Caso raro de embolia para o tronco da coronária esquerda, visto por ecocardiografia / Rare case of embolism to the left main coronary artery, seen by echocardiography

Pacientes com próteses valvares cardíacas podem apresentar complicações como trombose de prótese e endocardite infecciosa, elevando a morbimortalidade e frequentemente ocasionando a necessidade de reoperação. O ecocardiograma é o principal método utilizado no seguimento clínico e por vezes o diagnóstico do mecanismo de disfunção protética pode ser desafiador. RELATO DE CASO: Paciente de 54 anos, com antecedente de troca valvar mitral biológica em 2006, implante de marcapasso e fibrilação atrial permanente em anticoagulação com varfarina. Admitido no pronto-socorro em 2021 com febre e piora de classe funcional. Ao exame, apresentava-se em mau estado geral, confuso, taquidispnéico, com edema de membros inferiores e hipotensão arterial. Os exames laboratoriais evidenciaram hemograma com anemia, leucocitose com desvio à esquerda, marcadores inflamatórios elevados, INR fora da faixa terapêutica de anticoagulação (INR: 1,46). Eletrocardiograma em ritmo de marcapasso (FC 60 bpm). Ecocardiograma transtorácico com complementação esofágica mostrou aumento importante cavidades esquerdas, alteração segmentar (nova) grave em território de coronária esquerda, fração de ejeção reduzida em grau importante (FEVE= 14%, pelo método Simpson). Prótese mitral com folhetos espessados e mobilidade reduzida, área efetiva de fluxo= 1,2cm² (planimetria tridimensional), presença de múltiplas imagens ecogênicas em face ventricular com componente móvel, sugestivas de endocardite. Observou-se imagem ecogênica medindo 12 x 09 mm, relacionada ao seio coronariano esquerdo, estendendo-se para o interior do tronco da coronária esquerda (TCE), causando sua obstrução. Paciente evoluiu com piora clínica, choque refratário e óbito após 2 dias da admissão, não foi realizada autópsia para determinação diagnóstica da imagem ecogênica. DISCUSSÃO E CONCLUSÃO: O diagnóstico diferencial das massas embolizadas por ecocardiografia é desafiador, principalmente em casos cuja clínica sugere mais de uma possibilidade de fonte de embolia. O paciente descrito era portador de uma prótese cardíaca com alteração estrutural degenerativa suscetível tanto para quadro trombótico quanto para infeccioso (endocardite). Existem na literatura, relatos de diagnóstico de embolia séptica para a árvore coronária, a maioria deles, confirmado por cateterismo ou anatomia patológica (post mortem). Na revisão de literatura, não encontramos relatos de diagnóstico de embolia coronária feito por ecocardiografia, seja de trombose ou de vegetação, sendo, portanto, considerado um caso extremamente raro ou inclusive inédito.

Staphylococcal enterotoxin A regulates bone marrow granulocyte trafficking during pulmonary inflammatory disease in mice.

Pulmonary neutrophil infiltration produced by Staphylococcal enterotoxin A (SEA) airway exposure is accompanied by marked granulocyte accumulation in bone marrow (BM). Therefore, the aim of this study was to investigate the mechanisms of BM cell accumulation, and trafficking to circulating blood and lung tissue after SEA airway exposure. Male BALB/C mice were intranasally exposed to SEA (1µg), and at 4, 12 and 24h thereafter, BM, circulating blood, bronchoalveolar lavage (BAL) fluid and lung tissue were collected. Adhesion of BM granulocytes and flow cytometry for MAC-1, LFA1-α and VLA-4 and cytokine and/or chemokine levels were assayed after SEA-airway exposure. Prior exposure to SEA promoted a marked PMN influx to BAL and lung tissue, which was accompanied by increased counts of immature and/or mature neutrophils and eosinophils in BM, along with blood neutrophilia. Airway exposure to SEA enhanced BM neutrophil MAC-1 expression, and adhesion to VCAM-1 and/or ICAM-1-coated plates. Elevated levels of GM-CSF, G-CSF, INF-γ, TNF-α, KC/CXCL-1 and SDF-1α were detected in BM after SEA exposure. SEA exposure increased production of eosinopoietic cytokines (eotaxin and IL-5) and BM eosinophil VLA-4 expression, but it failed to affect eosinophil adhesion to VCAM-1 and ICAM-1. In conclusion, BM neutrophil accumulation after SEA exposure takes place by integrated action of cytokines and/or chemokines, enhancing the adhesive responses of BM neutrophils and its trafficking to lung tissues, leading to acute lung injury. BM eosinophil accumulation in SEA-induced acute lung injury may occur via increased eosinopoietic cytokines and VLA-4 expression.

Staphylococcus aureus brainstem abscess in a Brazilian Amazon man. Case report.

The brainstem is an uncommon site for a brain abscess. It accounts for less than 4% of all posterior cranial fossa abscesses, and less than 1% of all intracranial abscesses. The pons is the most common site for these abscesses. The aim of the present report was to describe the case of a Brazilian Amazon man with a brainstem abscess (BSA) managed with combined surgical drainage and systemic antibiotic therapy. This case reinforces the importance of an early suspicion of BSA in patients with unexplained fever and neurologic deficits, especially sixth and seventh cranial nerve lesions, to minimize permanent damage.

