CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / A histoplasmose à uma doenÃa causada por Histoplasma capsulatum var. capsulatum, nos seres humanos e em vÃrias outras espÃcies de animais. Trata-se de um fungo encontrado na natureza, principalmente em locais ricos em fezes de aves e morcegos: galinheiros sujos e abandonados, ambiente de cavernas, construÃÃes antigas, cÃpula de prÃdios e Ãrvores ocas. A infecÃÃo em humanos ocorre atravÃs das vias aÃreas superiores. Desde o inicio da epidemia de HIV na dÃcada de 80 à notada uma detecÃÃo crescente de histoplasmose disseminada em pacientes com aids de serviÃos de referÃncia em Fortaleza, sugerindo ser o Estado do Cearà uma Ãrea com elevada endemicidade para esse fungo. Este estudo teve o intuito de identificar a prevalÃncia de histoplasmose infecÃÃo em pacientes com HIV/aids, residentes na cidade de Fortaleza, CearÃ. Trata-se de um estudo transversal, descritivo e analÃtico, com uma amostra composta por 161 pacientes, acompanhados no ambulatÃrio de HIV/aids do Centro de Especialidades MÃdicas Josà de Alencar e que ao serem abordados, aceitaram participar do estudo. Para tanto, foi preenchido um formulÃrio, realizou-se teste intradÃrmico com histoplasmina (fase miceliana, fornecido pela Fiocruz-RJ) e coleta sanguÃnea para sorologia por imunodifusÃo (antÃgenos e anticorpos comerciais de Histoplasma capsulatum e Coccidioides immitis fornecidos pelo Centro Especializado em Micologia MÃdica-CEMM). A caracterizaÃÃo geral dos pacientes revelou que a maioria tinha, em mÃdia 35,11 anos, era do sexo masculino (76,40%; n=123), solteiros (67,70%, n=109), com renda familiar de no mÃximo trÃs salÃrios mÃnimos (81,99%; n=132) e com mais de 10 anos de estudo (44,10%; n=71). O tipo de ocupaÃÃo no passado obteve distribuiÃÃo variÃvel e atualmente parte do grupo (20,5%; n=33) encontrava-se desempregada. Um nÃmero de 137 pacientes (85,10%) relatou residir em casas, sendo Messejana o bairro de moradia mais citado pelos participantes (8,7%; n=14). Prevaleceram na amostra os pacientes com diagnÃstico recente de infecÃÃo por HIV, (66,46% identificados no ano de 2008). A prevalÃncia de histoplasmose infecÃÃo em pacientes com HIV/aids em Fortaleza foi de 12,42%. PresenÃa de galinheiro na vizinhanÃa atual do paciente (p=0,031); presenÃa de mangueira na residÃncia atual (p=0,023); atividade com terra no passado (p=0,021) e visitar sÃtio no passado (p=0,009), mostraram-se significantes para a infecÃÃo por Histoplasma capsulatum; jà o uso de medicaÃÃo anti-retroviral e o fato do paciente ter ou nÃo aids, nÃo influenciaram na reatividade à histoplasmina (ambos p=1,00). Pode-se concluir que Fortaleza constitui-se Ãrea com significativa prevalÃncia de histoplasmose infecÃÃo, levando-se em conta que a populaÃÃo estudada se referia a pacientes com supressÃo da resposta imune. O valor obtido aponta para a necessidade de identificaÃÃo dessas pessoas em risco para histoplasmose doenÃa e a implementaÃÃo de medidas profilÃticas naqueles susceptÃveis Ãs formas graves desta infecÃÃo. / Histoplasmosis is an infection disease caused by the fungus Histoplasma capsulatum var. capsulatum that can affect humans and several other animal. This fungus can be found in nature, mainly in places rich in bat and bird droppings: dirty and abandoned chicken coops, cave environments, old constructions, building domes and hollow trees. The infection in humans occurs through the upper airways. Since the HIV outbreak in the 1980s, it is noticed an increasing detection of disseminated histoplasmosis among aids patients assisted in reference clinics of Fortaleza, suggesting the Brazilian State of Cearà as an area with high endemicity related to this fungus. The purpose of this study is to identify histoplasmosis infection prevalence among HIV/aids-infected patients, who live in the city of Fortaleza, CearÃ. It is a transverse, descriptive and analytic study, with a sample of 161 patients observed at the HIV/aids