Granulomatosis With Polyangiitis: The Complexity of Clinical Manifestations, Therapeutic Challenges, and Complications of a Severe Multisystemic Case.

We report a case of a 34-year-old male with severe multisystemic involvement (including the testis, musculoskeletal system, skin, upper respiratory tract, ocular system, peripheral nerves, abdomen, and kidney) due to granulomatosis with polyangiitis (GPA) and a high proteinase 3 (PR3)-antineutrophil cytoplasmic antibodies (PR3ANCA) titer. A renal biopsy showed pauci-immune glomerulonephritis (GN). Systemic corticotherapy combined with cyclophosphamide was chosen for induction therapy. During the induction phase, clinical deterioration occurred in the form of severe alveolar hemorrhage, leading to admission to the intensive care unit (ICU). Influenza A (H1N1) was detected in the respiratory tract. Furthermore, blood sampling revealed an invasive Klebsiella pneumoniae infection that persisted despite multiple antibiotic regimens. A CT scan showed splenic vascular compromise, assumed to be the primary source of the infection, with sustained improvement after splenectomy. Maintenance therapy included a tapering dose of corticotherapy for 36 months and azathioprine 100mg daily for five years, which achieved full and sustained remission. The patient has been in full remission for nine years, with mild renal sequelae, including proteinuria and secondary hypertension.

Attachment and Depressive Symptoms in Adolescence: The Mediatory Role of Emotion Awareness.

Attachment seems to influence depression through emotion regulation. However, no study has yet examined the mediatory role of emotion awareness, a particular subset of emotion regulation abilities, in the relationship between attachment and depressive problems in early and middle adolescence. The aim of this study is to examine the direct and indirect effects of attachment on depressive symptoms in adolescence, considering the mediatory role of emotion awareness dimensions. A sample of adolescents (n = 223) filled up self-report questionnaires on attachment, emotion awareness and depression. Serial mediation models suggest direct effects on depression: negative for secure attachment and positive for anxious/ambivalent attachment. Anxious/ambivalent attachment has a positive indirect effect through lower differentiation of emotions. Both secure and anxious/ambivalent attachment have indirect positive effects on depression through the sequence of bodily unawareness and differentiation of emotions. Differentiating emotions has a central role in mediating the relationship between attachment and depressive symptoms, and the lack of bodily awareness of emotions contributes to such mediation.

Synchronous Neoplasms of the Small Bowel: A Diagnostic Challenge.

Small bowel tumours are rare, representing about 0.5% of all tumours and about 3% of gastrointestinal tract tumours. The low prevalence contrasts with the vast surface area of the small intestine, which accounts for over 90% of the surface area of the digestive tract. The frequency of small tumours decreases from proximal to distal, and therefore from the duodenum to the ileum. The histological types differ in terms of prevalence according to the affected segment, with adenocarcinoma being the most frequent in the duodenum and jejunum and carcinoid tumour in the ileum. Diagnosis is challenging due to clinical non-specificity, low prevalence and a low level of suspicion. Schwannomas are typically benign tumours that arise from Schwann's cells and are rarely found in the small intestine. It is even more rare to find them together with another histological type, namely adenocarcinoma. No cases have been reported in the literature of these lesions occurring in the small intestine simultaneously. Further studies are needed to clarify the underlying pathophysiology of these synchronous tumours. The authors present the case of an 86-year-old female patient admitted for high intestinal subocclusion, with refractory vomiting and involuntary weight loss. Two synchronous lesions in the digestive tract were identified: an adenocarcinoma in the duodenum and a schwannoma in the ileum. The patient underwent surgical resection of both lesions. A high level of suspicion combined with a multidisciplinary approach is necessary for timely diagnosis and surgical resolution. LEARNING POINTS: Small bowel neoplasms are rare and clinically non-specific; in addition, diagnosis is difficult due to imaging artifacts and tumour inaccessibility for biopsy for definitive histological diagnosis.Gastrointestinal schwannomas are rare and the pathophysiology of synchrony with other histological subtypes remains to be clarified.A multidisciplinary approach from the beginning is important for a timely diagnosis and better outcome.

McKittrick-Wheelock Syndrome: A Neoplastic Cause of Electrolyte Imbalance.

The authors present the case of a 79-year-old woman who presented with chronic secretory diarrhoea and severe electrolyte imbalance. A large rectal tubulovillous adenoma was discovered, leading to surgical resection of the tumour with complete resolution of the diarrhoea and electrolyte imbalance. The diagnosis of McKittrick-Wheelock syndrome was made. We hope this case report will contribute to a greater awareness among health professionals about this clinical condition. A multidisciplinary approach is essential for the best outcome. LEARNING POINTS: McKittrick-Wheelock syndrome is an important differential diagnosis in patients presenting with electrolyte abnormalities and secretory diarrhoea.A multidisciplinary approach from the beginning is important for a timely diagnosis and better outcome.Surgical removal of the hypersecretory villous adenoma is the definitive treatment for McKittrick-Wheelock syndrome and can be life-saving.

