Cystoid Macular Edema: A Rare Adverse Reaction to Rituximab.

Membranous glomerulonephritis is the leading cause of nephrotic syndrome in non-diabetic Caucasian adults. For patients at risk of progressing to end-stage renal disease, immunosuppression, particularly rituximab, is the recommended treatment. While extremely rare, cases of cystoid macular edema associated with rituximab have been documented in the literature. In this report, we present the case of a 54-year-old male with membranous glomerulonephritis at a high risk of progressing to end-stage renal disease who experienced cystoid macular edema hours after receiving rituximab infusion. Following the discontinuation of the medication, the patient spontaneously recovered visual acuity without the need for any targeted therapy.

Outcomes in Pregnant Women with Valvular Heart Disease from Portuguese-Speaking African Countries Treated in Portugal through an International Agreement of Health Cooperation.

Aims: We performed a clinical audit of maternal and fetal outcomes in pregnant women with valvular heart disease (VHD) from Portuguese-speaking African countries who were transferred for their care, during a twenty-year period, through a memorandum of agreement of international cooperation. Methods and results: A retrospective analysis of 81 pregnancies in 45 patients with VHD (median age 24, interquartile range 22-29 years) from 2000 to 2020 was performed. The main outcome measures were maternal cardiovascular and fetal outcomes. History of rheumatic heart disease was present in 60 (74.1%) pregnancies. Most were in New York Heart Association (NYHA) functional class I or II; at the first evaluation, 35 (43.2%) were on cardiac medication and 49 (60.5%) were anticoagulated. Forty-eight pregnancies had at least one valvular prosthesis, including 38 mechanical heart valves. During pregnancy, deterioration in NYHA functional class occurred in 35 (42.0%), and eight (9.9%) patients required initiation or intensified cardiac medication. Mechanical valve thrombosis complicated four (4.9%) pregnancies, all cases on heparin, and resulted in one maternal death. Haemorrhagic complications happened in 7 (8.6%) anticoagulated patients, in the immediate postpartum or puerperal period. The 81 pregnancies resulted in 56 (69.1%) live births, while miscarriage and fetal malformations occurred in 19 (23.5%) and 12 (14.8%) pregnancies, respectively. In multivariate analysis, vitamin K antagonist therapy was the only independent predictor of an unsuccessful pregnancy (p = 0.048). Conclusion: In a high-income country, successful pregnancy was possible with low rate of maternal events in women with VHD transferred from five low-middle income countries in Africa. The use of anticoagulation with a vitamin K antagonist was associated with an unsuccessful pregnancy.

Type II Abernethy Malformation: A Rare Cause of Hepatic Encephalopathy in Adulthood.

Abernethy malformation is a rare congenital extrahepatic portosystemic shunt with variable clinical manifestations, mainly associated with the portosystemic shunt. Hepatic encephalopathy can be the first manifestation. We present the case of a 50-year-old woman with hepatic encephalopathy without liver dysfunction. Further evaluation with contrast-enhanced abdominal computed tomography was performed, showing a large-calibre portocaval shunt from the left portal branch, suggestive of type 2 Abernethy malformation. The patient improved with lactulose and rifaximin but maintained rare encephalopathy episodes. She is therefore currently awaiting surgical treatment. Despite being a rare cause of hepatic encephalopathy, Abernethy malformation should be considered in patients with unexplained hyperammonaemia. Since it is potentially reversible, and early diagnosis and treatment may improve outcome, raising awareness of this malformation is essential. LEARNING POINTS: Abernethy malformation is a rare congenital extrahepatic portosystemic shunt with variable clinical manifestations, some associated with the portosystemic shunt; hepatic encephalopathy can be the first manifestation.Initial recognition of the presence of encephalopathy in non-cirrhotic individuals can be challenging, and patients may have symptoms for a long period of time before being diagnosed.This entity, although rare, should be looked for in patients with hepatic encephalopathy without evidence of liver disease, mainly because it can be submitted to targeted treatment.

