D Malheiro

Centro Hospitalar de Lisboa Ocidental, Lisboa, Lisbon, Portugal

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Publications (12)40.15 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Tuberculosis Case Report PostersSESSION TYPE: Case Report PosterPRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PMINTRODUCTION: Tuberculosis (TB) treatment faces many challenges because of adverse drug reactions (ADR) that can result in significant morbidity, leading to the withdrawal of first-line medication and its substitution for a less effective and often more poorly tolerated second-line medication. This case report is about a patient with active TB sensitive to all first-line drugs but with severe ADRs to all of them, and to ethionamide. A case of ADRs to all first-line anti-TB drugs and to ethionamide is, to the best of our knowledge, not reported. This case is about a Caucasian female patient, 42-year-old, previously healthy. She was diagnosed with pleural/pulmonary tuberculosis. GenoType MTBDR® revealed rifampicin/isoniazid sensitivity and cultured mycobacteria were sensitive to first-line drugs (as well as to streptomycin). A first-line regimen was initiated. At day 13 of treatment, she presented with important ADRs (fever, generalized rash, and hepatotoxicity). Regimen was changed to isoniazid, pyrazinamide, ethambutol and moxifloxacin (clinical suspicion of rifampicin as the offending agent) with clinical improvement. At day 30 of treatment, new clinical presentation of ADRs (fever, generalized rash and severe hepatotoxicity) - all drugs were suspended and allergy investigation was performed (positive reactions to all first-line drugs and ethionamide's malaise/dizziness association). An alternative regimen had to be instituted composed by streptomycin, ofloxacin, cicloserine and para-aminosalicylic acid. The patient revealed a good clinical, imaging and microscopic evolution with a complete resolution and cure. The recommended first-line regimen for active TB is associated with significant ADRs, which can make the successful treatment in drug-sensitive disease a challenge. There are some risk factors related to a higher risk of ADRs - in this case, age over 35 and female sex. An important but still not evidence-based answered issue is what to do after a severe ADR: try re-introduction, try to identify the offending agent or advance to a less effective second-line regimen. There are some cases reported of ADRs to many first-line drugs, but there is no single case reported with ADRs to all first-line and ethionamide as well. The need for a completely alternative regimen to face the patient's ADR became a multisensitive TB case in a real clinical challenge, nevertheless with good outcome. Anti-TB ADRs can result in significant morbidity and lead to unsuccessful outcome. However, an alternative and less effective regimen can achieve cure, even if all first-line drugs cannot be used.Reference #1: Saukkonen JJ, et al. An official ATS statement: hepatotoxicity of antituberculosis therapy. AJRCCM. 2006;174(8). The following authors have nothing to disclose: João Cordeiro da Costa, Daniela Malheiro, Susana Cadinha, Raquel DuarteNo Product/Research Disclosure Information.
    Chest 03/2014; 145(3 Suppl):94A. · 7.13 Impact Factor
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    ABSTRACT: Clopidogrel is an antiplatelet drug widely used for treatment and prevention of a variety of cardiovascular diseases. We report a successful desensitization to clopidogrel in a 70-year-old Caucasian man with delayed hypersensitivity (HS) reaction. He developed lip, hand and foot swelling, erythematous papular non-pruritic lesions and arthralgias 2 weeks after starting treatment with clopidogrel 75 mg/d. A 3-hour desensitization protocol was started, achieving a cumulative dose of 154 mg without any reaction, and a daily dose of 75 mg was recommended. On the 4th day, the patient developed skin lesions similar to the previously described. He was treated with topical steroids and oral antihistamines, and the daily dose of clopidogrel was reduced to 20 mg. A new desensitization protocol was established, with a slow dose increment, according to the patient's response. It was only possible to achieve the dose of 75 mg/d after 2 months. Although well tolerated by most patients, HS reactions with clopidogrel may occur and desensitization is rising as a safe alternative in those patients. In delayed reactions with cutaneous lesions, a slower desensitization protocol may be necessary, as in this case.
