Takayasu arteritis: differential diagnosis in a teenager with severe acute kidney injury - a case report / Arterite de Takayasu: diagnóstico diferencial em adolescente com lesão renal aguda grave - relato de caso

ABSTRACT Takayasu arteritis (TA) is a chronic granulomatous inflammatory condition of unknown cause that involves large vessels - particularly the aorta and its branches - such as the carotid, coronary, pulmonary, and renal arteries. The left subclavian artery is the most frequently involved vessel. Stenosis of the renal artery has been reported in 23-31% of the cases and may result in malignant hypertension, ischemic renal disease, decompensated heart failure, and premature death. Involvement of both renal arteries is uncommon. Early onset anuria and acute kidney injury are rare and have been reported only in a few cases in the literature. This report describes the case of a 15-year-old female with constitutional symptoms evolving for a year, combined with headache, nausea, and vomiting, in addition to frequent visits to emergency services and insufficient clinical examination. The patient worsened significantly six months after the onset of symptoms and developed acute pulmonary edema, oliguria, acute kidney injury, and difficult-to-control hypertension, at which point she was admitted for intensive care and hemodialysis. Initial ultrasound examination showed she had normal kidneys and stenosis-free renal arteries. The patient was still anuric after 30 days of hospitalization. A biopsy was performed and revealed her kidneys were normal. Computed tomography angiography scans of the abdominal aorta presented evidence of occlusion of both renal arteries. The patient met the diagnostic criteria for Takayasu arteritis and had a severe complication rarely described in the literature: stenosis of the two renal arteries during the acute stage of ischemic renal disease.

RESUMO A Arterite de Takayasu (AT) é uma doença inflamatória crônica, granulomatosa, de causa desconhecida, que afeta grandes vasos, principalmente a aorta e seus ramos, incluindo artérias carótidas, coronárias, pulmonares e renais, sendo a artéria subclávia esquerda o vaso mais acometido. A estenose da artéria renal é relatada em 23-31% dos casos e pode resultar em hipertensão maligna, insuficiência renal por isquemia, descompensação cardíaca e morte prematura. O acometimento bilateral de artérias renais é incomum, sendo rara a presença de anúria súbita e lesão renal aguda como sintoma inicial da doença, com poucos relatos na literatura. O caso reporta uma adolescente de 15 anos com sintomas constitucionais durante um ano de evolução, associados a problemas como cefaleia, náuseas e vômitos, com idas frequentes a serviços de emergência, sem adequada investigação clínica. Após 6 meses do início dos sintomas, a paciente evoluiu de forma grave, com quadro de edema agudo de pulmão, oligúria, lesão renal aguda e hipertensão arterial de difícil controle, sendo necessário suporte em Unidade de Terapia Intensiva e hemodiálise. A ultrassonografia inicial mostrava rins normais e artérias renais sem sinais de estenose. Após 30 dias de internamento, paciente permanecia anúrica, sendo realizada biópsia renal que se mostrou dentro dos padrões da normalidade. Angiotomografia de aorta abdominal evidenciou oclusão bilateral de artérias renais. A paciente descrita fechou critérios diagnósticos para arterite de Takayasu e manifestou uma complicação grave pouco descrita na literatura: estenose bilateral de artérias renais, ainda na fase aguda da nefropatia isquêmica.

Negative pressure pulmonary edema: report of case series and review of the literature / Edema pulmonar por pressão negativa: relato de casos e revisão da literatura