Implant site Nexplanon reaction?

Nexplanon (Schering-Plough Limited/Merck Sharp & Dohme Limited (MSD)) is a long active reversible contraceptive method that provides effective contraception for 3 years. It consists of a single, flexible, rod-shaped implant, containing 68 mg etonogestrel. It is 4 cm long, consists of an ethylene vinyl acetate copolymer, a non-absorbable material, and also contains 15 mg of barium sulfate, which makes it visible by X-ray. We describe a case of a 39-year-old woman who experienced a local reaction to the barium sulfate in Nexplanon. She was given medical treatment, but only the removal of the implant resolved the symptoms. After removal there was gradual improvement and 72 h later the patient was asymptomatic. Allergic reaction to barium sulfate is extremely rare: until now, there have only been two cases associated with Nexplanon described in the literature.

In situ breakage of Implanon®--two cases of a rare occurrence.

BACKGROUND: In situ breakage of Implanon® is a rare occurrence with unknown clinical significance. Authors report two different cases of broken Implanon® of women attended at our Family Planning Clinic. DISCUSSION: In situ implants may spontaneously and asymptomatically break, although some uncertainty relies on whether that situation has a real impact on the contraceptive effectiveness or on bleeding patterns. Even more, it can be argued if, as a result of an occurrence of that nature, the implant shall or shall not be removed before the envisaged 3-year period of effectiveness. CONCLUSION: Currently, the clinical significance of implant breakage remains unknown. The decision to remove a broken or bent implant should be based on clinical judgements considering patients' wishes.

Magnetic resonance imaging and gynecological devices.

BACKGROUND: Performing magnetic resonance imaging (MRI) on women with gynecological devices is a completely accepted practice. The goal of our review is to assess how safe it is to perform MRI on women using contraceptive implants or devices. STUDY DESIGN: Literature review, searching in PubMed-Medline/Ovid for the following keywords: magnetic resonance imaging, intrauterine devices, Implanon(®) and Essure(®). RESULTS: Though plastic devices do not represent a contraindication to the use of the technique, those including metallic components have been submitted to several tests, after which they were classified as MR Conditional (devices presenting no risks in MR-specific environments) by the Food and Drug Administration. Thus, the use of MRI can be safely advised to women with this type of device as long as the magnetic resonance equipment is ≤3.0 T. CONCLUSIONS: Presently, there is no scientific evidence that contraindicates performing MRI on women with any kind of gynecological device. Therefore, this procedure is safe as long as it is performed under previously tested conditions.

Prenatal determination of the fetal RhD blood group by multiplex PCR: a 7-year Portuguese experience.

OBJECTIVES: This is a retrospective study to evaluate the efficacy and accuracy of the multiplex polymerase chain reaction (PCR) amplification, for early detection of fetuses at risk for hemolytic disease, in the population living in Portugal, and to characterize the RhD-negative individuals at serologic and molecular level. METHODS: 2030 uncultured amniotic fluid samples and 2012 blood samples from the respective RhD-negative pregnant women were studied by multiplex PCR of intron 3/intron 4, exon 7 and 3'UTR. Amniocentesis was performed for a variety of medical indications. For quality control, serologic RhD blood groups were determined in the cord blood, after birth. RESULTS: 1361 fetal amniotic samples were RhD-positive (67%), 669 were RhD-negative. The average time for diagnosis was 2 days for uncultured amniocytes and the molecular versus serologic RhD typing (n = 809) had 99.5% concordance. Among the 2012 serologic RhD-negative mothers, 26 had an RhD-positive allele. CONCLUSION: The multiplex PCR amplification used in this study was a rapid and accurate method to determine the RhD blood type in the population living in Portugal, being a great tool for management of pregnancies with fetuses at risk for alloimmune hemolytic disease. In this population, 1.3% of the serologic RhD-negative women have an RHD-positive allele.