Seroprevalence of Chlamydia trachomatis and Associated Factors among Vulnerable Riverine in the Brazilian Amazon.

Due to social and individual conditions and access to health services, Amazonian riverside populations are highly vulnerable to sexually transmitted infections, including Chlamydia trachomatis. The aim is to estimate the seroprevalence of Chlamydia trachomatis and analyze the associated factors among riverside dwellers in a capital city in the Brazilian Amazon. A cross-sectional study was carried out with residents of the Combu Island, Belém. The study sample was calculated using the population survey technique in the EPI INFO. Only people aged 18 and over were included. ELISA serology was performed to detect antibodies against Chlamydia trachomatis. For data collection, a form containing vulnerability factor questions was applied. Binary regression analysis was performed using the Minitab 20 program. The study sample consisted of 325 participants. The prevalence of IgG/IgM antibodies against Chlamydia trachomatis was 22.2% and 5.5%, respectively. In the multiple regression, only participants with a broken condom were more likely to have antibodies against the bacteria (OR: 1.90; 95% CI: 1.01; 3.37; p = 0.046). Seroprevalence was associated with condom breakage. This factor demonstrates that despite having an attitude towards condom use, probably, they may have inadequate knowledge about the correct practice of introduction.

A Case Report: A 75-Year-Old Male With Abdominal Pain, Diarrhea, and Hypotension.

The differential diagnosis of abdominal pain ranges from benign to life-threatening conditions. This case report describes the importance of the differential diagnosis and a faster and more accurate diagnosis. A 75-year-old male presented to the emergency room (ER) with diffuse abdominal pain, associated nausea, vomiting, diarrhea, and a fever of 38.5ºC since the previous day. Medical history included hypertension, dyslipidemia, and obesity. Clinical examination showed hypotension and a distended abdomen with diffuse tenderness in all quadrants. Blood tests revealed a hemoglobin of 11.3 g/dL, and an arterial blood gas test revealed metabolic acidosis and lactate of 8 mmol/L. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed a large aneurysm in the infrarenal aorta with an extension of about 17x8x8 cm and an exuberant mural thrombus. The patient underwent endovascular treatment of the aneurysm; however, he died during surgery.

Light-Chain Multiple Myeloma: A Diagnostic Challenge.

Light-chain multiple myeloma (LCMM) is a less frequent type of multiple myeloma (MM), with a more aggressive course and poorer prognosis. It is characterized by the inability of the malignant plasma cells to produce heavy chains, resulting in the exclusive production of light chains. Therefore, no M-spike is visible in serum protein electrophoresis. We described the case of a 67-year-old female who presents to the emergency department with anemia, severe renal insufficiency, and multiple lytic bone lesions. After three days, the diagnosis of kappa light chain multiple myeloma was made in a patient with elevated serum and urinary kappa light chains and a bone marrow aspirate with 21.7% of atypical plasma cells. The rapid diagnosis allowed prompt referral to a specialized multiple myeloma center and early initiation of treatment.

Paraganglioma: An Unexpected Diagnosis in a Patient With Cerebral Venous Sinus Thrombosis and SARS-CoV-2 Infection.

Cerebral venous sinus thrombosis (CVST) is the complete or partial occlusion of the main venous sinuses or cortical veins. The most known risk factors are oral contraceptives, pregnancy, thrombophilias, malignancy and infections. The SARS-CoV-2 infection has been associated with a hypercoagulable state and there are some reported cases of CVST in SARS-CoV-2 patients. Although infection is one of the possible causes of CVST, it is important to rule out malignancy. We report a case of a 27-year-old male, with a recent SARS-CoV-2 infection, who went to the emergency department for a severe left occipital headache and was diagnosis with CVST. An etiological study revealed a retroperitoneal mass, compatible with a paraganglioma.

Hyperdynamic Valve: A Rare Case of Ehlers-Danlos Syndrome.

Ehlers-Danlos syndrome is a group of rare genetic disorders of collagen characterized by skin hyperextensibility, joint hypermobility and tissue fragility. The authors describe a rare case of a 52-year-old woman that presented to the clinic with chronic joint pain and talipes equinovarum since childhood. Large eyes, sunken cheeks, thin nose and lobeless ears were noticed on clinical examination. Beighton joint hypermotility criteria were met with a positive Walker and Steinberg sign, elbow extension superior to 10° and knee extension in genu recurvatum more than 10°. An aortic diastolic grade III/VI heart murmur was heard. The complementary study was unremarkable. Moderate aortic insufficiency was found on transthoracic echocardiogram. Genetic testing confirmed positivity for COL1A2, a gene that encodes pro-alpha2 chain type of collagen, which causes cardiac-valvular Ehlers-Danlos syndrome. Authors intend to warn to collagen-related syndromes, since severe complications are associated with a reduced life expectancy for individuals with this condition.

