Diagnóstico y manejo en primer nivel de atención de preeclampsia posparto de inicio tardío. Reporte de caso / Diagnosis and management of late-onset postpartum preeclampsia at the first level of care. Case report

Introducción: La hipertensión postparto de inicio tardío se presenta desde las 48 horas hasta las 6 semanas postparto, afectando al 2% de los embarazos relacionados o no con antecedentes de hipertensión gestacional. La preeclampsia posparto tiene una incidencia del 5,7% a las 72 horas del parto y está asociada a varios factores maternos como la edad (≥ 35 años), etnia (negra) y obesidad (IMC ≥ 30), presentando mayor riesgo en embarazos múltiples, madres añosas (mayores de 35 años) hogares con bajos ingresos económicos. Los síntomas más frecuentes de esta patología son cefalea, disnea, trastornos visuales y edema periférico.Objetivo: Describir la experiencia en un centro de salud de atención primaria, el manejo de una paciente diagnosticada de preeclampsia posparto de inicio tardío, así como las caracte-rísticas clínicas y factores de riesgo.Presentación del caso: Se presenta el caso de una paciente indígena de 32 años con antece-dente de parto gemelar quien en su control del puerperio a las 72 horas presentó hipertensión arterial, cefalea frontal, edema periférico y proteinuria estableciéndose el diagnóstico de pree-clampsia posparto de inicio tardío. No fue posible la referencia a un segundo nivel de atención por las características culturales de la paciente por lo cual recibió manejo clínico y tratamiento en el primer nivel de atención presentando una evolución favorable sin complicaciones. Conclusiones y recomendaciones: La hipertensión posparto de inicio tardío es una patolo-gía poco frecuente en el puerperio, infradiagnosticada, con complicaciones cardiovasculares a corto y largo plazo, por lo cual su diagnóstico, diferenciación y manejo debe ser óptimo en base a las recomendaciones existentes.

Introduction: Late-onset postpartum hypertension occurs from 48 hours to 6 weeks pos-tpartum, affecting 2% of pregnancies related or not to a history of gestational hypertension. Postpartum preeclampsia has an incidence of 5.7% at 72 hours postpartum and is associa-ted with several maternal factors such as age (≥ 35 years), ethnicity (black) and obesity (BMI ≥ 30), presenting higher risk in multiple pregnancies, elderly mothers (older than 35 years) low-income households. The most frequent symptoms of this pathology are headache, dysp-nea, visual disturbances and peripheral edema.Objective: To describe the experience in a primary care health center, the management of a patient diagnosed with late-onset postpartum preeclampsia, as well as the clinical characte-ristics and risk factors.Case presentation: We present the case of a 32-year-old indigenous patient with a history of twin birth who in her puerperium control at 72 hours presented arterial hypertension, frontal headache, peripheral edema and proteinuria establishing the diagnosis of late-onset pos-tpartum preeclampsia, after which treatment was initiated at the first level of care, making referral difficult due to cultural characteristics. Conclusions and recomendations: Late-onset postpartum hypertension is an infrequent pathology in the puerperium, underdiagnosed, with short and long-term cardiovascular com-plications, so its diagnosis, differentiation and management should be optimal based on existing recommendations

A case of late-onset capsular block syndrome and its surgical treatment / Um caso de síndrome de bloqueio capsular tardio e uma abordagem cirúrgica

ABSTRACT - Capsular block syndrome is a rare complication of phacoemulsification surgery with continuous curvilinear capsulorhexis and intraocular lens implantation. Here, we report a case of very late-onset capsular block syndrome that developed 13 years after cataract extraction and present the surgical approach used for its successful treatment.

RESUMO - Síndrome do bloqueio capsular é uma complicação incomum da cirurgia de facoemulsificação com capsulorrexis curvilínea contínua e implante de lente intraocular. Nós relatamos um caso de síndrome de bloqueio capsular de início tardio que se desenvolveu após 13 anos da extração da catarata e apresenta a abordagem cirúrgica utilizada para o sucesso do tratamento.

