Membranous nephropathy.

Membranous nephropathy is a glomerulopathy, which main affected target is the podocyte, and has consequences on the glomerular basement membrane. It is more common in adults, especially over 50 years of age. The clinical presentation is nephrotic syndrome, but many cases can evolve with asymptomatic non-nephrotic proteinuria. The mechanism consists of the deposition of immune complexes in the subepithelial space of the glomerular capillary loop with subsequent activation of the complement system. Great advances in the identification of potential target antigens have occurred in the last twenty years, and the main one is the protein "M-type phospholipase-A2 receptor" (PLA2R) with the circulating anti-PLA2R antibody, which makes it possible to evaluate the activity and prognosis of this nephropathy. This route of injury corresponds to approximately 70% to 80% of cases of membranous nephropathy characterized as primary. In the last 10 years, several other potential target antigens have been identified. This review proposes to present clinical, etiopathogenic and therapeutic aspects of membranous nephropathy in a didactic manner, including cases that occur during kidney transplantation.

Peritonitis caused by paracoccidioides spp. in a patient on continuous ambulatory peritoneal dialysis - A case report.

Paracoccidioidomycosis is a systemic mycosis found mainly in South America and is the most prevalent endemic and systemic mycosis in Brazil. The purpose of this paper was to report the case of a male patient who developed peritonitis caused by Paracoccidioides spp. Forty-eight-year-old, male patient, with type I Diabetes mellitus and chronic kidney disease who was undergoing a Continuous Ambulatory Peritoneal Dialysis (CAPD) program. After eighteen months of peritoneal dialysis, the patient developed turbidity of the peritoneal fluid and was diagnosed with peritonitis. Direct mycological examination of the peritoneal fluid revealed yeasts with morphology suggestive of Paracoccidioides spp. The patient was treated with sulfamethoxazole-trimethoprim (1,600 mg/320 mg dose/day) for 61 days, but he died because a bacterial septic shock. The diagnosis of opportunistic PCM peritonitis was later confirmed by autopsy and Paracoccidioides spp. isolation. This is the first reported case of a patient on CAPD who experienced complications due peritonitis caused by opportunistic PCM.

Membranous nephropathy / Nefropatia membranosa

ABSTRACT Membranous nephropathy is a glomerulopathy, which main affected target is the podocyte, and has consequences on the glomerular basement membrane. It is more common in adults, especially over 50 years of age. The clinical presentation is nephrotic syndrome, but many cases can evolve with asymptomatic non-nephrotic proteinuria. The mechanism consists of the deposition of immune complexes in the subepithelial space of the glomerular capillary loop with subsequent activation of the complement system. Great advances in the identification of potential target antigens have occurred in the last twenty years, and the main one is the protein "M-type phospholipase-A2 receptor" (PLA2R) with the circulating anti-PLA2R antibody, which makes it possible to evaluate the activity and prognosis of this nephropathy. This route of injury corresponds to approximately 70% to 80% of cases of membranous nephropathy characterized as primary. In the last 10 years, several other potential target antigens have been identified. This review proposes to present clinical, etiopathogenic and therapeutic aspects of membranous nephropathy in a didactic manner, including cases that occur during kidney transplantation.

RESUMO A nefropatia membranosa é uma glomerulopatia, cujo principal alvo acometido é o podócito, e acarreta consequências na membrana basal glomerular. Tem maior frequência em adultos, principalmente acima dos 50 anos. A apresentação clínica é a síndrome nefrótica, mas muitos casos podem evoluir com proteinúria não nefrótica assintomática. O mecanismo consiste na deposição de complexos imunes no espaço subepitelial da alça capilar glomerular com subsequente ativação do sistema do complemento. Grandes avanços na identificação de potenciais antígenos alvo têm ocorrido nos últimos vinte anos, e o principal é a proteína "M-type phospholipase-A2 receptor" (PLA2R) com o anticorpo anti-PLA2R circulante, o que possibilita avaliar a atividade e o prognóstico dessa nefropatia. Essa via de lesão corresponde aproximadamente a 70% a 80% dos casos da nefropatia membranosa caracterizada como primária. Nos últimos 10 anos vários outros antígenos alvo potenciais têm sido identificados. Esta revisão se propõe a apresentar de modo didático aspectos clínicos, etiopatogênicos e terapêuticos da nefropatia membranosa, incluídos os casos com ocorrência no transplante renal.

