Endoscopic endonasal transclival approach for resection of a pontine cavernous malformation.

Symptomatic cavernous malformations in the ventral region of the pons are difficult to access surgically. The authors present a case of a 46-year-old woman with a 10-year history of sudden and transitory diplopia and right hemiparesis, followed by five more episodes of mild right hemiparesis. Brain MRI showed a 2.6-cm cavernous malformation in the pons with an exophytic portion in the prepontine cistern. The patient underwent an endoscopic endonasal transclival approach for a complete resection of the lesion. CSF leak was noted and corrected on the sixth postoperative day. The patient progressed with complete motor deficit recovery. The video can be found here: https://youtu.be/ePgpyij2Wpo.

Neurotoxoplasmose em paciente imunocompetente: relato de caso / Neurotoxoplasmosis in an Immunocompetent Patient: Case Report

A toxoplasmose é uma doença causada pelo protozoário Toxoplasma gondii e é a principal causa de lesão com efeito de massa no sistema nervoso central (SNC) em pacientes imunodeprimidos, causando sintomas neurológicos significativos. Em pacientes imunocompetentes, a evolução clínica da toxoplasmose é habitualmente benigna e a infecção é, na maioria das vezes, assintomática. O diagnóstico da neurotoxoplasmose é presuntivo, baseado nos achados de tomografia computadorizada (TC) ou de ressonância magnética (RM), e emcasos inconclusivos, pode-se utilizar a biópsia cerebral estereotáxica. O paciente relatado apresentava lesões sugestivas de neurotoxoplasmose na RM de encéfalo, porém era imunocompetente, e a sorologia para neurotoxoplasmose era negativa para o IgM. Foi submetido então a biópsia estereotáxica como extensão de propedêutica. O presente trabalho visa, a partir do relato de um caso raro, discutir sobre as formas de diagnóstico e tratamento de uma infecção em paciente previamente sadio, cuja evolução foi benigna devido ao diagnóstico e tratamento precoces.

Toxoplasmosis is a disease caused by the protozoan Toxoplasma Gondii and is the leading cause of injury with mass effect on the central nervous system (CNS) in immunocompromised patients, that causes significant neurological symptoms. In immunocompetent patients, the clinical course of toxoplasmosis is usually benign and the infection is most often asymptomatic. The presumptive diagnosis of toxoplasmosis is based on findings of computed tomography (CT) or magnetic resonance imaging (MRI), and inconclusive cases, can use stereotactic brain biopsy . The reported patient had lesions suggestive of cerebral toxoplasmosis in brain MRI, but was immunocompetent and toxoplasmosis serology was negative for IgM. The, he underwent a stereotactic biopsy as an extension of workup. The present work aims, from a rare case description, discuss ways of diagnosing and treating an infection in a previously healthy patient whose evolution was benign diagnosis because early treatment.

C-reactive protein and cognition are unrelated to leukoaraiosis.

Elevated serum levels of C-reactive protein (CRP) have been associated with leukoaraiosis in elderly brain. However, several studies indicate that leukoaraiosis is associated with an increased risk of cognitive impairment. It is unknown how the effect of CRP on cognition is mediated by leukoaraiosis. The purpose of this study is to assess the relationship between serum levels of CRP, the presence of leukoaraiosis, and cognitive impairment in a population of coronary patients over 50 years old. CRP levels explained 7.18% (P: 0.002) of the variance of the MMSE. The adjustment for the presence of leukoaraiosis little changed this variance (5.98%, P: 0.005), indicating that only a small portion of the CRP influence on cognition was mediated via leukoaraiosis. Patients with CRP levels ≥ 5.0 had 2.9 (95% CI: 1.26-6.44) times more chance to present cognitive impairment (P: 0.012). We found that elevated serum levels of CRP were associated with increased risk of cognitive impairment in elderly and it was not mediated by presence of leukoaraiosis.

Bullous systemic lupus erythematosus in a pregnant woman: a case report.