Abstract Background and objectives: Negative pressure pulmonary edema occurs by increased intrathoracic negative pressure following inspiration against obstructed upper airway. The pressure generated is transmitted to the pulmonary capillaries and exceeds the pressure of hydrostatic equilibrium, causing fluid extravasation into the pulmonary parenchyma and alveoli. In anesthesiology, common situations such as laryngospasm and upper airway obstruction can trigger this complication, which presents considerable morbidity and requires immediate diagnosis and propaedeutics. Upper airway patency, noninvasive ventilation with positive pressure, supplemental oxygen and, if necessary, reintubation with mechanical ventilation are the basis of therapy. Case report: Case 1: Male, 52 years old, undergoing appendectomy under general anesthesia with orotracheal intubation, non-depolarizing neuromuscular blocker, reversed with anticholinesterase, presented with laryngospasm after extubation, followed by pulmonary edema. Case 2: Female, 23 years old, undergoing breast reduction under general anesthesia with oro-tracheal intubation, non-depolarizing neuromuscular blocker, reversed with anticholinesterase,presented with inspiration against closed glottis after extubation, was treated with non-invasiveventilation with positive pressure; after 1 hour, she had pulmonary edema. Case 3: Male, 44 yearsold, undergoing ureterolithotripsy under general anesthesia, without neuromuscular blocker,presented with laryngospasm after laryngeal mask removal evolving with pulmonary edema. Case 4: Male, 7 years old, undergoing crude fracture reduction under general anesthesia withorotracheal intubation, non-depolarizing neuromuscular blocker, presented with laryngospasmreversed with non-invasive ventilation with positive pressure after extubation, followed bypulmonary edema. Conclusions: The anesthesiologists should prevent the patient from perform a forced inspirationagainst closed glottis, in addition to being able to recognize and treat cases of negative pressurepulmonary edema.

Resumo Justificativa e objetivos: O edema pulmonar por pressão negativa ocorre por aumento da pressão negativa intratorácica após inspiração contra via aérea superior obstruída. A pressão gerada é transmitida aos capilares pulmonares e supera a pressão de equilíbrio hidrostático, o que causa extravasamento de líquido para o parênquima pulmonar e alvéolos. Em anestesiologia, situações comuns como laringoespasmo e obstrução de via aérea superior podem desencadear essa complicação, que apresenta considerável morbidade e exige diagnóstico e propedêutica imediatos. A desobstrução das vias aéreas superiores, ventilação não invasiva com pressão positiva, oxigênio suplementar e, se necessário reintubação com ventilação mecânica são a base da terapia. Relato de caso: Caso 1: Masculino, 52 anos, submetido a apendicectomia sob anestesia geral com intubação orotraqueal, uso de bloqueador neuromuscular adespolarizante, revertido com anticolinesterásico; apresentou laringoespasmo após extubação, seguido de edema pulmonar. Caso 2: Feminino, 23 anos, submetida a mamoplastia redutora sob anestesia geral com intubação orotraqueal, bloqueador neuromuscular adespolarizante revertido com anticolinesterásico, apresentou inspiração contra glote fechada após extubação, tratada com ventilação não invasiva com pressão positiva; após uma hora apresentou edema pulmonar. Caso 3: Masculino, 44 anos, submetido a ureterolitotripsia sob anestesia geral, sem bloqueador neuromuscular, apresentou laringoespasmo após retirada de máscara laríngea e evoluiu com edema pulmonar. Caso 4: Masculino, sete anos, submetido a redução cruenta de fratura sob anestesia geral com intubação orotraqueal, uso de bloqueador neuromuscular adespolarizante; apresentou laringo-espasmo revertido com ventilação não invasiva com pressão positiva após extubação, seguidode edema pulmonar. Conclusões: O anestesiologista deve evitar que o paciente faça inspiração forçada contra glotefechada, além de ser capaz de reconhecer e tratar os casos de edema pulmonar por pressãonegativa.

Sclerosing mediastinitis causing unilateral pulmonary edema due to left atrial and pulmonary venous compression. a case report and literature review

Abstract Sclerosing mediastinitis (SM), previously named chronic fibrosing mediastinitis, is an inflammatory process that in its end-stage results to sclerosis around the mediastinal structures. SM is quite rare and has been correlated with inflammatory and autoimmune diseases, as well as malignancy. SM may either present in a mild form, with minor symptoms and a benign course or in a more aggressive form with severe pulmonary hypertension and subsequent higher morbidity and mortality. The diagnosis of SM may be difficult and quite challenging, as symptoms depend on the mediastinal structure that is mainly involved; quite often the superior vena cava. However, practically any mediastinal structure may be involved by the fibrotic process, such as the central airways, as well as the pulmonary arteries and veins, leading to obstruction or total occlusion. The latter may be impossible to undergo proper surgical excision of the lesion, and is considered to be a real challenge to the surgeon. We herein report a case of SM that presented with arterial and venous compression. The imaging appearance was that of unilateral pulmonary edema, associated with lung collapse. The case is supplemented by a non-systematic review of the relevant literature.

