Concurrent catatonia and COVID-19 infection in a demented patient: A case report.

Catatonia is a complex neuropsychiatric syndrome that comprises motor, behavioral and autonomic abnormalities. It occurs in the context of general medical, neurological, and psychiatric conditions. The study of catatonia in the elderly is particularly challenging due to the higher somatic and cognitive comorbidity, polymedication and the higher prevalence of delirium. Catatonia remains underdiagnosed in this population, especially in those with dementia. We describe a case of an 82-years-old patient with mixed dementia, who developed catatonia for the first time, during her admission to our general medical ward due to SARS-CoV-2 organizing pneumonia. Besides the specific treatment for SARS-CoV-2 organizing pneumonia, catatonia was treated symptomatically with benzodiazepines and memantine with success. In general, catatonia in older patients tends to have a good prognosis if detected early, its cause treated, the symptoms managed, and complications avoided. We report this case to alert clinicians in medical wards to this condition, to improve its overall diagnosis and treatment rates.

Large-vessel vasculitis induced by pegfilgrastim.

Granulocyte colony-stimulating factor (G-CSF) is increasingly being used to prevent febrile neutropenia associated with chemotherapy. Large-vessel vasculitis (LVV) has been recognized as a rare side effect of G-CSF treatment. We report a case of G-CSF associated LVV in a patient with breast cancer. While clear pathogenic mechanisms remain unknown, G-CSF may cause vasculitis due to inflammatory cytokines production. This adverse reaction should be recognized in patients with suggestive symptoms following the administration of pegfilgrastim. A 56-year-old woman with luminal B breast cancer who had undergone surgery and adjuvant chemotherapy, initially with paclitaxel, was started on a doxorubicin plus cyclophosphamide protocol, followed by supportive use of long-acting G-CSF pegfilgrastim. Following the administration of pegfilgrastim, the patient developed intermittent fever and was given empiric antibiotics in the outpatient setting with no improvement. There were no signs of cancer progression, and the contrast-enhanced CT scan highlighted wall thickening of the aortic arch and the proximal segment of the subclavian artery, which was not present in previous imaging studies. The patient was diagnosed with LVV, and a differential diagnosis was performed to rule out paraneoplastic setting, immune-mediated diseases, infection or other drug-induced vasculitis. Treatment with steroids was initiated and tapered with significant improvement and resolution of the radiological signs of aortitis.

A Case of Brucellosis with Possible Ileal Involvement.

INTRODUCTION: Brucellosis is a zoonotic disease that can involve different organs and tissues. Fever, fatigue, lymphadenopathy, hepatosplenomegaly, cytopenia, and arthritis are the usual modes of presentation. Gastrointestinal manifestations of human brucellosis are common but documented ileal involvement is extremely rare. CASE DESCRIPTION: A 68-year-old female presented with a history of 10 days of intense temporal migraine, photophobia, and phonophobia with partial response to paracetamol. The patient referred night sweats, anorexia, and colicky abdominal pain after her meals for the past 4 months followed by diarrhea. She denied nausea, vomiting, hypersensitivity of the scalp, blurry vision, melena, or rectal bleeding. She denied travelling or contact with animals. Physical examination revealed fever (38.3°C) and splenomegaly. Laboratory workup revealed Hb 7.8 g/dL, leukopenia (3.47 × 109/L), C-reactive protein 5.94 mg/dL, and erythrocyte sedimentation rate 23 mm/h. Abdominal ultrasound showed hepatic steatosis and mild homogeneous splenomegaly. Chest radiography was normal. Lumbar puncture; transcranial, carotid, and temporal arteries Doppler, and head computed tomography (CT) did not show any significant changes. Abdominal CT showed diffuse thickening of the ileum and some mildly swollen locoregional lymph nodes. Fecal calprotectin was not elevated. Blood cultures and serologies were positive for Brucella (positive Rose-Bengal test, ELISA IgM-positive, IgG-negative anti-brucella antibody serology and positive Huddleson reaction - titer 1:320). The patient was started on rifampicin 600 mg/day and doxycycline 100 mg q. 12 h for 10 weeks with good clinical and analytical response. Upper and lower gastrointestinal endoscopy were normal, although the last was done already under antibiotic treatment. DISCUSSION: Although gastrointestinal manifestations of brucellosis are quite common, ileitis is thought to be extremely rare. In countries where brucellosis is endemic, doctors must consider this diagnosis when faced with patients with systemic symptoms and diarrhea or abdominal pain. Early recognition of brucellosis and institution of appropriate therapy usually leads to a good recovery without complications.