Avaliação da qualidade da informação de sites sobre Covid-19: uma alternativa de combate às fake news / Assessment of the quality of information on Covid-19 websites: an alternative for combating fake news

RESUMO As tecnologias de informação e comunicação têm-se disseminado globalmente. Elas estão cada vez mais presentes em quase todos os aspectos da vida humana, incluindo a saúde. Em meio à ampla disseminação de informações falsas, a questão da qualidade da informação tem assumido grande importância, especialmente em contexto de pandemia. Entre julho e agosto de 2020, foi realizada uma avaliação da qualidade da informação em sites sobre Covid-19 de quatro secretarias de saúde do estado de Mato Grosso do Sul. Essa avaliação participativa utilizou cinco critérios, acompanhando a literatura internacional, a saber: Técnico, Interatividade, Abrangência, Legibilidade e Acurácia, subdivididos em 46 indicadores. Os resultados apontam que os sites avaliados apresentaram baixo grau de conformidade com os indicadores e critérios utilizados e não divulgam as principais evidências científicas sobre o tema, disponíveis no site do Ministério da Saúde. A pandemia de Covid-19 tem sido marcada pela alta circulação de fake news. Nesse contexto, é imprescindível que páginas de secretarias de saúde apresentem informação sobre a doença com qualidade e legibilidade. Só assim, oferecerão um conteúdo informativo confiável e baseado em evidências científicas, contribuindo para o enfrentamento de notícias falsas e seus impactos negativos.

ABSTRACT Information and communication technologies have spread worldwide and are increasingly present in almost every aspect of human life, including health. The issue of information quality has assumed great importance amid the widespread dissemination of false knowledge, especially in a pandemic. We evaluated the quality of information on Covid-19 websites of four Health Secretariats in the state of Mato Grosso do Sul, Brazil, from July to August 2020. This participatory evaluation employed five criteria, following the international literature, namely: Technical, Interactivity, Comprehensiveness, Readability, and Accuracy, subdivided into 46 indicators. The results of the evaluated websites point to a low level of compliance with the indicators and criteria adopted and fail to disclose the primary scientific evidence on the topic, available on the Ministry of Health's website. The high circulation of fake news has marked the Covid-19 pandemic. In this context, Health Secretariats' pages should display quality and intelligible information about the disease. Only then will they offer reliable informational content based on scientific evidence, contributing to the fight against fake news and its adverse impacts.

Is the Effect of Body Dissatisfaction on Depressive Symptoms Dependent on Weight Status? A Study with Early-to-Middle Adolescents.

Depression is a recognized mental health problem in adolescence and body dissatisfaction is an important risk factor. The main goal of this study is to examine the relationship between body dissatisfaction and depressive symptoms, and whether it depends on adolescents' weight status, an issue that remains understudied. Two hundred and fourteen adolescents (12-16 years) completed self-report measures of depressive symptoms, body dissatisfaction and weight status (i.e., current body weight and height, to compute body mass index z-scores, BMIz). Hierarchical multiple regression and moderation analyses were conducted, accounting for gender and age effects on depressive symptoms. Body dissatisfaction was found to be a predictor of depressive symptoms for the low and median BMIz adolescents, but not for those with high BMIz. In addition, this interaction of body dissatisfaction and BMIz improved the ability of the regression model to explain depressive symptoms´ variance beyond the effect of gender and age. The high-BMIz adolescents presented higher body dissatisfaction but similar levels of depressive symptoms, compared to the lower BMIz adolescents. These findings suggest the influence of body dissatisfaction in the emergence of depressive symptoms in the first half of adolescence, and the importance of weight status throughout this path.

A Case of Pulmonary Mycetoma Caused by Paecilomyces variotii.

Fungal infections caused by Paecilomyces species are rare. Although most cases of human infection occur in immunocompromised patients, this species is also being increasingly recognized as a pathogen in immunocompetent individuals. Paecilomyces variotii and P. lilacinus are the most common pathogens in humans. P. variotii infection usually manifests as peritonitis, pneumonia or endophthalmitis. We present the case of an 84-year-old immunocompromised patient with interstitial lung disease, who developed pulmonary mycetoma with isolation of P. variotii in bronchoalveolar lavage fluid culture. We found one similar case in the literature, but Paecilomyces species was not identified. Therefore, this is the first described case of pulmonary mycetoma caused by P. variotii. LEARNING POINTS: Paecilomyces are rare causes of fungal infection in humans and occur more frequently in immunocompromised patients.Paecilomyces variotii is one of the most common pathogens of this species and is associated with peritonitis, pneumonia, osteomyelitis, endophthalmitis and fungaemia.To the date, pulmonary mycetoma caused by P. variotii has been described in only one patient in the literature.

