KC, MCP-1 and RANTES), and nitrite production by BMDM, since the MS-CFAgs showed potent immunostimulant effect. Moreover, the stimulus with different MS provoked a discreet increase in the CD86 cell expression. Also we verified an involvement of the transcription factor NF-B during the BMDM activation induced by MS. Even though the in vitro biological activities on BMDM, it was not possible to evidence a cellular immune response in immunized mice with the MS-LTB4+CFAgs or MS-CFAgs. Therefore, future experiments should be conducted in order to investigate the profilatic potential of MS containing LTB4 and/or CFAgs in the histoplasmosis.

A histoplasmose disseminada (HD) à uma grave infecÃÃo oportunista, causada por Histoplasma capsulatum, frequentemente observada em pacientes com aids em avanÃada imunossupressÃo atendidos em serviÃo de assistÃncia a pessoas vivendo com HIV/aids em Fortaleza, CearÃ. Como outras infecÃÃes oportunistas, a histoplasmose pode ser precocemente identificada pela presenÃa de manifestaÃÃes especÃficas na cavidade oral. Para conhecer a frequÃncia e caracterÃsticas das manifestaÃÃes orais de HD associada à aids foi realizado um estudo transversal em pacientes adultos com suspeita ou confirmaÃÃo de HD, de agosto de 2009 a marÃo de 2010. Os dados foram coletados mediante aplicaÃÃo de questionÃrio, exame clÃnico oral, exames histo-citopatolÃgicos, fotografias e consulta aos prontuÃrios mÃdicos. Foram diagnosticados 22 casos de HD, do total de 56 doentes. Cinco pacientes (5/22; 22,7%) apresentaram lesÃes orais com caracterÃsticas clÃnicas de histoplasmose e em quatro (4/22; 18,9%) desses a presenÃa do fungo foi detectada por meio de biÃpsia e citologia esfoliativa, em fragmentos e esfregaÃos examinados com coloraÃÃo por Grocott, PAS (Periodic Acid-Schiff) e Giemsa. Nove pacientes foram definidos como possÃveis casos de HD (com base em antecedentes patolÃgicos e manifestaÃÃes clÃnicas) e dois desses apresentaram, da mesma forma, lesÃes orais com caracterÃsticas clÃnicas de histoplasmose, porÃm essas nÃo foram biopsiadas. Ãlcera com crosta hemorrÃgica em mucosa labial foi a apresentaÃÃo mais frequente (60%), seguida da forma granulomatosa com lesÃes mÃltiplas em palato e gengiva (20%) e de lesÃo ulcerada na lÃngua (20%). Os pacientes com HD apresentaram mediana de 36,5 cels/mm de linfÃcitos T CD4 e nÃveis significativamente mais elevados de desidrogenase lÃctica (LDH; p=0,0001) e aspartato aminotransferase (AST/TGO; p=0,0002), assim como nÃveis significativamente mais baixos de hemoglobina (p= 00,2), leucÃcitos (p= 0,04) e plaquetas (p= 0,001). Odinofagia foi relatada por todos os pacientes com HD (p=0,000) e disfagia esteve presente em 10 (45,4%; p=0,011) desses. Disfonia foi observada em um paciente que apresentou histoplasmose na laringe. CandidÃase pseudomembranosa, seguida da forma eritematosa estiveram associadas à HD em 45,5% e 4,5% dos pacientes, respectivamente. A prevalÃncia de gengivite foi de 38,3% e em 57,4% dos pacientes foi identificada a presenÃa de cÃlculo o que indica saÃde oral precÃria e expressiva necessidade de serviÃos odontolÃgicos. / The disseminated histoplasmosis (DH) is a serious opportunistic infection caused by Histoplasma capsulatum, often seen in aids patients in advanced immunosuppression treated in health care service for people living with HIV/aids in Fortaleza, CearÃ. Like other opportunistic infections, histoplasmosis can be identified early by the presence of specific manifestations in the oral cavity. To know the frequency and characteristics of oral manifestations of DH aids-associated it was carried out a cross-sectional study in adult patients who were suspected or confirmed to have DH, from August 2009 to March 2010. The data were collected through questionnaire, oral clinical examination, histocyto-pathological examinations, photographs and observation of medical records. Twenty-two cases of DH were diagnosed in the total of fifty-six patients. Five out of the twenty-two patients (5/22, 22.7%) had oral lesions with clinical features of histoplasmosis and in four out of the twenty-two (4/22, 18.9%) the fungus was detected through biopsy and exfoliative cytology, in fragments and smears examined by staining with Grocott, PAS (Periodic Acid-Schiff) and Giemsa. Nine patients were defined as possible cases of DH (based on pathological background and clinical manifestations) and two of those presented, in the same way, oral lesions with clinical features of histoplasmosis, however, these were not biopsied. Ulcer with hemorrhagic crust on the lip mucosa was the most frequent (60%), followed by granulomatous form with multiple lesions on the palate and gums (20%) and ulcerated lesion on the tongue (20%). DH patients had a median of 36.5 cells / mm of lymphocyte T CD4 and significantly higher levels of lactate dehydrogenase (LDH; p= 0.0001) and aspartate aminotransferase (AST/TGO; p= 0.0002), as well as significantly lower levels of hemoglobin (p= 00.2), leukocytes (p= 0.04) and platelets (p= 0.001). Odynophagia was reported by all patients with DH(p = 0.000), and dysphagia was present in ten (45.4%, p = 0.011). Dysphonia was observed in a patient who presented histoplasmosis of the larynx. Pseudomembranous candidiasis, followed by the erythematous form was associated with DH in 45.5% and 4.5% of the patients, respectively. The prevalence of gingivitis was 38.3% and in 57.4% of the patients was identified calculus dental which indicates poor oral health and significant need for dental services.

