EBUS-TBNA-INDUCED PURULENT PERICARDITIS: A RARE COMPLICATION OF A COMMON PROCEDURE.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a diagnostic tool used to investigate mediastinal lesions. It has a good safety profile, but there are rare accounts of potentially deadly complications. The present article describes one such complication: pericardial empyema. A 70-year-old man underwent EBUS-TBNA for the differential diagnosis of a pulmonary mass with multiple mediastinal adenopathies. Two weeks after the procedure he developed chest pain, shortness of breath and fever, with rapid progression to hypotension, tachycardia and low peripheral saturation. He was diagnosed with purulent pericarditis with cardiac tamponade. Pericardial drainage and antibiotic therapy were employed with successful recovery from obstructive disease and septic shock. LEARNING POINTS: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has a good safety profile and is used to investigate peritracheal and peribronchial lesions, but severe complications have occurred so prophylactic measures should be implemented.Risk factors for infections due to EBUS-TBNA have not been properly established, but the presence of necrotic or cystic lesions and an elevated number of punctures during TBNA seem to be relevant.Although severe complications are rare, awareness of their existence may allow faster diagnosis and, consequently, a better prognosis.

Differential Diagnosis of Urticarial Lesions.

Urticaria is a mast cell-dependent disease, characterized by the presence of wheals, angioedema, or both in the absence of systemic symptoms. It is a common disease worldwide, with an important health burden especially in chronic situations, that last more than 6 weeks. Although urticaria is usually a straightforward diagnosis, some diseases presenting with urticarial lesions must be excluded, particularly urticarial vasculitis and auto-inflammatory syndromes. In these settings additional atypical features are often present (long-lasting lesions, bruising, fever, malaise, arthralgia), allowing the clinician to suspect a diagnosis other than urticaria. The authors propose an approach based on these atypical features, the presence or absence of systemic symptoms and on skin histopathology as well as some blood parameters.

Contact allergy to antifungals: Results of a 12-year retrospective study.

BACKGROUND: Contact allergy has been reported as a side effect of topical antifungals (TAFs), although most evidence has come from small case series. OBJECTIVE: To investigate the frequency and associated factors of contact allergy to TAFs. METHODS: We performed a retrospective analysis of the data of the Contact Allergy Unit of a University Dermatology Department between January 2009 and April 2021. From a cohort of 3788 patients tested in our unit, aimed testing was performed in 482 patients using TAFs from Chemotechnique Diagnostics (Vellinge, Sweden), allergEAZE, and, in some cases, commercial preparations 'as is'. RESULTS: Contact allergy to antifungals was found in 27 patients (0.71% of consecutively tested patients and 5.6% of those who had aimed testing). Foot and leg eczema were the clinical presentation in 12 (44.4%) and 10 (37.0%) patients, respectively. Positive reactions were observed mostly with econazole nitrate 1% alcohol (51.9%), miconazole 1% alcohol (48.9%), tioconazole 28% solution (40.7%), and clotrimazole 5% pet. (18.5%). Fifteen patients (55.6%) had sensitization to more than one antifungal. CONCLUSIONS: Contact allergy to antifungals was uncommon and occurred mostly associated with foot dermatitis. Most patients were sensitized to more than one chemical, particularly to azoles, which may limit future choices of TAF treatment.

Moonlighting in Rickettsiales: Expanding Virulence Landscape.

The order Rickettsiales includes species that cause a range of human diseases such as human granulocytic anaplasmosis (Anaplasma phagocytophilum), human monocytic ehrlichiosis (Ehrlichia chaffeensis), scrub typhus (Orientia tsutsugamushi), epidemic typhus (Rickettsia prowazekii), murine typhus (R. typhi), Mediterranean spotted fever (R. conorii), or Rocky Mountain spotted fever (R. rickettsii). These diseases are gaining a new momentum given their resurgence patterns and geographical expansion due to the overall rise in temperature and other human-induced pressure, thereby remaining a major public health concern. As obligate intracellular bacteria, Rickettsiales are characterized by their small genome sizes due to reductive evolution. Many pathogens employ moonlighting/multitasking proteins as virulence factors to interfere with multiple cellular processes, in different compartments, at different times during infection, augmenting their virulence. The utilization of this multitasking phenomenon by Rickettsiales as a strategy to maximize the use of their reduced protein repertoire is an emerging theme. Here, we provide an overview of the role of various moonlighting proteins in the pathogenicity of these species. Despite the challenges that lie ahead to determine the multiple potential faces of every single protein in Rickettsiales, the available examples anticipate this multifunctionality as an essential and intrinsic feature of these obligates and should be integrated into available moonlighting repositories.

Diffuse dermal angiomatosis: a rare cause of painful ulceration in renal insufficiency.

