Fatal necrotizing Candida esophagitis in a patient with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis

Esophageal infection by Candida spp. is a common opportunistic entity in immunocompromised hosts; however, systemic fungal dissemination due to perforation or transmural necrosis, also known as necrotizing Candida esophagitis (NCE), is rare. We report the case of a 61-year-old male patient with diagnosed ankylosing spondylitis, severe arteriosclerosis, and vasculitis under immunosuppressive therapy who presented NCE with fungal and bacterial septicemia diagnosed at autopsy. Necrotizing esophagitis is a rare manifestation of Candida infection, which may be a final complication in severely ill patients. Unfortunately, it may be underdiagnosed, and we call attention to this devastating complication in patients with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis.

Traumatic injury to the internal carotid artery by the hyoid bone: a rare cause of ischemic stroke

Central nervous system (CNS) ischemic events, besides being a common and devastating disease, are accompanied by severe disability and other morbidities. The cause of such events is not always that simple to diagnose, and among the young, a broad spectrum of possibilities should be considered. We present the case of a young man who presented two episodes of CNS ischemia with a 1 year gap between them, which occurred in the same situation while he was walking and carrying a heavy backpack. The second event first presented as a transient ischemic attack followed by a stroke the day after. The diagnostic work-up showed an indentation of the greater cornu of the hyoid bone over the internal carotid artery, which injured the media and intimal layers. At the arterial injury site, a micro thrombus was found, which explained the source of the embolic event to the CNS. The patient was operated on, and the procedure included the resection of the posterior horn of the hyoid bone, the resection of the injured segment of the internal carotid artery followed by carotid­carotid bypass with the great saphenous vein. The postoperative period and the recovery were uneventful as was the 5-month follow-up. We call attention to this unusual cause of stroke and present other cases reported in the literature.

Bone marrow necrosis and fat embolism syndrome: a dreadful complication of hemoglobin sickle cell disease

Sickle cell disease encompasses a wide range of genotypic presentation with particular clinical features. The entity affects millions of people, particularly those whose ancestors came from sub-Saharan Africa and other countries in the Western Hemisphere, Saudi Arabia, and India. Currently, the high frequency of S and C genes reflects natural selection through the protection of heterozygotes against severe malaria, the high frequency of consanguineous marriages, improvement of some public health policies and the nutritional standards in the poorer countries where newborns are now living long enough to present for diagnosis and management. Although there is a high burden of the disease, in many countries, the new-born sickle cell screening test is being performed and is rendering an early diagnosis; however, it is still difficult for sickle cell patients to find proper treatment and adequate follow-up. Moreover, in many countries, patients are neither aware of their diagnosis nor the care they should receive to prevent complications; also, they do not receive adequate genetic counseling. Hemoglobin SC (HbSC) disease is the most frequent double sickle cell heterozygosis found in Brazil. The clinical course tends to be more benign with fewer hospitalizations compared with double homozygotic SS patients. However, HbSC patients may present severe complications with a fatal outcome. We report the case of a 36-year-old man who presented to the emergency care facility with symptoms consistent with the diagnosis of sickling crisis. The outcome was unfavorable and death occurred just hours after admission. The autopsy revealed a generalized vaso-occlusive crisis by sickled red cells, bone marrow necrosis, and fat embolism syndrome.

Severe pulmonary hypertension due to combined pulmonary fibrosis and emphysema: another cause of death among smokers

In 2005, the combined pulmonary fibrosis and emphysema (CPFE) was first defined as a distinct entity, which comprised centrilobular or paraseptal emphysema in the upper pulmonary lobes, and fibrosis in the lower lobes accompanied by reduced diffused capacity of the lungs for carbon monoxide (DLCO). Recently, the fibrosis associated with the connective tissue disease was also included in the diagnosis of CPFE, although the exposure to tobacco, coal, welding, agrochemical compounds, and tire manufacturing are the most frequent causative agents. This entity characteristically presents reduced DLCO with preserved lung volumes and severe pulmonary hypertension, which is not observed in emphysema and fibrosis alone. We present the case of a 63-year-old woman with a history of heavy tobacco smoking abuse, who developed progressive dyspnea, severe pulmonary hypertension, and cor pulmonale over a 2-year period. She attended the emergency facility several times complaining of worsening dyspnea that was treated as decompensate chronic obstructive pulmonary disease (COPD). The imaging examination showed paraseptal emphysema in the upper pulmonary lobes and fibrosis in the middle and lower lobes. The echo Doppler cardiogram revealed the dilation of the right cardiac chambers and pulmonary hypertension, which was confirmed by pulmonary trunk artery pressure measurement by catheterization. During this period, she was progressively restricted to the minimal activities of daily life and dependent on caregivers. She was brought to the hospital neurologically obtunded, presenting anasarca, and respiratory failure, which led her to death. The autopsy showed signs of pulmonary hypertension and findings of fibrosis and emphysema in the histological examination of the lungs. The authors highlight the importance of the recognition of this entity in case of COPD associated with severe pulmonary hypertension of unknown cause.

