Fábio Fernandes Neves

Severe paraquat poisoning: clinical and radiological findings in a survivor* , **

Paraquat is a nonselective contact herbicide of great toxicological importance, being associated with high mortality rates, mainly due to respiratory failure. We report the case of a 22-year-old male admitted to the emergency room with a sore throat, dysphagia, hemoptysis, and retrosternal pain after the ingestion of 50 mL of a paraquat solution, four days prior to admission. Chest CT scans revealed pulmonary opacities, pneumomediastinum, pneumothorax, and subcutaneous emphysema. The patient was submitted to two cycles of immunosuppressive therapy with cyclophosphamide, methylprednisolone, and dexamethasone. The pulmonary gas exchange parameters gradually improved, and the patient was discharged four weeks later. The clinical and tomographic follow-up evaluations performed at four months after discharge showed that there had been further clinical improvement. We also present a brief review of the literature, as well as a discussion of the therapeutic algorithm for severe paraquat poisoning.

Tuberculose vertebral (doença de Pott) associada a abscesso de psoas: relato de dois casos e revisão da literatura

Tuberculosis is one of the most important infectious disease worldwide, with 3,9 million reported cases in the world in 2002. The skeletal form is responsible for 3% of the total number of cases, with 50% of these due to spinal tuberculosis. The psoas abscess is a rare clinical entity with approximately 12 cases per year described in the medical literature and has in the Mycobacterium tuberculosis , one of its etiologic agents. The objective of this work is to report two cases of spinal tuberculosis associated with psoas abscess attended at our service, as well as a review of the literature.

Influence of acute-phase inflammatory response on serum levels of retinol and retinol binding protein in HIV/AIDS patients

INTRODUCAO: a hiporretinolemia constitui fator prognostico independente em pacientes com AIDS, e a atividade inflamatoria causa reducao dos niveis sericos deste nutriente na populacao em geral. Entretanto, faltam estudos que avaliem o impacto da atividade inflamatoria sobre o nivel serico do retinol em pacientes com AIDS. METODOS: foram avaliados transversalmente 41 pacientes internados por complicacoes da AIDS, que tiveram quantificados alguns marcadores de inflamacao (proteina C reativa e fator de necrose tumoral alfa) e concentracoes sericas de retinol e da proteina de ligacao do retinol. RESULTADOS: apesar da baixa (14,6%) prevalencia de hiporretinolemia evidenciou-se correlacao negativa dos marcadores de inflamacao com os niveis sericos de retinol e de sua proteina de ligacao nos pacientes com AIDS. CONCLUSOES: a atividade inflamatoria de fase aguda esta associada a baixos niveis sericos de retinol em individuos com AIDS.INTRODUCTION Hyporetinolemia is an independent prognostic factor in AIDS patients. Inflammatory activity causes a reduction in the serum levels of this nutrient in the general population. However, there are no studies assessing the impact of inflammatory activity on the serum retinol level in AIDS patients. METHODS A cross-sectional assessment was conducted on 41 patients hospitalized due to AIDS complications. Inflammatory markers (C-reactive protein and tumor necrosis factor-alpha) and serum retinol and retinol binding protein concentrations were quantified. RESULTS Despite the low (14.6%) prevalence of hyporetinolemia, a significant negative correlation was observed between the inflammatory markers and the serum retinol and retinol binding protein levels in AIDS patients. CONCLUSIONS Acute-phase inflammatory activity is associated with low serum retinol levels in individuals with AIDS.