Carbohydrate antigen 125 predicts pulmonary congestion in patients with ST-segment elevation myocardial infarction

Carbohydrate antigen 125 (CA125) has long been used as an ovarian cancer biomarker. However, because it is not specific for ovarian cells, CA125 could also be used to monitor congestion and inflammation in heart disease. Acute heart failure (HF) is used to identify patients with a worse prognosis in ST-segment elevation myocardial infarction (STEMI). We aimed to determine the association of CA125 with acute HF in STEMI and to compare CA125 with N-terminal pro brain natriuretic peptide (NTproBNP) with a cross-sectional study. At admission, patients were examined to define Killip class and then underwent coronary angioplasty. Blood samples, preferably taken in the hemodynamic ward, were centrifuged (1500 g for 15 min at ambient temperature) and stored at −80°C until biomarker assays were performed. Patients were divided into two groups according to the presence or absence of congestion. Patients in Killip class ≥II were in the congestion group and those with Killip <II in the absence of congestion group. We evaluated 231 patients. The mean age was 63.3 years. HF at admission was identified in 17.7% of patients. CA125 and NTproBNP levels were higher in patients with Killip class ≥II than those with Killip class <II (8.03 vs 9.17, P=0.016 and 772.45 vs 1925, P=0.007, respectively). The area under the receiver operator characteristic curve was 0.60 (95%CI 0.53−0.66, P=0.024) for CA125 and 0.63 (95%CI 0.56−0.69, P=0.001) for NTproBNP. There was no statistical difference between the curves (P=0.69). CA125 has similar use to NTproBNP in identifying acute HF in patients presenting with STEMI.

New determinants for casual peripheral mechanism of neurogenic lung edema in subarachnoid hemorrhage due to ischemic degeneration of vagal nerve, kidney and lung circuitry. Experimental study

Abstract Purpose: To evaluate whether there is a relationship between renal artery vasospasm related low glomerular density or degeneration and neurogenic lung edema (NLE) following subarachnoid hemorrhage. Methods: This study was conducted on 26 rabbits. A control group was formed of five animals, a SHAM group of 5 to which saline and a study group (n=16) injected with homologous blood into the sylvian cisterna. Numbers of degenerated axons of renal branches of vagal nerves, atrophic glomerulus numbers and NLE scores were recorded. Results: Important vagal degeneration, severe renal artery vasospasm, intrarenal hemorrhage and glomerular atrophy observed in high score NLE detected animals. The mean degenerated axon density of vagal nerves (n/mm2), atrophic glomerulus density (n/mm3) and NLE scores of control, SHAM and study groups were estimated as 2.40±1.82, 2.20±1.30, 1.80±1.10, 8.00±2.24, 8.80±2.39, 4.40±1.14 and 154.38±13.61, 34.69±2.68 and 12.19±1.97 consecutively. Degenerated vagal axon, atrophic glomerulus and NLE scores are higher in study group than other groups and the differences are statistically meaningful (p<0.001). Conclusion: Vagal complex degeneration based glomerular atrophy have important roles on NLE following SAH which has not been extensively mentioned in the literature.

Edema agudo de pulmón no cardiogénico en el postoperatorio inmediato / Noncardiogenic acute pulmonary edema in the immediate postoperative period

Acute non-cardiogenic pulmonary edema is a rare clinical entity which sometimes complicates the perioperative period. Even though one of the main causes is the acute obstruction of the airway, which may occur during a laryngospasm event, its etiology is varied and must be known for an adequate clinical management. We report the case of an 18 year old patient who developed postoperative acute non-cardiogenic pulmonary edema, probably of mixed etiology.

El edema agudo de pulmón (EAP) no cardiogénico es una entidad poco habitual que complica en ocasiones el período perioperatorio. Aunque una de las principales causas es la obstrucción aguda de la vía aérea que puede ocurrir durante un episodio de laringoespasmo, su etiología es variada y debe ser conocida para un adecuado manejo clínico. Presentamos el caso de un paciente de 18 años que desarrolló un EAP no cardiogénico postoperatorio, de etiología probablemente mixta.

