Hemosiderosis pulmonar idiopática, caso clínico en México. Importancia de un diagnóstico y tratamiento oportuno / Idiopathic pulmonary hemosiderosis, clinical case in Mexico. The relevance of performed an early diagnosis and treatment

La hemosiderosis pulmonar idiopática (HPI) es una patología poco frecuente; su distribución geográfica, su incidencia y prevalencia se desconocen de manera exacta a nivel mundial. Tiene una fuerte asociación con condiciones autoinmunes y una adecuada respuesta al tratamiento inmunosupresor. A pesar de ser una patología grave, presenta una tasa de morbilidad y mortalidad mediana, siempre que se realice un diagnóstico y tratamiento precoz. Se presenta el caso clínico de una paciente femenina con diagnóstico de HPI quien cursó con la triada clásica de esta enfermedad: hemoptisis, anemia ferropénica e infiltrados pulmonares difusos. Se descartaron otras causas de hemorragia pulmonar difusa y se realizó el diagnóstico por biopsia pulmonar. Se trató con esteroides sistémicos e inhalados y azatioprina. Tras casi 2 años después del diagnóstico, estando sin tratamiento por 3 meses, presentó una exacerbación con hemorragia pulmonar masiva ocasionando el fallecimiento de la paciente.

Idiopathic pulmonary hemosiderosis (IPH) is a rare pathology; its geographic distribution, incidence and prevalence are not accurately known worldwide. It has a strong association with autoimmune conditions and has an adequate response to immunosuppressive treatment. Despite being a serious pathology, it has a medium morbidity and mortality rate, provided that early diagnosis and treatment is performed. We present the clinical case of a female patient diagnosed with IPH who presented with the classic triad of this disease: hemoptysis, iron deficiency anemia and diffuse pulmonary infiltrates. Other causes of diffuse pulmonary hemorrhage were ruled out and the diagnosis was made by lung biopsy. She was managed with systemic and inhaled steroids and azathioprine. After almost 2 years before the diagnosis, being without treatment for 3 month she had a massive pulmonary hemorrhage, causing the death of the patient.

Síndrome pulmón-riñón en pacientes con hallazgos incidentales de agentes infecciosos / Pulmonary-renal syndrome in patients with incidental findings of infectious agents

El síndrome pulmón-riñón (SPR) o síndrome reno-pulmonar es la combinación de glomerulonefritis aguda rápidamente progresiva (GNARP) y hemorragia alveolar difusa (HAD) de causa autoinmune. El SPR fue inicialmente descrito por Goodpasture en el contexto del síndrome anti-membrana basal glomerular (MBG). Actualmente, las vasculitis asociadas a ANCA (VAA) explican el 60% (rango 56­77.5%) de casos, el síndrome de Goodpasture el 15% (12.5­17.5%), y un 10% de casos se deben a otras causas. El SPR presenta un gran espectro clínico, desde la capilaritis pulmonar fulminante con HAD y falla respiratoria aguda, hasta formas más sutiles de enfermedad sólo detectables mediante lavado bronquio-alveolar (LBA). El objetivo de este estudio es presentar la primera serie peruana de SPR asociada a agentes infecciosos. Reportamos 3 casos, dos correspondieron a lupus eritematoso sistémico y uno a vasculitis asociada a poliangeítis microscópica. El primer caso se asoció a sobreinfección por C. tropicalis; el segundo caso a A. fumigatus y C. albicans; y el tercero a infestación por A. lumbricoides. Todos los casos se presentaron en mujeres, requirieron soporte ventilatorio invasivo y hemodiálisis, y dos resultaron letales. Concluimos que, el SPR es una condición clínica grave comúnmente asociada a sobreinfecciones o infestaciones, y que conlleva una elevada morbilidad y mortalidad. Puesto que no existen características clínicas específicas, resulta crucial tener un alto índice de sospecha. Las investigaciones pertinentes­pruebas inmunológicas, imagenológicas, y biopsia cutánea, renal y/o pulmonar­para precisar la etiología deben realizarse sin demora ya que el tratamiento precoz puede cambiar el pronóstico de estos pacientes(AU)

Pulmonary-renal syndrome (PRS) or reno-pulmonary syndrome is the combination of acute rapidly progressive glomerulonephritis (RPGNARP) and autoimmune diffuse alveolar hemorrhage (DAH). RPS was initially described by Goodpasture in the context of anti-glomerular basement membrane (GBM) syndrome. Currently, ANCA-associated vasculitides (AAV) explain 60% (range 56­77.5%) of cases, Goodpasture syndrome 15% (12.5­17.5%), and 10% of cases are due to other causes. PRS presents a wide clinical spectrum, from fulminant pulmonary capillaritis with ADH and acute respiratory failure, to subtler forms of disease that can only be detected by bronchoalveolar lavage (BAL). The objective of this study is to present the first Peruvian series of SPR associated with infectious agents. We report 3 cases, two corresponded to systemic lupus erythematosus and one to vasculitis associated with microscopic polyangiitis. The first case was associated with superinfection by C. tropicalis; the second case to A. fumigatus and C. albicans; and the third to infestation by A. lumbricoides. All cases occurred in women, required invasive ventilatory support and haemodialysis, and two were fatal. We conclude that SPR is a serious clinical condition commonly associated with superinfections or infestations, and that it carries high morbidity and mortality. Since there are no specific clinical features, a high index of suspicion is crucial. Relevant investigations­immunological tests, imaging tests, and skin, kidney, and/or lung biopsies­to specify the etiology should be carried out without delay, since early treatment can change the prognosis of these patients(AU)