INTRODUÇÃO: A brucelose é uma zoonose que pode envolver diferentes órgãos e tecidos. A apresentação habitual consiste em febre, cansaço, linfadenopatias, hepatoesplenomegalia, citopenias ou artrite. As manifestações gastrointestinais de brucelose humana são comuns, mas a documentação do envolvimento ileal é extremamente rara. DESCRIÇÃO DO CASO: Doente de 68 anos, sexo feminino, apresentouse com quadro com dez dias de evolução de cefaleia temporal intensa, fotofobia e sonofobia, com resposta parcial a terapêutica com paracetamol. A doente referia sudorese noturna, anorexia e dor abdominal tipo cólica após as refeições durante os últimos quatro meses seguida de diarreia. Negava náuseas, vómitos, hipersensibilidade do escalpe, visão turva, melenas ou retorragia. Negava viagens ou contacto com animais. Ao exame objetivo destacavase febre (38,3 ° C) e esplenomegalia. Os estudos laboratoriais revelaram Hb 7,8 g/dL, leucopenia (3,109 × 47/L), proteína C-reativa 5,94 mg/dL, velocidade de sedimentação 23 mm/h. A ecografia abdominal mostrou ligeiro aumento do fígado (estatose) e esplenomegalia ligeira e homogénea. Radiografia de tórax normal. Punção lombar; Doppler transcraniano, carotídeo e das artérias temporais e tomografia computorizada (CT) craniana sem alterações significativas. A CT abdominal mostrou espessamento difuso do íleon e algumas pequenas adenopatias locorregionais. As hemoculturas e serologias foram positivas para Brucela (Rosa Bengala positivo, serologia anti-Brucela ELISA IgM-positivo, IgG-negativo; reação de Huddleson positiva - título 1: 320). Foi iniciada terapêutica com rifampicina 600 mg/dia e doxiciclina 100 mg de 12 em 12 h durante 10 semanas com boa resposta clínica e laboratorial. Endoscopia digestiva alta e baixa sem alterações, apesar de a última ter sido realizada já sob terapêutica antibiótica. DISCUSSÃO: Embora as manifestações gastrointestinais de brucelose sejam comuns, pensase que a ileíte seja extremamente rara. Em países onde a brucelose é endémica, os médicos devem considerar esta hipótese diagnóstica quando na presença de sintomas sistémicos e diarreia ou dor abdominal. O reconhecimento precoce da brucelose e a instituição de terapêutica adequada levam geralmente a uma boa recuperação sem complicações.

Cystatin C: A Promising Marker of Renal Function in Patients with Systemic Lupus Erythematosus?

