Ivo Barreiro’s research while affiliated with Hospital da Figueira da Foz and other places

A síndrome de DRESS (drug rash with eosinophlia and systemic symptoms) trata-se de uma reação de hipersensibilidade induzida por fármacos, rara, complexa e potencialmente fatal. Geralmente evolui com erupção cutânea, alterações hematológicas, linfadenopatia, com envolvimento de órgãos. Os autores apresentam o caso clínico de um homem caucasiano de 79 anos que deu entrada no serviço de urgência devido a uma queimadura no tórax e abdómen após férias e exposição solar sem proteção solar. A sua medicação habitual há 2 anos é: perindopril+amlodipina, sinvastatina e alopurinol. Apresentava também um eritema maculopapular pruriginoso no dorso e erupção eritematosa confluente nos membros inferiores, semelhantes a lesões purpúricas. Dados laboratoriais demonstraram linfopenia e elevação das enzimas hepáticas. De acordo com o score RegiSCAR, este caso classifica-se como provável síndrome de DRESS. O alopurinol foi suspenso imediatamente e foi iniciada prednisolona. Foi observado um mês depois, com melhoria progressiva das lesões. O diagnóstico da síndrome de DRESS é desafiante e deve-se suspeitar do seu diagnóstico num doente sob fármacos de alto risco com clínica característica. A abordagem inicial consiste no tratamento de suporte e na suspensão imediata do fármaco. No caso apresentado, o doente queixava-se de queimadura, mas apresentava uma toxidermia por alopurinol que se manifestou de forma bizarra.

Celiac disease is a relatively common autoimmune disease that affects the gut's ability to process gluten. It is frequently associated with other autoimmune diseases. In this article, the authors present a clinical case of a 65-year-old female patient with a history of celiac disease and autoimmune hypothyroidism. This patient was admitted to the emergency room with generalized edema and chronic diarrhea with mucus as well as reports of unusual weight loss. A requested fecal analysis tested positive for fecal calprotectin. An endoscopic study further displayed flattening of the intestinal villi. A subsequent biopsy expressed overlapping evidence for both celiac disease and lymphocytic colitis. This case illustrates how a diagnosis of microscopic colitis should be explored when celiac patients with a history of a stable gluten-free diet display a sudden onset of chronic diarrhea. As the symptoms associated with this disease can often become debilitating, an early diagnosis and treatment are crucial.

Lymphomas result from the proliferation of malignant lymphocytes, which can affect lymph nodes, blood, and other organs. Primary involvement of the spine by haematological diseases is rare. Non-Hodgkin's lymphoma with an extranodal location most frequently involves the gastrointestinal tract and airways, affecting the bone, muscle, and nervous system. We present a clinical case of an atypical form of non-Hodgkin's lymphoma. A 78-year-old woman was admitted to the hospital with complaints of pain in the lumbar region, hip, and left leg for the last month. Computed tomography of the lumbar spine revealed a mass of left paravertebral tissue with involvement from L3 to L5. Thoraco-abdominal CT-guided biopsy revealed diffuse large-cell non-Hodgkin B lymphoma. The remainder of the study did not show lymphatic involvement, so a diagnosis of primary extranodal large cell non-Hodgkin B lymphoma was made.

The COVID-19 pandemic is currently responsible for over 526 million infections and over 6.3 million deaths. As a new disease, the number of papers on the subject is extensive, motivating considerable heterogeneity in its approach. Despite some medicines having sound evidence of benefit, new interventions and strategies continue to be proposed, and some still lack scientific evidence, which hinders a uniform and consensual approach. This article aims to standardize healthcare to adult patients with moderate-to-critical COVID-19, from the emergency department to hospitalization, either in a general ward or in level 2 or level 3 intensive care units, based on the best and most updated scientific evidence available. This protocol presents recommendations for the stratification of adult patients with COVID-19 disease, adequate workup at admission and during hospitalization, inpatient treatment criteria, general treatment measures, pharmacological treatment, management of complications such as organizing pneumonia and bacterial superinfection, thromboprophylaxis, special considerations on pregnancy and breastfeeding and possible future therapies.

Cutaneous infections caused by the Mycobacterium chelonae complex show a heterogeneous clinical presentation, which varies according to the patient's immune status. Most standard antimycobacterials have no effect against these species. Clarithromycin alone was shown to provide adequate treatment, although resistance has been reported. Consequently, the literature supports multi-drug therapy to combat resistant strains. Here, we describe the case of a 59-year-old man under systemic immunosuppressive therapy who developed cutaneous lesions whose evolution was highly suggestive of atypical infection. Learning points: Mycobacterium chelonae is a ubiquitous species of mycobacteria found in the environment; cutaneous infections by the M. chelonae complex show a heterogeneous clinical presentation.The combination of linezolid and clarithromycin has been used in some cases, with rapid clinical resolution and less or no relapse observed after long-term follow-up.Internal Medicine is the appropriate speciality to treat particularly complex or multisystem diseases, such as infections in immunocompromised patients.