Avaliação endoscópica das vias aéreas, do perfil de gases, dos eletrólitos e do equilíbrio ácido-base em equinos submetidos ao treinamento de três tambores / Endoscopic airway, blood gas, electrolytes, and acid-base in equine submitted to three-barrel training

O objetivo deste estudo foi avaliar as vias aéreas por endoscopia, o perfil de gases, de eletrólitos e o equilíbrio ácido-base de equinos da raça Quarto de Milha (QM) antes e após o exercício de três tambores. Dezesseis cavalos, divididos em dois grupos de oito animais, treino regular (TR - cinco vezes) e treino esporádico (TE - duas vezes por semana), foram utilizados no experimento. A endoscopia foi realizada antes e 90 min após o exercício. Foram realizadas duas coletas de sangue por punção da artéria facial transversa antes do aquecimento (M0) e imediatamente após o exercício (M1), e as leituras foram realizadas com o I-Stat(r). Foram determinadas PCO2, PO2, SO2, pH, BE, HCO3 e TCO2, Na+, K+, iCa, glicose, Hg e Ht. Foi utilizada ANOVA com medidas repetidas no tempo para comparações dos grupos e dos momentos (P<0,05). A HFL acometeu em grau leve (1-2) os animais de ambos os grupos, com 8/8 (100%) no TR e 5/8 (62,5%) no TE. Observou-se presença de secreção serosa na traqueia em 4/8 (50%) para ambos os grupos. A HPIE acometeu em grau leve (1-2) os animais de ambos os grupos, com 4/8 (50%) no grupo TR e 3/8 (37,5%) no grupo TE. Os animais com grau 2 de HPIE apresentaram leve hipoxemia e hipercapnia pós-exercício. SO2, PCO2, pH, HCO3, BE, K e iCa+ não diferiram estatisticamente (P>0,05) entre os grupos. Os cavalos da raça QM submetidos ao exercício de TT apresentam HPIE e acidose metabólica.(AU)

The aim of this study was to evaluate the airways by endoscopy, gas profile, electrolytes and acid-base balance of horses in the Quarter Horse (QM) race before and after training three drums. Sixteen horses divided into two groups of 8 animals, with regular training (RT - 5 times a week) and sporadic training (ET - 2 times a week) were used in the experiment. Endoscopy was performed before and 90 min after training. Two blood samples were taken by puncturing the transverse facial artery before heating (M0) and immediately after training (M1), and the readings were performed with the I-Stat(r). PCO2, PO2, SO2, pH, BE, HCO3 and TCO2, Na +, K +, iCa, Glucose, Hg, and Ht were determined. ANOVA was used with repeated measures over time for comparisons of groups and time (P<0.05). The HFL befell was mild (1-2), the animals from both groups with 8/8 (100%) in the TR and 5/8 (62.5%) for the TE. There was presence of serous trachea 4/8 (50%) for both groups. The EIPH befell was mild (1-2) in the animals from both groups with 4/8 (50%) in the RT group and 3/8 (37.5%) for the TE group. Animals with grade 2 EIPH had mild hypoxemia and hypercapnia after exercise. The SO2, PCO2, pH, HCO3, BE, K, and iCa did not differ P <0.05 between groups. QM race submitted to TT exercise have EIPH and metabolic acidosis.(AU)

Prevalence, risk factors and outcomes associated with pulmonary hemorrhage in newborns / Prevalência, fatores de risco e prognóstico associados à hemorragia pulmonar em recém-nascidos

OBJECTIVES: to determine the prevalence of pulmonary hemorrhage in newborns and evaluate the associated risk factors and outcomes. METHODS: this was a retrospective case-control study involving 67 newborns who met the criteria for pulmonary hemorrhage. A control was selected for each case: the next-born child of the same gender, similar weight (± 200 g) and gestational age (± 1 week), with no previous pulmona ry hemorrhage and no malformation diagnosis. Factors previous to pulmonary hemorrhage onset, as well as aspects associated to the condition, were assessed. RESULTS: the prevalence was 6.7 for 1,000 live births, and the rates observed were: 8% among newborns < 1,500 g, and 11% among newborns < 1,000 g. Intubation in the delivery room (OR = 7.16), SNAPPE II (OR = 2.97), surfactant use (OR = 3.7), and blood components used previously to pulmonary hemorrhage onset (OR = 5.91) were associated with pulmonary hemorrhage. In the multivariate logistic regression model, only intubation in delivery room and previous use of blood components maintained the association. Children with pulmonary hemorrhage had higher mortality (OR = 7.24). Among the survivors, the length of stay (p < 0.01) and mechanical ventilation time were longer (OR = 25.6), and oxygen use at 36 weeks of corrected age was higher (OR = 7.67). CONCLUSIONS: pulmonary hemorrhage is more prevalent in premature newborns, and is associated with intubation in the delivery room and previous use of blood components, leading to high mortality and worse clinical evolution. .

