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Tofacitinib has emerged as a new option for ulcerative colitis. Its rapid absorption, metabolism, and clinical improvement make it an interesting option for rescue therapy in acute severe ulcerative colitis (ASUC), a situation with limited therapeutic options in patients with a long-term disease course and multiple drug failure. The management of ASUC in this setting becomes challenging, underlying the need for new drugs and data on their efficacy and safety. We describe 2 cases of acute episodes in which tofacitinib was used as a rescue therapy.
O tofacitinib surgiu como uma nova terapêutica para a colite ulcerosa. A rapidez da sua absorção, metabolismo e melhoria clínica tornam-no uma opção apelativa como terapêutica de resgate na colite ulcerosa aguda grave (termo em inglês ASUC), entidade esta com opções terapêuticas limitadas em doentes com longo curso de doença e falência prévia a múltiplos fármacos. A abordagem da ASUC neste contexto é desafiante, salientando-se a necessidade de novos fármacos e dados reais sobre a sua eficácia e segurança. Descrevemos dois casos de episódios agudos nos quais o tofacitinib foi utilizado como terapêutica de resgate.
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INTRODUCTION: We aim to discuss the utility of self-expandable esophageal metal stent (SEMS) in variceal bleeding in challenging cases. METHODS: Case description, discussion on patient management and decision-making process in an uncommon situation, from a multidisciplinary point of view. RESULTS: We report a case of a cirrhotic patient with refractory variceal bleeding who underwent a SEMS placement, which remained in situ for 9 months. This decision was based on the initial poor status and short life expectancy, limiting the consideration of other options for lowering portal hypertension, along with an underlying prothrombotic predisposition. However, the patient's general and hepatic improvement and the development of dysphagia led to the SEMS removal, exposing a large esophageal-tracheal fistula. DISCUSSION: Early patient evaluation, risks of long-term SEMS, and life expectancy should be taken in consideration before SEMS placement.
Assuntos
Transtornos de Deglutição , Estenose Esofágica , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Hepatite B Crônica/complicações , Cirrose Hepática Alcoólica/complicações , Complicações Pós-Operatórias , Stents Metálicos Autoexpansíveis , Fístula Traqueoesofágica , Idoso , Anticoagulantes/uso terapêutico , Carcinoma Hepatocelular/etiologia , Doenças do Esôfago/etiologia , Doenças do Esôfago/terapia , Varizes Esofágicas e Gástricas/etiologia , Artéria Femoral , Estado Funcional , Hemorragia Gastrointestinal/etiologia , Hemostase Endoscópica , Humanos , Expectativa de Vida , Cirrose Hepática/complicações , Neoplasias Hepáticas/etiologia , Masculino , Nutrição Parenteral , Doença Arterial Periférica/complicações , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Artéria Poplítea , Fatores de TempoRESUMO
Cystoisospora belli colitis is a rare complication of immunosuppression in solid organ transplant recipients. We describe a case of Cystoisospora belli infection with colitis following renal transplantation.
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Colite/parasitologia , Isosporíase/diagnóstico , Transplante de Rim/efeitos adversos , Diarreia/parasitologia , Humanos , Hospedeiro Imunocomprometido , Isospora , Masculino , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: Systemic inflammatory diseases are related to an increased risk of lymphoproliferative disorders. Although inflammatory bowel disease (IBD) was also associated with these conditions, population-based studies failed to demonstrate this relationship, and most studies only identified a very small number of cases. In the last few years, concerns arose regarding the role of thiopurines and tumour necrosis factor-alpha (TNF-α)-blocking agents in the development of lymphoma, influencing therapeutic decisions in IBD patients. The aim of this study was to describe a case series of IBD patients who developed a lymphoproliferative disorder in our tertiary referral centre. MATERIAL AND METHODS: The clinical records of all IBD patients who were observed in our unit between January 2007 and December 2016 were retrospectively reviewed, and IBD subjects who were diagnosed with a lymphoproliferative disorder were selected. Clinical and demographic data regarding both conditions were collected. RESULTS: Six IBD patients were diagnosed with a lymphoma - 4 Hodgkin lymphomas and 2 B-cell non-Hodgkin lymphomas - of which 3 corresponded to primary colonic lymphomas. Immunohistochemical analysis detected the presence of Epstein-Barr virus in the tumour cells of 2 patients, both of them with Hodgkin lymphomas. Only 2 patients were previously treated with thiopurines or anti-TNF-α drugs; none of the remaining had any history of immunosuppressive treatment. DISCUSSION AND CONCLUSIONS: Despite major attention being currently focused on the effect of treatment, which may play the main role in the increased susceptibility to lymphoma in IBD patients, and although it may be difficult to demonstrate, IBD itself may contribute to the development of lymphoproliferative disorders, particularly primary intestinal lymphomas.
