Pre-hospital Care for Suspected Stroke Patients, Cared for by Mobile Emergency Care Units in Northern Minas Gerais

Abstract Background Stroke management require rapid identification, assessment, and transport of patients to qualified health care centers. However, there is little description in the literature on the multiple challenges associated with the pre-hospital transport of suspected stroke patients. Objective To characterize the pre-hospital care provided to suspected stroke patients by the Brazilian Emergency Medical Service (SAMU in Portuguese), by means of a descriptive case study. Methods This is a descriptive study of a series of cases. Data from the SAMU regarding the responses to emergency calls from suspected stroke patients were collected. Independent reviewers confirmed the diagnostic hypothesis and all discordances were assessed using kappa statistics. Clinical data and transport times were described as frequency and proportion or central tendency and dispersion measures. Normality of continuous variable distribution was assessed using the Kolmogorov-Smirnov test. The Mann-Whitney U test was used for comparison of medians, with a 5% significance level. Results During the studied period, 556 suspected stroke patients were treated. The kappa index was 0.82 (95% CI 0.737 to 0.919) CI. In 74.7% of the cases, the symptom onset time was not recorded. The median time elapsed between the call for emergency services and the ambulance arrival was 18 minutes, and the median transport time was 38 minutes. A total of 34% of the patients were taken to referral hospitals for stroke. Conclusion This study revealed a low level of knowledge regarding the need to determine the exact time of symptom onset of suspected stroke patients. Also, the study showed the low rate of patients taken to referral hospitals. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

Hospital-acquired intestinal toxemia botulism in a newly diagnosed adult colon cancer patient.

This manuscript reports a case of intestinal toxemia botulism in an adult with recently diagnosed metastatic colon cancer in whom botulism symptoms began 23 days after hospital admission. Representing the rarest form of botulism presentation in clinical practice, this infectious disease may have developed due to a cluster of predisposing factors that favored Clostridium botulinum colonization and the endogenous production of neurotoxins, among which are previous use of broad-spectrum antibiotics and colon changes related to the development of the neoplasia. This case highlights the importance of considering intestinal toxemia botulism in the differential diagnosis of a patient presenting with symmetrical descending flaccid paralysis, since immediate treatment with botulinum antitoxin may improve clinical outcomes.

Ischemic stroke and infectious diseases in low-income and middle-income countries.

PURPOSE OF REVIEW: To address the important relationships between stroke and infection, focusing on the most frequent infections found in low-income and middle-income countries. RECENT FINDINGS: Stroke is one of the leading causes of mortality and disability worldwide, with a great proportion of the stroke burden occurring in low-income and middle-income countries. Infectious diseases are still a great health problem in developing countries and it is possible that the proportion of infection-related strokes is greater in these nations. Infectious diseases and stroke have a bidirectional relationship. Common infections may act as risk factors and can trigger stroke through different mechanisms in their acute phase. Several intracranial and systemic infections can cause stroke as a direct complication, such as Chagas disease, neurosyphilis, tuberculous meningitis, and neurocysticercosis. These conditions are of particular interest to low-income and middle-income countries, but also relevant to high-income nations because of increasing migration. Finally, infection is a frequent poststroke complication, with great impact in the patient outcome. SUMMARY: Infectious diseases and stroke are common problems in low-income and middle-income countries. More studies are necessary to fully elucidate the real impact of infectious diseases on stroke burden, especially in countries where epidemiological data are still scarce.

Características Clínicolaboratoriais da Criptococose em Pacientes Admitidos em Pronto Socorro Hospital das Clínicas, Universidade Federal de Minas Gerais, Referência Terciária do Sistema Único de Saúde: Análise Retrospectiva desde 2000 a 2013 / Clinical Laboratory Characteristics of Cryptococcosis in Patients Admitted to the Emergency Room Hospital das Clínicas, Federal University of Minas Gerais, Tertiary Reference of the Unified Health System: Retrospective Analysis from 2000 to 2013

