E M De Capitani

Diagnostic investigation of ventilator-associated pneumonia using bronchoalveolar lavage: comparative study with a postmortem lung biopsy

The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54%) were diagnosed as having VAP and 17 (46%) as not having the condition. Quantitative culture of BAL effluent showed 90% sensitivity (18/20), 94.1% specificity (16/17), 94.7% positive predictive value and 88.8% negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1% of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1% (16/17), and a cut-off point of 50% of BAL neutrophils showed a sensitivity of 90% (19/20). In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP.

PRESENCE OF MICRONUCLEI IN LYMPHOCYTES OF MERCURY EXPOSED WORKERS

We have investigated the presence of micronuclei in mercury exposed workers. The study group consisted of 15 workers from a mercury-producing plant, mean age 39.5 years and a mean exposed period of 12 years. At the time of testing and for the six previous months, the exposed population had urinary mercury levels below the currently accepted limit of 50 ug/g creatinine. A significant increase in the percentage of micronuclei was observed in the mercury exposed individuals when compared to the non exposed group. We have not found any correlation between the percentage of micronuclei and age, length of exposure or urinary mercury concentrations. Our results suggest a genotoxic effect of mercury, which is observed in workers exposed chronically to levels considered biologically safe for the exposed population.

Association Between Paracoccidioidomycosis And Tuberculosis: Reality And Misdiagnosis [associação Entre Paracoccidioidomicose E Tuberculose: Realidade E Erro Diagnóstico]

OBJECTIVE To evaluate the frequency of the real association between paracoccidioidomycosis (PCM) and tuberculosis (TB) as well as the rate of previous TB misdiagnosis in individuals with PCM among the patients treated in the Pulmonology Division of the State University of Campinas Hospital das Clínicas, Campinas, Brazil. METHODS A retrospective study of 227 adult patients with PCM (chronic form) treated between 1980 and 2005. RESULTS Of the 227 patients studied, 36 (15.8%) had been previously treated for TB. However, only 18 (7.9%) presented positive sputum smear microscopy results. The remaining 18 (7.9%) neither presented positive sputum smear microscopy nor showed improvement after receiving specific anti-TB treatment. CONCLUSION Although the existence of an association between PCM and TB has been documented in the literature, misdiagnosis is common due to the superimposition of and the similarity between their clinical and radiographic presentations, thereby warranting the need for bacteriological diagnosis before initiating specific treatment.OBJECTIVE: To evaluate the frequency of the real association between paracoccidioidomycosis (PCM) and tuberculosis (TB) as well as the rate of previous TB misdiagnosis in individuals with PCM among the patients treated in the Pulmonology Division of the State University of Campinas Hospital das Clinicas, Campinas, Brazil. METHODS: A retrospective study of 227 adult patients with PCM (chronic form) treated between 1980 and 2005. RESULTS: Of the 227 patients studied, 36 (15.8%) had been previously treated for TB. However, only 18 (7.9%) presented positive sputum smear microscopy results. The remaining 18 (7.9%) neither presented positive sputum smear microscopy nor showed improvement after receiving specific anti-TB treatment. CONCLUSION: Although the existence of an association between PCM and TB has been documented in the literature, misdiagnosis is common due to the superimposition of and the similarity between their clinical and radiographic presentations, thereby warranting the need for bacteriological diagnosis before initiating specific treatment.

Subcutaneous injection of elemental mercury with distant skin lesions

Background: Mercury poisoning presents a variety of clinical pictures depending on chemical structure, amount absorbed, total mercury burden, and individual factors. Distant skin lesions, after subcutaneous injection of metallic mercury, have not been previously described. Case Report: We present a homicidal, subcutaneous injection of mercury resulting in widespread skin lesions, remote from the radiologically visible mercury. The lesions appeared at 40 days and began to clear at 6 months after the injection.

