Huge Candida albicans normal native tricuspid valve endocarditis

Fungal endocarditis has become an important infection associated with medical progress and the modern lifestyle. In particular, Candida spp. is a rare but important cause of infective endocarditis. We report the case of a 28-year-old woman­quadriplegic and bedridden from birth­who died after repeated episodes of pneumonia treated with different regimens of intravenous antibiotics. A medico legal autopsy was performed, which diagnosed severe Candida native valve infective endocarditis (CIE). This case report illustrates the prolonged use of antibiotic treatment as a possible risk factor for the development of CIE. We also considered how the bedridden condition and the presence of a central venous catheter may be additional risk factors for the development of this entity. Finally, we examined the absence of peripheral embolization in the setting of endocarditis of the right side of the heart.

Métodos de avaliação do estado nutricional de crianças e adolescentes com Paralisia Cerebral Tetraespástica / Assessment of nutritional status of children and adolescents with spastic quadriplegic cerebral palsy

ABSTRACT BACKGROUND: Due to several factors, such as gastrointestinal's diseases and difficulty in feeding, children with Spastic Quadriplegic Cerebral Palsy tend to present nutritional deficits. OBJECTIVE: To assess the nutritional status of pediatric patients with Spastic Quadriplegic Cerebral Palsy according to reference curves for this population and with the measures of folds and circumferences, obtained by the upper arm circumference and triceps skin fold. METHODS: The data were obtained from: knee-height, estimated height, weight, upper arm circumference, and triceps skin fold. Values of folds and circumferences were compared with Frisancho, and specific curves for these patients were used as reference. The relationship between the values in the growth curve for healthy children, Z-Score, and comparison with the reference curve were verified by Fisher's exact test. We adopted the significance level of 5%. RESULTS: We evaluated 54 patients. The mean age was 10.2 years, and 34 were male, 25 fed by gastrostomy and 29, orally. The frequency of low weight by the reference curve was 22.22%. More than half of the patients presented the parameters indicating lean mass below the 5th percentile. The height of all patients was classified as adequate for the age by the reference curve. CONCLUSION: Low weight was found in 22% of patients, and there is a greater tendency to present reduced muscle mass and increased fat mass, showing the need for evaluation and appropriate interventions for patients with Spastic Quadriplegic Cerebral Palsy.

RESUMO CONTEXTO: Devido a diversos fatores, como doenças do trato gastrointestinal e dificuldade de alimentação, frequentemente crianças com Paralisia Cerebral Tetraespástica apresentam prejuízo no estado nutricional. OBJETIVO: Avaliar o estado nutricional de pacientes pediátricos com Paralisia Cerebral Tetraespástica de acordo com curvas de referência para essa população e comparar com as curvas de referência utilizadas para a população pediátrica em geral. MÉTODOS: Foram obtidos os dados de: altura do joelho, estatura estimada, peso, circunferência braquial e dobra cutânea triciptal. Valores de dobras e circunferências foram comparados com Frisancho e curvas específicas para esses pacientes foram utilizadas como referência. A relação entre os valores plotados na curva de crescimento para crianças saudáveis, Escore-Z e comparação com a curva referencial foram verificados através do teste exato de Fisher. O nível de significância adotado foi de 5%. RESULTADOS: Foram avaliados 54 pacientes. A média de idade foi de 10,2 anos, 34 eram do sexo masculino. Vinte cinco se alimentavam via gastrostomia e 29 via oral. A frequência de baixo peso pela curva referencial foi de 22,22%. Mais da metade dos pacientes apresentaram os parâmetros indicativos de massa magra abaixo do percentil 5. A estatura de todos os pacientes foi classificada como adequada para idade pela curva referencial. CONCLUSÃO: O baixo peso foi encontrado em 22% dos pacientes, e há maior tendência para que esses pacientes apresentem massa muscular reduzida e aumento da massa gorda, mostrando a necessidade de avaliação e intervenções apropriadas para pacientes com Paralisia Cerebral Tetraespástica.

