Hematoma subperiosteal orbitário secundário a barotrauma em aviação civil / Orbital subperiosteal hematoma secondary to barotrauma in civil aviation

RESUMO Os diagnósticos diferenciais que compõem as proptoses agudas são, muitas vezes, desafiadores. A anamnese e o exame clínico exigem do oftalmologista atenção especial aos detalhes que permitem diferenciar quadros relativamente benignos e autolimitados de quadros que evoluirão com incapacidades permanentes. Relatamos o caso de uma paciente de 49 anos que, durante viagem de avião, apresentou dor ocular, hematoma periorbitário e proptose do olho esquerdo súbitos. Referia diplopia aguda incapacitante. Exames de tomografia e angiorressonância magnética confirmaram diagnóstico de sinusopatia do seio etmoidal esquerdo e hematoma subperiosteal da órbita esquerda, associado ao barotrauma. Apesar de raro, o diagnóstico de hematoma subperiosteal não traumático deve ser considerado diferencial em relação a proptoses agudas, sendo a anamnese fundamental para essa elucidação diagnóstica.

ABSTRACT Differential diagnoses of acute proptosis are often challenging. History and clinical examination require from ophthalmologists special attention to details, which make it possible to differentiate relatively benign and self-limited conditions from those that will progress to permanent disabilities. We report a 49-year-old female patient who had sudden eye pain, periorbital hematoma and proptosis of the left eye during a commercial flight. She also complained of disabling acute diplopia. Computed tomography and magnetic resonance angiography imaging confirmed the diagnosis of subperiosteal hematoma of the left orbit, associated with left ethmoid sinus disease. Although rare, non-traumatic subperiosteal hematoma should be considered in differential diagnoses of acute proptosis, and history taking is fundamental to elucidate the picture.

Mucormicosis: Una micosis emergente / Mucormycosis: An emergent mycosis

El objetivo de este trabajo es presentar la incidencia, frecuencia, características clínicas y evolución de los pacientes con mucormicosis atendidos en el Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, entre los años 1982 y 2010. Durante ese período se diagnosticaron 10 casos de mucormicosis. Los tres primeros entre 1982 y 2004 y los últimos 7 entre 2005 y 2010. La incidencia y frecuencia de esta enfermedad, para el período 1980-2004 fue 0.13 pacientes/año y 0.1 casos/10 000 egresos (IC 95%: 0.00 a 0.3) respectivamente. En el período 2005-2010 la incidencia fue 0.86 pacientes/año y la frecuencia de 1.1 casos/10 000 egresos (IC 95%: 0.5 a 2.4). Hubo nueve casos de mucormicosis rinosinuso-orbitaria, siete en pacientes con diabetes mellitus, uno en una paciente con una hemopatía maligna y neutropenia, y el restante en un paciente con HIV/sida que además estaba neutropénico y con un síndrome hemofagocítico. En una paciente se realizó el diagnóstico post mortem de mucormicosis pulmonar. El diagnóstico se efectuó por la observación de filamentos cenocíticos en los diez casos. Hubo desarrollo de mucorales en los cultivos de 8/9 pacientes; cinco Rhizopus spp y tres Mucor spp. Todos los pacientes recibieron un tratamiento inicial con anfotericina B deoxicolato, que en tres de ellos fue continuado con anfotericina B liposomal, y cirugía. Tres enfermos recibieron además un tratamiento adyuvante con oxigeno hiperbárico. La mortalidad fue 30%.

Mucormycosis is an opportunistic infection caused by fungi of the order Mucorales. It is characterized by rapid progression and high morbidity and mortality in the absence of early diagnosis and prompt treatment. It was an infrequent disease, but in recent years, its incidence appears to have increased. The aim of this paper is to report the cases of mucormycosis diagnosed from 1982 to 2010 at the Hospital de Clinicas José de San Martín, University of Buenos Aires. We diagnosed 10 cases of mucormycosis; the first three between 1982 and 2004 and the last 7 between 2005 and 2010. The incidence from 1980 to 2004 was 0.13 patient-years and the frequency 0.1/10 000 discharges (95% CI 0.00- 0.3). In the period 2005 to 2010, the incidence was 0.86 patients per year with 1.1/10 000 discharges (95% CI 0.5-2.4). There was a pulmonary mucormycosis case (in a patient treated with corticosteroids) and nine rhinocerebral cases, two in neutropenic and seven in diabetic patients. The diagnosis was made by observation of cenocytic hyphae in 10/10 patients. Mucorales were recovered in 8/9 cultures (5 Rhizopus spp and 3 Mucor spp.). In one case diagnosis of pulmonary mucormycosis was made post-mortem. Nine patients were treated with amphotericin B deoxycholate (in 3 patients supplemented with liposomal amphotericin B) and surgery. Three patients underwent hyperbaric chamber. Seven patients had favorable outcome. In conclusion, mucormycosis is a rare disease, but its incidence has increased over the past five years. A good evolution of the patients is linked to early diagnosis and treatment.

