Vitorino Modesto dos Santos

Twenty years of hantavirus pulmonary syndrome in Brazil: a review of epidemiological and clinical aspects

Hantavirus infection is transmitted to humans by wild rodents and the most common clinical form in Brazil is the Hantavirus Pulmonary Syndrome (HPS). The first serological evidence of the disease was identified in 1990, in Recife, Pernambuco State, and later in 1993 in Juquitiba, State of São Paulo. Since then there has been a progressive increase in case notification in all regions of the country. The clinical aspects of the disease in Brazil are characterized by a prodromal phase, with nonspecific signs and symptoms of an acute febrile illness. After about three days, respiratory distress develops, accompanied by dry cough that turns progressively productive, evolving to dyspnea and respiratory failure with cardiogenic shock. Although the majority of patients receive hospital care in intensive care therapy units, case-fatality rate in Brazil ranges from 33% to 100% depending on the region. Besides it has to be added the problem of differential diagnosis with other prevalent diseases in the country, like dengue and leptospirosis. Questions about the impact of uncontrolled urbanization and other environmental changes caused by human action have been raised. Due to increasing incidence and high case-fatality, there is an urge to respond to such questions to recommend preventative measures. This article aims to review the main acquisitions in clinical and epidemiological knowledge about HPS in Brazil in the last twenty years.

Demência reversível e quedas associadas ao biperideno

As drogas anticolinergicas podem causar efeitos adversos, mais frequentemente nos pacientes idosos. Relatamos um caso de demencia reversivel e quedas, associadas ao uso de biperideno. A paciente, com 82 anos, foi admitida em lar geriatrico devido a quedas frequentes no domicilio, acentuado deficit cognitivo, tremores de extremidades ao movimento e perda de autonomia. Na verdade, era portadora de tremor essencial, que foi confundido com doenca de Parkinson e tratado com biperideno; posteriormente, desenvolveu deficit cognitivo que foi erroneamente diagnosticado como demencia do tipo Alzheimer. Apos submeter-se a avaliacao especializada, foi suspensa a droga anticolinergica e houve reversao completa do quadro demencial; o tremor essencial foi controlado com uso de propranolol. Ao avaliar um paciente com deficit cognitivo, o clinico deve descartar possiveis causas de demencia reversivel, em especial, o grupo das iatrogenicas.

Association of PTH and carotid thickness in patients with chronic kidney failure and secondary hyperparathyroidism

INTRODUCTION Cardiovascular diseases (CVDs) are the leading cause of death in terminal patients with chronic kidney failure (CKF). Diverse risk factors are involved in the pathogenesis, and are classified as traditional, which affect the general population; and non-traditional, which are peculiar to patients with CKF. Secondary hyperparathyroidism, a non-traditional and common factor in CKF, can cause an increased rate of bone absorption with mobilization of calcium and phosphorus. If the product of calcium x phosphorus is increased, the solubility of this ionic pair may be exceeded and deposition of calcium phosphate in cardiac and vascular tissues occur (called metastatic calcification). OBJECTIVE To verify eventual relationship between the thickness of the common carotid artery and the levels of PTH in patients with CKF. METHODS Evaluations by Doppler ultrasonography were performed to measure the width of the carotid artery wall and to search for possible correlations between different values of PTH serum levels, mineral disturbances and traditional risk factors in the carotid changes found in individuals with dialytic CKF and secondary hyperparathyroidism. RESULTS Differences in the cholesterol level and age were observed in patients with signals of arterial calcification. A significant relationship was also observed between the PTH serum levels and the carotid artery wall thickness (r = 0.31, p = 0.03). CONCLUSION Data from this study show the possible concomitance of traditional factors and factors related to CKF in the genesis of CVDs in uremia.