Edema pulmonar agudo grave secundario a tratamiento de neumotórax espontáneo primario: caso clínico / Pulmonary expansion edema during the management of a spontaneous pneumothorax: report of one case

Pulmonary expansion edema is a rare complication of the management of primary spontaneous pneumothorax. We report a 20 year old male admitted with a right primary spontaneous pneumothorax. A chest tube connected to a water seal was placed, achieving lung expansion. Immediately, the patient presented hypotension and a reduction in arterial oxygen saturation to 78%. Non-invasive ventilation was started. A chest X ray showed extensive right lung edema. The patient was managed with noradrenaline and albumin infusion with good response. Pulmonary edema resolved on day 3 but air leak was persistant so, the patient required surgery to excise apical bullae in the right lung. He was discharged during the following days in good condition.

Estrangulamento acidental em crianças por fechamento automático de vidro de carro / Accidental strangulation in children by the automatic closing of a car window

RESUMO Entre as principais causas de morte em nosso meio, situam-se acidentes automobilísticos, afogamento e queimaduras acidentais. O estrangulamento é uma injúria potencialmente fatal, além de importante causa de homicídio e suicídio em adultos e adolescentes. Em crianças, sua ocorrência é usualmente acidental. No entanto, nos últimos anos, vários casos de estrangulamento acidental em crianças ao redor do mundo têm sido reportados. Paciente masculino de 2 anos de idade foi vítima de estrangulamento em vidro do carro. Admitido na unidade de terapia intensiva pediátrica com Escala de Coma de Glasgow de 8, piora progressiva da disfunção respiratória e torpor. Paciente apresentou quadro de Síndrome da Angústia Respiratória Aguda, edema agudo de pulmão e choque. Foi manejado com ventilação mecânica protetora, drogas vosoativas e antibioticoterapia. Recebeu alta da unidade de terapia intensiva sem sequelas neurológicas ou pulmonares. Após 12 dias de internação, teve hospitalar alta para casa em ótimo estado. A incidência de estrangulamento por vidro de automóvel é rara, mas de alta morbimortalidade, devido ao mecanismo de asfixia ocasionado. Felizmente, os automóveis mais modernos dispõem de dispositivos que interrompem o fechamento automático dos vidros se for encontrada alguma resistência. No entanto, visto a gravidade das complicações de pacientes vítimas de estrangulamento, é significativamente relevante o manejo intensivo neuroventilatório e hemodinâmico das patologias envolvidas, para redução da morbimortalidade, assim como é necessário implementar novas campanhas para educação dos pais e cuidadores das crianças, visando evitar acidentes facilmente preveníveis e otimizar os mecanismos de segurança nos automóveis com vidros elétricos.

ABSTRACT Among the main causes of death in our country are car accidents, drowning and accidental burns. Strangulation is a potentially fatal injury and an important cause of homicide and suicide among adults and adolescents. In children, its occurrence is usually accidental. However, in recent years, several cases of accidental strangulation in children around the world have been reported. A 2-year-old male patient was strangled in a car window. The patient was admitted to the pediatric intensive care unit with a Glasgow Coma Scale score of 8 and presented with progressive worsening of respiratory dysfunction and torpor. The patient also presented acute respiratory distress syndrome, acute pulmonary edema and shock. He was managed with protective mechanical ventilation, vasoactive drugs and antibiotic therapy. He was discharged from the intensive care unit without neurological or pulmonary sequelae. After 12 days of hospitalization, he was discharged from the hospital, and his state was very good. The incidence of automobile window strangulation is rare but of high morbidity and mortality due to the resulting choking mechanism. Fortunately, newer cars have devices that stop the automatic closing of the windows if resistance is encountered. However, considering the severity of complications strangulated patients experience, the intensive neuro-ventilatory and hemodynamic management of the pathologies involved is important to reduce morbidity and mortality, as is the need to implement new campaigns for the education of parents and caregivers of children, aiming to avoid easily preventable accidents and to optimize safety mechanisms in cars with electric windows.