Invasive aspergillosis involving multiple paranasal sinuses--a case report.

A case of invasive multiple paranasal sinus aspergillosis with bony involvement is reported. A young immunocompetent lady presented with bilateral nasal obstruction due to polyps. Radiologically and histopathologically a fungal cause was kept a possibility, and the diagnosis of Aspegillus fumigatus was established by demonstration of acute angle branching septate hyphae on direct wet mount and repeated isolation in culture. Patient responded favourably to surgical excision of polyps and oral itraconazole post operatively.

Mucormicosis. Reporte de tres casos / Mucormycosis. Report of 3 cases

Mucormycosis is an acute and often fatal infection caused by a fungus of the Mucorales order of the Zygomycetes class. There are various clinical types, usually associated with an underlying disorder. The rhinocerebral mucormycosis is usually seen in diabetics, especially in ketoacidosis, but may also appear in healthy people. We report three cases of mucormycosis diagnosed since april 1987 through january 2001 at the Dr. Domingo Luciani Hospital, Caracas, Venezuela. Two of them had diabetes and one was apparently healthy. The most common clinical presentation of mucormycosis was the rhinocerebral infection, seen in the two diabetic patients, both of them had cavernous sinus thrombosis one with involvement of the carotid artery. The other patient with sinus involvement had no predisposing factors. All patients were treated with amphotericin B and two of them had surgical debridement of involved tissue. We emphasize the importance of an early clinical diagnosis and treatment with surgical debridement of infected tissue combined with amphotericin B.

Doença nasossinusal em pacientes HIV positivos / Naso-sinus sickness in HIV positive patients

A doença nasossinusal é extremamente prevalente em pacientes com sorologia positiva para o vírus da imunodeficiência humana (HIV +), por isso a necessidade de que muitos estudos sejam realizados sobre esta doença, principalmente com o advento das novas drogas anti-retrovirais. Foi realizado um estudo de revisão bibliográfica buscando razões para justificar esta alta prevalência, sendo determinada a alteração da imunidade humoral e celular, distúrbios da mobilidade ciliar e alterações anatômicas prévias como fatores etiológicos. Verificou-se que o diagnóstico é eminentemente clínico e a conduta terapêutica inicial é semelhante a da população não infectada. Nestes pacientes se faz necessário um acompanhamento mais criterioso e atenção especial deve ser dada ao nível de linfócitos T helper (CD4), pois tem se verificado casos de dificil manejo terapêutico e aparecimento de complicações nasossinusais em pacientes com níveis de células CD4 abaixo de 200 por milímetro cúbico(mm3). Os autores relatam que a ausência de resposta ao tratamento clínico após punção, lavagem e cultura da secreção dos seios maxilares determina a indicação do tratamento cirúrgico que, na maioria dos casos, melhora a qualidade de vida destes pacientes.

Paranasal sinus mycoses.

The incidence of paranasal sinus mycoses (fungal sinusitis) varies widely with higher frequency in Sudan, southwestern states of USA and north India, which have hot and dry climate. The disease has been described as having four types: allergic, non-invasive, invasive and fulminate. A possible fifth type: non-invasive destructive may also exist. In a prospective study of 176 cases of fungal sinusitis from our centre, on the basis of clinical, radiological, histopathologic and mycologic findings the patients could be categorized into: allergic (12), non-invasive without bone destruction (81), non-invasive destructive (16), chronic invasive (55) and fulminant (12) types. Except the fulminate variety, the disease is commonly found in young immuno-competent population of rural areas. Aspergillus spp. are the commonest etiological agents though the importance of dematiaceous fungi in allergic fungal sinusitis has been stressed. Zygomycetes are common agents in fulminate type. In our series A. flavus (80%) was the commonest isolate, followed by A.fumigatus (9.7%), Rhizopus arrhizus (6.3%) and Alternaria spp. (1.1%). Curvularia lunata, Apophysomyces elegans and Candida albicans were isolated from one patient each. Different host and environmental factors may help in lodging the causal fungi in mucosal plugs of these patients. Fungal allergy is associated with all varieties of the disease. But it is not clear what determines the invasion of mucosa. Rabbit can be used as an animal model. Histopathology and radio-imaging techniques help to distinguish different types and delineate extension of disease process. Culture helps to identify the responsible etiological agent. The presence or absence of precipitating antibody correlates well with disease progression or recovery. For effective management, non-invasive disease requires surgical debridement and sinus ventilation only. But for invasive type the need of adjuvant medical therapy is recommended to prevent recurrence and further extension. Itraconazole was found to be most useful in our study to prevent recurrence. Patients with fulminate type require radical surgery and immediate chemotherapy.