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 Māori, 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.

Thoracic duct lymphangioma and chylous ascites in a 24-year-old female

Lymphangiomas are rare and correspond to 0.7% to 4.0% of mediastinal tumors, and isolated mediastinal location occurs in 1% of cases. They are benign tumors that originate from a congenital malformation of the lymphatic vessels and are diagnosed more frequently in children less than 2 years of age. Chylous ascites is a clinical manifestation of thoracic duct lymphangioma and is composed of lymph accumulation caused by dilation of this lymphatic channel. It appears milky in the peritoneal cavity, containing triglyceride levels higher than 200 mg/dl. We report the case of a young patient with chylous ascites and lymphangioma of the thoracic duct, who was conservatively treated with octreotide and a low-fat diet with medium-chain triglycerides.

Rectal Metastases of Breast Carcinoma: A Case Report

The scarcely reported hematogenous rectal metastases from breast cancer are rare and the diagnosis is challenging. They may be recognized before, concomitantly with, or after the diagnosis of the primary site of breast cancer. Invasive lobular cancer is the histological type more frequently described, and most of the affected patients have a late diagnosis. Tardive recognition is associated with poor outcomes, despite the management options. Endoscopic and imaging evaluations, mainly magnetic resonance studies, are useful, but the anatomopathological findings are mandatory to confirm the diagnostic hypothesis. We describe a middle-aged woman with advanced rectal metastases of unsuspected breast cancer found during the evaluation of manifestations due to intestinal implants. One must highlight long-term follow-up of breast cancers even if seeming in remission. The aim of this report is to enhance the suspicion index of primary health care workers.

A Brazilian male with typical oral and pulmonary paracoccidioidomycosis

An autochthonous case of paracoccidioidomycosis was reported in a city of north Iran. This condition is a well-known endemic fungal infection highly prevalent in Latin American countries, with an incidence of 1 to 3.7 cases per 100.000 annually in Brazil. The classical features are cutaneous lesions, lymph node, and pulmonary involvements, while typical oral changes are superficial ulcers with hemorrhage and moriform aspect. Herein is reported an adult male patient with characteristic oral and pulmonary lesions. Rural environment, male gender, cigarette smoking, and alcohol abuse were risk factors; and clinical history, imaging studies, and histopathologic data established the diagnosis. The patient improved well by administration of sulfamethoxazole plus trimethoprim. The aim of this case study is to enhance the awareness of generalists about this mycosis.

Miliary tuberculosis: the role of necropsy studies

This case study of generalized miliary tuberculosis in a Brazilian man without AIDS is reported in order to emphasize the role of histopathological study for diagnosis. We comment on a recent Indian study involving 40 cases of surgical and necropsy specimens in which the diagnosis of tuberculosis was made, as well as a previous Brazilian case report. The authors believe that non-specialists should be better informed about the possibility of miliary tuberculosis, which involves clinical diagnostic challenges. Despite limitations, minimally invasive necropsy may be an alternative to elucidate causes of death in low-income countries.

Caput Medusae due to portal hypertension in schistosomiasis mansoni

A 62-year-old Brazilian man who lived in endemic areas of tropical diseases had an episode of hematemesis associated with portal hypertension. He used to swim in natural ponds during childhood and developed the hepatosplenic form of schistossomiasis with moderate ascites, in addition to the characteristic features of abdominal Caput Medusae. The aim of the report is highlight the role of chronic liver disease and schistossomiasis.

A 52-year-old man with gouty arthritis and erosive lesion in the hip

The case study of peripheral and axial gouty arthritis is described in a 52-year-old man without concomitant clinical evidence of tophaceus gout on physical evaluation on admission. Gout is a metabolic disorder related to excess of uric acid in the extracellular compartment, and deposition of monosodium urate crystals in the joints and other sites. Arthritis and tophi are major manifestations, which more often involve the peripheral joints asymmetrically. Chronic tophaceous gout commonly develops after a decade of recurrent polyarticular gout. With lower frequency, the axial skeleton (spine and sacroiliac region) may be affected, condition sometimes associated with additional concerns, diagnostic challenges and pitfalls. Higher suspicion index and utilization of novel radiographic tools can settle these matters. Radiographic imaging exams include plain radiography, computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy to show bone erosion and joint lesions characterizing the spectrum of gouty osteoarthropathy.

