Mário Terra Filho

Imagem em tuberculose pulmonar

Tuberculosis is a disease of high incidence and prevalence in Brazil. Imaging methods can reveal signs suggestive of tuberculosis activity or sequelae. Chest radiographs can reveal active lung tuberculosis through consolidations, cavitations, interstitial patterns (nodular and reticulo-nodular), mediastinal or hilar lymphadenopathy and pleural effusions. Images compatible with the active disease, such as centrilobular nodules segmentarily distributed, thick-walled cavities, thickened bronchial or bronchiolar walls, bronchiectasis and lymphadenopathy can be observed by computerized tomography. Thin-walled cavities, traction bronchiectasis, parenchymal bands, emphysema and mosaic pattern are signs suggestive of inactive disease. Gallium-67 citrate scyntigraphy is a complementary method useful in the detection of infectious diseases, including tuberculosis, especially in immunocompromised patients. Inhalation / perfusion analyses are used in the pre-operative assessment of patients carrying tuberculosis sequelaes and multiresistant tuberculosis. Positron emission tomography with fluorine-18 labeled deoxyglucose allows the detection of the inflammatory process that takes place during the active stage of tuberculosis and may persist, not so intense, after specific treatment is over. Imaging methods are valuable tools to be used in the diagnosis and follow up of pulmonary tuberculosis.

Tuberculose e silicose: epidemiologia, diagnóstico e quimioprofilaxia

Silicosis, the most prevalent of the pneumoconioses, is caused by inhalation of crystalline silica particles. Silica-exposed workers, with or without silicosis, are at increased risk for tuberculosis and nontuberculous mycobacteria-related diseases. The risk of a patient with silicosis developing tuberculosis is higher (2.8 to 39 times higher, depending on the severity of the silicosis) than that found for healthy controls. Various regimens for tuberculosis chemoprophylaxis in patients with silicosis have been studied, all of which present similar efficacy and overall risk reduction to about one half of that obtained with placebo. Long-term regimens have potential side effects (particularly hepatotoxicity). In addition, the use of such regimens can jeopardize adherence to treatment. The current guidelines recommend that tuberculin skin tests be performed, and, if positive, that chemoprophylaxis be instituted. There are several possible regimens, varying in terms of the drugs prescribed, as well as in terms of treatment duration. We recommend the use of isoniazid at 300 mg/day (or 10 mg/kg/day) for six months for patients with silicosis, as well as for healthy patients with periods of exposure to silica longer than 10 years and strongly positive tuberculin skin test results (induration > 10 mm). Nevertheless, further studies are necessary so that indications, drugs, doses and duration of chemoprophylaxis regimens can be more properly defined.

Pulmonary alterations in cocaine users

CONTEXT Brazilian researchers have recently recognized a marked increase in the number of people using abusable drugs and the consequences of this habit. It has become a major public health problem in a potentially productive segment of the general population. In the last few years, several medical articles have given special emphasis to pulmonary complications related to cocaine use. This review is based on this information and experience acquired with groups of cocaine users. OBJECTIVE To present to physicians the pulmonary aspects of cocaine use and warn about the various effects this drug has on the respiratory system, stressing those related to long-term use. DESIGN Narrative review. METHOD Pulmonary complications are described. These may include infections (Staphylococcus aureus, pulmonary tuberculosis, acquired immunodeficiency syndrome/aids, etc.), aspiration pneumonia, lung abscess, empyema, septic embolism, non-cardiogenic pulmonary edema, barotrauma, pulmonary granulomotosis, branchiolitis obliterans and organizing pneumonia, pneumonitis and interstitial fibrosis, pneumonitis hypersensitivity, lung infiltrates and eosinophilia in individuals with branchial hyperreactivity, diffuse alveolar hemorrhage, vasculitis, pulmonary infarction, pulmonary hypertension and alterations in gas exchange. It is concluded that physicians should give special attention to the various pulmonary and clinical manifestations related to cocaine use, particularly in young patients.