Systemic lupus erythematosus (SLE) can cause numerous skin lesions. Despite being rare, lupus-specific bullous lesions demonstrate characteristic clinical and immunopathological features and require differential diagnosis among numerous bullous conditions that may overlap with SLE. The present study presents a case of bullous systemic lupus erythematosus (BSLE) in a pregnant woman.

c-ANCA associated vasculitis in patients with ulcerative colitis: case report.

The pulmonary manifestations of ulcerative colitis (UC) are rare and include inflammation of small and large airways, parenchymal disease and serositis among others. A substantial proportion of patients with inflammatory bowel disease, particularly those with ulcerative colitis presents positive ANCA, most p-ANCA pattern. We present a case of patient with ulcerative colitis, with positive c-ANCA, which progressed to hemoptysis associated with radiological findings consistent with pulmonary vasculitis.

Lúpus eritematoso sistêmico bolhoso em gestante: relato de caso / Bullous systemic lupus erythematosus in a pregnant woman: a case report

O lúpus eritematoso sistêmico pode apresentar inúmeras lesões cutâneas. As lesões bolhosas específicas do lúpus, apesar de raras, apresentam características clínicas e imunopatológicas próprias e implicam em diagnóstico diferencial entre inúmeras patologias bolhosas que podem sobrepor-se ao lúpus eritematoso sistêmico. Apresenta-se um caso de lúpus eritematoso sistêmico bolhoso em gestante.

Systemic lupus erythematosus (SLE) can cause numerous skin lesions. Despite being rare, lupus-specific bullous lesions demonstrate characteristic clinical and immunopathological features and require differential diagnosis among numerous bullous conditions that may overlap with SLE. The present study presents a case of bullous systemic lupus erythematosus (BSLE) in a pregnant woman.

Vasculite c-ANCA relacionada em paciente com retocolite ulcerativa: relato de caso / c-ANCA associated vasculitis in patients with ulcerative colitis: case report

As manifestações pulmonares da retocolite ulcerativa (RCU) são raras e incluem inflamação de pequenas e grandes vias aéreas, doença parenquimatosa e serosite, entre outras. Uma proporção substancial de pacientes com doença inflamatória intestinal, particularmente aqueles com RCU, apresenta ANCA positivo, a maioria padrão p-ANCA. Apresentamos um caso de paciente com RCU, com c-ANCA positivo, que evoluiu com hemoptise, associada a alterações radiológicas compatíveis com vasculite pulmonar.

The pulmonary manifestations of ulcerative colitis (UC) are rare and include inflammation of small and large airways, parenchymal disease and serositis among others. A substantial proportion of patients with inflammatory bowel disease, particularly those with ulcerative colitis presents positive ANCA, most p-ANCA pattern. We present a case of patient with ulcerative colitis, with positive c-ANCA, which progressed to hemoptysis associated with radiological findings consistent with pulmonary vasculitis.

Vibrio vulnificus infection in Southern Brazil -- case report.

The genus Vibrio is a member of the family Vibrionaceae, and among their disease-causing species, Vibrio vulnificus, a lactose-positive gram-negative bacillus, is one of the most virulent pathogen of the noncholerae vibrios. We describe the case of a 39-year-old male patient, who was using immunosuppressive therapy, admitted to the hospital for liver transplantation. Twelve hours later, the patient presented high fever, myalgia, anuria and erythematous plaques on lower limbs, of rapid growth and proximal progression. The patient was treated with ceftriaxone, meropenem and oxacillin, however he expired within 30 hours. Blood cultures showed growth of a gram-negative bacillus, which was later identified as Vibrio vulnificus.

