Acute Limb Ischemia After Self-Injection of Crushed Morphine Tablets into the Radial Artery: Role of Infrared Thermography in the Assessment of Tissue Perfusion.

BACKGROUND This article presents a case involving complications after intentional injection of crushed tablets into the arterial circulation, its diagnosis, and the treatment adopted. The diagnosis process illustrates the potential of techniques based on thermal imaging as tools to assess tissue perfusion. Inadvertent intravenous injection of crushed tablets is more common, but there are few reports on arterial circulation, and no studies were found on the self-injection of crushed morphine tablets, particularly into the radial artery. CASE REPORT A 51-year-old man with alcoholism and a history of illegal drug usage intentionally self-injected 3 crushed morphine tablets into his right radial artery. The patient progressed with compartment syndrome, requiring decompressive fasciotomy of the right forearm and ischemia of the right fingers, which were amputated. He presented with rhabdomyolysis and required dialysis. The patient agreed to full heparinization, corticotherapy, and the use of nitroglycerin and prostaglandin E1. Due to the progression of the necrotic area, the patient underwent proximal phalanx excision and surgical reconstruction of the right-hand remnant. CONCLUSIONS The injection of morphine tablets into circulation caused severe complications, which led to the excision of the proximal phalanx and the surgical reconstruction of the remnant of the right hand. In the present case, infrared thermography proved to be an effective method in assessing tissue perfusion.

The first Acanthamoeba keratitis case in the Midwest region of Brazil: diagnosis, genotyping of the parasite and disease outcome.

We report an Acanthamoeba keratitis case associated with the use of contact lens in a 28-year-old female from Brasília, Brazil. Samples from corneal scraping and contact lens case were used for culture establishment, PCR amplification, and partial sequencing (fragments of ~400kb) of small subunit rDNA; both culture and PCR were positive. The sequence analyses of the cornea and of isolates from the contact lens case showed similarity with the T4 genotype. To the best of our knowledge, this is the first report of T4 Acanthamoeba keratitis case from the Midwest region of Brazil.

The first Acanthamoeba keratitis case in the Midwest region of Brazil: diagnosis, genotyping of the parasite and disease outcome

Abstract We report an Acanthamoeba keratitis case associated with the use of contact lens in a 28-year-old female from Brasília, Brazil. Samples from corneal scraping and contact lens case were used for culture establishment, PCR amplification, and partial sequencing (fragments of ~400kb) of small subunit rDNA; both culture and PCR were positive. The sequence analyses of the cornea and of isolates from the contact lens case showed similarity with the T4 genotype. To the best of our knowledge, this is the first report of T4 Acanthamoeba keratitis case from the Midwest region of Brazil.

Facial trauma reconstruction with polymethyl methacrylate-A case report.

BACKGROUND: Polymethyl methacrylate (PMMA) is a dermatologic filler commonly used in esthetic procedures. However, it can also be used in more severe cases such as reconstruction of facial traumas. AIMS: The aim of this report was to describe the use of PMMA in a nasal reconstruction of a patient victim of an automobilist accident which presented previous rejection of autograft. PATIENT: A young female patient, 26 y, victim of automobilist accident, with no bone support due to trauma both in the mandibulum and maxilla, presented fracture of several facial bones. Presented rejection of a bone autograft from the skullcap implanted on the nose. In order to harmonize the facial aspect, a nasal fill with PMMA for the anatomic reconstruction of the nose was performed. RESULTS AND CONCLUSIONS: PMMA promoted the recovery of facial and nasal esthetic characteristics of the patient ensuring a satisfactory result.

Anaerobic Metabolism in T4 Acanthamoeba Genotype.

Members of the genus Acanthamoeba are of the most common protozoa that has been isolated from a variety of environment and affect immunocompromised individuals, causing granulomatous amoebic encephalitis and skin lesions. Acanthamoeba, in immunocompetent patients, may cause a keratitis related to corneal microtrauma. These free-living amoebas easily adapt to the host environment and wield metabolic pathways such as the energetic and respiratory ones in order to maintain viability for long periods. The energetic metabolism of cysts and trophozoites remains mostly unknown. There are a few reports on the energetic metabolism of these organisms as they are mitochondriate eukaryotes and some studies under aerobic conditions showing that Acanthamoeba hydrolyzes glucose into pyruvate via glycolysis. The aim of this study was to detect the energetic metabolic pathways with emphasis on anaerobic metabolism in trophozoites of three isolates of Acanthamoeba sp belonging to the T4 genotype. Two samples were collected in the environment and one was a clinical sample. The evaluation of these microorganisms proceeded as follows: rupture of trophozoites (7.5 × 103 parasites/ml) and biochemical analysis with high performance liquid chromatography and spectrophotometry. The anaerobic glycolysis was identified through the detection of glucose, pyruvate, and lactate. The protein catabolism was identified through the detection of fumarate, urea, and creatinine. The fatty acid oxidation was identified through the detection of acetate, beta-hydroxybutyrate, and propionate. The detected substances are the result of the consumption of energy reserves such as glycogen and lipids. The anaerobic glycolysis and protein catabolism pathways were observed in all three isolates: one clinical and two environmental. This study represents the first report of energetic pathways used by trophozoites from different isolates of the T4 genotype Acanthamoeba.