OBJETIVOS : determinar a prevalência de hemorragia pulmonar entre os recém-nascidos internados no serviço e avaliar os fatores de risco e prognóstico associados. MÉTODOS: estudo retrospectivo caso-controle com 67 recém-nascidos que preencheram os critérios pré-estabelecidos de hemorragia pulmonar. Para cada caso, foi selecionado um controle: a próxima criança nascida do mesmo sexo, com semelhantes peso (± 200 g), idade gestacional (± 1 semana) e sem hemorragia pulmonar ou malformações. Foram estudados fatores prévios à ocorrência da hemorragia pulmonar e aspectos decorrentes do evento. RESULTADOS: a prevalência foi de 6,7 a cada 1.000 nascidos vivos, sendo de 8% entre os recém-nascidos menores que 1.500 g e de 11% entre os recém-nascidos menores que 1.000 g. A necessidade de intubação (IOT) em sala de parto (OR = 7,16), uso de hemoderivados previamente à ocorrência de hemorragia pulmonar (OR = 5,91), uso de surfactante (OR = 3,7) e SNAPPEII > 30 (OR = 2,97) foram associados à hemorragia pulmonar. No modelo de regressão logística multivariado, a necessidade de IOT (OR = 5,12) e uso de hemoderivados (OR = 4,2) mantiveram essa associação. As crianças com hemorragia pulmonar apresentaram maior mortalidade (OR = 7,24), entre as sobreviventes, maior tempo de internação (p < 0,01), mais uso de oxigênio com 36 semanas (OR = 7,67) e maior duração da ventilação mecânica (OR = 35,6). CONCLUSÃO: a hemorragia pulmonar é uma doença de maior prevalência em recém-nascidos pré-termos, e está associada à intubação em sala de parto e ao uso prévio de hemoderivados, acarretando maior mortalidade e pior evolução clínica das crianças. .

Avanços no conhecimento da imunopatogênese da leptospirose e a aplicação do método do imprint como ferramenta qualitativa e quantitativa de leptospiras / Advances in understanding the immunopathogenesis of leptospirosis and application of the imprint method as a qualitative and quantitative tool leptospires

A leptospirose é uma zoonose causada por espiroquetas patogênicas pertencentes ao gênero Leptospira. O modelo da doença em camundongos tem vantagens devido à ampla gama de ferramentas genéticas e imunológicas disponíveis para pesquisas básicas. A maior limitação na conduta clínica e na pesquisa experimental da leptospirose é o fraco desempenho dos métodos disponíveis para detecção direta e para quantificação de leptospiras. Foi incluído nesta tese um conjunto de três manuscritos que visam investigar o desfecho da infecção pela cepa virulenta de Leptospira interrogans nas linhagens de camundongos selvagens (A, CBA, BALB/c e C57BL/6)...

Leptospirosis is a zoonosis caused by pathogenic spirochaetes belonging to the genus Leptospira. The mouse disease model is advantagous due to the broad array of immunological and genetic tools available for basic research. A major limitation in the clinical management and experimental research of leptospirosis is the poor performance of the available methods in the direct detection and quantification of leptospires. This thesis includes three manuscripts that investigate the outcome of infection by a virulent strain of Leptospira interrogans in wildtype mice strains: A, CBA, BALB/c and C57BL/6; in iNOS knockout (KO) mice, recombination activating gene 1 (RAG1) KO mice and CB17 severe combined immunodeficiency (SCID) mice. To investigate whether the imprint method (IM) of quantification was reliable we compared it with against real time PCR (qPCR) for the detection and quantification of leptospires in kidney samples from rats and hamsters. As expected, none of the wildtype mice were susceptible to lethal leptospirosis. The A and C57BL/6 strains exhibited high leptospiral loads in the kidney samples and the CBA and C57BL/6...