Heterogeneous remodeling of lung vessels in idiopathic pulmonary fibrosis

Recently, several reports suggest differences in the vascularization of the various histopathologic patterns of parenchymal remodeling seen in usual interstitial pneumonia (UIP). In this study, we sought to validate the importance of vascular remodeling in patients with idiopathic pulmonary fibrosis (IPF) and to examine the relationship between vascular remodeling and parenchymal remodeling or pulmonary function. Open lung biopsies were performed in 57 patients with IPF, and vascular changes in alternating areas of parenchymal remodeling (UIP histologic patterns) were studied. Quantitative analysis of the internal area, internal perimeter, wall thickness, and surrounding cellularity of medium or large pulmonary arteries, as well as their distribution according to air/parenchymal ratios, was performed. Semiquantitative analysis also was used to determine the grade of vascular occlusion. An inverse association was found between vascularization and UIP parenchymal remodeling (p < 0.05); that is, the decreased internal luminal area and perimeter as well as the increased wall thickness run in parallel with progression from alveolar collapse toward severe mural-organizing fibrosis with honeycombing. Vascular regression (diminished internal area and perimeter of vessels) was also associated with higher FEV1, FVC, and RV values (r = 0.48, p< 0.05), reflecting a tight relationship between vascular remodeling and pulmonary function. A progressive regression of vascularization, reflected by different degrees of luminal occlusion after vascular remodeling, coincided with parenchymal remodeling (alveolar collapse, mural-organizing fibrosis, and honeycombing). This vascular regression may be responsible for the impaired wound healing and progressive fibroproliferation found in patients with IPF. Further studies are needed to determine whether this relationship is causal or consequential.

Consenso Brasileiro sobre a Terminologia dos Descritores de Tomografia Computadorizada do Tórax

JORGE L PEREIRA-SILVA PRESIDENTE Faculdade de Medicina da Universidade Federal da Bahia. JORGE KAVAKAMA VICE-PRESIDENTE Faculdade de Medicina da Universidade de São Paulo. MÁRIO TERRA FILHO SECRETÁRIO Faculdade de Medicina da Universidade de São Paulo. NELSON DA S. PORTO PRESIDENTE DE HONRA Universidade Federal do Rio Grande do Sul. ARTHUR SOARES SOUZA JÚNIOR Faculdade de Medicina de São José do Rio Preto. EDSON MARCHIORI Universidade Federal Fluminense. CÉSAR DE ARAÚJO NETO Faculdade de Medicina da Universidade Federal da Bahia. MARCELO CHAVES Faculdade de Medicina da Universidade de São Paulo. KLAUS L. IRION Universidade Federal do Rio Grande do Sul. DANY JASINOVODOLINSK Universidade Federal de São Paulo. PEDRO DALTRO Clínica de Diagnóstico por Imagem do Centro Médico Barrashopping. LUIZ FELIPE NOBRE Faculdade de Medicina de Santa Catarina. MARCELO FUNARI Faculdade de Medicina da Universidade de São Paulo. DANTE L. ESCUISSATO Universidade Federal do Paraná.

Pleurodesis Induced by Talc or Silver Nitrate: Evaluation of Collagen and Elastic Fibers in Pleural Remodeling

This study evaluated the extracellular matrix (collagen and elastic fibers) in pleurodesis induced by intrapleural talc (TL) or silver nitrate (SN). Study subjects were 420 rabbits divided into two groups and sacrificed from 15 min to 12 months after the injection of the sclerosing agents at intervals previously defined. Pleural adhesions and fibrosis were graded (0–4), and the collagen and elastin were quantified. The maximum score of the pleural adhesions was observed two months after TL (2.80 ± 0.99) and 15 days after SN (3.75 ± 0.25). More intense pleural adhesions were observed in the SN group from day 5 (p < 0.05). Pleural thickness and pleural fibrosis were, in general, significantly higher after SN (p < 0.05). Increased deposition of collagen and elastin was observed in both groups but was more evident in the SN group. In the TL group, a linear correlation was observed between pleural adhesions and fibrosis (r = 0.775), between pleural adhesions and collagen (r = 0.779), and between fibrosis and collagen (r = 0.709). In the SN group, these correlations were acceptable (r = 0.605, 0.665, and 0.663). The elastin presented a correlation of 0.707 (p < 0.001) in the TL group and of 0.564 (p < 0.001) in the SN group. In conclusion, intrapleural 0.5% silver nitrate and talc (400 mg/kg) are effective in the induction of pleurodesis. However, the intensity of adhesions and the richness of collagen after SN, in combination with the early onset of tissue remodeling, demonstrate the local superiority of this agent. Considering the easy availability and instillation, the low cost, and the absence of important side effects, silver nitrate might be considered as a sclerosing agent to induce pleurodesis in humans.

