Cardiac abnormalities in the acquired immunodeficiency syndrome. A prospective study with a clinical-pathological correlation in twenty-one adult patients.

OBJECTIVE: To evaluate the cardiac abnormalities and their evolution during the course of the acquired immunodeficiency syndrome, as well as to correlate clinical and pathological data. METHODS: Twenty-one patients, admitted to the hospital with the diagnosis of acquired immunodeficiency syndrome, were prospectively studied and followed until their death. Age ranged from 19 to 42 years (17 males). ECG and echocardiogram were also obtained every six months. After death, macro- and microscopic examinations were also performed. RESULTS: The most frequent causes of referral to the hospital were: diarrhea or repeated pneumonias, tuberculosis, toxoplasmosis or Kaposi sarcoma. The most frequent findings were acute or chronic pericarditis (42%) and dilated cardiomyopathy (19%). Four patients died of cardiac problems: infective endocarditis, pericarditis with pericardial effusion, bacterial myocarditis and infection by Toxoplasma gondii. CONCLUSION: Severe cardiac abnormalities were the cause of death in some patients. In the majority of the patients, a good correlation existed between clinical and anatomical-pathological data. Cardiac evaluation was important to detect early manifestations and treat them accordingly, even in asymptomatic patients.

Rheumatic carditis treated with high doses of pulsetherapy methylprednisolone. Results in 70 children over 12 years.

PURPOSE: To report the result of patients treated with IV methylprednisolone divided into three groups and compare their follow-up during the last 12 years. METHODS: Seventy children with active rheumatic carditis (76 episodes) in heart failure Class III and IV (NYHA) were studied. The diagnosis was based on modified Jones' criteria. After ruling out infections and strongyloidiasis, treatment with IV methylprednisolone bolus was started three times a week until the laboratory tests became negative. Patients were divided into 3 groups, according to the time of hospital admittance: Groups 1, 2 and 3, comprising of 40, 18 and 12 children, respectively. RESULTS: Eighteen children in Group 1 (45%) were in their 1st attack: 2 series of pulsetherapy were used in 10 (25%), 3 in 9 (23%) and 4 in 21 (52%). In Group 2, 14 cases (77%) were in their 1st attack: 2 series were used in 7 (39%), 4 in 9 (50%) and 5 in 2 (11%). The echocardiogram showed a flail mitral valve in 12 (66%) of these patients (1 death occurred after mitral valvoplasty). In Group 3, 6 patients needed 5 or more series of pulsetherapy and a flail mitral valve was present in 5 (41%). One child underwent mitral valve replacement while still in the active phase, after 8 series of pulsetherapy, and another died. The number of patients who needed 5 or more series was significantly higher in Group 3. CONCLUSION: There were variations in the presentation and evolution of the cases during these 12 year. The established pulsetherapy protocol continues to be useful to treat severe cases.

[Perinatal asphyxia and heart problems]. / Asfixia perinatal e problemas cardíacos.

PURPOSE: To evaluate the severity of cardiac complications of neonatal asphyxia in relation to the length and degree of hypoxia. METHODS: Ninety babies with an Apgar score < or = 6 were examined in the intensive care unit at our institution during seven years. Arterial blood for measuring pH, glucose, LDH and MB fraction of CK, together with serial electrocardiogram (ECG), echocardiogram and chest X rays was obtained. The fatal cases were studied with macro and microscopic examination. RESULTS: From a total of 90 cases, 73 were premature: 30 (41%) appropriate for gestation age (AGA) and 43 (59%) small for gestation age (SGA). Twenty one (23%) cases had arterial pH < 7.2. The most common clinical conditions were: pneumonia 28 (31%), anemia 24 (26%) and jaundice 12 (13%). The main cardiological findings were: systolic murmur in 46 (50%), signs of heart hypertrophy in 18 (20%) and heart failure in 8 (9%). On ECG the main findings were ST and T abnormalities. The echocardiogram showed a patent ductus arteriosus (PDA) in 20 (22%), tricuspid regurgitation in 6 (7%), pulmonary hypertension in 6 (7%), dyskinesia and ventricular dilatation in 4 (5%). Necropsy was performed in 23 cases and macro and microscopy obtained in 14; the most frequent findings were: myocite necrosis in 8 (54%), congestion, vacuolization and loss of striae in 4 (29%). CONCLUSION: In the majority of cases, patients had a benign course, even those presenting with severe acidemia. Many abnormal EKGs and echocardiograms became normal after a few weeks. Among those who had a fatal outcome, the severity of histological lesions was observed in babies who had suffered asphyxia for more prolonged periods.