Síndrome de enclaustramiento: presentación de un caso / Locked-in syndrome: case report

El síndrome de enclaustramiento (Locked-in syndrome) es una entidad neurológica altamente discapacitante, producida por lesiones en la porción ventral de la protuberancia; de etiología principalmente vascular. Clínicamente se manifiesta por tetraplejía, anartria, preservación de la conciencia y capacidad de expresarse mediante movimientos oculares. Presentamos el caso de un paciente masculino de 33 años, transferido de otra institución de salud con un cuadro clínico progresivo y poco específico, caracterizado principalmente por deterioro del estado de conciencia, dificultad respiratoria, cefalea de intensidad moderada y vómitos. Mediante pruebas de imágenes se comprobó la presencia de un área de isquemia en la región irrigada por el sistema vertebrobasilar. Se realizó un enfoque diagnóstico y terapéutico invasivo de orden endovascular.

Locked-in syndrome is a highly disabling neurological entity, due to lesions in the ventral portion of the pons, mainly vascular etiology. Clinical features are quiadriplegia, anarthria, preservation of consciousness and the ability to express by ocular movements. We shown a case of a 33 years-old man, who was transfer from another institution with a progressive and poorly specific clinical manifestations, mainly characterized by diminishing of consciousness, breathing difficulty, headache and vomiting, with the presumptive diagnosis of central nervous system infection. We performed image diagnostic tests and they shown and ischemic feature in the region of the vertebrobasilar irrigation. It was perform an endovascular diagnostic therapeutic approach.

Video-assisted thoracoscopic implantation of a diaphragmatic pacemaker in a child with tetraplegia: indications, technique, and results / Implante de marca-passo diafragmático por videotoracoscopia em criança com tetraplegia: indicações, técnica e resultados

We report the case of a child with tetraplegia after cervical trauma, who subsequently underwent diaphragmatic pacemaker implantation. We reviewed the major indications for diaphragmatic pacing and the types of devices employed. We highlight the unequivocal benefit of diaphragmatic pacing in the social and educational reintegration of individuals with tetraplegia.

Relatamos o caso de uma criança tetraplégica após trauma cervical que foi posteriormente submetida a implante de marca-passo diafragmático. Revisamos as principais indicações da estimulação diafragmática e os tipos de dispositivos empregados, assim como apontamos o inequívoco benefício da reinserção socioeducacional desses indivíduos na sociedade.

Tetraparesia como única manifestación clínica en una paciente con Vasculitis ANCA + / Tetraparesis as the only clinical manifestation in a patient with ANCA + vasculitis

The involvement of the Peripheral Nervous System (PNS) occurs in a small proportion of patients with vasculitis. In our case report, the patient appears with a sensory-motor polyneuropathy, manifestation of a systemic vasculitis, which involved only the vasa nervorum.

El compromiso del Sistema Nervioso Periférico (SNP) ocurre en una pequeña proporción de pacientes afectados por vasculitis. En nuestro caso clínico, la paciente en cuestión debuta con una polineuropatía sensitivo-motora, manifestación de una vasculitis sistémica que comprometía sólo la vasa nervorum.

Avaliação cardiorrespiratória e da densidade mineral ossea de pacientes com lesão medular / Cardio respiratory assessment and mineral bone density of spinal cord injured subjects