PURPOSE: Cystatin C has a higher correlation with glomerular filtration rate and a more significant clinical prognosis than creatinine. We sought to determine whether it is a marker of renal function different from creatinine (cystatin C potentially superior to creatinine), in patients with systemic lupus erythematosus. MATERIAL AND METHODS: 37 patients with systemic lupus erythematosus were evaluated. Serum cystatin C was determined by nephelometry and creatinine by modified Jaffe method. We compared five formulas: Chronic Kidney Disease â Epidemiology Collaboration cystiatin; Chronic Kidney Disease â Epidemiology Collaboration creatinine-cystatin; Cockcroft-Gault; Modification of Diet in Renal Disease and Chronic Kidney Disease â Epidemiology Collaboration creatinine, using the latter as a reference. We analyzed the influence of clinical and laboratory factors in cystatin C variation, using multivariate linear regression. RESULTS: Cystatin C was singly elevated in ten participants, versus none isolated creatinine elevation, and this difference was significant (p = 0.002). There was a difference between the estimated glomerular filtration rate by Chronic Kidney Disease â Epidemiology Collaboration cystatin and by Chronic Kidney Disease â Epidemiology Collaboration creatinine (-6.0541 mL/min/1.73 m², p = 0.07), more pronounced for lower glomerular filtration rate. Consequently, Chronic Kidney Disease â Epidemiology Collaboration cystatin reclassified 4 patients as having chronic kidney disease de novo and 1 patient as not having chronic kidney disease (p = 0.375). Cystatin C was only significantly influenced by age (p < 0.001). DISCUSSION: Several reports showed cystatin C as a better marker to define chronic kidney disease, allowing more accurate classification and risk stratification, compared with creatinine. In this study, Cystatin C revealed as a promisor marker of renal function in patient with lupus, mainly in patients with lower glomerular filtration rates. The correlation between age and cystatin C seems to be a confounding factor, as glomerular filtration rate physiologically declines with ageing. CONCLUSION: Cystatin C was potentially superior to creatinine and in this study and cystatin C seems to detect changes in glomerular filtration rate earlier than creatinine and may be a better screening method for chronic kidney disease in systemic lupus erythematosus.

Introdução: A cistatina C possui uma correlação superior com a taxa de filtrado glomerular e um prognóstico clínico mais significativo do que a creatinina. Procurou-se averiguar se constitui um marcador de função renal diferente da creatinina (cistatina C potencialmente superior à creatinina), em doentes com lúpus eritematoso sistémico.Material e Métodos: Foram avaliados 37 doentes com lúpus eritematoso sistémico, sem evidência de nefrite lúpica activa. Determinouse a cistatina C sérica por nefelometria e a creatinina pelo método de Jaffe modificado. Compararam-se cinco fórmulas: Chronic Kidney Disease â Epidemiology Collaboration cystatin; Chronic Kidney Disease â Epidemiology Collaboration creatinine-cystatin; Cockcroft-Gault, Modification of Diet in Renal Disease e Chronic Kidney Disease â Epidemiology creatinine, utilizando-se esta última como referência. Analisou-se a influência de factores clínicos e laboratoriais na variação da cistatina C, por regressão linear multivariada. Resultados: A cistatina C encontrava-se isoladamente elevada em dez participantes, ao invés de nenhuma elevação isolada dacreatinina, sendo esta diferença significativa (p = 0,002). Verificou-se uma diferença entre a taxa de filtrado glomerular estimada pela Chronic Kidney Disease â Epidemiology Collaboration cystatin e pela Chronic Kidney Disease â Epidemiology Collaboration creatinine (-6,0541 mL/min/1,73 m2, p = 0,07), mais acentuada para taxas de filtração glomerular mais baixas. Assim, a fórmula Chronic Kidney Disease â Epidemiology Collaboration cystatin reclassificou 4 doentes como tendo doença renal crónica de novo e um doente como não tendo doença renal crónica (p = 0,375). A cistatina C foi influenciada significativamente apenas pela idade (p < 0,001).Discussão: Vários estudos demonstraram que a cistatina C melhora a definição de doença renal crónica, permitindo uma classificação e uma estratificação do risco mais exactas, comparativamente à creatinina. A cistatina C revelou-se, neste estudo, um marcador de função renal promissor nos doentes com lupus, principalmente para taxas de filtrado glomerular mais baixas. A correlação da cistatina C com a idade para ser um factor confundente, na medida em que existe um declínio fisiológico da taxa de filtração glomerular com o envelhecimento.Conclusão: A cistatina C foi potencialmente superior à creatinina e nesta amostra a cistatina C pareceu detectar mais precocemente do que a creatinina alterações na taxa de filtrado glomerular, podendo ser um melhor método de rastreio de doença renal crónica no lúpus eritematoso sistémico.

Acute kidney injury after major abdominal surgery: a retrospective cohort analysis.