Diffuse dermal angiomatosis is a rare, benign, reactive cutaneous vascular proliferation that has been reported in the context of end-stage renal failure and can rarely be associated with arteriovenous fistulas. We report a striking clinical resolution following prompt diagnosis and subsequent arteriovenous fistula reversal. This case further demonstrates that accurate diagnosis is particularly rewarding since correct therapeutic approach can be curative.

A Case of Liver Injury after Exposure to Isopropanol: A Challenging Diagnosis.

Drug-induced liver injury is hardly diagnosed, considering not only the wide range of hepatotoxic substances but also the diversity of associated phenotypes and the absence of specific biomarkers. Symptom chronology, drug or toxic exposure, and temporal association help to establish the diagnosis. Exposure to isopropanol has known but rare toxic effects. We report the clinical case of a 33-year-old female hairdresser admitted to the hospital with fatigue, epigastric pain, and jaundice. She presented the following values: aspartate aminotransferase, 485 U/L; alanine transaminase, 908 U/L; ALP, 240 U/L; GGT, 370 U/L; total bilirubin, 3.5 mg/dL; and direct bilirubin, 2.1 mg/dL. Albumin, platelet, and INR values were normal. Structural, infectious, immune, and vascular causes were excluded. Liver biopsy was suggestive of toxic hepatitis. A possible association with ibuprofen intake was considered. The patient resumed professional activity, with fatigue and jaundice relapse, as well as a new liver enzyme increase, despite ibuprofen withdrawal. It was concluded that a new hair product containing isopropanol had recently been introduced. As soon as its professional use was discontinued, there was no recurrence of the symptoms. Given the temporal association between the development of acute hepatitis and the use of an isopropanol-containing product, liver toxicity by exposure to isopropanol was assumed. This substance is metabolized in the liver and toxicity may occur by ingestion, skin exposure, or inhalation, and it is described in cases of occupational or accidental exposure. The treatment is symptomatic and comprises toxic suspension.

A lesão hepática induzida por tóxicos é um dos distúrbios de mais difícil diagnóstico, quer pela existência de múltiplos hepatotóxicos, quer pela diversidade de fenótipos associados e ausência de biomarcadores específicos. A cronologia dos sintomas, exposição a fármacos ou tóxicos e associação temporal auxilia o diagnóstico. A exposição a isopropanol tem efeitos tóxicos conhecidos e raros. Descrevemos o caso clínico de uma mulher de 33 anos, cabeleireira, admitida por fadiga, epigastralgias e icterícia. Apresentava AST 485 U/L, ALT 908 U/L, FA 240 U/L, GGT 370 U/L, bilirrubina total 3,5 mg/dL e bilirrubina direta 2,1 mg/dL; o doseamento sérico de albumina, plaquetas e o valor de INR eram normais. Foram excluídas lesões estruturais, causas infeciosas, imunes e vasculares. Biópsia hepática sugestiva de hepatite tóxica. Considerada possível associação a toma de ibuprofeno. Retomou atividade profissional, com recorrência de fadiga e icterícia, bem como elevação das enzimas hepáticas novamente, apesar de suspensão de ibuprofeno. Apurada exposição a tóxicos profissionais, percebendo-se que o quadro coincidiu com início da utilização de novo produto capilar contendo isopropanol. A doente retomou atividade profissional, não utilizando o produto, sem recorrência. Dada a relação temporal entre o desenvolvimento de hepatite aguda e a utilização de produtos contendo isopropanol, assumiu-se hepatotoxicidade por exposição profissional ao isopropanol. Esta substância é metabolizada no fígado e a toxicidade pode ocorrer por ingestão, exposição cutânea ou inalação, estando descrita em casos de exposição ocupacional ou acidental. O tratamento é sintomático e inclui a suspensão do tóxico.

Clusters of abusive parenting: a latent class analysis of families referred to Child Protective Services in Portugal.

From the perspective of ecological models, it is suggested that a thorough behavior analysis of parental mistreatment and neglect is undertaken from a general approach to a more comprehensive and multi-dimensional perspective. Hence, the main goal of the present study was to determine if meaningful groups or clusters of abusive parenting in Portugal could be identified based on the characterization of the children and adolescents, their parents and context variables. An instrument was developed to assess variables of the children or adolescents, the family and the social context, all of which have been shown to be important in the literature. Child and Youth Protection Commissions from the whole of Portugal participated in the study, a total of 504 cases. Latent class analysis was applied in order to identify distinct parenting abusing behavior. The results showed four distinct clusters of families which are clearly defined in light of the types of risk and associated variables. The four groups are probabilistic and propose the composition of clusters with socio-demographic variables related to the types of risk. The significant interrelationships of different profiling characteristics are directly related to parenting abusing behavior. The results of this study confirmed our hypothesis of heterogeneous abusive parenting in Portugal. The findings yield useful policy-oriented results. Meaningfully organizing abusive parenting may be an important step not only in understanding the origins of abuse and neglect, but also in integrating this information into intervention models with children, young people and their families.