João Meneses Santos

Multiple Aseptic Liver Abscesses as the Initial Manifestation of Crohn's Disease: Report of a Case

ABSTRACT: Aseptic liver abscesses preceding the diagnosis of Crohns disease are extremely rare. We report a patient with multiple liver abscesses that yielded negative microbiologic investigation and failed to develop full remission under antibiotic therapy. Diagnosis of Crohns disease of small and large bowel was later established and she was started on sulfasalazine and azathioprine with total regression of the hepatic abscesses. This case illustrates the rare possibility of aseptic liver abscesses as an initial manifestation of Crohns disease, which could be interpreted in the light of recent data on aberrant homing of gut T memory/effector lymphocytes in the liver.

Linfoma MALT do pulmão – Uma forma rara de linfoma

Resumo Os autores apresentam um caso de linfoma MALT do pulmao numa doente assintomatica mas com imagens radiologicas exuberantes, cujo diagnostico so foi possivel por biopsia pulmonar cirurgica obtida por toracoscopia assistida por video, apos a ineficacia da biopsia pulmonar transbronquica e da puncao aspirativa transtoracica. Descrevem os aspectos clinicos e radiologicos daquela forma de linfoma, salientando a possibilidade de expressao assintomatica prolongada e discutem problemas de diagnostico, prognostico e terapeutica.

Blood cultures on internal medicine: utilization profile and clinical implications

Introducao: o uso excessivo de hemoculturas tem sido associado a aumento do tempo de internamento e de custos hospitalares. Adicionalmente, a literatura medica reporta taxas de positividade abaixo do esperado, levando a criacao de indices de predicao de positividade. Metodos: estudo prospectivo observacional conduzido numa enfermaria de Medicina Interna de um hospital terciario, com recolha de dados de todos os doentes a quem foram realizadas hemoculturas. Resultados: em 414 admissoes, foram colhidas hemoculturas em 39.9%. Os doentes a quem foram colhidas hemoculturas tiveram maior tempo de internamento e mais exames laboratoriais e imagiologicos pedidos. 7,5% das hemoculturas foram positivas. Nos doentes com criterios de sepsis a taxa de positividade das hemoculturas foi 21,7% e nao houve nenhuma hemocultura positiva em doente sem criterios de sepsis, nomeadamente em doentes com elevacao isolada de proteina c-reactiva, leucocitose ou febre. O resultado da hemocultura nao foi um determinante de de-escalacao antibiotica. Conclusoes: este estudo sugere que as hemoculturas devem ser colhidas essencialmente em doentes com sepsis, podendo esta pratica diminuir o seu sobreuso.

Multisystemic Sarcoidosis with Early Gastrointestinal Symptoms

Sarcoidosis involving the digestive tract is very rare and requires a strict differential diagnosis with other systemic granulomatous diseases. We present a case of multisystemic granulomatosis involving the stomach and colon, causing initial digestive symptoms. Pulmonary nodules, pleural effusion, ascites, hepatomegaly, splenomegaly, and mesenteric as well as retroperitoneal and axillary lymphadenopathy were subsequently identified. The reticulo-endothelial expression, the hypercalcemia and, above all, a rapid and complete resolution after corticosteroids supported the hypothesis of sarcoidosis involving the digestive tract. A brief review of digestive tract involvement in sarcoidosis and of the distinctive features of sarcoidosis with gastrointestinal involvement and Crohns disease with a rare form of pleuro-pulmonary involvement is presented.

Disseminated Necrotizing Leukoencephalopathy Complicating Septic Shock in an Immunocompetent Patient

Disseminated necrotizing leukoencephalopathy (DNL) is characterized by multiple microscopic foci of white matter necrosis. DNL was initially thought to be exclusively associated with immunosuppression conditions but it has been recently described in immunocompetent patients in septic shock. A 90-year-old immunocompetent woman with no previous neurological impairment presented with septic shock and drowsiness that responded well to therapy with clinical improvement and a full neurological recovery. Unexpectedly deterioration with progression to coma occurred. Investigation excluded other causes and Magnetic Resonance Imaging (MRI) was consistent with the diagnosis of DNL showing bilateral multifocal white matter lesions with a nonvascular pattern with restricted diffusion. Neurological impairment persisted with progression to death. DNL is an unexpected diagnosis in an immunocompetent patient. We compared the present case to those found in the literature of DNL complicating septic shock and discuss the antemortem diagnosis based on MRI findings.

Massive Bleeding as the First Clinical Manifestation of Metastatic Prostate Cancer due to Disseminated Intravascular Coagulation with Enhanced Fibrinolysis

Disseminated intravascular coagulation (DIC) is the most frequent coagulation disorder associated with metastatic prostate adenocarcinoma. However, DIC with enhanced fibrinolysis as an initial presentation of prostate cancer is extremely rare. The appropriate treatment to control bleeding in these situations is challenging, controversial, and based on isolated case reports in the literature. A 66-year-old male presented at the emergency department with acute severe spontaneous ecchymoses localized to the limbs, laterocervical hematoma, and hemothorax. Prostate specific antigen level was 385 μg/L, bone scintigraphy revealed multiple bone metastases, and prostate biopsy confirmed adenocarcinoma (Gleason 9; 4 + 5). Laboratory investigation showed a pattern of enhanced fibrinolysis rather than the more common intravascular coagulation mechanism. Epsilon aminocaproic acid in monotherapy was initiated with a clear and rapid control of bleeding manifestations. This rare case of massive bleeding due to DIC with enhanced fibrinolysis as the first manifestation of prostate cancer suggests that in selected cases where the acute bleeding dyscrasia is clearly associated with a dominant fibrinolysis mechanism it is possible to use an approach of monotherapy with antifibrinolytics.

Inflammatory myofibroblastic tumour: report of a rare form with exclusive pleural involvement.

Inflammatory myofibroblastic tumour (IMT) is a rare scleroinflammatory lesion, characterized by a myofibroblastic proliferation with inflammatory infiltrates, with many possible locations and diagnosis based on immunohistochemistry. Pleural IMT is uncommon and is usually an extension of a pulmonary involvement. We report on a 28-year-old woman with a new form of this rare entity, characterized by exclusive pleural involvement.