Valproic acid-induced pancreatitis in an adult

Ribeirao Preto School of Medicine, University of Sao Paulo, Sao Paulo SP, Brazil: Physician Resident in Neurology, Department of Neurosciences and Behaviour Sciences; Neurologist and Associated Professor, Department of Neurosciences and Behaviour Sciences; Emergencist Physician, Departament of Internal Medicine. Idiosyncratic reactions to drugs are adverse effects not straightly related with pharmacodynamic mechanisms of the drug and they can take place on unpredictable way by abnormal interaction between the drug and the organism, usually mediated by immunologic or cytotoxic effects triggered by the drug or its metabolites. Even being responsible for 6-10 % of all the adverse reactions to drugs, the idiosyncratic effects can be important sources of morbidity and mortality, mainly in children. The anti-epileptic drugs (AED) also can cause adverse effects by these mechanisms, which impairs the seizure control and obliges the physician to use second line drugs. A study in epileptic patients showed that 10 to 27 % stopped their first treatment with AED on account of the adverse effects, being several of them idiosyncratic. Valproic acid (VPA) is a carboxylic acid used as anti-epileptic in idiopathic and symptomatic generalized epilepsies and in some cases of symptomatic focal epilepsies, as well as for trigeminal neuralgia, migraine and bipolar disorders. Its mechanism is unknown, however it is probably associated with the metabolism of the neurotransmitter GABA. The toxic effects it provokes can be dose-dependent or idiosyncratic. There are several VPA-related idiosyncrasies, being the most noteworthy alopecia, bone marrow aplasia, immune-mediated hepatotoxicity and pancreatitis. The acute pancreatitis is a disease of several etiologies, sometimes caused by use of determined drugs. The pancreatitis provoked by VPA is a rare entity, with estimated incidence of 1:40000, occurring mainly during the first year of treatment or after increase in the dose, with higher incidence in young individuals, in polytherapy (mainly with carbamazepine, phenytoin, phenobarbital and some benzodiazepines), with chronic encephalopathies and in dialysis treatment. The supposed pathogenic mechanism is by direct toxic effect of free radicals in the membranes of the pancreatic cells. The onset can be a slight asymptomatic hyperamylasemia up to a fatal necrohemorragic pancreatitis, and the mortality varies from 17 to 20%, with many complications in the non-lethal cases (pseudocysts, infections, septic shock, chronic pancreatitis, endocrine pancreatic insufficiency). The treatment is based on the immediate withdrawal of the drug, general clinical support and specific treatment of the possible complications. We present the case of a patient who, in less than 2 months of treatment with appropriate dose of VPA, evolved to pancreatitis.

Impact of implementing an exclusively dedicated respiratory isolation room in a Brazilian tertiary emergency department

Background Occupational risk due to airborne disease challenges healthcare institutions. Environmental measures are effective but their cost-effectiveness is still debatable and most of the capacity planning is based on occupational rates. Better indices to plan and evaluate capacity are needed. Goal To evaluate the impact of installing an exclusively dedicated respiratory isolation room (EDRIR) in a tertiary emergency department (ED) determined by a time-to-reach-facility method. Methods A group of patients in need of respiratory isolation were first identified—group I (2004; 29 patients; 44.1±3.4 years) and the occupational rate and time intervals (arrival to diagnosis, diagnosis to respiratory isolation indication and indication to effective isolation) were determined and it was estimated that adding an EDRIR would have a significant impact over the time to isolation. After implementing the EDRIR, a second group of patients was gathered in the same period of the year—group II (2007; 50 patients; 43.4±1.8 years) and demographic and functional parameters were recorded to evaluate time to isolation. Cox proportional hazard models adjusted for age, gender and inhospital respiratory isolation room availability were obtained. Results Implementing an EDRIR decreased the time from arrival to indication of respiratory isolation (27.5±9.3 × 3.7±2.0; p=0.0180) and from indication to effective respiratory isolation (13.3±3.0 × 2.94±1.06; p=0.003) but not the respiratory isolation duration and total hospital stay. The impact on crude isolation rates was very significant (8.9 × 75.4/100.000 patients; p<0.001). The HR for effective respiratory isolation was 26.8 (95% CI 7.42 to 96.9) p<0.001 greater for 2007. Conclusion Implementing an EDRIR in a tertiary ED significantly reduced the time to respiratory isolation.

Acute Type a Aortic Dissection and Cardiac Tamponade

ost cases of cardiac tamponade are diagnosed on the linical findings of elevated systemic venous pressure, achycardia, quiet heart sounds, and paradoxical arteial pulse pressure, but ancillary examinations are eeded for defining proper intervention and defining rognosis (1). Widened mediastinum and cardiac silhouette on chest -ray study are classical radiographic signs of aortic issection, but these signs have been reported in just half f cases (1). The classical “water-bottle” cardiac silhoutte finding on large pericardium effusion is rarely found n the acute settings of aortic dissection. Echocardiography is the gold standard for the diagosis of hemopericardium. Findings of hemopericardium nclude pericardial effusion, right atrial compression, and bnormal ventricular dimensions during the respiratory ycle, right ventricular diastolic collapse in severe cases, nd abnormal respiratory variation in tricuspid and mitral ow velocities (2). Unfortunately, in the following case, his technique was not available when the patient arrived t the hospital. Computed tomography (CT) is seldom used as the rst approach for cardiac tamponade, even though it is ommonly indicated for aortic dissection evaluation. e present CT findings in a patient with aortic disection who developed cardiac tamponade during the T evaluation.