Oxigenación por membrana extracorpórea y plasmaféresis en un paciente con hemorragia pulmonar grave secundaria a poliarteritis nodosa / Extracorporeal membrane oxygenation and plasmapheresis in the treatment of severe pulmonary hemorrhage secondary to nodose polyarteritis

Se comunica el caso de un paciente de 23 meses de edad, con hemorragia pulmonar, hipoxemia refractaria, hipertensión arterial y falla renal secundarias a poliarteritis nodosa (PN) que ha requerido asistencia simultánea con soporte cardiopulmonar extracorpóreo (ECMO), plasmaféresis, hemodiafiltración y surfactante exógeno. La PN es una vasculitis autoinmunitaria que afecta los vasos arteriales de pequeño y mediano calibres. La hipoxemia, refractaria al tratamiento con ventilación mecánica convencional y de alta frecuencia oscilatoria, fue sostenida con ECMO mientras se controló la enfermedad autoinmunitaria mediante plasmaféresis y tratamiento inmunosupresor. La combinación de ECMO con plasmaféresis es infrecuente, pero ha sido descripta en relación al trasplante de órganos, intoxicaciones, fallo cardíaco y sepsis. Existen dos casos descriptos en la bibliografía sobre el uso combinado de estas terapéuticas para el tratamiento de hemorragia pulmonar secundaria a vasculitis autoinmunitaria en niños.

We report to simultaneous use of extracorporeal life support (ECLS), plasmapheresis, hemodiafiltration and exogenous surfactant for the treatment of pulmonary hemorrhage, arterial hypertension, and renal failure secondary to nodose polyarteritis (NPA) in a 23-month-old patient. NPA is an autoimmune disease that affects small -and medium- caliber muscular arteries. Hypoxemia refractory to treatment with conventional and high frequency oscillatory ventilation was supported by ECMO while awaiting control of the autoimmune disease through the use of plasmapheresis and immunosuppressive treatment. Although the combination of ECLS with plasmapheresis is rare, it has been described during the management of cases of organ transplant, intoxication, cardiac failure, and sepsis. There are only two previous reports describing the use of this combined therapy for the treatment of pulmonary hemorrhage secondary to autoimmune vasculitis in childhood.

Hemorragia pulmonar en enfermedades del tejido conectivo y comparación con lo descripto en la literatura / Pulmonary hemorrhage in connective tissue diseases and comparison with previous literature reports

Introducción: La hemorragia pulmonar difusa se caracteriza clínicamente por la presencia de disnea y hemoptisis, infiltrados alveolares bilaterales y difusos en la Rx de tórax y caída brusca de los valores de hemoglobina. Esta hemorragia puede ocurrir en el contexto de una enfermedad autoinmune (poliangeítis microscópica, enfermedad de Wegener, LES, síndrome de Goodpasture), síndrome antifosfolípidos, enfermedades infecciosas (leptospirosis y neumonía necrotizante), uremia, insuficiencia cardíaca congestiva, infarto pulmonar, desórdenes de la coagulación y secundaria a drogas (penicilamina). Dada su alta mortalidad y la escasez de síntomas (mucho mayor en pacientes inmunocomprometidos) es necesario un alto índice de sospecha y un rápido tratamiento. Objetivo: Comparar las manifestaciones clínicas, radiológicas y de laboratorio de los pacientes con hemorragia de pulmón con otras series publicadas. Material y métodos: Estudio retrospectivo y descriptivo, realizado revisando las historias clínicas de los pacientes con diagnóstico de hemorragia de pulmón secundaria a enfermedades autoinmunes. Criterios de inclusión (adaptados de Barile y cols.): caída en la hemoglobina de por lo menos 1,5 g/dl o anemia (Hb menor o igual a 11 g/dl), ambas relacionadas al evento; insuficiencia respiratoria de comienzo agudo; hemoptisis; infiltrados en ¾ de los campos pulmonares; hipoxemia y lavado bronquioloalveolar con al menos 20% de macrófagos con hemosiderina o sangre por tubo endotraqueal. Criterios de exclusión: infecciones, tromboembolismo de pulmón, falta de confirmación por lavado bronquioloalveolar o tubo endotraqueal. Resultados: 19 pacientes con hemorragia de pulmón. 5 de ellos excluidos por la presencia de tromboembolismo de pulmón en uno y ausencia de método confirmatorio de hemorragia de pulmón en 4...

Introduction: Pulmonary or diffuse alveolar hemorrhage is clinicallycharacterized by the presence of dypsnea and hemoptysis, bilateraland diffuse alveolar infiltrates on chest X-ray and sudden drop in bloodhemoglobin. This hemorrhage may occur in the setting of autoimmunediseases (microscopic polyarteritis, Wegener’s disease, systemic lupuserythematosus, Goodpasture syndrome), antiphospholipid syndrome,infectious diseases (such as leptospirosis and necrotizing pneumonia),uremia, congestive heart failure, pulmonary infarction, coagulation disordersand hemorrhages secondary to drugs (such as penicilamina).Due to its high mortality and the paucity of symptoms (mostly in theinmunocompromise patients), it is necessary a high index of suspiciousto promptly treat...(AU)Objective: To compare the clinical, radiological and lab tests findings ofthe patients selected with the published series.Material and Method: A retrospective and descriptive analysis wasperformed on the records of all patients with a diagnosis of pulmonaryhemorrhage secondary to autoimmune diseases. Inclusion criteria(adapted of Barile et al): Fall in hemoglobin of at least 1.5 g/dl or anemia(hemoglobin 11 g/dl or less), both related to the event, respiratoryfailure of rapid onset, hemoptysis, dense infiltrates in ¾ or more of thelung fields, hypoxemia and bronchoalveolar lavage, with at least 20% ofmacrophages with hemosiderin inside or the presence of blood in endotrachealtube. Exclusion criteria: Pulmonary infections, tromboembolismdisease, lack of confirmation by method of pulmonary haemorrhage...

