Prolonged arthralgias in Whipple's disease - A common but often overlooked symptom of a rare disease.

Whipple's disease is a multisystemic chronic infectious condition caused by Tropheryma whipplei (T. whipplei). Though characterised often by insidious weight loss, diarrhoea, and arthralgia, three other distinct manifestations can be observed, namely localised disease, acute infection and asymptomatic carriage. The diagnosis relies on histopathological examination of duodenal biopsies and polymerase chain reaction analysis of the 16S rRNA gene for T. whipplei. We report the case of a middle-aged man admitted for etiologic investigation of prolonged, migrating, and inflammatory arthralgias and subsequent development of gastrointestinal symptoms. Despite its reputation as a great mimicker of many different illnesses, the difficulty in diagnosis probably lies with its rarity rather than its masking.

Autoimmune Hepatitis on a Living Liver Donor: An Unexpected Long-Term Complication.

In Western countries, deceased donor liver transplantation remains the standard of care for patients with end-stage liver disease. Living donor liver transplantation is a viable and feasible strategy for patients with end-stage liver disease designed to mitigate the deceased organ shortage. Donor safety is the primary concern because liver donors, ideally, should not have any complication. We report a case of middle-aged woman without a history of chronic liver disease who developed autoimmune hepatitis more than 20 years after live liver donation. Changes in these patients' liver enzymes should prompt swift referral to an hepatologist for initial liver disease work-up.

Occult hepatitis C infection identified in injection drug users with direct antiviral agents therapy and spontaneous resolution of hepatitis C virus infection.

BACKGROUND: Occult hepatitis C infection (OCI) is characterized by the detection of hepatitis C virus (HCV) RNA in hepatocytes and in peripheral blood mononuclear cells (PBMCs) without detection in serum. We aimed to evaluate OCI in drug and no drug users who achieved sustained virological response (SVR) after therapy with direct-acting antivirals (DAAs) and with HCV spontaneous resolution. METHODS: Twenty-four patients in the AVP group (who achieved a SVR after DAAs therapy), 13 in the NAVP group (with HCV spontaneous resolution) and 7 HCV-RNA positive patients (CPP, control positive group) were included in the study. HCV/OCI-RNA was screened in serum and PBMCs samples of the patients by ddPCR for OCI patients' identification. Plasma and red blood cells (RBCs) samples of the patients were also evaluated for HCV/OCI-RNA detection by ddPCR. RESULTS: OCI was presented in injection drug users (IDUs) in the AVP (20.8%) and NAVP (23.1%) groups by ddPCR with a higher statistically significant percentage detected in RBCs samples of the patients in the AVP group comparatively to NAVP (p<0.01) and CPP (p < 0.05) groups. CONCLUSION: OCI was identified in IDUs patients of the AVP and NAVP groups by ddPCR. These results suggest that OCI patients in the AVP group might not be entirely cured, and that OCI patients in the NAVP group were not identified at clinical evaluation time when just serum samples were analysed. A higher percentage of HCV/OCI-RNA was detected in RBCs samples. Overall results recommends that HCV/OCI identification in patients with DAAs therapy and spontaneous resolution of HCV infection should be studied more accurately in future and in larger patient groups if possible. Additionally, suggest also PBMCs and RBCs samples as predictors for HCV/OCI diagnosis and management.

Concomitant Nitrofurantoin-Induced Autoimmune Hepatitis and Interstitial Lung Disease.

Antibiotics are known to cause adverse reactions, but multiple organ involvement associated with nonspecific symptoms can lead to a delay in diagnosis. A definitive correlation between each toxin and its effects is difficult to establish due to concomitant potential toxins in the circulation. This article highlights an uncommon case of concomitant nitrofurantoin-induced autoimmune hepatitis and lung fibrosis that fulfills the definitive clinical criteria for diagnosis, presenting histological, imagiological, and immunological evidence of nitrofurantoin-induced toxicity. It occurred in a 68-year-old woman with extended nitrofurantoin intake for urinary tract infection prophylaxis who presented with progressive exercise dyspnea and jaundice. Similar published cases are also reviewed in this article.