Peritonitis caused by paracoccidioides spp. in a patient on continuous ambulatory peritoneal dialysis - A case report

ABSTRACT Paracoccidioidomycosis is a systemic mycosis found mainly in South America and is the most prevalent endemic and systemic mycosis in Brazil. The purpose of this paper was to report the case of a male patient who developed peritonitis caused by Paracoccidioides spp. Fortyeight-year-old, male patient, with type I Diabetes mellitus and chronic kidney disease who was undergoing a Continuous Ambulatory Peritoneal Dialysis (CAPD) program. After eighteen months of peritoneal dialysis, the patient developed turbidity of the peritoneal fluid and was diagnosed with peritonitis. Direct mycological examination of the peritoneal fluid revealed yeasts with morphology suggestive of Paracoccidioides spp. The patient was treated with sulfamethoxazole-trimethoprim (1,600 mg/320 mg dose/day) for 61 days, but he died because a bacterial septic shock. The diagnosis of opportunistic PCM peritonitis was later confirmed by autopsy and Paracoccidioides spp. isolation. This is the first reported case of a patient on CAPD who experienced complications due peritonitis caused by opportunistic PCM.

Testicular histology after intestinal pedicle flap (cecum) apposition in rats / Histologia testicular depois da aposição de um retalho intestinal (ceco) em ratos

PURPOSE: Histological study of vascularization between a cecal pedicle flap and the testicle of Wistar rats. METHODS: Fifty-three rats were studied. G1: submitted to celiotomy (a), mobilization of the right testicle (RT) to the abdomen (b), cecal flap suture to the RT (d) and cavity closure. G1: procedures a, b and d and fixation of RT into abdomen. G3: procedures a, b and d, exposition of RT to air and reposition into scrotum. G4: not operated. Euthanasia and histology was done after 20 days. Histometry and lesions score classification was done. Testicular vascularization was studied with comparison between G1 and G3. A p < .05 was considered significant. RESULTS: The G1 RT diameters were not different to G2 RT and all have decreased size in comparison with RT of G3 and G4. The lesions score in the RT was 5.83 in G1 and 3.3 in G2 without statistical difference. The vascularization's average in G1 was 16.9 vessels in 400X field in the RT. In the G3 this average was 0.96 to the RT and 0.92 to left testicles. The weight's average in G1 was similar with G2 but different of G3 and G4. CONCLUSION: A significant increase of vascularization was observed between the intestinal flap and the rat testicle.(AU)

OBJETIVOS: Estudar histologicamente a vascularização entre um retalho cecal e o testículo de ratos Wistar. MÉTODOS: Cinquenta e três ratos foram estudados. G1, submetidos a (a) celiotomia, (b) mobilização do testículo direito (TD) para o abdome, (c) sutura do retalho cecal ao TD, (d) fechamento da cavidade. G2, procedimentos (a, b e d), com o TD fixado no abdome. G3, procedimentos (a, b e d), com exposição do TD ao ar e retorno ao escroto. G4 não operados. Após 20 dias, eutanásia e histologia. Realizou-se histometria e classificação segundo escore de lesão. Avaliou-se a vascularização testicular, comparando-se os grupos 1 e 3. Considerou-se significativo um p < 0,05. RESULTADOS: Diâmetros dos TD no G1, iguais ao G2 e diferentes de G3 e G4. O escore de lesão nos TD foi de 5,83 pontos para o G1, de 3,3 pontos para o G2, não havendo diferença significativa, porém diferentes de G3 e G4 (sem lesão). A vascularização no G1 teve média de 16,9 vasos por campo de grande aumento no TD. No G3 a média foi de 0,96 no TD e 0,92 no TE, com diferença significativa. O peso médio do G1 foi igual ao G2 e diferente de G3 e G4. CONCLUSÃO: Houve aumento significativo da vascularização entre o retalho e o testículo do rato.(AU)

Testicular histology after intestinal pedicle flap (cecum) apposition in rats / Histologia testicular depois da aposição de um retalho intestinal (ceco) em ratos