Pulmonary hemorrhage in horses seropositive to leptospirosis / Hemorragia pulmonar em cavalos soropositivos para leptospirose

The aim of this study was to verify the occurrence and severity of pulmonary hemorrhage (PH) in horses seropositive or not to leptospirosis. A total of 84 training horses were tested for anti-Leptospira antibodies and submitted to endoscopy of the upper airways 30-60 minutes after exercise. Forty-nine (46.4 percent) horses were seropositive (titer>100) to serovar Copenhageni. Seventeen horses (20.2 percent) presented PH in different grades, significantly more commonly observed in seropositives (34.7 percent) than seronegatives (8.6 percent) (p<0.05), and also more severe in the first. Additionally, a seropositive horse is 4.26 times more likely (OR) to present PH than a seronegative one. Fifteen days after specific antibiotic treatment for leptospirosis a significant improvement in grade of hemorrhage was observed. Therefore it is suggested that leptospirosis may potentiate the severity of PH and that specific antibiotic treatment directed towards leptospirosis may help to control the disease.

O objetivo foi estudar a ocorrência e severidade de hemorragia pulmonar (HP) em cavalos soropositivos ou não à leptospirose. Um total de 84 cavalos em treinamento foi testado para anticorpos anti-Leptospira e submetidos à endoscopia das vias aéreas superiores de 30-60 minutos após exercício. Quarenta e nove (46,4 por cento) animais foram soropositivos (títulos>100) para o serovar Copenhageni. Dezessete cavalos (20,2 por cento) apresentaram HP, significativamente mais observada em soropositivos (34,7 por cento) do que em soronegativos (8,6 por cento) (p<0,05) e também mais grave nos primeiros. Adicionalmente, um cavalo soropositivo tem 4,26 mais chances (OR) de apresentar PH do que um soronegativo. Quinze dias após o tratamento com antibiótico específico para leptospirose uma melhoria significativa no grau de hemorragia foi observada. Portanto, sugere-se que a leptospirose pode potencializar a severidade da HP e que o tratamento com antibióticos específicos recomendados para leptospirose pode ajudar a controlá-la.

Neumonía aguda de la comunidad y hemorragia pulmonar por leptospirosis en el área metropolitana Buenos Aires / Community acquired pneumonia and pulmonary hemorrhage in leptospirosis in the Buenos Aires metropolitan area

El objetivo del trabajo es comunicar los hallazgos epidemiológicos, clínicos y de diagnóstico de la neumonía y hemorragia pulmonar por leptospirosis, en el período enero 2007 a octubre 2009. Un 64% (20/31) de pacientes con diagnóstico de leptospirosis tuvieron neumonía. Quince de ellos (75%) presentaron neumonía grave, de los cuales siete (35%) desarrollaron hemorragia pulmonar. En diez enfermos (32%) el motivo de consulta e inicio del cuadro clínico fue una gastroenteritis secretoria con fiebre y dolor abdominal. La ictericia sólo se manifestó en once pacientes (35%). La técnica de reacción en cadena de la polimerasa (PCR) fue útil para el diagnóstico en muestra obtenida post mortem. De un hemocultivo se aisló una cepa clasificada dentro del serogrupo canicola. Se clasificaron las neumonías en tres tipos: neumonías de curso no grave con escasa repercusión general; neumonías graves asociadas a formas clínicas sistémicas con ictericia, insuficiencia renal, trombocitopenia y hemorragia pulmonar; también de curso grave, no asociada a ictericia, insuficiencia renal o trombocitopenia grave. El tratamiento antibiótico iniciado en los primeros días de enfermedad (promedio 3.2 días) no tuvo influencia en la evolución de las neumonías graves. Se plantea además considerar tres formas clínicas de leptospirosis: anictérica, ictérica (con sus variantes evolutivas) y hemorragia pulmonar.

The aim of this paper is to report the epidemiological, clinical and diagnosis findings of pneumonia and pulmonary hemorrhage observed in patients with leptospirosis in the period January 2007 to October 2009. A 64% (20/31) of patients diagnosed with leptospirosis presented pneumonia. Fifteen of them (75%) had severe pneumonia, of which seven (35%) were pulmonary hemorrhage. In ten patients (32%) reason for consultation and clinical early stage was a secretory gastroenteritis with fever and abdominal pain. Jaundice was only expressed in eleven patients (35%). The technique of chain reaction (PCR) was useful for diagnosis in samples obtained post mortem. A strain classified in serogroup canicola was isolated from blood culture. Pneumonia was classified into three types: non-severe pneumonia course with little overall impact; severe pneumonia associated with systemic clinical forms with jaundice, renal failure, thrombocytopenia, and pulmonary hemorrhage, and of serious course, not associated with jaundice, kidney failure or thrombocytopenia. Antibiotic treatment started in the early stages of disease (average 3.2 days) had no influence on the development of severe pneumonia. It is puggested to consider three clinical forms of leptospirosis: anicteric, icteric (with its evolutionary variants) and pulmonary hemorrhage.