Tomografia por emissão de pósitrons com 18F fluordesoxiglicose como exame não invasivo para o diagnóstico de sarcomas primários de artéria pulmonar

Os sarcomas de arteria pulmonar sao tumores raros e de dificil diagnostico, simulando frequentemente o tromboembolismo pulmonar cronico. Relatamos dois casos de pacientes do sexo feminino com quadro clinico de dispneia e massas pulmonares associadas a falhas de enchimento na arteria pulmonar em angiotomografia de torax. A tomografia por emissao de positrons com 18F fluordesoxiglicose mostrou hipercaptacao das respectivas lesoes. O sarcoma de arteria pulmonar foi confirmado posteriormente por exame anatomopatologico. Ressaltamos a importância do uso desse tipo de tomografia como exame nao invasivo no auxilio diagnostico desses tumores

Pulmonary tuberculosis: tomographic evaluation in the active and post-treatment phases

CONTEXT Adequate knowledge of images consistent with tuberculosis activity is an important resource for tuberculosis diagnosis and treatment. OBJECTIVE To evaluate the structural alterations caused by tuberculosis in the pulmonary parenchyma, both during the active phase of the disease and after the end of the treatment, through computerized tomography of the thorax. TYPE OF STUDY Prospective study. SETTING Pulmonary Division, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo. PARTICIPANTS 20 patients, carriers of pulmonary tuberculosis, confirmed by Mycobacterium tuberculosis culture. PROCEDURES Conventional tomography scans of the patients were obtained at two times: upon diagnosis and after the end of the treatment. The following were considered suggestive signs of tuberculosis activity: centrilobular nodules with segmented distribution, confluent micronodules, consolidations, thick-walled cavities, nodules, masses, thickening of the bronchial walls, tree-in-bud appearance and cylindrical bronchiectasis. MAIN MEASUREMENTS The presence of suggestive signs of tuberculosis activity was compared between the start and the end of treatment by means of the signs test (z). RESULTS All patients (20/20) presented suggestive signs of tuberculosis activity at the start of treatment. After the end of treatment, 13 patients (13/20) still presented some suggestive signs consistent with activity. A reduction in the extent of lung attack was seen post-treatment, in relation to its start (z = 10.10). This change was statistically significant (p < 0.001). CONCLUSION Signs suggestive of tuberculosis activity are present in the active disease and are seen via computed tomography. The extent of parenchymal attack significantly decreases following treatment. Such signs may be useful in the diagnosis of pulmonary tuberculosis.

Theophylline metabolism in patients with hepatosplenic mansoniasis and cirrhosis

The pharmacokinetics of theophylline were studied in 12 patients with hepatosplenic mansoniasis, 14 patients with cirrhosis and 16 normal controls. Following a single intravenous dose of aminophylline volumes of distribution, serum half-lives and body clearances were determined. Volumes of distribution of theophylline in patients with schistosomiasis (mean 0.624 l/kg) did not differ from cirrhotic patients (mean 0.616 l/kg) or normal controls (mean 0.593 l/kg). Cirrhotic patients had a prolonged half-life compared to normal subjects (mean 22.1 vs. 9.9 h), while patients with schistosomiasis did not substantially differ from normal controls (15.8 vs. 9.9 h). Body clearance in patients with schistosomiasis was similar to controls (34.02 vs. 49.20 ml/h per kg) but decreased (29.24 ml/h per kg) in patients with cirrhosis. Individual analysis of the group with schistosomiasis disclosed three patients with reduced theophylline elimination. No relationship was found between laboratory tests of liver function and the pharmacokinetics of theophylline in any group. The administration of theophylline to patients with hepatosplenic schistosomiasis, although less dangerous than in cirrhosis, must be closely followed.

Câncer pleuropulmonar ocupacional

The objective of this chapter was to review the occupational risk factors for developing lung cancer. Initially, the significance of lung cancer in the Brazilian population is addressed. Subsequently, the relationships between the genesis of this type of neoplasia and various physical and chemical agents generated by industrial processes are discussed. In the conclusion, the roles that clinical diagnosis and early prevention play in controlling occupational lung cancer are addressed.