Compartment syndrome after South American rattlesnake (Crotalus durissus terrificus) envenomation.

CONTEXT: In order to report the outcome of a patient who developed compartment syndrome after South American rattlesnake (Crotalus durissus terrificus) envenomation, confirmed by subfascial pressure measurement and magnetic resonance imaging (MRI). CASE DETAILS: A 63-year-old male was admitted 1 h after being bitten on the right elbow by a "large" snake, which was not brought for identification. Physical and laboratory features upon admission revealed two fang marks, local tense swelling, paresthesia, intense local pain, hypertension, coagulopathy, and CK = 1530 U/L (RV < 170 U/L). The case was initially treated with bothropic antivenom (80 mL, intravenously), with no improvement. Evolution within 13-14 h post-bite revealed generalized myalgia, muscle weakness, palpebral ptosis, and severe rhabdomyolysis (CK = 126,160 U/L) compatible with envenoming by C. d. terrificus. The patient was then treated with crotalic antivenom (200 mL, intravenously), fluid replacement, and urine alkalinization. Twenty-four-hour post-bite MRI showed marked muscular edema in the anterior compartment of the right forearm, with a high subfascial pressure (40 mmHg) being detected 1 h later. ELISA of a blood sample obtained upon admission, before antivenom infusion, revealed a high serum concentration of C. d. terrificus venom. No fasciotomy was performed and the patient was discharged seven days later without sequelae. CONCLUSION: Snakebite by C. d. terrificus with subfascial venom injection may lead to increased intracompartmental pressure.

Coagulopathy as the main systemic manifestation after envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus): case report.

CONTEXT: Rattlesnake bites in Brazil are generally caused by adult individuals, with most of the envenomed patients showing systemic manifestations that include varying degrees of neurotoxicity (acute myasthenia), rhabdomyolysis and coagulopathy, with only mild or no local manifestations. We report a case of envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus) that involved coagulopathy as the main systemic manifestation. CASE DETAILS: A 19-year-old male was admitted to our Emergency Department with coagulopathy (incoagulable PT, APTT and INR), no remarkable local manifestations and no signs/symptoms of myasthenia or rhabdomyolysis (serum CK, LDH, ALT and AST within reference levels) 5 days after being bitten by a small snake that was described as a rattlesnake but was not brought for identification at admission. The patient had already been treated in another Emergency Department with i.v. bothropic antivenom (AV) 1 h and 4 days post-bite. Based on the possibility of an unusual rattlesnake bite, crotalic AV was administered i.v., which improved the coagulation (9 h post-CroAV, INR = 2.11; 36 h post-CroAV, INR = 1.42). During hospitalization, relatives brought the snake that caused the bite, which was identified as a 38-cm long C. d. terrificus. DISCUSSION: Little is known about the clinical manifestations after bites by juvenile C. d. terrificus. This case shows that systemic envenoming by juvenile C. d. terrificus may result in coagulopathy as the main systemic manifestation, without neuromyotoxic features normally associated with bites by adult specimens. Despite the delayed administration, crotalic AV was effective in improving the blood coagulation.

Occupational and environmental human lead exposure in Brazil.

The purpose of this paper is to present a review of data on assessment of exposure and adverse effects due to environmental and occupational lead exposure in Brazil. Epidemiological investigations on children lead exposure around industrial and mining areas have shown that lead contamination is an actual source of concern. Lead in gasoline has been phasing out since the 1980s, and it is now completely discontinued. The last lead mining and lead refining plant was closed in 1995, leaving residual environmental lead contamination which has recently been investigated using a multidisciplinary approach. Moreover, there are hundreds of small battery recycling plants and secondary smelting facilities all over the country, which produce focal urban areas of lead contamination. Current regulatory limits for workplace lead exposure have shown to be inadequate as safety limits according to a few studies carried out lately.

Patterns of anti-tuberculosis drug resistance among HIV-infected patients in Maputo, Mozambique, 2002-2003.

SETTING: Two tuberculosis (TB) reference hospitals in Maputo, Mozambique. OBJECTIVES: To assess the pattern of TB drug resistance and its risk factors in human immunodeficiency virus (HIV) patients. DESIGN: Adult HIV-positive patients with TB diagnosed by culture of sputum or bronchial washing were enrolled during 2002-2003. Cultures of 111 patients were tested for rifampicin, isoniazid, streptomycin and ethambutol sensitivity. Chest X-ray, haemoglobin (Hb), total lymphocyte and CD4 counts were also performed. RESULTS: Overall resistance to any drugs was found in 18% and multidrug-resistant TB (MDR-TB) in 9%. New cases of TB accounted for 62% of the studied group. Drug resistance in this subgroup was 13% compared with 26.3% in the previously treated subgroup, and MDR-TB was 5.8% vs. 15.8%. All patients presented Hb levels < 9 g/dl and total lymphocyte counts < 1200/microl. CD4 counts were significantly low in the drug resistance subgroup, with levels mostly < 100/microl. Cavities on X-ray were seen only in drug-sensitive patients. No risk factors for drug resistance were detected. CONCLUSIONS: Overall observed drug resistance was 18%, and MDR-TB 9%. Previously treated patients had high drug resistance (26.3%) and MDR-TB (15.8%).