Tratamento da hemorragia pulmonar maciça com fator VII recombinante ativado em prematuro de muito baixo peso / Treatment of massive pulmonary hemorrhage with activated recombinant factor VII in a very low birth weight premature

Neste relato, apresenta-se um caso de prematuro com 33 semanas de idade gestacional e 1.310 gramas, nascido de parto cesariano por retardo de crescimento intrauterino e alterações de fluxo uteroplacentário. Na evolução, apresentou sinais de choque séptico, com hipotensão e necessidade de dopamina e adrenalina contínuas. No sextodia de vida, observou-se hipoxemia refratária a altos parâmetros de ventilação mecânica. O quadro evoluiu com insuficiência renal, sem diurese após o uso de furosemida contínuo. Teve hemorragia pulmonar maciça, sem resposta às transfusões de plasma e plaquetas convencionais. Respondeu ao tratamento com dose de 120 μg/kg do fatorVII recombinante ativado. Após o controle do sangramento, foi instalado cateter para diálise peritoneal contínua, e o recém-nascido recuperou-se gradativamente das disfunções de múltiplos órgãos. Recebeu alta da unidade de terapia intensiva aos 49 dias de vida. Em conclusão, o fator VII recombinante ativado é uma alternativa eficaz de agentepan-hemostático para o controle de hemorragias pulmonares agudas graves no recém-nascido que não responde às manobras ventilatórias e ao uso de concentrados de hemocomponentes.

In this report, the authors present the case of a male premature with 33 weeks of gestation and weighing 1,310 grams, born from cesarean section indicated by retarded intrauterine growth and changes in uteroplacental flow. He showed signs of septic shock with hypotension and needed continuous adrenaline and dopamine. On the sixth day oflife, hypoxemia refractory to high mechanical ventilation parameters was observed. He developed renal failure, without diuresis after continuous furosemide. There was massive pulmonary hemorrhage unresponsive to transfusions of plasma and platelets. He responded to treatment with a dose of recombinant factor VIIa (120 μg/kg). After controlof the bleeding, a catheter for continuous peritoneal dialysis was inserted and the baby gradually recovered from multiple organ dysfunction. He was discharged from the neonatal intensive care unit at 49 days of life. Concluding, the recombinant factor VIIa is an effective pan-hemostatic agent for control of severe acute pulmonary hemorrhagein the newborn that does not respond to ventilatory maneuvers and to the use of conventional blood derivates.

Hemorrhagic pulmonary leptospirosis: three cases from the Yucatan peninsula, Mexico / Leptospirose hemorrágica pulmonar: três casos na península de Yucatán, México

Three leptospirosis cases with lung involvement are reported from the Yucatan Peninsula, Mexico. All three patients were admitted to the intensive care unit due to acute respiratory failure. Treatment with antibiotics resulted in favorable evolution despite the negative prognosis. Leptospirosis should be included in the differential diagnosis of patients with fever and lung involvement.

Analisamos três casos de leptospirose com envolvimento pulmonar na Península Yucatán, México. Os três pacientes com seqüelas pulmonares entraram na unidade de cuidados intensivos devido à insuficiência respiratória grave. Todos os casos evoluíram favoravelmente ao tratamento com antibióticos, apesar do prognóstico negativo. Leptospirose deve ser incluída no diagnóstico diferencial de pacientes com febre e comprometimento pulmonar.

Hemorragia pulmonar y síndrome de insuficiencia respiratoria aguda secundaria a golpe de calor / Pulmonary hemorrhage and acute respiratory distress syndrome secondary to heat stroke

El golpe de calor es una entidad poco frecuente y subdiagnosticada. Se presenta relativamente más en los estados del norte del país, al exponerse los migrantes a condiciones climáticas extremas. La elevacion de la temperatura corporal es la que dispara las disfunciones metabólicas que pueden incluso llevar a la muerte. Se presenta el caso de un migrante chiapaneco que fue encontrado en el desierto de Altar, Sonora en malas condiciones generales; fue traído al Servicio de urgencias del Hospital General del Estado en Hermosillo, Sonora. La evolución inicial fue tórpida, con deterioro de la función respiratoria, infiltrados pulmonares, necesidad de ventilación mecánica, datos de falla renal y cifras muy elevadas de creatinincinasa; se establecieron los diagnósticos de golpe de calor, insuficiencia renal, rabdomiólisis, hemorragia pulmonar y SIRA. Se le dio manejo de sostén con buena evolución, egresó al 21° día de estancia hospitalaria por resolución del problema. El caso nos recuerda que la exposición a condiciones de calor por arriba de la temperatura corporal, lo cual es muy frecuente en las áreas desérticas del norte del país, deteriora los mecanismos de control de calor corporal y metabólico. Es necesario un diagnóstico rápido y un manejo de sostén para conseguir una evolución satisfactoria.

