Carlos Jesus Pereira Haygert

Osteomielite esternal por Mycobacterium tuberculosis

We report the case of a 74-year-old male patient with a one-year history of chest pain in the suprasternal notch associated with erythema, edema and drainage of purulent material from a fistulous lesion. The patient was HIV-negative with no history of TB. A CT scan of the chest showed an osteolytic lesion in the sternum, and a biopsy revealed caseous granuloma, which, in the microbiological evaluation, was negative for fungi and acid-fast bacilli. The diagnosis of sternal osteomyelitis caused by Mycobacterium tuberculosis was confirmed using PCR.We report the case of a 74-year-old male patient with a one-year history of chest pain in the suprasternal notch associated with erythema, edema and drainage of purulent material from a fistulous lesion. The patient was HIV-negative with no history of TB. A CT scan of the chest showed an osteolytic lesion in the sternum, and a biopsy revealed caseous granuloma, which, in the microbiological evaluation, was negative for fungi and acid-fast bacilli. The diagnosis of sternal osteomyelitis caused by Mycobacterium tuberculosis was confirmed using PCR.

Transverse myelitis associated to HCV infection

Complications involving the central nervous system in patients suffering from hepatitis C virus (HCV) infection have been rare. Among them, it appears the transverse myelitis, which has already been reported in likely association with HCV. This paper presents the case study of a 65-year-old woman who developed cervical transverse myelitis linked to chronic HCV infection and anti-HCV antibodies in the spinal fluid, being excluded other etiologies for transverse myelitis. Current evidence has reinforced the likely association between chronic HCV infection and transverse myelitis, especially as recurrent manifestations of the disease. These findings reveal the need for more searching to establish the causal relationship between transverse myelitis and hepatitis C.

Diaphragmatic amplitude and accessory inspiratory muscle activity in nasal and mouth-breathing adults: A cross-sectional study

The purpose of this study was to evaluate the electromyographic activity of the accessory inspiratory muscles and the diaphragmatic amplitude (DA) in nasal and mouth-breathing adults. The study evaluated 38 mouth-breathing (MB group) and 38 nasal-breathing (NB group) adults, from 18 to 30years old and both sexes. Surface electromyography (sEMG) was used to evaluate the amplitude and symmetry (POC%) of the sternocleidomastoid (SCM) and upper trapezius (UT) muscles at rest, during nasal slow inspiration at Lung Total Capacity (LTC) and, during rapid and abrupt inspiration: Sniff, Peak Nasal Inspiratory Flow (PNIF) and Maximum Inspiratory Pressure (MIP). M-mode ultrasonography assessed the right diaphragm muscle amplitude in three different nasal inspirations: at tidal volume (TV), Sniff and inspiration at LTC. The SCM activity was significantly lower in the MB group during Sniff, PNIF (p<0.01, Mann-Whitney test) and MIP (p<0.01, t-test). The groups did not differ during rest and inspiration at LTC, regarding sEMG amplitude and POC%. DA was significantly lower in the MB group at TV (p<0.01, Mann-Whitney) and TLC (p=0.03, t-test). Mouth breathing reflected on lower recruitment of the accessory inspiratory muscles during fast inspiration and lower diaphragmatic amplitude, compared to nasal breathing.

Bilioma espontâneo: relato de caso e revisão da literatura

Biloma is defined as any collection of bile outside the biliary tree, usually resulting from surgery complications and abdominal trauma. Spontaneous occurrence of bilomas is rare, occasionally associated with choledocolithiasis. The present report describes a case of spontaneous biloma, whose diagnosis was radiologically confirmed. At laparotomy, the presence of a retroperitoneal biloma was observed. Intraoperative cholangiography has not demonstrated the presence of fistula. After drainage, the patient progressed well and was discharged.

Spontaneous pneumomediastinum (Hamman's syndrome)

A previously healthy, 21-year-old female nonsmoker sought emergency room treatment complaining of recent and progressive swelling of the face, neck, and chest (Figure 1). The patient reported no pain, dyspnea, or dysphagia at admission. She reported a brief history of odynophagia in the previous week, when, during an episode of cough, she felt intense (dissecting) retrosternal pain, which subsided within a few minutes after its onset. After that episode, she had no symptoms other than the abovementioned swelling.Physical examination revealed extensive subcutaneous emphysema, which extended from the xiphoid process to the temporal muscle and involved the entire neck and face. Pulmonary percussion and auscultation revealed no abnormalities. Cardiac auscultation revealed the presence of Hamman’s sign (crackles—as was the case in our patient—or bubbling sounds, synchronous with the heartbeat). Oral endoscopy revealed no abnormalities, and the remainder of the physical examination was normal.A CT scan of the skull, neck, and chest confirmed the presence of pneumomediastinum, pneumothorax (Figure is known as the Macklin effect or phenomenon, 2A), and extensive soft tissue emphysema in the cervical region (Figure having been named after Charles C. Macklin, 2B)—involving the face, periorbital tissues, and temporal muscles (Figure 2C)—as well as revealing the presence of pneumorrhachis (Figure in the case reported here, spontaneous 2D).From postadmission day two onward, the subcutaneous emphysema gradually improved. The patient received conservative treatment, including rest, unrestricted diet, and analgesia, if necessary. The results of routine laboratory tests, including blood workup and urinalysis, were normal. Follow-up chest X-rays revealed a sustained reduction in the abovementioned signs and symptoms. The patient remained under observation for another five days, being asymptomatic and showing nearly complete resolution of the clinical picture at discharge (Figure 1).Spontaneous pneumomediastinum, also known as Hamman’s syndrome, is defined as the presence of free air in the mediastinum, being unrelated to trauma or procedures (surgical or otherwise).

