Cristina Asvolinsque Pantaleão Fontes

High-resolution computed tomography findings from adult patients with Influenza A (H1N1) virus-associated pneumonia

OBJECTIVE The aim of this study was to assess the high-resolution computed tomography (HRCT) findings at presentation in patients diagnosed with Influenza A (H1N1) virus-associated pneumonia. MATERIALS AND METHODS We reviewed the HRCT findings from 20 patients diagnosed with Influenza A (H1N1) and compared their HRCT scans with chest radiographs, obtained on the same day. The imaging studies were obtained 4-9 days after the onset of symptoms. The patients included 11 men and 9 women (ages 24-62 years; mean 42.7 years). All patients had a body temperature greater than 100.4 degrees F (>38 degrees C), tachypnea, and cough. Other common symptoms included diarrhea (60%) and sore throat (30%). The radiographs and HRCT scans were reviewed independently by two observers who reached a consensus decision. RESULTS The predominant HRCT findings consisted of bilateral ground-glass opacities (n=12), bilateral areas of consolidation (n=2), or a mixed bilateral pattern of ground-glass opacities and areas of consolidation (n=6). The abnormalities were bilateral in all of the 20 patients, had a predominantly sub-pleural distribution in 13 patients, and had a random distribution in the remaining 7 patients. The predominant radiographic findings were consolidations. Normal radiographs were found in 4 out of the 20 patients. CONCLUSION HRCT may reveal parenchymal abnormalities in patients with Influenza A (H1N1) infection who have normal findings on radiographs. The predominant HRCT findings were bilateral, peripheral, ground-glass opacities and/or bilateral areas of consolidation. The patients who presented consolidations had more severe clinical course.

Influenza A (H1N1) virus-associated pneumonia: High-resolution computed tomography–pathologic correlation

OBJECTIVE The purpose of this study was to describe the high-resolution computed tomography (HRCT) features of fatal cases of Influenza A (H1N1) virus-associated pneumonia and to correlate them with pathologic findings. METHODS The study included six adult patients who died following Influenza A (H1N1) virus-associated pneumonia. All patients had undergone HRCT, and the images were retrospectively analyzed by two chest radiologists, who reached decisions by consensus. Two experienced lung pathologists reviewed all pathological specimens. The HRCT findings were correlated with the histopathologic data. RESULTS The predominant HRCT findings included areas of airspace consolidation (n=6) and ground-glass opacities (n=3). The main pathological features consisted of diffuse alveolar damage with hyaline membrane formation (n=5), associated with various degrees of pulmonary congestion, edema, hemorrhage, inflammatory infiltration and bronchiolitis. A patient who survived longer showed findings of organizing pneumonia. CONCLUSION Fatal cases of Influenza A (H1N1) virus-associated pneumonia can present as areas of consolidation on CT, with or without ground-glass opacities. These abnormalities can be pathologically correlated with diffuse alveolar damage. Patients with longer survival may present with findings of organizing pneumonia.

Magnetic resonance imaging findings in Guillain-Barré syndrome caused by Zika virus infection

