Liliana Fernandes

IgG4-related disease presenting with an epidural inflammatory pseudotumor: a case report.

BackgroundInflammatory pseudotumor is a rare clinical condition that can be related to immunoglobulin G4 disease. Only a few cases of spinal inflammatory pseudotumors have been reported in the literature and an association with immunoglobulin G4 disease was not conclusive in any of them. We describe what we believe to be the first biopsy-proven case of an epidural inflammatory pseudotumor related to immunoglobulin G4 disease.Case presentationA 57-year-old Caucasian woman presented to our hospital with severe paraparesis, gait disturbance, and sensory loss secondary to a relapsing epidural mass. Examination of a biopsy specimen revealed a lymphoplasmacytic infiltration with fibrosis and an immunoglobulin G4-positive plasma cell ratio of over 50 %, which are compatible with a diagnosis of immunoglobulin G4-related inflammatory pseudotumor. Our patient was successfully treated with systemic and epidural administration of glucocorticoids.ConclusionImmunoglobulin G4-related disease is an emerging clinical condition in which central nervous system involvement is still uncommon. We describe the case of a patient with an epidural mass with medullar compression, which was proved to be an immunoglobulin G4-related epidural inflammatory pseudotumor. Our findings suggest a new manifestation of immunoglobulin G4-related disease. This disorder should be considered in the differential diagnosis of spinal tumors as a potentially treatable condition with glucocorticoids.

Awareness of Stroke Risk Factors and Warning Signs and Attitude to Acute Stroke

Background: Stroke is a leading cause of death and disability worldwide. Knowledge of stroke risk factors and warning signs might improve its prevention and ensure prompt activation of emergency medical services and access to thrombolysis. Educational campaigns have been held in Portugal though its impact on knowledge of medical patients has not been assessed. Methods : A cross-sectional observational study was performed to medical outpatients, through an interview. Main objectives were to assess the extent of knowledge on risk factors and warning signs and the attitude to stroke and to identify predictive factors of stroke-related knowledge. Two subgroups were studied: hypertensive and elderly. Results: Two hundred and forty eight patients were randomly selected. Two hundred and nine patients (84,3 %) spontaneously recalled at least one risk factor, most frequently hypertension, dyslipidemia and stress. One hundred and eighty four patients (74,2%) spontaneously named at least one warning sign, most frequently hemiparesis, speech impairment and facial palsy, but few (6,5%) spontaneously recalled the three together. One hundred and sixty nine patients would activate emergency medical service (69,5%). Hypertensive patients revealed a better stroke-related knowledge while no significant difference was found in elderly. Educational level was a predictor of better knowledge. Failure to activate emergency medical service was inversely associated to knowledge of risk factors, but not to warning signs. Conclusion: Despite reasonable stroke-related knowledge, it is insufficient particularly concerning awareness of three main warning signs and behavior to acute stroke. Further investigation is necessary to identify barriers to activation of emergency medical service.

Severe Metformin Associated Lactic Acidosis: a Case Series of an Intensive Care Unit

Background: Severe metformin-associated lactic acidosis (MALA) is a rare but potentially fatal side effect of metformin. The clinical presentation is often unspecific, thus hindering early recognition. We aimed to assess the prevalence of MALA in an intensive care unit (ICU) and describe the demographic and clinical characteristics according to patient outcome. Methods: We conducted a 13-year single-center retrospective study, including all patients admitted in ICU with a high anion-gap metabolic acidosis and hyperlactatemia secondary to therapeutic use of metformin, after excluding other medical causes of acidosis. Results: Twenty one patients were admitted in ICU due to severe MALA (less than 1% of all admissions) with an ICU mortality rate of 23.8% (N=5). The baseline clinical characteristics were similar in survivors and nonsurvivors, both with a high prevalence of cardiovascular comorbidities as well as frequent concomitant therapy with angiotensin-converting-enzyme inhibitors and diuretics. All patients were treated with continuous renal replacement therapy (CRRT) and other organ failure support. Normal acid-base balance was achieved in all survivors in the first 24 hours. At baseline, the clinical and laboratory features of nonsurvivors were undistinguishable from survivors. Conclusions: Severe MALA is a rare cause of admission in the ICU. Although early institution of supportive therapy, MALA can progress to severe multiple-organ failure, especially when diagnosis and CRRT are delayed. Clinicians should suspect of MALA in all diabetic patients taking metformin with unexplained high anion-gap metabolic acidosis and hyperlactatemia.

Prognostic factors of patients admitted in a medical intermediate care unit: a prospective observational study

Background Medical Intermediate Care Units (IntCU’s) are high-dependency units intended for treatment of patients who do not meet criteria for admission to intensive care units (ICU’s) but require a higher level of care than can be provided in general ward. IntCU’s operate as a transitional unit, improving patients outcome. In addition, IntCU’s permit better resource utilization, reducing the length of stay in ICU and therefore increasing availability of critical care. Regardless of admission of unstable patients in IntCU’s, studies on prognostic factors are scarce. Our purpose was to identify prognostic factors of patients admitted in IntCU. Methods A prospective observational study was performed during 32 months in a IntCU of a central hospital. Main objective was evaluation of mortality and analysis of acute illness severity, nurse workload, comorbidity and previous functional status as prognostic factors. Assessment of these variables was performed using several standardized scores: Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA), Therapeutic Intervention Scoring System-28 (TISS-28), Nursing Activities Score (NAS), Charlson comorbidity index and Barthel index of basic activities of daily living. Bivariate and multiple logistic regression with forwards stepwise selection were used to identify prognostic factors of IntCU and in-hospital mortality. Results Two hundred and eighty-eight patients were included, mean age 65,67 ± 20,38 years-old. IntCU and in-hospital mortality was 9,38 and 17,71%, respectively. All the scores applied, concerning comorbidity, functional status, acute illness severity and nurse workload were good predictors of mortality. SAPS II was the better predictor of mortality followed by NAS. Conclusions Acute illness severity and nursing workload scores validated in ICU are useful and reliable in IntCU setting, being SAPS II and NAS the strongest predictors of mortality. Comorbidity, functional status and age were also prognostic factors. Consequently, a comprehensive assessment of patients admitted in IntCU is mandatory to reliably predict outcome. Several scores might be used to help clinical judgment, concerning admission criteria and clinical decisions.

Severe hypercalcaemia and colon ischaemia: dehydration as an unusual cause?

Hypercalcaemia is an emergency with severe consequences. Dehydration can be an uncommon cause of hypercalcaemia, as seen in this case. A 63-year-old woman with type 2 diabetes mellitus, hypothyroidism and osteoporosis, was admitted to the emergency room with abdominal distension and vomiting for 24 h. Initial evaluation was Hg 18.5 g/dL, Htc 56.2%, creatinine 2 mg/dL, metabolic acidaemia, lactate 8.3 mmol/L, anion gap 19, total Ca2+ 17.7 mg/dL and PO4+ 6.6 mg/dL. CT revealed colonic distension without obstruction or ischaemia. Renal replacement therapy and pamidronate were initiated. The patients clinical condition deteriorated with septic shock in the context of toxic megacolon and she underwent an emergency subtotal colectomy (10 kg). Hypercalcaemia was corrected in 24 h with aggressive fluid replacement (8 L NaCl 0.9% first 12 h), with a reduction of total Ca2+ to 8.2 mg/dL. Other causes of hypercalcaemia were excluded. ‘Hypercalcaemic crisis’ secondary to severe acute dehydration is not mentioned in the literature.