Doença de Madelung: relato de caso e revisão da literatura

AbstractResumo * Study developed at the Service of Head & Neck Surgery,Hospital Universitario de Santa Maria (HUSM) – UniversidadeFederal de Santa Maria (UFSM), Santa Maria, RS, Brazil.1. Specialization in Cancerology and Oncological Surgery,Assistant Professor, Universidade Federal de Santa Maria (UFSM),Santa Maria, RS, Brazil.2. Medical Residence in Radiology and Imaging Diagnosis,Assistant Professor at Universidade Federal de Santa Maria(UFSM), Santa Maria, RS, Brazil.3. MD, General Surgeon, Medical Residence in General Sur-gery at Hospital Universitario de Santa Maria (HUSM) – Univer-sidade Federal de Santa Maria (UFSM), Santa Maria, RS, Brazil.4. MD, Resident in General Surgery at Hospital Orencio Frei-tas, Niteroi, RJ, Brazil.5. MD, Resident in Ophthalmology at Hospital de Clinicas dePorto Alegre (HCPA), Porto Alegre, RS, Brazil.6. Graduate Student of Medicine, Universidade Federal deSanta Maria (UFSM), Santa Maria, RS, Brazil.Mailing address: Dra. Sâmia Adaime. Rua Jornalista MoacirPadilha, 70, Bloco 1, ap. 1001, Centro. Niteroi, RJ, Brazil,24020-350. E-mail: sbra5@hotmail.comReceived October 19, 2009. Accepted after revision Febru-ary 5, 2010.The authors report the case of a patient with Madelungs disease, which is clinically described as the presence of multiple and symmetric non-encapsulated masses of fatty tissue, usually involving the neck and the upper region of the trunk. Computed tomography was selected as the imaging method for diagnosis confirmation, considering its lower cost and higher availability as compared with magnetic resonance imaging.

Hemichorea-hemiballism: the role of imaging in diagnosing an unusual disorder in patients with nonketotic hyperglycemia.

An 81-year-old man presented to the emergency room with a 4-day history of progressive confusion followed by frontal headache and left-sided choreiform movements. His medical history was remarkable for smoking, dyslipidemia, and poorly-controlled hypertension, with no previous diagnosis of diabetes mellitus (DM). On laboratory investigation, his serum glucose was 460 mg/dL and his glycated hemoglobin was 17.4% (consistent with a prolonged period of undiagnosed DM). A computed tomography scan of the brain revealed hyperdensity of the right putamen without an associated mass effect (Figure 1), which suggested a diagnosis of hyperglycemic hemichorea-hemiballism (HCHB). The patient was started on insulin, and few hours following glucose correction there was great improvement in his mental status and a decrease in involuntary movements. On an unenhanced T1weighted spin-echo magnetic resonance imaging (MRI) sequence obtained two weeks after initial presentation, there were hyperintense lesions, consistent with hyperglycemic HCHB, located in right putamen. Diffusion-weighted imaging showed no corresponding signal alterations. T2*-weighted imaging demonstrated bilateral punctiform hypointensities in the globus pallidus, which were presumably physiological in nature and did not match the unilateral T1 abnormality (Figure 2). The patient completely recovered his previous cognitive and motor functions after glycemic control, being discharged without sequelae. Ballistic and choreic movements are characterized by hyperkinetic, random, involuntary movements in the proximal and distal extremities, respectively. Because they usually occur concomitantly, the term HCHB was created to unify these signs into a clinical syndrome when presented unilaterally. Although HCHB syndrome is secondary to lesions in the basal ganglia, the source of the neuronal damage is controversial, the putative mechanisms including disruption of the blood-brain barrier, decreased thalamic gamma-aminobutyric acid input secondary to anaerobic metabolism, small hemorrhages in the striatal region, hyperviscosity related to hyperglycemia, and Wallerian degeneration of putaminal white matter with protein desiccation. Vascular cerebral lesions constitute the most common cause of HCHB. Hyperglycemia is considered an important, albeit rare, risk factor for the development of HCHB, which is most commonly seen in elderly female patients with uncontrolled DM. The predominance of Asian patients in the published data suggests an ethnic predisposition. The clinical course tends to vary depending on the patient’s glycemic status—the hemiballism and hemichorea usually start together with the hyperglycemia, resolving after its correction. Computed tomography findings of hyperglycemic HCHB include unilateral hyperdensity in the basal ganglia contralateral to the affected site. On T1-weighted MRI scans, the most common finding is signal hyperintensity in the caudate nucleus and putamen, usually sparing the internal capsule. The apparent diffusion coefficient and diffusion-weighted MRI generally indicate

