RESUMO
CONTEXT: In order to report the outcome of a patient who developed compartment syndrome after South American rattlesnake (Crotalus durissus terrificus) envenomation, confirmed by subfascial pressure measurement and magnetic resonance imaging (MRI). CASE DETAILS: A 63-year-old male was admitted 1 h after being bitten on the right elbow by a "large" snake, which was not brought for identification. Physical and laboratory features upon admission revealed two fang marks, local tense swelling, paresthesia, intense local pain, hypertension, coagulopathy, and CK = 1530 U/L (RV < 170 U/L). The case was initially treated with bothropic antivenom (80 mL, intravenously), with no improvement. Evolution within 13-14 h post-bite revealed generalized myalgia, muscle weakness, palpebral ptosis, and severe rhabdomyolysis (CK = 126,160 U/L) compatible with envenoming by C. d. terrificus. The patient was then treated with crotalic antivenom (200 mL, intravenously), fluid replacement, and urine alkalinization. Twenty-four-hour post-bite MRI showed marked muscular edema in the anterior compartment of the right forearm, with a high subfascial pressure (40 mmHg) being detected 1 h later. ELISA of a blood sample obtained upon admission, before antivenom infusion, revealed a high serum concentration of C. d. terrificus venom. No fasciotomy was performed and the patient was discharged seven days later without sequelae. CONCLUSION: Snakebite by C. d. terrificus with subfascial venom injection may lead to increased intracompartmental pressure.
Assuntos
Síndromes Compartimentais/etiologia , Mordeduras de Serpentes/complicações , Animais , Antivenenos/uso terapêutico , Síndromes Compartimentais/diagnóstico , Venenos de Crotalídeos/antagonistas & inibidores , Crotalus , Antebraço/irrigação sanguínea , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mordeduras de Serpentes/tratamento farmacológicoRESUMO
CONTEXT: Rattlesnake bites in Brazil are generally caused by adult individuals, with most of the envenomed patients showing systemic manifestations that include varying degrees of neurotoxicity (acute myasthenia), rhabdomyolysis and coagulopathy, with only mild or no local manifestations. We report a case of envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus) that involved coagulopathy as the main systemic manifestation. CASE DETAILS: A 19-year-old male was admitted to our Emergency Department with coagulopathy (incoagulable PT, APTT and INR), no remarkable local manifestations and no signs/symptoms of myasthenia or rhabdomyolysis (serum CK, LDH, ALT and AST within reference levels) 5 days after being bitten by a small snake that was described as a rattlesnake but was not brought for identification at admission. The patient had already been treated in another Emergency Department with i.v. bothropic antivenom (AV) 1 h and 4 days post-bite. Based on the possibility of an unusual rattlesnake bite, crotalic AV was administered i.v., which improved the coagulation (9 h post-CroAV, INR = 2.11; 36 h post-CroAV, INR = 1.42). During hospitalization, relatives brought the snake that caused the bite, which was identified as a 38-cm long C. d. terrificus. DISCUSSION: Little is known about the clinical manifestations after bites by juvenile C. d. terrificus. This case shows that systemic envenoming by juvenile C. d. terrificus may result in coagulopathy as the main systemic manifestation, without neuromyotoxic features normally associated with bites by adult specimens. Despite the delayed administration, crotalic AV was effective in improving the blood coagulation.
Assuntos
Transtornos da Coagulação Sanguínea/etiologia , Mordeduras de Serpentes/complicações , Animais , Antivenenos/uso terapêutico , Brasil , Venenos de Crotalídeos/efeitos adversos , Venenos de Crotalídeos/antagonistas & inibidores , Crotalus , Humanos , Masculino , Mordeduras de Serpentes/terapia , Adulto JovemRESUMO
The purpose of this paper is to present a review of data on assessment of exposure and adverse effects due to environmental and occupational lead exposure in Brazil. Epidemiological investigations on children lead exposure around industrial and mining areas have shown that lead contamination is an actual source of concern. Lead in gasoline has been phasing out since the 1980s, and it is now completely discontinued. The last lead mining and lead refining plant was closed in 1995, leaving residual environmental lead contamination which has recently been investigated using a multidisciplinary approach. Moreover, there are hundreds of small battery recycling plants and secondary smelting facilities all over the country, which produce focal urban areas of lead contamination. Current regulatory limits for workplace lead exposure have shown to be inadequate as safety limits according to a few studies carried out lately.
