Marcelo Alcântara Holanda

Diretrizes brasileiras para pneumonia adquirida na comunidade em adultos imunocompetentes - 2009

Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.

Controle da asma e qualidade de vida em pacientes com asma moderada ou grave

OBJECTIVE To evaluate the association between degree of asthma control and health-related quality of life in patients with moderate or severe asthma. METHODS This was a descriptive observational study involving 59 outpatients with moderate or severe asthma under treatment at the Asthma Outpatient Clinic of the Federal University of Ceará Walter Cantídio University Hospital, in the city of Fortaleza, Brazil. The patients were evaluated regarding sociodemographic and clinical characteristics, as well as spirometric parameters. The asthma control status was assessed using the asthma control test (ACT), and quality of life was assessed using the Saint Georges Respiratory Questionnaire (SGRQ). RESULTS The mean age of the patients was 55.0 ± 12.4 years, and 76.3% were female. The ACT score showed statistically significant negative correlations with all SGRQ scores: total (r = -0.72); symptoms (r = -0.78); activity (r = -0.67); and impact (r = -0.68). Multiple regression analysis showed that the most robust predictive variables for SGRQ total score were ACT score (coefficient = -3.18; 95% CI: -4.14 to -2.23) and duration of disease (coefficient = -0.29; 95% CI: -0.54 to -0.03). The ACT score also explained the linear variation of the SGRQ domains: symptoms (coefficient = -3.41; 95% CI: -4.45 to -2.37); activity (coefficient = -3.07; 95% CI: -4.57 to -1.57); and impact (coefficient = -2.68; 95% CI: -3.71 to -1.65). CONCLUSIONS The degree of asthma control appears to have a significant impact on health-related quality of life.

Histoplasmose disseminada aguda em indivíduo imunocompetente

A histoplasmose e uma doenca fungica causada pela inalacao de esporos de Histoplasma capsulatum. A maioria dos individuos normais nao apresenta doenca apos pequena inalacao, porem exposicoes mais prolongadas podem levar ao desenvolvimento de infeccao pulmonar aguda, cronica ou disseminada. Nos pacientes imunocomprometidos a infeccao e disseminada e grave. Relatamos o caso de um paciente de treze anos, imunocompetente, com febre, tosse seca e dispneia progressiva havia dois meses. O radiograma e a tomografia computadorizada de torax evidenciavam infiltrado intersticial com micronodulos difusos. O paciente relatava contato intenso com passaros em sua residencia. Foi submetido a biopsia pulmonar a ceu aberto, que evidenciou Histoplasma capsulatum em tecido pulmonar. A cultura do fragmento da biopsia confirmou a presenca de Histoplasma capsulatum sp. O paciente foi tratado com anfotericina-B por 28 dias, seguida de itraconazol por seis meses, com resolucao do quadro.

Liver transplantation in a patient with Niemann-Pick disease and pulmonary involvement

Do ponto de vista respiratorio, os varios tipos de DNP, incluindo o tipo B, podem apresentar acometimento pulmonar com progressiva perda da funcao pulmonar e achado radiologico sugestivo. Relatamos o caso de uma paciente do sexo feminino, 27 anos, com DNP tipo B. Foi inicialmente encaminhada para acompanhamento ambulatorial em 2003, com historia de hepatoesplenomegalia e retardo no desenvolvimento neuropsicomotor desde a infância. A DNP foi confirmada por dosagem de esfingomielinase em leucocitos perifericos, a qual estava diminuida (0,009 −1nmol

Protective ventilation and alveolar recruitment maneuver in a patient with leptospirosis-induced acute respiratory distress syndrome

