RESUMO
Introducción: El sarcoma de Ewing es un tumor maligno de alto grado con localización principalmente ósea; se han reportado aproximadamente 12% con presentación extra-esquelética. Actualmente, existen alrededor de 20 casos descritos en la literatura con origen mediastinal y 10 casos con origen pulmonar. Caso clínico: Se presenta el caso de una mujer de 25 años con un mes de disnea y dolor torácico, con el hallazgo de derrame pleural masivo y tumoración mediastinal en hemitórax derecho. Se le realiza toracotomía anterior bilateral con esternotomía transversa de Clamshell, con resección parcial que demuestra, por patología, sarcoma monomórfico de alto grado e inmunohistoquímica concluyente de sarcoma de Ewing. Conclusión: Este caso es una entidad rara y conlleva un reto diagnóstico para el clínico; sin embargo, debe sospecharse considerando la presentación clínica y radiológica del paciente, buscando incrementar la tasa de supervivencia mediante el diagnóstico y tratamiento oportuno.
Introduction: Ewing's sarcoma is a high-grade malignant tumor with mainly bony lo-calization; approximately 12% have been reported with extraskeletal presentation. Currently, there are about 20 cases described in the literature with mediastinal origin and 10 pulmonary cases. Case Report: We present the case of a 25-year-old woman with one month of dysp-nea and chest pain, with massive pleural effusion and mediastinal tumor in the right hemithorax who underwent bilateral anterior thoracotomy with Clamshell transverse sternotomy, with partial resection demonstrating, by pathology, high-grade monomorphic sarcoma and conclusive immunohistochemistry of Ewing's sarcoma. Conclusion: This case is a rare entity and involves a diagnostic challenge for the clinician; however, it should be suspected considering the clinical and radiological presentation of the patient, seeking to increase the survival rate through timely diagnosis and treatment.
Assuntos
Humanos , Feminino , Adulto , Sarcoma de Ewing/diagnóstico , Neoplasias Ósseas , Neoplasias do Mediastino/cirurgia , Derrame Pleural , Biópsia , Dor no Peito , Síndrome da Veia Cava Superior , Diagnóstico por Imagem , Toracotomia , Biomarcadores Tumorais , Agroquímicos , Dispneia , Esternotomia , LinfadenopatiaRESUMO
INTRODUÇÃO: A agenesia do pericárdio é uma patologia rara, com prevalência de 1:14.000 casos pela literatura. Seu diagnóstico é habitualmente incidental, visto que a maioria dos casos são assintomáticos. Pode ocorrer de forma total ou parcial, sendo três vezes mais prevalente entre indivíduos do sexo masculino. DESCRIÇÃO DO CASO: Paciente do sexo feminino, 28 anos de idade com história de derrame pleural à esquerda recorrente desde 2012 associada a dor ventilatório-dependente em hemitórax esquerdo. Ao exame físico apresentava desvio de ictus para linha axilar posterior, sem outros achados. Eletrocardiograma com desvio extremo do eixo para a direita e distúrbio de condução pelo ramo direito, Holter 24h com ausência de ectopias ou pausas, Ecocardiograma com desvio extremo do ápice cardíaco (ambos os ventrículos) para região axilar posterior e hipermobilidade cardíaca durante o exame, além de Ressonância Magnética Cardíaca evidenciando levoposição excessiva do coração, hipermobilidade ventricular e interposição de parênquima pulmonar entre o tronco pulmonar e a aorta ascendente, todos achados sugestivos de agenesia de pericárdio. DISCUSSÃO: A agenesia de pericárdio, embora frequentemente assintomática, pode manifestar-se com sintomas variados como dor torácica, dispneia, tonturas ou síncope, decorrentes de um defeito congênito no desenvolvimento da membrana pleuropericárdica esquerda. Em casos de defeitos parciais, onde os sintomas são mais prevalentes, pode ocorrer herniação e encarceramento do apêndice atrial esquerdo ou do ventrículo esquerdo, situações que demandam reparo cirúrgico urgente utilizando materiais sintéticos ou pericárdio bovino. No caso relatado, os achados de desvio extremo do ápice cardíaco e interposição de parênquima pulmonar entre o tronco pulmonar e a aorta ascendente indicam agenesia total. A decisão contra a intervenção cirúrgica foi baseada na ausência de risco iminente de morte súbita, sublinhando a importância de uma avaliação criteriosa dos riscos versus benefícios da cirurgia em casos de agenesia completa.
