[Meningoencephalitis in the acute phase of measles. Report of 6 cases]. / Meningoencefalite na fase aguda do sarampo: relato de seis casos.

We present the clinical and laboratory manifestations of encephalitis following measles in six patients which were diagnosed during the epidemics that occurred in the city of São Paulo, Brazil, in 1997. We performed retrospective case analysis of the six patients diagnosed as having encephalitis due to measles. Encephalitis was diagnosed based on clinical grounds and on the cerebrospinal fluid (CSF) alterations. All the cases were serologically confirmed. Of 467 patients with measles who presented themselves for medical care at the Instituto de Infectologia Emílio Ribas six were diagnosed with encephalitis. Patient's age was 2 months to 28 years old. The most frequent symptoms were drowsiness and nuchal rigidity. CSF showed an increased of white cell count in all cases. Four patients were admitted to the intensive care unit. Two of them required mechanical ventilation. In only two patients did the computerized tomography show abnormalities. All showed good recovery without sequelae.

Acute lung injury in leptospirosis: clinical and laboratory features, outcome, and factors associated with mortality.

Forty-two consecutive patients with leptospirosis and acute lung injury who were mechanically ventilated were analyzed in a prospective cohort study. Nineteen patients (45%) survived, and 23 (55%) died. Multivariate analysis revealed that 3 variables were independently associated with mortality: hemodynamic disturbance (odds ratio [OR], 6.0; 95% confidence interval [CI], 0.9-38.8; P=. 047), serum creatinine level >265.2 micromol/L (OR, 10.6; 95% CI, 0. 9-123.7; P =.026), and serum potassium level >4.0 mmol/L (OR, 19.9; 95% CI, 1.2-342.8; P=.009). These observations can be used to identify factors associated with mortality early in the course of severe respiratory failure in leptospirosis.

Fatal group A Streptococcal toxic shock-like syndrome in a child with varicella: report of the first well documented case with detection of the genetic sequences that code for exotoxins spe A and B, in São Paulo, Brazil.

A previously healthy seven-year-old boy was admitted to the intensive care unit because of toxaemia associated with varicella. He rapidly developed shock and multisystem organ failure associated with the appearance of a deep-seated soft tissue infection and, despite aggressive treatment, died on hospital day 4. An M-non-typable, spe A and spe B positive Group A Streptococcus was cultured from a deep soft tissue aspirate. The criteria for defining Streptococcal toxic shock-like syndrome were fulfilled. The authors discuss the clinical and pathophysiological aspects of this disease as well as some unusual clinical findings related to this case.

[Necrotizing fasciitis. Case report and review of literature]. / Fasciíte necrotizante. Relato de caso e revisão de literatura.

Necrotizing fasciits (NF) is a rapidly progressive disease characterized by extensive necrosis of the fascia, skin, and subcutaneous tissue, with characteristical sparing of the underlying muscle. It is considered to be a rare entity and is associated with a high mortality rate since early recognition and treatment are not provided. Extensive surgical debridement of all necrotic tissues and appropriate antimicrobial treatment are the cornerstones for a successful treatment. We present a case of NF in a 36-year-old man and discuss it's pathophysiology, clinical manifestations and the best therapeutic choice for this potential life threatening disease.

Acute disseminated encephalomyelitis: an unusual cause of encephalitic syndrome in childhood.

Acute disseminated encephalomyelitis is a rare central nervous system demyelinating disease that occurs most frequently in children. It usually runs a monophasic course, beginning with fever, headache, and meningeal signs and rapidly progressing to coma when appropriate diagnosis and treatment are not provided. We report a case of a 14-year-old patient to alert emergency physicians to consider acute disseminated encephalomyelitis when presented with any child with encephalitic signs with nonspecific cerebrospinal fluid findings, failure to detect any causative agent, and only mild alterations on computerized tomography scan. The role of magnetic resonance imaging for the diagnosis is emphasized.

Hantavirus pulmonary syndrome. Report of the first three cases in São Paulo, Brazil.