Mesotelioma maligno de pleura com associação etiológica a asbesto: a propósito de três casos clínicos

O mesotelioma maligno de pleura (MM) e tumor de ocorrencia rara em nosso meio e tem-se mostrado, quando em elevada incidencia, relacionado a exposicao pregressa a asbesto ou amianto nas series descritas em outros paises. OBJETIVO. A partir de casos clinicos atendidos no Hospital de Clinicas da Unicamp, procurou-se evidenciar tal associacao epidemiologica, visando alertar profissionais medicos quanto a possivel elevacao da incidencia de tal tumor nesta decada e, futuramente, por caracteristicas proprias da historia natural desse tipo de tumor. METODOS. Sao descritos tres casos de MM de pleura ocorridos na regiao de Campinas, SP, num periodo de dois anos, dos pontos de vista clinico, laboratoriais complementares e anatomopatologico, incluindo minuciosa investigacao anamnesica ocupacional e ambiental. RESULTADOS. Todos os casos foram confirmados do ponto de vista anatomopatologico, incluindo microscopia eletronica, como casos de MM. Os tres casos mostraram relacao epidemiologica, comprovada por meio de historia ocupacional, com exposicao a asbesto no passado. Um dos casos teve exposicao ocupacional pregressa de curta duracao (cerca de um ano); outro teve exposicao domestica a partir de asbesto trazido do ambiente de trabalho por seu pai, durante sua infância, e o terceiro caso com contaminacao ocupacional indireta. CONCLUSAO. A ocorrencia de MM de pleura relacionada a exposicao a asbesto, no passado, parece ser realidade em nosso meio, como mostram estes tres casos clinicos. Destaca-se a necessidade da anamnese ocupacional e ambiental detalhadas na abordagem desses casos, alertando-se para maior atencao no diagnostico dos tumores primarios da pleura e do peritonio, nos proximos anos, em funcao de provavel aparecimento de novos casos relacionados a exposicao a asbesto pregressa, tendo em vista o intervalo de tempo entre o inicio da manipulacao do asbesto em nosso pais e o aparecimento destes primeiros casos coincidir com o tempo de latencia medio esperado para a ocorrencia de MM. Destacam-se, ainda, as necessidades de definicao precisa de criterios diagnosticos, para esse tipo de tumor, e criacao de registro centralizado de casos.

Compartment syndrome after South American rattlesnake (Crotalus durissus terrificus) envenomation

Abstract Context. In order to report the outcome of a patient who developed compartment syndrome after South American rattlesnake (Crotalus durissus terrificus) envenomation, confirmed by subfascial pressure measurement and magnetic resonance imaging (MRI). Case details. A 63-year-old male was admitted 1 h after being bitten on the right elbow by a “large” snake, which was not brought for identification. Physical and laboratory features upon admission revealed two fang marks, local tense swelling, paresthesia, intense local pain, hypertension, coagulopathy, and CK = 1530 U/L (RV < 170 U/L). The case was initially treated with bothropic antivenom (80 mL, intravenously), with no improvement. Evolution within 13–14 h post-bite revealed generalized myalgia, muscle weakness, palpebral ptosis, and severe rhabdomyolysis (CK = 126,160 U/L) compatible with envenoming by C. d. terrificus. The patient was then treated with crotalic antivenom (200 mL, intravenously), fluid replacement, and urine alkalinization. Twenty-four–hour post-bite MRI showed marked muscular edema in the anterior compartment of the right forearm, with a high subfascial pressure (40 mmHg) being detected 1 h later. ELISA of a blood sample obtained upon admission, before antivenom infusion, revealed a high serum concentration of C. d. terrificus venom. No fasciotomy was performed and the patient was discharged seven days later without sequelae. Conclusion. Snakebite by C. d. terrificus with subfascial venom injection may lead to increased intracompartmental pressure.

