Marta Rebelo

Background With increased incidence and survival of cancer patients (pts), more oncological candidates are considered for admission in Intensive Care Unit (ICU). Trials demonstrated no significant difference in the outcome of cancer pts compared to non-cancer pts. Our study describes characteristics and outcomes of cancer pts in a polyvalent ICU in Portugal. Methods Single-centre retrospective cohort study of consecutive oncological pts admitted to a polyvalent ICU (January 2013 to December 2017). Only pts with active cancer were included. A Cox model was fit with time to death within 6 months as the dependent variable and type of cancer and organ support therapy as the independent ones. Covariate Cox regressions were performed. ROC curve analysis was used to determine the sensitivity of prognostic scores. Results Two hundred and thirty-six pts included (1400 ICU admissions), mean age of 53.5 ± 15.3 years and 65% were male. Median length of stay was 3 days (IQR 5). Central nervous s...

Background The Clinical Frailty Scale (CFS) is frequently used to measure frailty in critically ill adults. There is wide variation in the approach to analysing the relationship between the CFS score and mortality after admission to the ICU. This study aimed to evaluate the influence of modelling approach on the association between the CFS score and short-term mortality and quantify the prognostic value of frailty in this context. Methods We analysed data from two multicentre prospective cohort studies which enrolled intensive care unit patients ≥ 80 years old in 26 countries. The primary outcome was mortality within 30-days from admission to the ICU. Logistic regression models for both ICU and 30-day mortality included the CFS score as either a categorical, continuous or dichotomous variable and were adjusted for patient’s age, sex, reason for admission to the ICU, and admission Sequential Organ Failure Assessment score. Results The median age in the sample of 7487 consecutive pati...

Wunderlich syndrome is a rare and possibly life-threatening haemorrhagic syndrome presenting as spontaneous nontraumatic renal rupture with subcapsular and perinephric haemorrhage. Apixaban, a direct oral anticoagulant recommended in patients with atrial fibrillation, has previously been associated with atraumatic solid organ rupture but, to date, no case of apixaban-related Wunderlich syndrome has been reported. We report a rare case of Wunderlich syndrome associated with apixaban while addressing the difficulties face by clinicians when managing anticoagulation in bleeding patients.

The Ehlers-Danlos syndrome type IV (EDS-IV) is a hereditary, autosomal dominant disease that causes a defect in the procollagen III synthesis, which results in a structural modification in this protein. An awareness of the disease is of vital importance for the optimal outcome, since the affected individuals have a high risk of vascular, intestinal and uterine rupture. It's a disease with great clinical variability and the diagnosis is confirmed by detection of a mutation in the gene encoding collagen type III. The authors present a case report of a patient who appeared at the emergency ward with acute abdomen and hypovolemic shock after spontaneous aortic rupture. The diagnosis was confirmed after genetic study that identified a mutation in the (c.970G>A) in the COL3A1 gene, only reported once in the literature in a family with internal carotid dissections in some of its members. It's the first time that this mutation is reported in association with the EDS-IV. The autho...

INTRODUCTION Hypovitaminosis D (hypoD) is a vitamin deficiency that has been rising in the developed countries, due not only to inappropriate eating habits, but also because of lower sun exposure and lack of exercise. OBJECTIVE To determine the prevalence of vitamin D deficiency and to analyze associated factors, in patients admitted to an Internal medicine Ward. METHODS Cross-sectional study which included 123 hospitalized patients admitted to an Internal Medicine Ward between April and May. Serum levels of vitamin D [25-hydroxyvitamin D, 25(OH)D] were determined and the sample divided into three groups based on 25(OH)D levels: severe hypoD (<10ng/mL), moderate deficiency of 25(OH)D (>10ng/mL and <20ng/mL) and third group with normal levels of 25(OH)D (>20ng/mL). Demographic variables were recorded as were factors potentially related to vitamin D deficiency. RESULTS In this sample (52.0% women) the average age was 71 ± 17 years, 67.5% of patients had severe hypoD, 25.2%...

The Ehlers-Danlos syndrome type IV (EDS-IV) is a hereditary, autosomal dominant disease that causes a defect in the procollagen III synthesis, which results in a structural modification in this protein. An awareness of the disease is of vital importance for the optimal outcome, since the affected individuals have a high risk of vascular, intestinal and uterine rupture. It's a disease with great clinical variability and the diagnosis is confirmed by detection of a mutation in the gene encoding collagen type III. The authors present a case report of a patient who appeared at the emergency ward with acute abdomen and hypovolemic shock after spontaneous aortic rupture. The diagnosis was confirmed after genetic study that identified a mutation in the (c.970G>A) in the COL3A1 gene, only reported once in the literature in a family with internal carotid dissections in some of its members. It's the first time that this mutation is reported in association with the EDS-IV. The autho...