Background. We analyzed the incidence, risk factors, and prognosis of acute kidney injury (AKI) in a cohort of patients undergoing major abdominal surgery. Methods. A total of 450 patients were retrospectively studied. AKI was defined by an increase in serum creatinine (SCr) ≥ 0.3 mg/dl or by an increase in SCr ≥ 50% and/or by a decrease in urine output to 0.5 ml/kg/hour for 6 hours, in the first 48 hours after surgery. Logistic regression method was used to determine predictors of AKI and in-hospital mortality. A two-tailed P value <0.05 was considered significant. Results. One hundred one patients (22.4%) had postoperative AKI. Age (adjusted odds ratio (OR) 1.02, 95% confidence interval (CI) 1.01-1.05), nonrenal Revised Cardiac Risk Index score (adjusted OR 1.9, 95% CI 1.3-3.1, P = 0.003), intraoperative erythrocytes transfusions (adjusted OR 2.2, 95% CI 1.4-3.5, P <.0001), and nonrenal Simplified Acute Physiology Score II (adjusted OR 1.03, 95% CI 1.01-1.06, P = 0.0191) were associated with postoperative AKI. AKI was associated with increased in-hospital mortality (20.8% versus 2.3%, P <.0001; unadjusted OR 11.2, 95% CI 4.8-26.2, P <.0001; adjusted OR 3.7, 95% CI 1.2-11.7, P = 0.024). Conclusion. AKI was common in patients undergoing major abdominal surgery and was associated with in-hospital mortality.

Effect of fluoride gels supplemented with sodium trimetaphosphate in reducing demineralization.

OBJECTIVES: The objective of this study was to evaluate the in vitro effect of low-fluoride (F) gels supplemented with sodium trimetaphosphate (TMP) on enamel demineralization. MATERIALS AND METHODS: Bovine enamel blocks (n = 160) were selected based on surface hardness (SH) and divided into eight treatment groups (n = 20 per group): no F or TMP (placebo), 3 % TMP (3 %TMP), 5 % TMP (5 %TMP), 4,500 µg F/g (4,500), 4,500 µg F/g + 3 % TMP (4,500 3 %TMP), 4,500 µg F/g + 5 % TMP (4,500 5 %TMP), 9,000 µg F/g (9,000), and 12,300 µg F/g (acid gel). Blocks were subjected to demineralization/remineralization cycling for 5 days. Subsequently, surface hardness (SH1) and integrated loss of subsurface hardness (ΔKHN) were assessed, and the concentrations of loosely bound (CaF2-like) and firmly bound (FA-like) formed and retained F were determined. RESULTS: The 4,500 5 %TMP and acid gel groups showed similar results and had the lowest mineral loss (SH1 and ∆KHN). The acid gel group had the highest concentration of CaF2-like F, but the formation and retention of FA-like F was greater in the 4,500 5 %TMP group than in the acid gel group (p < 0.05). CONCLUSION: It is possible to inhibit enamel demineralization with low-F gels supplementing these gels with 5 % TMP. CLINICAL RELEVANCE: The low-F gel containing TMP can be regarded as a safer alternative for clinical use from a toxicological point of view since it contains half of the amount of a conventional formulation while promoting similar anticaries effect.

Hypocalcemic cardiomyopathy.

The association between hypocalcemia and heart failure is rare. There are few reported cases in the literature of this association, which is termed hypocalcemic cardiomyopathy. We report the case of a 61-year-old woman with no relevant medical history, admitted for progressively worsening exertional dyspnea, orthopnea and edema of the lower limbs for a previous month. Physical examination showed diffuse muscle spasms, with no signs of latent tetany.Further investigation revealed ionized calcium 0.54 mmol/l (normal 1.12-1.30), phosphorus 9.8 mg/dl, parathyroid hormone <2.5 pg/ml and CK >3000 U/l, with normal thyroid function. The electrocardiogram showed long QT interval and a pattern of left ventricular overload, and myocardial biomarkers were negative. The echocardiogram revealed regional wall motion abnormalities, coronary angiography was normal and a cranial CT scan detected calcification of basal ganglia and white matter. She started diuretic and calcium replacement therapy which resulted in complete clinical recovery, with no need for heart failure therapy after normalization of serum calcium.