Estrogen-secreting adrenocortical tumor in a postmenopausal woman: a challenging diagnosis.

SUMMARY: Adrenocortical carcinoma (ACC) is a malignant disorder with rapid evolution and severe prognosis in adults and most produce cortisol and androgen. Estrogen-secreting adrenocortical carcinomas are extremely rare, especially in women, tend to be larger and have worse prognosis compared with other types of ACCs. We report the case of a 58-year-old woman who presented with bilateral breast enlargement and postmenopausal genital bleeding. She presented high estradiol (818 pg/mL - 25 times above upper normal limit for postmenopausal women) and testosterone (158 ng/dL - 2 times above upper normal limit) levels and no suppression of cortisol after overnight 1 mg dexamethasone test (12.5 µg/dL; normal reference value: < 1.8 µg/dL). The patient had no clinical features of cortisol excess. MRI showed a 12 cm tumor in the right adrenal. Clinical findings of bilateral breast enlargement and postmenopausal genital bleeding with no signs of hypercortisolism associated with hormonal findings of elevated estradiol and testosterone levels would indicate either an ovarian etiology or an adrenal etiology; however, in the context of plasma cortisol levels non-suppressive after dexamethasone test and the confirmation of an adrenal tumor by MRI, the diagnosis of an adrenal tumor with mixed hormonal secretion was made. The patient underwent an open right adrenalectomy and pathological examination revealed an ACC with a Weiss' score of 6. Estradiol and testosterone levels decreased to normal range soon after surgery. She was put on mitotane treatment as adjuvant therapy, but due to side effects, we were unable to up-titrate the dose and she never achieved serum mitotane dosage above the desired 14 µg/mL. The patient remained in good health without any local recurrence or metastasis until 5 years after surgery, when increased levels of estradiol (81 pg/mL - 2.5 times above upper normal limit) and testosterone (170 ng/dL - 2.1 times above upper normal limit) were detected. MRI revealed a retroperitoneal nodule measuring 1.8 × 1.2 cm. The pathological finding confirmed the recurrence of the estrogen-secreting ACC with a Weiss' score of 6. After the second procedure, patient achieved normal estrogen and androgen serum levels and since then she has been followed for 3 years. The overall survival was 8 years after the diagnosis. In conclusion, although extremely rare, a diagnosis of an estrogen-secreting ACC should be considered as an etiology in postmenopausal women presenting with bilateral breast enlargement, genital bleeding and increased pure or prevailing estrogen secretion. LEARNING POINTS: Estrogen-secreting adrenocortical carcinomas are exceedingly rare in adults and account for 1-2% of adrenocortical carcinomas. Estrogen-secreting adrenal tumors can be present in females, but are even more rare, we found few cases described in the literature. In women, they present with precocious puberty or postmenopausal bleeding. Feminization in the context of an adrenal tumor is considered almost pathognomonic of malignancy. Feminizing ACCs tend to be larger and with worse prognosis compared with nonfeminizing ACCs.

Effect of chemical and mechanical degradation on surface roughness of three glass ionomers and a nanofilled resin composite.

Nanofillers have been incorporated into glass ionomer (GI) restorative materials to improve their mechanical and surface properties. The aim of this present laboratory study was to compare the superficial roughness (Ra) of nanofilled GI (Ketac N100) with that of conventional GI (Fuji IX GP), resin-modified GI (Vitremer), and a nanofilled resin composite (Filtek Supreme) after pH cycling and toothbrush abrasion. Ten specimens of each material were made using Teflon molds, which were polished using aluminum-oxide abrasive disks. Three measurements of Ra were made of each specimen to serve as baseline values. The specimens were submitted to pH cycling for 10 days in a demineralization solution for six hours (pH 4.3) and were then stored in remineralization solution for 18 hours (pH 7.0). Ra measurements were recorded after the pH cycling. Specimens were then submitted to toothbrush abrasion in a brushing machine with a 200g load for 30,000 cycles at 250 cycles/min. The Ra values were then recorded. The surface morphology of specimens from each group was analyzed using a scanning electron microscope. Data were analyzed by analysis of variance, Tukey, and t-tests. After toothbrushing, only Fuji IX GP (1.10 ± 0.80) showed Ra values that were statistically different from those of the other materials evaluated. Ketac N100 (0.68 ± 0.16) showed intermediate Ra values, but it did not differ statistically from the results associated with Vitremer (1.04 ± 0.46) and Filtek (0.30 ± 0.15). Ketac N100 showed intermediate values of superficial roughness among the conventional glass ionomer cement, resin-modified glass ionomer cements, and the nanofilled resin after chemical and mechanical degradation.

