Browsing by Issue Date, starting with "2023-12"
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- Tofacitinib-induced eosinophiliaPublication . Archer, Sara; Ferreira, Daniela; Ferreira, Ana Teresa; Ponte, Sofia; Caetano, Cidalina; Salgado, Marta; Lago, Paula; Pedroto, IsabelTofacitinib is an oral small molecule JAK inhibitor approved for the treatment of moderate to severe ulcerative colitis (UC). Its efficacy and safety have been demonstrated in phase III clinical trials and supported by real-life data. We report the case of an 18-year-old woman with a 1-year diagnosis of left-sided UC, with multiple admissions due to disease exacerbation or infections, refractory to infliximab (with azathioprine) and currently under treatment with vedolizumab and tacrolimus. She was admitted due to a severe disease exacerbation and, because of a previous history of neuropsychiatric side effects to corticotherapy, tofacitinib was initiated. In the following 6 days, there was no clinical improvement of UC, and serial blood work-up revealed moderate grade persistent peripheral eosinophilia (3000 cells/mm3) and acute kidney injury grade 1 KDIGO. Tofacitinib temporary suspension was decided, with a rapid normalization of renal function/eosinophil levels. Tofacitinib was restarted 2 days after its suspension. However, she developed moderate eosinophilia (2000 cells/mm3) again, which was considered an adverse effect (AE) to tofacitinib, leading to its suspension with eosinophilia resolution. Given the severity of the disease, after a multidisciplinary discussion, it was decided to start high-dose corticotherapy and ustekinumab with maintenance therapy every 4 weeks, and to add tacrolimus. Clinical and biochemical remission were achieved, and the patient was discharged. Three-month follow-up after tofacitinib suspension showed no recrudescence of eosinophilia. Tofacitinib represents a significant advance in the management of UC patients. The drug has a good safety profile with few related AE. This case aims to warn about an adverse reaction to tofacitinib not reported so far, including in a multicenter real-life setting recently published by Hernández et al where eosinophilia is also not described, thus emphasizing the rarity of this AE. To our knowledge this is the first case of tofacitinib-induced eosinophilia in the context of UC.
- Mycobacterium szulgai Pulmonary Infection in an Immunocompromised PatientPublication . Neves, Sara; Pos, Ema; Horta, Ana; Vasconcelos, António LudgeroMycobacterium szulgai is a slow-growing nontuberculous mycobacterium (NTM). It was first described in 1972 and is responsible for less than 0.2% of all NTM infections. The most common presentation resembles pulmonary tuberculosis, but it may also present as an extrapulmonary disease. It primarily affects individuals with underlying lung disease or immunocompromising conditions. The increasing use of tumor necrosis factor-alpha inhibitors, such as adalimumab, is associated with an increased risk of serious infections. We report a case of Mycobacterium szulgai infection in a 23-year-old woman with a history of childhood pneumonia and Crohn's disease on adalimumab.
- Methadone Withdrawal-Related Psychosis in a Patient With Hormone-Dependent Breast Cancer: A Case ReportPublication . Pinho, Mauro; Martins, Daniela O; Coutinho, FranciscoMethadone withdrawal usually presents as a classical opiate withdrawal syndrome, including symptoms such as restlessness, pupillary dilation, sweating, insomnia, irritability, sneezing, nausea, vomiting, and diarrhea. It rarely manifests as psychosis. Here, we discuss the case of a 43-year-old female with a history of long-term methadone use who presented with first-episode psychosis during methadone down-titration. She exhibited persecutory delusions and auditory hallucinations, unrelated to classical opiate withdrawal symptoms. Medical tests were unremarkable. The patient was diagnosed with first-episode psychosis and was involuntarily admitted to our psychiatric hospital. As she suffered from hormone-dependent breast cancer and presented paliperidone-induced hyperprolactinemia, we switched this drug to aripiprazole, a prolactin-sparing antipsychotic. Her psychotic symptoms remitted in six weeks, with no reintroduction of methadone. It remains unclear whether this presentation is attributable to a rare manifestation of withdrawal or methadone's antipsychotic properties, masking an underlying psychotic disorder. This case contributes to understanding psychosis emergence post-opioid withdrawal, underscoring the need for further investigation into withdrawal-related psychosis and opioid antipsychotic properties. It also prompts the discussion of antipsychotic treatment in patients with comorbid breast cancer, while evidence about hyperprolactinemia as a risk factor for breast cancer remains conflicting
- Synergic Difficulties in an Anticipated Physiologically and Anatomically Difficult Airway in a Trauma Patient: A Case ReportPublication . Martins Lima, Patrícia; Adams, Mariana; Pinto, Sérgio G; Mexedo, CarlosThe American Society of Anesthesiologists (ASA) defines a difficult airway as a clinical situation in which a physician who is trained in anesthesiology experiences difficulty or fails in either face mask ventilation, laryngoscopy, using a supraglottic airway, tracheal intubation, extubation, or front-of-neck airway. Classically, this has been defined in relation to anatomic factors, but the concept of a physiologically difficult airway has been growing in relevance, in which physiologic factors, such as hypoxemia and hypercapnia, act to reduce safe apnea times. The case reports on a trauma patient with an unstable thoracic vertebral fracture requiring correction via the posterior approach. Our patient had multiple anatomical difficult airway predictors, namely, a short neck, greatly limited neck mobility, and a Mallampati class IV airway, among others, and multiple physiological difficult airway predictors, such as a baseline hypoxemic respiratory failure and severe sleep apnea, in addition to the restrictions on mobility imposed by the fracture itself. We describe a successful perioxygenation strategy, using high-flow nasal oxygen (HFNO) during the preoxygenation, intubation, extubation, and post-anesthesia care phases, and with an awake fiberoptic intubation technique for securing the airway.