ambulatory from Josà de Alencar Center of Medical Specialties, and when invited, agreed to participate. For this, they filled in a form, took an intradermal test with histoplasmin (mycelial phase, provided by Fiocruz â RJ), and had their blood collected to serology via immunodiffusion (commercial antigens and antibodies from Histoplasma capsulatum and Coccidioides immitis were provided by Immy Immunodiagnostics laboratory). The general characterization of patients revealed that, on average, most participants were 35,11 years old, men (76,40%; n=123), single (67,70%, n=109), with a maximum family income of three minimum salaries (81,99%; n=132), and having more than 10 years of education (44,10%; n=71). Their previous employment situation had a variable distribution, although the majority of the group is currently unemployed. A number of 137 patients (85,10%) live in houses, and Messejana was the most informed quarter by the participants (8,7%; n=14). The year of 2008 had the most frequent HIV diagnoses among patients, with 66,46% (n=107). The prevalence of histoplasmosis infection among HIV/aids-infected patients, who live in the city of Fortaleza, was 12,42%. Some variables, such as the presence of chicken coops in the patientâs current neighborhood (p=0,031), the presence of mango trees in the current residence (p=0,023), dealing with soil in the past (p=0,021) and visiting small farms in the past (p=0,009) proved to be significant to the Histoplasma infection. However, the use of antiretroviral medication and having or not AIDS did not influence the reactivity to histoplasmin (both p=1,000). It can be concluded that Fortaleza constitutes an area with significant prevalence of histoplasmosis infection, considering that the analyzed population referred to people with suppression of the immune response. This result points out the necessity of identifying patients at risk for histoplasmosis, and also of implementing prophylactic measures on those susceptible to the severe forms of this disease.

A histoplasmose à uma micose sistÃmica causada pelo fungo Histoplasma capsulatum que acomete seres humanos e vÃrias espÃcies de animais. O fungo à encontrado na natureza, principalmente em locais ricos em fezes de aves e morcegos. Cerca de 90% dos indivÃduos que se infectam nÃo adoecem, ou se o fazem apresentam manifestaÃÃes clÃnicas inexpressivas. Apesar do Estado do Cearà vir apresentando uma das maiores casuÃsticas de histoplasmose em pacientes com aids no mundo, poucos estudos abordaram a epidemiologia, os fatores de risco e a frequÃncia deste fungo neste estado. Este estudo tem como objetivo avaliar a prevalÃncia da infecÃÃo por H. capsulatum em profissionais e estudantes de saÃde de trÃs instituiÃÃes de Fortaleza (dois hospitais e um centro de referÃncia ambulatorial) e identificar fatores associados à aquisiÃÃo do fungo. Foram examinados 248 profissionais e 31 estudantes, no perÃodo de 17 de junho de 2010 a 31 de marÃo de 2011, por meio da aplicaÃÃo do teste intradÃrmico com 0,1ml de soluÃÃo 1:1000 de histoplasmina e da realizaÃÃo de imunodifusÃo dupla para Histoplasma. A leitura foi realizada entre 48 e 72 horas, sendo considerada positiva a presenÃa de induraÃÃo ≥ 5 mm. A mÃdia de idade da populaÃÃo do estudo foi de 43,46 anos, a maioria dos participantes pertencia ao sexo feminino (74,19%), tinha renda familiar de um a trÃs salÃrios mÃnimos (36.9%), estudaram mais de 12 anos (45,9%) e residia em casa (69,9%). A prevalÃncia de histoplasmose infecÃÃo na amostra estudada foi de 20,78% e a positividade do exame de imunodifusÃo foi de 0,35%. PresenÃa de morcegos na residÃncia na atualidade (RP= 1,76; IC95%= 1,03â2,99), presenÃa de Ãrvore mangueira (Mangifera indica) na residÃncia na atualidade (RP= 1,72; IC95%= 1,02â2,89), ser estudante (RP= 2,07; IC95%= 1,07-4,03) foram fatores associados à positividade ao teste, enquanto ter idade acima 40 anos (RP= 0,43; IC95%= 0,25â0,72) e presenÃa de pombos no trabalho