Marcio F. Chedid

Nocardial infections: report of 22 cases

Twenty-two cases of nocardial infections were diagnosed in our city between 1977- 1998. All patients whose clinical specimens showed Nocardia spp. at Gram stain, which were further confirmed by culture, were selected to be included in the study. Data from patients who were cured were compared with those from patients who died by statistical tests using EPIINFO version 6.04 software. Six isolates were identified as Nocardia asteroides complex, one as Nocardia asteroides sensu stricto and other as Nocardia brasiliensis. We had 17 cases of lung nocardiosis, being one out of them also a systemic disease. Other four cases of systemic nocardiosis were diagnosed: nocardial brain abscesses (one); nocardiosis of the jejunum (one); multiple cutaneous abscesses (one); and a case of infective nocardial endocarditis of prosthetic aortic valve. One patient had a mycetoma by N. brasiliensis. Fifteen (68.2%) out of 22 patients were immunosuppressed, being most (93.3%) by high-doses corticotherapy. Mortality by nocardial infection was 41%; mortality of systemic nocardiosis was 60%. Nocardiosis has a bad prognosis in immunosuppressed patients and also in non-immunosuppressed patients if the diagnosis is delayed. We propose that the delay in diagnosis should be examined in larger series to document its influence in the prognosis of the disease.

Isolated central nervous system histoplasmosis in immunocompetent hosts: A series of 11 cases

Histoplasmosis of the central nervous system occurs in a significant percentage of patients with Histoplasma capsulatum infection, but has usually been described in association with immunosuppression and/or disseminated histoplasmosis. We aim to review the clinical and laboratory features of isolated histoplasmosis of the central nervous system in the immunocompetent host by presenting a series of 11 cases with this condition. Most of these patients presented with headache, meningeal irritation signs and mental status changes, comprising a somewhat different picture from that described in immunosuppressed patients. Moreover, almost all patients had signs of ventricular dilatation in neuroimaging studies, and 8 of the 11 patients had a ventriculoperitoneal shunt at the time of diagnosis, suggesting hydrocephalus to be an important feature of this condition and/or the possibility of shunt infection by the fungus. Immunodiffusion analysis of the cerebrospinal fluid appeared to be the most efficient way to reach the diagnosis and should be considered in immunocompetent patients with chronic lymphocytic meningitis, especially in those who have ventricular shunt or live in endemic areas of Histoplasma capsulatum.

Histoplasmosis presenting as addisonian crisis in an immunocompetent host

A 71-year-old man with presumptively treated pulmonary tuberculosis ten years earlier and previous alcoholism presented with adrenal insufficiency. HIV serology was negative. A computerized tomography scan of the abdomen showed enlarged right adrenal. He recovered after emergency treatment with hydrocortisone IV. Right adrenalectomy was performed. Histoplasmosis was diagnosed and the patient was treated with itraconazole, corticosteroid replacement, and discharged with good health.

Fatores prognósticos na ressecção de metástases hepáticas de câncer colorretal

AIM: To determine the impact of prognostic factors on survival of patients with metastases from colorectal cancer that underwent liver resection. METHODS: The records of 28 patients that underwent liver resection for metastases from colorectal cancer between April 1992 and September 2001 were retrospectively analyzed. Thirty-eight resections were performed (more than one resection in eight patients and two patients underwent re-resections). The primary tumor was resected in all the patients. A screening protocol for liver metastases including clinical examinations every three months, ultrassonography and CEA level until 5 years of follow-up and after every 6 months, was applied. The prognostic factors analyzed regarding the impact on survival were: Dukes C stage of primary tumor, size of metastasis >5 cm, a disease-free interval from primary tumor to metastasis 100 ng/mL, resection margins < 1 cm and extrahepatic disease. The Kaplan-Meier curves, log rank and Cox regression were used for the statistical analysis. RESULTS: Perioperative morbidity and mortality were 39.3% and 3.6%, respectively. The 5-year survival rate was 35%. The independent prognostic factors were: disease-free interval from primary tumor to metastasis < 1 year and extrahepatic disease. CONCLUSIONS: The liver resection for metastases from colorectal cancer is a safe procedure with more than 30% 5-year survival. Disease-free interval from primary tumor to metastasis < 1 year and extrahepatic disease were independent prognostic factors.