Os antibióticos são causas conhecidas de reações adversas, mas o envolvimento multiorgânico associado à sintomatologia inespecífica pode conduzir ao atraso diagnóstico. Devido às potenciais toxinas concomitantemente em circulação, é muitas vezes difícil estabelecer uma correlação definitiva entre cada toxina e os seus efeitos.Este artigo salienta um caso incomum de hepatite autoimune e fibrose pulmonar induzidas pela nitrofurantoína e que cumpre critérios definitivos de diagnóstico, apresentando-se dados histológicos, imagiológicos e imunológicos da toxicidade induzida pela nitrofurantoína.O caso ocorre numa mulher de 68 anos de idade, com toma prolongada de nitrofurantoína como profilaxia de infeção urinária, e que se apresenta com dispneia de esforço progressiva e icterícia. O artigo faz ainda uma revisão de casos semelhantes publicados.

Perfusion Magnetic Resonance as a Biomarker for Sorafenib-Treated Advanced Hepatocellular Carcinoma: A Pilot Study.

BACKGROUND: Sorafenib is the currently recommended therapy in patients with advanced hepatocellular carcinoma (HCC). Among the several biomarkers available for the evaluation of the therapeutic response and prognosis, there is perfusion magnetic resonance imaging (p-MRI) that, through measurement of the vascular permeability unit (ktrans), may retrieve useful information regarding the microvascular properties of focal liver lesions. The aim of this study was to evaluate the impact of sorafenib therapy in patients with advanced HCC using the p-MRI technique. MATERIALS AND METHODS: In this retrospective study, 27 patients with the diagnosis of advanced HCC were included for palliative therapy using sorafenib. MRI of the liver was performed before the beginning of the oral therapy (T0), after 3 (T3), and after 6 months (T6). Dynamic acquisitions of the tumor (n = 50, during the first 2 min after contrast injection) were obtained in the coronal plane and were used to compute the parametric perfusion maps, acquiring the ktrans value using the extended Tofts pharmacokinetic model. RESULTS: The value of ktrans obtained at T0 was significantly different from the value of ktrans obtained at T6 (p = 0.028). There were no significant differences between T0 and T3 (p = 0.115) or a correlation between ktrans at T0 and the size of the lesion (p = 0.376). The ktrans value at T0 in patients with progression-free survival (PFS) > 6 months was not significantly different from the ktrans value in patients with PFS ≤6 months (p = 0.113). The ktrans value at T0 was not significantly different between patients who were previously submitted to chemoembolization and those who were not submitted (p = 0.587). CONCLUSION: In this pilot study, the ktrans value may serve as a biomarker of tumor response to antiangiogenic therapy, but only 6 months after its initiation. Clinical outcomes such as PFS were not predicted before the initiation of treatment.