The role of imaging in diagnosing an unusual manifestation of neurofibromatosis type 1: calvarial dysplasia

A 25-year-old man was referred to our institution for investigation of a one-year history of gradually developing nodules covering his skin. His medical history was unremarkable. On physical examination, multiple cutaneous nodules were noted, as were café au lait spots, bilateral Lisch nodules (Figure 1A), and axillary freckles (Figure 1B). The results of neurologic and fundoscopic examinations were unremarkable. The father of the patient, who was also examined, presented with similar cutaneous nodules. Those findings met the criteria for neurofibromatosis type 1 (NF1), which had previously gone undiagnosed. To determine the extent of the newly diagnosed NF1, computed tomography (CT) of the head was performed. The CT scan revealed an unsuspected left-sided discontinuity in the occipital bone along the left lambdoid suture (Figures 1C and 1D), measuring 3.1 × 2.7 cm. There were no signs of brain herniation through the bone aperture, and we detected no neurofibromas over the bone defect on the clinical examination or on the CT scan. Given the presence of NF1 and the absence of a history of neurologic surgery that could account for such a finding, a diagnosis of occipital calvarial dysplasia was established. Because the patient had no neurological symptoms, we opted for periodic clinical and imaging follow-up over surgical intervention. After one year of follow-up, the lesion remained unchanged and no neurologic symptoms had arisen. NF1 is an autosomal dominant, multisystem disorder with extreme clinical heterogeneity. The incidence of bony defects is higher in patients with NF1 than in the general population, and studies in the recent radiology literature of Brazil have addressed the role of different imaging modalities in the evaluation of bone lesions. However, although sphenoid wing dysplasia, pseudarthrosis of the tibia, and vertebral defects are hallmarks of NF1 and compose its standard diagnostic criteria, calvarial involvement in NF1 is uncommon. Many patients with such defects are asymptomatic, although headache, visual symptoms, and concurrent bony skull defects can be present. Therefore, a thorough clinical and imaging evaluation is called for when calvarial defects are detected. Two hypotheses try to explain cranial vault defects in NF1. One theory suggests that the calvarial lesions stem from an intrinsic bone development abnormality related to mutations within the NF1 gene itself. However, some authors postulate that NF1-related bone defects derive from increased exogenous pressure exerted by underlying neurofibromas, thereby leading to bone erosion and patency of cranial sutures. Because calvarial lesions have been observed in the presence and absence of adjacent tumors, it remains unclear whether these defects represent

Incidentally detected massive scrotal cystocele

1. Cetrim – Centro de Treinamento em Imaginologia, João Pessoa, PB, Brazil. 2. Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brazil. 3. Escola Paulista de Medicina da Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil. Mailing address: Dr. Edward Araujo Júnior. Rua Belchior de Azevedo, 156, ap. 111, Torre Vitória, Vila Leopoldina. São Paulo, SP, Brazil, 05089030. E-mail: araujojred@terra.com.br. no associated complications were identified. Cesarean section was performed at 35 weeks of gestation, because of fetal distress. The newborn weighed 2183 g; the 1and 5-minute Apgar scores were 7 and 10, respectively. Postnatal echocardiography confirmed the LVD in the free wall of the left ventricle. On the 3rd day of life, the newborn underwent surgery to correct the defect, and there were no postoperative complications. The newborn remained in the neonatal intensive care unit for 9 days and was discharged from the hospital on the 18th day of life, with preserved cardiac function and no complications. An LVD is defined as a protrusion of the free wall of a ventricle. Although it is of unknown etiology, it is probably congenital. The weakness of the myocardial wall during embryogenesis can lead to a focal protrusion of the heart wall. An LVD has a narrow neck through which it communicates with the ventricular cavity; in contrast, a left ventricular aneurysm (LVA) has a wide base for connecting with the ventricular cavity. The wall of an LVA is akinetic, whereas an LVD contracts synchronously with the ventricle. An LVD can be accompanied by Figure 3. Spectral Doppler ultrasound showing triphasic flow and high pulsatility within the diverticulum. other congenital and cardiac anomalies such as the pentalogy of Cantrell. The prenatal diagnosis of LVD or LVA can be made by ultrasound, and these anomalies are frequently accompanied by pericardial effusion, which can cause fetal pulmonary hypoplasia and progressive hydrops. LVD is reported to have a more favorable long-term prognosis than does LVA. The prognosis is usually favorable when there is no change in the size of the diverticulum, which was the case in the patient described here. When a fibrous LVD has a thin wall, disruption can occur and is usually fatal, although such a development is rare. Prenatal monitoring, with serial examinations by fetal cardiology and cardiac surgery teams for proper programming of prenatal or postnatal interventions, will therefore be necessary.

Malignant peripheral nerve sheath tumor of the vagus nerve: an uncommon cause of progressive dyspnea

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