PURPOSE: Histological study of vascularization between a cecal pedicle flap and the testicle of Wistar rats. METHODS: Fifty-three rats were studied. G1: submitted to celiotomy (a), mobilization of the right testicle (RT) to the abdomen (b), cecal flap suture to the RT (d) and cavity closure. G1: procedures a, b and d and fixation of RT into abdomen. G3: procedures a, b and d, exposition of RT to air and reposition into scrotum. G4: not operated. Euthanasia and histology was done after 20 days. Histometry and lesions score classification was done. Testicular vascularization was studied with comparison between G1 and G3. A p < .05 was considered significant. RESULTS: The G1 RT diameters were not different to G2 RT and all have decreased size in comparison with RT of G3 and G4. The lesions score in the RT was 5.83 in G1 and 3.3 in G2 without statistical difference. The vascularization's average in G1 was 16.9 vessels in 400X field in the RT. In the G3 this average was 0.96 to the RT and 0.92 to left testicles. The weight's average in G1 was similar with G2 but different of G3 and G4. CONCLUSION: A significant increase of vascularization was observed between the intestinal flap and the rat testicle.

OBJETIVOS: Estudar histologicamente a vascularização entre um retalho cecal e o testículo de ratos Wistar. MÉTODOS: Cinquenta e três ratos foram estudados. G1, submetidos a (a) celiotomia, (b) mobilização do testículo direito (TD) para o abdome, (c) sutura do retalho cecal ao TD, (d) fechamento da cavidade. G2, procedimentos (a, b e d), com o TD fixado no abdome. G3, procedimentos (a, b e d), com exposição do TD ao ar e retorno ao escroto. G4 não operados. Após 20 dias, eutanásia e histologia. Realizou-se histometria e classificação segundo escore de lesão. Avaliou-se a vascularização testicular, comparando-se os grupos 1 e 3. Considerou-se significativo um p < 0,05. RESULTADOS: Diâmetros dos TD no G1, iguais ao G2 e diferentes de G3 e G4. O escore de lesão nos TD foi de 5,83 pontos para o G1, de 3,3 pontos para o G2, não havendo diferença significativa, porém diferentes de G3 e G4 (sem lesão). A vascularização no G1 teve média de 16,9 vasos por campo de grande aumento no TD. No G3 a média foi de 0,96 no TD e 0,92 no TE, com diferença significativa. O peso médio do G1 foi igual ao G2 e diferente de G3 e G4. CONCLUSÃO: Houve aumento significativo da vascularização entre o retalho e o testículo do rato.

Testicular histology after intestinal pedicle flap (cecum) apposition in rats.

PURPOSE: Histological study of vascularization between a cecal pedicle flap and the testicle of Wistar rats. METHODS: Fifty-three rats were studied. G1: submitted to celiotomy (a), mobilization of the right testicle (RT) to the abdomen (b), cecal flap suture to the RT (d) and cavity closure. G1: procedures a, b and d and fixation of RT into abdomen. G3: procedures a, b and d, exposition of RT to air and reposition into scrotum. G4: not operated. Euthanasia and histology was done after 20 days. Histometry and lesions score classification was done. Testicular vascularization was studied with comparison between G1 and G3. A p < .05 was considered significant. RESULTS: The G1 RT diameters were not different to G2 RT and all have decreased size in comparison with RT of G3 and G4. The lesions score in the RT was 5.83 in G1 and 3.3 in G2 without statistical difference. The vascularization's average in G1 was 16.9 vessels in 400X field in the RT. In the G3 this average was 0.96 to the RT and 0.92 to left testicles. The weight's average in G1 was similar with G2 but different of G3 and G4. CONCLUSION: A significant increase of vascularization was observed between the intestinal flap and the rat testicle.

Osteíte fibrosa cística causando paraplegia crural / Crural paraplegia for osteitis fibrosa cystica

A osteíte fibrosa cística é uma apresentação avançada do hiperparatireoidismo e pode acometer, mais raramente, a coluna vertebral. No presente relato, a paciente evoluiu de um quadro de dor localizada para paraplegia por compressão medular. Destaca-se a importância de investigação e abordagem precoces dessa condição, a fim de evitar complicações irreversíveis.

Osteitis fibrosa cystica is an advanced consequence of hiperparathyroidism and, eventually, it is situated in spine. In this report, the patient showed a localized pain which quickly evaluated to paraplegia caused by spinal cord compression. Early investigation and intervention in this clinical condition are important in order to prevent irreversible complications.

Tectal plate tumors.