INTRODUÇÃO: Doenças inflamatórias crónicas estão relacionadas com um aumento de risco de doenças linfoproliferativas. Apesar da doença inflamatória intestinal (DII) também ter sido associada a estas complicações, estudos de base populacional falharam em demonstrar esta relação, e a maioria dos estudos apenas identificou um baixo número de casos. Nos últimos anos, preocupações foram levantadas no que diz respeito ao papel das tiopurinas e dos bloqueadores do factor de necrose tumoral alpha (TNF-α) no desenvolvimento de linfomas, influenciando decisões terapêuticas em doentes com DII. O objectivo deste estudo foi o de descrever uma série de casos de doentes com DII que desenvolveram doenças linfoproliferativas num centro de referência. MATERIAL E MÉTODOS: Os registos clínicos dos doentes que foram observados na nossa unidade entre Janeiro de 2007 e Dezembro de 2016 foram retrospectivamente analisados, tendo sido seleccionados os doentes diagnosticados com uma doença linfoproliferativa. Os dados clínicos e demográficos respeitantes a ambas as condições foram colectados. RESULTADOS: Seis doentes com DII foram diagnosticados com linfoma - 4 linfomas de Hodgkin e 2 linfomas não-Hodgkin de células B -, dos quais 3 corresponderam a linfomas primários do cólon. Análise imunohistoquímica detectou a presença do vírus Epstein-Barr nas células tumorais de 2 doentes, ambos com linfoma de Hodgkin. Apenas 2 doentes tinham recebido tratamento prévio com tiopurinas ou agentes anti-TNF-α; nenhum dos restantes tinha qualquer história de terapêutica imunossupressora. DISCUSSÃO E CONCLUSÃO: Apesar da maioria das atenções estar focada no efeito do tratamento, o qual será o principal responsável pela maior susceptibilidade para linfomas em doentes com DII, e apesar da dificuldade em demonstrá-lo, a própria DII poderá contribuir para o desenvolvimento de doenças linfoproliferativas, particular de linfomas intestinais primários.
RESUMO
Inflammatory bowel disease is associated with an increased likelihood of developing lymphoma. However, it is still controversial if this risk may be attributed to the disease itself or rather represents an effect of immunosuppressive treatment. Although tumor necrosis factor alpha (TNFα) is a key cytokine for cancer immunosurveillance, the potential relationship between anti-TNFα agents and the pathogenesis of lymphoproliferative disorders remains unclear. Here, we describe the case of a patient with severe perianal Crohn's disease, treated with infliximab monotherapy, whose unusual presentation with acute groin pain required surgical intervention and led to the diagnosis of diffuse large B-cell lymphoma. However, 10 months after this episode, treatment with infliximab was restarted because the patient continued with refractory and disabling perianal disease. Currently, with a follow-up of 36 months, under infliximab 10 mg/kg every 4 weeks, he maintains mild perianal Crohn's disease and persists in sustained clinical and imaging remission of the lymphoproliferative disorder.