INTRODUÇÃO: O sorafenib é a terapêutica atualmente recomendada em doentes com carcinoma hepatocelular avançado. Entre os vários biomarcadores disponíveis para a avaliação da resposta terapêutica e do prognóstico, existe a perfusão por Ressonância Magnética na qual, através da unidade de permeabilidade vascular (ktrans), se obtém informação relativa às propriedades microvasculares das lesões tumorais. O objetivo deste estudo foi avaliar o impacto da terapêutica com sorafenib em doentes com carcinoma hepatocelular avançado, através da técnica de perfusão por Ressonância Magnética (p-RM). MATERIAIS E MÉTODOS: Neste estudo observacional retrospetivo, foram incluídos 27 doentes, com diagnóstico de carcinoma hepatocelular avançado com indicação para terapêutica paliativa com sorafenib. Foi realizado estudo de Ressonância Magnética hepática antes do início da terapêutica com sorafenib (T0), aos 3 (T3) e aos 6 meses (T6) após o seu início. As imagens adquiridas no plano coronal (n = 50, durante os primeiros 2 minutos após a injeção de contraste paramagnético) foram utilizadas para fusão dos mapas paramétricos de perfusão, obtendo-se o valor de ktrans, usando o modelo farmacocinético de Tofts. RESULTADOS: O valor de ktrans obtido em T0 foi significativamente diferente do valor de ktrans obtido em T6 (p = 0.028). Não existiram diferenças significativas entre T0 e T3 (p = 0.115) ou correlação entre o valor de ktrans em T0 e a dimensão da lesão (p = 0.376). Associadamente, o valor de ktrans em T0 nos doentes com sobrevivência livre de progressão superior a 6 meses não foi significativamente diferente do valor de ktrans nos doentes com sobrevivência livre de progressão inferior ou igual a 6 meses (p = 0.113). O valor de ktrans em doentes com ou sem tratamento prévio por quimioembolização não mostrou diferença estatisticamente significativa (p = 0.587). CONCLUSÃO: Neste estudo inicial, o valor de ktrans pode servir como biomarcador da perfusão tumoral na resposta à terapêutica anti-angiogénica, 6 meses após o seu início. O seu valor antes do inicio do tratamento não permitiu predizer o desfecho clinico em termos de sobrevivência livre de doença nos pacientes submetidos ou não a prévia quimioembolização.© 2019 Sociedade Portugueasa de Gastrenterologia.

Epidemiology of Clostridium difficile infection in Portugal: Experience at a tertiary care hospital.

BACKGROUND: Clostridium difficile is the main cause of healthcare-associated diarrhoea. Its incidence, severity and relapse rates increased over the past two decades. AIM: To study epidemiologic characteristics and treatment of Clostridium difficile infection (CDI) and compare with a previous cohort from the same hospital. METHOD: Retrospective analysis of clinical records of CDI diagnosed from 2010 to 2015 and comparison with data from 2004 to 2009. RESULTS: 259 cases were diagnosed, compared to 83 in 2004-2009. There was no difference in mean annual incidence (8.66 versus 7.11 per 1000 patients; p = .116), but a dramatic increase was observed in 2009/2010 (peak incidence: 21.63 cases per 1000 admissions). Females were more affected (61.4% versus 69.9%; p = .177). Median age was 80 and 83 (p = .097). We observed an increase in median number of antibiotics previously used (2 versus 3; p = .147) and in community-associated CDI (6% versus 19.7%; p = .003). There was a continued increase in the use of carbapenems and quinolones until 2010 and a high percentage of refractory cases in 2010. Female gender (p = .043), long-term care facility (LTCF) residency (p = .022) and a higher number of previous antibiotics (median of 3; p = .025) were independent predictors for refractory and recurrent CDI. CONCLUSIONS: CDI incidence achieved a peak in 2009/2010 coinciding with the introduction of alcohol-based hand products, increase in quinolone and carbapenem prescription and a possible outbreak of an epidemic strain. Female gender, LTCF residency and exposure to three or more antibiotics are risk factors for refractory and recurrent CDI. We emphasize the need to restrict use of large spectrum antibiotics.

Intrahepatic sarcomatoid cholangiocarcinoma.

Sarcomatoid carcinoma is a rare tumour composed of intermingled malignant epithelial and mesenchymal cells, and it has been reported in various organs including the liver. Sarcomatoid cholangiocarcinoma (CCC) is an extremely rare liver primary tumour. Here, we report a case of an elderly man who was admitted to our hospital after head trauma. He performed a head CT that diagnosed cerebral metastasis. On abdominal CT, he presented a 10×8×9 cm-sized hypodense liver mass in the VII and VIII segments, with peripheral enhancement. Histological and immunohistochemical examination of the tumour showed a malignant neoplasm with both carcinomatous and sarcomatous components and positive expression of cytokeratin and vimentin antibodies. The patient was diagnosed with intrahepatic sarcomatoid CCC at an advanced stage and died 45 days after the diagnosis. We emphasise the importance of immunohistochemistry which may provide a clue to proper diagnosis.

Advanced Stage Hepatocellular Carcinoma with Multiple Metastasis and Vascular Thrombosis: A Case of Complete Response to Sorafenib.

