Diffuse Large B-Cell Lymphoma with Cutaneous Manifestations in a Young Patient Using Clozapine for Schizophrenia: A Case Report

BACKGROUND Non-Hodgkin lymphoma is the most common hematological malignancy in the world. Diffuse large B-cell lymphoma the most common type and the cutaneous involvement due to this neoplasm is rare. Some risk factors, such as exposure to pesticides, alcohol consumption, and tobacco use, are well established. Over the past 10 years, the association between clozapine, which is the criterion standard treatment for refractory schizophrenia, and hematological malignancies has been described. CASE REPORT We report a case of a 44-year-old woman diagnosed with schizophrenia 31 years previously, who had been taking clozapine since 2009, presenting with diffuse cutaneous nodules and subcutaneous masses accompanied by asthenia, dry cough, and a weight loss of 12 kg. Computed tomography revealed multiple enlarged lymph nodes on both sides of the diaphragm, in addition to multiple large subcutaneous masses located on the right flank and on the right upper lateral chest wall (infra-axillary), homogeneous splenomegaly, and heterogeneous nodular areas of hypoenhancement, poorly delimited, in both kidneys. Diffuse large B-cell lymphoma in an advanced stage (IVBX) was diagnosed by skin biopsy, with extranodal involvement. Chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone every 21 days) was performed and the decision to maintain clozapine was made. At 1.5 years after the initial diagnosis the patient presented with relapse of the disease and is in follow-up. CONCLUSIONS This case report suggests the potential association between clozapine and an increased risk of lymphoma, with a few case reports in the literature reinforcing this association. Additional studies are required to either confirm or dismiss this association, and new guidelines are needed to define the safety and monitoring of the long-term usage of clozapine.

The relationship between chikungunya virus and the kidneys: A scoping review

Several atypical forms of chikungunya fever (CHIK) have been described, including neurological, cardiac and renal involvement. These forms may be related to high morbidity and mortality rates. This scoping review based on the PubMed, Scopus, and WOS databases aims to identify and summarise all the available evidence regarding the clinical and histopathological presentations and risk factors associated with kidney injury related to CHIK, as well as the clinical impact. Thus, a total of 54 papers were selected from 1606 initial references after applying the defined inclusion criteria. Data on the association between kidney injury and CHIK are scarce, with studies only conducted in the acute phase of the disease, lacking further characterisation. Kidney injury incidence in hospitalised patients using the Kidney Disease Improving Global Outcomes criteria varies from 21% to 45%, being higher among patients with atypical and severe manifestations. Although acute kidney injury does not seem to be related to viraemia, it may be related to higher mortality. Few studies have described the renal histopathological changes in the acute phase of CHIK, with prevalent findings of acute interstitial nephritis with mononuclear infiltrate, glomerular congestion and nephrosclerosis. Only one study assessed the kidney function of patients in the subacute and chronic phases of CHIK. Additionally, individuals with comorbidities, including chronic kidney disease, may be among those with a greater risk of presenting worse outcomes when affected by CHIK. The results described herein may contribute to better understand the relationship between the kidneys and chikungunya virus.

Long-Term Persistence of Serum-Specific Anti-Chikungunya IgM Antibody - A Case Series of Brazilian Patients

The persistence of serum-specific anti-chikungunya IgM antibodies (CHIKV-IgM) can vary after chikungunya fever (CHIK) infection. However, the factors related to its production are not yet known. We described a case series drawn up from data collected from 57 patients between 12 and 36 months after the acute phase of CHIK infection in Northeastern Brazil. CHIKV-IgM was detectable in 7/57 (12.3%) patients after 28.3 months of infection. No frequency differences in chronic musculoskeletal manifestations and underlying conditions were detected between patients with or without CHIKV-IgM. CHIKV-IgM was detected for up to 35 months in Brazilian patients after CHIK infection.

Exuberant bullous vasculitis associated with SARS-CoV-2 infection

•

COVID-19 can present varied dermatological manifestations.