[Cardiac changes in children with AIDS]. / Alterações cardíacas em crianças com SIDA.

PURPOSE: To describe the cardiac findings in children with AIDS, the follow-up with treatment and the correlation between clinical and pathological features. METHODS: We studied prospectively 25 children with clinical-laboratorial diagnosis of AIDS, ages between 3 months and 11 years, even those without cardiac symptoms. We classified the signs of AIDS following that of CDC-Atlanta 1994. Eight children died and it was done necropsy in six with macro and microscopic examinations. RESULTS: Fifteen cases had already complications of AIDS and were classified as C2 and C3, 5 as B2, 3 B1 and 2 as A1. Beside the symptoms related to the disease and infections we found signs of congestive heart failure III and IV (NYHA) in 5 children, pericardial effusion in 5, (one of them had cardiac tamponade). In the electrocardiogram (EKG), 8 children had repolarization abnormalities. In 1st echocardiogram (ECHO) we found some features of dilated myocardiopathy in 8 (6 were asymptomatic) 5 of those had pericardial effusion, one child had huge amount of pericardial liquid and also increased measures of intraventricular septum and posterior wall of left ventricle by ECHO and confirmed by necropsy examination. All cases of diagnosis of myocardiopathy received treatment with captopril and 4 also received furosemide and digoxina. Even under oral treatment three of them had deterioration of heart failure but after combined anti-retroviral drugs they showed better cardiac functions. From the six necropsied cases, two had increased heart weight without myocarditis, one had toxoplasma pancarditis and other one had fibrocalcic vasculopathy. CONCLUSION: We found several assymptomatic cases already with decreased ventricular function. Some worsened of heart failure even under apropriate treatment and showed better cardiac index after combined anti-retroviral drugs.

[Secondary prophylaxis in rheumatic fever. Oral antibiotic therapy versus benzathine penicillin]. / Profilaxia secundária na febre reumática. Antibioticoterapia oral versus penicilina benzatina.

PURPOSE: To detect problems related to secondary prophylaxis of rheumatic fever in the setting out patient follow-up. METHODS: Among 113 pediatric patients admitted with diagnosis of this disease, in a period of five years, we selected 80 records. They were divided in group 1 (60 cases), that only received prescription of benzathine penicillin for prophylaxis and group 2 (20 patients) to whom it was changed from parenteral to oral antibiotics after the detection problems using the first scheme. RESULTS: In group 1, among 53 who had carditis, 27 (45%) had severe disease; 22 cases (37%) were re-admitted with relapsed carditis following the refusal to use benzathine penicillin. Also, we observed that after discharged 32 (55%) did not return to the out-patient clinic in HUAP. In group 2, from 16 who had carditis, 10 (50%) had severe disease. Only two (10%) did not return to ambulatory control and there was no case of readmission. The difference between the groups was statistically significant. (p < 0.01). CONCLUSION: It was very high the percentage of cases that missed the control visits and abandoned the prophylaxis when it was insisted on parenteral penicillin. We should evaluate every case and remember that oral antibiotics might avoid a major problem.

Estudo clínico e ecocardiográfico das alteraçöes do aparelho mitral em crianças com cardite reumática grave. Aspecto de prolapso ou ruptura / Clinical and echocardiographic study of mitral valve in children with severe rheumatic carditis. Aspects of prolapse or rupture

Objetivo - Descrever casos de cardite reumática com aspecto ecocardiográfico de prolapso ou ruptura de cordoalha da mitral. Métodos - foram estudados 16 casos de cardite aguda (entre 5 e 15 anos), sendo que em 10 havia aspecto de prolapso mitral (grupo 2). As medidas das cordoalhas anteriores e anéis foram comparadas a 5 casos de febre reumática fora da atividade com dilataçäo de ventrículo esquerdo com insuficiência aórtica (grupo 3) e a 20 crianças normais com mesmas idades. Nos grupos 1 e 2 repemos as medidas após o tratamento. Resultados - A média das medidas no grupo 1 foi cordoalha naterior 26,48 + ou - 11,46 mm, diâmetro do anel 32,13 + ou - 7,35 mm; no grupo 2, respectivamente 29,72 + ou - 4,57 mm e 35,63 + ou - 7 mm e no grupo 3, 34,52 + ou - 6,8 mm para cordoalha anterior e 34,8 + ou - 4,61 mm para o anel. Entre as crianças normais as medidas foram, respectivamente, 18,19 + ou - 4,26 mm e 24,66 + ou - 2,85 mm. Após imunossupressäo (corticoterapia) ocorreur melhora do aspecto ecocardiogrfco em alguns casos. A analise estatística revelou que comparando as medidas das crianças dos grupos 1 e 2 com as normais, a diferença foi significativa, mas näo com as do grupo 3. Comparando as medidas antes e depois do tratamento também näo houve diminuiçäo siginificativa (grupo 1 e 2). Conclusäo - a cardite aguda provocou, nestes casos, alongamento significativo das cordoalhas e dilataçäo do anel mitral. A diminuiçäo das medidas após o tratamento näo foi significativa.

