Causa de mortes de indivíduos encontrados em decomposição na cidade de São Paulo / Cause of deaths of individuals found in decomposition in the city of São Paulo

Na cidade de São Paulo são realizadas aproximadamente 40 autópsias forenses por dia e 2% delas correspondem a corpos em decomposição.Todo o corpo encontrado em decomposição é enquadrado como uma morte suspeita e deverá ser submetido a uma autópsia forense.As análises das perícias de corpos putrefeitos mostram claramente que a maioria das mortes é de causa natural com predominância das doenças cardiovasculares em indivíduos com mais de 40 anos.A morte em crianças, resulta, quase sempre, de fetos ou recém-nascidos abandonados e as mortes violentas são predominantemente por arma de fogo, sendo o cadáver escondido para evitar investigação. Em síntese, esses dados refletem as grandes causas de morte em São Paulo e no Brasil: indivíduos com mais de 40 anos, doenças cardiovasculares e, em mais jovens, homicídios por projéteis de arma de fogo.

Abordagem terapêutica dos projéteis retidos no coração / Management of bullets lodged in the heart

Paciente do sexo masculino, 29 anos, apresentando ferimento por arma de fogo, com projétil alojado no coração e que chegou ao hospital hemodinamicamente estável. O diagnóstico, evidenciando a localização da bala, foi feito pelo ecocardiograma transesofágico(ET). Após 18 dias, foi submetido a cirurgia eletiva, sem circulação extracorpórea(CEC), para retirada do projétil encravado em parede anterior do ventrículo direito(VD) e septo interventricular(SIV), com sucesso. Os autores discutem a conduta terapêutica para os projéteis retidos no coração, com base na literatura consultada, concluindo que a cirurgia para remoção dos mesmos pode ser indicada em pacientes assintomáticos individualizados

Tuberculous pericarditis in acquired immune deficiency syndrome patients

Two quite dyspneic HIV positive patients were admitted to the Emergency Room; they presented clinical signs and images suggesting pericardial effusion. The analysis of an initial liquid puncture did not show any specificity and the patients did not exhibit any clinical improvement. Both patients were submitted to a subxiphoid pericardial window, all the effusion liquid was drained, and a biopsy of the pericardium tissue was completed, revealing a granulomatous process. Immediately after the onset of specific treatment, the patients showed a good evolution. Such findings draw attention to a high possibility of pericardial suffusion in AIDS patients being tuberculosis, particular if one considers the high prevalence of this disease in Brazil. The results also showed that the opening of a subxiphoid pericardial window and the specific triple scheme was a procedure that led to good therapeutic evolution in these patients.

Spontaneous rupture of the esophagus: report of two cases

Objetive - To study the diagnosis, prognosis and management of spontaneous rupture of the esophagus. Design: This is a retrospective study through the analysis of two cases with delayed diagnosis and subsequent treatment at the Track Surgery Service. Locale: The study was performed at the Thoracic Surgery Unit of the Hospital do Servidor Público Estadual Francisco Morato de Oliveira in the city of Sao Paulo. This is a specialized service. Participants: The two patients reported on had suffered spontaneous rupture of the esophagus. They were transferred to the Thoracic Surgery Unit because of the worsening of their condition in the previous institution which they had been admitted into. Measurement: The two patients with esophagus pleural fistula received similar treatment, initially advocated by Kanashin in Russia and Hauer-Santos in the United States, which consists of washing the fistula and using continous pleural aspiration. Results: Although both patients had to spend a long period of time in hospital, their evolution was satisfactory with the treatment adopted, and the fistulla closed. Conclusion: The authors conclude that the method of lavage of the mediastinum and continuous pleural aspiration, in patients who after spontaneous rupture of the esophagus developed a pleural esophagus fistula due to belated diagnosis, is an alternative and satisfactory therapy. Furthermore, in order to have the best outcome, an early diagnosis is recommended and thoracostomy as the surgical procedure, with primary suture.