Coagulopathy as the main systemic manifestation after envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus): Case report

Abstract Context. Rattlesnake bites in Brazil are generally caused by adult individuals, with most of the envenomed patients showing systemic manifestations that include varying degrees of neurotoxicity (acute myasthenia), rhabdomyolysis and coagulopathy, with only mild or no local manifestations. We report a case of envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus) that involved coagulopathy as the main systemic manifestation. Case details. A 19-year-old male was admitted to our Emergency Department with coagulopathy (incoagulable PT, APTT and INR), no remarkable local manifestations and no signs/symptoms of myasthenia or rhabdomyolysis (serum CK, LDH, ALT and AST within reference levels) 5 days after being bitten by a small snake that was described as a rattlesnake but was not brought for identification at admission. The patient had already been treated in another Emergency Department with i.v. bothropic antivenom (AV) 1 h and 4 days post-bite. Based on the possibility of an unusual rattlesnake bite, crotalic AV was administered i.v., which improved the coagulation (9 h post-CroAV, INR = 2.11; 36 h post-CroAV, INR = 1.42). During hospitalization, relatives brought the snake that caused the bite, which was identified as a 38-cm long C. d. terrificus. Discussion. Little is known about the clinical manifestations after bites by juvenile C. d. terrificus. This case shows that systemic envenoming by juvenile C. d. terrificus may result in coagulopathy as the main systemic manifestation, without neuromyotoxic features normally associated with bites by adult specimens. Despite the delayed administration, crotalic AV was effective in improving the blood coagulation.

Auditory neurotoxicity and hepatotoxicity after MSMA (monosodium methanarsenate) high dose oral intake.

INTRODUCTION Organic arsenic compounds have been considered of low toxicity compared to inorganic arsenic compounds such as pentavalent and trivalent salts. A recent literature review shows a remarkable lack of toxicological studies or clinical cases of organic arsenic compound intoxication. Most of the works published in this field are related to toxic effects of organic hepatic metabolites of inorganic arsenic, like MMA (monometilarsonic acid) and DMA (dimetilarsinic acid or cacodylic acid), or natural organic forms found in water and fish such as arsenobetaine and arsenocholine. The latter ones (also known as ‘‘fish arsenic’’) have been shown to be essentially nontoxic (1,2). Synthetic forms of organic arsenicals, contained in many pesticides in use today, like MSMA (monosodium methanarsenate), are poorly studied, considering the rather well established low toxicity of fish arsenic. We report a case of MSMA intoxication leading to severe auditory, hepatic and neurological sequelae.

Antidotes And Medicines Used To Treat Poisoning In Brazil: Needs, Availability And Opportunities [antídotos E Medicamentos Utilizados Para Tratar Intoxicações No Brasil: Necessidades, Disponibilidade E Oportunidades]

Antidotes and certain other drugs are essential for treating some types of poisoning. Failures in their supply can jeopardize the populations health and safety. The current study aimed to assess the availability of antidotes and other drugs used in the treatment of poisonings in Brazil. International guidelines were used as the basis for selecting 41 antidotes for analysis, none of which currently protected by patents. Of these, 27 are registered in Brazil, but 11 of these are available in inadequate forms for treating poisoning, leaving 16 commercially available antidotes. Only one-third of the drugs needed for treating poisoning are included in the countrys list of essential drugs. The article also presents a proposal for supplying the demand for one of the antidotes, anti-digoxin antibody, considering Brazils domestic capacity for manufacturing immunobiologicals. The studys results show the limitations to adequate treatment for poison victims in Brazil and reinforce the urgent need to strengthen public policies in this area.Antidotos e determinados medicamentos sao essenciais ao tratamento de algumas intoxicacoes e nao podem sofrer falhas no abastecimento, sob o risco de prejudicar a saude e a seguranca da populacao. O objetivo deste trabalho foi avaliar a disponibilidade de antidotos e medicamentos recomendados para o tratamento de intoxicacoes no Brasil. A partir de consensos internacionais, foram selecionados 41 antidotos para analise, todos sem patente em vigencia. Desses, 27 sao registrados, porem 11 estao disponiveis em formas inadequadas ao tratamento de intoxicacoes, restando 16 medicamentos comercialmente disponiveis. Somente um terco dos medicamentos necessarios para o tratamento de intoxicacoes esta incluido na relacao de medicamentos essenciais do pais. Em adicao, e apresentada proposta de suprimento das demandas a um dos antidotos, anticorpo antidigoxina, considerando a capacidade de producao nacional de imunobiologicos. Os resultados demonstram limitacao da assistencia adequada aos pacientes intoxicados no pais e reforcam a necessidade urgente de politicas publicas na area.