- Hemothorax After Retroclavicular Approach to the Infraclavicular Region in a Critically Ill Patient: A Case ReportPublication . Ribeiro, Sara; Pombo, André; Lages, Neusa; Correia, Carlos; Teixeira, Carla MargaridaThe retroclavicular approach to the infraclavicular region (RAPTIR) is a recently described locoregional technique for upper limb analgesia that offers advantages over the classic infraclavicular block. RAPTIR is considered an effective and easy-to-perform block associated with few complications and better patient comfort. We present a case of a critically ill patient with thoracic and upper limb trauma. Despite multimodal analgesia, the patient developed delirium and experienced suboptimal pain control. An ultrasound-guided continuous RAPTIR block was performed, resulting in improved pain scores and delirium control. Twenty-four hours post block, the patient presented with dyspnea and chest pain, leading to the diagnosis of hemothorax. Chest computed tomography angiography revealed no vascular damage. The perineural catheter was removed 48 hours after its placement and the patient had a satisfactory recovery without long-term complications. The RAPTIR requires the needle to pass underneath the clavicle's acoustic shadow, putting the structures beneath the clavicle at risk of injury. Cadaver studies have raised concerns about potential vascular complications of the RAPTIR in a noncompressible location. This case highlights, for the first time, a rare but serious complication of the RAPTIR, demonstrating the potential risks of passing the needle through a blind spot
- Posterior Reversible Encephalopathy Syndrome in a Pediatric Intensive Care Unit: A Case SeriesPublication . Teixeira, Beatriz; Gonçalves, Vera; Cardoso, Ana Lúcia; Ribeiro Fernandes, Sofia; Rocha, Liliana; Garrido, Cristina; Sarmento, AlziraPosterior reversible encephalopathy syndrome (PRES) is a reversible clinical-radiographic abnormality. It is characterized by headache, altered consciousness, seizures, and visual disruption, in addition to characteristic white matter edema lesions in the parieto-occipital areas of the brain. Early detection and treatment are crucial to prevent irreversible damage. This paper presents the cases of three patients with PRES with concurrent diagnoses of glomerulonephritis, Guillain-Barré syndrome, and sickle cell disease. All patients experienced systemic hypertension, seizures, and altered consciousness. All patients were admitted to intensive care for decreased level of awareness or status epilepticus requiring invasive mechanical ventilation. Anticonvulsants and antihypertensive therapy were essential. No chronic complications were recorded.
- Global warming and heat wave risks for cardiovascular diseases: A position paper from the Portuguese Society of CardiologyPublication . Caldeira, Daniel; Dores, Hélder; Franco, Fátima; Bravo Baptista, Sérgio; Cabral, Sofia; Cachulo, Maria do Carmo; Peixeiro, António; Rodrigues, Rui; Santos, Mario; Timóteo, Ana Teresa; Campos, Luís; Vasconcelos, João; Nogueira, Paulo Jorge; Gonçalves, LinoGlobal warming is a result of the increased emission of greenhouse gases. The consequences of this climate change threaten society, biodiversity, food and resource availability. The consequences include an increased risk of cardiovascular (CV) disease and cardiovascular mortality. In this position paper, we summarize the data from the main studies that assess the risks of a temperature increase or heat waves in CV events (CV mortality, myocardial infarction, heart failure, stroke, and CV hospitalizations), as well as the data concerning air pollution as an enhancer of temperature-related CV risks. The data currently support global warming/heat waves (extreme temperatures) as cardiovascular threats. Achieving neutrality in emissions to prevent global warming is essential and it is likely to have an effect in the global health, including the cardiovascular health. Simultaneously, urgent steps are required to adapt the society and individuals to this new climatic context that is potentially harmful for cardiovascular health. Multidisciplinary teams should plan and intervene healthcare related to temperature changes and heat waves and advocate for a change in environmental health policy.