Assuntos
Humanos , Feminino , Adulto , Pericárdio/anormalidades , Derrame Pleural , EcocardiografiaRESUMO
OBJECTIVE: Pleural effusion is a common medical problem. It is important to decide whether the pleural fluid is a transudate or an exudate. This study aims to measure the attenuation values of pleural effusions on thorax computed tomography and to investigate the efficacy of this measurement in the diagnostic separation of transudates and exudates. MATERIALS AND METHODS: 380 cases who underwent thoracentesis and thorax computed tomography with pleural effusion were classified as exudates or transudates based on Light's criteria. Attenuation measurements in Hounsfield units were performed through the examination of thorax computed tomography images. RESULTS: 380 patients were enrolled (39 % women), the mean age was 69.9 ± 15.2 years. 125 (33 %) were transudates whereas 255 (67 %) were exudates. The attenuation values of exudates were significantly higher than transudates (15.1 ± 5.1 and 5.0 ± 3.4) (p < 0.001). When the attenuation cut-off was set at ≥ 10 HU, exudates were differentiated from transudates at high efficiency (sensitivity is 89.7 %, specificity is 94.4 %, PPV is 97 %, NPV is 81.9 %). When the cut-off value was accepted as < 6 HU, transudates were differentiated from exudates with 97.2 % specificity. CONCLUSION: The attenuation measurements of pleural fluids can be considered as an efficacious way of differentiating exudative and transudative pleural effusions.
Assuntos
Exsudatos e Transudatos , Derrame Pleural , Sensibilidade e Especificidade , Tomografia Computadorizada por Raios X , Humanos , Feminino , Derrame Pleural/diagnóstico por imagem , Masculino , Exsudatos e Transudatos/diagnóstico por imagem , Idoso , Diagnóstico Diferencial , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X/métodos , Idoso de 80 Anos ou mais , Toracentese/métodos , Reprodutibilidade dos Testes , Valores de Referência , AdultoRESUMO
Introducción: El biliotórax es una condición infrecuente definida por la presencia de bilis en el espacio pleural. Actualmente, hay alrededor de 70 casos descritos en la litera-tura. Sigue siendo relativamente desconocido, por lo tanto, poco sospechado. Esta entidad suele ser el resultado de una lesión iatrogénica, a menudo secundaria a cirugías o traumatismos del tracto biliar, que conduce a la formación de una fístula pleurobiliar.
Introduction: Bilothorax is a rare condition defined by the presence of bile in the pleural space. Currently, there are around 70 cases described in the literature. It remains relatively unknown and, therefore, little suspected. This entity is usually the result of an iatrogenic injury, often secondary to surgery or trauma to the biliary tract, leading to the formation of a pleurobiliary fistula
Assuntos
Humanos , Masculino , Idoso , Derrame Pleural/complicações , Bile , Empiema Pleural/tratamento farmacológico , Neoplasias Hepáticas/diagnóstico , Neoplasias Pulmonares/diagnóstico , Procedimentos Cirúrgicos Operatórios , Sistema Biliar , Biópsia , Tomografia , Cavidade Pleural , Metástase Neoplásica/diagnósticoRESUMO
The pulmonary manifestations of Systemic Lupus Erythematosus (SLE) in pediatric patients are poorly understood and the pulmonary manifestations reported from the adult population are generally extrapolated to the pediatric population. In the present work, the review of 228 files was carried out, in which the pulmonary manifestations, symptoms and antibody levels of the patients treated at the Hospital Regional de Alta Especialidad de Ixtapaluca (HRAEI), State of Mexico, Mexico, were identified. Statistical significance between groups was estimated using the Chi-square and Mann-Whitney U test. The main pulmonary manifestations identified were pleurisy (14 %), pulmonary hemorrhage (3.9 %), pulmonary thromboembolism (0.9 %), acute lupus pneumonitis (0.4 %), pulmonary arterial hypertension (0.4 %), and small lung syndrome (0.4 %). While the initial symptomatology was dyspnea with an incidence of 9.6 %, the mean oxygen saturation in the population was 96.87 %. Pleural effusion was identified as the most frequent pulmonary manifestation in radiographic changes. No statistically significant difference was found in antibody levels when comparing the groups. The most common pulmonary manifestation associated with SLE is pleurisy, however, the range of pulmonary manifestations in this type of patient can be very varied, as well as the presentation of each of them.
Assuntos
Pneumopatias , Lúpus Eritematoso Sistêmico , Derrame Pleural , Pleurisia , Adulto , Humanos , Criança , Lúpus Eritematoso Sistêmico/complicações , Lúpus Eritematoso Sistêmico/epidemiologia , Pneumopatias/diagnóstico por imagem , Pneumopatias/epidemiologia , Pneumopatias/etiologia , Pulmão/diagnóstico por imagem , Pleurisia/etiologia , Pleurisia/complicações , Derrame Pleural/diagnóstico por imagem , Derrame Pleural/epidemiologia , Derrame Pleural/etiologiaRESUMO
OBJECTIVE: In complicated parapneumonic effusion or Empyema, approximately 25% of patients require surgical intervention which can be associated with a mortality risk of almost 20%. However, the use combination of rt-tPA and DNase in elderly patients with prohibitive surgical risk has improved outcomes. The main goal of our study is to highlight the utility of intrapleural thrombolysis in patients with prohibitive risk for surgery. METHODS: A retrospective record review study of patients (n=23) with complicated parapneumonic pleural effusion or empyema treated with tPA and DNase from January 1st of 2015 to March 18th, 2019 at VACHCS. Data collected to describe the outcome of intrapleural thrombolytics included demographic, pleural fluid analysis, surgical risk assessment, diagnosis and initiation treatment day, doses, chest imaging, drainage rate, chest tube size and average days in place, inflammatory markers, microbiology, antibiotics, and complications. RESULTS: Only 21.7% of patients were considered surgical candidates. Seventy-four percent had a 30-day post-surgical mortality risk of > 2.5% using the National Surgery Office (NSO) risk calculator. Post-operative inpatient stay was 99.7% and estimated post operative ICU stay average was >80%. Primary outcome (pleural drainage improvement) obtained in 73.9%. Most common serious complications included sepsis (52.2%) and nonserious was residual hydropneumothorax (47.8%). CONCLUSION: This study demonstrates that administration of intrapleural thrombolytics through a percutaneous pleural catheter achieved successful drainage safely and without the need for surgical interventions in a selected group of advanced age, elderly patients with pleural infections who were deemed to be high surgical risk.