Mercury toxicity in the Amazon: contrast sensitivity and color discrimination of subjects exposed to mercury.

We measured visual performance in achromatic and chromatic spatial tasks of mercury-exposed subjects and compared the results with norms obtained from healthy individuals of similar age. Data were obtained for a group of 28 mercury-exposed subjects, comprising 20 Amazonian gold miners, 2 inhabitants of Amazonian riverside communities, and 6 laboratory technicians, who asked for medical care. Statistical norms were generated by testing healthy control subjects divided into three age groups. The performance of a substantial proportion of the mercury-exposed subjects was below the norms in all of these tasks. Eleven of 20 subjects (55%) performed below the norms in the achromatic contrast sensitivity task. The mercury-exposed subjects also had lower red-green contrast sensitivity deficits at all tested spatial frequencies (9/11 subjects; 81%). Three gold miners and 1 riverine (4/19 subjects, 21%) performed worse than normal subjects making more mistakes in the color arrangement test. Five of 10 subjects tested (50%), comprising 2 gold miners, 2 technicians, and 1 riverine, performed worse than normal in the color discrimination test, having areas of one or more MacAdam ellipse larger than normal subjects and high color discrimination thresholds at least in one color locus. These data indicate that psychophysical assessment can be used to quantify the degree of visual impairment of mercury-exposed subjects. They also suggest that some spatial tests such as the measurement of red-green chromatic contrast are sufficiently sensitive to detect visual dysfunction caused by mercury toxicity.

Mercury toxicity in the Amazon: contrast sensitivity and color discrimination of subjects exposed to mercury

We measured visual performance in achromatic and chromatic spatial tasks of mercury-exposed subjects and compared the results with norms obtained from healthy individuals of similar age. Data were obtained for a group of 28 mercury-exposed subjects, comprising 20 Amazonian gold miners, 2 inhabitants of Amazonian riverside communities, and 6 laboratory technicians, who asked for medical care. Statistical norms were generated by testing healthy control subjects divided into three age groups. The performance of a substantial proportion of the mercury-exposed subjects was below the norms in all of these tasks. Eleven of 20 subjects (55 percent) performed below the norms in the achromatic contrast sensitivity task. The mercury-exposed subjects also had lower red-green contrast sensitivity deficits at all tested spatial frequencies (9/11 subjects; 81 percent). Three gold miners and 1 riverine (4/19 subjects, 21 percent) performed worse than normal subjects making more mistakes in the color arrangement test. Five of 10 subjects tested (50 percent), comprising 2 gold miners, 2 technicians, and 1 riverine, performed worse than normal in the color discrimination test, having areas of one or more MacAdam ellipse larger than normal subjects and high color discrimination thresholds at least in one color locus. These data indicate that psychophysical assessment can be used to quantify the degree of visual impairment of mercury-exposed subjects. They also suggest that some spatial tests such as the measurement of red-green chromatic contrast are sufficiently sensitive to detect visual dysfunction caused by mercury toxicity.

Degradation of polychlorinated biphenyls (PCBs) by Staphylococcus xylosus in liquid media and meat mixture.

We investigated the growth of the meat starter Staphylococcus xylosus (10(4) cells mL(-1)) in liquid media containing 0.01 ppm of each polychlorinated biphenyls (PCBs 10, 28, 52, 138, 153, and 180) and its ability to degrade PCBs during 168 h of incubation in liquid media (10(4) cells mL(-1), 0.01 ppm of each PCB congener) and cured meat mixture (0.1% of meat starter, 1 microg g(-1) fat of each PCB congener). PCBs did not affect the growth of the starter microorganism in nutritive (brain heart infusion, BHI) or mineral salts medium (MSM) when compared to control (no PCB). S. xylosus degraded some of the PCB congeners tested. PCBs 138 and 153 were degraded both in BHI (78% and 68%, respectively; p<0.05) and in MSM (71% and 66%, respectively; p<0.05), with maximum degradation being observed within 24 h. Highly significant negative exponential relationships was observed between incubation time and concentrations of PCB 28 and 180 in BHI, as well as for PCBs 52 and 180 in MSM. In the cured meat mixture highly significant negative exponential relationship was observed between incubation time and the concentration of PCB 10. These results indicate that although S. xylosus reduced residues of various PCB congeners in liquid media, it was less effective in cured meat.

QBC for the diagnosis of human and canine american visceral leishmaniasis: preliminary data.

"Quantitative Buffy Coat" (QBC) is a direct and fast fluorescent method used for the identification of blood parasites. Since Leishmania chagasi circulates in blood, we decided to test it in American visceral leishmaniasis (AVL). Bone marrow (BM) and peripheral blood (PB) of 49 persons and PB of 31 dogs were analyzed. QBC was positive in BM of 11/11 patients with AVL and in 1/6 patients with other diseases. Amastigotes were identified in PB of 18/22 patients with AVL and in none without AVL. The test was positive in 30 out of the 31 seropositive dogs and in 28/28 dogs with Leishmania identified in other tissues. QBC is a promising method for diagnosis of human AVL, and possibly for the exam of PB of patients with AVL/AIDS, for the control of the cure and for the identification of asymptomatic carriers. Because it is fast and easy to collect and execute, QBC should be evaluated for programs of reservoir control.