Vibrio vulnificus infection in Southern Brazil - Case report / Infecção por Vibrio vulnificus no sul do Brasil - Relato de caso

The genus Vibrio is a member of the family Vibrionaceae, and among their disease-causing species, Vibrio vulnificus, a lactose-positive gram-negative bacillus, is one of the most virulent pathogen of the noncholerae vibrios. We describe the case of a 39-year-old male patient, who was using immunosuppressive therapy, admitted to the hospital for liver transplantation. Twelve hours later, the patient presented high fever, myalgia, anuria and erythematous plaques on lower limbs, of rapid growth and proximal progression. The patient was treated with ceftriaxone, meropenem and oxacillin, however he expired within 30 hours. Blood cultures showed growth of a gram-negative bacillus, which was later identified as Vibrio vulnificus.

O gênero Vibrio é membro da família Vibrionaceae, e entre as espécies patogênicas, Vibrio vulnificus, bacilo gram negativo lactose positivo, tem sido frequentemente citado. Descrevemos o caso de um paciente masculino de 39 anos, em uso de medicação imunossupressora, admitido no hospital para transplante hepático. Doze horas após a internação, o paciente evoluiu com febre, mialgias, anúria e placas eritematosas em membros inferiores, com rápido crescimento e evolução proximal. O paciente foi tratado com ceftriaxona, meropenem e oxacilina sem melhora, evoluindo para óbito em 30 horas. Hemocultura mostrou crescimento de bacilo gram negativo posteriormente identificado como Vibrio vulnificus.

Genetic studies in a coexistence of acromegaly, pheochromocytoma, gastrointestinal stromal tumor (GIST) and thyroid follicular adenoma / Estudos genéticos na coexistência de acromegalia, feocromocitoma, tumor do estroma gastrointestinal (GIST) e adenoma folicular de tireoide

We report on an adult woman with rare coexistence of acromegaly, pheochromocytoma (PHEO), gastrointestinal stromal tumor (GIST), intestinal polyposis, and thyroid follicular adenoma. At the age of 56, she was diagnosed with acromegaly caused by a pituitary macroadenoma, treated by transsphenoidal surgery, radiotherapy, and octreotide. During routine colonoscopy, multiple polyps were identified as tubular adenomas with high-grade dysplasia on histology. Years later, an abdominal mass of 8.0 x 6.2 cm was detected by routine ultrasound. Surgical exploration revealed an adrenal mass and another tumor adhered to the lesser gastric curvature, which were removed. Pathology confirmed the diagnosis of PHEO and GIST. PHEO immunohistochemistry was negative for GHRH. During follow-up, nodular goiter was found with normal levels of calcitonin and inconclusive cytology. Near-total thyroidectomy was performed, revealing a follicular adenoma. Her family history was negative for all of these tumor types. Genetic analysis for PHEO/paraganglioma genes (SDH A-D, SDHAF2, RET, VHL, TMEM127, and MAX), and pituitary-related genes (AIP, MEN1, and p27) were negative. Though the finding of PHEO and acromegaly with multiple other tumors could be a fortuitous coexistence, we suggest that this case may represent a new variant of MEN syndrome with a de novo germline mutation in a not yet identified gene. Arq Bras Endocrinol Metab. 2012;56(8):507-12.

Relatamos o caso de uma mulher com rara coexistência de acromegalia, feocromocitoma (FEO), tumor do estroma gastrointestinal (GIST), polipose intestinal e adenoma folicular de tireoide. Aos 56 anos, ela foi diagnosticada com acromegalia por um macroadenoma hipofisário, tratado com cirurgia transesfenoidal, radioterapia e octreotide. Uma colonoscopia de rotina detectou múltiplos pólipos, que à histologia eram adenomas tubulares com alto grau de displasia. Anos mais tarde, uma ecografia detectou uma massa abdominal de 8.0 x 6.2 cm, que na exploração cirúrgica era uma lesão adrenal e outro tumor aderido à pequena curvatura gástrica. A patologia confirmou os diagnósticos de FEO e GIST. A imuno-histoquímica do FEO foi negativa para GHRH. No seguimento, encontrou-se um bócio nodular com níveis normais de calcitonina e citologia inconclusiva. Após tireoidectomia total o diagnóstico histológico foi de adenoma folicular. A história familiar era negativa para todos esses tumores. As análises genéticas para genes de síndromes de FEO/paragangliomas (SDH A-D, SDHAF2, RET, VHL, TMEM127 e MAX) e para hipofisárias (AIP, MEN1 e p27) foram todas negativas. Embora a presença de FEO e acromegalia com múltiplos outros tumores possa ser uma coexistência fortuita, acreditamos na possibilidade de uma nova variante de NEM com uma mutação germinativa de novo em um gene ainda não identificado Arq Bras Endocrinol Metab. 2012;56(8):507-12.