•

Cutaneous small-vessel vasculitis is one of these forms of cutaneous manifestation of COVID-19.

•

Vesicobullous hemorrhagic lesions can be the clinical presentation.

•

Most cases of cutaneous vasculitis present in mild cases of COVID-19.

•

Microvascular thrombosis seems to be part of the pathophysiological process of the cutaneous lesion in COVID-19.

We described a case of exuberant cutaneous small-vessel vasculitis in a 27-year-old male with mild CoVID-19 in Brazil. The patient presented painful purpuric papules and vesicobullous lesions with hemorrhagic content located in the larger amount in the lower limbs and, to a lesser extent in the region of the back and upper limbs, saving palms and soles of the feet. Influenza-like syndrome with anosmia and ageusia was reported seven days before the skin lesions. A real-time reverse transcription polymerase chain reaction was positive on a nasopharyngeal swab for SARS-CoV-2. Histopathological study showed leukocytoclastic cutaneous vasculitis affecting small vessels and microthrombi occluding some vessels. The patient presented an improvement in skin lesions by the fifth day of prednisone therapy. This case highlights the importance of the SARS-CoV-2 test in investigating the etiology of cutaneous vasculitis during this pandemic.

Reversible Pulmonary Hypertension Secondary to Scurvy in a Patient with a Psychiatric Disorder: a Case Report and Literature Review

Pulmonary hypertension (PH) can be related to several diseases, such as connective tissue disorders and pulmonary embolism, or to drugs; it may also be idiopathic. Few cases have been reported demonstrating an association between ascorbic acid deficiency and reversible PH. We report the case of a patient who arrived at the emergency department with dyspnoea, tachycardia and lower limb perifollicular haemorrhage. Examinations, including a transthoracic echocardiogram, revealed enlarged right chambers and an estimated pulmonary artery systolic pressure of 61 mmHg. Further evaluation revealed poor food intake due to paranoid personality disorder, leading to ascorbic acid deficiency and manifestations of scurvy.

Factors associated with burnout syndrome in medical residents of a university hospital

Objective:

To determine the prevalence of burnout syndrome among resident physicians of various specialties and to evaluate associated factors.

Method:

The Maslach Burnout Inventory questionnaire and a sociodemographic questionnaire were used to evaluate factors associated with the syndrome. Burnout was defined as the association of high emotional exhaustion, depersonalization and low professional achievement. Multivariate analysis was performed after adjustment of the Poisson model with the identification of risk factors and calculation of prevalence ratios (PR). Of the 250 resident physicians registered with Hospital das Clínicas of Pernambuco, 129 participated in the study.

Results:

In the three domains that characterize burnout syndrome, we found a low level of professional achievement in 94.6% of resident physicians interviewed, a high level of depersonalization in 31.8%, and 59.7% with a high level of emotional exhaustion. The prevalence of burnout was 27.9%. Having suffered a stressful event in the last six months (PR: 8.10; 95CI 1.2-57.2) and being a student of surgical specialty (PR: 1.99; 95CI 1.2-3.3) were independently associated with burnout.

Conclusion:

The prevalence of burnout found in resident physicians is in accordance with previous Brazilian studies. Residents of surgical specialties and those who suffered some stressful event were identified as susceptible in this study. The early identification of risk factors is fundamental for the implementation of preventive measures against burnout syndrome.

Comparative analysis of primary and secondary glomerulopathies in the northeast of Brazil: data from the Pernambuco Registry of Glomerulopathies - REPEG

INTRODUCTION

In Brazil, glomerulopathies are the third leading cause of chronic renal disease, accounting for 11% of dialysis patients. Studies on the prevalence of this disease in Northeastern Brazil are scarce.

OBJECTIVE

The aim was to describe the findings of biopsies and to conduct a comparative analysis on the clinical laboratory presentation of primary glomerulopathies (PG) and secondary glomerulopathies (SG).

METHODS

This was a retrospective study conducted at two public teaching hospitals in the state of Pernambuco, Northeastern Brazil.