Atualização sobre ultrassom doppler das artérias vertebrais: síndrome do roubo da subclávia / An update on doppler ultrasound of vertebral arteries: subclavian steal syndrome

A síndrome do roubo da subclávia refere-se a uma desordem vascular na qual ocorre inversão do fluxo de sangue da artéria vertebral ipsilateral, decorrente de uma estenose proximal à sua origem, geralmente uma oclusão da artéria subclávia ou, mais raramente, do troncobraquiocefálico. É uma doença relativamente rara, relatadaem aproximadamente 6% dos pacientes assintomáticos com sopros cervicais. O Doppler pulsado (PW) é útil na análiseda artéria vertebral, registrando informações capazes de identificar a presença da Síndrome do Roubo da Subclávia. Com base nas alterações hemodinâmicas da artéria vertebralavaliadas pelo estudo com Doppler espectral, pode ser classificada nos tipos 1 (oculto), 2 (intermitente ou parcial)e 3 (completo). Com o advento da angioplastia transluminal percutânea e, em seguida, dos stents, muitos advogam essa combinação de procedimentos como o tratamento de escolha dos casos sintomático dessa síndrome.

Experimental infection of T4 Acanthamoeba genotype determines the pathogenic potential.

T4 is the Acanthamoeba genotype most related to cases of granulomatous amoebic encephalitis (GAE) in immunocompromised patients and of keratitis in contact lens wearers. The determination of the pathogenic potential of Acanthamoeba clinical and environmental isolates using experimental models is extremely important to elucidate the capacity of free-living organisms to establish and cause disease in hosts. The aim of this study was to compare and evaluate the histopathology and culture between two different routes of experimental infection of T4 Acanthamoeba isolated from environmental and clinical source in mice (intracranial and intraperitoneal). Swiss isogenic healthy mice were inoculated with 10(4) trophozoites by intracranial (IC) and intraperitoneal (IP) routes and observed during 21 days. The brains from animals inoculated by the IC route were collected and from the animals of the IP inoculation group, the brains, livers, kidneys, spleens, and lungs were removed. The organs were prepared and appropriately divided to be evaluated with histopathology and culture. There was no significant difference between the inoculation routes in terms of isolates recovery (χ(2) = 0.09; p = 0.76). In the IC group, isolate recovery rate was significantly higher in histopathology than the one achieved by culture (χ(2) = 6.45; p < 0.01). Experimental infection revealed that all isolates inoculated could be considered invasive because it was possible to recover evolutive forms of Acanthamoeba in both routes. This work represents the first in vivo pathogenicity assay of primary isolation source in Central region of Brazil showing in vivo pathogenicity and hematogenous spread capacity of these protozoa, improving the knowledge on free-living amoebae isolates.

Síndrome do roubo oculto da subclávia direita causado por dissecção aórtica tipo A de Stanford que evoluiu no pós-operatório tardio com suboclusão do tronco braquicefálico / Occult-right subclavian steal syndrome caused by stanford type A aortic dissection that evolved in the late postoperative period with subocclusion of the brachiocephalic trunk

Paciente de 50 anos, sem fatores de risco e/ou desencadeantes conhecidos, apresentou dissecção aórtica tipo A de Stanford. Foi submetido à excisão da valva aórtica nativa, implante de prótese mecânica e reconstrução da raiz da aorta com enxerto orgânico. Três meses após cirurgia, estando totalmente assintomático, foi submetido, em nosso serviço, à ecografia vascular, com Doppler colorido, das carótidas e vertebrais que mostrou fluxo em artéria vertebral direita com padrão de desaceleração mediossistólica (roubo oculto da subclávia direita), também chamado Sinal do Coelho. A angiotomografia mostrou tronco braquiocefálico com lâmina de dissecção em toda a sua extensão, artéria subclávia direita com lâmina de dissecção em seu terço proximal, artéria carótida comum direita com lâmina de dissecção visualizada em seu terço proximal, artéria vertebral direita com origem na artéria subclávia direita (na sua porção sem dissecção). Em face do estado clínico do paciente, foi adotada observação clínica, com acompanhamento angiotomográfico e ecográfico dos vasos cervicais, semestralmente.