Sorafenib is a multi-targeted tyrosine kinase inhibitor, with antiangiogenic and antiproliferative properties, approved for the treatment of advanced hepatocellular carcinoma. It induces a significant increase in the median overall survival, despite a complete response to treatment being rare. We report a clinical case of a 60-year-old male with hepatic cirrhosis, Child-Pugh class A and performance status 0, and advanced hepatocellular carcinoma. The primary tumor measured 17 x 8 cm and had diffuse intrahepatic metastization, extensive lung and left adrenal invasion, as well as thrombosis of inferior vena cava, with projection to the right atrium. This patient showed a rapid and complete response to sorafenib, evaluated by mRECIST (modified Response Evaluation Criteria in Solid Tumors), that remains after three years of treatment.

O sorafenib, um inibidor de múltiplas cinases com propriedades antiangiogénicas e antiproliferativas foi aprovado para o tratamento de carcinoma hepatocelular em estádio avançado por induzir um prolongamento da sobrevivência global estatisticamente significativo, sendo a resposta completa rara. Relata-se o caso clínico de um homem de 60 anos com cirrose hepática classe A de Child-Pugh e performance status 0 e carcinoma hepatocelular em estádio avançado (com tumor primitivo medindo 17 X 8 cm, metastização intra-hepática difusa, pulmonar maciça e da suprarrenal esquerda e ainda trombose da veia cava inferior com extensão e projeção na c'mara da aurícula direita), que apresentou resposta completa com sorafenib, avaliada pelos critérios mRECIST (modified Response Evaluation Criteria in Solid Tumors). Esta resposta mantem-se após três anos de tratamento.

Polymyositis and the Spectrum of Scleroderma Disorders.

Polymyositis (PM) is usually associated to other autoimmune or connective tissue diseases. The authors report the case of a 59-year-old man with pulmonary fibrosis, who presented with constitutional symptoms and gradually developed proximal muscle weakness, Raynaud phenomenon, and dysphagia. Besides creatine kinase (CK) elevation, he had positive anti-Polymyositis-Scleromyositis (PM-Scl) and anti-Sjögren's-syndrome A (SSA) antibodies. Nailfold capillaroscopy showed a scleroderma pattern and muscle biopsy revealed necrosis, regeneration of muscle fibers, and inflammatory infiltrate. Prednisolone was started, with great improvement. Taking into account the overlap features between PM and systemic sclerosis sine scleroderma, it is important to closely monitor the patient for signs of pulmonary and cardiac decompensation. LEARNING POINTS: Polymyositis (PM) may be associated with connective tissue diseases such as systemic sclerosis, including its variant without skin involvement.Necrotizing muscle fibers are typically found in patients with overlap syndrome, in opposition to patients only with polymyositis.PM-Scl antibodies are associated to a good response to corticoids.

[Metallosis: A Rare Cause of Autoimmune Hemolytic Anemia]. / Metalose: Causa Rara de Anemia Hemolítica Autoimune.

INTRODUCTION: Hemolytic anemia may be associated with multiple etiologies, including toxic substances, such as metals, which is a rare cause. CASE STUDY: 55-year-old male, who underwent a total arthroplasty of the right hip (uncemented prostheses with ceramic-ceramic articulation with an acetabular component consisting of a dome composed of an alloy of titanium, aluminum and vanadium into which fitted a ceramic 'insert'). Approximately 4 years after surgery the patient complained of noise originating from the prosthesis which occurred on movement. A surgical revision was performed and showed the presence of dark thick intracapsular fluid, fracture of the ceramic acetabular 'insert' and signs of wear of the acetabular metal dome. Extensive washing was carried out and the fractured ceramic 'insert' was replaced for a polyethylene 'insert'. Two months later he was referred to the Emergency Room due to worsening of his general health, floating in the right hip and mucocutaneous jaundice. Laboratory tests suggested autoimmune hemolytic anemia. Arthrocentesis was performed and a large volume of metal fluid was drained off. The CT scan showed a large heterogeneous pelvic cystic collection seeded with prosthesis fragments, suggestive of metallosis. Hemolytic anemia was explained as toxicity of the particles and metal ions caused by the wear of the prosthesis. The patient was started on a high-dose steroid treatment. Afterwards, when he was stable, prosthesis components replacement and drainage of pelvic debris fluid were carried out. DISCUSSION: After the fracture of the ceramic 'insert' the ceramic head began to articulate directly with the metallic acetabular component, causing noise and wear with release of particles and ions. This caused a cystic pelvic abscess, which went unnoticed on the first surgical revision. Surgical debridement lead to the cystic collection extending into the adjacent tissues and the systemic circulation, triggering serious systemic effects, such as autoimmune hemolytic anemia. The potential toxicity of each of the metal elements of this prosthesis is unknown, and there are still no available laboratory tests for its detection. CONCLUSION: Metallosis is a rare cause of autoimmune hemolytic anemia.