Pacientes com lesão medular reconhecidamente desenvolvem muitas adaptações sistêmicas. Condições, como fraqueza da musculatura respiratória, paralisia e alterações na função pulmonar e conseqüentemente o aumento do índice de doenças pulmonares, são observadas. Recentemente, o aumento de doenças cardiovasculares também tem ocorrido entre esses pacientes, além das complicações provenientes da osteoporose que já são bem conhecidas. O objetivo deste trabalho foi avaliar as alterações do sistema cardiorrespiratório e esquelético de pacientes com lesão medular em 4 estudos. O estudo 1 avaliou a variabilidade da frequência cardíaca na posição supina e sentada e arritmia sinusal respiratória (ASR) de 37 homens com e sem lesão medular. Os pacientes tetraplégicos apresentaram uma redução dos valores máximos da frequência cardíaca durante ASR. O estudo 2 avaliou a função pulmonar de 23 pacientes com tetraplegia. Os valores de capacidade vital forçada, volume expiratório forçado 1s e ventilação voluntária máxima mostraram que a capacidade pulmonar dos pacientes com lesão medular foi reduzida. O estudo 3 propôs a adaptação do teste de caminhada de 6 minutos para 9 pacientes com paraplegia completa auxiliados por marcha artificial com eletroestimulação neuromuscular e andador. O estudo 4 investigou a densidade mineral óssea e fatores de risco cardiovascular de 44 homens com e sem lesão medular. Os pacientes com lesão medular apresentaram osteoporose e/ou osteopenia e o espessamento da camada íntima-média da carótida, porém os valores do lipidograma e triglicérides foram dentro da faixa de normalidade. A pressão arterial foi menor nos pacientes tetraplégicos. Análise estatística: Os dados foram apresentados em mediana (intervalo interquartil) e/ou média (±DP) e em Box-plot. Diferenças entre grupos foram demonstradas pelo intervalo de confiança da mediana, nível de significância em 5% ou teste t pareado...

It is known that individuals with Spinal Cord Injury (SCI) present systemic adaptation. SCI causes respiratory muscle weakness, paralysis and abnormal pulmonary function. Cardiovascular disease is also increased in spinal cord injured subjects and osteoporosis as well. The aim of this study was to assess cardio respiratory and bone diseases in subjects with SCI. Four studies were performed. The first study assessed heart rate variability in supine and seated position and respiratory sinus arrhythmia (RSA) maneuver in 37 subjects with and without SCI. Tetraplegic subjects showed the lowest values of maximal heart rate during RSA. The second study assessed pulmonary function in 23 tetraplegic subjects. Forced vital capacity, maximal voluntary ventilation, forced expired volume showed that the SCI subjects’ pulmonary capacity was reduced when compared with able body subjects. The third study adapted the “6 minutes’ walk test” to assess complete patients with SCI during gait therapy. The fourth study investigated the clinical presence of osteoporosis and cardiovascular risk factors in 44 subjects with and without SCI. Subjects showed osteoporosis or osteopenia and increased intima-media thickness, although lipids and triglycerides were with normal ranges. Blood pressure in tetraplegic subjects was lower than in paraplegic and control groups. Statistical Analysis: Data are expressed as median (interquartile interval) and presented in box-plot (median, 1st and 3rd quartiles, minimum and maximum). Differences between groups were demonstrated by confidence interval of median, significance level set at á = 0.05, or mean (±SD) and paired t test...

Efeito da radioterapia na profilaxia da ossificação heterotópica em pacientes com lesão medular traumática / The effect of radiotherapy on the prophylaxis of heterotopic ossification in patients with spinal cord injury

O objetivo deste trabalho foi estudar o efeito da radioterapia na profilaxia da ossificação heterotópica (OH) em pacientes com lesão medular traumática. Foram estudados 19 pacientes (15 homens e quatro mulheres), média de idade de 30,4 ± 10,8 anos (19 a 58 anos), com lesão medular traumática. A causa mais freqüente da lesão medular foi acidente de trânsito (42,1%), seguida por queda (26,3%), ferimento por projétil de arma de fogo (21%), mergulho (5,3%) e queda de objeto sobre as costas (5,3%). Dez pacientes eram tetraplégicos (52,6%) e nove (47,4%) eram paraplégicos. Apresentavam lesão medular completa (Frankel A) 14 pacientes (73,7%) e cinco pacientes (25,3%) tinham lesão incompleta (Frankel B). Todos os pacientes incluídos no estudo realizaram cintilografia óssea inicial até um mês após o traumatismo raquimedular e apresentaram diagnóstico negativo para OH. Os pacientes foram divididos em dois grupos: nove pacientes receberam radioterapia em dose única de 8 Gy nos quadris (Grupo Estudo) e 10 pacientes compuseram o Grupo Controle. Após seis meses de seguimento clínico e radiológico, um paciente do Grupo Estudo (11%) e cinco pacientes do Grupo Controle (50%) apresentaram OH. A distribuição da freqüência do desenvolvimento da OH nos dois grupos não mostrou diferença estatística significante, apesar da menor incidência de OH no grupo submetido à radioterapia (Grupo Estudo). Concluiu-se que, com o número de pacientes estudados, não foi possível comprovar a eficácia da radioterapia na prevenção da ossificação heterotópica, ainda que haja uma forte tendência para a correlação estatística.