Leptospirosis is an infectious disease that is characterized by vasculitis, the underlying cause of the clinical manifestations being capillary endothelial cell injury. Leptospirosis can involve multiple organ systems and cause renal tubular dysfunction, hepatic dysfunction, myocarditis, and alveolar hemorrhage.(1) Pulmonary involvement can manifest as acute respiratory distress syndrome (ARDS), in which the need for mechanical ventilation is associated with a mortality rate of 30-60%.(2) The controversy regarding the various alveolar recruitment maneuvers (ARMs) and their role in patients with ARDS motivated us to describe the case of a patient with ARDS secondary to leptospirosis, in whom a CT-guided ARM with sustained high pressure was successfully performed.(3,4) A previously healthy 21-year-old male patient was admitted to the emergency room with a one-week history of headache, myalgia, and fever (39 °C), as well as with a two-day history of progressive dyspnea. The patient developed respiratory failure requiring orotracheal intubation and ventilatory support, being transferred to our hospital. He reported occupational exposure to soil during gardening activities. The patient presented with poor general health status, being on mechanical ventilation and hemodynamically stable without the use of vasoactive drugs. He also presented with right conjunctival hemorrhagic suffusion. The initial laboratory test results were as follows: • hematocrit, 29.8% • hemoglobin, 11 g/dL • leukocytes, 14,000 cells/mm3 (12,082 segmented neutrophils and 1,040 lymphocytes) • platelets, 145,000 cells/mm3 • C-reactive protein, 95.1 mg/L • sodium, 143 mEq/L • potassium, 3.1 mEq/L • urea, 38 mg/dL • creatinine, 1.2 mg/dL • indirect bilirubin, 0.66 mg/dL • direct bilirubin, 1.65 mg/dL • prothrombin time, 1.19 • activated partial thromboplastin time, 111% • albumin, 2.5 g/dL • glutamic-oxaloacetic transaminase, 96 U/L • glutamic-pyruvic transaminase, 43 U/L • lactate dehydrogenase, 883 U/L • creatine phosphokinase, 995 U/L • urinalysis, normal Arterial blood gas analysis results were as follows: pH, 7.34; PaO2, 79.8 mmHg; PaCO2, 55.3 mmHg; bicarbonate, 29.2 mEq/L; SaO2, 95.1%; FiO2, 0.8; and PaO2/FiO2 ratio, 99. A chest X-ray revealed bilateral homogeneous diffuse opacity. An echocardiogram revealed normal cardiac function. The patient was started on antibiotic therapy with ceftriaxone, clarithromycin, and oxacillin for severe community-acquired pneumonia. Because the patient was suspected of having influenza A (H1N1) infection, he was started on antiviral treatment with oseltamivir. Because the patient presented with refractory hypoxemia, a CT scan was taken. During the procedure, an ARM was performed. The patient remained properly sedated and was hemodynamically stable. He was submitted to pressure-controlled ventilation (PCV), as follows: RR, 15 breaths/min; inspiratory time, 2 s; inhalation/exhalation ratio, 1:1; FiO2, 1; and pressure, 15 cmH2O above a positive end-expiratory pressure (PEEP) of 25 cmH2O for 2 min. The functional and radiological responses were evaluated immediately before the ARM Protective ventilation and alveolar recruitment maneuver in a patient with leptospirosis-induced acute respiratory distress syndrome

Gravidez em paciente com microlitíase alveolar pulmonar grave

Pulmonary alveolar microlithiasis (PAM) is a rare disease that affects both lungs. It is characterized by the presence of small calculi (calcium phosphate) within the alveolar spaces. We report the case of a 26-year-old female whose diagnosis was based on characteristic findings on chest X-rays and high-resolution computed tomography scans. The patient, 28 weeks pregnant, was rehospitalized 10 months after the diagnosis, presenting hypoxemic acute respiratory failure and severe restrictive ventilatory defect on spirometry. After 32 completed weeks of gestation (228 days), she was submitted to cesarean section, and the outcome was successful for mother and newborn. PAM has a variable clinical course. It is suggestive of an autosomal recessive inheritance pattern and has been associated with positive family history. The etiology of PAM is unclear, and many authors speculate that there is a local enzymatic defect responsible for the intra-alveolar accumulation of calcium. Reports of patients with PAM who become pregnant are exceptional, and this is the first case described in Brazil. The course of this disease is usually slow and progressive, and patients typically die of cardiorespiratory failure. The present case illustrates the need to offer female patients, especially those with advanced disease, genetic counseling and orientation regarding the risks of pregnancy. Currently, the only effective therapy is lung transplantation.

Hemangiomatose capilar pulmonar, uma rara causa de hipertensão pulmonar: primeiro caso brasileiro

A hemangiomatose capilar pulmonar e uma doenca rara, caracterizada por proliferacao de capilares que invadem o intersticio pulmonar e o septo alveolar. Documentamos o primeiro caso brasileiro: um paciente do sexo masculino, de 21 anos, com hipertensao pulmonar grave, que evoluiu para obito. Na tomografia computadorizada de alta resolucao apresentava pequenas opacidades intersticiais nodulares maldefinidas, bilateralmente. Foi realizada biopsia pulmonar post-mortem e encontrada intensa proliferacao multifocal de capilares nas paredes alveolares, septos interlobulares e tecido conjuntivo peribronquico. O diagnostico de hemangiomatose capilar pulmonar deve ser considerado nos pacientes com hipertensao pulmonar e alteracoes sugestivas na tomografia computadorizada de alta resolucao.