[From Vegetative State to Participation: Amantadine As a Trigger of the Rehabilitation Program]. / Do Estado Vegetativo à Participação: A Amantadina Como Potenciadora do Programa de Reabilitação.

The use of amantadine in clinical practice still seems limited, despite its increasing evidence in the emergence of vegetative state after traumatic brain injury. We describe the case of an adolescent with severe traumatic brain injury after being run over by a car. After four months of hospitalization in a Central Hospital where he remained in a vegetative state, he was transferred to a Rehabilitation Center. He underwent a comprehensive rehabilitation program with physiotherapy, occupational therapy and speech therapy, including multisensory stimulation and intervention in the surrounding environment. He started amantadine, 50 mg/day, titrated up to 200 mg/day, with significant clinical and functional improvements, and emerged from vegetative state to minimally conscious state at week three and recovered consciousness at the sixth week of amantadine, maintaining progressive improvement, even after drug suspension. The case described underlines the importance of a holistic intervention and corroborates the literature in demonstrating the efficacy and safety of amantadine in the emergence from vegetative state.

A utilização da amantadina na prática clínica ainda parece pouco difundida, apesar da evidência crescente na emergência de alterações do estado de consciência após traumatismo cranioencefálico. Descrevemos o caso de um adolescente com traumatismo cranioencefálico grave por atropelamento. Após quatro meses de internamento num hospital central onde se manteve em estado vegetativo foi transferido para um centro de reabilitação. Iniciou um programa de reabilitação integral liderado por equipa médica, incluindo estimulação multissensorial e intervenção no meio envolvente. Iniciou amantadina, 50 mg/dia, titulada até 200 mg/dia, verificando-se melhoria clínica e funcional significativas, com emergência para estado de consciência mínima à terceira semana e recuperação da consciência à sexta semana de amantadina. Manteve melhoria progressiva mesmo após suspensão do fármaco. O caso descrito salienta a importância da intervenção holística e corrobora a literatura ao demonstrar a eficácia e segurança da amantadina na emergência do estado vegetativo.

Pneumococcal pneumonia vaccine breakthroughs and failures after 13-valent pneumococcal conjugated vaccine.

The rate of invasive pneumococcal disease has markedly declined after the introduction of pneumococcal conjugated vaccines. In spite of the high effectiveness of this vaccine, there are some reports of vaccine failure and vaccine breakthroughs. Data on children with pneumococcal pneumonia in a European tertiary Hospital, from 2012 to 2014, were retrospectively collected before the implementation of pneumococcal conjugated vaccines in our country. We found four cases of pneumococcal serotype 3 vaccine failure and three cases of vaccine breakthroughs (two with serotype 3 and one with serotype 19A). All of these children were previously healthy.

Spontaneous Pneumothorax With Subcutaneous Emphysema: A Rare Complication of Respiratory Syncytial Virus Infection.

Viral bronchiolitis is the most common lower respiratory tract infection in infants and children under the age of 2. Respiratory syncytial virus (RSV) is the infecting agent in more than 50% of the cases. Usually the clinical course is uneventful and complications are uncommon. Secondary air leaks are a recognized rare complication of bronchiolitis, although the real incidence remains unknown. We report a case of a 21-month-old female that developed a spontaneous pneumothorax (PNO) with subcutaneous emphysema (SE) late in the course of RSV acute bronchiolitis. Additional investigation ruled out any underlying disease predisposing to spontaneous PNO. Physicians, especially those who work with small children, must be aware of this uncommon complication of bronchiolitis that may appear late in the course of the disease despite an initial clinical improvement.

Sydenham's chorea in a family with Huntington's disease: case report and review of the literature.

