Paciente psiquiátrico em uso de clozapina com febre e taquicardia / Patient on clozapine with fever and tachycardia

A clozapina é uma droga de suma importância para o manejo de pacientes com sintomas psicóticos. Entretanto, efeitos adversos graves como agranulocitose e miocardite podem limitar o seu uso. Apresentamos o caso de um homem de 20 anos de idade que desenvolveu febre e taquicardia alguns dias após o início de uso de clozapina para um provável quadro de esquizofrenia. Após tentativas frustradas de tratamento com antipsicóticos atípicos e lítio, o tratamento com clozapina foi iniciado para controlar sintomas psicóticos. Alguns dias depois, surgiram febre e taquicardia sinusal persistente no eletrocardiograma (ECG). O hemograma revelou leucocitose e eosinofilia. Um ecocardiograma foi realizado e evidenciou aumento do ventrículo esquerdo, hipocinesia difusa e uma fração de ejeção diminuída. Um diagnóstico clínico de miocardite foi feito, e a clozapina foi suspensa, com melhora dos padrões ecocardiográficos e clínicos. A miocardite é um dos muitos potenciais efeitos adversos da clozapina e tem características semelhantes às produzidas pelo ajuste de dose normal da medicação, tornando-se um diagnóstico importante e perigosamente ignorado. Apesar de raros, os efeitos miocárdicos da clozapina podem ser bastante graves, levando ao óbito em alguns casos. Dessa forma, recomenda-se a realização de ECG pré e pós-tratamento e a suspensão da droga caso haja suspeita de acometimento cardíaco.

Clozapine is a useful drug in the treatment of patients with psychotic symptoms. However, severe adverse effects, such as myocarditis and agranulocytosis, can restrict its indications. We present the case of a 20-year-old male who developed fever and tachycardia a few days after initiating treatment with clozapine for a diagnosis of schizophrenia. After unsuccessful treatment attempts with atypical anti-psychotics and lithium, clozapine was initiated to control psychotic symptoms. A few days later, he presented with fever and persistent sinus tachycardia on electrocardiogram (ECG). Blood cell count revealed leukocytosis and eosinophilia. An echocardiogram was performed, which showed left ventricular enlargement, diffuse hypokinesis, and a decreased ejection fraction. A clinical diagnosis of myocarditis was made and clozapine was discontinued, with improvement of both echocardiographic and clinical features. Myocarditis is one of the many potential adverse effects of clozapine and has similar features with its normal dose titration, making it an important and dangerously overlooked diagnosis. Although rare, clozapine’s myocardial effects may be extremely severe, leading to death in some patients. Therefore, it is advisable to obtain an ECG before and after initiating treatment and to immediately discontinue the drug in suspected cases.

Shunt direita-esquerda através de forame oval patente sem hipertensão pulmonar / Right to left shunt through a patent foramen ovale without pulmonary hypertension

Este artigo descreve um paciente que se apresentou com quadro de hipoxemia e platipnéia e cujo único achado na investigação foi a presença de um forame oval patente com shunt direita-esquerda sem hipertensão pulmonar, caracterizando uma síndrome rara conhecida como platipnéia-ortodeoxia, de interessantes características fisiopatológicas e com opções terapêuticas ainda não totalmente definidas.

This article describes a patient presenting with dyspnea and platypnea and whose only clinical finding was presence of patent foramen ovale with a right to left shunt, without pulmonary hypertension, characteristic of the rare Platypnea-Orthodeoxya Syndrome, with very interesting pathophysiological findings and with therapeutic alternatives not yet defined.

Doença diverticular do cólon / Disease of the diverticulosis colonic

Os autores fazem uma revisão bibliográfica sobre a doença diverticular colônica, objetivando abordar informações quanto a sua prevalência, patogenia, manifestações clínicas e estratégia diagnóstica e terapêutica

Implications of the hemodynamic optimization approach guided by right heart catheterization in patients with severe heart failure

OBJECTIVE: To report the hemodynamic and functional responses obtained with clinical optimization guided by hemodynamic parameters in patients with severe and refractory heart failure. METHODS: Invasive hemodynamic monitoring using right heart catheterization aimed to reach low filling pressures and peripheral resistance. Frequent adjustments of intravenous diuretics and vasodilators were performed according to the hemodynamic measurements. RESULTS: We assessed 19 patients (age = 48±12 years and ejection fraction = 21±5 percent) with severe heart failure. The intravenous use of diuretics and vasodilators reduced by 12 mm Hg (relative reduction of 43 percent) pulmonary artery occlusion pressure (P<0.001), with a concomitant increment of 6 mL per beat in stroke volume (relative increment of 24 percent, P<0.001). We observed significant associations between pulmonary artery occlusion pressure and mean pulmonary artery pressure (r=0.76; P<0.001) and central venous pressure (r=0.63; P<0.001). After clinical optimization, improvement in functional class occurred (P< 0.001), with a tendency towards improvement in ejection fraction and no impairment to renal function. CONCLUSION: Optimization guided by hemodynamic parameters in patients with refractory heart failure provides a significant improvement in the hemodynamic profile with concomitant improvement in functional class. This study emphasizes that adjustments in blood volume result in imme-diate benefits for patients with severe heart failure