Tectal plate is a rare location for a tumor. Many papers have described different types of pathology arising in that location including tumors, vascular lesions, inflammatory and infectious processes. In this paper we describe our experience in treating seven patients with tectal plate lesions, with different ages and types of pathology: five patients presented with low grade gliomas, one with lung cancer metastasis and the last presenting with a tectal plate cavernoma. Open surgery was performed in three cases (due to tumor enlargement or need for the exact diagnosis). In the other cases, the treatment of non-communicating hydrocephalus was the only treatment employed. The prognosis is of course dependent on the underlining pathology. In our series, except in the metastatic tumor case and the cavernoma, the other types of lesion consisted of low grade gliomas. These lesions represent a different type of brain stem tumor sharing a common good prognosis, with a benign behavior. We believe that tectal tumors must be managed case by case. When a patient presents with a benign lesions in the tectal region, treating the main symptom--hydrocephalus--should be the first attempt in management of these lesions.

Tectal plate tumors

Tumores na região do teto mesencefálico são raros. Vários tipos de lesões como tumores, lesões vasculares, inflamatórias e infecciosas localizam-se nesta região. Nós revimos o tratamento adotado em sete pacientes com diferentes tipos de lesões tectais: cinco pacientes apresentando gliomas de baixo grau, um paciente com lesão metastática proveniente de câncer de pulmão e um com cavernoma. O tratamento cirúrgico com abordagem direta da lesão foi realizado em três casos (devido ao aumento do volume tumoral ou quando houve necessidade da confirmação diagnóstica). Nos demais casos o tratamento para a hidrocefalia não-comunicante foi o método empregado. O prognóstico dessas lesões é baseado no tipo de patologia em questão. Em nossa série, com exceção do caso de metástase e do paciente com cavernoma, as demais lesões foram gliomas de baixo grau. Estas lesões representam um subgrupo diferenciado de tumores de tronco encefálico, apresentando bom prognóstico e tendo comportamento benigno com sobrevida elevada. Acreditamos que tumores da região tectal devam ser avaliados caso a caso. Na hipótese diagnóstica de uma lesão benigna, o tratamento do principal complexo sindrômico – hidrocefalia não-comunicante – é provavelmente a melhor conduta a ser empregada.

Craniocervical fixation using inside-outside instrumentation

Os estudos sobre a biomecânica do complexo occipto-atlanto-axial explicam a alta incidência da instabilidade que ocorre após a descompressão anerior da junção craniocervical. O objetivo deste relato é apresentar a técnica de fixação occipito-cervical tipo inside-outside proposta por Pait e cols. São apresentados dois pacientes operados pela via transoral e submetidos à fixação occipto-cervical com instrumentação tipo inside-outside: um paciente portador de artrite reumatóide, com severa compressão ventral da junção craniocervical, e outro portador de um volumoso tumor acometendo o corpo, a apófise odontóide e invadindo o canal vertebral cervical. A técnica utiliza uma haste de titânio moldada para adaptar-se à curvatura occipital e implantada lateralmente até a coluna cervical, a haste é fixada por meio de parafuso, cuja parte achatada é colocada no espaço epidural. Na coluna cervical, a haste é fixada por parafusos que são introduzidos no quadrante supero-lateral das massas articulares. No axix, o parafuso é introduzidpo na pars interarticularis podendo terminar no corpo desta vértebra ou na massa articular do atlas. A técnica de fixação occipito-cervical tipo inside-outside, nos casos descritos, mostrou-se segura e de fácil aplicabilidade.

Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control.

The surgical management of cerebrospinal fluid (CSF) rhinorrhea has changed after the introduction of functional endoscopic sinus surgery.The following three cases illustrate the repair of CSF leaks with the use of rigid endoscope. Two patients had the diagnosis and the site confirmed after intrathecal fluoresceine saline injection. The obliteration of the CSF was achieved with fat free, mucoperichondrial or mucoperiostal free grafts taken from middle or inferior turbinate and kept in place by fibrin glue. Primary closure was achieved in all patients. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, effective and is a valid alternative to the cranial approach.

Remote hemorrhage from the site of craniotomy.

Postoperative intracranial hemorrhage is a serious and sometimes a fatal neurosurgical complication. Hemorrhage occurring at regions remote from the site of intracranial operations comprises an uncommon affection, most ignored by the assistant physicians. It bares a still incomprehensive pathophysiology, despite several theories trying to explain it. Looks like a common sense that the presence of the remote site hemorrhage cannot be related to concomitant presence of hypertension, coagulopathy or undiscovered lesions. We report three cases of postoperative hemorrhages occurring in a remote site of supratentorial craniotomies, two patients presented cavernous sinus meningeoma and one patient was submitted to intracranial vascular surgery.

Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control

Descrevemos a técnica de oclusão endoscópica por via endonasal de fístula liquórica proveniente do andar anterior em três pacientes. Dois pacientes tiveram o diagnóstico e os orifícios da fístula localizados após injeção intratecal de fluoresceína sódica. A oclusão foi obtida com enxerto de gordura livre, fragmentos de mucopericôndrio septal ou mucoperiósteal retirado do corneto médio ou inferior e selados com o auxílio de cola de fibrina. A cirurgia endoscópica endonasal é técnica segura e eficaz no tratamento da fístula esfeno-etmoidal, constituindo alternativa à abordagem craniana.

Remote hemorrhage from the site of craniotomy

Hemorragia intracraniana de ocorrência em pós-operatório é grave complicação das cirurgias intracranianas. O aparecimento de foco hemorrágico em regiões distantes ao sítio operatório original é considerado incomum, e muitas vezes ignorado pelos médicos assistentes. A fisiopatologia envolvida no processo não é de todo compreendida, apesar das diversas teorias já propostas. São apresentados três casos de hemorragia á distancia da área cirúrgica, no pós-operatório de dois pacientes portadores de meningeoma do seio cavernoso e de um submetido à clipagem de aneurisma intracraniano.

Pseudoaneurisma da artéria carótida interna após ressecção transesfenoidal de macroadenoma hipofisário. Uma proposta de tratamento endovascular / Internal carotid pseudoaneurysm after transsphenoidal resection of a pituitary adenoma: an endovascular approach model

É apresentado um caso de pseudoaneurisma de artériacarótida interna após ressecção endoscópica transnasaltransesfenoidal de um adenoma de hipófise, com uma proposta de tratamento endovascular: como o paciente tornou-sesintomático no teste de oclusão da artéria carótida interna,um modelo alternativo - endovascular - foi proposto,consistindo no uso de molas e de um Stent vascular colocadoadjacente à luz do pseudoaneurisma.Após uma grave manifestação clínica, consistindo emhemorragia nasal maciça, o paciente evoluiu satisfatoriamenteapós o tratamento.

Malignant paraganglioma with vertebral metastasis: case report.

A paraganglioma is a rare tumor, composed of chromaffin cells, groups of cells associated to the autonomous system. When the tumor occurs in the adrenal gland, it is called pheochromocitoma. The malignant paraganglioma is a very rare presentation; it is diagnosed by local recurrence after total resection of the primary mass, or findings of distant metastases. We present a case report of a 29-year-old woman with cervico-brachial pain. In 1995 she underwent a carotid body tumor resection. Magnetic resonance imaging (MRI), plain X-rays and computerized tomography scan revealed multiple lesions in C5, T5 and T12. She underwent a surgical procedure to correct the cervical lesion. The histological and immunohistochemical assays revealed a malignant paraganglioma. She received adjuvant radiotherapy, showing clinical improvement after treatment, presenting no symptoms after one year. The therapeutic approach is based on the total resection of the tumor. The treatment of distant metastases can be made with adjuvant measures such as conventional radiotherapy, I 131-MIBG, or chemotherapy, especially in malignant pheochromocitomas.

Malignant paraganglioma with vertebral metastasis: case report

A paraganglioma is a rare tumor, composed of chromaffin cells, groups of cells associated to the autonomous system. When the tumor occurs in the adrenal gland, it is called pheochromocitoma. The malignant paraganglioma is a very rare presentation; it is diagnosed by local recurrence after total resection of the primary mass, or findings of distant metastases. We present a case report of a 29-year-old woman with cervico-brachial pain. In 1995 she underwent a carotid body tumor resection. Magnetic resonance imaging (MRI), plain X-rays and computerized tomography scan revealed multiple lesions in C5, T5 and T12. She underwent a surgical procedure to correct the cervical lesion. The histological and immunohistochemical assays revealed a malignant paraganglioma. She received adjuvant radiotherapy, showing clinical improvement after treatment, presenting no symptoms after one year. The therapeutic approach is based on the total resection of the tumor. The treatment of distant metastases can be made with adjuvant measures such as conventional radiotherapy, I -MIBG, or chemotherapy, especially in malignant pheochromocitomas