A young woman with abrupt changes in skin and mucosa

Cutaneous and mucosal changes due to adverse drug effects are relatively common in clinical daily practice; however, the etiology often follows unsuspected, undetermined and underreported. More severe lesions like the Stevens-Johnson syndrome should be early recognized and treated. As the entity is potentially lethal if not properly managed, and diagnosis is imminently clinical, the characteristic images might contribute to enhance the suspicion index about this syndrome.

Parotid Cystic Lesion in Amelanotic Malignant Melanoma

A 60-year Brazilian woman, presented with an enlarged lymph node in the neck for one year, and a superficial nonulcerated lesion was observed in the scalp. Fine needle aspiration and biopsy of the lymph node revealed amelanocytic metastasis, and immunohistochemistry study showed Melan-A/ Mart-1 antigen (clone A103 and S-100 protein). The entire suspected area of the scalp was further resected and an amelanotic melanoma without angiolymphatic invasion was diagnosed. Ultrasonography and PET-computed tomography showed hypermetabolic cystic area in the right parotid. Furthermore, aspiration biopsy and surgical samples from parotid cyst confirmed the malignant amelanotic melanoma. Cystic metastases are scarcely reported in parotid gland, and can pose diagnostic challenges.

An 81-year-old patient with recent diagnosis of classic testicular seminoma

An old patient with recent diagnosis of classic seminoma is reported. The tumor of left testicle was heralded by tenderness about 30 days before medical attention and enlarged testis confirmation. There was antecedent of left testis hypotrophy treated with testosterone and a surgery for varicocele at 15 years of age. Clinical hypothesis of testicular tumor was strengthened by ultrasonography images and elevated tumor markers (lactate dehydrogenase, <span>α</span>-fetoprotein, and <span>β</span>-hCG). Radical orchiectomy was performed and a classic seminoma (pT1pNx) was diagnosed. Active waiting was the first choice for management, but six months later a retroperitoneal mass with lymph node enlargement were found, and he underwent four sessions of carboplatin (AUC 5), bleomycin and etoposide (BEP regimen). Asymptomatic, he was referred to outpatient surveillance on Oncology. Population-based studies about frequency and outcome of early-stage testis seminoma in elderly are scarce. Case studies might contribute to the knowledge about this condition.

A 61-year-old woman with adult T-cell leukemia÷lymphoma

Adult T-cell leukemia÷lymphoma (ATL) is caused by human T-cell lymphotropic virus type-1 (HTLV-1) infection. Classification of ATL includes acute, chronic, lymphomatous and smoldering, and main features are hypercalcemia, organomegaly, bone, brain, lung, and skin changes. Elevated mortality rates of ATL may be due to the advanced age at diagnosis, because this malignancy can evolve unsuspected for decades before the first clinical manifestations. Palliative therapy, chemotherapy and stem cell transplantation are often utilized, but response to treatment is poor. The patient herein reported presented diffuse abdominal pain with duration of eight months in addition to ascites. The diagnosis of the acute leukemia type of ATL was done with base on clinical, laboratory and imaging findings. Gastrointestinal symptoms and ascites are uncommon first manifestations of ATL, and pose challenging diagnosis.