Linfoma de Burkitt como adenopatía axilar en un paciente inmunosuprimido / Burkitt lymphoma as an axillary adenopathy in an immunosuppressed patient

Burkitt lymphoma is derived from germinal or post-germinal center B cells and is a highly aggressive B cell non-Hodgkin lymphoma that represents <1 percent of adult non-Hodgkin lymphomas. The authors describe the case of a 63 years old Caucasian male, with history of human immunodeficiency virus infection, latent syphilis and varicella zoster infection on the left limb (L3 dermatome) who came to the emergency department with a palpable left axillary mass with three weeks evolution accompanied with vesicles 48 hours after. He reported a history of anorexia and weight loss on the past 3 months. Complete blood count was within normal range but was observed a fivefold elevation of lactate dehydrogenase and a CD4 count <200cells/microL. The histology of the adenopathic axillar conglomerate made the diagnosis of Burkitt lymphoma but, besides all efforts, the patient ended to die before starting a regimen of chemotherapy. (AU)

Hyponatremia: A Tip of the Iceberg in the Late Diagnosis of Tuberous Sclerosis Associated With Lymphangioleiomyomatosis.

Tuberous sclerosis (TS) is a rare, autosomal dominant, multisystem genetic disease that causes multiple benign tumors in the brain and other vital organs. Rarely, it can be associated with lymphangioleiomyomatosis (LMA) that is characterized by the proliferation of immature smooth muscle cells in the walls of the airways, venules, and lymphatic vessels in the lung. Here, we present the case of a 44-year-old intellectually disabled woman with a history of marked polydipsia who presented to the emergency department with persistent vomiting. She was hemodynamically stable and did not have any fever. The analytical study showed severe and symptomatic hyponatremia. On physical examination, multiple skin lesions compatible with angiofibromas were noted and the diagnosis of TS was made (confirmed with the genetic study). The multiorgan study documented the presence of multiple cystic images in the lung parenchyma associated with LMA. The aim of this case report is to highlight the importance of targeting cutaneous lesions for a rapid diagnosis of this pathology and to identify the etiology of a severe (symptomatic) ionic disorder and referral to a multidisciplinary team.

A Rare Cause of Dyspnoea: Right-sided Bochdalek Hernia in an Adult.

Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults. It commonly presents with gastrointestinal symptoms (pain, abdominal distension and vomiting). Breathlessness, recurrent chest infections and other pulmonary sequelae can also be present. We report the case of a 92-year-old man with a 3-day history of dyspnoea, fever and thoracic pain and multiple episodes of vomiting. An x-ray was performed, and the diagnosis of a large BH hernia was confirmed by computed tomography of the thorax. The condition may be fatal in cases where the small bowel undergoes necrosis or perforation. An emergent laparotomy was performed, but the patient did not improve clinically and died immediately after the procedure. LEARNING POINTS: Right-sided Bochdalek hernia (BH) is very rarely diagnosed in adults.Misdiagnosis of BH as a tension pneumothorax (which has a similar clinical presentation) can delay treatment and put patients at risk.The outcome of BH depends on the presentation, early diagnosis and emergent intervention.

Acute Kidney Failure: When Multiple Myeloma Doesn´t Give Additional Clues.

