Brazilian spotted fever, a zoonotic disease transmitted by ticks, is caused by Rickettsia rickettsii. We report a fulminant case of this zoonosis in a healthy 46-year-old military man in the urban region of Rio de Janeiro city, in October, 2021. Ticks and capybaras (Amblyomma sculptum, Hydrochoerus hydrochaeris, respectively) were identified in the military fields, pointing to the participation of this large synanthropic rodent, recognized as an efficient amplifier host of Rickettsia rickettsii in Brazil. As the military population is considered a risk group for spotted fever, it is necessary to alert health professionals to the importance of the early detection of the disease and its adequate management, mainly in populations that are particularly at risk of exposure to ticks, in order to avoid fatal outcomes.

HIV-infected patients are at particular risk for invasive pneumococcal disease (IPD). We describe cases of IPD in people living with HIV/AIDS (PLWHA) and find associated risk factors for infection and death. Methods: A retrospective case-control study, nested in a cohort, including PLWHA with and without IPD, conducted in Brazil, 2005–2020. Controls were of the same gender/age and seen at the same time/place as cases. Results: We identified 55 episodes of IPD (cases) in 45 patients and 108 controls. The incidence of IPD was 964/100,000 person-years. A total of 42 of 55 (76.4%) IPD episodes presented with pneumonia and 11 (20%) with bacteremia without a focus and 38/45 (84.4%) were hospitalized. Blood cultures were positive in 54/55 (98.2%). Liver cirrhosis and COPD were the only factors associated with IPD in PLWHA in univariate analysis, although no associated factors were found in multivariate analysis. Penicillin resistance was found in 4/45 (8.9%). Regarding antiretroviral therapy (ART), 40/45 (88.9%) cases vs. 80/102 controls (74.1%) were in use (p = 0.07). Patients with HIV and IPD had a higher CD4 count of 267 cells/mm³ compared with the control group, in which it was 140 cells/mm³ (p = 0.027). Pneumococcal vaccination was documented in 19%. Alcoholism (p = 0.018), hepatic cirrhosis (p = 0.003), and lower nadir CD4 count (p = 0.033) were associated with the risk of death in patients with IPD. In-hospital mortality among PLWHA and IPD was 21.1%, and it was associated with thrombocytopenia and hypoalbuminemia, elevated band forms, creatinine, and aspartate aminotransferase (AST). Conclusions: The incidence of IPD in PLWHA remained high despite ART. The vaccination rate was low. Liver cirrhosis was associated with IPD and death.

Trimethoprim-sulfamethoxazole (TMP-SMX) is the primary therapeutic option for Pneumocystis jirovecii pneumonia (PCP). Gastrointestinal symptoms and cutaneous rash are common side effects, with hyperkalemia being uncommon in patients without kidney dysfunction, and myelotoxicity being even rarer. We present the case of a male patient with hypertension and a recent diagnosis of non-Hodgkin lymphoma, undergoing rituximab treatment for two months. He was admitted to the intensive care unit due to dyspnea, tachypnea, and pleuritic pain, requiring mechanical ventilation. Chest computed tomography showed bilateral and multilobed ground-glass opacities, compromising more than 80% of the lung parenchyma. Pulmonary tuberculosis and COVID-19 were ruled out. An angiotomography and Doppler ultrasound revealed an extensive pulmonary thrombus and deep venous thrombosis. Empiric treatment with TMP-SMX for PCP was initiated, but within four days, the patient experienced metabolic acidosis and severe hyperkalemia, necessitating hemodialysis. He also presented with progressive pancytopenia and critical levels of leukopenia and thrombocytopenia. The hypothesis of TMP-SMX-induced myelotoxicity was suspected. Considering the unavailability of an alternative treatment, it was opted to continue TMP-SMX and initiate a granulocyte-colony-stimulating factor. However, the patient maintained medullary deterioration, becoming refractory to the transfusion of blood derivates. On the 17^th day of treatment, a clinical decision was made to suspend TMP-SMX, leading to improvements within 48 hours in marrow and kidney functions, metabolic acidosis, and hyperkalemia. Despite all efforts, the patient died after 35 days of hospitalization due to hospital-acquired infections. This case highlights the importance of clinicians recognizing potential myelotoxicity with TMP-SMX and promptly discontinuing the drug if necessary.

Tuberculosis stands as one of humanity’s oldest afflictions, intrinsically intertwined with social disparities. This formidable disease spares no age group and remains the prevailing cause of infection-induced mortality worldwide, particularly in developing nations. We present a case of a 56-year-old woman with diabetes who was diagnosed with Pulmonary Tuberculosis. After receiving antituberculosis drugs as part of her treatment, she experienced a range of systemic manifestations and suffered from severe ulcerative esophagitis. This adverse reaction led to uncontrollable gastrointestinal intolerance, tragically resulting in her untimely demise. The incident underscores the potential seriousness of adverse reactions that can arise from tuberculosis treatment medications.

Introdução: A Brugmansia suaveolens, conhecida como “trombeta de anjo,” é uma planta com alcaloides anticolinérgicos que provocam inibição da atividade de receptores muscarínicos no sistema nervoso central e periférico. Sua toxicidade resulta em agitação, alucinações, hipertermia, taquicardia, rabdomiolise, insuficiência renal e morte. Objetivo: Descrever um caso de intoxicação aguda por chá de trombeta, cursando com hepatite fulminante. Materiais e Métodos: Trata-se de um relato de caso, com dados clínicos e laboratoriais coletados a partir dos registros em prontuário. Termo de Consentimento Livre e Esclarecido foi obtido com familiar e o projeto foi aprovado pelo Comitê de Ética em Pesquisa. Relato de Caso: Masculino de 19 anos, saudável, internado por quadro de febre de 41°C e crises convulsivas tônico-clônicas generalizadas, evoluindo para intubação orotraqueal. Apresentava midríase fixa e rigidez de nuca. Família relata que o paciente tinha feito uso de chá de “trombeta de anjo”. À admissão, realizou tomografia computadorizada de crânio, que não evidenciou desvio de linha média, líquor sem alterações, gasometria arterial com acidose metabólica grave, insuficiência renal aguda com necessidade dialítica e insuficiência hepática aguda fulminante. Conclusões: A intoxicação pelo “chá de trombeta” é uma emergência neurológica que deve ser rapidamente reconhecida por ser potencialmente fatal. Tendo meningite como diagnóstico diferencial, é importante obter história clínica completa para investigar possível contato prévio com a planta. Para nosso conhecimento, esse é o primeiro caso a relatar quadro de hepatite fulminante pela “trombeta de anjo,” além dos sintomas neurológicos já descritos em literatura, o que corrobora ainda mais para a importância do tema em questão.