Heat stroke is a rare and underdiagnosed entity, it is more frequently seen in the northern states of Mexico after exposure to high environmental temperatures that induce elevation of the body temperature, triggering metabolic derangements that can result in death. We present the case of a 24 year old immigrant from the southeast state of Chiapas found in the Desert of Altar, in the northern state of Sonora; he was semiconscious, dehydrated and in poor general condition after attempting to cross the desert in his way to the border with the USA. He was brought to our hospital with labored breathing, hemoptysis, lung infiltrates and progressive deterioration of his blood gases. He was intubated and mechanically ventilated; the initial course was characterized by increased CPK levels suggestive of rabdomyolisis, acute renal failure, disseminated intravascular coagulation, lung hemorrhage and acute respiratory distress syndrome secondary to the heat stroke. He spent 14 days in the ICU receiving 4 courses of hemodyalisis, ventilatory support, iv fluids, antibiotics and monitoring of his respiratory, renal, cardiovascular, neurologic and metabolic parameters. He was discharged 21 days after admission. Heat stroke prevention is mandatory by public education; early diagnosis should avoid the full-blown systemic derangements; adequate support can reverse an otherwise potentially fatal course.

Eficacia de la pentoxifilina en el tratamiento de la hemorragia pulmonar inducida por el ejercicio en equinos purasangres de carreras / Efficacy of pentoxifylline in the treatment of exercise-induced pulmonary hemorrhage in thoroughbred racehorses

El propósito de esta investigación fue determinar la eficacia de la pentoxifilina en el tratamiento de la hemorragia pulmonar inducida por el ejercicio (HPIE) en equinos Purasangres de carreras. Para tal fin, se seleccionaron en forma aleatoria 146 animales con edades comprendidas entre 3 y 8 años de edad, los cuales fueron sometidos a dos ejercicios intensos (14,6 ± 0,4 m/s) en distancia de 1000 metros, procediéndose luego a realizar una evaluación endoscópica del tracto respiratorio superior, entre 30 y 90 minutos después de cada ejercicio, con el fin de determinar la presencia de la HPIE y caracterizar la intensidad del sangramiento. Posteriormente, del conjunto de animales que presentaron HPIE en ambos ejercicios, se seleccionó al azar una muestra representativa constituida por 40 equinos, los cuales fueron asignados a dos grupos, 20 animales (grupo I) a los cuales se les administró pentoxifilina (8,5 mg/kg, q 12 h, PO) por 7 días y 20 ejemplares (grupo II) que no recibieron tratamiento. Seguidamente el día posterior a la finalización del tratamiento, a cada uno de los animales (grupo I y II), se les realizó una tercera evaluación endoscópica del tracto respiratorio superior de 30 a 90 minutos después de un ejercicio intenso en distancia de 1000 metros, para determinar la ocurrencia y severidad de la HPIE. El análisis de los datos demostró diferencia estadísticamente significativa (P < 0,05) entre la presencia e intensidad de la HPIE y la administración de la pentoxifilina, observándose que 8 (40%) de los animales tratados no presentaron HPIE, mientras que 20 (100%) de los equinos a los cuales no se les suministró la droga evidenciaron HPIE. Igualmente se determinó que la ocurrencia de HPIE moderada, profusa y visible, respectivamente, fue mayor en los animales no tratados. Por lo tanto, el tratamiento con pentoxifilina ayuda a prevenir o disminuir la HPIE.

The purpose of this investigation was to determine the efficacy of the pentoxifylline in the treatment of exercise-induced pulmonary hemorrhage (EIPH) in Thoroughbred racehorses. One hundred forty six (146) animals were randomly selected with ages between 3 and 8 years old, they were subjected to two intense exercises (14.6 ± 0.4 m/s) on distances of 1000 meters each, the horses were submitted to endoscopic evaluation of the respiratory tract, between 30 and 90 minutes after each exercise, the objective was to determine the presence of the EIPH and to characterize the intensity of the bleeding. Later, the group of animals which presented EIPH on both exercises was selected in random order as representative sample of bleeding racehorses. They were 40 equines divided in two groups, 20 animals (group I) received pentoxifylline (8.5 mg/kg, q 12 h, PO) for 7 days and 20 horses (group II) that did not receive treatment. Subsequently, the day after the end of the treatment, on each one of the horses (group I and II), a third endoscopic evaluation of the upper respiratory tract was performed, 30 to 90 minutes after an intense exercise on 1000 meters distance, in order to see the occurrence and severity of the EIPH. The analysis of the data demonstrated statistically significant difference (P < 0.05) between the presence and intensity of the EIPH and the administration of the pentoxifylline. Eight (40%) of the pentoxifilline-treated animals showed not EIPH, 20 (100%) not treated horses had evidence of EIPH. It was determined that the occurrence of moderate, profuse and visible EIPH respectively was larger in the not treated animals. Therefore, the treatment with pentoxifylline helps to prevent or to diminish the EIPH.