Meningite bacteriana: análise retrospectiva em um hospital universitário / Bacterial meningitis: retrospective analysis in a community hospital

Com o objetivo de avaliar a incidência e a evoluçào da meningite em um hospital comunitário, analisamos retrospectivamente os pacientes internados na Clínica Médica do HU-USP de janeiro de 1985 à dezembro de 1993. Estudamos 79 casos, excluindo-se 29 pacientes com meningitis tuberculosa ou criptocócica. A média de idade foi de 29 anos, com predominância do sexo masculino, a média de tempo de internação de 9,7 dias e a média de temperatura de admissão de 38,6ºC. Os achados mais freqüentes foram: cefaléia, febre, vômitos, lesões cutânes de aparecimento recente e confusão mental. Analisam-se os resultados obtidos do exame de líquor e tomografia computadorizada. Quatorze pacientes foram tratados somente com medicação sintomática, com boa evoluçào. Os pacientes receberam antibióticos por 8,8 dias, em média, permanecendo com febre, em média, por 4 dias. Setenta e três pacientes tiveram alta hospitalar, quatro pacientes evoluíram para óbito e dois foram transferidos. Concluímos que a incidência predominou em uma faixa bastante jovem; a taxa geral de mortalidade encontrada foi de 5,1(per cent); grande número de pacientes não apresentava sinais de irritaçào meníngea na admissão (au)

Miosite tropical / Tropical myositis

Os autores descrevem seis casos de miosite tropical ou piomiosite que ocorreram na Divisao de Clinica Medica do Hospital Universitario da USP durante o periodo de 1985 a 1992. O Staphylococcus aureus foi o agente responsavel por este quadro infeccioso sendo isolado a partir de abscessos musculares em quatro casos e de hemoculturas em dois casos. A antibioticoterapia adequada associada a drenagem cirurgica determinou evolucao satisfatoria, sem mortalidade e sequelas osteomusculares.

Estudo clínico e terapêutico de 13 casos de artrite gonocócica / Clinical and therapeutic study of 13 cases of gonococcal arthritis

A propósito de 13 casos de artrite gonocócica registrados entre janeiro de 1979 e dezembro de 1984, os autores fazem análise das principais manifestaçöes clínicas e consideraçöes de ordem diagnóstica e terapêutica. Comparam os dados encontrados com os da literatura e chamam a atençäo para a importância do diagnóstico precoce, uma vez que a incidência de doenças venéreas e suas complicaçöes, segundo dados da OMS, apresentou aumento estatístico nas últimas décadas

Tamponamento cardíaco por tuberculose em portadores de lupus disseminado: diagnóstico através de pericardiocentese: relato de caso / Cardiac tamponade due to tuberculosis in patients with systemic lupus. Diagnosis through pencardiacentesio. Report of a case

Pacientes portadores de lupus erimatoso disseminado desenvolveu tamponamento pericárdico e foi submetido à pericardicentese, a qual permitiu o diagnóstico de tuberculose pericárdica através da identificaçäo do bacilo. A importância do diagnóstico precose da tuberculose para o sucesso terapêutico é sublinhada

Suboclusäo intestinal por leiomioma de jejuno: relato de caso / Intestinal suboclusion by leiomyoma of jejunum: a case report

Relata-se caso de obstruçäo do intestino delgado por leiomioma em jejuno. A lesäo ocasionou episódios sintomáticos caracterizados por dor abdominal em cólica, que se estenderam por cerca de 18 meses antes que se estabelecesse o diagnóstico da causa orgânica. O agravamento da sintomatologia, a palpaçäo de massa tumoral perimbilical de presença inconstante e a imagem radiológica verificada ao estudo do trânsito intestinal de processo estenosante de jejuno, ao lado de história de longa duraçäo e o bom estado geral do paciente permitiram a hipótese pré-operatória de tumor benigno do intestino delgado. O estudo histológico do segmento jejunal ressecado concluiu por leiomioma. A evoluçäo clínica pós-operatória foi normal. A revisäo dos 182 casos de tumores do intestino delgado internados de janeiro de 1961 a dezembro de 1982 no Hospital das Clínicas da FMUSP verificou-se que 19,7% eram benignos e destes 16,6% eram leiomiomas (seis casos)