Whipple's disease: rare disorder and late diagnosis / Doença de Whipple: patologia rara e de diagnóstico tardio

Whipple's disease is a rare systemic infectious disorder caused by the bacterium Tropheryma whipplei. We report the case of a 61-year-old male patient who presented to emergency room complaining of asthenia, arthralgia, anorexia, articular complaints intermittent diarrhea, and a 10-kg weight loss in one year. Laboratory tests showed the following results: Hb = 7.5 g/dL, albumin = 2.5 mg/dL, weight = 50.3 kg (BMI 17.4 kg/m²). Upper gastrointestinal endoscopy revealed areas of focal enanthema in the duodenum. An endoscopic biopsy was suggestive of Whipple's disease. Diagnosis was confirmed based on a positive serum polymerase chain reaction. Treatment was initiated with intravenous ceftriaxone followed by oral trimethoprim-sulfamethoxazole. After one year of treatment, the patient was asymptomatic, with Hb = 13.5 g/dL, serum albumin = 5.3 mg/dL, and weight = 70 kg (BMI 24.2 kg/m²). Whipple's disease should be considered a differential diagnosis in patients with prolonged constitutional and/or gastrointestinal symptoms. Appropriate antibiotic treatment improves the quality of life of patients.

Doença de Whipple é uma rara infecção sistêmica causada pelo Tropheryma whipplei. Caracteriza-se por fase prolongada de sintomas inespecíficos, levando longo período até o seu diagnóstico. Sem tratamento, pode ser grave e fatal, mas com antibioticoterapia tem ótima resposta clínica e laboratorial. Relatamos o caso de paciente masculino, 61 anos, internado por astenia, anorexia, diarréia intermitente e perda de 10 kg em um ano. Apresentava-se com hemoglobina (Hb) 7,5 g/dL, albumina de 2,5 mg/dL, peso 50,3 kg (IMC 17,4). Endoscopia digestiva alta com áreas de enantema focal da mucosa duodenal e biópsia compatível com doença de Whipple. O diagnóstico foi confirmado com PCR sérica positiva, sendo instituído tratamento com ceftriaxone seguido de sulfametoxazol-trimetropim. Após um ano de tratamento, encontrava-se assintomático, com Hb 13,5 g/dL, albumina sérica de 5,3 mg/dL e peso de 70 kg. Doença de Whipple deve fazer parte da lista de diagnósticos diferenciais em pacientes com sintomas constitucionais e/ou com queixas gastrointestinais com evolução prolongada. O tratamento antibiótico pode curar a infecção, recuperando a qualidade de vida do paciente.

Whipple's disease: rare disorder and late diagnosis.

Whipple's disease is a rare systemic infectious disorder caused by the bacterium Tropheryma whipplei. We report the case of a 61-year-old male patient who presented to emergency room complaining of asthenia, arthralgia, anorexia, articular complaints intermittent diarrhea, and a 10-kg weight loss in one year. Laboratory tests showed the following results: Hb = 7.5 g/dL, albumin = 2.5 mg/dL, weight = 50.3 kg (BMI 17.4 kg/m²). Upper gastrointestinal endoscopy revealed areas of focal enanthema in the duodenum. An endoscopic biopsy was suggestive of Whipple's disease. Diagnosis was confirmed based on a positive serum polymerase chain reaction. Treatment was initiated with intravenous ceftriaxone followed by oral trimethoprim-sulfamethoxazole. After one year of treatment, the patient was asymptomatic, with Hb = 13.5 g/dL, serum albumin = 5.3 mg/dL, and weight = 70 kg (BMI 24.2 kg/m²). Whipple's disease should be considered a differential diagnosis in patients with prolonged constitutional and/or gastrointestinal symptoms. Appropriate antibiotic treatment improves the quality of life of patients.

Evaluation of morbidity of suction drains after retroperitoneal lymphadenectomy in gynecological tumors: a systematic literature review.

INTRODUCTION: The prophylactic use of closed suction drains after retroperitoneal lymphadenectomy in the management of gynecologic tumors has been widely used to prevent collections of clots or lymph and to avoid infections and postoperative fistulas. The improvement of newer surgical techniques, the use of antibiotic prophylaxis, and the nonclosure of the peritoneum led to the need to reevaluate the use of drains. Retrospective, prospective, and randomized studies did not find differences in the postoperative morbidity between the use and nonuse of drains. Some studies even suggested worse morbidity with the use of drains. OBJECTIVES: To assess the morbidity of the use of drains compared with no drains in a systematic literature review with aggregate effect measure (meta-analysis). MATERIALS AND METHODS: Between 1966 and August 2007, 3 independent reviewers analyzed all studies that assessed the use of drains or no drains through a comprehensive literature search of the MEDLINE, EMBASE, and Cochrane Central Databases. Statistical analysis was carried out through the RevMan software. RESULTS: Of the 285 studies initially reviewed, 11 were selected. Only 4 were considered adequate for group analysis, totaling 571 patients. When assessing outcomes altogether, namely, fever morbidity, symptomatic lymphocysts, deep vein thrombosis, pelvic infection, and fistulas, the relative risk was 1.76 (95% confidence interval, 1.04-3.01) and number necessary to harm was 12.2 referring to the use of drains. CONCLUSIONS: The prophylactic use of continuous suction drains after retroperitoneal lymphadenectomy in the management of gynecologic tumors should be avoided.

Estudo comparativo da identificaçäo de isquemia miocárdica pela cineventriculografia contrastada sob efeito de mononitrato de isossorbitol e pela cintilografia miocárdica perfusional em portadores de cardiopatia isquêmica / Comparative study for the identification of myocardial ischemia by contrast ventriculography under the effect of isosorbide mononitrate and by perfusional myocardial scintigraphy in patients with ischemic heart disease

Objetivo - Avaliar a utilidade das cineventriculografias esquerdas constratadas sob o efeito de nitrato na Identificação de isquemia miocárdica e comparar com os achados da cintilografia miocárdica. Métodos - Foram estudadas as ventriculografias obtidas antes e após o uso de 0,3 mg/kg de mononitrato de iosossorbitol de 26 pacientes portadores de cardiopatia isquêmica (CI). A motilidade segmentar e o desempenho do ventrículo esquerdo (VE) foram posteriormente comparados com os achados da cintilografia com (99m)Tc-Sestamibi. Resultados - Em condições basais foram identificados 30 segmentos normais, 62 hipocinéticos, 28 discinéticos e 14 acinéticos. Após o medicamento 99 segmentos foram normais, 11 hipocinéticos, 11 discinéticos e 13 acinéticos. A cintilografia miocárdica apresentou 110 segmentos com isquemia e 18 com fibrose (p<0,005). Após o uso do medicamento, a cineventriculografia contrastada identificou aumento da velocidade de encurtamento circunferencial (p=0,0142), da fração de ejeção (p=0,0462), diminuição do volume sistólico final (p=0,0031), e sem alteração do volume diastólico final.