Purpose - To describe cases of rheumatic carditis with echocardiographic aspects of prolapse or rupture of mitral structures. Methods - We described 16 cases of acute carditis (ages between 5-15 years). In 10 (group 1) there was aspect of mitral prolapse, in 6 (group 2) aspect of "flail". The measurements of anterior chordae and anuli were compared to the ones of 5 cases of chronic rheumatic fever with dilated left ventricle and aortic regurgitation (group 3) and to 20 normal children of same ages. The same measurements were repeated after treatment. Results - The mean of the measurements in group I was; 26.48±11.46mm ­ anterior chordae; 32.13±7.35mm anuli; in the group 2 was respectively 29.63±4.57mm and 35.63±7mm. In the group 3 anterior chordae was 34.52 ±6.8mm, anuli: 34.8 ±4.61mm. In the normal group, respectively was: 18.19±4.26mm and 24.66±2.85mm. After corticosteroid many cases improved. In the statistical. In the statistical analyses, the measurements among patients of group 1 and 2 compared to normal children, the difference was significant but it was not compared to group 3. Comparing the measurements pre and post treatment the decrease was not significant. Conclusion ­ The acute carditis in these cases lead to significant elongation of anterior chordae and dilatation of anuli, but there was not a significant decrease after treatment

[Clinicopathologic correlation in 50 cases of acquired immunodeficiency syndrome. Retrospective study]. / Correlação clínicopatológica de 50 casos de síndrome de imunodeficência adquirida. Estudo retrospectivo.

PURPOSE: To analyze myocardial abnormalities in patients of acquired immunodeficiency syndrome with clinical and pathological correlation. METHODS: We selected 50 cases, retrospectively, age ranged from 3 months to 40 years, all of them had myocardial changes and the data of clinical records fulfilled our protocol. Cases of others cardiac diseases were not included. RESULTS: The pathological findings were: myocarditis in 33 (11 had severe myocarditis) and degenerative hystological lesions in 17. The etiologic agents detected were: Toxoplasma in 11, Cryptococcus in 7 and Cytomegalovirus in 3. In 12 cases we could not find any agent. In 15 cases occurred others lesions: endocarditis, pericarditis and sarcoma of Kaposi. It was noted tachycardia in 15 cases, decrease of heart sounds in 12, arterial hypotension in seven, systolic murmur in 8, galop rhythm in 7, pericardial friction rub in 3, arrhythmia in 2. Four patients had congestive heart failure. The EKG showed sinus tachycardia in 18, ST and T changes in 10, low voltage in 5, ST segment elevation in 5 and extrasystoles in 3 cases. The echocardiogram findings were: pericardial effusion in 9 cases and 9 had ventricular dysfunction. CONCLUSION: The cardiac lesions were very important even in patients without clinical signals. We need others prospective studies with viral identification trying to detect specific lesions of HIV.

[Pulse therapy (high doses of venous methylprednisolone) in children with rheumatic carditis. Prospective study of 40 episodes]. / Pulsoterapia (altas doses de metil-prednisolona venosa) em crianças com cardite reumática. Estudo prospectivo de 40 episódios.

PURPOSE: To use corticosteroids in a shorter period to treat rheumatic carditis, keeping the patient in the hospital; and verify the time interval of normalization of rheumatic activity tests with this method. METHODS: In 36 patients (40 episodes) intravenous methyl-prednisolone (1g/day) was administered. The number of series ranged from two to four, according to severity of the disease. The ages ranged from 6 to 17 years old, all of them fulfilled the criteria of Jones for diagnosis of rheumatic fever. They were submitted to treatment to eradicate the streptococcus, worms, PPD and dental focus extraction, before use of corticosteroids. RESULTS: In all patients the signals and symptoms of heart failure improved. In six cases occurred complications during pulse therapy that were easily controlled with clinical measures. Two series of methylprednisolone were used in 10 children, three in nine and four in 21 episodes. Eight patients were sent to valve replacement. The interval of time that laboratory tests of rheumatic activity became negative was 41.2 +/- 13.3 days. CONCLUSION: Using this IV corticotherapy it was possible decrease the amount of days of this medication, keeping the patient in the hospital. In this way we eliminate the problem of interruption of the treatment. There was not significative difference between oral and IV corticotherapy in order to the laboratory tests become negative.