Multiple myeloma and secondary plasma cell leukemia

Plasma cell leukemia is very rare condition characterized by malignant proliferation of plasma cells in blood and bone marrow, which is aggressive and has a short survival even with conventional treatment. This ominous entity may be primary, or develops secondarily during the course of multiple myeloma. A 53-year-old Brazilian woman with multiple myeloma is described with bone marrow evaluation revealing 25% plasma cells. The quantification of plasma cell infiltration in bone marrow aspirate and immunohistochemistry study revealed consistent features of myeloma and plasma cell leukemia, and lambda light chain expression. Worthy of note was the absence of CD56 expression and the expression of CD20; moreover, 23% of circulating plasma cells were detected in peripheral blood smears. Therefore, the diagnosis of plasma cell leukemia was characterized and therapeutic schedules with dexamethasone, thalidomide, cisplatin, doxorubicin, cyclophosphamide, and etoposide were utilized. With significant clinical improvement, the patient is currently waiting for bone marrow transplant.

Respiratory changes, hand fingers edema and yellow nails in a 94-year old woman

A 94-year old woman, with antecedent of chronic bronchitis, bronchiectasis, recurrent pneumonitis, arterial hypertension and chronic renal failure was admitted to control an episode of cardiac and respiratory insufficiency. Yellow nail changes and a tendency to pincer nails developed in her hand and toe fingers, preceded by longstanding course of respiratory diseases with pleural involvement. Laboratory tests detected moderate anemia and mildly elevated levels of urea and creatinine, thyroid function was normal. This case study is about yellow nail syndrome in absence of ankle lymphedema, and affecting a woman of the oldest-old age group with renal failure.

A 57-year-old Brazilian woman with a giant mucinous cystadenocarcinoma of the ovary: a case report

Introduction

Giant cystadenocarcinomas of the ovary are rarely described conditions.

Case presentation

The authors describe a 57-year-old Brazilian woman who presented with an increase in abdominal girth in February 2003. Imaging studies showed a giant abdominal pelvic mass with probable origin in the right ovary. Cancer antigen-125 was elevated, while carcinoembrionic antigen and alpha-fetoprotein were normal. Total abdominal hysterectomy, bilateral salpingoophorectomy and omentectomy were done. The mass weighed 40Kg, and the histopathology study revealed a mucinous cystadenocarcinoma. She underwent chemotherapy with paclitaxel and cisplatin with no side effects. Under follow-up for more than 10 years, she is asymptomatic and with normal imaging and laboratory parameters, including the cancer antigen-125 marker.

Conclusion

This huge tumor evolved for a long time unsuspected and without metastases in a patient from a developing region. The diagnostic and management challenges posed by this unexpected and unusual presentation of an ovarian cystadenocarcinoma are discussed.

Twenty years of hantavirus pulmonary syndrome in Brazil: a review of epidemiological and clinical aspects

Hantavirus infection is transmitted to humans by wild rodents and the most common clinical form in Brazil is the Hantavirus Pulmonary Syndrome (HPS). The first serological evidence of the disease was identified in 1990, in Recife, Pernambuco State, and later in 1993 in Juquitiba, State of São Paulo. Since then there has been a progressive increase in case notification in all regions of the country. The clinical aspects of the disease in Brazil are characterized by a prodromal phase, with nonspecific signs and symptoms of an acute febrile illness. After about three days, respiratory distress develops, accompanied by dry cough that turns progressively productive, evolving to dyspnea and respiratory failure with cardiogenic shock. Although the majority of patients receive hospital care in intensive care therapy units, case-fatality rate in Brazil ranges from 33% to 100% depending on the region. Besides it has to be added the problem of differential diagnosis with other prevalent diseases in the country, like dengue and leptospirosis. Questions about the impact of uncontrolled urbanization and other environmental changes caused by human action have been raised. Due to increasing incidence and high case-fatality, there is an urge to respond to such questions to recommend preventative measures. This article aims to review the main acquisitions in clinical and epidemiological knowledge about HPS in Brazil in the last twenty years.

