Inês Sanches

Who are the patients with extrapulmonary tuberculosis

INTRODUCTION Tuberculosis (TB) remains a major global public health problem and 20% of all cases are extrapulmonar. The purpose of this study was to identify risk factors associated with extrapulmonar tuberculosis. METHODS We carried out a transversal study which included all patients with extrapulmonary tuberculosis registered in a TB reference center in northern Portugal, between January 2008 and January 2012. We evaluated demographic data, comorbidities, BCG vaccination and previous tuberculosis treatments. Multivariable logistic regression was used to identify independent risk factors (p<0.05). RESULTS Among the 386 patients studied, 260 (67.4%) had pulmonary tuberculosis (PTB) and 126 (32.6%) extrapulmonary TB (EPTB). Age over 40 years old (OR=2.09; 95%CI: 1.29-3.38), female gender (OR=1.63; 95%CI=1.02-2.6) and HIV infection (OR=2.72, 95%CI=1.25-5.93) were independent risk factors for EPTB. Alcoholism (OR=2.22, 95%CI: 1.00-4.95) was associated with higher risk for PTB. Previous liver disease (OR=22.30; 95%IC: 1.89-263.57) was an independent risk factor for peritoneal TB. HIV co-infection (OR=12.97; 95%IC: 1.71-48.42) and the presence of previous TB treatment (OR=7.62; 95%IC: 1.00-57.9) increase the risk of disseminated disease. CONCLUSION We identified independent risk factors for EPTB. Recognizing risk factors associated with EPTB is essential for suspicion of disease and may help make an accurate diagnosis.

Apnea obstructiva del sueño refractaria al tratamiento por floppy epiglottis

The standard treatment of obstructive sleep apnea–hypopnea syndrome (OSAHS) is nasal continuous positive airway pressure (CPAP), but 17% of patients do not respond to this intervention.1 Drug induced sleep endoscopy (DISE) is a technique used to evaluate the site of obstruction in the airway of OSAHS patients when planning surgery. We present the case of a 69-year-old patient with severe OSAHS (apnea–hypopnea index: 38.2 h), who began treatment with automatic positive airway pressure (autoPAP). Despite treatment compliance, correction of leaks, abstinence from alcohol and change to bilevel ventilation, obstructive respiratory events persisted, so DISE was performed. During induced sleep with spontaneous breathing, 75% airway obstruction by the soft palate was identified. When IPAP at 18 cmH2O was applied, a floppy epiglottis was observed that completely occluded the airway. The patient began a weight loss program and has joined a respiratory rehabilitation group. He has discontinued bilevel ventilatory support and returned to autoPAP. Weight loss was 11.4% and obstructive events have been corrected: respiratory disturbance index of 3.4 was determined by polysomnography. DISE performed under spontaneous breathing and PAP has proved useful in the evaluation of patients with treatmentrefractory OSAHS, since physiopathological factors inherent to

WITHDRAWN: Who are the patients with extrapulmonary tuberculosis?

This article has been withdrawn for editorial reasons because the journal will be published only in English. In order to avoid duplicated records, this article can be found at http://dx.doi.org/10.1016/j.rppnen.2014.06.010. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Tumor carcinóide do timo - Caso clínico

Resumo Os tumores neuroendocrinos primarios representam cerca de 4% do total dos tumores do mediastino anterior, incluindo o timo, afectando mais homens que mulheres numa razao de 3:1 e apresentando uma maior incidencia entre os 40 e os 60 anos. Antigamente classificados como timomas, desde 1972 sao considerados um grupo distinto de neoplasias timicas, podendo ser biologicamente activos, estando sobretudo associados a sindroma NEM-1 (19 a 25% dos doentes, sendo nestes casos mais agressivos). Sao descritos como tendo grande progressao local, recorrencia e metastases em elevada percentagem de casos, o que determina um mau prognostico. O estadiamento e o parâmetro mais importante para determinar a sobrevida. Tumores detectados em fase precoce e capsulados associam-se a um excelente prognostico, enquanto em estadios avancados, localmente invasivos, tem prognostico relativamente pobre. A remocao cirurgica completa, para todos os tumores timicos, e a base da terapeutica e o factor critico para a sobrevivencia a longo prazo, independentemente do tipo histologico. Sao uma causa de morte importante, nomeadamente os tumores associados a NEM-1 e sindroma de Cushing, e ha autores que defendem a realizacao de timectomia profilactica nestes doentes.