A 50-year old patient with an aortic dissection (Stanford type A) with no previous risk factors. Excision of the native valve and implantation of mechanical aortic prosthesis were made. Also, carried out reconstruction of the aortic root with organic graft. Postoperatively, the patient came to our department after three months totally asymptomatic and the color Doppler of carotid and vertebral arteries showed a right vertebral artery flow pattern with mid-systolic deceleration (partial subclavian steal) – bunny rabbit sign. The angiotomography showed brachiocephalic trunk dissection with progression to the proximal third of the right subclavian and common carotid arteries. The right vertebral artery had its origin from the right subclavian artery (in its portion without dissection). Considering the patient’s clinical status, conservative clinical approach was adopted, with angiotomography and ultrasound of cervical vessels every six months.

Echocardiographic diagnosis of acute aortic dissection in the emergency room: case report / Diagnóstico ecocardiográfico da dissecção aórtica aguda na sala de emergência: relato de caso

BACKGROUND AND OBJECTIVES: The transthoracic echocardiography in the emergency room, by ultra-portable equipment has been increasingly useful for the diagnosis of acute dissection of ascending aorta, reason for the present report, the objective of which was to elucidate this emergency, using that important propedeutic method.CASE REPORT: A previously healthy, 49 year-old patient admitted to the Emergency Unit with typical chest pain (without triggers) whose diagnosis of acute aortic dissection was performed with the aid of transthoracic echocardiography. CONCLUSION: Considering that 65% of intimal tears occurin the ascending aorta, transthoracic echocardiography is afast and effective tool in a medical emergency. The method has a sensitivity of 59% - 85% and specificity of 63% - 96% for the diagnosis of aortic dissection. It is noteworthy that, even though infrequent in experienced hands, negative findings at transthoracic echocariography do not rule out the diagnosis of this disease.

JUSTIFICATIVA E OBJETIVOS: A ecocardiografia transtorácica na sala de emergência, por meio de equipamentos ultraportáteis, tem sido cada vez útil no diagnóstico da dissecção aguda da aorta ascendente, o que justifica o presente relato, cujo objetivo foi elucidar o quadro emergencial com o auxílio desta importante ferramenta propedêutica.RELATO DO CASO: Paciente de 49 anos, previamente saudável, admitido na Unidade de Emergência com quadro de dor torácica típica (sem fatores desencadeantes) cujo diagnóstico de dissecção aórtica aguda foi realizado com o auxílio do ecocardiograma transtorácico.CONCLUSÃO: Considerando-se que 65% das lacerações intimais ocorrem na aorta ascendente, o ecocardiograma transtorácico é uma ferramenta rápida e eficaz em uma situação de emergência médica. O método apresenta sensibilidade de 59 a 85%e especificidade de 63% a 96% para o diagnóstico de dissecção aórtica. Ressalta-se que, mesmo infrequentes em mãos experientes, achados negativos ao ecocardiograma transtorácico não descartam o diagnóstico desta comorbidade.

Síndrome do roubo da subclávia / Suclavian steal syndrome

A síndrome do roubo da subclávia refere-se a uma desordem vascular na qual ocorre inversão do fluxo de sangue da artéria vertebral ipsilateral, decorrente de uma estenose proximal à sua origem, geralmente uma oclusão da artéria subclávia ou, mais raramente, do tronco braquiocefálico. É uma doença relativamente rara, relatada em aproximadamente 6% dos pacientes assintomáticos com sopros cervicais. O Doppler pulsado (PW) é útil na análise da artéria vertebral, registrando informações capazes de identicar a presença da Síndrome do Roubo da Subclávia. Com base nas alterações hemodinâmicas da arteria vertebral avaliadas pelo estudo com Doppler Espectral, podem ser identificados três tipos de roubo da subclávia: oculto, parcial e completo. Com o advento da angioplastia transluminal percutânea e, em seguida, dos Stents, muitos advogam esta combinação de procedimentos como o tratamento de escolha dos casos sintomático desta síndrome.