Variables associated with lung congestion as assessed by chest ultrasound in diabetics undergoing hemodialysis / Variáveis associadas a congestão pulmonar avaliada por ultrassonografia em diabéticos submetidos a hemodiálise

Abstract Introduction: Ultrasound is an emerging method for assessing lung congestion but is still seldom used. Lung congestion is an important risk of cardiac events and death in end-stage renal disease (ESRD) patients on hemodialysis (HD). Objective: We investigated possible variables associated with lung congestion among diabetics with ESRD on HD, using chest ultrasound to detect extracellular lung water. Methods: We studied 73 patients with diabetes as the primary cause of ESRD, undergoing regular HD. Lung congestion was assessed by counting the number of B lines detected by chest ultrasound. Hydration status was assessed by bioimpedance analysis and cardiac function by echocardiography. The collapse index of the inferior vena cava (IVC) was measured by ultrasonography. All patients were classified according to NYHA score. Correlations of the number of B lines with continuous variables and comparisons regarding the number of B lines according to categorical variables were performed. Multivariate linear regression was used to test the variables as independent predictors of the number of B lines. Results: None of the variables related to hydration status and cardiac function were associated with the number of B lines. In the multivariate analysis, only the IVC collapse index (b = 45.038; p < 0.001) and NYHA classes (b = 13.995; p = 0.006) were independent predictors of the number of B lines. Conclusion: Clinical evaluation based on NYHA score and measurement of the collapsed IVC index were found to be more reliable than bioimpedance analysis to predict lung congestion.

Resumo Introdução: A ultrassonografia é um método emergente e ainda raramente utilizado na avaliação da congestão pulmonar. A congestão pulmonar é um importante fator de risco para eventos cardíacos e óbito entre pacientes com doença renal terminal (DRT) em hemodiálise (HD). Objetivo: Foram investigadas as possíveis variáveis associadas a congestão pulmonar em indivíduos diabéticos com DRT em HD, utilizando a ultrassonografia torácica para detectar água extracelular nos pulmões. Métodos: Foram estudados 73 pacientes com diabetes como causa primária de DRT submetidos a HD regular. A congestão pulmonar foi avaliada pela contagem do número de linhas B detectadas por ultrassonografia torácica. O estado de hidratação foi avaliado por análise de bioimpedância e a função cardíaca por ecocardiografia. O índice de colabamento da veia cava inferior (VCI) foi medido por ultrassonografia. Todos os pacientes foram classificados segundo a escore da NYHA. Foram analisadas as correlações entre o número de linhas B e variáveis contínuas e as comparações entre o número de linhas B em relação às variáveis categóricas. Regressão linear multivariada foi utilizada para testar as variáveis enquanto preditores independentes do número de linhas B. Resultados: Nenhuma das variáveis relacionadas a estado de hidratação e função cardíaca apresentou associação com o número de linhas B. Na análise multivariada, apenas o índice de colabamento da VCI (b = 45,038; p < 0,001) e as classes da NYHA (b = 13,995; p = 0,006) foram preditores independentes do número de linhas B. Conclusão: A avaliação clínica baseada na classificação da NYHA e na medição do índice de colabamento da VCI foram mais confiáveis do que a análise de bioimpedância para predizer congestão pulmonar.

Usefulness of radiological signs of pulmonary congestion in predicting failed spontaneous breathing trials / Utilidade de sinais radiológicos de congestão pulmonar para predizer o fracasso do teste de respiração espontânea