    European annals of allergy and clinical immunology 01/2014; 46(1):53-5.
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    ABSTRACT: Drug-induced anaphylaxis is an unpredictable and potentially fatal adverse drug reaction. The aim of this study was to identify the causes of drug-induced anaphylaxis in Portugal. During a 4-year period a nationwide notification system for anaphylaxis was implemented, with voluntary reporting by allergists. Data on 313 patients with drug anaphylaxis were received and reviewed. Statistical analysis included distribution tests and multiple logistic regression analysis to investigate significance, regression coefficients, and marginal effects. The mean (SD) age of the patients was 43.8 (17.4) years, and 8.3% were younger than 18 years. The female to male ratio was 2:1.The main culprits were nonsteroidal anti-inflammatory drugs (NSAIDs) (47.9% of cases), antibiotics (35.5%), and anesthetic agents (6.1%). There was a predominance of mucocutaneous symptoms (92.2%), followed by respiratory symptoms (80.4%) and cardiovascular symptoms (49.0%). Patients with NSAID-induced anaphylaxis showed a tendency towards respiratory and mucocutaneous manifestations. We found no significant associations between age, sex, or atopy and type of drug. Anaphylaxis recurrence was observed in 25.6% of cases, and the risk was higher when NSAIDs were involved. NSAIDs were the most common cause of anaphylaxis in this study and were also associated with a higher rate of recurrence. We stress the need for better therapeutic management and prevention of recurring episodes of drug-induced anaphylaxis.
    Journal of investigational allergology & clinical immunology: official organ of the International Association of Asthmology (INTERASMA) and Sociedad Latinoamericana de Alergia e Inmunología 01/2014; 24(1):40-8. · 1.89 Impact Factor
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    ABSTRACT: Background: Anaphylaxis to drugs is an unpredictable and potentially fatal adverse drug reaction. The true prevalence in different population groups and the related risk factors are mostly unknown. Objective: To contribute to better understanding the epidemiology of drug-induced anaphylaxis in our country.Methods: During a 4 years period (January 2007 to December 2010) a national notification system for anaphylaxis was implemented, focused on voluntary reporting by physicians with allergy differentiation. In this period the data from 313 patients with drug anaphylaxis have been received and analysed. The statistical analysis included distribution tests and multiple logistic regression analysis to obtain the significance, the regression coefficients and marginal effects.Results: The mean age was 43.8 ± 17.4 years, 8% younger than 18 years old. The ratio female/male was 2/1. The mean age at first episode was 39 ± 18.2 years. Nine patients had more than one cause of drug anaphylaxis, corresponding to a total of 322 reports of different groups of drugs involved. The main culprit drugs were the non -steroidal anti-inflammatory drugs (NSAIDs), antibiotics and anesthetic agents in 48%, 36% and 6% of the cases respectively. Other drugs involved were cytostatics, corticosteroids, proton pump inhibitors and iodinated contrast media, among others. There was a predominance of mucocutaneous symptoms (92%), followed by respiratory (81%) and cardiovascular (49%) symptoms. Patients with NSAIDs anaphylaxis showed a tendency to have co-respiratory and mucocutaneous manifestations. We didn’t find a significant association between age, gender and atopy within the different groups of drugs. Reactions occurred in 53% of cases within 15 minutes after drug administration, 45% of the cases occurred in inpatients and in 35% hospitalization was needed. The recurrence of anaphylaxis was observed in 26% of cases, with an increased risk when NSAIDs were involved. Only 48% of patients were treated with epinephrine and in 9% of cases an epinephrine auto-injector was prescribed.Conclusions: In this study the most frequent culprit drugs were NSAIDs and they were associated with a higher rate of recurrence of anaphylaxis. We stress the under-treatment with epinephrine and the need to achieve a better therapeutic management and prevention of recurrence of anaphylaxis to drugs.