Chronic periaortitis (CP) refers to a spectrum of diseases whose common denominator is a fibro-inflammatory tissue developing in the periaortic space and frequently encasing surrounding structures like the kidney and ureters. There is no unified concept regarding the primary aetiology of CP, but recent studies have demonstrated that CP may present features of auto-immune diseases. CP involves three main entities, namely idiopathic retroperitoneal fibrosis (IRF), inflammatory aneurysms of the abdominal aorta (IAAAs) and perianeurysmal retroperitoneal fibrosis (PRF). These entities are usually diagnosed using computed tomography or magnetic resonance imaging, which typically show a retroperitoneal mass surrounding the aorta and that extends laterally without displacing it. Positron emission tomography is useful for the full assessment of the extent of the disease and its metabolic activity. The inflammatory and chronic relapsing nature of these diseases compels the use of medical ther...

Lipoprotein (Lp(a)) is considered a cardiovascular risk factor, and nicotinic acid is the only available drug for reducing its levels. The authors present the case of a 44-year-old male patient with hypercholesterolemia that responded poorly to statin therapy. After identifying high Lp(a) levels, combined therapy with nicotinic acid was initiated, resulting in normalization of LDL-cholesterol levels. The authors also carried out a theoretical review of Lp(a) and nicotinic acid.

Background The number of intensive care patients aged ≥ 80 years (Very old Intensive Care Patients; VIPs) is growing. VIPs have high mortality and morbidity and the benefits of ICU admission are frequently questioned. Sepsis incidence has risen in recent years and identification of outcomes is of considerable public importance. We aimed to determine whether VIPs admitted for sepsis had different outcomes than those admitted for other acute reasons and identify potential prognostic factors for 30-day survival. Results This prospective study included VIPs with Sequential Organ Failure Assessment (SOFA) scores ≥ 2 acutely admitted to 307 ICUs in 21 European countries. Of 3869 acutely admitted VIPs, 493 (12.7%) [53.8% male, median age 83 (81–86) years] were admitted for sepsis. Sepsis was defined according to clinical criteria; suspected or demonstrated focus of infection and SOFA score ≥ 2 points. Compared to VIPs admitted for other acute reasons, VIPs admitted for sepsis were younger,...

Hypersensitivity pneumonitis, also known as extrinsic allergic alveolitis, is a heterogeneous syndrome with nonspecific symptoms and physical findings, and probably under-diagnosed due to confusion with infectious diseases and other lung diseases. Atypical forms are a diagnostic challenge and the histological findings may provide a major contribution to the presence of hypersensitivity pneumonitis. We present a case report of a woman, ex -smoker, recently hospitalized for suspected sepsis, with a past medical history of progressive dyspnea and outdoor exposure to parrots since 2000. Initial work-up is suggestive of usual interstitial pneumonia, but bronchoalveolar lavage showed lymphocytosis 43%. To resolve apparent contradictive findings a lung biopsy was performed and showed histopathological changes suggestive of subacute hypersensitivity pneumonitis. After cessation of the exposure and treatment with corticosteroids, both clinical and radiological resolution occurred.

Chronic periaortitis (CP) refers to a spectrum of diseases whose common denominator is a fibro-inflammatory tissue developing in the periaortic space and frequently encasing surrounding structures like the kidney and ureters. There is no unified concept regarding the primary aetiology of CP, but recent studies have demonstrated that CP may present features of auto-immune diseases. CP involves three main entities, namely idiopathic retroperitoneal fibrosis (IRF), inflammatory aneurysms of the abdominal aorta (IAAAs) and perianeurysmal retroperitoneal fibrosis (PRF). These entities are usually diagnosed using computed tomography or magnetic resonance imaging, which typically show a retroperitoneal mass surrounding the aorta and that extends laterally without displacing it. Positron emission tomography is useful for the full assessment of the extent of the disease and its metabolic activity. The inflammatory and chronic relapsing nature of these diseases compels the use of medical ther...