Association of anti-nuclesome and anti C1q antibodies with lupus nephritis in an Egyptian cohort of patients with systemic lupus erythematosus

Abstract Introduction: Anti-nucleosome and anti-C1q antibodies demonstrated an association with the development of glomerulonephritis in systemic lupus erythematosus (SLE). Some investigators have proposed that monitoring anti- C1q and anti-nucleosome antibodies might be valuable for making predictions about lupus nephritis (LN) and assessment of disease activity as a non-invasive biological marker of renal disease. Objectives: The current study was proposed to investigate the presence of anti-C1q and anti-nucleosome antibodies in the sera of Egyptian patients with SLE and their association with LN. Methods: Eighty patients with SLE were included. Patients were classified into, a LN group including 40 cases with active LN (based on the results of renal biopsy and renal SLEDAI≥4) and a non renal SLE group including 40 patients (with no clinical or laboratory evidence of renal involvement that were attributed in the past or present to SLE). They were subjected to full medical history taking, clinical examination, routine laboratory investigations, measurement of antinuclear antibody (ANA), anti-ds DNA, anti-C1q & anti-nucleosome antibodies. Results: Anti-C1q antibody showed a statistically significant association with the presence of vasculitis and nephritis while anti-nucleosome antibody didn't show a significant association with the presence of any clinical features. Double positivity of anti-nucleosome and anti-C1q antibodies showed a statistically significant association with the presence of vasculitis and photosensitivity, high ECLAM score, elevated ESR, low serum albumin and low C3 levels. Conclusion: Serum anti-C1q antibody has a significant association with LN while double positive antibodies have a significant association with vasculitis and low C3 levels in Egyptian patients with SLE.

Sleep quality and new onset postpartum hypertension

Background: Chronic sleep deficiency is a stressful situation which has an association with high blood pressure. After delivery, mothers have disrupted sleep due to frequent awakenings by their infants. What is not known is how significant this relationship is in women during the postpartum period as well as other factors that may affect their Sleep quality. Sleep quality is a measure of duration and disruption. Aim and Objectives: Study is aimed at determining the relationship between Sleep quality and new onset postpartum hypertension. The specific objectives are; to determine the Sleep quality of mothers in the postpartum period using the Pittsburgh Sleep quality index (PSQI), identify factors that affect Sleep quality of mothers in the post-partum period and determine blood pressure patterns of mothers in the postpartum period. Materials and Methods: This was a longitudinal study. Using systematic random sampling, a sample size of 126 women were recruited between June and August 2016 in the Postnatal clinic of the 37 Military Hospital. Written consent was obtained from participants. Sitting blood pressure was checked and recorded and a modified form of the Pittsburgh Sleep quality index (PSQI) was used to assign a global score for Sleep quality. A global score of more than 5 indicated poor Sleep quality in that mother. Clients were first recruited at the 1st postnatal visit with follow-up at the 2nd routine postnatal visit (6weeks). Only mothers whose blood pressures were normal during pregnancy and upon discharge from hospital were included. For categorical data, Pearson's chisquare test was used for comparisons and logistic regression as used to determine significant factors that contribute to new onset hypertension in postpartum women. A P-value less than 0.05 was considered significant. Results: Majority of mothers (92.1% and 90.5% at first and second visits respectively) had poor Sleep quality. Mothers who slept away from their babies at the sixth week visit had better sleep. Mean global Sleep quality scores had no significant association with new onset hypertension but mean scores of some Age , p=0.001, OR =1.20 (C.I: 1.09-1.32) and some sleep components sleep disturbance, p=0.041, OR =1.86(C.I: 1.02-3.37), and use of sleep medicine, p=0.031, OR =1.54 (C.I:1.04- 2.29) were significantly associated with new onset postpartum hypertension. Conclusion: Global poor Sleep quality is not associated with increased odds of new onset hypertension but the Sleep quality components, sleep disturbance and increased use of sleep medicine, were significantly associated with new onset hypertension in mothers

Recognizing Late Onset Frontotemporal Dementia with the DAPHNE scale: A case report / Reconhecendo a demência frontotemporal de início tardio com a escala daphne: um relato de caso