Introdução: A anemia hemolítica pode estar associada a múltiplas etiologias, nomeadamente a tóxicos, como os metais, sendo esta uma causa rara.Caso Clínico: Homem de 55 anos de idade, sujeito a artroplastia total da anca direita (prótese não cimentada com articulação cerâmica-cerâmica, cujo componente acetabular era constituído por uma cúpula metálica composta por uma liga de titânio, vanádio e alumínio na qual encaixava um insert cerâmico). Cerca de quatro anos após esta intervenção cirúrgica referia ruídos na prótese com os movimentos. Foi sujeito a revisão cirúrgica tendo-se constatado a presença de líquido espesso intracapsular de cor escura, fractura do insert acetabular cerâmico e sinais de desgaste da cúpula metálica acetabular. Procedeu-se a lavagem abundante e substituição do insert cerâmico fracturado por um insert de polietileno. Dois meses depois recorreu ao Serviço de Urgência por degradação do estado geral, flutuação na anca direita e icterícia muco-cutânea. Analiticamente evidenciava valores compatíveis com anemia hemolítica autoimune. Foi feita punção articular com saída de abundante líquido metalótico. A tomografia computorizada revelou extensa colecção heterogénea quística intrapélvica com múltiplos fragmentos de prótese no seu interior, sugestivos de metalose. A anemia hemolítica foi interpretada como consequência da toxicidade das partículas e iões metálicos oriundos do desgaste da prótese. Iniciou corticoterapia em altas doses e posteriormente quando houve condições procedeu-se à substituição de todos os componentes da prótese e drenagem do material acumulado intra-pélvico.Discussão: Após a fractura do insert cerâmico a cabeça cerâmica passou a articular directamente com o componente acetabular metálico, originando os ruídos e desgaste com libertação de partículas e iões. Este material formou uma coleção quística intrapélvica, que passou despercebida na primeira revisão cirúrgica. O desbridamento cirúrgico pôs em comunicação esta coleção com os tecidos adjacentes e com a circulação sistémica, desencadeando efeitos sistémicos graves, como anemia hemolítica auto-imune. Desconhece-se o potencial de toxicidade de cada um dos elementos metálicos desta prótese, não estando ainda disponíveis testes laboratoriais de detecção.Conclusão: A metalose é uma causa rara de anemia hemolítica auto-imune.

A new cluster-based oversampling method for improving survival prediction of hepatocellular carcinoma patients.

