Rare case of symmetrical peripheral gangrene due to septic shock, disseminated intravascular coagulation and inotropic use.

INTRODUCTION: Symmetrical peripheral gangrene (SPG) is a rare syndrome defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease. PRESENTATION OF CASE: A 45yo woman, admitted in intensive care unit due to urinary septic shock, in need of high doses of amines, developed cold extremities with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, liver shock, thrombocytopenia, prolonged coagulation times, increased D-Dimers and isolation of Acinetobacter baumanni in urine culture. An intravenous vasodilator was initiated with clinical benefits. After improvement and delimitation of the lesions, the patient underwent the amputation of the distal phalanges of the 2nd, 3rd and 4th fingers of the right hand and the toes of both feet. DISCUSSION/CONCLUSION: Even though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasodilators are used, in order to avoid major amputation.

Effects of L-Arginine Supplementation on Leukogram, Inflammatory Bowel Infiltrates and Immunoglobulins with 5-FU Use in Rats.

This study evaluated the effects of L-arginine supplementation on blood parameters, kidney and liver function, immunoglobulins and noninflammatory infiltrates in the small intestines of rats subjected to chemotherapy with 5-fluorouracil (5-FU). Thirty-two Wistar rats were randomly distributed into 4 groups (8 rats/group): an untreated control group, and test groups receiving one dose of 5-FU (G5-FU group), one dose of 5-FU and 295 mg L-arginine/day (GArg295 group) or one dose of 5-FU and 458 mg L-arginine/day (GArg458 group). Neutrophil count, platelet count, serum IgA, and fibrinogen levels in GArg295 and GArg458 remained within normal limits after chemotherapy. In addition, in GArg458 the inflammatory bowel infiltrates improved in 57% of the rats, which showed mild inflammation. The results suggest that daily supplementation with 295 or 458 mg L-arginine attenuates the side effects of 5-FU, including thrombocytopenia and neutropenia, and modulates IgA production. Supplementation with 458 mg of L-arginine/day can also reduce mucositis levels in the small intestine after 5-FU chemotherapy.

Adult right-sided Bochdalek hernia with ileo-cecal appendix: Almeida-Reis hernia.

INTRODUCTION: Bochdalek hernia is one of the most common congenital abnormalities manifested in infants. In the adult is a rarity, with a prevalence of 0.17-6% of all diaphragmatic hernias. Right-sided Bochdalek hernias containing colon are even more rare, with no case described in the literature with ileo-cecal appendix. PRESENTATION OF CASE: The authors present a case of a right-sided Bochdalek hernia in an adult female of 49 years old, presented with severe respiratory failure. During laparotomy for hernia correction, were found in an intrathoracic position the cecum and ileo-cecal appendix, the right colon and the transverse colon. DISCUSSION: Although useful in patient evaluation, clinical history and physical examination are not helpful in making diagnosis because of their nonspecific character. CT scan is the most accurate exam for making diagnosis. Most of the times there is no hernial sac. Surgery is the treatment of choice, and it is always indicated even if asymptomatic. In general suture of the defect is possible. Due to patient's weak respiratory function we chose laparotomy by Kocher incision. CONCLUSION: Being the first case of a right-sided Bochdalek hernia in the adult with a herniated ileo-cecal appendix, we name it Almeida-Reis hernia.