ABSTRACT Frontotemporal dementias are classically described as early onset dementias with personality and behavioral changes, however, late onset forms can also be found. Considering the paucity of information about late onset behavioral variant frontotemporal dementia and its challenging diagnosis, we present a case report of an 85-year-old woman with behavioral changes and slow progression to dementia who was first diagnosed as having bipolar disorder and then Alzheimer's disease. The Daphne scale provided a structured means to improve clinical diagnosis, also supported by characteristic features on MRI and SPECT, while CSF biomarkers ruled out atypical Alzheimer's disease.

RESUMO As demências frontotemporais são classicamente descritas como demências de início precoce com mudanças de personalidade e comportamento, porém as formas de início tardio também podem ser encontradas. Considerando a escassez de informações sobre a demência frontotemporal - variante comportamental de início tardio e o diagnóstico desafiador, apresentamos um relato de caso de uma mulher de 85 anos com alterações comportamentais e progressão lenta para demência que foi diagnosticada pela primeira vez com transtorno bipolar e, em seguida, doença de Alzheimer. A escala DAPHNE foi utilizada permitindo a estruturação das características clínicas, aumentando a precisão do diagnóstico clínico, apoiado por características em RM e SPECT, enquanto os biomarcadores no líquor descartaram a doença de Alzheimer.

Associations of Cerebrovascular Metabolism Genotypes With Neuropsychiatric Symptoms and Age at Onset of Alzheimer's Disease Dementia

Objective: To study associations of cerebrovascular metabolism genotypes and haplotypes with age at Alzheimer’s disease dementia (AD) onset and with neuropsychiatric symptoms according to each dementia stage. Methods: Consecutive outpatients with late-onset AD were assessed for age at dementia onset and Neuropsychiatric Inventory scores according to Clinical Dementia Rating scores, apolipoprotein E gene (APOE) haplotypes, angiotensin-converting enzyme gene (ACE) variants rs1800764 and rs4291, low-density lipoprotein cholesterol receptor gene (LDLR) variants rs11669576 and rs5930, cholesteryl ester transfer protein gene (CETP) variants I422V and TaqIB, and liver X receptor beta gene (NR1H2) polymorphism rs2695121. Results: Considering 201 patients, only APOE-ɛ4 carriers had earlier dementia onset in multiple correlations, as well as less apathy, more delusions, and more aberrant motor behavior. Both ACE polymorphisms were associated with less intense frontally mediated behaviors. Regarding LDLR variants, carriers of the A allele of rs11669576 had less anxiety and more aberrant motor behavior, whereas carriers of the A allele of rs5930 had less delusions, less anxiety, more apathy, and more irritability. CETP variants that included G alleles of I422V and TaqIB were mostly associated with less intense frontally mediated behaviors, while severely impaired carriers of the T allele of rs2695121 had more anxiety and more aberrant motor behavior. Conclusion: Though only APOE haplotypes affected AD onset, cerebrovascular metabolism genotypes were associated with differences in several neuropsychiatric manifestations of AD.

Late-onset MELAS with Chronic Kidney Disease

Mitochondrial encephalomyopathy with lactic acid and stroke-like episodes (MELAS) is a multisystem mitochondrial disorder that typically presents in childhood. We report a case of MELAS syndrome diagnosed in a 45-year-old man presented with chronic kidney disease before a stroke-like episode. Genetic testing revealed a m.3243A>G point mutation in the mtDNA. The original diagnostic criteria for MELAS required the onset of stroke-like episodes prior to 40 years of age but this case demonstrates that disease onset may delay in certain individuals.

Clinical and pathological challenges in the diagnosis of late-onset biliary atresia: four case studies

Biliary atresia (BA) is classically described at the neonatal age. However, rare cases of BA in older infants have also been reported. We report four cases of late-onset BA in infants older than 4 weeks (3 males, 1 female), and describe the diagnostic and management difficulties. One of the cases had a late-onset (29 weeks) presentation with a successful surgical procedure. We highlight the importance of this unusual differential diagnosis in infants with cholestatic syndrome, who may benefit from Kasai surgery, regardless of age.

