Abstract This is a case report about the only confirmed death in the State of Espírito Santo due to acute Chagas-related myocarditis in a 2-year-old child living in the rural area of Guarapari. He presented with fever, abdominal pain, headache, and vomiting, resulting in death 21 days after the presentation of symptoms. Amastigote forms were observed in the myocardial fibers in histological examination. The boy’s mother had reported finding “kissing bugs” in the child’s hand. This case highlights the need to include Chagas disease in the differential diagnosis in health care to provide early treatment and avoid death in affected individuals.

Alguns pacientes sob terapêutica antirretroviral (TARV) não obtêm recuperação imune quando a carga viral se torna indetectável. Isto é chamado resposta imunológica e virológica discordante. A prevalência varia entre 8% e 24%. Este estudo descreve sua prevalência e características dos afetados em ambulatório de um centro de cuidados especializados brasileiro. De 934 pacientes sob TARV, 536 tinham carga viral indetectável. A prevalência foi 51/536, ou 9% (Intervalo de Confiança de 95% de 6,6% a 11,4%). Idade mediana no início da TARV foi 37 anos (distância interquartílica - DQ: 31 a 45). Gênero masculino e cor parda predominaram (76,5% e 47,1%, respectivamente). Doenças definidoras de Aids estavam ausentes no início da TARV em 60,8%. Cinquenta e um por cento recebiam inibidores da Protease, 43,2% Efavirenz e 5,8% ambos. Tempo mediano de TARV foi 36 meses (DQ: 17-81). Tratamento irregular foi registrado em 21,6%. TARV havia sido anteriormente modificado em 63% e 15,7% haviam usado mono ou dupla terapêutica. A contagem mediana de CD4 foi 255 células/mm³ (DQ: 200-284). O logaritmo mediano da carga viral antes do TARV foi 4,7 (DQ: 4,5-5,2). Aqueles com resposta discordante não eram diferentes dos pacientes com AIDS em geral, mas houve alta frequência de múltiplos esquemas terapêuticos.

Some patients under antiretroviral therapy (ART) do not reach immune recovery when the viral load becomes undetectable. This is called discordant immunologic and virologic responses. Its prevalence varies between 8% and 24%. This study describes its prevalence and the characteristics of the affected subjects in the outpatient clinic of a Brazilian specialized-care center. Of 934 patients on ART, 536 had undetectable viral loads. Prevalence was 51/536 or 9% (95% confidence interval: 6.6% to 11.4%). Median age at the beginning of ART was 37 years (interquartile range - IQR: 31 to 45). Male gender and mixed race predominated (76.5% and 47.1% respectively). AIDS-defining illnesses were absent at the beginning of ART in 60.8%. Fifty-one percent were taking protease inhibitors, 43.2% Efavirenz and 5.8% both. Median time on ART was 36 months (IQR: 17-81 months). Irregular treatment was recorded for 21.6%. ART had been modified for 63% prior to the study, and 15.7% had used monotherapy or double therapy. Median CD4 count was 255 cells/mm³ (IQR: 200-284). Median viral load before ART was 4.7 log10 copies/mL (IQR: 4.5-5.2). Discordant responders were not different from AIDS patients in general, but there was a high frequency of multiple schedules of treatment.

Twelve cases of histoplasmosis in HIV-infected patients were found in a retrospective analysis at the Hospital Universitário Cassiano Antônio de Moraes of the Universidade Federal do Espírito Santo (HUCAM), Vitória (ES), from June 1999 to May 2001. The frequency of histoplasmosis among HIV-positive patients was 2.1% in the infectious diseases division of the hospital during this period. Histoplasmosis compromised mainly males (11/12), 27 to 44 years old, and residents of the metropolitan urban area (10/12). Alcohol abuse and tobacco smoking were described in 10 of the 12 patients. For all patients, this was the first opportunistic infection. Two of the 12 patients died; 10 patients had disseminated disease, one patient had an intestinal presentation and one had disease restricted to the lungs. The most frequent clinical manifestations were weight loss, fever, hepatomegaly and splenomegaly, coughing, abdominal pain, and diarrhea. Six of the 12 patients had skin lesions. Time of symptoms preceding the diagnosis varied from two months to one year. CD4 counts were below 200 cells/mm³ in 9 of 10 patients. Diagnosis was made by histology in two thirds of the patients. The typical adult patient with HIV infection and histoplasmosis in our series was male, had a CD4 count below 200 cells/mm³, had fever, weight loss, cough, abdominal pain and hepatomegaly in the last two months or more, had a high probability of alcohol and tobacco addiction, was having his first opportunistic infection, and had no identifiable environmental exposure risk.