- Elective Revision Surgery in Head and Neck Cancer Patients: A Retrospective Analysis at an Oncology Centre in Porto, PortugalPublication . Sousa-Machado, André; Monteiro, EuricoIntroduction Elective revision surgery in head and neck cancer is crucial for refining and optimizing outcomes, ensuring complete tumor removal, and enhancing both functional and aesthetic aspects, ultimately improving the overall quality of life for patients. The aim of this study is to analyze the overall survival (OS) of head and neck cancer patients who underwent elective revision surgery with or without adjuvant treatment between 2019 and 2022, reflecting on the practice between those years in IPO-Porto, Porto, Portugal. Methods This study included 58 patients who underwent 116 major neck surgeries. Multidisciplinary head and neck follow-up records were obtained for every patient. Overall survival and disease-specific survival (DSS) curves were calculated using the Kaplan-Meier method, and statistical significance was determined by the Log-Rank test. We did a retrospective study with an anterograde direction, evaluating the treatments that were previously done by the patients. Results The sample comprised 51 males (87.9%) and seven females (12.1%), with a mean age of 59.02±11.014 years. Head and neck pathology was mostly in the larynx (36.2%). The type of the first surgery was mainly directed to the primary tumor in 62.1% (n=36). In the other 37.9% (n=22), surgery was directed to the primary tumor in association with neck dissection. The type of the second surgery was mainly revision surgery. We found that T4 tumors (HR (hazard ratio) = 10.219, p = 0.006) and hypopharynx tumors (HR = 5.306, p =0.035) were significantly associated with inferior OS. Conclusion In our sample, we found that a T4 and a tumor located in the hypopharynx were significantly associated with inferior OS in elective head and neck oncologic revision surgery. Disease-free survival in patients undergoing revision surgery in our sample is generally poor. In our sample, there was a statistically significant difference in overall survival between the group who underwent surgery for microscopic evidence of persistent tumor (R1) versus clinical and imagiological tumoral persistency. In our sample, the time between the first and second surgeries wasn't linked with an inferior OS. Further studies with larger populations and prospective design, with longer follow-ups can be the road to a better understanding of this issue.
- Adrenal Crisis During Cesarean Section in a Patient With Primary Adrenal InsufficiencyPublication . Pestana, Inês; Guimarães, Henrique; Saraiva, Alexandra; Veiga, Dalila; Machado, HumbertoCongenital adrenal hyperplasia (CAH) is a type of primary adrenal insufficiency (AI) that predisposes to adrenal crisis (AC) during stress. We describe a case of a primipara with CAH who was admitted in labor. To prevent AC, glucocorticoid replacement was given according to guidelines. Due to fetal decelerations, an emergency C-section was performed under general anesthesia following which refractory hypotension emerged. The diagnosis of AC was considered, and hydrocortisone was given with sustained hemodynamic improvement. AC is a life-threatening emergency whose diagnosis requires a high index of suspicion. Despite adequate steroid coverage, additional stressors may precipitate AC, so it is of paramount importance that anesthesiologists consider this emergency
- Ewing Sarcoma Developed at the Site of Previous Mast Cell ProliferationPublication . Ranchor, Ridhi; Magalhães, Manuel; Rosendo, Eugénia; Coelho, André; Cardoso, PedroKIT gene mutations in Ewing sarcomas are rare; however, they are much more frequent in other neoplasms, namely mastocytosis. We describe a case of an adult male with a one-year duration of recurrent episodes of pain, swelling, and redness on the proximal phalanx of the third finger of his right hand. A core biopsy suggested a possible mastocytosis. After four years of recurrent episodes and worsening symptoms, an incisional biopsy revealed an Ewing sarcoma with a KIT gene mutation (M541L, on exon 10). KIT gene mutations with gain-of-function were identified in 2.6% of Ewing sarcomas. In this case, the detection of a KIT mutation in an Ewing sarcoma developed at the site of previous mast cell proliferation raises the hypothesis of a possible sarcomatous evolution of the original lesion. To the best of our knowledge, similar cases are not described in the current literature. This is also the first report describing the KIT M541L mutation (exon 10) in Ewing sarcoma