Liver cancer is the sixth most frequently diagnosed cancer and, particularly, Hepatocellular Carcinoma (HCC) represents more than 90% of primary liver cancers. Clinicians assess each patient's treatment on the basis of evidence-based medicine, which may not always apply to a specific patient, given the biological variability among individuals. Over the years, and for the particular case of Hepatocellular Carcinoma, some research studies have been developing strategies for assisting clinicians in decision making, using computational methods (e.g. machine learning techniques) to extract knowledge from the clinical data. However, these studies have some limitations that have not yet been addressed: some do not focus entirely on Hepatocellular Carcinoma patients, others have strict application boundaries, and none considers the heterogeneity between patients nor the presence of missing data, a common drawback in healthcare contexts. In this work, a real complex Hepatocellular Carcinoma database composed of heterogeneous clinical features is studied. We propose a new cluster-based oversampling approach robust to small and imbalanced datasets, which accounts for the heterogeneity of patients with Hepatocellular Carcinoma. The preprocessing procedures of this work are based on data imputation considering appropriate distance metrics for both heterogeneous and missing data (HEOM) and clustering studies to assess the underlying patient groups in the studied dataset (K-means). The final approach is applied in order to diminish the impact of underlying patient profiles with reduced sizes on survival prediction. It is based on K-means clustering and the SMOTE algorithm to build a representative dataset and use it as training example for different machine learning procedures (logistic regression and neural networks). The results are evaluated in terms of survival prediction and compared across baseline approaches that do not consider clustering and/or oversampling using the Friedman rank test. Our proposed methodology coupled with neural networks outperformed all others, suggesting an improvement over the classical approaches currently used in Hepatocellular Carcinoma prediction models.

Plasma osteopontin is a biomarker for the severity of alcoholic liver cirrhosis, not for hepatocellular carcinoma screening.

BACKGROUND: Implementation of surveillance programs for at-risk populations and identification of biomarkers for early hepatocellular carcinoma (HCC) detection are a major public health goal. Recently, osteopontin (OPN) has attracted attention as a promising biomarker, with some potential advantages compared to alpha-fetoprotein (AFP), but its role in the context of alcoholic cirrhosis has never been assessed. The aims of this study are to assess the utility of plasma OPN in the diagnosis of HCC in alcoholic cirrhotic patients and to investigate whether increased values are due to the tumor or underlying liver disease severity. METHODS: A total of 90 consecutively alcoholic cirrhosis patients, observed between Jun 2013 and May 2014 at a Liver Disease Unit, were included and divided into two groups: 45 without (group I) and 45 with HCC (group II). Plasma levels of OPN (ELISA, Immuno-Biological Laboratories, Gunma, Japan) and AFP (IMMULITE® 2000 AFP, Siemens Healthcare Diagnostics, Tarrytown, New York) were assessed. The diagnostic accuracy of each marker was evaluated using Receiver-Operating Characteristic (ROC) curve analysis (AUC) and its 95 % Confidence Interval (CI). RESULTS: Plasma OPN levels in group I patients (1176.28 +/-744.59 ng/mL) weren't significantly different from those of group II (1210.75 +/-800.60 ng/mL) (p = 0.826). OPN levels significantly increased with advancing BCLC tumor stage and with advancing Child-Pugh class, in both groups. Comparing the two groups, AUC for OPN and AFP were 0.51 (95 % CI: 0.39-0.63) and 0.79 (95 % CI: 0.70-0.89), respectively. Based on the ROC analysis, there were no satisfactory cut-off values for OPN that would distinguish patients with from those without tumour. CONCLUSIONS: Despite having a correlation with BCLC stage, the same was observed with progressive deterioration of underlying liver function in terms of Child-Pugh class and MELD score, and isn't a useful diagnostic biomarker for HCC in alcoholic cirrhotic patients, particularly in the early stages. AFP confirms the performance evidenced in other studies, being superior to OPN. Searching more specific biomarkers for early diagnosis of HCC in alcoholic cirrhosis is still warranted.

A 22-year-old male patient with ascites.

A 22-year-old male patient presented with a 3-day history of abdominal pain, diarrhoea, nausea and vomiting. He reported abdominal distention of a couple of weeks' duration. He had been hospitalised 7 months earlier, owing to the same symptoms, however, the cause was never clarified. Initial examination showed abdominal distention and blood tests indicated eosinophilia. An abdominal CT scan showed mild ascites and a diffuse thickening of the small intestinal loops, and a cystic formation 3 cm in diameter on the liver. The differential diagnosis included parasite infection and eosinophilic gastroenteritis. Liver MRI revealed a simple biliary cyst. Microbiological tests, stool and blood cultures as well as stool examination for parasites were negative. The diagnostic paracentesis revealed eosinophilic ascites. An endoscopy was performed and histopathology revealed presence of moderate to marked lymphoplasmacytic infiltrate containing eosinophils, compatible with eosinophilic gastroenteritis. The patient responded well to the initiation of corticosteroids.