A criptococose é uma micose sistêmica, de ocorrência relativamente rara, potencialmente grave, geralmente oportunista e de elevada frequência em pacientes imunossuprimidos, com amplo espectro de acometimento de órgãos, tropismo especial para o sistema nervoso central (SNC), evolução subaguda ou crônica, e manifestações clínicas variadas. Este estudo descritivo, retrospectivo, observacional, transversal, objetivou descrever os dados demográficos, clínicos, comorbidades, sintomas ou sinais, e o prognóstico de pacientes com neurocriptococose, atendidos e internados no Hospital das Clínicas (HC) da Universidade Federal de Minas Gerais desde 2000 até 2013. O HC é unidade universitária, pública e geral, de nível terciário e quaternário, com 450 leitos de internação, integrado ao Sistema Único de Saúde (SUS), com clientela universalizada, cerca de 40% do total proveniente do interior do estado de Minas Gerais, predominando da região Metropolitana de Belo Horizonte, aberto à transferência de pacientes de todo o território mineiro, com área de abrangência de população de mais de cinco milhões de pessoas, de todas as faixas etárias e todas as especialidades médicas, encaminhados pela intensidade de sua expressão clínica, especialmente em situação crítica, o que torna sua casuísticade máxima gravidade. Os pacientes foram internados a partir do Pronto Socorro do HC que admite, em média, 80 pacientes com urgência clínicas por dia, incluindo obstétricas, e excluídas aquelas devido à acidente ou violência de qualquer natureza. Foram analisados 40 pacientes com neurocriptococose o que significou 0,13% de toda demanda de admissão de urgência para o período estudado, cerca de 603.000 pessoas, isto é 12% da população referida, e associou-se à letalidade de 25%; com frequência da distribuição de acordo com o gênero em 2:1, entre homens e mulheres, respectivamente; e nas faixas etárias entre 20-40, 40-60 e mais de 60 anos de idade, de 36%, 42%, e 22%, respectivamente, sendo a proporção entre 20 a 60 e mais de 60 de aproximadamente, 2:1. A neurocriptococose associou-se em mais de 50% dos pacientes com a: SIDA (57,5%); internação prévia (52,5%) relacionada à quimio e corticoterapia, transplante, cirurgias para ressecção de neoplasias; e, em menos de 20% com doença cardiovascular hipertensiva sistêmica (17,5%), cirurgia prévia (15%) e tuberculose (5%). A sintomatologia isolada presente em pelo menos 40% dos pacientes foi: cefaleia (70%), astenia (50%), febre (45%), vômitos (40%); entretanto, em até um terço deles constituiu-se de: emagrecimento (30%), tontura (30%), dor abdominal (27,5%), convulsão (22,5%). As anormalidades mais e menos especificamente indicadoras de acometimento do SNC foram cefaleia; e, vômito, tontura e convulsão,respectivamente. As alterações do exame neurológico foram relacionadas aos distúrbios da consciência (35%), lesão focal (30%), alteração da marcha (25%) e distúrbio do comportamento (15%). A concomitância de cefaléia, convulsão e vômitos foi anotada em 5% dos pacientes; enquanto de cefaléia e convulsão em 22,5%. Foi observada, à admissão hospitalar, em 40%, dos pacientes a associação de cefaléia e vômito; mas todos os pacientes com vômito e também os com lesão focal apresentavam cefaleia. A presença de cefaleia não foi descrita em 35% dos pacientes com alteração da consciência à admissão hospitalar. O diagnóstico presuntivo de neurocriptococose deve ser realizado, independentemente da sintomatologia clínica neurológica, o que realça a percepção geral do paciente, incluindo epidemiologia, história familiar, história prévia, manifestações clínicas, presença de imunossupressão, para surpreender a criptococose, e iniciar a terapêutica o mais apidamente possível para que possa ser reduzida sua letalidade. A limitação deste estudo relaciona-se ao fato de ter sido retrospectivo, em que o controle dos dados registrados é muito limitada, sendo impossível corrigir a ausência de dados registrados. (AU)