[Severe tricuspid valve insufficiency due to papillary anterior muscle infarction of the right ventricle secondary to neonatal hypoxia]. / Insuficiência tricúspide severa por infarto do músculo papilar anterior do ventrículo direito secundário à hipóxia neonatal.

A fatal case of a stressed newborn baby who developed tricuspid insufficiency due to an anterior papillary muscle infarction of the right ventricle, related to perinatal anoxia is reported. The baby needed resuscitation management and had a systolic murmur soon after birth. The echocardiographic examination showed a flail anterior leaflet of the tricuspid valve due to an avulsed anterior papillary muscle. There was rupture of chordae tendineae between anterior and posterior leaflet. Necrosis and calcium deposit were found in the area. The conclusion was that the anoxia in perinatal period, in most cases, causes transient lesions, but in few cases might be severe and fatal. It is important a complete cardiac evaluation in every case of prolonged perinatal stress.

A rapid test for the detection of a B-cell marker (D8/17) in rheumatic fever patients.

A new, rapid blood test for the detection of B-cell markers in patients with rheumatic fever (RF) was applied to 10 patients with RF, 26 of their family members and 14 normal subjects. Three-hundred microliters of blood was obtained by finger-pricking from each subject and submitted to the immunofluorescence technique using three different antibodies, i.e., D8/17 monoclonal ascites antibody, FIRC-conjugated goat anti-mouse IgM (mu chain specific) and phycoerythrin-conjugated murine anti-HLA-DR antibody. D8/17 lymphocytes (green stain) and B-lymphocytes (red stain) were counted using a double-filter microscope. The percentage of positive cells was 20-64% (average 38.5%) in patients, siblings, fathers and mothers, 4.5% in 12 normal controls and 27.5% in the other 2 controls with a family history of RF. In 90% of the families studied, the patients had the highest percentage of positive cells. We conclude that this rapid test can be used as an aid for RF diagnosis and possibly to detect siblings who are at risk to develop the disease.

[Coxsackie B virus in children with acute myocarditis]. / Virus Coxsackie B em crianças com miocardite aguda.

PURPOSE: To study etiopathogenic and follow-up aspects of patients with myocarditis. PATIENTS AND METHODS: Among 44 cases of acute myocarditis in children studied from clinical and virological point of view, it was selected 16 which were positive to coxsackie B virus. The clinical investigation included blood test to enzyme dosage, chest X-ray, electro and echocardiogram. The virological work up to coxsackie B1, B3, B4, B5 and B6 included culture neutralization test and IgM (indirect immunofluorescence). RESULTS: The positive results were: B4 in 9 (57%); B5 in 4 (25%), B1 in 2 (12%) and B3 in 1 (6%). It was not used immunosuppressive treatment. The follow-up (at least one year it was: 7 patients became free of symptoms (43%); 4 (25%) turned to be chronic dilated myocardiopathy 1 (6%) died and 4 (25%) were discharged from hospital but did not return to out-patient clinic. One of patients of chronic group during 4 years of follow-up had ventricular extrasystoles, second degree heart block and now is asymptomatic. CONCLUSION: We did not observe significative differences among the several types of coxsackie B related to clinical course.

Ação do espilantol (extraído do jambu) sobre a atividade elétrica do coração do coelho. Eletrocardiograma experimental / Effect of spilanthol (extracted from jambu) on electrical activity of the heart of rabbits. Experimental electrocardiogram

Foram estudados os efeitos do espilantol, extraido do Jambu (Spilanthes oleracea Jacq), sobre a atividade eletrica do coracao isolado do coelho. Esta substancia e uma amida que produz na mucosa oral uma sensacao semelhante a dos anestesicos locais. Seus efeitos sobre o eletrocardiograma foram comparados aos produzidos pela procainamida. A tecnica empregada foi o eletrocardiograma experimental durante a perfusao de Langendorff. Foram feitas 20 experiencias usando concentracoes decrescentes de espilantol (40-0,1 mg/l) e os resultados obtidos mostram que o espilantol e arritmogenico (arritmias ventriculares e supravenventriculares). Provoca disturbios da conducao que se traduzem como bloqueio de 1o., 2o. e 3o. graus. Conclui-se que o espilantol, provavelmente, age sobre o componente rapido do potencial de acao de modo semelhante aos antiarritmicos do grupo 1. Difere fa procainamida, principalmente, porque exacerba a ritmicidade.Contrariamente as espectativas, essa substancia nao serve como antiarritmico e podera servir de modelo arritmogenico para testar drogas antiarritmicas