Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal Protein, and Skin Changes Associated With Castleman Disease: A Common Misdiagnosis

Castleman disease is a rare lymphoproliferative disorder. Co-presentation with polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes (POEMS syndrome) has been documented in 11-30% of Castleman disease cases. POEMS syndrome is a rare paraneoplastic disorder characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes. Not all features are required to make the diagnosis. We report a case of a woman who presented with a 1-year history of a left-side supraclavicular swelling associated with constitutional symptoms and symmetrical paresthesia of the lower limbs. In addition, she had skin hyperpigmentation, multiple supra and infra-diaphragmatic lymphadenopathies, hepatosplenomegaly and osteosclerotic lesions. Serum immunofixation was positive for immunoglobulin G-kappa gammopathy. A lymph node excisional biopsy was compatible with Castleman disease. The diagnosis of POEMS syndrome associated with Castleman disease was made. Our patient started treatment with a combination of bortezomib, cyclophosphamide, and dexamethasone with clinical and analytical improvement. Current treatment of POEMS syndrome associated with Castleman disease is focused on the management of POEMS syndrome. Early diagnosis requires a high index of suspicion and is crucial to reduce morbidity and mortality. This case report aims to raise awareness about this rare entity.

Síndrome Antifosfolipídica: Uma Revisão a Propósito de Três Casos Clínicos

A síndrome antifosfolipídica é uma doença autoimune e sistémica que se define com base em achados clínicos e laboratoriais, ou seja, presença de tromboses recorrentes, arteriais ou venosas em pessoas jovens, abortos espontâneos recorrentes, trombocitopenia e níveis elevados de anticorpos antifosfolipídeos: anticoagulante lúpico, anticorpos anticardiolipina IgM ou IgG, assim como anticorpos IgM ou IgG anti-beta 2 glicoproteína I e antiprotrombina. Os indivíduos com síndrome antifosfolipídica podem apresentar a síndrome isoladamente, ou em associação a outros distúrbios, nomeadamente autoimunes, sendo o lúpus eritematoso sistémico aquele que dentre todos é o mais comummente associado.  No presente artigo os autores apresentam três casos clínicos nos quais as manifestações trombóticas levaram à investigação de síndrome antifosfolipídica, a qual veio a confirmar-se através de estudo imunológico. A adequação terapêutica permitiu prevenir episódios de recorrência, quando o grau de gravidade dos mesmos o possibilitou. Recebido: 31/05/2016 – Aceite: 19/07/2016

Meningite Asséptica por Rickettsia conorii: Importância da Repetição do Doseamento dos Títulos de Anticorpos

A infeção por Rickettsia conorii é uma etiologia rara de meningite asséptica: inflamação das leptomeninges sem isolamento de agente no líquido cefalorraquidiano e com quadro clínico benigno. Os autores descrevem o caso clínico de mulher de 63 anos que recorreu ao Serviço de Urgência por quadro de cefaleias, febre, náuseas, vómitos, mal-estar-geral e alterações cutâneas. Ao exame físico apresentava exantema maculopapular, rigidez da nuca e Brudzinski’s positivo. Anticorpos anti-Rickettsia conorii IgM negativo e IgG positivo (+). Punção lombar com liquor transparente, pleocitose de predomínio neutrofílico (72%), proteinorráquia de 0,76 g/dL e glicorráquia de 59,0 mg/dL, com quociente glicose liquor/soro de 0,45. Internada por quadro clínico e analítico de meningite. Por etiologia provável de rickettsiose foi medicada empiricamente com doxiciclina com boa evolução clínica. Repetiu-se doseamento de Ac. anti-Rickettsia: IgM positiva (++) e IgG positiva (+++) para Rickettsia conorii, tendo tido alta após resolução completa da sintomatologia, sem sequelas. Recebido: 12/10/2016 - Aceite: 25/10/2016

Pyogenic liver abscess: uncommon presentation

Pyogenic liver abscess is a rare entity, but it is fatal when untreated. With a peak incidence in the fifth decade of life, its early recognition and intervention are key to successful treatment and better prognosis of patients. In recent years, its approach has been enhanced by the use of percutaneous drainage, improved imaging techniques and a better microbiological characterisation, allowing for a more appropriate use of antibiotics. Clinical manifestations are variable and depend on the size of the abscess, the condition of the patient, associated diseases and possible complications. Among the most common symptoms that stand out are the pain in the upper quadrants of the abdomen, high fever, nausea and vomiting. The authors present the case of a patient who developed an atrial flutter as the initial presentation of a hepatic abscess that imagiologically mimicked a hepatic tumour.

Intralobar pulmonary sequestration: diagnostic expertise

An obese 22-year-old man with a history of recurrent respiratory infections presented to the emergency room with left pleuritic chest pain, productive cough with mucupurulent sputum and an axillary temperature of 37.7°C. Blood work showed elevated inflammatory parameters and chest X-ray was relevant for heterogeneous infiltration in the left base and opacity of the left costophrenic angle. An angio-CT scan revealed areas of bilateral consolidation with presence of an arterial branch originating from the aorta to the collected area of the left lower lobe, consistent with a respiratory infection grafted on a intralobar pulmonary sequestration of the left lung base. The infectious process was treated and the patient was planned for a lower left lobectomy.

Trazodone in the elderly: risk of extrapyramidal acute events

Trazodone is a second-generation atypical antidepressant exercising selective inhibitory action on the transport of serotonin. It also has an antagonist effect, similar to nefazodone, on the 5HT1 and 5HT2 receptors, probably due to the therapeutic effects of such substances. It is very effective in the treatment of depression, in anxiety and insomnia. Its known side effects mainly occur with prolonged use of daily doses of 150-200 mg. The ability to enhance drowsiness may be associated with some risk in elderly patients. This clinical case illustrates an acute extrapyramidal event induced by a low dose of trazodone.