Re: Epidemiology of giant cell arteritis in Waikato, Aotearoa New Zealand.

The interest in epidemiological data on giant cell arteritis (GCA) increased both in New Zealand and in Latin America, resulting in updated articles like those here commented. Of more relevance are two very recent contributions by van Dantzig et al. with novel conclusive findings from their evaluations on GCA performed in the region of Waikato. The authors emphasised that the diagnosis of GCA remained stable in this region from 2014 to 2022, being uncommon among Maori, Pacific peoples and Asian ethnic groups. Short comments on some literature data from Argentina, Brazil, Colombia, Peru and Mexico about the systemic arteritis are here addressed to show the Latin American view. The authors strongly believe that this kind of report may enhance the general interest on diagnostic and management issues related to this very important systemic vasculitis.

Endocarditis due to Burkholderia cepacia and an intracardiac foreign body in a renal transplant patient.

The authors describe the case of a renal transplant patient who developed late infective endocarditis associated with an intracardiac fragment of a catheter inserted 16 years before. Clinical presentation was anemia of undetermined cause and weight loss. Three blood cultures were positive for Burkholderia cepacia. Transesophageal echocardiography revealed a foreign body in the right atrium and right ventricle, confirmed by computed tomography. The patient underwent intravenous antibiotic therapy, followed by cardiac surgery to remove the foreign body. There were no postoperative complications, with improvement of anemia and stabilization of renal function.

Unsuspected tuberculosis in COPD and use of levofloxacin: diagnostic challenges.

A 92-year-old female ex-smoker with chronic obstructive pulmonary disease (COPD) GOLD III, was admitted because of communitarian pneumonia in November 2013. She had been using inhaled corticosteroids and bronchodilators and presented five exacerbations of COPD due to pneumonia in the same year, with hospitalizations in March and September. The patient underwent the routine protocol for exacerbated COPD, and bacilloscopy for tuberculosis (TB) was negative. On admission, she had intense dyspnea and a productive cough that improved by administration of levofloxacin. Tests with Ziehll-Neelsen staining in bronchopulmonary secretions resulted negative. Notwithstanding, during actual admission, the culture in Lowenstein-Jensen medium seeded in September was found positive for M. tuberculosis susceptible to isoniazid, rifampin, streptomycin, and ethambutol. Therefore, the patient underwent the standard regimen for tuberculosis. Except in September, when she used piperacillin-tazobactam, all previous exacerbations of COPD were treated with levofloxacin. This effective drug against M. tuberculosis can hinder its growth in culture. The use of levofloxacin in unsuspected TB may constitute an additional diagnostic challenge, and risk of late diagnosis is increased in patients with COPD in use of inhaled corticosteroids. Case studies may contribute to increase the suspicion index about TB associated with COPD.

[Acute hepatitis due to infectious mononucleosis in a 21-year-old-man]. / Hepatitis aguda por mononucleosis infecciosa en un varón de 21 años.

A 21-year-old mole was admitted because of fever, fatigue, headache, pharyngitis, abdominal pain, loss of appetite, vomiting and dark urine for three days. The patient denied recent use of medicines or any other drug. His physical examination disclosed jaundice, hepato-splenomegaly, whitish-yellow covered tonsils, bilateral anterior and posterior cervical lymph node enlargement associated with edema on the face and neck. Routine blood tests detected abnormalities in serum bilirubins and liver enzymes (total bilirubin: 14.5 mg/dl, direct-reacting bilirubin: 12.9 mg/dl, AST: 697 U/l, ALT: 619 U/l, alkaline phosphatases: 260 U/l, and GGT: 413 U/l). Serological tests showed negative results for viral hepatitis, cytomegalovirus, HIV-1 and HIV-2, and toxoplasmosis markers, while serology for recent infection by EBV was positive (IgM: 70 and 29 U/ml; EBV IgG: 25 and 156 U/ml). Although infrequently, EBV infection can cause acute hepatitis with accentuated cholestatic jaundice (5% of cases), which may constitute an additional diagnostic challenge for primary care physicians. The patient improved with supportive management and was discharged after 12 days. This case study might contribute to increase the suspicion index about acute hepatitis related to EBV.