Divertículo único do ceco: experiência de um hospital geral brasileiro

BACKGROUND Cecal diverticulitis is a rare condition, specially in western people. Its importance concerns of being part of the differential diagnosis of acute appendicitis and ulcerated cecal carcinoma. AIM To present the experience of southern Brazilian general hospital in the treatment of cecal diverticulitis. MATERIAL AND METHODS We present four cases of single inflamed cecal diverticulum. One was diagnosed by pre-operatively computer tomography and was treated medically without complications. The other three cases were diagnosed during operation and treated by right hemicolectomy and ileotransverse anastomosis. RESULTS There were no deaths or complications. When cecal diverticulitis is pre-operatively diagnosed it may be treated medically. We preclude laparotomy when the diagnosis is uncertain. CONCLUSION We recommend radical surgical management when the diagnosis is made during operation.

Community-acquired pneumonia by Chlamydophila pneumoniae: a clinical and incidence study in Brazil

As there was not any data on Chlamydia pneumoniae (TWAR) infections in Brazil so far, a prospective cohort study of adult patients hospitalized due to CAP was carried out for one year in a Brazilian university general hospital to detect the incidence of CAP by Chlamydophila pneumoniae (TWAR) for one year. During a whole year 645 consecutive patients hospitalized due to an initial presumptive diagnosis of respiratory diseases by ICD-10 (J00-J99), excluding upper respiratory diseases, were screened; 59 consecutive patients with CAP were diagnosed. They had determinations of serum antibodies to C. pneumoniae by microimmunofluorescence at the Infectious Diseases Laboratory of University of Louisville (KY, USA); 37 patients (63.8%) had seroreactivity to TWAR antigens, from which 23 (39.6%) had previous infection; 3 patients (5.2%) were diagnosed with CAP by TWAR and got cured. The incidence of TWAR CAP in our hospital by seroconversion was 5.2%. Our incidence of 5.2% is probably underestimated since TWAR culture was not available; we suggest that Real-Time PCR be used along with other diagnostic methods in future studies to detect the actual incidence of TWAR CAP. We propose that the serological criterion of IgM >1:16 alone to the diagnosis of acute infection by TWAR are discontinued due a lack of specificity.

Development of clinical celiac disease after pancreatoduodenectomy: a potential complication of major upper abdominal surgery

BackgroundCeliac disease is a gluten-induced disease of global malabsorption. There is a subset of patients with celiac disease who are free of major symptoms but who have typical damage to the intestinal mucosa (silent disease). We present the case of a 50-year-old white woman with no clinical symptoms of celiac disease who developed diarrhea and weight loss 12 weeks after a pancreatoduodenectomy for ampullary cancer.MethodsMicrobiological and biochemical examination of the feces did not provide clues useful to diagnosis, and diarrhea was not affected by pancreatic enzyme replacement or administration of antiperistaltic drugs.Results Review of the pathologic specimen and blood tests were compatible with celiac disease.ConclusionThis clinical scenario illustrates that subclinical celiac disease may be an underdiagnosed cause of malabsorption after major upper gastrointestinal surgery and should be considered in the differential diagnosis of diarrhea after pancreatoduodenectomy.

Nonalcoholic Steatohepatitis: The Second Leading Indication for Liver Transplantation in the USA