Leucotrienos e prostaglandinas são metabólitos do ácido araquidônico que, além de mediadores da inflamação são importantes imunomoduladores da liberação de citocinas, nas respostas imune inata e adquirida. Embora estes mediadores apresentem potencial para serem utilizados como adjuvantes ou imunomoduladores da resposta imune, eles são altamente instáveis, dificultando o uso in vivo. Por esta razão, estas substâncias foram incorporadas em um sistema polimérico microestruturado. Este foi constituído de microesferas de quatro a seis micrômetros de diâmetro, contendo leucotrieno B4 (LTB4) ou prostaglandina E2 (PGE2) incorporados na matriz polimérica (PLGA). A caracterização in vitro das microesferas de PLGA, contendo LTB4 ou PGE2, foi feita através da determinação da morfologia e medida dos diâmetros médios, taxa de encapsulação e perfil de liberação in vitro dos mediadores. Além disso, foi avaliada a preservação da atividade biológica do LTB4 liberado das microesferas, através do efeito do mesmo sobre a expressão de moléculas de adesão Mac-1 por citometria de fluxo. Também foram avaliadas a preservação da atividade biológica do LTB4 e da PGE2 liberados do interior das microesferas, através de estudos com microscopia intravital e a ativação de células endoteliais humanas (HUVECs e HUAECs). Realizamos ainda, ensaio de fagocitose com as microesferas contendo os dois mediadores encapsulados, utilizando macrófagos peritoneais murinos, além da avaliação da sobrevivência dos animais tratados intranasalmente com microesferas contendo LTB4 ou PGE2 durante a infecção pelo H. capulatum. Nestes animais, avaliamos a reação inflamatória pulmonar, o número de UFCs recuperadas dos pulmões e a modulação da resposta imune, através da quantificação de citocinas inflamatórias. Os estudos abordados neste trabalho revelaram achados interessantes e importantes quanto ao uso de microesferas biodegradáveis contendo mediadores lipídicos em situação de terapia, especialmente quando estes estão envolvidos em processos inflamatórios e/ou infecciosos. / Leukotrienes and prostaglandins are arachidonic acid metabolites, which participate in the inflammatory response and modulate cytokines release in both adaptive and innate immune responses. However, some physicochemical characteristics of these mediators, such as poor solubility in water and chemical instability, make them difficult to administer in vivo. In this sudy, we developed a polymeric microparticulate system for the encapsulation of lipid mediators. Regarding the in vitro characterization of the microspheres, we determined their diameters, evaluated the in vitro release of the mediators and the microspheres uptake by peritoneal macrophages. To assess the preservation of the biological activities of these mediators, we conducted intravital microscopy studies and determined the effect of LTB4 and PGE2-loaded biodegradable microspheres on inflammatory mediators release by murine peritoneal macrophages and human endothelial cells. In mice infected by H. capsulatum, we investigated the effects of intranasal administration of the microspheres on pulmonary inflammatory response. In this context, we analyzed the inflammatory cells recruited to the bronchoalveolar space, the mice survival and the number of CFUs recovered from the lungs after the administrations. We also assessed the cytokines release by the lung cells after the treatment with microspheres during the course of the infection. In conclusion, our findings showed that biodegradable microspheres could preserve the biological activity of the encapsulated mediators indicating their use as a new strategy to modulate cell activation, especially in the innate immune response.

