Bedside ultrasound in post-anaesthetic care unit for the diagnosis of post-extubation negative pressure pulmonary oedema: A paediatric case.

BACKGROUND: Post-extubation negative pressure pulmonary oedema is a rare, potentially life-threatening complication associated with general anaesthesia. Chest radiography is used as a diagnostic tool, but it implies a non-negligible radiation exposure, a very important consideration, especially for the paediatric population. However, lung ultrasound can overcome this problem and can be used to detect postoperative pulmonary complications. CASE REPORT: A 16-year-old male was scheduled for tympanoplasty. General anaesthesia was conducted, and after extubation, the patient developed a laryngospasm. On arrival at the post-anaesthetic care unit, the patient started to cough, a pink frothy sputum and hypoxemia were noticed, and auscultation revealed crepitations. A bedside lung ultrasound showed more than three B-lines per intercostal window, suggesting an alveolar-interstitial syndrome. DISCUSSION: With this case report, we would like to raise awareness to this clinical entity and demonstrate bedside ultrasound has an important role in the diagnostic and therapeutic assessment during the perioperative period.

An unusual case of osteoarthritis?

Forestier disease is a condition characterized by calcification and ossification of ligaments and entheses particularly affecting axial skeleton. Diagnosis is difficult and mandates a high suspicion level, but unexpensive and accessible examinations like a simple radiography might provide useful diagnostic clues in these challenging clinical scenarios and improve clinical assistance.

Barium aspiration - Accident or complication?

Aspiration of barium sulfate is possible during radiographic contrast procedures and is potentially life-threatening in severe cases. In patients with dysphagia or suspected tracheoesophageal fistula, barium compounds may be used, considering lateral projection fluoroscopy of the pharyngeal phase of swallowing, but iso-osmotic agents should also be considered.

Unusual Pneumonia Mimic.

Disease in atypical organ locations can mimic other pathologies, hampering the right diagnosis. Such conditions may even be emergencies, like appendicitis. Subhepatic appendix is a very rare entity which may be caused by caecum dehiscence failure. The authors present the case of a 55-year-old immunocompetent man admitted to the Emergency Department with sepsis and severe hypoxaemia. Chest x-ray showed right lower lobe infiltrate, and community-acquired pneumonia was diagnosed. The patient was started on broad-spectrum antibiotics, but he continued to deteriorate and after 3 days developed abdominal complaints. Exploratory laparoscopy revealed an abscess caused by perforated subhepatic appendicitis. Subhepatic appendicitis presents a diagnostic challenge and its clinical presentation may mimic that of other entities. This case highlights an atypical presentation, where the early development of inflammatory lung injury mimicked common pneumonia. Maintenance of a high index of suspicion and knowledge of these atypical locations is crucial. LEARNING POINTS: Control of the source of infection in sepsis is vital for survival.Acute inflammatory lung injury is common in sepsis and is correlated with clinical severity.A high index of suspicion and awareness of anatomical variants of the appendix are necessary for correct diagnosis of appendicitis mimicking other conditions.

Aortic Dissection with Haemothorax Mimicking a Stroke.

Aortic dissection is a life-threatening clinical emergency and a challenging diagnosis. Depending on its initial location, it may present with several symptoms with the most common being chest pain. We describe the case of a 62-year-old man admitted to the Emergency Department with acute neurological deficits and triaged for the stroke protocol. After unexpected findings on physical examination, other diagnostic hypotheses were evaluated, culminating in the diagnosis of aortic dissection with haemothorax mimicking a stroke. LEARNING POINTS: Aortic dissection is a clinical emergency with a high rate of misdiagnosis; it may present with unusual symptoms depending on its initial location.Stroke mimics are diverse non-vascular conditions that can present with acute neurological deficits simulating an acute stroke, some of which are contraindications for thrombolytic treatment.An accurate initial physical examination in the emergency department is crucial so less common conditions can be evaluated and fatal thrombolytic treatment avoided.

A Case of Mesenteric Pseudocyst Causing Massive Abdominal Swelling.

We present the case of a 55-year-old man with a self-limiting febrile condition associated with polyserositis with an inconclusive investigation. Bilateral pleural and pericardial effusions resolved. The peritoneal fluid loculated and was compatible with an exudate. The patient remained clinically asymptomatic. However, 2 years later, examination revealed a palpable and painless abdominal mass, which imaging suggested a cystic lesion. Surgical resection was performed and histological examination identified a mesenteric pseudocyst. Mesenteric pseudocysts are rare intra-abdominal cystic masses which are mostly benign and do not cause specific symptoms. Although imaging tests are useful for their differential diagnosis, histology is mandatory. LEARNING POINTS: Mesenteric pseudocysts are rare intra-abdominal cystic masses with a clinical presentation that sometimes is a diagnostic challenge.Abdominal imaging used to investigate a concomitant systemic illness may reveal a fluid lesion which may delay the diagnosis.Ultrasound, computed tomography and magnetic resonance imaging can be used for pre-operative diagnosis, but exact differentiation is only achieved through histopathological examination.

[The network of methotrexate toxicity]. / A teia de toxicidade do metotrexato.

INTRODUCTION: Methotrexate is a folic acid antagonist recognised as one of the most important DMARD's in the rheumatoid arthritis treatment. Although the indisputable efficacy and the good tolerance profile, the broad toxicity spectrum is very variable with respect both to symptoms and intensity. The side effects vary from malaise and asthenia to pneumonitis or pancytopenia, which can be fatal. OBJECTIVES: To review the adverse effects of methotrexate in the treatment of rheumatoid arthritis. MATERIALS AND METHODS: Literature review, using Medline as a starting point, searching with the keywords "methotrexate", "toxic effects", "adverse effects", "rheumatoid arthritis". The relevant papers and selected references found therein were used. RESULTS: The gastrointestinal symptoms are the most frequent, but myelossupression and pneumonitis are the most feared ones. Elevation of transaminases could indicate hepatic toxicity, placing the risk of cirrhosis. Cutaneous lesions, neurologic symptoms, changes in the bone metabolism, teratogenecity and hyperhomocysteinemia are other examples of the adverse effects of methotrexate. The post-dosing reactions are still not well known. The folate supplementation is important in the prevention of folate metabolism dependent symptoms. The farmacogenomics may help to identify patients in greater risk for multiple side effects. CONCLUSIONS: Knowing and monitoring the methotrexate side effects is extremely important and should be carefully considered in order to prevent both therapeutic withdrawals due to toxicity as well as fatal outcomes.

[Rheumatic manifestations and neoplasms]. / Manifestações reumáticas e neoplasias.

Links between rheumatic manifestations and neoplasms are today an evidence. Certain syndromes have epidemiologic studies confirming strong association with malignancy, such as dermatomyositis and polymyositis, hyperthrophic osteoarthropathy and Lambert - Eaton myasthenic syndrome. These disorders may mimic idiopathic conditions, difficulting diagnosis. Besides that, longstanding rheumatic syndromes may, in their course, behave like premalignant conditions, as a result of their pathophysiology or drugs used in their treatment. The mechanisms whereby the neoplasm leads to rheumatic symptoms are: direct invasion of the musculoskeletal system, synovial reaction of justa-articular bony or capsular carcinomatous, secondary gout and paraneoplastic manifestations. Neoplasms constitute an important admission cause in Internal Medicine wards and rheumatic manifestations are common causes of Internal Medicine and Rheumatology appointments. The objective of the present work is to review the literature concerning rheumatic syndromes more frequently associated with malignancy, characterizing features that may suggest the presence of a hidden neoplasm as well as the potential diagnostic and prognostic value of their presence in malignant diseases.