Letter to the editor Discrepancy between immunosuppressive status and extensiveness of fungal infections?

Vitorino Modesto, Dos Santos, Vitorino Modesto, Santos, Lister Arruda, Modesto Dos Santos
2016 Le Infezioni in Medicina, n   unpublished
Sir, Fungal invasive infections are more frequent in individuals with immunodeficiency related to HIV infection, chemotherapy, and bone marrow or solid organ transplants, and approximately 80% of cryptococcal infections occur in immunocompro-mised individuals [1, 2]. Carniato et al. described two apparently immunocompetent Caucasian male patients with meningoencephalitis by Cryp-tococcus neoformans, and their immunological condition was evaluated in the acute phase of infection, which did not
more » ... on, which did not rule out eventual previous immunodeficiency [1]. These infections were well controlled by amphotericin B, 5-flucytosine and fluconazole. Interestingly, the authors questioned if the current state of partial or substantial immune competence of those individuals might be related to the lack of more ominous outcomes [1]. De Rosa et al. reported invasive aspergillosis in a young female with immunosuppression after brief use of metilprednisolone in high-dose for autoimmune thrombocytopenia [2]. Pulmonary and central nervous system lesions were well controlled by voriconazole and caspofungin. The authors emphasized the variability of host susceptibility to invasive fungal infections depending upon either transitory or permanent immuno-suppressive conditions [2]. Recently, we read the very interesting review by Cheon et al. about disseminated aspergillosis in immunocompetent hosts, a propos of the case study of an old man without risk factors, presenting with pneumonia, endophthalmitis and spon-dylitis due to Aspergillus [3]. Worthy of note, the fungi were not found by histopathology study of lung and bone samples, and cultures of lung tissue and vitreous humor were positive for Asper-gillus. Moreover, the specific fungal polymerase chain reaction was positive, and the determina-tions of serum galactomannan antigen were significantly elevated (1.75 and 5.4; normal: ≤0.45 index) [3]. The authors highlighted the rarity of this condition, the role of previous pulmonary involvement in a possible invasive infection, and antifungal treatment of good outcome [3, 4]. They also emphasized the increased number of disseminated Aspergillus infections affecting immuno-suppressed individuals in the last three decades, related to organ transplants and AIDS, in addition to malignancy and long courses of corticosteroids and chemotherapy [3, 4]. We would like to comment two prostatic cryp-tococcal infections in Brazilian patients, and two Italian patients, immunocompetent and immuno-compromised, with fungal infections. A 32-year-old man had AIDS and widespread infection by Mycobacterium avium-intracellulare, which was not controlled by antimicrobial treatment, and the patient died [5]. Necropsy revealed unsuspected cryptococcoma measuring 2 cm of diameter characterized by the finding of abundant yeast-like fungi of uniform volume, unique gemmulation, and "tear drop" pattern. The fungi were surrounded by mucinous matter without inflammatory reaction , and the capsules stained by mucicarmine [5]. In spite of the advanced grade of immunosup-pression, the infection by C. neoformans was restricted to the prostate, and without eliciting local
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