Fungal infections are ignored by social and political communities. However, they are estimated to affect more than a billion people, resulting in approximately 11.5 million life-threatening infections in the 'at risk' population and more than 1.5 million deaths annually. Though there have been huge advances in diagnostics and antifungal drug development over the past two decades, however, resource limited settings have not benefited from these advances. The aim of this research was to determine the burden of serious fungal infections in Nigerians with the appropriate underlying diseases. This epidemiological research was conducted across four study populations. Study 1; HIV-infected patients with CD4+ counts < 250 cells/mm³, irrespective of their ART status, a CrAg lateral flow assay was used for detecting cryptococcal antigenaemia (n=214). Study 2; a cross-sectional multicentre survey of TB patients being managed for smear negative or treatment failure TB irrespective of their HIV status (n=208). Study 3; a multicentre histoplasmin skin sensitivity survey amongst healthy HIV-infected and non-HIV infected participants; intradermally; induration ≥ 5 mm was considered to be histoplasmin positive (n=750). Study 4; a prospective cohort study of critically ill patients in a Nigerian ICU (n=71). Two retrospective studies to analyse the clinical picture of serious fungal infections in two at risk populations (HIV/AIDS and neonatal intensive care babies) in Nigerians was also conducted (n=7034; n=2712 respectively). Results revealed an overall seroprevalence of cryptococcal antigenemia of 8.9% with 6 (9.8%) in those with CD4+ cell counts < 100cells/mm³, 4 (5.0%) in the 100-200 group and 9 (12.3%) in 200-250 cells/mm³ group; a CPA prevalence of 8.7% (6.5% had HIV infection and 14.5% were HIV-negative) and a prior subclinical histoplasmosis of 4.4%. The ICU study revealed a 45% healthcare associated infection rate representing an incidence rate of 79/1000 patient-days in the ICU. The retrospective studies revealed a 2.3% rate of neonatal ICI with a case fatality rate of 18.5%. In the 12 years retrospective study 18% had a fungal OI with 88% of patients having initiated ART. In conclusion, serious fungal infections do occur in the at risk population in Nigeria and they constitute a significant public health challenge. Our findings demonstrate that there has been an underestimation of the burden of the problem in Nigerians. There is a dire need to design guidelines for the management of fungal infections in at risk population.

Introdução: A tuberculose e a histoplasmose são clínica-radiológica e histopatologicamente semelhantes, o que pode levar ao tratamento equivocado. Neste sentido, a importância do atual projeto é a confirmação de casos de histoplasmose em pacientes com suposta tuberculose, no Vale d Sinos – Rio Grande do Sul. Objetivo: Demonstrar a prevalência de histoplasmose a partir da detecção de anticorpos anti- Histoplasma capsulatum (H. capsulatum) em pacientes que possuíam diagnóstico inconclusivo e que receberam tratamento para tuberculose. Métodos e resultados: A primeira fase do estudo foi retrospectiva, com análise de prontuários para a seleção de pacientes cadastrados no Sistema Único de Saúde que receberam tratamento tuberculostático sem diagnóstico etiológico conclusivo para tuberculose. A segunda fase do estudo foi prospectiva, onde o soro dos pacientes que se enquadraram nos critérios de inclusão/exclusão foi analisado por imunodifusão radial dupla para a detecção da presença de anticorpos anti-H. capsulatum. Dos 42 soros testados, três (7,14%) tiveram resultado positivo para a presença de anticorpos anti-H. capsulatum. Conclusão: A ausência de achados etiológicos conclusivos para a tuberculose aliados à positivação da imunodifusão para H. capsulatum, demonstra que três pacientes apresentavam histoplasmose e não tuberculose, sugerindo a necessidade de pesquisa da micose nos casos com suspeita de tuberculose, mas sem confirmação diagnóstica. / Introduction: Tuberculosis and histoplasmosis are clinic-radiologic and hitopatologically similar, and so the treatment may be mistaken. In this sense, the importance of this project is to confirm histoplasmosis cases on patients who are being treated for supposed tuberculosis, in Vale do Sinos – Rio Grande do Sul. Aim: To demonstrate the prevalence of histoplasmosis by the presence of anti-Histoplasma capsulatum (H. capsulatum) antibodies in patients whose diagnosis is inconclusive and who have been treated for tuberculosis. Methods and Results: The first stage of the study was retrospective, by the analysis of medical records to select patients who are filed on Sistema Único de Saúde and who have received tuberculostatic treatment without conclusive etiologic diagnosis for tuberculosis. The second stage of the study was prospective, and the serum of patients who are integrated to inclusion/exclusion criteria was examined by double radial im munodiffusion to detect the presence of anti-H. capsulatum antibodies. From the 42 serum which were tested, three of them (7,14%) have had positive results for the presence of anti-H. capsulatum antibodies. Conclusion: The lack of conclusive etiologic find for tuberculosis associated to the positivation of immunodiffusion for H. capsulatum, proves that three patients have showed histoplasmosis and not tuberculosis, proposing then the necessity of a research of mycosis on the cases which there is the suspect of tuberculosis, but without diagnostic confirmation.