Severe hyponatremia in older patients at admission in an internal medicine department.

Hyponatremia is common in older people, most often of multifactorial origin, and can be associated with poor clinical outcomes. The aim was to analyze the frequency of severe hyponatremia (sodium concentration below 125 mmol/L), risk factors and mortality association in hospitalized older patients. A retrospective study was performed in older patients (over 65 years) with hyponatremia, diagnosed at admission in an Internal Medicine Department during one year. A control group of 127 older patients without hyponatremia was considered. Statistical analysis of the data gathered was made with SPSS Statistics 20. The main results were: a group of 1060 patients with age superior to 65 years was identified (representing 72.26% of total admissions); incidence of hyponatremia in those patients was 27.55% and severe hyponatremia was 5.94%; diagnosis of hyponatremia was mentioned in the discharge note in 66.67% of cases; mortality was 27.0%, against 16.0% in the control group (p=0.057, Odds Ratio (OR)=1.940); drugs were a significant risk factor (p<0.001), specially thiazide diuretics (p=0.029, OR=2.774), angiotensin receptor blockers (ARB) (p=0.001, OR=4.097), proton-pump inhibitors (PPI) (p=0.007, OR=2.561) and spironolactone (p=0.011, OR=4.473); other relevant risk factors were: increased water intake (p=0.004), tube feeding (p<0.001), vomiting (p=0.032, OR=2.492), cirrhosis (p=0.008, OR=10.862) and hyperhidrosis (p=0.017, OR=2.542). We conclude that, although this group of patients had a high mortality, hyponatremia is often not investigated and not always mentioned as a diagnosis. Clinicians should have a clear appreciation of the roles that iatrogenic interventions and lapses in nutrition frequently play in upsetting the homeostatic balance in older patients.

Chronic hepatitis C treated with peginterferon alfa plus ribavirin in clinical practice.

BACKGROUND/AIMS: The role of genotype and viremia were retrospectively evaluated on sustained virological response (SVR) rates in routine clinical practice. METHODOLOGY: From 1907 patients with chronic hepatitis C proposed for treatment, we analysed 1380 (1124 naive and 256 treatment-experienced) with complete follow-up. Genotype and HCV RNA quantification were assayed by commercial tests. Viremia was considered high if >800,000IU/mL, and low if <400,000IU/mL. Liver fibrosis was staged in 614 patients. RESULTS: Genotype 1 was the most frequent (60%), followed by 3 (25%), 4 (9%) and 2 (2%); 3.2% had other or unclassified genotype. Genotype 1 was more prevalent in central Portugal and genotype 4 in the south. Viremia was =800,000IU/mL in 54.6% and <400,000IU/mL in 34.6% of the patients, particularly in genotype 2 (p<0.03) and 4 (p<0.001). Genotype non-1 had a significantly lower viral load (p=0.004). Mild or moderate fibrosis was present in 71.7% and bridging fibrosis or cirrhosis in 28.3%, with no differences among genotypes. Treatment was discontinued in 19.8%. SVR was achieved in 55.3% of naive and 36.3% of re-treated patients. CONCLUSIONS: Standard treatment of chronic hepatitis C in real-life achieves similar results obtained in clinical trials, despite differences of demographic and viral parameters.

[Mediastinal masses: case series]. / Massas mediastínicas: análise de uma casuística.