A 56-year-old woman with ampullary adenocarcinoma and acute pancreatitis

This challenging condition has scarcely been reported on. A 56-year-old woman was admitted with jaundice, and laboratory data were indicative of pancreatitis, which recurred in spite of adequate clinical and nutritional management. The patient was an overweight diabetic using metformin, who had antecedents of cholelithiasis and recent cholecystectomy. Clinical and laboratory features were not conclusive about the cause of this acute pancreatitis. However, imaging data contributed to diagnosis suspicion, and the histopathology study of the transpapillary biopsy confirmed the ampullary adenocarcinoma. Whipples surgery was the procedure of choice, associated with radical lymphadenectomy, followed by an uneventful outcome. Recrudescence of signs and symptoms of acute pancreatitis, with elevated serum levels of bilirrubins and of hepatic canalicular enzymes, should enhance the suspicion index about periampullary tumors. High levels of CA 19-9 can constitute a useful marker of this condition. Transpapillary biopsy can characterize the diagnosis of ampullary malignancies.

A 57-year-old Brazilian woman with a giant mucinous cystadenocarcinoma of the ovary: a case report

IntroductionGiant cystadenocarcinomas of the ovary are rarely described conditions.Case presentationThe authors describe a 57-year-old Brazilian woman who presented with an increase in abdominal girth in February 2003. Imaging studies showed a giant abdominal pelvic mass with probable origin in the right ovary. Cancer antigen-125 was elevated, while carcinoembrionic antigen and alpha-fetoprotein were normal. Total abdominal hysterectomy, bilateral salpingoophorectomy and omentectomy were done. The mass weighed 40Kg, and the histopathology study revealed a mucinous cystadenocarcinoma. She underwent chemotherapy with paclitaxel and cisplatin with no side effects. Under follow-up for more than 10 years, she is asymptomatic and with normal imaging and laboratory parameters, including the cancer antigen-125 marker.ConclusionThis huge tumor evolved for a long time unsuspected and without metastases in a patient from a developing region. The diagnostic and management challenges posed by this unexpected and unusual presentation of an ovarian cystadenocarcinoma are discussed.

Abdominal Challenging Image in an Elderly Woman

Address for Correspondence: Dr. Vitorino Modesto dos Santos, Armed Forces Hospital, Brasilia-DF, Brazil Phone: +55-61 39662103 e-mail: vitorinomodesto@gmail.com Received: 14 September 2016 Accepted: 6 January 2017 • DOI: 10.4274/balkanmedj.2016.1364 Available at www.balkanmedicaljournal.org Cite this article as: Santos VM, Menezes FEF. Abdominal Challenging Image in an Elderly Woman. Balkan Med J 2017;34:378-9 ©Copyright 2017 by Trakya University Faculty of Medicine / The Balkan Medical Journal published by Galenos Publishing House. A 72-year-old Brazilian woman with hypertension, diabetes, dyslipidaemia, hyperuricaemia, hypothyroidism, obesity, and alcohol abuse had dyspnoea, cough, and vomiting for 3 weeks. Drugs in use: amlodipine, indapamide, atenolol, losartan, simvastatin, metformin, glimepiride, allopurinol and levothyroxine. No previous abdominal invasive studies or surgical procedures. Physical examination was unremarkable. Laboratory: normal haemoglobin, haematocrit, and platelets; leukocytes 12.940/mm3, eosinophils 776/mm3; normal proteins, transaminases, calcium, thyroid-stimulating hormone, free thyroxine 4, lipidogram, and amylase; lipase 111 IU/L; glycated haemoglobin 11.1%, creatinine 2.1 mg/dL, urea 129.3 mg/dL, and C-reactive protein (CRP) 4.7 mg/L. Abdominal X-ray showed a tortuous tubular radiopaque image fixed on the left-upper quadrant (Figure 1a); computed tomography revealed isolated calcification of the splenic artery (Figure 1b). Written informed consent was obtained from the patient. 1Catholic University Medical Course, Brasilia-DF, Brazil 2Armed Forces Hospital, Brasilia-DF, Brazil Vitorino Modesto dos Santos1,2, Filipe Emanuel Fonseca Menezes2

Comments on Saint’s triad

Yamanaka et al. described two case studies involving coexistent cholelithiasis, hiatal hernia, and umbilical hernias, and discussed clinical similarities with the classical features of the Saint’s triad. Cholelithiasis, hiatal hernia, and colonic diverticulosis characterize the classical triad, but some authors have included any type of hernia due to herniosis—a developmental disorder of the extracellular matrix. The main features of this triad, which seem to be underdiagnosed and/or underreported, are discussed. Therefore, the commented manuscript contributed to better understanding the scarcely reported condition.