Glomerulonefritis aguda y hemorragia pulmonar: un desafío diagnóstico / Acute glomerulonephritis and pulmonary hemorrhage: a diagnostic challenge

La presencia de glomerulonefritis aguda y hemorragia pulmonar son característicos de la enfermedad de Goodpasture. Sin embargo, estos hallazgos no son específicos de la enfermedad por anticuerpos anti-membrana basal glomerular (Acs. anti-MBG) o Enfermedad de Goodpasture, ya que pueden hallarse en otros desórdenes como la Granulomatosis de Wegener, lupus y otras formas de glomerulonefritis agudas. La Granulomatosis de Wegener y la enfermedad de Goodpasture son las causas más comunes de estos desórdenes. La enfermedad de Goodpasture es un desorden autoinmune infrecuente caracterizado por el desarrollo de autoanticuerpos contra la cadena 3 del colágeno tipo IV, que se encuentra en la membrana basal glomerular y pulmonar, entre otras. Los pacientes presentan glomerulonefritis rápidamente progresiva y, en aproximadamente dos tercios de los casos, hemorragia pulmonar. La Granulomatosis de Wegener es una enfermedad sistémica caracterizada por una vasculitis necrotizante de los pequeños vasos de etiología desconocida. Está asociada con granulomas inflamatorios en el tracto respiratorio y enfermedad renal glomerular e intersticial. Se presenta el caso de un hombre de 53 años que se interna por síndrome urémico, desarrollando en su evolución una paresia braquiocrural izquierda y una hemorragia pulmonar que lo condujo al óbito, efectuándose un diagnóstico compatible con Síndrome de Goodpasture mediante la necropsia. Estudios post-morten mostraron anticuerpos anticitoplasma de neutrófilo (ANCA) positivos y Factor Anti-nuclear (FAN) negativos. Se realiza una revisión bibliográfica poniendo especial énfasis en el diagnóstico y tratamiento de las dos patologías que más frecuentemente se asocian a este síndrome.

Acute glomerulonephritis and pulmonary bleeding are two characteristics of Goodpasture's disease. However, these findings are not specific for the glomerubody disease (anti-GBM Ab) or Goodpasture's disease, since they can be seen in other disorders such as Wegener's Granulomatosis, lupus and other forms of acute glomerulonephritis. Wegener's Granulomatosis and Goodpasture's Disease are the commonest causes for these disorders. Goodpasture's Disease is a rare, autoimmune disorder characterized by the development of antibodies against collagen 3 (IV) chain located in the glomerular and pulmonary basal membrane, among other sites. Patients present rapidly progressing glomerulonephritis and, in about two thirds of the cases, pulmonary bleeding. Wegener's granulomatosis is a systemic disease characterized by a necrotizing angiitis (vasculitis) of the small vessels of unknown origin. It is associated to inflammatory granuloma in the respiratory tract and glomerular and interstitial kidney disease. In this paper, the case of a 53 year old male patient hospitalized due to uremic syndrome is presented. This patient developed left brachiocrural paresia and pulmonary bleeding that caused his death and the diagnosis at the autopsy was Goodpasture's disease. Post-mortem studies showed positive anti-neutrophilic cytoplasmic antibodies (ANCA) and negative Antinuclear Factor (ANF) antibodies. A review of the literature is carried out focusing especially in diagnosis and treatment of the most frequent pathologies associated to this disease.

Poliangiíte microscópica com hemorragia pulmonar / Microscopic polyangiitis with lung hemorrhage

Os autores relatam um caso de Poliangiíte Microscópica em paciente idosa, diabética, que apresentou quadro agudo de dor abdominal, edema dos membros inferiores, dor nas panturrilhas e poliartralgia. Evoluiu com insuficiência renal aguda, sendo dializada. Surgiram púrpuras não palpáveis generalizadas. Enquanto se submetia a hemodialíse, sofreu dispnéia súbita, sendo entubada e aspirado grande quantidade de sangue vivo, falecendo em seguida. A necropsia no Serviço de Patologia do HUAP-UFF revelou aspectos de Poliangiíte Microscópica.

The autors present one fatal case lung hemorrhage caused by microscopic polyangiitis, that was confirmed by postmortem examination. She was a diabetic old woman who complained of acute abdominal pain, purpuric cutaneous lesions myalgia and arthralgia followed by acute renal failure requiring hemodialysis. She had a sudden death in respiratory failure and through the tracheal tube a lange volume of blood was aspirated.