Assuntos
Exposição Ambiental/análise , Monitoramento Ambiental , Poluentes Ambientais/análise , Chumbo/análise , Carga Corporal (Radioterapia) , Brasil , Exposição Ambiental/efeitos adversos , Poluentes Ambientais/sangue , Poluentes Ambientais/toxicidade , Gasolina/análise , Humanos , Chumbo/sangue , Chumbo/toxicidade , Exposição Ocupacional/efeitos adversos , Exposição Ocupacional/análise , Sintase do Porfobilinogênio/metabolismoAssuntos
Intoxicação por Arsênico/patologia , Intoxicação por Arsênico/psicologia , Arsenicais , Doença Hepática Induzida por Substâncias e Drogas/patologia , Perda Auditiva Neurossensorial/induzido quimicamente , Síndromes Neurotóxicas/patologia , Síndromes Neurotóxicas/psicologia , Adulto , Antídotos/uso terapêutico , Arsênio/urina , Audiometria , Bilirrubina/metabolismo , Doença Hepática Induzida por Substâncias e Drogas/enzimologia , Potenciais Evocados Auditivos do Tronco Encefálico/efeitos dos fármacos , Perda Auditiva Neurossensorial/diagnóstico , Hemodinâmica/efeitos dos fármacos , Humanos , Fígado/enzimologia , Testes de Função Hepática , Masculino , Tentativa de SuicídioRESUMO
The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54 percent) were diagnosed as having VAP and 17 (46 percent) as not having the condition. Quantitative culture of BAL effluent showed 90 percent sensitivity (18/20), 94.1 percent specificity (16/17), 94.7 percent positive predictive value and 88.8 percent negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1 percent of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1 percent (16/17), and a cut-off point of 50 percent of BAL neutrophils showed a sensitivity of 90 percent (19/20). In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP
Assuntos
Humanos , Masculino , Adulto , Feminino , Lavagem Broncoalveolar/normas , Infecção Hospitalar/patologia , Pulmão/microbiologia , Pneumonia Bacteriana/patologia , Respiração Artificial/efeitos adversos , Biópsia/métodos , Líquido da Lavagem Broncoalveolar/citologia , Líquido da Lavagem Broncoalveolar/microbiologia , Broncoscopia , Infecção Hospitalar/microbiologia , Pulmão/patologia , Pneumonia Bacteriana/microbiologia , Valor Preditivo dos Testes , Sensibilidade e EspecificidadeRESUMO
The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54%) were diagnosed as having VAP and 17 (46%) as not having the condition. Quantitative culture of BAL effluent showed 90% sensitivity (18/20), 94.1% specificity (16/17), 94.7% positive predictive value and 88.8% negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1% of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1% (16/17), and a cut-off point of 50% of BAL neutrophils showed a sensitivity of 90% (19/20). In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP.
Assuntos
Lavagem Broncoalveolar/normas , Infecção Hospitalar/patologia , Pulmão/microbiologia , Pneumonia Bacteriana/patologia , Respiração Artificial/efeitos adversos , Adulto , Biópsia/métodos , Líquido da Lavagem Broncoalveolar/citologia , Líquido da Lavagem Broncoalveolar/microbiologia , Broncoscopia , Infecção Hospitalar/microbiologia , Feminino , Humanos , Pulmão/patologia , Masculino , Pneumonia Bacteriana/microbiologia , Valor Preditivo dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Mercury poisoning presents a variety of clinical pictures depending on chemical structure, amount absorbed, total mercury burden, and individual factors. Distant skin lesions, after subcutaneous injection of metallic mercury, have not been previously described. CASE REPORT: We present a homicidal, subcutaneous injection of mercury resulting in widespread skin lesions, remote from the radiologically visible mercury. The lesions appeared at 40 days and began to clear at 6 months after the injection.