Nonalcoholic steatohepatitis (NASH) is a severe form of nonalcoholic fatty liver disease (NAFLD), characterized by the histologic presence of hepatic steatosis, ballooning degeneration, and lobular inflammation, with or without peri-sinusoidal fibrosis [1]. In NASH, steatosis is associated with chronic inflammation that may progress to cirrhosis and hepatocellular carcinoma (HCC). Progression to cirrhosis is variable, being influenced by genetic and environmental factors; approximately 11% of patients with NASH progress to cirrhosis within 15 years [2]. HCC may develop in up to 13% in patients with NASH and cirrhosis [2]. NASH is strongly related to obesity and metabolic syndrome (MS), conditions with a high prevalence in the USA and in several countries worldwide. As of 2014, 20% of American teenagers and 36% of adults are obese (BMI C 30 kg/m) [3]. Since NASH was first assigned as a diagnostic category by United Network for Organ Sharing (UNOS) in 2001 [3], the prevalence of NASH as an indication for liver transplantation (LT) was unknown prior to 2001. Most cases that were formerly classified as cryptogenic cirrhosis (CC) were most likely cases of NASH-induced end-stage liver disease (ESLD). In this issue of Digestive Diseases and Sciences, Cholankeril et al. [3] report on the temporal trends and outcomes of LT for NASH in the USA based on a review of the United Network for Organ Sharing and Organ Procurement and Transplantation (UNOS/OPTN) 2003–2014 database. The authors reported that infection with the hepatitis C virus (HCV) was the leading indication for LT, encompassing nearly 33% of all LTs. Overall, the second leading indication for LT was alcoholic liver disease (ALD) with 15% of all cases. NASH was the third most common indication for LT overall, being accountable for 13% of all LTs. Yet, NASHrelated LTs experienced a 162% increase in prevalence from 2003 to 2014. Indeed, NASH became the second leading indication for LT after 2008, accounting for 17.4% of all LTs performed in the USA in 2014 [3]. Cholankeril et al. have reclassified from CC to NASH the cases of all obese patients (BMI C 30 kg/m) that underwent LT for CC [3]. This measure was clearly justified, as it is now accepted that the majority of CC patients actually have undiagnosed NASH [4]. Nevertheless, there are enough reasons to believe that the prevalence of NASH-related LT in the USA might have been even higher than reported by the authors. It is not uncommon to diagnose NAFLD in patients with a BMI\ 30 [1]. Thus, patients with CC that were previously obese and lost weight before being listed for LT could have had NASH as the cause of their ESLD. Reclassifying CC patients with BMI\ 30 kg/m that were previously obese into NASH cirrhosis would further increase the prevalence of NASH as an indication for LT in the USA. Unfortunately, information on prior obesity and weight loss is not usually available on transplant registries worldwide. Obesity and MS may also contribute to chronic liver damage due to other etiologies. In other words, obese individuals suffering from ESLD attributed to diseases other than NASH (e.g., HCV, ALD) do have some ‘‘NASH component’’ contributing to the etiology of ESLD. This potential influence of obesity and MS on ESLD secondary to HCV and ALD was not evaluated in the study. & Marcio F. Chedid marciochedid@hotmail.com; mchedid@hcpa.edu.br

First Report of Human Pancreas Transplantation Using IGL-1 Preservation Solution: A Case Series.

I Georges Lopez preservation solution (IGL-1) is an extracellular type of preservation solution that has lesser viscosity and lower potassium concentration than the criterion of University of Wisconsin preservation solution (UW). Institute Georges Lopez-1 preservation solution has been used for preservation of human kidney and liver allografts, resulting in transplant outcomes that are similar to those obtained with UW. Although IGL-1 has been used successfully for preservation of human islet cells prior transplantation, and also for experimental pancreas transplantation, no previous report of human pancreas transplantation using IGL-1 was found in the medical literature. From February to October 2015, 5 consecutive simultaneous pancreas and kidney transplants were performed using IGL-1 preservation solution at our institution (Table 1). Procurement operations and pancreas transplantswere performed by a same surgeon (Chedid, M.F.). After cross clamping, 5 L of IGL-1 was infused through deceased donors aorta, and 1 Lwas infused through inferiormesenteric vein. Intravenous

Transarterial Embolization and Percutaneous Ethanol Injection as an Effective Bridge Therapy before Liver Transplantation for Hepatitis C-Related Hepatocellular Carcinoma

Background. Transarterial chemoembolization alone or in association with radiofrequency ablation is an effective bridging strategy for patients with hepatocellular carcinoma awaiting for a liver transplant. However, cost of this therapy may limit its utilization. This study was designed to evaluate the outcomes of a protocol involving transarterial embolization, percutaneous ethanol injection, or both methods for bridging hepatocellular carcinomas prior to liver transplantation. Methods. Retrospective review of all consecutive adult patients who underwent a first liver transplant as a treatment to hepatitis C-related hepatocellular carcinoma at our institution between 2002 and 2012. Primary endpoint was patient survival. Secondary endpoint was complete tumor necrosis. Results. Forty patients were analyzed, age 58 ± 7 years. There were 23 males (57.5%). Thirty-six (90%) out of the total 40 patients were within Milan criteria. Complete necrosis was achieved in 19 patients (47.5%). One-, 3-, and 5-year patient survival were, respectively, 87.5%, 75%, and 69.4%. Univariate analysis did not reveal any variable to impact on overall patient survival. Conclusions. Transarterial embolization, ethanol injection, or the association of both methods followed by liver transplantation comprises effective treatment strategy for hepatitis C-related hepatocellular carcinoma. This strategy should be adopted whenever transarterial chemoembolization and/or radiofrequency ablation are not available options.