    Revista Portuguesa de Imunoalergologia 04/2012; 20(2):93-107.
  • Allergologia et Immunopathologia 01/2009; 37(1):50-1. · 1.23 Impact Factor
  • European Journal of Anaesthesiology 04/2007; 24(3):289-90. · 2.79 Impact Factor
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    ABSTRACT: Corticosteroids (CS) are widely used in the treatment of asthma, allergic disorders and other immunological diseases due to their anti-inflammatory and immunosuppressive properties. Physicians seldom suspect them of causing allergic reactions. However, more and more cases of hypersensitivity reactions to CS have been described. Reports of delayed allergic reactions to CS in patients with asthma or allergic rhinitis are scarce. We report the case of a 44-year-old woman with a history of mild persistent asthma and intermittent allergic rhinitis, treated with inhaled beclomethasone and salbutamol, who developed a delayed mucocutaneous and respiratory reaction after substitution of beclomethasone with budesonide. The interest of this case lies in the rarity of allergic reactions from inhaled CS in patients with asthma and/or rhinitis. These reactions therefore represent a diagnostic and therapeutic challenge.
    Allergologia et Immunopathologia 01/2005; 33(6):329-32. · 1.23 Impact Factor
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    ABSTRACT: Nimesulide is a cyclooxygenase (COX) inhibitor with a high degree of selectivity to COX-2. It is a widely used and well tolerated nonsteroidal antiinflammatory drug that also has analgesic and antipyretic properties. The most frequently reported side effects concern the gastrointestinal tract. Pruritus and skin rash are the most common cutaneous adverse reactions. There are only eight cases of fixed drug eruptions due to nimesulide, described in the literature. The authors report a case of a patient with a history of antihistamine hypersensitivity who developed a bullous form of pigmented fixed drug eruption after nimesulide ingestion. Patch tests performed on residual skin lesion were positive to nimesulide, confirming that this was the culprit drug. Fixed drug eruptions are common cutaneous drug reactions, often misdiagnosed. A detailed anamnesis and physical examination are the key to suspect this condition.
    Allergologia et Immunopathologia 01/2005; 33(5):285-7. · 1.23 Impact Factor
  • Allergy & Clinical Immunology International-journal of The World Allergy Organization - ALLERGY CLIN IMMUNOL INT. 01/2005; 17(02):48-52.
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    ABSTRACT: The asthma diagnosis is primarily based on clinical data, sometimes, however, objective measures are useful. We aimed to study the use of Exhaled Nitric Oxide (eNO) and spirometry before and after inhaled albuterol (PFT) in asthma screening of adult volunteers recruited through media announcements. Each individual also answered structured questionnaires including the LQ Test (ACAAI), a valid test for asthma screening and disease impact. Sixty one patients were analyzed, 38% were men, with mean(SD age of 46(16 years, nasal symptoms 79%; smokers 20%; LQ 10(5; eNO 34.6(41.3 ppb; FEV1 % predicted 102(16% e fev1/fvc 96(13%. The eNO measurement duration ranged between 2,3 and 11,6 minutes (median 4,8) and a total of 317 (165 valid) exhalations were performed (3-9 per individual; median -5).All ATS guideline measurement criteria were fulfilled for 48(79%) individuals for eNO and 39(64%) for PFT. When applying GINA PFT criteria for asthma diagnosis 45% of patients with LQ(13 were identified as asthmatics, and when using a cut-off of 20 ppb for eNO, 46% were identified. The use of eNO and PFT in asthma screening can be technically performed and useful, nevertheless are, at present, insufficient for diagnosis of asthma.
    Revista portuguesa de pneumologia 12/2003; 9(5 Suppl):47-8. · 0.56 Impact Factor
  • Journal of Allergy and Clinical Immunology 02/2003; 111(1). · 12.05 Impact Factor
  • Journal of Allergy and Clinical Immunology 02/2003; 111(1). · 12.05 Impact Factor