Diagnostic investigation of ventilator-associated pneumonia using bronchoalveolar lavage: comparative study with a postmortem lung biopsy

The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54 percent) were diagnosed as having VAP and 17 (46 percent) as not having the condition. Quantitative culture of BAL effluent showed 90 percent sensitivity (18/20), 94.1 percent specificity (16/17), 94.7 percent positive predictive value and 88.8 percent negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1 percent of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1 percent (16/17), and a cut-off point of 50 percent of BAL neutrophils showed a sensitivity of 90 percent (19/20). In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP

Diagnostic investigation of ventilator-associated pneumonia using bronchoalveolar lavage: comparative study with a postmortem lung biopsy.

The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54%) were diagnosed as having VAP and 17 (46%) as not having the condition. Quantitative culture of BAL effluent showed 90% sensitivity (18/20), 94.1% specificity (16/17), 94.7% positive predictive value and 88.8% negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1% of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1% (16/17), and a cut-off point of 50% of BAL neutrophils showed a sensitivity of 90% (19/20). In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP.

Subcutaneous injection of elemental mercury with distant skin lesions.

BACKGROUND: Mercury poisoning presents a variety of clinical pictures depending on chemical structure, amount absorbed, total mercury burden, and individual factors. Distant skin lesions, after subcutaneous injection of metallic mercury, have not been previously described. CASE REPORT: We present a homicidal, subcutaneous injection of mercury resulting in widespread skin lesions, remote from the radiologically visible mercury. The lesions appeared at 40 days and began to clear at 6 months after the injection.

Lead poisoning after gunshot wound.

CONTEXT: Despite the absence of symptoms in the majority of patients carrying lead bullet fragments in their bodies, there needs to be an awareness of the possible signs and symptoms of lead intoxication when bullets are lodged in large joints like knees, hips and shoulders. Such patients merit closer follow-up, and even surgical procedure for removing the fragments. OBJECTIVE: To describe a patient who developed clinical lead intoxication several years after a gunshot wound. DESIGN: Case report. CASE REPORT: A single white 23-year-old male, regular job as a bricklayer, with a history of chronic alcohol abuse, showed up at the emergency department complaining of abdominal pain with colic, weakness, vomiting and diarrhea with black feces. All the symptoms had a duration of two to three weeks, and had been recurrent for the last two years, with calming during interval periods of two to three weeks. Abdominal radiograms showed a bullet lodged in the left hip, with a neat bursogram of the whole synovial capsule. A course of chelating treatment using calcium versenate (EDTACaNa2) intravenously was started. After the chelation therapy the patient had recurrence of his symptoms and a radical solution for the chronic mobilization of lead was considered. A hip arthroplasty procedure was performed, leading to complete substitution of the left hip.

A clinico-epidemiological study of bites by spiders of the genus Phoneutria.

From January, 1984 to December, 1996, 422 patients (ages 9 m-99 y, median 29 y) were admitted after being bitten by spiders which were brought and identified as Phoneutria spp. Most of the bites occurred at March and April months (29.2%), in the houses (54.5%), during the day (76.5%), and in the limbs (feet 40.9%, hands 34.3%). Upon hospital admission, most patients presented only local complaints, mainly pain (92.1%) and edema (33.1%) and were classified as presenting mild (89.8%), moderate (8.5%) and severe (0.5%) envenomation. Few patients (1.2%) did not present signs of envenomation. Severe accidents were only confirmed in two children (9 m, 3 y). Both developed acute pulmonary edema, and the older died 9 h after the accident. Patients more than 70 year-old had a significantly greater (p<0.05) frequency of moderate envenomations compared to the 10-70-year-old individuals. Proceedings to relief local pain were frequently performed (local anesthesia alone 32.0%, local anesthesia plus analgesics 20.6% and oral analgesics alone 25. 1%). Only 2.3% of the patients (two cases classified as severe and eight as moderate, eight of them in children) were treated with i.v. antiarachnid antivenom. No antivenom early reaction was observed. In conclusion, accidents involving the genus Phoneutria are common in the region of Campinas, with the highest risk groups being children under 10 years of age and adults over 70 years of age. Cases of serious envenomation are rare (0.5%).

Presence of micronuclei in lymphocytes of mercury exposed workers.

We have investigated the presence of micronuclei in mercury exposed workers. The study group consisted of 15 workers from a mercury-producing plant, mean age 39.5 years and a mean exposed period of 12 years. At the time of testing and for the six previous months, the exposed population had urinary mercury levels below the currently accepted limit of 50 ug/g creatinine. A significant increase in the percentage of micronuclei was observed in the mercury exposed individuals when compared to the non exposed group. We have not found any correlation between the percentage of micronuclei and age, length of exposure or urinary mercury concentrations. Our results suggest a genotoxic effect of mercury, which is observed in workers exposed chronically to levels considered biologically safe for the exposed population.