RESULTS

A total of 1151 biopsies performed between 1998 and 2016 were analyzed. The sample consisted of 670 biopsies of native kidneys, after excluding extra glomerular diseases and unsuitable material. PG were more frequent than SG (58% vs. 42%). There was a prevalence among PG of focal segmental glomerulosclerosis (43%). Membranoproliferative glomerulonephritis and collapsing glomerulopathy, accounted for 9% and 3% of the PG, respectively. For SG, the main etiologies were lupus nephritis (67%) and infections (10%). Female sex, hematuria and an elevated level of creatinine were related to a greater chance of SG, at multivariate analysis. An increase of proteinuria reduced this chance. Nephrotic syndrome was more common among the PG, while urinary abnormalities and nephritic syndrome prevailed in patients with SG.

CONCLUSION

This is the first registry of glomerulopathies in Northeastern Brazil. It also presents a comparative analysis of the main clinical laboratory abnormalities of PG and SG, and includes the current classifications of glomerular diseases.

Predictors of loss to follow-up among children registered in an HIV prevention mother-to-child transmission cohort study in Pernambuco, Brazil

Background

Mother-to-child transmission of HIV (MTCT) is the major form of acquiring the disease among children. The loss to follow-up (LTF) of mothers and their children is a problem that affects the effectiveness of programs for the prevention of mother-to-child transmission (PMTCT). The aim of this study is to identify risk factors associated with the LTF of HIV-exposed children in the state of Pernambuco, Brazil.

Methods

A retrospective cohort study was carried out with 1200 HIV-exposed children born between 2000 and 2009, registered up to the age of 2 months in a public health PMTCT program. Children were considered LTF if they did not return for scheduled visits to monitor infection status. Univariate and multivariate logistic regression analyses were conducted to identify risk factors for LTF.

Results

A total of 185 children (15.4%; CI: 95%: 13.4 - 17.4%) met the case definition of LTF before the determination of serological HIV status. Risk factors independently associated with LTF were mother-child pairs who reside in rural and remote areas (OR 1.86; 95% CI: 1.30-2.66) and mothers who use illicit drugs (OR 1.8; 95% CI: 1.08-3.0). Initiation of the PMTCT during pregnancy was a protective factor for LTF (OR 0.69; 95% CI: 0.49-0.96).

Conclusions

The decentralization of support services for HIV-exposed children to other cities in the state seems to be crucial for the accurate monitoring of outcomes. It is also important to introduce additional measures addressing mothers who are drug users so that they remain in the program: an intensive follow-up program that actively searches for absentee mother-child pairs, support from social services and treatment for drug-dependency. The findings of this study highlight the importance of diagnosing mothers as early as possible in order to conduct a more complete follow-up period of the children. Solving the above-mentioned problems is a challenge, which must be overcome so as to improve the quality of PMTCT.

Tendência temporal do tétano acidental no período de 1981 a 2004 em Pernambuco com avaliação do impacto da assistência em unidade de terapia intensiva sobre a letalidade

Apesar da redução na incidência de tétano acidental no Brasil, não houve queda significativa na letalidade. Nesta série de casos, comparamos a letalidade antes e após o estabelecimento padrão de manejo em unidade de terapia intensiva do paciente com tétano no Hospital Universitário Oswaldo Cruz, no período de 1981 a 2004. Em 24 anos, foram internados 1.971 pacientes e antes do manejo em Unidade de terapia intensiva a letalidade era de 35%. Durante 1997 foi instituída a unidade de terapia intensiva para assistência dos pacientes com tétano, e de 1998 a 2004, a letalidade caiu para 12,6%, OR= 0,27 (IC95%= 0,18- 0,39); p<0,001. Esta tendência foi evidenciada em todas as faixas etárias e em ambos os sexos. A centralização da assistência a esses pacientes em um único serviço especializado com Unidade de terapia intensiva de forma precoce, portanto, tem sido decisiva na redução da letalidade, por contar com a vasta experiência da equipe de saúde no manejo do tétano e melhor tratamento sintomático, antecipando as graves complicações da doença.