Sarcoma indiferenciado primário no sistema nervoso central / Primary undifferentiated sarcoma of the central nervous system

INTRODUÇÃO: O sarcoma de sistema nervoso central (SNC) é uma neoplasia rara, com incidência de 0,1% a 4,3% dos tumores intracranianos. São tumores agressivos com prognóstico reservado e a maioria é tratada com ressecção radical. RELATO: Homem, 29 anos, com episódios de crises convulsivas e diagnóstico de hemorragia intraparenquimatosa. Durante a cirurgia, foi identificada lesão bem delimitada. A histologia demonstrou neoplasia fusocelular com atipias e numerosas mitoses. Os únicos marcadores imuno-histoquímicos positivos foram vimentina e S-100. O diagnóstico foi de sarcoma indiferenciado de alto grau. CONCLUSÃO: No diagnóstico diferencial de sarcomas de SNC, devem-se excluir lesões metastáticas e gliossarcoma.

INTRODUCTION: The central nervous system (CNS) sarcoma is a rare neoplasm with an incidence of 0.1% to 4.3% in intracranial tumors. They are aggressive with poor prognosis, and mostly treated with radical resection. REPORT: 29 year-old male patient with episodes of seizures and diagnosed with intraparenchymal hemorrhage. During the surgery a well-defined lesion was identified. Histology showed a spindle cell neoplasm with atypia and numerous mitoses. The immunohistochemical markers were positive only for vimentin and S-100. The diagnosis was high-grade undifferentiated sarcoma. CONCLUSION: Metastatic lesions and gliosarcoma should be excluded in the differential diagnosis of CNS sarcomas.

Genetic studies in a coexistence of acromegaly, pheochromocytoma, gastrointestinal stromal tumor (GIST) and thyroid follicular adenoma.

We report on an adult woman with rare coexistence of acromegaly, pheochromocytoma (PHEO), gastrointestinal stromal tumor (GIST), intestinal polyposis, and thyroid follicular adenoma. At the age of 56, she was diagnosed with acromegaly caused by a pituitary macroadenoma, treated by transsphenoidal surgery, radiotherapy, and octreotide. During routine colonoscopy, multiple polyps were identified as tubular adenomas with high-grade dysplasia on histology. Years later, an abdominal mass of 8.0 x 6.2 cm was detected by routine ultrasound. Surgical exploration revealed an adrenal mass and another tumor adhered to the lesser gastric curvature, which were removed. Pathology confirmed the diagnosis of PHEO and GIST. PHEO immunohistochemistry was negative for GHRH. During follow-up, nodular goiter was found with normal levels of calcitonin and inconclusive cytology. Near-total thyroidectomy was performed, revealing a follicular adenoma. Her family history was negative for all of these tumor types. Genetic analysis for PHEO/paraganglioma genes (SDH A-D, SDHAF2, RET, VHL, TMEM127, and MAX), and pituitary-related genes (AIP, MEN1, and p27) were negative. Though the finding of PHEO and acromegaly with multiple other tumors could be a fortuitous coexistence, we suggest that this case may represent a new variant of MEN syndrome with a de novo germline mutation in a not yet identified gene.

Da privação ao excesso de comida

Entrevista com o Prof. Carlos Augusto Monteiro, docente da Faculdade de Saúde Pública da USP. Ele discorre sobre o fenômeno da transição nutricional e mostra como a obesidade destronou a fome no rol dos grandes problemas de saúde do país.