A 76-year-old man with a right lung adenocarcinoma and invasive Aspergillosis

A 76-year-old male with adenocarcinoma on the right lung underwent five cycles of chemotherapy with pemetrexed disodium, cisplatin, and dexamethasone. Imaging studies of control showed a node in a cavitary lesion on the left lung, and the main hypothesis was Aspergillus infection. PCR was utilized and contributed to establish the early diagnosis in this patient with invasive aspergillosis. Furthermore, the species Aspergillus fumigatus was characterized by its growing at 50 °C but not at 10 °C, typical culture features, and presence of subclavate vesicles. Diagnosis criteria for Aspergillus pulmonary infection include characteristic clinical and imaging findings, elevated C-reactive protein and erythrocyte sedimentation rate, positive specific serological test, and isolation of Aspergillus from bronchoalveolar cultures. Molecular methods, as PCR, have been useful to complement the conventional microbiological investigations in immunocompromised people with invasive fungal infections. The patient was successfully treated with a schedule of voriconazole 4 mg/kg intravenous infusion every 12 h for 21 days and then switched to oral administration of 200 mg twice a day. He has been comfortable, maintaining normal vital signs, and the results of the periodical microbiologic tests of control are negative. Pathogenesis of invasive aspergillosis in patients with lung cancer is not completely understood. Case studies may contribute to a better knowledge about Aspergillus infection in this setting.

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.

Unsuspected giant hydatid cyst of the liver in an 87-year-old woman

Hydatid cystic disease from Echinococcus granulosus is described in some Brazilian as well as Italian areas. Liver hydatidosis is the most common presentation, which may evolve without symptoms. The authors describe an 87-year-old woman with an unsuspected giant hydatid cyst of the liver and emphasize the diagnostic challenges, mainly involving patients from non-endemic regions.

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.

Morphometric Study of Desmosomes from Oral Squamous Cell Carcinoma

The authors studied ultrastructural characteristics of desmosomes from oral squamous cell carcinoma, reporting the cellular differentiation and size of the desmosomes. The length of the desmosome profiles was measured with a Zeiss KS-300. The desmosomes were grouped according to their size and the tumor histological grading. Statistical analysis indicated a significant correlation (p < .001) between the size of the desmosomes and the histological grading group of the malignancy. The comparison of the desmosome size among the tumor histological grading groups also showed significant difference (p < .001). A multiple comparisons test indicated homogeneity in the size of desmosomes within the histological grading groups: 100% in the well differentiated, 95.2% in the moderately differentiated, and 50% in the poorly differentiated group. The preliminary data strongly suggest that the homogeneity of length of the desmosome profiles may be exploited for diagnostic strategies.

Morbid obesity in an adolescent with Prader-Willi syndrome

Prader-Willi syndrome is an uncommon multisystem genetic disorder caused by defects of chromosome 15 (15qll-ql3), often due to deletions or uniparental disomy The syndrome is characterized by neonatal hypotonia, dysmorphic facial features, short stature, motor and mental disabilities, behavioral changes, hyperphagia, precocious obesity and hypogonadotropic hypogonadism. We present a 17 year-old woman, with a previous genetic diagnosis of Prader-Willi syndrome and BMI of 74 Kg/m(2), that was admitted in anasarca, with marked cyanosis, dyspnea and oliguria. She presented high levels of blood urea, creatinine and aminotransferases, in addition to hyperkalemia and hyperuricemia. She had been in regular use of fluoxetine during the last six months, and evolved with severe high blood pressure and respiratory failure, which needed intensive care support. Moreover, sequels and clear signs of recent self-injuries were observed in her trunk, forearms and hands. The findings of morbid obesity, anasarca, self-injury, hyperuricemia and hypoxemia in Prader-Willi syndrome are emphasized.

[Acral skin necrosis in a patient with malaria]

A case of acral skin necrosis in a 21-year-old farm workman, associated with Plasmodium falciparum malaria is reported. Patient presented jaundice, disorientation and delirium, high parasitemia, hypoglycemia, anemia, low platelets, and dark necrotic maculae surrounded by an erythematous halo, circumscribed to toes. After malaria treatment, the clinical evolution was uneventful and the skin lesions also improved without sequels. The possibility that some of the skin changes, eventually observed in malaria patients, may be related with responses to Plasmodium infection is emphasized.