INTRODUCTION: Mediastinal masses are tumoral lesions arising from intra-thoracic organs. They are an infrequent diagnostic challenge, requiring a structured clinical and radiological approach. OBJECTIVES: The study of the clinical, radiological and pathological characteristics, treatment and prognosis of patients, with mediastinal masses, admitted to an Internal Medicine ward in an University Hospital. METHODS: A retrospective analysis of the medical records of patients with this diagnosis made between years 2000 and 2008. RESULTS: Twenty-eight patients were included (15F/13M), with a mean age of 55.5 years (17-88). Twenty-six patients presented with symptoms, most frequently, dyspnoea, fatigue, dry cough, chest pain and anorexia. At examination, six exhibited superior vena cava syndrome. Chest X-ray showed pathological changes in 26. Chest CT scan added relevant information in all cases whenever it was performed. Histology was most frequently obtained by mediastinoscopy, open surgical biopsy, percutaneous thoracic biopsy and at necropsy. Histological diagnosis was not possible in ten patients. Final diagnoses included: lymphoma in four patients; sarcoidosis, thymic hyperplasia and undifferentiated squamous carcinoma of unknown origin in two patients each; other diagnosis in single cases were: thyroid teratoma, thymoma, atrial myxoid malignant fibrous histiocytoma, ganglioneuroblastoma, neuroendocrine thymic carcinoma, squamous cell lung cancer and germinative cell tumour. Thirteen patients were submitted to surgery, chemo and/or radiotherapy. Fifteen patients died during admission or when in follow-up. CONCLUSIONS: At our center, mediastinal masses are frequently of a malignant origin, affecting relatively young people; a late diagnosis and an associated poor prognosis was the rule, prompting for early intervention to improve outcome.

[Lung abscess and thoracic empyema: retrospective analysis in an internal medicine department]. / Abcesso pulmonar e empiema torácico: análise retrospectiva num serviço de medicina interna.

INTRODUCTION: Lung abscess is a collection of necrotic and suppurated tissue located at the pulmonary parenchyma. Empyema is defined as the presence of pus in the pleural space. OBJECTIVES: To study the clinical and microbiological characteristics, treatment and prognosis of patients with lung abscess and/or empyema admitted to an Internal Medicine ward. METHODS: A retrospective analysis of medical records was performed, including all patients admitted to an Internal Medicine ward for lung abscess or empyema, between 2000 and 2008. RESULTS: Thirty patients were included (22 males/ eight females), accounting for 0.18% of all patients admitted in this ward in the same period. Three patients had pulmonary abscess, 18 empyema, and nine both diseases. The average age was 68.5 years (31 to 90). The most frequent complaints were dyspnoea (90%), fever (73.3%), cough (66.7%), weight loss (60%) and chest pain (53.3%). The most frequent associated disorders were stroke associated disability (46.7%), heart failure (43.3%) and arterial hypertension (33.3%). Thoracentesis was performed in all patients with empyema. In one patient with lung abscess an anaerobic microorganism was identified. In patients with empyema, cultures were positive in 61.1% of cases, with a slight predominance of methicillin-resistant Staphylococcus aureus (27.3%) and Prevotella intermedia (18.2%). In patients with both abscess and empyema, cultures of the abscess were positive in 44.4% and of the pleural fluid in 33.3%, with no predominant microorganism. Empiric antimicrobial therapy was started in all patients and later adapted to the antibiotic sensitivity test results. Surgery was performed in three patients. Seven patients (23.3%) died during admission. The average age of the patients who died was 81.3 years and of those who survived was 64.5 years. CONCLUSION: Lung abscess and empyema are infrequent diseases in an Internal Medicine ward, affect mostly males and have unspecific clinical manifestations. The chest X-ray, computed tomography (CT) and thoracentesis were the main diagnostic tests. Most cultures were negative. Medical treatment was the most frequent choice, with surgery being used in 10% of cases. Older age and multiple associated conditions were associated with a worse prognosis.

[Negative paraquaturia does not exclude paraquat fatal poisoning]. / Paraquatúria negativa não exclui intoxicação fatal por paraquat.

The authors present a case report of fatal paraquat poisoning demonstrating persistently negative urine paraquat test. A brief review is also made, concerning the importance of blood test for paraquat, the false negative results in urine test and the need for new effective therapeutic approaches that can change the tragic course of most of these poisoning cases.