atual mostraram associaÃÃo negativa (RP= 0,61; IC95%= 0,37-0,99) a reatividade ao teste intradÃrmico. Na anÃlise por sexo, os homens apresentaram significÃncia estatÃstica para presenÃa de morcego na residÃncia na atualidade (RP= 2,91; IC95%= 1,34â6,33) e presenÃa de mangueira na residÃncia na atualidade (RP= 2,91; IC95%= 1,34â6,33), enquanto as mulheres para presenÃa de morcego na vizinhanÃa no passado (RP= 1,86; IC= 1,07â3,22) e associaÃÃo negativa para a faixa etÃria de 41 anos e mais (RP= 0,27; IC95%= 0,15â0,49). Encontrou-se uma associaÃÃo entre ser estudante e as seguintes variÃveis: presenÃa de morcegos na vizinhanÃa na atualidade (RP= 2,1; IC95%= 1,26â4,40) e no passado (RP= 2,4; IC95%= 1,18â4,85), visita a sÃtio na atualidade (RP= 3,84; IC95%= 2,03â7,22) e no passado (RP= 2,4; IC95%= 1,57â3,65). Pode-se concluir que a cidade de Fortaleza constitui-se Ãrea com expressiva prevalÃncia de infecÃÃo por Histoplasma e que condiÃÃes associadas à presenÃa de morcegos se associaram mais vezes à infecÃÃo pelo fungo. / Histoplasmosis is a systemic mycosis caused by the fungus Histoplasma capsulatum that affects humans and various animal species. The fungus is found in nature, especially in places rich in bird and bat droppings. About 90% of individuals who become infected do not get sick, or if they do have clinical manifestations meaningless. Despite the state of Cearà come with one of the largest series of histoplasmosis in patients with aids in the world, few studies have addressed the epidemiology, risk factors and frequency of this fungus in this state. This study aims to evaluate the prevalence of infection by H. capsulatum health professionals and students from three institutions of Fortaleza (two hospitals and a referral center for outpatient) and identify factors associated with the acquisition of the fungus. Were examined 248 professionals and 31 students in the period from June 17, 2010 to March 31 2011, through the application of intradermal test with 0.1 ml of 1:1000 solution of histoplasmin and performing for Histoplasma immunodiffusion. Reading was held between 48 and 72 hours, and considered positive the presence of ≥ 5 mm induration. Mean age of the study population was 43.46 years, the majority of participants belonged to females (74.19%) had a family income of one to three minimum wages (36.9%) studied over 12 years (45.9%) and resided at home (69,9%). Prevalence of histoplasmosis infection in the sample was 20.78% and the positivity of the immunodiffusion test was 0.35%. Presence of bats in residence at today (RP = 1.76, 95% CI 1.03 to 2.99), presence of tree mango (Mangifera indica) in residence today (RP = 1.72, 95% CI 1.02 to 2.89) , being a student (RP = 2.07, 95% CI 1.07 to 4.03) were associated with positive testing, while having age above 40 years (RP = 0.43, 95% CI = 0.25 to 0.72) and the presence of pigeons in the present work showed a negative association (RP = 0.61, 95% CI 0.37 to 0.99) intradermal skin test reactivity. Analyzing gender, men showed statistical significance for the presence of bat the residence today (RP = 2.91, 95% CI 1.34 to 6.33), presence of mango tree in residence today (RP = 2.91, 95% CI 1.34 to 6.33) and women for the presence of bats in the neighborhood in the past (RP = 1.86, CI: 1.07 to 3.22) and negative association between age group of 41 years and over (RP = 0.27, 95% CI 0.15 to 0.49). Was found an association between being a student and the following variables: presence of bats in the neighborhood today (RP = 2.1, 95% CI 1.26 to 4.40) and in the past (RP= 2.4, 95% CI 1.18 to 4.85), visit the site today (RP = 3.84; 95% CI = 2.03 to 7.22) and in the past (RP = 2.4, 95% CI 1.57 to 3.65). It can be concluded that the city of Fortaleza is up area with high prevalence of Histoplasma infection and conditions associated with the presence of bats is more often associated with infection by the fungus.

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.