The Clinical Usefulness of Beta-Amyloid Positron Emission Tomography Imaging in the Elderly Patients: Case Series & Brief Review

The aim was to evaluate the diagnostic utility of beta-amyloid positron emission tomography (PET) in elderly patients with cognitive impairment in the clinical setting. Five subjects underwent beta-amyloid PET imaging to explore the cerebral beta-amyloid deposition. The two male patients with minor neurocognitive disorder due to Alzheimer's disease, who displayed similar degree of cognitive impairment and medial temporal atrophy but different in apolipoprotein E4 status, both showed negative for beta-amyloid PET. On the other hand, a female major neurocognitive disorder due to probable Alzheimer's disease patient was tested positive for beta-amyloid PET, with increased beta-amyloid density in frontal and parietal lobes. Beta-amyloid PET was also used for the differential diagnosis of neurocognitive disorder from other psychiatric disorders in two elderly patients. The results were negative but assisted the diagnositic confirmation. A female patient was determined to be a case of late-onset schizophrenia and a male patient was determined as delirium due to minor traumatic brain injury, persistent. Beta-amyloid PET imaging was able to demonstrate cerebral beta-amyloid deposition in major neurocognitive disorder due to probable Alzheimer's disease in visual scale. However, further studies are needed for its clinical utility in the minor neurocognitive disorders. Moreover, beta-amyloid PET imaging may provide additional information in diagnosing primary psychiatric disorders with new onset in the old age.

Clinical characteristics and influence of childhood trauma on the prodrome of bipolar disorder

Objectives: To describe the onset pattern, frequency, and severity of the signs and symptoms of the prodrome of the first hypomanic/manic episode and first depressive episode of bipolar disorder (BD) and to investigate the influence of a history of childhood maltreatment on the expression of prodromal symptoms. Methods: Using a semi-structured interview, the Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R), information regarding prodromal symptoms was assessed from patients with a DSM-IV diagnosis of BD. History of childhood maltreatment was evaluated using the Childhood Trauma Questionnaire (CTQ). Results: Forty-three individuals with stable BD were included. On average, the prodrome of mania lasted 35.8±68.7 months and was predominantly subacute or insidious, with rare acute presentations. The prodrome of depression lasted 16.6±23.3 months and was also predominantly subacute or insidious, with few acute presentations. The prodromal symptoms most frequently reported prior to the first hypomanic or manic episode were mood lability, depressive mood, and impatience. A history of childhood abuse and neglect was reported by 81.4% of participants. Presence of childhood maltreatment was positively associated with prodromal symptoms, including social withdrawal, decreased functioning, and anhedonia. Conclusions: This study provides evidence of a long-lasting, symptomatic prodrome prior to first hypomanic/manic and depressive episode in BD and suggests that a history of childhood maltreatment influences the manifestations of this prodrome.

Onset of psychosis at age 81? With regard to frontal lobe syndromes / Psicose inaugural aos 81 anos? A propósito das síndromes do lobo frontal

When the frontal lobe of the brain is affected important behavioral changes may occur mainly at the level of executive functioning, i.e., planning, decision-making, judgment and self-perception. However, the behavioral changes may be of different nature with marked indifference and apathy. We report a clinical case of an 81-year-old patient with sudden onset of behavioral changes that were initially interpreted as an acute confusional episode of infectious etiology, but actually they were due to an ischemic lesion in the frontal lobe.

O lobo frontal, quando afetado, pode provocar alterações importantes do comportamento, principalmente na função executiva: planejamento, tomada de decisões, juízo e autopercepção. Contudo, as alterações podem ser de outra natureza, caracterizando-se por marcada indiferença e apatia. É relatado aqui o caso de uma paciente de 81 anos, com alterações súbitas do comportamento, que foram interpretadas inicialmente como um quadro confusional agudo de natureza infecciosa, mas que se mostraram provocadas por uma lesão isquêmica na região frontal.