CONTEXT: Sydenham's chorea affects almost 30% of patients with acute rheumatic fever. It is more frequent in females and is rare in the first decade of life, and genetic vulnerability underlies it. Because of easy access to antibiotics, it is now rare in so-called developed countries. CASE REPORT: A 6-year-old boy with a family history of Huntington's disease, who was the only child of an unscreened and asymptomatic mother, was brought for a consultation because of migratory arthralgia, depressed mood, and rapid, abrupt and unintentional movements of his right arm and leg, that had evolved over a three-week period. On physical examination, he presented a grade III/VI systolic heart murmur and right-side choreic movements, giving rise to a deficit of active mobilization. Laboratory tests revealed elevated erythrocyte sedimentation rate (63 mm/h), C-reactive protein (25 mg/l) and antistreptolysin O titer (1,824 U/ml). Cardiovascular evaluation showed mild aortic insufficiency, moderate mitral insufficiency and a prolonged PR interval. A clinical diagnosis of Sydenham's chorea/acute rheumatic fever was made, and therapy consisting of penicillin, haloperidol, captopril and furosemide was instituted, with excellent results. CONCLUSION: In developed countries, Sydenham's chorea seems forgotten and, because of this, little is known about its clinical course and controversy surrounds the therapeutic options available. This occurrence of rheumatic chorea in a family with Huntington's disease highlights the importance of the differential diagnosis for the different forms of chorea.

Sydenham's chorea in a family with Huntington's disease: case report and review of the literature / Coreia de Sydenham numa família com doença de Huntington: relato de caso e revisão da literatura

CONTEXT: Sydenham's chorea affects almost 30 percent of patients with acute rheumatic fever. It is more frequent in females and is rare in the first decade of life, and genetic vulnerability underlies it. Because of easy access to antibiotics, it is now rare in so-called developed countries. CASE REPORT: A 6-year-old boy with a family history of Huntington's disease, who was the only child of an unscreened and asymptomatic mother, was brought for a consultation because of migratory arthralgia, depressed mood, and rapid, abrupt and unintentional movements of his right arm and leg, that had evolved over a three-week period. On physical examination, he presented a grade III/VI systolic heart murmur and right-side choreic movements, giving rise to a deficit of active mobilization. Laboratory tests revealed elevated erythrocyte sedimentation rate (63 mm/h), C-reactive protein (25 mg/l) and antistreptolysin O titer (1,824 U/ml). Cardiovascular evaluation showed mild aortic insufficiency, moderate mitral insufficiency and a prolonged PR interval. A clinical diagnosis of Sydenham's chorea/acute rheumatic fever was made, and therapy consisting of penicillin, haloperidol, captopril and furosemide was instituted, with excellent results. CONCLUSION: In developed countries, Sydenham's chorea seems forgotten and, because of this, little is known about its clinical course and controversy surrounds the therapeutic options available. This occurrence of rheumatic chorea in a family with Huntington's disease highlights the importance of the differential diagnosis for the different forms of chorea.

CONTEXTO: A coreia de Sydenham surge em cerca de 30 por cento dos casos de febre reumática aguda. É mais frequente no sexo feminino, é rara na primeira década de vida e tem por base uma vulnerabilidade genética. Devido ao fácil acesso aos antibióticos, é uma doença rara atualmente nos países ditos desenvolvidos. RELATO DO CASO: Criança de seis anos, sexo masculino, com história familiar de coreia de Huntington, único filho de mãe assintomática e não rastreada, foi trazido à consulta por artralgias migratórias, humor deprimido e movimentos rápidos, abruptos e não intencionais dos membros superior e inferior direitos, com três semanas de evolução. Ao exame físico, apresentava um sopro cardíaco sistólico grau III/VI, e foram presenciados movimentos coreicos à direita, condicionando um défice de mobilização activa. Os exames laboratoriais mostraram aumento da velocidade de sedimentação (63 mm/h), proteína C-reativa (25 mg/L) e título de antiestreptolisina O (1.824 U/mL). O exame cardiovascular revelou insuficiência aórtica ligeira e insuficiência mitral moderada e aumento do intervalo PR. Foi feito o diagnóstico de coreia de Sydenham/febre reumática aguda, tendo sido instituída terapêutica com penicilina, haloperidol, captopril e furosemida, com excelente resultado. CONCLUSÃO: Nos países desenvolvidos, a coreia de Sydenham parece esquecida e, por isso, pouco se sabe quanto ao seu curso clínico e as opções terapêuticas disponíveis são controversas. A ocorrência de um caso de coreia reumática numa família com doença de Huntington realça a importância do diagnóstico diferencial das diferentes formas de coreia.