Dear Sir, The recent Zika virus infection (Zika) epidemic in Brazil has been associated with neurological anomalies, including an increase in the number of cases of microcephaly and, more recently, Guillain-Barré syndrome (GBS) [1, 2]. The correlation between Zika and GBS was first reported in 2013 in French Polynesia [3]. Committees and research groups are being created internationally to study this arbovirus. Since May of 2015, authorities have been issuing warnings about Zika transmission in Brazil, describing its epidemic potential as being similar to that of dengue fever and chikungunya [1, 2]. We would like to present the magnetic resonance imaging (MRI) neural axis findings in a 51-year-old female patient who developed neurological symptoms compatible with acute demyelinating polyneuropathy, characteristic of GBS [4]. She presented in our emergency department with symptoms suggestive of Zika including difficulty walking, non-purulent conjunctivitis, rash, myalgia, and arthralgia for 12 days. Her neurological examination showed bilateral peripheral facial diplegia and paresis of the lower limbs that was sufficiently severe to necessitate assistance with walking. The patient’s serum was tested for a panel of viruses at a reference laboratory and found to be positive for the Zika virus (also confirmed in a urine test), but negative for chikungunya, dengue, herpes, cytomegalo-, syphilis (i.e., venereal disease research laboratory test), human immunodeficiency, human T-lymphotropic, and hepatitis viruses. A cerebrospinal fluid test demonstrated albumin-cytological dissociation compatible with GBS [2, 3], acute inflammatory demyelinating polyradiculoneuropathy subtype [3]. Electromyography of the lower limbs showed a pattern of demyelinating disease. Based on these findings, the patient was given a 5-day immunoglobulin treatment, during which clinical improvements were observed. Brain MRI (Fig. 1a, b) demonstrated contrast enhancement of the facial nerves, bilaterally in all segments, and also of the right trigeminal nerve. MRI of the lumbar spine (Fig. 1c, d) showed enhancement in the medullary cone, in the roots of cauda equina in dorsal, and in ventral nerve roots; T2 images revealed increased signal intensity in the spinal ganglia bilaterally at all levels of the lumbar spine with intense contrast enhancement. These features have been described in prior cases of GBS [5] and attributed to demyelination, ischemia, inflammation, and breakdown of the bloodnerve barrier, as occurs in autoimmune polyneuropathy [4, 5]. In conclusion, imaging studies can assist in the differential diagnosis of complications in patients with Zika. * Edson Marchiori edmarchiori@gmail.com

Efficacy of a ketogenic diet with concomitant intranasal perillyl alcohol as a novel strategy for the therapy of recurrent glioblastoma

It has been hypothesized that persistent ketotic hypoglycemia represents a potential therapeutic strategy against high-grade gliomas. Perillyl alcohol (POH) is a non-toxic, naturally-occurring, hydroxylated monoterpene that exhibits cytotoxicity against temozolomide-resistant glioma cells, regardless of O6-methylguanine-methyltransferase promoter methylation status. The present study aimed to evaluate the toxicity and therapeutic efficacy of intranasal POH when administered in combination with a ketogenic diet (KD) program for the treatment of patients with recurrent glioblastoma. The 32 enrolled patients were divided into two groups, KD or standard diet, with intranasal POH treatment (n=17 and n=15, respectively). The nutritional status and anthropometric parameters of the patients were measured. Patients that adhered to the KD maintained a strict dietary regimen, in addition to receiving 55 mg POH four times daily, in an uninterrupted administration schedule for three months. Neurological examination and magnetic resonance imaging analysis were used to monitor disease progression. A total of 9/17 patients in the KD group survived and maintained compliance with the KD. After three months of well-tolerated treatment, a partial response (PR) was observed for 77.8% (7/9) of the patients, stable disease (SD) in 11.1% (1/9) and 11.1% (1/9) presented with progressive disease (PD). Among the patients assigned to the standard diet group, the PR rate was 25% (2/8 patients), SD 25% (2/8) and PD 50% (4/8 patients). The patients assigned to the KD group presented with reduced serum lipid levels and decreased low-density lipoprotein cholesterol levels. These results are encouraging and suggest that KD associated with intranasal POH may represent a viable option as an adjunct therapy for recurrent GBM.

Meningiomas parasselares: aspectos na ressonância magnética

We reviewed 22 cases of patients with parasellar meningiomas evaluated with magnetic resonance imaging (MRI) in private clinics of the cities of Niteroi and Rio de Janeiro, RJ, Brazil. Our aim was to characterize the imaging findings in this type of tumor. MRI scanners with 0.5 and 1.0 Tesla magnets were used for the acquisition of multiplanar T1-weighted (pre- and post-gadolinium administration) and T2-weighted images. The main symptoms observed were headache and visual disturbances. Hyperprolactinemia was observed in only one patient. The most frequent imaging finding was a parasellar mass which appeared hypointense on T1-weighted and hyperintense on T2-weighted images, and enhanced intensively after gadolinium administration. MRI is useful to demonstrate the lesion and to assess the damage to adjacent structures, particularly when the patient presents visual disturbances due to involvement of the cavernous sinuses.