Abnormal antioxidant system in erythrocytes of mercury-exposed workers.

To investigate the effects of chronic exposure to mercury we studied the red cell antioxidant system in mercury-exposed workers through the evaluation of reduced glutathione, catalase and superoxide dismutase systems. Of these workers, some were being exposed at the time and had presented urinary mercury levels considered safe for occupational exposure for at least 3 months prior to the initiation of this study, and others had been on leave for at least 6 months because of intoxication symptoms. Reduced glutathione levels were lower and catalase activity was higher in the workers which were still being exposed, compared to those on leave and controls. No differences were observed between the workers on leave and controls.

[Malignant mesothelioma of the pleura with etiological association to asbestos: report of 3 clinical cases]. / Mesotelioma maligno de pleura com associação etiológica a asbesto: a propósito de três casos clínicos.

UNLABELLED: Diffuse Malign Mesotheliomas (DMM) has a low background prevalence. High incidences of this tumor have been related to asbestos exposure in the past. PURPOSE: To describe and discuss three clinical cases treated in our hospital, in which precise histopathologic diagnosis was made, and detailed occupational and environmental histories were taken, trying to identify in their past some kind of asbestos exposure. METHODS: Three cases of DMM are described. Diagnosis was confirmed by histochemical analysis and electronmicroscopy. Detailed occupational and environmental histories were taken from subjects and their families, searching for past contact with asbestos. RESULTS: The cases were diagnosed in a short period of time (two years), in a region of the country where many asbestos cement plants are located since the mid sixties. Skillful histological procedures were used. From these cases we found out that one had a twelve months period of exposure, 24 years before, in one of those plants. Another patient had an exposure for three years, as a bystander, in the same plant (also 24 years before) and a third patient was contaminated by asbestos brought home by his father in the 1950s (latency period of 30 years). All cases were histochemically studied and diagnosis confirmed by the presence of microvilli at electronmicroscopic examination. CONCLUSIONS: These three cases seem to confirm the existence of the epidemiologic association with asbestos exposure in our country. Definition of diagnosis criteria, centralization of cases registry and the necessity of more attention to this kind of asbestos related disease are discussed and stressed, as many new cases like those described are thought to occur in the near future, as the latency period of the disease seems to match with that of industrial asbestos manipulation in Brazil.

Cerebellar atrophy related to chronic exposure to toluene. Case report.

A 31-year-old woman presented slowly progressing ataxia and neurasthenic symptoms after 14-year occupational exposure to low concentration toluene vapour. Examination disclosed only cerebellar signs. Cognitive functions were normal except moderate visuo-spatial and constructive deficit. CT imaging showed severe pancerebellar atrophy without pathological signs in other brain structures. Two years after she was removed from workplace, CT imaging and ataxia showed no worsening, while visuo-constructive function improved. The authors warn against possible neurotoxic risk associated with this kind of exposure.

Immunoglobulin levels in workers exposed to inorganic mercury.

The serum immunoglobulin (IgG, IgM and IgA) concentrations of 44 mercury-exposed workers were examined and compared with those of non-exposed, age- and sex-matched individuals. At the time of testing, the exposed population had a mean (+/- S.D.) mercury urinary concentration of 24.7 +/- 19.1 and in 40 of them urinary mercury levels were below the currently accepted limit of 50 micrograms/g creatinine. Increased IgG, IgA and IgM levels were found in the mercury-exposed individuals and in 16, a second evaluation was performed six months later. During the intervening six months, the level of hygiene was improved throughout the plant, and urinary mercury concentrations were determined monthly in each worker. Despite a significant reduction in mercury urinary concentrations, serum immunoglobulin levels did not return to the normal range. There was no correlation between the length or level of exposure and the immunoglobulin levels. Liver protein synthesis, as studied by factor V, prothrombin time, prealbumin and transaminase activity, was normal and liver injury, as evaluated by serum aspartate and alanine aminotransferase activities (AST and ALT, respectively), was not observed. No haematological abnormalities were noted. These results indicate that "safe" levels of mercury exposure may lead to humoral immunological stimulation.

[Prevalence of pneumoconiosis in workers exposed to phosphate rocks]. / Prevalência de pneumoconiose em trabalhadores expostos a rocha fosfática.

The occurrence of pneumoconiosis among workers at a phosphate rock mill in Paulinia, S. Paulo (Brazil), is analysed. Among the 73 exposed workers the occurrence of 20 cases of pneumoconiosis (27.4%) is registered. Beyond the physical examination, the investigation included spirometric examination, thorax X-rays, and lung biopsies during thoracotomy. The majority of the pneumoconiotic workers were assymptomatic with mild alterations in the spirometric pattern, mainly in the maximal medium expiratory flow, with 2 cases of restrictive pattern. The two lung biopsies did not reveal any degree of fibrosis and the analysis of the inhaled material, using X-ray spectrometry and colorimetric method, did not show enough SiO2 to promote fibrosis. It is concluded that the pneumoconiosis in question must be included in the non-fibrogenic group until further investigation can be made, by prospective research.