The hantavirus pulmonary syndrome was first recognized in cases that occurred in the U.S. in 1993, which served as an alert not only for American physicians but also for physicians in other countries for the identification of the disease. In the city of São Paulo, Brazil, 3 cases of the syndrome were recorded in 1993. The patients were young brothers residing in the Mata Atlântica (Atlantic Forest) region submitted to recent deforestation. Two of the patients died of acute respiratory insufficiency and the third recovered without sequelae. In the surviving patient the diagnosis was established by a laboratory criterion based on the detection of specific IgM and IgG class antibodies by indirect immunofluorescence. In the two patients who died, the diagnosis was confirmed by laboratory tests using immunoperoxidase technique for hantavirus in tissue, in histological lung and heart sections in one case, and by clinical and epidemiological data in the other.

Outcome of leptospirosis in children.

We conducted a retrospective analysis of 43 consecutive children (35 boys and 8 girls), 4-14 years of age and living in an urban area, who were hospitalized at the Instituto de Infectologia Emilio Ribas (Sao Paulo, Brazil) from January 1989 to December 1995 with an acute illness subsequently diagnosed as leptospirosis. Epidemiologic data indicated contact with contaminated water in most cases (88%). The patient sera reacted most strongly with Leptospira interrogans serovars copenhageni (45%) and icterohaemorrhagiae (32.7%). Jaundice was present in 70% of the patients, elevated transaminase levels in 56%, renal failure in 79%, meningitis in 23%, thrombocytopenia in 65%, and hemorrhagic manifestations in 11.6%. Three children had pulmonary hemorrhage with respiratory failure and one death occurred as a consequence of respiratory failure. We also observed that antimicrobial therapy reduced the extent of renal failure and thrombocytopenia. These data indicate that antibiotics benefit children with late, severe leptospirosis and that severe disease also occurs in children and should be considered in the differential diagnosis.

Outcome of acute renal failure in meningococcemia.

We studied 28 consecutive patients (18 males and 10 females), 1-32 years of age, admitted to the intensive care unit from January 1989 to July 1995, with acute renal failure (ARF) due to meningococcal septicemia. All patients were treated with dexamethasone, penicillin, and/or chloramphenicol. Twenty-two patients presented septic shock and needed fluid replacement and vasoactive drugs. Acute renal failure was oliguric in 67.8%. Maximum levels of blood urea and serum creatinine were 210.3 +/- 26.6 mg/dL and 6.9 +/- 1.3 mg/dL, respectively. Metabolic acidosis was observed in 89.3% and hyperkalemia in 43%. The fractional excretion of sodium on day 1 was high (9.9 +/- 0.6%). The urinalysis did not show trace protein, but hematuria was positive in 81%. The mortality rate was 63.3%. In the 10 survivors, oliguria was present for a period of 12.7 +/- 2.4 days, and the period to reach a normal serum creatinine level was 20.2 +/- 4.7 days, although in two female patients, 7 and 17 years old, the elevated serum creatinine persisted. Renal biopsy was performed in one of these patients which revealed bilateral cortical necrosis. These data show that acute renal failure in meningococcemia presents high mortality rate associated to shock; 80% of the survivors recover renal function; and bilateral cortical necrosis occurred in one patient in this series.

Cutaneous immediate and late phase reactions to schistosomin in schistosomiasis patients.

Cutaneous immediate and late phase reactions (LPR) to schistosomin were studied in 29 patients with schistosomiasis mansoni. In 12 of these patients, the determination of total and specific serum IgE by immunoenzymatic method against schistosome antigen was carried out using serum samples obtained on the same day as the cutaneous tests. Skin biopsies were taken from 4 typical LPRs. Immediate reactions occurred in all except one and LPRs in 12 (41.3%). Patients with positive cutaneous reactions had highe levels of specific serum IgE against schistosome antigen. Histopathological studies showed a moderate exudate consisting mainly of neutrophils (60%) and eosinophils (40%). LPRs in schistosomiasis have the same characteristics reported in the medical literature in relation to time of appearance, morphology and histopathology. The immunopathogenic role played by LPRs in the patients remains to be clarified.