ABSTRACT Objective: Inspiratory fall in intrathoracic pressure during a spontaneous breathing trial (SBT) may precipitate cardiac dysfunction and acute pulmonary edema. We aimed to determine the relationship between radiological signs of pulmonary congestion prior to an SBT and weaning outcomes. Methods: This was a post hoc analysis of a prospective cohort study involving patients in an adult medical-surgical ICU. All enrolled individuals met the eligibility criteria for liberation from mechanical ventilation. Tracheostomized subjects were excluded. The primary endpoint was SBT failure, defined as the inability to tolerate a T-piece trial for 30-120 min. An attending radiologist applied a radiological score on interpretation of digital chest X-rays performed before the SBT. Results: A total of 170 T-piece trials were carried out; SBT failure occurred in 28 trials (16.4%), and 133 subjects (78.3%) were extubated at first attempt. Radiological scores were similar between SBT-failure and SBT-success groups (median [interquartile range] = 3 [2-4] points vs. 3 [2-4] points; p = 0.15), which, according to the score criteria, represented interstitial lung congestion. The analysis of ROC curves demonstrated poor accuracy (area under the curve = 0.58) of chest x-rays findings of congestion prior to the SBT for discriminating between SBT failure and SBT success. No correlation was found between fluid balance in the 48 h preceding the SBT and radiological score results (ρ = −0.13). Conclusions: Radiological findings of pulmonary congestion should not delay SBT indication, given that they did not predict weaning failure in the medical-surgical critically ill population. (ClinicalTrials.gov identifier: NCT02022839 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: A queda inspiratória da pressão intratorácica durante o teste de respiração espontânea (TRE) pode provocar disfunção cardíaca e edema pulmonar agudo. Nosso objetivo foi determinar a relação entre sinais radiológicos de congestão pulmonar antes do TRE e desfechos do desmame. Métodos: Análise post hoc de um estudo prospectivo de coorte envolvendo pacientes em uma UTI medicocirúrgica de adultos. Todos os indivíduos incluídos preencheram os critérios de elegibilidade para liberação da ventilação mecânica. Pacientes traqueostomizados foram excluídos. O desfecho primário foi o fracasso do TRE, cuja definição foi a incapacidade de tolerar o teste de tubo T durante 30-120 min. Um radiologista assistente usou um escore radiológico na interpretação de radiografias de tórax digitais realizadas antes do TRE. Resultados: Foram realizados 170 testes de tubo T; o TRE fracassou em 28 (16,4%), e 133 indivíduos (78,3%) foram extubados na primeira tentativa. Os escores radiológicos foram semelhantes nos grupos fracasso e sucesso do TRE [mediana (intervalo interquartil) = 3 (2-4) pontos vs. 3 (2-4) pontos; p = 0,15] e caracterizaram, segundo os critérios do escore, congestão pulmonar intersticial. A análise das curvas ROC revelou que os achados de congestão na radiografia de tórax antes do TRE apresentavam baixa precisão (área sob a curva = 0,58) para discriminar entre fracasso e sucesso do TRE. Não houve correlação entre o balanço hídrico nas 48 h anteriores ao TRE e os resultados do escore radiológico (ρ = −0,13). Conclusões: Achados radiológicos de congestão pulmonar não deveriam atrasar o TRE, já que não previram o fracasso do desmame na população médico-cirúrgica em estado crítico. (ClinicalTrials.gov identifier: NCT02022839 [http://www.clinicaltrials.gov/])

Comprometimento pulmonar grave em paciente com associação entre diagnóstico de malária e HIV: relato de caso / Severe pulmonary involvement in a patient with associated malaria and HIV: a case report

A associação entre Vírus da Imunodeficiência Humana (HIV) e Malária é um evento de grande repercussão clínica. A grande importância de tal concomitância de diagnósticos dá-se por sua associação negativa, na qual se observa risco aumentado de infecção por malária em pacientes com HIV e o aumento de replicação viral nesses pacientes em decorrência da coinfecção pela malária. Os achados radiológicos incluem infiltrado intersticial ou alveolar, localizado preferencialmente nas regiões peri-hilares e em bases pulmonares, que pode ser associado a derrame pleural. O caso relatado é de um homem de 40 anos, branco, previamente hígido, que interna por quadro de febre, mialgia difusa e fadiga, após viagem de turismo ao continente africano. Em investigação laboratorial inicial, apresenta hemoconcentração e plaquetopenia importante. No decorrer da internação, tem diagnóstico de malária (demonstração do parasita no esfregaço sanguíneo) e inicia tratamento específico. Solicitou-se sorologia para HIV, a qual se apresentou positiva. O paciente evolui com febre ictero-hemorrágica, confusão mental, vômitos, insuficiência ventilatória e insuficiência renal aguda, sendo transferido para Unidade de Terapia Intensiva. Comprovou-se comprometimento pulmonar grave através da realização de Tomografia Computadorizada de Tórax de Alta Resolução, que evidenciou espessamento de septos interlobulares e de bainhas peribroncovasculares, com áreas esparsas de atenuação em vidro fosco e de consolidações, além de evidência de derrame pleural. Conclui-se que padrão de comprometimento radiológico do paciente foi compatível com os relatos já descritos pela literatura, o que corrobora para unificação de apresentação do quadro nos exames de imagem (AU)