Assuntos
Intoxicação do Sistema Nervoso por Mercúrio/complicações , Intoxicação do Sistema Nervoso por Mercúrio/diagnóstico , Dermatopatias/induzido quimicamente , Adulto , Fibrose/induzido quimicamente , Fibrose/patologia , Fibrose/cirurgia , Antebraço/diagnóstico por imagem , Reação a Corpo Estranho/etiologia , Reação a Corpo Estranho/patologia , Mãos/diagnóstico por imagem , Humanos , Injeções Subcutâneas , Masculino , Mercúrio/administração & dosagem , Mercúrio/sangue , Mercúrio/urina , Intoxicação do Sistema Nervoso por Mercúrio/terapia , Radiografia , Dermatopatias/diagnóstico , Dermatopatias/terapia , Espectrofotometria Atômica , Resultado do TratamentoRESUMO
CONTEXT: Despite the absence of symptoms in the majority of patients carrying lead bullet fragments in their bodies, there needs to be an awareness of the possible signs and symptoms of lead intoxication when bullets are lodged in large joints like knees, hips and shoulders. Such patients merit closer follow-up, and even surgical procedure for removing the fragments. OBJECTIVE: To describe a patient who developed clinical lead intoxication several years after a gunshot wound. DESIGN: Case report. CASE REPORT: A single white 23-year-old male, regular job as a bricklayer, with a history of chronic alcohol abuse, showed up at the emergency department complaining of abdominal pain with colic, weakness, vomiting and diarrhea with black feces. All the symptoms had a duration of two to three weeks, and had been recurrent for the last two years, with calming during interval periods of two to three weeks. Abdominal radiograms showed a bullet lodged in the left hip, with a neat bursogram of the whole synovial capsule. A course of chelating treatment using calcium versenate (EDTACaNa2) intravenously was started. After the chelation therapy the patient had recurrence of his symptoms and a radical solution for the chronic mobilization of lead was considered. A hip arthroplasty procedure was performed, leading to complete substitution of the left hip.
Assuntos
Cabeça do Fêmur/lesões , Intoxicação por Chumbo/etiologia , Ferimentos por Arma de Fogo/complicações , Adulto , Artroplastia de Quadril , Quelantes/uso terapêutico , Ácido Edético/uso terapêutico , Humanos , Intoxicação por Chumbo/tratamento farmacológico , Masculino , Ferimentos por Arma de Fogo/tratamento farmacológico , Ferimentos por Arma de Fogo/cirurgiaRESUMO
From January, 1984 to December, 1996, 422 patients (ages 9 m-99 y, median 29 y) were admitted after being bitten by spiders which were brought and identified as Phoneutria spp. Most of the bites occurred at March and April months (29.2%), in the houses (54.5%), during the day (76.5%), and in the limbs (feet 40.9%, hands 34.3%). Upon hospital admission, most patients presented only local complaints, mainly pain (92.1%) and edema (33.1%) and were classified as presenting mild (89.8%), moderate (8.5%) and severe (0.5%) envenomation. Few patients (1.2%) did not present signs of envenomation. Severe accidents were only confirmed in two children (9 m, 3 y). Both developed acute pulmonary edema, and the older died 9 h after the accident. Patients more than 70 year-old had a significantly greater (p<0.05) frequency of moderate envenomations compared to the 10-70-year-old individuals. Proceedings to relief local pain were frequently performed (local anesthesia alone 32.0%, local anesthesia plus analgesics 20.6% and oral analgesics alone 25. 1%). Only 2.3% of the patients (two cases classified as severe and eight as moderate, eight of them in children) were treated with i.v. antiarachnid antivenom. No antivenom early reaction was observed. In conclusion, accidents involving the genus Phoneutria are common in the region of Campinas, with the highest risk groups being children under 10 years of age and adults over 70 years of age. Cases of serious envenomation are rare (0.5%).
Assuntos
Picada de Aranha/epidemiologia , Aranhas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Brasil/epidemiologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Picada de Aranha/complicações , Picada de Aranha/tratamento farmacológicoRESUMO
We have investigated the presence of micronuclei in mercury exposed workers. The study group consisted of 15 workers from a mercury-producing plant, mean age 39.5 years and a mean exposed period of 12 years. At the time of testing and for the six previous months, the exposed population had urinary mercury levels below the currently accepted limit of 50 ug/g creatinine. A significant increase in the percentage of micronuclei was observed in the mercury exposed individuals when compared to the non exposed group. We have not found any correlation between the percentage of micronuclei and age, length of exposure or urinary mercury concentrations. Our results suggest a genotoxic effect of mercury, which is observed in workers exposed chronically to levels considered biologically safe for the exposed population.