Acute hepatitis due to infectious mononucleosis in a 21-year-old-man / Hepatitis aguda por mononucleosis infecciosa en un varón de 21 años

A 21-year-old mole was admitted because of fever, fatigue, headache, pharyngitis, abdominal pain, loss of appetite, vomiting and dark urine for three days. The patient denied recent use of medicines or any other drug. His physical examination disclosed jaundice, hepato-splenomegaly, whitish-yellow covered tonsils, bilateral anterior and posterior cervical lymph node enlargement associated with edema on the face and neck. Routine blood tests detected abnormalities in serum bilirubins and liver enzymes (total bilirubin: 14.5 mg/dl, direct-reacting bilirubin: 12.9 mg/dl, AST: 697 U/l, ALT: 619 U/l, alkaline phosphatases: 260 U/l, and GGT: 413 U/l). Serological tests showed negative results for viral hepatitis, cytomegalovirus, HIV-1 and HIV-2, and toxoplasmosis markers, while serology for recent infection by EBV was positive (IgM: 70 and 29 U/ml; EBV IgG: 25 and 156 U/ml). Although infrequently, EBV infection can cause acute hepatitis with accentuated cholestatic jaundice (5% of cases), which may constitute an additional diagnostic challenge for primary care physicians. The patient improved with supportive management and was discharged after 12 days. This case study might contribute to increase the suspicion index about acute hepatitis related to EBV.

Un paciente varón de 21 años, fue hospitalizado por fiebre, astenia, cefalea, faringitis, dolor abdominal, pérdida del apetito, vómitos y orina oscura desde tres días antes. El paciente negó uso reciente de medicamentos y cualquier otra droga. Su examen físico reveló ictericia, hepato-esplenomegalia, amigdalitis, adenopatías cervicales anteriores y posteriores, asociadas con edema facial y cervical. Los exámenes de laboratorio mostraron elevación sérica de bilirrubina y enzimas hepáticas (bilirrubina total: 14,5 mg/dl, bilirrubina directa: 12,9 mg/dl, AST: 697 U/l, ALT: 619 U/l, fosfatasas alcalinas: 260 U/l, y gama-GT: 413 U/l). Los tests serológicos resultaron negativos para hepatitis viral A, B o C, citomegalovirus, VIH-1 y VIH-2, y toxoplasmosis; pero la serología de infección reciente por VEB fue positiva (IgM: 70 y 29 U/ml; IgG: 25 y 156 U/ml). Aunque raramente, las infecciones por VEB pueden causar una hepatitis aguda con acentuada ictericia colestásica (5% de los casos), que suele constituir un desafío diagnóstico adicional para los médicos en atención primaria. El paciente mejoró durante un tratamiento de apoyo y recibió alta hospitalaria después de 12 días. Este caso estimula a aumentar el índice de sospecha de hepatitis aguda relacionada con VEB.

Reversible cardiotoxicity in a 54-year-old woman treated with trastuzumab / Cardiotoxicidad reversible en una mujer con 54 años tratada con trastuzumab

Background: We report a 54-year-old woman with an stage IIA (T2N0M0) RE and RP negative and HER2-positive ductal invasive breast cancer who developed a reversible cardiotoxicity associated with chemotherapy. After surgery, she received four cycles of doxorubicin and cyclophosfamide. Later, she used paclitaxel and trastuzumab. At the 7th cycle of trastuzumab, she had symptoms of heart failure with left ventricle ejection fraction = 59%. Trastuzumab dosage was reduced in 25%, and heart function progressively improved. Two years after her discharge, the patient remains asymptomatic. Systolic function of the left ventricle was normal before the initial dosis of trastuzumab, but significantly worsened following the beginning of drug administration. Moreover, a clear improvement of heart function was observed soon after the daily dose of trastuzumab was reduced. Better knowledge of risk factors for cardiotoxicity related to chemotherapy, and longstanding surveillance with serial echocardiograms can avoid more severe cardiotoxicity by chemotherapy.