Cryptococcosis is a systemic, relatively rare, potentially severe, often opportunistic and systemic mycosis in immunosuppressed patients with a broad spectrum of organ involvement, a special central nervous system (CNS) tropism, subacute or chronic clinical manifestations. This descriptive, retrospective, observational, cross-sectional study aimed to describe the demographic, clinical, comorbidities, symptoms or signs, and the prognosis of patients with neurocryptococcosis, attended and hospitalized at the Hospital das Clínicas (HC) of the Universidade Federal de Minas Gerais since 2000 until 2013. The HC is a university unit, public and general, tertiary and quaternary level, with 450 beds of hospitalization, integrated into the Unified Health System (SUS), with a universalized clientele, about 40% of the total coming from the interior of the state of Minas Gerais, predominating in the metropolitan region of Belo Horizonte, which is open to the transfer of patients from all over Minas Gerais, with an area of population of more than five million people, of all age groups and all medical specialties. intensity of its clinical expression, especially in a critical situation, which makes its series of age.The patients were hospitalized from the HC Emergency Room, which admitted, on average, 80 urgently needed clinics per day, including obstetrics, and excluded due to accidents or violence of any kind. We analyzed 40 patients with neurocryptococcosis, which represented 0.13% of all urgent admission demands for the period studied, about 603,000 people, ie 12% of the referred population, and was associated with a 25% lethality; with frequency of distribution according to gender in 2: 1, between men and women, respectively; and in the age groups between 20-40, 40-60 and over 60 years of age, of 36%, 42%, and 22% respectively, the ratio being between 20 to 60 and more than 60 of approximately 2: 1. Neurocryptococcosis was associated in more than 50% of patients with: AIDS (57.5%); previous hospitalization (52.5%) related to chemo and corticoid therapy, transplantation, surgeries for resection of neoplasias; and in less than 20% with systemic hypertensive cardiovascular disease (17.5%), previous surgery (15%) and tuberculosis (5%). The isolated symptoms present in at least 40% of the patients were: headache (70%), asthenia (50%), fever (45%), vomiting (40%); (30%), dizziness (30%), abdominal pain (27.5%), and seizure (22.5%). The most and least specific abnormalities of CNS involvement were headache; and, vomiting, dizziness and convulsion, respectively. Changes in neurological examination were related to disturbances of consciousness (35%), focal lesion (30%), gait alteration (25%) and behavior disorder (15%). The concomitance of headache, convulsion and vomiting was noted in 5% of the patients; while headache and seizure in 22.5%. The association of headache and vomiting was observed in 40% of patients; but all patients with vomiting and those with focal lesion also had headache. The presence of headache was not described in 35% of patients with altered consciousness at hospital admission. The presumptive diagnosis of neurocryptococcosis should be performed independently of the clinical neurological symptomatology, which highlights the general perception of the patient, including epidemiology, family history, previous history, clinical manifestations, presence of immunosuppression, to start cryptococcosis, and initiate therapy. as soon as possible so that their lethality can be reduced. The limitation of this study is the fact that it was retrospective, in which the control of the recorded data is very limited, and it is impossible to correct the absence of recorded data. (AU)

Varicella-zoster virus longitudinally extensive myelitis in animmunocompetent patient / Mielite longitudinalmente extensa secundária ao vírus varicela-zóster em paciente imunocompetente

Longitudinally extensive myelitis is a severe rare complication of varicella-zoster virus infection. We report a case in a 20-year-oldimmunocompetent patient who presented with a two-week history of lower-limb paresis and paresthesia below dermatome T12, andsphincter dysfunction. He presented with a zoster rash a week prior tothe onset of neurological symptoms. Spinal cord magnetic resonanceimaging revealed a C5-T12 intramedullary lesion and cerebrospinalfluid showed lymphocytic pleocytosis and elevated varicella-zostervirus immunoglobulin G. Patient had not gained much improvement after acyclovir and pulse therapy with methylprednisolone, which prompted a five-day course of plasmapheresis. He partially recovered, but remained with sphincter impairment.