The goal of this study was to evaluate the effect of radiotherapy on the prophylaxis of heterotopic ossification (HO) after spinal cord injury (SCI). Nineteen SCI patients were studied (15 men and four women). The mean age was 30.4 ± 10.8 years (range 19 to 58 years). The most frequent causes of lesion were traffic accident (42.1%), fall (26.3%), shot gun (21%), diving (5.3%) and objects falling on the vertebral column (5.3%). Ten patients were tetraplegics (52.6%) and nine were paraplegics. Fourteen patients (73.7%) had complete lesion (Frankel A) and five had incomplete lesion (Frankel B). All patients realized initial scintigraphy until one month after SCI and showed negative results for HO. The patients were randomized in two groups: nine patients received single dose irradiation with 8 Gy on the hips (Study Group) and 10 patients were the Control Group. After six months of clinical and radiological follow up, one patient of the Study Group (11%) and five patients of Control Group (50%) showed HO. The frequency distribution of the development of HO in both groups showed no significant statistical difference, although there was lower incidence of HO in the radiotherapy group. We concluded that, with the number of patients studied, it was no possible to prove the efficacy of radiotherapy to prevent HO, although had a strong tendency for the statistical correlation.

Complicaciones respiratorias de la tetraplejia: una mirada a las alternativas terapéuticas actuales / Respiratory complications in tetraplegia: overview to current therapeutic alternatives

Respiratory complications are the first cause of death in patients with tetraplegia, including both the acute and chronic stage of the disease. They include a wide variety of respiratory problems, such as repeated pneumonias, atelectasis, unsatisfactory secretions manage, respiratory failure, hypoventilation, and other complex pathologies such as pulmonary embolism and sleep apnea syndrome. It has been postulated that the main cause of all these respiratory complications is weakness of inter costais and abdominal muscles, and partial or complete dysfunction of the diaphragm. Today we have multiple therapeutic alternatives to prevent, manage and specifically treat the multiple types of complications. The main objective of this article is to review the different therapeutical alternatives and encourage the study of this important topic.

Las complicaciones respiratorias son la principal causa de muerte en los pacientes con tetraplejia, tanto en el período agudo como crónico. En esta categoría se incluyen diversas alteraciones como neumonías recurrentes, atelectasias, mal manejo de las secreciones, insuficiencia respiratoria e hipoventilación. Además, son frecuentes patologías más complejas como el tromboembolismo pulmonar y la apnea obstructiva del sueño. Se postula que las causas principales de los problemas respiratorios son la debilidad de los músculos intercostales y abdominales, y la disfunción parcial o total del diafragma. Hoy en día existen múltiples alternativas terapéuticas para prevenir, manejar y tratar en forma específica las diversas complicaciones. El propósito de este artículo es revisar las opciones terapéuticas actualmente vigentes y despertar el interés entre los clínicos para profundizar más en este importante tema.