The association between human immunodeficiency virus (HIV) and malaria is an event of great clinical repercussion. The great importance of such concomitance of diagnoses is due to its negative association, where there is an increased risk of malaria infection in patients with HIV and increased viral replication in these patients due to malaria co-infection. Radiological findings include interstitial or alveolar infiltrate, preferably located in the peri-hilar regions and at the lung bases, which may be associated with pleural effusion. The case reported here is of a white 40-year-old man, previously healthy, who was hospitalized for fever, diffuse myalgia and fatigue after a trip to the African continent. In initial laboratory investigation, he presented hemoconcentration and important thrombocytopenia. During the hospitalization, malaria was diagnosed (demonstration of the parasite in the blood smear) and specific treatment was initiated. HIV serology was requested and positive. As the patient progressed with icterohemorrhagic fever, mental confusion, vomiting, ventilatory failure and acute renal failure, he was transferred to the Intensive Care Unit. Severe pulmonary involvement was confirmed by high-resolution computed tomography, which showed thickening of interlobular septa and peribroncovascular sheaths, with sparse areas of ground-glass attenuation and consolidations, as well as evidence of pleural effusion. It was concluded that the patient's radiological involvement pattern was consistent with the reports already described in the literature, which corroborates the unification of the presentation of the picture in the imaging tests (AU)

Neurogenic pulmonary edema due to ventriculo-atrial shunt dysfunction: a case report / Edema pulmonar neurogênico devido à disfunção da derivação ventrículo-atrial: relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: Pulmonary edema is caused by the accumulation of fluid within the air spaces and the interstitium of the lung. Neurogenic pulmonary edema is a clinical syndrome characterized by the acute onset of pulmonary edema following a significant central nervous system insult. It may be a less-recognized consequence of raised intracranial pressure due to obstructive hydrocephalus by blocked ventricular shunts. It usually appears within minutes to hours after the injury and has a high mortality rate if not recognized and treated appropriately. CASE REPORT: We report a patient with acute obstructive hydrocephalus due to ventriculo-atrial shunt dysfunction, proposed to urgent surgery for placement of external ventricular drainage, who presented with neurogenic pulmonary edema preoperatively. She was anesthetized and supportive treatment was instituted. At the end of the procedure the patient showed no clinical signs of respiratory distress, as prompt reduction in intracranial pressure facilitated the regression of the pulmonary edema. CONCLUSIONS: This report addresses the importance of recognition of neurogenic pulmonary edema as a possible perioperative complication resulting from an increase in intracranial pressure. If not recognized and treated appropriately, neurogenic pulmonary edema can lead to acute cardiopulmonary failure with global hypoperfusion and hypoxia. Therefore, awareness of and knowledge about the occurrence, clinical presentation and treatment are essential.

RESUMO JUSTIFICATIVA E OBJETIVOS: o edema pulmonar é causado pelo acúmulo de líquido nos alvéolos e no interstício pulmonar. Edema pulmonar neurogênico é uma síndrome clínica caracterizada por edema pulmonar de início agudo após um acometimento súbito do sistema nervoso central. Pode ser uma consequência menos reconhecida de pressão intracraniana aumentada por causa da hidrocefalia obstrutiva por derivações ventriculares bloqueadas. Geralmente aparece em minutos ou horas após o insulto e tem uma alta taxa de mortalidade, caso não seja identificado e tratado adequadamente. RELATO DE CASO: relatamos o caso de paciente com hidrocefalia obstrutiva aguda por causa da disfunção da derivação ventrículo-atrial, programado para cirurgia em caráter de urgência para a colocação de derivação ventricular externa, que apresentou edema pulmonar neurogênico no pré-operatório. A paciente foi anestesiada e o tratamento de manutenção instituído. No fim do procedimento, a paciente não apresentou quaisquer sinais de distúrbio respiratório, pois a redução rápida da pressão intracraniana facilitou a regressão do edema pulmonar. CONCLUSÕES: este relato aborda a importância da identificação de um edema pulmonar neurogênico como uma possível complicação no período perioperatório resultante de um aumento da pressão intracraniana. Quando não identificado e tratado adequadamente, o edema pulmonar neurogênico pode levar à insuficiência cardiorrespiratória aguda, com hipoperfusão global e hipóxia. Portanto, a conscientização e o conhecimento de sua ocorrência, apresentação clínica e seu tratamento são essenciais.