Abdominal mycobacterial infection in acquired immunodeficiency syndrome patients

The authors studied 12 patients with AIDS and abdominal mycobacteriosis hospitalized in the Hospital lpiranga (Sao Paulo, Brazil), from June 1989 to January 1992. Diagnosis was confirmed by the histopathological examination of organ specimens collected during laparotomy, which, in most cases, was carried out due to an emergency situation. Observations included perforation of the ileum, seropurulent fluid involved and bloked by viscera, epiploon, and fibrin. Hepatoesplenomegaly was present in all patients and generalized granulomatous peritonitis was observed in more than 50 percent. A patient died in the immediate post-op period, four after an average period of 55 days in the hospital. A patient evolved with stercoral fistula and asked to be discharged. Six patients were discharged after an average hospitalization period of 27 days. The authors stress that in developing regions where tuberculosis incidence is high, a patient with AIDS and a painful and irritative abdominal picture should always lead to the hypothesis of mycobacteriosis.

Acquired immunedeficiency syndrome in forensic autopsies

No Instituto Médico Legal de Säo Paulo, de maio de 1985 a maio de 1989, foram realizadas 126 necrópsias de indivíduos portadores de AIDS cujo óbito foi motivo de investigaçöes policiais. 119 eram do sexo masculino e 17 do sexo feminino e o pico de incidência etária foi dos 20 aos 30 anos. Foram observadas 54 mortes em estabelecimentos penais, 29 suicídios, 17 homicídios dolosos, 17 mortes suspeitas, 5 homicídios culposos e 4 corpos em putrefaçäo. Os presidiários, à exceçäo de um que foi estrangulado, faleceram do curso natural da doença. Chamou atençäo nas perícias a alta incidência de micobacteriose extra pulmonar. Os suicídios se procederam das mais diferentes forma e as vítimas, em sua maioria, apresentavam o quadro inicial da doença. As mortes suspeitas e os corpos encontrados em deterioraçäo resultaram do abandono dos pacientes pelos familiares. Nos homicídios, a morte quase sempre ocorreu tardiamente nos hospitais e a doença contribuiu certamente para o agravamento das lesöes. Os autores chamam atençäo sobre os problemas jurídicos e sociais que envolvem as vítimas da AIDS e realçam esses últimos como um obstáculo a um controle efetivo da epidemia

Mediastinitis after cervical suppuration

The objective of this study is to decode the etiopathogenesis, the clinical feature, the diagnosis and the prognosis of the acute mediastinitis resulting of infectious processes of the cephalic segment. Three out of five patients studied presented focus of dental origin and two patients presented focus in the face area. One of them presented Ludwig's Angina before the suppurative process would spread over the mediastinum. In the others, there was fast expansion through the fascial spaces of the neck and, in two of them, besides the mediastinum, there was pleuropericardial involvement. Three patients died due to respiratory insufficiency and two survived with complications. The mediastinitis after cervical suppuration is a special and extremely serious kind of endothoracic infection. The pus reaches that area through the fascial spaces of the neck, taking the organism to an alarming toxemic feature. The rarity of the disease, the little is known about its physiopathology and the initial care of the patient in non-specialized services, which are not familiarized with this type of feature, are factors that can delay the diagnosis and worsen the prognosis

Perfuraçäo de alça ileal por tuberculose em portadores da síndrome da imunodeficiência adquirida / Ileal loops perforation due to tuberculosis in AIDS patients with acquired inmunodeficiency syndrome

Objetivo do estudo: pesquisar a etiologia e o tratamento do abdome agudo perfurativo em portadores da síndrome de imumnodeficiência adquirida, em particular no caso de tuberculose intestinal. Tipo de estudo: clínico, através da conduta clínica e cirúrgica para a perfuraçäo intestinal por tuberculose em aidéticos. Local: Enfermaria de Moléstias Infecciosas do hospital Ipiranga - Inamps - S. Paulo. Pacientes: dois pacientes, adultos jovens do sexo masculino. Intervençöes: duas laparotomias para abdome agudo perfurativo, por perfuraçäo tuberculosa de alça ileal. Medidas e resultados: um dos pacientes veio a falecer no pós-operatório imediato em conseqüência do precário estado geral em que se encontrava. Outro teve boa evoluçäo e ainda continua sendo seguido ambulatorialmente. A laparotomia imediata, a oclusäo da perfuraçäo e a biópsia realizada, que permitiu chegar a uma etiologia, contribuíram para a boa evoluçäo do segundo paciente. Conclusöes: a literatura responsabiliza o citomegalovírus como sendo o principal causador da perfuraçäo intestinal em aidéticos. Em nossos pacientes, a etiologia foi tuberosa e talvez essa possa ser uma causa importante de abdome agudo perfurativo em portadores de AIDS em nosso meio, dada a grande pervalência de tuberculose nesse tipo de doente no Brasil