The Effect of Selective Tibial Neurotomy and Rehabilitation in a Quadriplegic Patient with Ankle Spasticity Following Traumatic Brain Injury

Ankle spasticity following brain injury leads to abnormal posture and joint contracture; making standing or walking impossible. This study investigates the efficacy of selective tibial neurotomy (STN) and intensive rehabilitation in a patient who suffered ankle spasticity after brain injury. This case describes a 37-year-old man whose traumatic brain injury (TBI) resulted in severe right ankle spasticity and contracture. He was unable to stand due to severe right ankle spasticity and contracture. Intensive rehabilitation and STN allowed him to walk without brace at 6 months and run at 12 months after STN. STN is an effective procedure to resolve localized spasticity of the ankle and it may be considered as a management strategy after local injection to alleviate ankle spasticity and/or contracture prior to orthopaedic surgery.

Quadriplegia complicating ossification of the posterior longitudinal ligament.

We report a case of quadriplegia complicating ossification of posterior longitudinal ligament (OPLL) in a patient who was also found to have diffuse idiopathic skeletal hyperostosis (DISH). She also had osteomalacia (Vit. D deficiency) with secondary hyperparathyroidism. There could be a cause and effect relationship between the abnormal biochemistry and OPLL.

Anterior retropharyngeal approach to the cervical spine.

The anterior retropharyngeal approach (ARPA) accesses anteriorly situated lesions from the clivus to C3, in patients with a short neck, Klippel Feil anomaly or those in whom the C2-3 and C3-4 disc spaces are situated higher in relation to the hyoid bone and the angle of mandible where it is difficult to approach this region using the conventional anterior approach, due to the superomedial obliquity of the trajectory. The ARPA avoids the potentially contaminated oropharyngeal cavity providing for a simultaneous arthrodesis and instrumentation during the primary surgical procedure. Experience of five patients with high cervical extradural compression, who underwent surgery using this approach between 1994 and 1999, is presented. The surgical procedures included excision of ossified posterior longitudinal ligament (n=2); excision of prolapsed disc and osteophytes (n=2); and excision of a vertebral body neoplasm (n=1). Following the procedure, vertebral arthrodesis was achieved using an iliac graft in all the patients. Only one patient with vertebral body neoplasm required an additional anterior cervical plating procedure for stabilisation the construct. The complications included transient respiratory insufficiency and neurological deterioration in two patients; and, pharyngeal fistula and donor site infection in one patient.

Characteristic Plain Radiographic and Intravenous Urographic Findings of Bladder Calculi Formed over a Hair Nidus: A Case Report

We present the characteristic plain radiographic and intravenous urographic (IVU) findings of calculus formed over a hair. A 66-year-old man who had been quadriplegic for 40 years because of vertebral injury was admitted for further evaluation of frequent urinary tract infection. Plain radiography showed a linear, serpiginous calcification in the lower abdomen, and IVU revealed a round filling defect with linear radiopacity in the bladder, suggesting calculus. The gross appearance of the stone after extraction demonstrated that calcification had formed over a hair.

Hemorragia gastrintestinal em pacientes com tetraplegia traumática / Gastrointestinal hemorrhage in patients with traumatic tetraplegia

Os autores estudaram a eficácia da administraçäo de cimetidina na reduçäo da incidência de hemorragia gastrintestinal em dois grupos de pacientes tetraplégicos após traumatismo raquimedular, na fase aguda, em uso decorticoterapia. Observou-se incidência de 10,6% de hemorragia gastrintestinal no grupo controle e 3,5% no grupo que recebeu cimetidina profilaticamente. Os autores concluem favoravelmente pela eficácia deste método na preservaçäo da hemorragia gastrintestinal, nos pacientes vítimas de traumatismo raquimedular

Artrodese anterior precoce nas luxaçöes da coluna cervical com tetraplegia / Early anterior arthrodesis in luxations of the cervical spine with tetraplegia

Apresentam-se 20 casos de luxaçäo de coluna cervical com tetraplegia que foram tratados por fusäo anterior e estabilizaçäo com placa e dois parafusos. A consolidaçäo foi obtida em um período médio de três meses nos 16 pacientes que sobreviveram, näo sendo observada melhora de tetraplegia. Os autores acreditam que este método seja util nos pacientes com tetraplegia por permitir uma reabilitaçäo precoce pois fornece estabilizaçäo imediata