Se reporta un caso de cardiotoxicidad asociada con quimioterapia con trastuzumab, en una mujer con 54 años de edad que presentó un cáncer de mama ductal invasivo, con receptores de estrógeno y de progesterona negativos y HER2-positivo, en estadio IIA (T2N0M0). En el posoperatorio, recibió cuatro ciclos de doxorubicina y ciclofosfamida. Después recibió paclitaxel y trastuzumab. En el séptimo ciclo de trastuzumab, la paciente presentó síntomas de falla cardiaca, con fracción de eyección de ventrículo izquierdo = 59%. La dosis de trastuzumab fue reducida en 25%, y la función cardiaca se normalizó progresivamente. Más de 2 años después del alta hospitalaria, permanece sin síntomas. En esta paciente la función sistólica de ventrículo izquierdo estaba normal previo al uso de trastuzumab y hubo un significativo deterioro desde el início de este medicamento. Se observó una mejoría importante en la función cardiaca cuando se redujo la dosis diaria de trastuzumab. Un mejor conocimiento acerca de los factores de riesgo para cardiotoxicidad relacionados con quimioterapia y el seguimiento prolongado con ecocardiogramas pueden evitar la cardiotoxicidad más severa debida a quimioterapia.

Reversible cardiotoxicity in a 54-year-old woman treated with trastuzumab.

We report a 54-year-old woman with an stage IIA (T2N0M0) RE and RP negative and HER2-positive ductal invasive breast cancer who developed a reversible cardiotoxicity associated with chemotherapy. After surgery, she received four cycles of doxorubicin and cyclophosfamide. Later, she used paclitaxel and trastuzumab. At the 7th cycle of trastuzumab, she had symptoms of heart failure with left ventricle ejection fraction = 59%. Trastuzumab dosage was reduced in 25%, and heart function progressively improved. Two years after her discharge, the patient remains asymptomatic. Systolic function of the left ventricle was normal before the initial dosis of trastuzumab, but significantly worsened following the beginning of drug administration. Moreover, a clear improvement of heart function was observed soon after the daily dose of trastuzumab was reduced. Better knowledge of risk factors for cardiotoxicity related to chemotherapy, and longstanding surveillance with serial echocardiograms can avoid more severe cardiotoxicity by chemotherapy.

Erysipelas in the elderly: Are the concerns and economic burden increasing? Apropos of a case.

Blistering erysipelas has been reported only rarely and may be under-diagnosed. Very often, patients presenting with erysipelas are treated by non-dermatologist primary physicians. The current growth in the elderly population may increase the economic burden resulting from this disease. Therefore, case reports highlighting possible misdiagnoses of erysipelas can contribute to greater awareness among primary care professionals and lead to earlier diagnosis and prompt treatment. This description seeks to emphasize the main risk factors and predisposing factors, in addition to some atypical features and current challenges involved in the differential diagnosis for erysipelas.

Coexistent cervical spine fusion and thoracic disc herniations with acute myelitis.

Thoracic disc herniations are commonly found in asymptomatic individuals, sometimes with genetic predisposition. Congenital fusions of cervical vertebrae occur in Klippel-Feil syndrome, which may be asymptomatic or cause compressive myelitis due to cervical instability or associated herniated discs. We report the case of a 72-year-old man with monophasic acute transverse myelitis probably caused by herpes simplex virus, coexistent with fused cervical vertebrae (C4-C5) and thoracic herniated discs. Establishment of the aetiology in cases of transverse acute myelitis can constitute a challenge in patients with cervical spine anomaly and disc herniations.