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)

Participation of the neutrophin brain-derived neurotrophic factor in neuropsychiatric systemic lupus erythematosus.

OBJECTIVE: Brain-derived neurotrophic factor (BDNF) is associated with the pathogenesis of several neuropsychiatric (NP) diseases, but there are few studies involving SLE. The aim of this study was to investigate whether plasma BDNF levels are associated with disease activity in SLE patients with severe NPSLE and non-NPSLE manifestations. METHODS: We assessed 131 SLE patients and 24 randomly selected healthy individuals. SLE patients were evaluated in a cross-sectional study allocated according to the presence or not of NP manifestations and disease activity: (i) active NPSLE (n = 40), (ii) inactive NPSLE (n = 26), (iii) active SLE (n = 29) and (iv) inactive SLE (n = 36). In addition, NPSLE patients (n = 40) were evaluated before and after treatment. Disease activity was assessed according to the SLEDAI score. The plasma BDNF was measured by ELISA. RESULTS: BDNF levels were increased in inactive NPSLE when compared with active SLE and controls (P < 0.0001). We observed similar findings in inactive SLE when compared with active SLE (P < 0.0001). In addition, we found an inverse correlation between plasma BDNF levels and the SLEDAI (r = -0.54, P < 0.0001) and a positive correlation with complement levels. We also observed an increase in BDNF levels in parallel with the improvement in NP symptoms. CONCLUSION: Plasma BDNF level is increased in SLE patients and this increase is independent of the occurrence of NP manifestations. In addition, plasma BDNF levels increased with control of SLE activity, which points to the potential use of BDNF as a biomarker of response to treatment.

Psychiatric disorders in myasthenia gravis.

OBJECTIVE: To investigate the prevalence of psychiatric disorders in patients with myasthenia gravis (MG). METHOD: Forty-one patients with MG answered to a structured psychiatric interview (MINI-Plus). RESULTS: Eleven (26.1%) patients were diagnosed with a depressive disorder and 19 (46.3%) were diagnosed with an anxiety disorder. Patients with dysthymia were older (p=0.029) and had longer disease duration (p=0.006). Patients with social phobia also had longer disease duration (p=0.039). CONCLUSION: Psychiatric disorders in MG are common, especially depressive and anxiety disorders.

Psychiatric disorders in myasthenia gravis / Transtornos psiquiátricos na miastenia gravis

OBJECTIVE: To investigate the prevalence of psychiatric disorders in patients with myasthenia gravis (MG). METHOD: Forty-one patients with MG answered to a structured psychiatric interview (MINI-Plus). RESULTS: Eleven (26.1 percent) patients were diagnosed with a depressive disorder and 19 (46.3 percent) were diagnosed with an anxiety disorder. Patients with dysthymia were older (p=0.029) and had longer disease duration (p=0.006). Patients with social phobia also had longer disease duration (p=0.039). CONCLUSION: Psychiatric disorders in MG are common, especially depressive and anxiety disorders.

OBJETIVO: Investigar a prevalência de transtornos psiquiátricos em pacientes com miastenia gravis (MG). MÉTODO: Quarenta e um pacientes com MG responderam a uma entrevista psiquiátrica estruturada (MINI-Plus). RESULTADOS: Onze (26,1 por cento) pacientes foram diagnosticados com transtorno depressivo e 19 (46,3 por cento) foram diagnosticados com um transtorno de ansiedade. Pacientes com distimia eram mais velhos (p=0,029) e tinham maior tempo de doença (p=0,006). Os pacientes com fobia social também tiveram maior tempo de doença (p=0,039). CONCLUSÃO: Transtornos psiquiátricos na MG são bastante comuns, principalmente transtornos depressivos e de ansiedade.

Severe depression, suicide attempts, and ideation during the use of interferon beta by patients with multiple sclerosis.

BACKGROUND: Interferon (IFN) beta is a safe and efficient drug for treating multiple sclerosis (MS). It is widely accepted that previously depressed patients may get worse when using IFN-beta. There are few reports on the association of IFN-beta and severe depression among patients without previous psychiatric history. METHODS: Discussion of a case of a patient with MS who developed severe depression and attempted suicide while using IFN-beta encouraged us to review the subject. A group of neurologists in Brazil retrospectively gathered together their similar cases for the present paper. RESULTS: The present paper reports on 11 cases of severe depression with suicide attempts or ideation among patients with MS who were using IFN-beta. These patients had no previous history of any psychiatric disease. Nine patients developed the symptoms over a relatively short period (4 months, on average). Two patients developed severe depression after more than 1 year of treatment with IFN-beta. Phobic, aggressive, behavioral, psychotic, and manic symptoms also were observed in these patients, thus suggesting the existence of a complex mood-behavior disorder associated with this drug. Interferon beta withdrawal led to complete remission of symptoms. The Naranjo algorithm established a highly probable association between IFN-beta and this adverse reaction in these patients. CONCLUSIONS: Although uncommon, severe depression with suicide ideation or attempts may be observed during treatment of MS with IFN-beta. This association should not discourage the use of this drug, but physicians need to be aware of this possible adverse event from IFN-beta.

Increased plasma levels of brain derived neurotrophic factor (BDNF) after multiple sclerosis relapse.

Brain derived neurotrophic factor (BDNF) has been related to neuroprotection in a series of central nervous system diseases, although its role in multiple sclerosis (MS) was only partially investigated. In this work, we aimed to evaluate the plasma levels of BDNF from 29 MS patients and 24 control subjects. MS patients had decreased levels of BDNF in comparison with healthy controls. BDNF levels increased significantly after MS relapse. Our results provide some evidence for the involvement of BDNF in the pathogenesis of MS and suggest a role for this neurotrophin during the recovery of acute demyelinating inflammatory lesion.

Mutismo após ressecçäo de tumor de fossa posterior em criança associado a hematoma do IV ventrículo: relato de caso / Mutism after posterior fossa tumor surgery in a child associated to IV ventricle hematoma: case report

O mutismo após ressecçao de tumores de fossa posterior em criança é uma manifestaçao bem descrita mas ainda pouco conhecida no meio neurocirúrgico. Manifesta-se como perda da capacidade da fala após ressecçao de tumores do IV ventrículo e é, na maioria dos casos, reversível. Ainda nao há explicaçao fisiopatológica bem definida. A ocorrência do mutismo, neste caso, após hematoma no leito tumoral com compressao da face medial do cerebelo, parece confirmar a teoria de lesao orgânica como causa da manifestaçao.

Pielonefrite xantogranulomatosa: relato de cinco casos e revisäo da literatura / Xanthogranulomatous pyelonephritis: report of five cases and review of the literature

Os autores descrevem cinco casos de pielonefrite xantogranulomatosa em mulheres com idades variando entre 22 e 67 anos e fazem uma revisäo da literatura a respeito dessa instigante afecçäo. Uma paciente (caso 3) apresentou-se em franca insuficiência renal e com sinais de doença bilateral. Todas as pacientes foram submetidas à nefrectomia. Em dois casos (4 e 5) suspeitou-se do diagnóstico no pré-operatório: ambas as pacientes exibiam uma massa no flanco esquerdo acompanhada, no caso 4, de um extenso derrame pleural ipsilateral e, no caso 5, de drenagem de material purulento ao nível da regiäo lombar. No caso 1, no sexto dia pós-operatório, desenvolveu-se uma fístula estercoral, fazendo-se necessária a realizaçäo de uma colostomia transversa seguida, nove meses depois, da reconstituiçäo do trânsito intestinal.