Pulmonary edema following transcatheter closure of atrial septal defect.

We describe an incident of development of acute pulmonary edema after the device closure of a secundum atrial septal defect in a 52-year-old lady, which was treated with inotropes, diuretics and artificial ventilation. Possibility of acute left ventricular dysfunction should be considered after the defect closure in the middle-aged patients as the left ventricular compliance may be reduced due to increased elastic stiffness and diastolic dysfunction. Baseline left atrial pressure may be > 10 mmHg in these patients. Associated risk factors for the left ventricular dysfunction are a large Qp:Qs ratio, systemic hypertension, severe pulmonary hypertension and paroxysmal atrial fibrillation.

Edema agudo de pulmão causado por mixoma atrial esquerdo móvel: relato de caso / Acute pulmonary edema caused by mobile left atrial myxoma: case report

O mixoma é o tumor cardíaco primário benigno mais frequente e em cerca de 90% dos casos, localiza-se no átrio esquerdo. Seu curso indolente favorece o retardo no diagnóstico, o que pode levar a graves complicações...

P2L2A0 Emergency Lower Segment Caesarean Section (LSCS) with Atrial Septal Defect (ASD) with severe Pulmonary Arterial Hypertension (PAH) with Bidirectional flow with Pulmonary Edema with Sepsis.

Severe pulmonary Arterial Hypertension with Pulmonary Edema with Sepsis in a postnatal mother with Atrial Septal Defect (ASD) followed by LSCS is uncommon. Atrial Septal Defect (ASD) is the commonest adult congenital heart defect (CHD). 15 % of these patients will eventually develop pulmonary hypertension if left untreated. ASD closure is not recommended when pulmonary hypertension is irreversible. Congenital heart disease should be considered in the evaluation of dyspnoea in a young adult. The management of ASD with associated pulmonary hypertension is difficult. It is pertinent that a detailed hemodynamic assessment be undertaken. The present case report focusses on a patient with severe ASD with pulmonary hypertension with pulmonary edema and sepsis who was with 35 weeks of gestation and the control of symptoms during Caesarean section.

Post extubation negative pressure pulmonary edema due to posterior mediastinal cyst in an infant.

A 3‑month‑old male child underwent uneventful inguinal herniotomy under general anesthesia. After extubation, airway obstruction followed by pulmonary edema appeared for which the baby was reintubated and ventilated. The baby made a complete recovery and extubated after about 2 h. A post‑operative computed tomography scan revealed a posterior mediastinal cystic mass abutting the tracheal bifurcation. Presumably, extrinsic compression by the mass on the tracheal bifurcation led to the development of negative pressure pulmonary edema.

Cardiogenic shock due to coronary artery disease associated with interrupted aortic arch / Choque cardiogênico decorrente de cardiomiopatia isquêmica associada à interrupção do arco aórtico

Acute pulmonary edema is a serious event. Its occurrence in association with interrupted aortic arch and coronary heart disease is rare. Recently, an old patient developed cardiogenic shock and acute pulmonary edema due to acute coronary insufficiency, associated with interrupted aortic arch. The coronary angiography revealed occlusion of the right coronary artery and 95% obstruction in the left main coronary artery, associated with interruption of the descending aorta. Coronary artery bypass graft was performed, without extracorporeal circulation, to the anterior descending coronary artery. We discuss the initial management, given the seriousness of the case.

A associação de interrupção do arco aórtico e doença coronária é rara. Entretanto, recentemente nos deparamos com um paciente nessa condição, que culminou com choque cardiogênico e edema agudo de pulmão. A finalidade desta comunicação breve é transmitirmos e discutirmos se a conduta adotada foi a mais indicada. Sua coronária direita estava 100% ocluída e havia obstrução de 95% em tronco de coronária esquerda, associada à interrupção de aorta descendente. Realizamos apenas enxerto de veia safena para ramo da coronária esquerda, sem circulação extracorpórea. O paciente apresentou boa evolução imediata. Destacamos a conduta inicial adotada, diante da gravidade do caso.