Purification and characterization of a new trypsin inhibitor from Dimorphandra mollis seeds.

A second trypsin inhibitor (DMTI-II) was purified from the seed of Dimorphandra mollis (Leguminosae-Mimosoideae) by ammonium sulfate precipitation (30-60%), gel filtration, and ion-exchange and affinity chromatography. A molecular weight of 23 kDa was estimated by gel filtration on a Superdex 75 column SDS-PAGE under reduced conditions showed that DMTI-II consisted of a single polypeptide chain, although isoelectric focusing revealed the presence of three isoforms. The dissociation constant of 1.7 x 10(-9) M with bovine trypsin indicated a high affinity between the inhibitor and this enzyme. The inhibitory activity was stable over a wide pH range and in the presence of DTT. The N-terminal sequence of DMTI-II showed a high degree of homology with other Kunitz-type inhibitors.

Evaluation of the areas of neuronal cell bodies and nuclei in the myenteric plexus of the duodenum of adult rats

This study compared the areas of cell body and nucleus profiles of the myenteric neurons in the antimesenteric and intermediate regions of the duodenum of adult rats. Five male rats were used. The duodenum was removed and dissected to whole-mount preparations, which were stained by the Giemsa technique. The areas of cell body and nucleus profiles of 100 neurons, 50 from each region, of each animal, were assessed with image analyser. Based on the global mean +/- SD of the areas of cell body profiles, neurons were labelled as small, medium or large. It was observed that the neurons did not differ significantly in size or incidence between the antimesenteric and intermediate regions. However, the nuclei of the small and medium neurons were significantly smaller in the latter region. It is discussed that the smaller nuclear size could be related to the cell bodies being slightly smaller on this region and to a possible smaller biosynthetic activity which would influence nuclear size.

Number and size of myenteric neurons of the duodenum of adult rats with acute diabetes

This study had as its purpose to assess the effects of acute diabetes induced by streptozotocin (35 mg/kg body weight) on the number and size of the myenteric neurons of the duodenum of adult rats considering equally the antimesenteric and intermediate regions of the intestinal circunference. Experimental period extended for a week. Neuronal counts were carried out on the same number of fields of both regions of the duodenal circunference and measurements of neuronal and nuclear areas on equal numbers of cells. Number and size of the myenteric neurons stained with Giensa were not significantly different between groups. On the other hand, the proportion of NADH-positive neurons increased from 18.54 per cent on the controls to 39.33 per cent on the diabetics. The authors discuss that this increased reactivity probably results from a greater NADH/NAD* ratio, described in many tissues of diabetic animals, which has consequences on the modulation of the enzymes that use these cofactors and whose activity is detected by the NADH-diaphorase technique.

Fracture resistance of endodontically treated roots after restoration.

This study evaluated the shear strength resistance of endodontically treated roots that were restored by two different techniques. Twenty-seven recently extracted single-rooted teeth with similar anatomic characteristics were sectioned to obtain the same length for all specimens. Group I (GI) consisted of 14 roots restored with cast post-core (nickel-chromium alloy) and cemented using zinc phosphate cement; group II (GII) consisted of 13 roots restored with steel prefabricated posts (FKG) cemented with zinc phosphate cement and rotated with caution for anchorage. The crown portion of this group was made using a hybrid composite resin (Prisma APH). Results showed that on all specimens of GI the fracture occurred in the cervical root structure while in GII the composite resin fractured in all specimens. Statistical analysis showed a significantly higher resistance to fracture for GI than GII. The specimens were sectioned longitudinally for stereoscopic microscope analysis (63x) and did not show fracture lines in the dentin anchorage post area for any of the specimens.

The value of unenhanced CT in the diagnosis of acute appendicitis.

OBJECTIVE: To establish the accuracy of unenhanced CT in the preoperative diagnosis of acute appendicitis. DESIGN: Accuracy study, prospective and blinded. SETTING: The University Hospital. PARTICIPANTS: 52 patients with clinical and laboratorial manifestations of acute appendicitis. CT diagnosis was made by: presence of an abnormal appendix, appendiceal calculi with pericecal phlegmon or alterations in the pericecal appendicular site and absence of signs that may lead to other diagnosis. MAIN OUTCOME MEASURES: Overall accuracy, comparing the tomographic aspects with the intra-operative findings and pathological reports ("gold standard"). RESULTS: Acute appendicitis was confirmed in 44 cases. Efficacy was 92%, sensitivity was 91%, specificity was 100%, positive predictive value was 100% and negative predictive value was 67%. CONCLUSIONS: Unenhanced CT presents a similar overall accuracy to that reported by other authors who studied enhanced CT diagnosis of acute appendicitis.