Joana Oliveira

Serological and Vaccination Profile of Hemodialysis Patients during an Outbreak of Hepatitis B Virus Infection

During an outbreak of hepatitis B virus (HBV) infection in a hemodialysis unit, patients were assessed for serological viral markers and vaccination status. HBV infection was identified in 26 patients. Twenty of these were positive for hepatitis B surface antigen (HBsAg), and 6 were negative for HBsAg but positive for IgM antibody to hepatitis B core (anti-HBc) and HBV DNA. The primary source of infection was not clearly identified, although 2 patients were suspected to be the index cases. A multiple logistic regression analysis revealed low anti-HBs titers and vaccination status to be independently associated with the risk of acquiring HBV infection. Both the high prevalence of HBV infection (31%) detected in this unit and the low vaccine response (53%) observed reinforce the importance of universal and preventive measures in controlling HBV infection. The detection of HBV DNA in HBsAg-negative/IgM anti-HBc-positive patients emphasizes the value of anti-HBc testing in the routine screening of HBV in hemodialysis units.

The infratentorial supracerebellar approach in surgery of lesions of the pineal region

Background: Surgery of pineal region lesions is considered a challenging task, due to the particular relationship of lesions in this location with neural and vascular structures. Few series with a significant experience of dealing with these patients have been reported. Methods: We review our experience using infratentorial supracerebellar approach in the surgery of pineal region, regarding the extension of the removal, postoperative morbidity, and discussing details of the surgical technique. In all cases, a supracerebellar infratentorial approach was used in the semi sitting position. Results: A total of 32 patients were operated in the past 20 years (3 germinomas, 3 teratoma, 3 pineocitoma, 2 pineal tumor of intermediate differentiation, 6 pineoblastomas, 6 low grade astrocytoma, 2 glioblastoma, 2 metastasis, 1 ependymoma, 1 epidermoid tumor, 1 cavernoma, and 2 arachnoid cyst). Total removal was achieved in 15 cases and subtotal extensive removal in 7 patients. In the remaining cases, only partial removal was possible, due to the involved pathological types. There was no surgical mortality and no cases of cerebellar venous infarction. Morbidity consisted of transient ocular movement disturbance in 14 patients, transient ataxia in 3 patients, and 1 case of local cerebrospinal fluid (CSF) fistula with meningitis that required surgical treatment. Conclusion: Supracerebellar infratentorial is a safe approach to lesions in the pineal region, and total or extensive subtotal removal is possible in most cases, with acceptable morbidity.

Graves' disease in a mediastinal mass presenting after total thyroidectomy for nontoxic multinodular goitre

Case report: A 67-year-old woman presented with palpitations, fatigue and weight loss. She had a history of TT for nontoxic multinodular goitre at the age of 60 without any signs of malignancy on microscopic examination. She was medicated with levothyroxine 100 μg/day since the surgery without follow-up. She was tachycardic and had no cervical mass nor eye involvement. The TSH levels were suppressed (0.000 μU/ml) and the free T4 (3.22 ng/dl) and free T3 (8.46 pg/ml) increased. No mediastinal enlargement nor trachea deviation on chest roentgenogram. Levothyroxine treatment was stopped but patient showed no improvement on free T 4 or free T3 10 days later. Thyroglobulin was increased: 294 mg/ml. Cervical ultrasound revealed no thyroid remnant. Anti-TSH receptor antibodies were high (19.7 U/l). Corporal scintigraphy demonstrated increased intrathoracic radioiodine uptake. CT scan confirmed a 60×40 mm mediastinal mass. Methimazole 10 mg/day was started. Three months later her thyroid function was normal and she was submitted to surgical resection. Microscopic examination showed thyroid tissue with no signs of malignancy.

Paraparesis as the Presenting Form of a Lumbar Hemorrhagic Synovial Cyst

Intraspinal synovial or ganglion cysts are uncommon lesions associated with degenerative lumbosacral spine disease. They have been reported with increasing frequency in part because of the availability of increasingly sensitive imaging studies1. These juxtafacet cysts are usually located in the lumbar spine and mostly present with back pain associated with progressive radiculopathy, or less often with spinal cord compression syndrome2-5. Hemorrhage into these cysts is uncommon but explains acute symptomatology caused by nerve root compression6. To our knowledge, there have been only sixteen cases of hemorrhagic juxtafacet cysts associated with motor deficit reported in the English-language literature2-5,7-17. We report a case in which hemorrhage into an L4-L5 juxtafacet cyst presented as paraparesis; we also describe its successful treatment and review the literature. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. An eighty-year-old man presented with a history of chronic intermittent bilateral lumbar pain. Five days before admission while exerting minor physical effort, he experienced a sudden exacerbation of lumbar pain radiating to both legs; he also noticed weakness and impaired sensation in both lower limbs that made it difficult to walk without help. He had no incontinence or bowel/bladder dysfunction. There had been no previous traumatic event, and he did not use anticoagulant medication. Findings at clinical examination revealed asymmetrical hyporeflexic paraparesis. The motor deficit was more pronounced in flexion and dorsiflexion of the ankle, was grade 3/5 in the left lower limb and grade 4/5 in the right, and there was hypesthesia in the left L4 and bilateral L5 and S1 territories. The straight leg-raising test was positive bilaterally. Computed tomography (CT) revealed an isodense left intracanalar extramedullary cystic mass adjacent to the …