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Doença de Crohn/tratamento farmacológico , Fármacos Gastrointestinais/uso terapêutico , Infliximab/uso terapêutico , Linfoma Difuso de Grandes Células B/diagnóstico , Linfoma Difuso de Grandes Células B/cirurgia , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adulto , Anti-Inflamatórios/uso terapêutico , Doença de Crohn/complicações , Humanos , Linfoma Difuso de Grandes Células B/complicações , Masculino , Prednisolona/uso terapêuticoAssuntos
Doença de Crohn/complicações , Doença de Crohn/tratamento farmacológico , Infecções por HIV/diagnóstico , Infecções por HIV/patologia , Imunossupressores/administração & dosagem , Infliximab/administração & dosagem , Quimioterapia de Manutenção/métodos , Adolescente , Contagem de Linfócito CD4 , Feminino , HIV/isolamento & purificação , Humanos , Carga ViralAssuntos
Adalimumab/efeitos adversos , Antirreumáticos/efeitos adversos , Doença de Crohn/tratamento farmacológico , Vasculite Leucocitoclástica Cutânea/induzido quimicamente , Adalimumab/uso terapêutico , Adulto , Antirreumáticos/uso terapêutico , Doença de Crohn/complicações , Substituição de Medicamentos , Feminino , Humanos , Infliximab/uso terapêutico , Quimioterapia de Manutenção , Masculino , Pessoa de Meia-Idade , RecidivaRESUMO
INTRODUCTION: Lymphoproliferative disorders, particularly non-Hodgkin's and Hodgkin's lymphomas, are rare in patients with inflammatory bowel diseases. The use of thiopurines and infection by Epstein-Barr virus are well-known cofactors that can raise its prevalence. Other risk factors such as disease activity and biological treatment are the subject of discussion, without enough data in the literature to confirm a potential association. METHODS: We report a case of Hodgkin's lymphoma in a patient who had been treated with azathioprine and was on long-term monotherapy with infliximab. CONCLUSIONS: We stress the importance of recognizing the possible occurrence of a lymphoproliferative disorder in association with anti-tumor necrosis factor-α therapy.
INTRODUÇÃO: As doenças linfoproliferativas, em particular os linfomas não-Hodgkin e Hodgkin, são raras em doentes com doença inflamatória intestinal. O uso de tiopurinas e infecção pelo vírus Epstein-Barr são reconhecidos cofactores que podem aumentar a sua incidência. Outros factores de risco como a actividade da doença e o tratamento biológico são tema de discussão, não existindo dados suficientes na literatura para confirmar uma potencial associação. MÉTODOS: Os autores descrevem um caso de linfoma Hodgkin num doente previamente medicado com azatioprina e em monoterapia de longa duração com infliximab. CONCLUSÕES: Este caso destaca a importância de reconhecer a possível ocorrência e/ou associação das doenças linfoproliferativas com a terapêutica com anti-factor de necrose tumoral-α.
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The continuous delivery of a levodopa/carbidopa gel suspension (Duodopa®) into the small bowel through a jejunal tube inserted via percutaneous endoscopic gastrostomy represents a new treatment method in advanced Parkinson disease. Some severe device-related complications have been described in the last few years. Some of them are associated with phytobezoar formation at the pigtail of the catheter. We present the case of a Parkinson disease patient treated with the Duodopa infusion system complicated by jejunal tube fistulization into the colon. We suggest a possible treatment strategy for this complication, which has not been described in the literature to date.
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Diseases causing colonic ischemia may be mistaken with other causes of segmental colitis such as inflammatory bowel disease, especially in young patients. The authors present the case of a 47-year-old male with severe proctosigmoiditis. Assessment excluded infectious causes, thrombophilia and systemic vasculitis. The initial histological specimen was suggestive of inflammatory bowel disease and therapy was initiated with intravenous steroids and, at day 5, infliximab, with no response. The patient was proposed for surgery. Pathological examination of the surgical specimen revealed an idiopathic myointimal hyperplasia of mesenteric veins, a rare entity exhibiting necrotizing phlebitis with rapid progression to segmental necrosis in the rectosigmoid colon. In this paper the authors discuss the differential diagnosis of proctosigmoiditis in young ages and the approach to this exceptionally rare ischemic entity.
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Colite/etiologia , Veias Mesentéricas/patologia , Biópsia , Colite/diagnóstico , Colite/cirurgia , Humanos , Hiperplasia , Masculino , Veias Mesentéricas/cirurgia , Pessoa de Meia-Idade , Necrose , Flebite/etiologia , Flebite/patologia , Flebite/cirurgiaRESUMO
Intramural dissecting hematoma is an unusual esophageal condition with a threatening presentation but excellent prognosis when managed conservatively.We report the case of an 88-year-old woman who developed an intramural hematoma of the esophagus after intravenous thrombolysis for an acute ischemic stroke. Before thrombolysis, nasogastric intubation was attempted unsuccessfully. She was kept on nil by mouth, intravenous hydration, proton pump inhibitor, antiemetics,and an antibiotic initiated 2 days before for periodontal disease. The esophageal hematoma regressed, and she resumed oral diet asymptomatically.To our knowledge, this is the first report of this type of lesion after thrombolysis for an ischemic stroke. A brief discussion and literature review are presented.