Mielite longitudinalmente extensa é uma rara e grave complicação da infecção pelo vírus varicela-zóster. Relatamos o caso de um pacientede 20 anos de idade, imunocompetente, que há duas semanas apresentou paresia de membros inferiores e parestesias abaixo dodermátomo T12, associadas com disfunção esfincteriana. Ele apresentouum rash cutâneo sugestivo de herpes uma semana antes do início dos sintomas neurológicos. A ressonância magnética de medula espinhal demonstrou uma lesão intramedular de C5 a T12, e o líquido cerebroespinhal revelou uma pleocitose linfocítica com aumento de imunoglobulina IgG para o vírus varicela-zóster. O paciente não apresentou melhora após uso de aciclovir e pulsoterapia com metilprednisolona, o que motivou um curso de cinco dias de plasmaférese.Houve recuperação parcial, porém ele permaneceu com distúrbio esfincteriano.

Reversible cerebral vasoconstriction syndrome secondary to catheter ablation / Síndrome de vasoconstrição reversível secundária à ablação por cateter

We report a case of a 41-year-old woman with chagasic cardiomyopa-thy who was submitted to ventricular septal catheter ablation. After the procedure she evolved with new-onset thunderclap headaches followed by migraine-type headaches. Cerebral angiography revealed bilateral segmental stenosis of the middle cerebral arteries.

Relatamos um caso de uma mulher de 41 anos de idade, portadora de cardiomiopatia chagásica, que foi submetida à ablação ventricu-lar septal por cateter. Após o procedimento, a paciente apresentou cefaleia em trovoada de início recente seguida de cefaleia do tipo migranosa. A angiografia cerebral revelou estenoses segmentares bilaterais em território de artéria cerebral média.

Multiple myeloma with cauda equina infiltration.

We report a case of a 51-year-old man with multiple myeloma who presented with lumbar pain and left limb paresis. Cerebrospinal fluid, brain and spinal cord resonance imaging revealed a diffuse infiltration of the cauda equina without any cranial leptomeningeal enhancement. An infiltration limited to the cauda equina is extremely rare.

Cefepime encephalopathy and normal renal function / Encefalopatia induzida por cefepime em um paciente com função renal normal

BACKGROUND: Several cases of cefepime neurotoxicity have been reported. Herein reported is a case of cephalosporin-associated neurotoxicity in apatient with normal renal function. CASE REPORT: A 64-year-old woman with a history of post-transplantation chronic myeloid leukemia was admittedto hospital due to hyporexia, fever, productive cough and mild dyspnea. Initial blood screen revealed pancytopenia and a normal renal function.Intravenous cefepime was empirically started and after 40 hours the patient developed sudden mental confusion. Neurological examination was normal. Cranial computed tomography and brain magnetic resonance scans were normal. Electroencephalography showed triphasic waves of diffuse slowness without ongoing epileptic activity. Lumbar puncture was normal. Cefepime neurotoxicity was promptly considered and antibiotics were switched to piperacillin and tazobactam. After five days, the patient recovered completely with remission of myoclonus. CONCLUSIONS: Awareness should be given to possible central nervous system complications induced by cefepime, especially in the elderly, even without renal failure

INTRODUÇÃO: Existem vários relatos de casos de toxicidade do sistema nervoso central induzida pelo cefepime. Relata-se um caso de toxicidade do sistema nervoso central associada ao uso de uma cefalosporina em um paciente com função renal normal. RELATO DE CASO: Uma mulher de 64 anos com história de transplante de medula óssea devido a leucemia mielóide crônica foi admitida ao hospital devido a hiporexia, febre, tosse produtiva e dispnéia leve. Os exames laboratoriais de rotina demonstraram pancitopenia e função renal normal. O cefepime intravenoso foi empiricamente iniciado e, após 40 horas da administração, o paciente apresentou quadro súbito de confusão mental. Exame neurológico foi normal, assim como a tomografia computadorizada craniana e a ressonância magnética encefálica. O eletroencefalograma demonstrou ondas trifásicas de lentificação difusa sem evidência de atividade epileptiforme. O líquor estava normal. A toxicidade do sistema nervoso central pelo cefepime foi rapidamente considerada e o antibiótico foi trocado para piperacilina e tazobactan. Após cinco dias, o paciente apresentou recuperação completa com remissão da mioclonia. CONCLUSÃO: Deve-se dar atenção às possíveis complicações do sistema nervoso central induzidas pelo cefepime, especialmente em idosos, mesmo sem insuficiência renal.