Risk factors for mortality in cardiovascular disease and treatment for malignancy

I read with interest the recent article “Assessment of risk factors for mortality in patients with cardiovascular disease and a history of treatment for malignancy” by Rydzek et al. [1]. These authors studied 326 patients with cardiovascular disease (CVD), who were receiving palliative treatment for advanced pulmonary (69.5%) and breast (30.5%) malignancies, and the objective was to evaluate the role of risk factors on surviving for a year in good clinical condition. The mean age was 67.8 ± 10 (42–89) years, 54% were men, and the main concomitant conditions were ischaemic cardiac disease, cachexia, chronic obstructive pulmonary disease, atrial fibrillation, arterial hypertension, and diabetes [1]. The role played by drugs, including tamoxifene, megestrol acetate, angiotensin-converting enzyme inhibitor (ACEI), beta-blockers, diuretics, and dexamethasone, was also discussed [1]. The authors concluded that previous radioand/or chemotherapy for malignancy represent prognostic factors related to increased one-year mortality in this group of patients, and the study is the first one about both oncological and CVD factors influencing survival [1]. I would like to address some comments about reversible cardiotoxicity of trastuzumab in a 54-year-old woman treated for an invasive breast cancer. She was diabetic and hypertensive, and underwent surgery for IIA ductal carcinoma of the breast presenting HER2 receptors [2]. The adjuvant chemotherapy included four cycles of doxorubicin and cyclophosphamide, plus four cycles of trastuzumab and placlitaxel. Before chemotherapy the echocardiogram was normal with a left ventricular ejection fraction (LVEF) of 76%, but at the seventh cycle of trastuzumab the patient had symptoms of heart failure and echocardiogram showed an LVEF of 59%. She improved significantly with the use of ACEI and a reduction of the dose of chemotherapy by 25% [2]. Four years later she remains in regular outpatient control, maintaining good clinical condition. Mortality risk scores are important tools during patient selection for invasive procedures, especially among old-age groups, which involve individuals with higher risk of malignancy; however, prognostic factors related to malignancy and its treatment are not yet included [1]. The commented studies might stimulate the interest for researchers about these risk factors, cardiotoxicity related to chemotherapy, survival time, and better quality of life for oncologic patients.

Endocardite por Burkholderia cepacia e corpo estranho intracardíaco

The authors describe the case of a renal transplant patient who developed late infective endocarditis associated with an intracardiac fragment of a catheter inserted 16 years before. Clinical presentation was anemia of undetermined cause and weight loss. Three blood cultures were positive for Burkholderia cepacia. Transesophageal echocardiography revealed a foreign body in the right atrium and right ventricle, confirmed by computed tomography. The patient underwent intravenous antibiotic therapy, followed by cardiac surgery to remove the foreign body. There were no postoperative complications, with improvement of anemia and stabilization of renal function.

Intravenous lipoma and pulmonary sarcoidosis treated with prednisone

Corticosteroid-induced lipomatosis is not a rare condition, but lipoma in the central veins has scarcely been described. According to the databases consulted, this is the first report of a lipoma within the central veins coexistent with long-term use of corticosteroid. It involved a 47-year-old male under treatment for pulmonary sarcoidosis with prednisone. Computerized tomography of the thorax was performed and incidentally the images showed a mass within the central veins with the characteristics of lipoma. He was asymptomatic and refused surgical procedures. The intraluminal lipoma originated in the right brachiocephalic and subclavian veins. Control tomography showed a slow development of this lipoma, without obstructive effects or malignant features. Oral prednisone was changed for methotrexate. The patient is asymptomatic and under longstanding out-patient surveillance. Corticosteroid treatments for sarcoidosis can play a role in the development of intravascular lipoma, but this association is not well defined. Case reports could contribute to clarifying whether this relationship is causal or merely casual.