Adult presentation of Bartter syndrome type IV with erythrocytosis / Apresentação tardia de síndrome de Bartter tipo IV com eritrocitose

Abstract Bartter syndrome comprises a group of rare autosomal-recessive salt-losing disorders with distinct phenotypes, but one unifying pathophysiology consisting of severe reductions of sodium reabsorption caused by mutations in five genes expressed in the thick ascending limb of Henle, coupled with increased urinary excretion of potassium and hydrogen, which leads to hypokalemic alkalosis. Bartter syndrome type IV, caused by loss-of-function mutations in barttin, a subunit of chloride channel CLC-Kb expressed in the kidney and inner ear, usually occurs in the antenatal-neonatal period. We report an unusual case of late onset presentation of Bartter syndrome IV and mild phenotype in a 20 years-old man who had hypokalemia, deafness, secondary hyperparathyroidism and erythrocytosis.

Resumo A síndrome de Bartter compreende um grupo raro de doenças autossômicas recessivas perdedoras de sal, decorrentes de mutações em genes expressos na porção ascendente espessa da alça de Henle, com fenótipos distintos, porém fisiopatogenia única, que consiste em redução severa da reabsorção de sódio, e aumento da excreção urinária de hidrogênio e potássio, levando à alcalose hipocalêmica. A síndrome de Bartter tipo IV, causada por mutações com perda de função da bartina, uma subunidade do canal de cloro CLC-Kb expressa no rim e ouvido interno, geralmente se apresenta nos períodos ante e neonatal. No presente relato, descreve-se um caso não usual de síndrome de Bartter tipo IV com apresentação tardia e fenótipo atenuado, diagnosticado por análise molecular, em um homem adulto de 20 anos que se apresentava com hipocalemia, surdez, hiperparatireoidismo secundário e eritrocitose.

Late complication of a renal calculus: fistulisation to the psoas muscle, skin and bronchi

ABSTRACTKidney disease presenting with cutaneous fistula is a rare condition. We present a case of a 90-year-old woman with dementia who had no prior urological problems and had a cutaneous fistula in the left lumbar region. A fistulogram and computer tomography examination revealed a large staghorn calculus with signs of xanthogranulomatous pyelonephritis in the left kidney and renal fistulisation to the psoas muscle, skin and bronchi. To our knowledge this is the first report in the literature of coexisting renal fistulisation to the psoas major muscle, skin and bronchi. This report illustrates how computed tomography in combination with fistulography can resolve the diagnostic dilemma that pertains to the complex spread of the disease in cases involving nephrocutaneous fistula. Furthermore, the report shows how a renal calculus, even asymptomatic, can cause a serious medical condition, and highlights the importance of early medical intervention.

Lupus eritematoso sistémico de inicio tardío / Late-onset systemic lupus erythemathosus

El lupus de inicio tardío ha sido definido en diversos estudios como aquel que se presenta después de los 50 años y se manifiesta entre un 6% y un 18% de los pacientes lúpicos. De acuerdo con la literatura las manifestaciones clínicas más frecuentes son la enfermedad pulmonar intersticial, la serositis y el síndrome de Sjögren. Su diagnóstico puede retrasarse debido a su inicio insidioso, baja prevalencia, manifestaciones atípicas al comienzo de la enfermedad y su similitud con otras entidades. Aunque la actividad de la enfermedad es menor en estos pacientes, esta población acumula más daño y tiene una mayor mortalidad que los pacientes con lupus de inicio temprano. Por lo tanto, el LES de inicio tardío no debe considerarse como una enfermedad de comportamiento benigno.

Late-onset lupus has been defined in different studies as onset of lupus after age 50 and constitutes 6-18% of the lupus population. According to literature the most common clinical features are interstitial lung disease, serositis and Sjögren´s syndrome. An insidious onset, low prevalence, non-specific manifestations at the beginning of the disease and similarity to other common disorders may delay its diagnosis. Although disease activity tends o be lower in these patients, they tend to accrue more damage and experience higher mortality than patients with early-onset lupus. Thus, late-onset SLE should not be considered as a benign disease.