Multiple myeloma (MM) is characterized by a proliferation of malignant plasma cells and a subsequent overabundance of monoclonal paraprotein. This disease commonly presents with hypercalcemia, kidney failure, anemia, and bone lesions. Acute kidney failure (AKF) as an initial presentation of MM has rarely been reported. Herein, we present a case of a 49-year-old female who was admitted to our intensive care unit (ICU) for AKF in June 2017. The patient was admitted to our emergency room (ER) with abdominal pain and biliary vomiting within six days. From the laboratory tests, we highlight a serum creatinine of 19 mg/dl and urea of 377 mg/dl. The physical examination was globally unremarkable. Once clinically stable, she was admitted to our infirmary with a creatinine of 8.00 mg/dl. The patient underwent an extensive study: markers for hepatitis B and C, human immunodeficiency syndrome (HIV), and autoimmune markers were all negative; renal ultrasound, abdominal and pelvic CT had no relevant alteration; and the skeletal survey had no significant change. Peripheral blood smear showed no abnormalities. Serum immunoglobulin analysis revealed an elevated immunoglobulin A (IgA). Serum protein electrophoresis showed a monoclonal spike and urine protein electrophoresis showed an increased amount of protein consistent with Kappa light chains. The Kappa:Lambda chain ratio was increased. In order to understand the etiology of this AKF, we ended up performing a kidney biopsy, which was compatible with a myeloma kidney. The patient was transferred to the Portuguese Oncology Institute in Porto and initiated chemotherapy. Two months after the hospital discharge, creatinine levels were stable around 1.5 g/dL. This case illustrates AKF as the initial and sole presentation of MM. This presentation, even though previously reported, is very uncommon, especially considering that it occurred in a young woman and it was associated with light chain precipitation of IgA. MM is an important differential diagnosis in AKF, particularly when excluded pre and post-renal etiologies. Although being an invasive procedure with inherent possible complications, a kidney biopsy is still a very important procedure that was essential in this case to achieve a final diagnosis and, therefore, the patients' treatment.

Isoniazid-induced Lupus: When the Cure Can Be Lethal.

A 50-year-old female with a past medical history of bone tuberculosis diagnosed nine months ago was admitted in our infirmary for persistent fever with no evident cause. The patient was treated with isoniazid, rifampicin, pyrazinamide, and ethambutol for seven months and for the past two months, she was taking isoniazid and rifampicin. She went to our emergency room (ER) for back pain and fever that she had been experiencing for the last month. She was admitted with suspicion of disseminated tuberculosis that was never confirmed. Physical examination was unremarkable. Blood tests showed an elevation of inflammation parameters. A computed tomography (CT) scan of the chest showed a mild pleural effusion. She remained with fever during the three weeks in the infirmary while undergoing many other studies that were all negative. The back pain would change sides, and three consecutive thoracic radiographies showed a small-sized pleural effusion that was either predominantly right-sided or left-sided. Several differential diagnoses were considered in the process, namely an active infection, neoplasia, or autoimmune disease. The search for circulating lupus anticoagulant was positive. Antinuclear antibodies (ANA) were positive and the anti-histone antibody was strongly positive. At this point, we suspected a drug-induced lupus diagnosis, and isoniazid was discontinued. Following discontinuation of isoniazid, back pain and fever subsided and patient was discharged after one week. This case is a diagnostic challenge because of the rarity and symptom severity of isoniazid-induced lupus. Isoniazid rarely induced this lupus-like syndrome, with an incidence of considerably less than 1%.

An Overlapping Case of Miller Fisher Syndrome and the Pharyngeal-Cervical-Brachial Variant of Guillain-Barré Syndrome.

A 55-year-old Caucasian male presented initially to the emergency room (ER) reporting myalgia, chills and fever. Physical examination and laboratory tests were unremarkable and he was discharged with symptomatic care. He returned to our ER 2 weeks later reporting dizziness, loss of balance, blurred vision, mild dysarthria and bilateral hand paraesthesia. On examination, he presented complete bilateral ophthalmoplegia, mild dysarthria, left finger-to-nose dysmetria, ataxia, areflexia and bilateral hand hypoaesthesia without fever. Blood tests and head computed tomography were normal. The patient was admitted to the Internal Medicine department. On the second day on the ward, the patient presented dysphagia. A head magnetic resonance angiogram showed no signs of ischaemia or vascular disease and a lumbar puncture was performed but no pleocytosis, albumin-cytological dissociation or hypoglycorrhachia was present. Despite the normal results we suspected a Guillain-Barré syndrome variant, and started treatment with intravenous immunoglobulin (IVIG) at a dose of 400 mg per kilogram which continued for 5 days with immediate neurological improvement. We present a rare overlapping case of Miller Fisher syndrome and the pharyngeal-cervical-brachial variant of Guillain-Barré syndrome. LEARNING POINTS: The overlap of Miller Fisher syndrome and pharyngeal-cervical-brachial variants of Guillain-Barré syndrome are rarely described in the literature but should be considered when multiple cranial nerves are involved with normal neuroimaging results, even with normal cerebrospinal fluid analysis.Due to similar clinical presentation, a misdiagnosis of cerebral ischaemia, botulism or ocular myasthenia gravis can delay treatment and put patients at risk.In its natural history, this syndrome evolves to respiratory arrest and death, but with accurate diagnosis and prompt treatment, the prognosis improves considerably.

Ischemic enteritis with unusual presentation / Enteritis isquémica con presentación inusual

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