MCNP simulation to optimise in-pile and shielding parts of the Portuguese SANS instrument.

A Small Angle Neutron Scattering instrument is being installed at one end of the tangential beam tube of the Portuguese Research Reactor. The instrument is fed using a neutron scatterer positioned in the middle of the beam tube. The scatterer consists of circulating H2O contained in a hollow disc of Al. The in-pile shielding components and the shielding installed around the neutron selector have been the object of an MCNP simulation study. The quantities calculated were the neutron and gamma-ray fluxes in different positions, the energy deposited in the material by the neutron and gamma-ray fields, the material activation resulting from the neutron field and radiation doses at the exit wall of the shutter and around the shielding. The MCNP results are presented and compared with results of an analytical approach and with experimental data collected after installation.

[Use of digitalis in elderly patients admitted to a geriatric unit at a general hospital]. / Uso de digital em idosos admitidos em unidade de geriatria de um hospital geral.

PURPOSE: To determine the prevalence of digoxin use as well as its indications in elderly patients at the time of admission to a geriatric unit of a general hospital. METHODS: One hundred and thirty elderly patients aged 65 and over (mean age = 80 +/- 9 years), 100 women and 30 men were consecutively investigated. Each patient was submitted to a thorough clinical investigation, laboratory work-up, chest X-ray, electrocardiogram and doppler echocardiogram. The use of digoxin was considered appropriate, questionable or inappropriate. RESULTS: At the time of admission to the geriatric unit 27.6% of the patients were receiving digoxin. The indication was considered appropriate in 36.1%, questionable in 11.1% and inappropriate in 52.7%. CONCLUSION: We found a high prevalence of digoxin use in elderly patients admitted to a geriatric unit of a general hospital. In most cases its indications were considered inappropriate or questionable. Due to the increased risk of digitalis intoxication in this age group the drug should be prescribed under more strict indications.

Plague surveillance in Brazil: 1983-1992.

Plague caused by Yersinia pestis, has persisted in Brazil in several natural foci spread throughout rural areas in the States of Ceara, Paraiba, Pernambuco, Piaui, Rio Grande do Norte, Alagoas, Bahia, Minas Gerais and Rio de Janeiro. Nationwide surveillance of plague in Brazil based on serological testing started in 1983. We now present an update report of the examinations carried out in our laboratory from 1983 to 1992. The passive hemagglutination test for antibodies against fraction 1A antigen of Y. pestis and the passive hemagglutination inhibition control were employed for testing a total of 220,769 sera. Samples analyzed included 2,856 sera from clinically diagnosed plague cases or suspects, 49,848 sera from rodents of 24 species and 2 species of small wild carnivores (marsupials), 122,890 sera from dogs, and 45,175 sera from cats. Specific antibodies were found in 92 (3.22%) human sera; 143 (0.29%) sera from rodents of 8 species and from the two species of marsupials, 1,105 (0.90%) sera from dogs and 290 (0.64%) sera from cats. The presence of significant levels of specific anti-F1A antibodies among rodents and wild or domestic carnivores (dogs and cats) indicates that all the Brazilian plague foci remain active in spite of the absence of human cases in some of them.

American cutaneous leishmaniasis in Pernambuco, Brazil: eco-epidemiological aspects in 'Zona da Mata' region.

American cutaneous leishmaniasis (ACL) has been increasing in Pernambuco, thus becoming an important problem for Public Health. The incindence is predominant in the region called 'Zona da Mata', in the east of this state. This region corresponds geographically to the primitive area of the Atlantic forest. In order to characterize the eco-epidemiology expression of ACL in this region, two localities situated in the municipalities of Amaraji e Cortes have been selected by the criterion of higher incindence of human cases. Five stocks of patients were characterized and identified on the basis of enzyme profiles as a new variant of Leishmania (V.) braziliensis. A survey of wild and domestic animals was carried out by means of a parasitological and serological diagnosis. Through the analysis of the spleen and liver imprints, were detected amastigotes compatible with Leishmania in five Nectomys s. squamipes, five Bolomys 1. pixuna, two Rattus r. alexandrinus and one Rattus r. frugivorus. For two years we carried out monthly sandflies captures using CDC light traps as well as manual captures. Lutzomyia whitmani was predominant, which accounted for 97.4% of the total. These data indicate a strong evidence on the vector and the potential reservoirs of L. braziliensis in this region.