Assuntos
Empiema , Derrame Pleural , Idoso , Humanos , Estudos Retrospectivos , Derrame Pleural/etiologia , Derrame Pleural/terapia , Fibrinolíticos , DesoxirribonucleasesRESUMO
BACKGROUND Pseudochylothorax is a rare entity, with only a few hundred case reports worldwide. It presents as a pleural effusion rich in lipids, typically with a cloudy, milky appearance. The diagnosis is made based on the levels of cholesterol and triglycerides in the pleural fluid. CASE REPORT This is the case report of a 55-year-old woman with a history of pleuropulmonary tuberculosis that was treated in childhood, with a new infection and treatment in adulthood that evolved to a left pleural effusion. Thirteen years after completing her last treatment for tuberculosis, the patient developed general fatigue and dyspnea on exertion. Computed tomography of the chest confirmed the presence of a pleural collection in the same location as in adolescence, suggesting a chronic evolution with encystation. The patient underwent ultrasound-guided diagnostic thoracentesis. The collected liquid was thick, chocolate-colored, with the following biochemical characteristics: pH, 7.3; glucose, 37.9 mg/dL; LDL, 2059.8 IU/L; total protein, 8.8 mg/dL; triglycerides, 90 mg/dL; adenosine deaminase, 56 U/L; and cholesterol, 300 mg/dL. The effusion was characterized as a pseudochylothorax. The cell count showed 631 000 leukocytes/µL, with 87.9% polymorphonuclear cells. Owing to the patient's respiratory symptoms, an evacuatory thoracentesis was performed. After the procedure, the patient's symptoms improved. CONCLUSIONS Although pseudochylothorax is a rare condition, its possibility must always be kept in mind to avoid the hazards of misdiagnosis. In addition to the 'classic' milky and machine oil appearance, a chocolate-colored appearance should also serve as a clue to the diagnosis of pseudochylothorax.
Assuntos
Chocolate , Derrame Pleural , Adolescente , Feminino , Humanos , Pessoa de Meia-Idade , Derrame Pleural/etiologia , Pleura , Exsudatos e Transudatos , DispneiaRESUMO
The coinfections by some microorganisms have been related to severe diseases in humans and animals, where immunosuppressive agents favor opportunistic behavior of other pathogens. A 4-month-old, female mixed-breed dog with a two-week history of inappetence, prostration, emaciation, and respiratory distress was admitted at a veterinary hospital in Brazil. Tachycardia, pale mucous membranes, severe respiratory distress, and a large number of ticks (Rhipicephalus sanguineus s.l.) in different body regions were observed at clinical examination. Hematological examination of dog showed leukocytosis, neutrophilia, mild anemia, and thrombocytopenia, whereas unremarkable values in biochemical tests. Thoracic radiography revealed a pleural effusion image. Blood and the pleural fluid (purulent aspect) samples were subjected to qPCR (16S rRNA and dsb genes) and sequencing, which identified Ehrlichia canis and Anaplasma platys coinfection. An aggregate of coccoid-to-branching or long filamentous microorganisms, surrounded by pyogranulomatous inflammatory reaction was seen at the cytology of the pleural fluid. Bacteriological culture of pleural effusion showed colonies compatible with the genus Nocardia, which revealed gram-positive filamentous organisms with a tendency of fragmentation and were identified as Nocardia otitidiscaviarum in mass spectrometry (MALDI-TOF MS). Therapy of N. otitidiscaviarum isolate using levofloxacin (supported by a previous in vitro susceptibility testing) and doxycycline for E. canis and A. platys resulted in complete resolution of the clinical picture. Here, we report for the first time a triple coinfection by Nocardia otitidiscaviarum, A. platys, and E. canis in a dog with pleural effusion, where debilitating or immunosuppressive conditions induced by A. platys and E. canis coinfection probably contributed to the opportunistic behavior of N. otitidiscaviarum.