Periodic Fever with Pharyngitis, Aphthous Stomatitis and Cervical Adenitis Syndrome: A Rare Cause of Fever in Adults.

Periodic fever with pharyngitis, aphthous stomatitis and cervical adenitis (PFAPA syndrome) is a common cause of periodic fever in children and usually manifests as episodes of fever recurring with a clockwork periodicity. Although rare after adolescence, adult patients with PFAPA syndrome may present with a wider range of symptoms and may lack the clockwork periodicity of fever. A 24-year-old patient presented with a 4-year history of periodic fever with pharyngitis and cervical adenitis. She also complained of vomiting, fatigue and sporadically presented with aphthous stomatitis. During crises, laboratory evaluation showed a moderate elevation of inflammatory markers. Blood cultures and ANA titres were negative. Immunoglobulins and serum ferritin levels were normal. After other causes of periodic fever had been excluded, a diagnosis of PFAPA syndrome was made. LEARNING POINTS: PFAPA syndrome is characterized by periodic fever accompanied by pharyngitis, aphthous stomatitis and cervical adenitis.It is a common cause of periodic fever in children but can also present in adults with a wider range of clinical manifestations.Establishing a firm diagnosis of PFAPA syndrome may avoid excessive work-up and potentially harmful treatment.

Senile Systemic Amyloidosis: An Underdiagnosed Disease.

Senile systemic amyloidosis is caused by a non-mutated form of transthyretin with the heart being the major organ involved. This infiltrative cardiomyopathy usually presents as slowly progressive heart failure. An 82-year-old female patient was admitted for newly diagnosed heart failure. A year later she presented with decompensated heart failure and syncope. Inpatient work-up showed persistently elevated troponin and N-terminal-pro BNP levels, rapid progression to severe left ventricular concentric hypertrophy, and sinus pauses on the Holter. Cardiac MRI revealed diffuse late gadolinium enhancement in the left ventricle. The demonstration of amyloid protein with the clinical findings and complementary investigations allowed for the diagnosis of senile systemic amyloidosis. LEARNING POINTS: Senile systemic amyloidosis is a rare disease with a common clinical presentation that is probably underdiagnosed in patients with heart failure with preserved systolic function.A new unexplained heart failure diagnosis, increased ventricular wall thickness and particularly low voltage on the ECG should raise the suspicion of cardiac amyloidosis.Histopathological evidence of amyloid deposition elsewhere and typical advanced imaging features can support the diagnosis, rendering endomyocardial biopsy no longer mandatory.

Synchronous presentation of two rare forms of extrapulmonary tuberculosis.

Tuberculosis (TB) remains one of the leading infectious causes of death throughout the world. Extrapulmonary forms, namely adrenalitis and prostatitis, are rare presentations of TB and pose a difficult diagnostic challenge, given their non-specific manifestations. The authors present a case of a 42-year-old man with long-standing symptoms of fatigue, anorexia, weight loss, nightly fever and sudoresis. He also suffered from sporadic vomiting and episodic hypotension, and had skin hyperpigmentation, as well as frequent urination, perineal discomfort and pain at ejaculation. Laboratory investigation confirmed primary adrenal failure. On CT scan there were two hypodense right adrenal nodules and bilateral lung condensations with a tree-in-bud pattern. Another hypodense nodule was seen in the prostate. TB was diagnosed by isolatingMycobacterium tuberculosisfollowing cultures of bronchoalveolar lavage, bronchial secretions, urine and ejaculate. Antibacillary treatment resolved the infectious lesions but the patient remained on corticosteroid replacement therapy for ongoing adrenal failure.

Malignant Otitis Externa and Stroke.

Malignant otitis externa (MOE) is an aggressive but benign entity which evolves into skull base osteomyelitis. An 81-year-old female patient was admitted for left hemiparesis and homonymous hemianopia. She complained of headache radiating to the right cervical area. A recent history of recurrent otitis media was present. Head and neck imaging showed an ischemic infarction (right temporo-occipital) and a parapharyngeal soft tissue mass originating in an external and medial ear infection. Culture samples revealed Pseudomonas aeruginosa infection leading to the diagnosis of Malignant otitis externa (MOE). Parenteral antibacterial therapy and hyperbaric oxygen therapy resulted in improvement. LEARNING POINTS: Malignant otitis externa is an aggressive and life-threatening disease which must be identified early and treated promptly for therapeutic success.Although starting as an outer ear infection (typically caused by Pseudomonas aeruginosa) local spread can involve noble head and neck structures leading to variable signs and symptoms.Modern imaging techniques can help define structure involvement (MRI) and may help identify disease activity and prognosis (nuclear medicine).