ABSTRACT A 60-year-old Portuguese man was admitted to the Inter-nal Medicine ward with a 3-week-history of fever, weight loss, and anorexia. He complained of bilateral temporal headaches, increasing confusion, and aphasia. His visual acuity and fundo-scopic examination results were normal. His medical history was unremarkable. Family history revealed that his father died from gastric tumor, and he had a sister with breast cancer. Laboratory tests revealed a C-reactive protein of 1.8 mg/dL (reference range, 0.0Y0.82) and an erythrocyte sedimentation rate of 13 mm/h, whereas serum angiotensin converting enzyme, antinuclear anti-bodies, and antineutrophil cytoplasmic antibodies were within the reference range. Hematology parameters, renal and liver function tests, and urine analysis were all within normal limits. Results of Epstein-Barr virus, cytomegalovirus, toxoplasmosis, human im-munodeficiency virus, viral hepatitis, syphilis, brucella, and chla-mydia serological tests were all negative. Blood cultures were negative. The frontal chest radiography was normal. A lumbar puncture was done, and the cerebrospinal fluid (CSF) formula revealed pleocytosis with polymorphonuclear leukocyte pre-dominance, normal glucose concentration, and high protein con-tent. Results of Venereal Disease Research Laboratory test and cryptococcal antigen test were negative. A cranial computed to-mographic (CT) scan revealed a right subcortical nodule. Mag-netic resonance imaging (MRI) showed multiple nodular (large lesion, 1.5 cm) enhanced lesions on T1-weighted images after administration (Figs. 1 and 2). What are these lesions? DIFFERENTIAL DIAGNOSIS Metastasis, intracranial abscess, intracranial tuberculomas, neurosarcoidosis, and cryptococcosis. DIAGNOSIS Intracranial tuberculomas. DISCUSSION The existence of multiple intracranial lesions in MRI and a positive family history of neoplasia were in favor of central nervous system (CNS) metastatic tumor. Intracranial abscess was unlikely based on radiological findings. Imaging features of brain abscess are different from other lesions, such as tuber-culomas. On MRI, they usually demonstrate a ring of enhance-ment surrounding the intracranial lesion, and they tend to grow toward the white matter, away from the better-vascularized gray matter with thinning of the medial wall. 1 Nodular enhancement, as in this case, was more suggestive of tumor, fungal infection, or tuberculoma. Cryptococcosis is an infection caused by the Cryptococcus fungus, which can appear as leptomeningeal nod-ules or focal parenchymal mass most commonly located in the basal ganglia, thalamus, and midbrain. In this patient, crypto-coccal antigen was negative, which made this diagnosis unlikely. The medical history, radiological findings, and CSF formula find-ings were more suggestive of CNS tuberculosis (noncaseating tuberculoma). Because CNS tuberculosis can be a challenging diagnosis, antituberculous chemotherapy should be initiated on the basis of clinical or radiological suspicion and should never be delayed until proof of infection is obtained. The patient began treatment with isoniazid, rifampin, pyrazinamide, ethambutol, and pyridoxine for 2 months, followed by isoniazid and rifampin for 10 more months. After 5 weeks of incubation, CSF culture, conducted as part of the research protocol, was positive for M. tuberculosis and confirmed the diagnosis of intracranial tuberculomas. The patient showed gradual improvement with complete resolution of the symptoms. The MRI done at the third and sixth month of treatment showed marked reduction of the tuberculomas with no evidence of disease recurrence on follow-up. Tuberculosis still remains a major health problem in Portugal, which is the country in Western Europe with the highest rates of this infectious disease (34/100,000). Even so, CNS tuberculosis is quite rare, especially in immunocompetent people.

Apesar de a maioria dos doentes tratados com amiodarona permanecer em eutiroidia, alguns desenvolvem hipertiroidismo (HPEIA) ou hipotiroidismo (HPOIA) induzidos pela amiodarona. Os autores apresentam uma análise retrospectiva dos processos de dez doentes com disfunção tiróidea induzida pela amiodarona. Verificou-se que seis doentes eram mulheres e que o tempo médio de toma da amiodarona foi de 17,7 meses. O HPOIA foi o mais frequente (seis doentes). Dos doentes com HPEIA, dois tinham HPEIA tipo 2, um tipo 1 e um tipo 3. Sintomas sugestivos de disfunção tiróidea ocorreram em cinco doentes, a maioria com HPOIA. No HPEIA, a clínica mais comum foi exacerbação da arritmia de base (três doentes). A interrupção da amiodarona e administração de levotiroxina foi a terapêutica escolhida em 83,3% dos casos de HPOIA, enquanto a tionamida associada a corticoide com suspensão da amiodarona foi opção em 75% dos casos de HPEIA. Registraram-se três óbitos, todos com HPEIA. O HPEIA constituiu uma com...

Meckel’s diverticulum, a congenital malformation of the gastrointestinal tract, is asymptomatic in the majority of patients but can be associated with some complications. Gastrointestinal bleeding is one such complication and is more common in children than in adults. Despite the variety of examinations available, diagnosis can be difficult, especially in older patients, because the sensitivity of examinations decreases with patient age. Here we present the case of a young man with gastrointestinal bleeding in whom a diagnosis of Meckel’s diverticulum was made intra-operatively. LEARNING POINTS Meckel’s diverticulum is more commonly found in children than in adults and can cause gastrointestinal bleeding. The diagnosis of Meckel’s diverticulum can be complicated, especially in adults because the sensitivity of examinations decreases with patient age. Despite appropriate diagnostic evaluation, Meckel’s diverticulum is sometimes only diagnosed at surgery.