[Intracranial cavernous angioma]. / Angioma cavernoso intracraniano.

Clinical, radiological and histopathological features of eight cases of symptomatic cavernous angioma are presented. Five patients were being evaluated for seizure, two for mass lesions and one for intracranial hemorrhage. CT and/or MRI detected the lesion in all cases, but there is not a characteristic image for cavernous angioma. Good results were obtained by microsurgical approach to these malformations in seven patients with only one patient suffering a worsening of neurological status after surgery.

[Duodenocolonic fistula. Report of a case and review of the literature]. / Fístula duodeno-cólica. Relato de um caso e revisão da literatura.

Malignant duodenocolic fistula due to carcinoma of the colon is an infrequent condition. The authors describe a case treated by right hemicolectomy associated with gastrectomy and partial duodenectomy. After a review of the literature, they discuss the surgical possibilities.

[Natural infection by Yersinia pestis, in fleas from plague foci in the northeast of Brazil]. / Pesquisa da infecção natural por Yersinia pestis, em pulicídeos provenientes de focos pestosos do Nordeste do Brasil.

Three different containment transport processes of fleas were evaluated as an approach to the bacteriologic isolation of Yersinia pestis. The three methods employed were: live fleas in glass tubes containing pieces of wrapped filter paper; dead fleas in saline solution; and macerated fleas in Cary-Blair culture medium. The two latter methods were almost equal and superior to the first method. A total of 29512 flea pools, from plaque foci in Northeast Brazil collected during 1966 to 1982 were evaluated by the three methods. Among these samples, 236 (0.80%) flea pools were positive with regard to bacteriological cultivation and/or infection of susceptible animals.

Tratamento cirúrgico da pancreatite aguda: experiência de um hospital geral / Surgical treatment of acute pancreatitis: experience in a general hospital

Foram estudados 15 casos de pancreatite aguda no Serviço de Clínica Cirúrgica do Hospital Universitário de Säo Paulo. Todos os pacientes desta série foram submetidos a laparotomia exploradora, com seqüestrectomia e drenagem. Foram relacionados etiologia, sexo, idade, complicaçöes e os critérios prognósticos de Ranson, com a mortalidade. A mortalidade geral foi de 33%

[Surgical treatment of acute pancreatitis: experience at a general hospital]. / Tratamento cirúrgico da pancreatite aguda: experiência de um hospital geral.

The authors present a study of 15 cases of necrotizing acute pancreatitis treated surgically at the Surgery Department of the University Hospital of the University of São Paulo. All patients in the series were submitted to exploratory laparotomy with sequestrectomy and drainage. Etiology, sex, age, complications, and Ranson prognostic criteria were compared to mortality. Overall mortality was 33%.

Endocardite infecciosa. Acometimento neurologico em cinco casos. / Infectious endocarditis. Neurological involvement in 5 cases

Dando maior enfase as alteracoes neurologicas, sao analisadas as caracteristicas clinicas de cinco pacientes com endocardite infecciosa. Os disturbios neuropsiquiatricos, em muitos casos desta patologia, sao os que abrem a cena clinica do enfermo ou sao as alteracoes que dominam a atencao do examinador, na fase inicial dificultando o reconhecimento da verdadeira origem dos achados de exame clinico.A presenca de sindromes neurologicas, na endocardite infecciosa, ensombrece o prognostico, sendo responsavel por morbidade e mortalidade. Os achados de exame fisico, de tomografia computadorizada cerebral, de cirurgia e de necropsia sao apresentados, demonstrando a multiplicidade e gravidade desta ocorrencia que parece nao ter diminuido com a introducao dos antibioticos.Nesta enfermidade, mesmo em presenca de queixas pequenas, tais como cefaleia persistente, estados confusionais, disturbios psiquiatricos ou, ainda, de discretas alteracoes liquoricas torna-se cada vez mais premente que realizemos uma investigacao completa, incluindo tomografia computadorizada cerebral e estudos angiograficos, para esclarecimentos e/ou determinar a conduta medica a ser seguida