A doença de Madelung é uma condição rara, caracterizada pelo depósito maciço de gordura. Esta doença é conhecida como lipomatose simétrica múltipla ou benigna. Encontram-se descritos dois tipos de doença. No tipo 1, a gordura acumula-se no pescoço, ombros, membros superiores e tronco superior. No tipo 2, os lipomas distribuem-se por todo o corpo, incluindo nos membros inferiores. Os doentes geralmente referem algum desconforto, no entanto, em casos avançados, os lipomas podem causar sintomas como dispneia ou disfagia. Os autores apresentam o caso clínico de um doente do género masculino de 70 anos, referenciado para o Serviço de Urgência por dispneia com alguns meses de evolução, com agravamento nos últimos 6 dias, associada a tosse. Ao exame objetivo, destacava-se a presença de lipomas a nível da região cervical e torácica, com distribuição simétrica e circulação venosa colateral. Em angio-tomografia computorizada (TC) cervical e torácica, evidenciou-se a presença de proliferação da gordura cervical simétrica sugestiva de doença de Madelung, com compressão da veia jugular e braquiocefálica direita, assim como, formação de veias colaterais e consolidação peribrônquica dos lobos inferiores e médio com broncograma aéreo. Admitido no Serviço de Medicina para antibioterapia e oxigénio suplementar. Apresentou uma evolução clínica e analítica favoráveis, tendo alta ao quinto dia de hospitalização, orientado para consulta de Cirurgia. O caso apresentado corresponde a uma doença de Madelung tipo 1, em que o envolvimento mais profundo levou ao desenvolvimento de dispneia, agravado por intercorrência infeciosa. O diagnóstico desta patologia é baseado sobretudo na história clínica, exame objetivo (com a presença de múltiplos lipomas simétricos) e estudo imagiológico. A etiologia desta patologia permanece desconhecida. Atualmente, a cirurgia é o único tratamento disponível, apesar da elevada taxa de recorrência.

Os autores apresentam o caso de um doente, género masculino, 64 anos, que recorreu ao Serviço de Urgência por perda ponderal, astenia, anorexia e epigastralgias persistentes com cerca de 6 meses de evolução. Analiticamente, objetivou-se uma anemia microcítica com Hb 6,7 g/dL, com necessidade de suporte transfusional e em estudo imagiológico tomográfico, verificou-se a presença de lesão estenosante a nível gástrico, condicionando uma distensão marcada. Internado no Serviço de Medicina para suporte transfusional e nutricional e para estudo endoscópico. Submetido a cirurgia paliativa ao 28º dia de internamento. Desta forma, os autores apresentam uma imagem apelativa e rara em termos da dimensão da distensão gástrica decorrente de lesão estenosante a nível do antro gástrico em doente com carcinoma gástrico em estádio avançado. O carcinoma gástrico pode apresentar-se de modo assintomático em fases iniciais ou com sintomatologia como anorexia, disfagia, epigastralgias, perda ponderal ou vómitos em estádios mais avançados.

PurposeAn individualized approach should be taken regarding the use of novel oral anticoagulants (NOAC) in frail and older patients with atrial fibrillation (AF). We hypothesized that there would be a high proportion of underdosed patients among an older and frail population, where bleeding risk is higher.Methods We retrospectively analyzed patients admitted to an Internal Medicine ward with a previous diagnosis of AF and discharged with a NOAC (n = 327). We compared survival and incidence of dosing-related events (stroke, systemic embolism, and major bleeding) at 1-year between inappropriately underdosed patients (dose reduction without a formal indication) and the rest of the population.ResultsA total of 167 patients (51%) received a reduced dose despite lacking formal criteria for dose reduction. Before adjustment, underdosed patients, in comparison with non-underdosed patients, had a higher mortality at 1 year (HR = 1.6, 95% CI 1.2–2.1, p = 0.003) and a higher combined stroke, systemic embolism, and major bleeding event rate at 1-year (HR = 3.2, 95% CI 1.3–8.0, p = 0.015). After adjustment, combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients (HR 3.7, 95% CI 1.1–12.3, p = 0.030), but survival was not different in the adjusted model (HR 1.4, 95% CI 0.9–2.1, p = 0.110).Conclusions Underdosed patients have a significant survival disadvantage and this may be due to clinician prescription bias, since this difference does not remain after adjusting for confounders. Combined stroke, systemic embolism, and major bleeding event rate was higher in underdosed patients.

Background An individualized approach should be taken regarding the utilization of direct oral anticoagulants (DOAC) in frail and elderly populations with atrial fibrillation (AF). We hypothesized that among an elderly and frail population, where the risk of bleeding, both real and perceived, is very high, the proportion of patients with a dose regimen different from the formal indication would be particularly high due to potential underdosing. Methods We conducted a retrospective, observational study enrolling 327 patients with AF admitted to an Internal Medicine ward during a 1-year period and discharged with a DOAC prescription. We divided the population in 2 groups: patients prescribed a reduced dose without formal dose reduction criteria (underdosed, n=170) and the rest of the population (n=157), which included adequately dosed patients, both with normal dose (n=99) and correctly reduced dose (n=43) and overdosed patients (n=15). A 1-year follow-up was completed for all patients, assessing the following outcomes: all-cause mortality, stroke, systemic embolism and major bleeding. Results Patients were elderly (81.9±7.68) and frail (Katz index 3.35±2.36). Apixaban was the most commonly prescribed NOAC (38.8%), followed by rivaroxaban (36.4%) and dabigatran (24.8%). Among underdosed patients, apixaban was prescribed in 45.3% of patients, dabigatran in 29.4% and rivaroxaban 25.3%. Although only 18.3% of patients had clinical criteria for dose reduction, 65.4% were discharged with reduced dose and thus 52% were underdosed. Regarding 1-year outcomes, mortality (40.8% vs 25.5%, RR=1.6, p=0.003) and the combined stroke, systemic embolism and major bleeding event rate (10.1% vs 3.2%, RR=3.16, p=0.015) were higher for underdosed patients. Among underdosed patients, comparing with the rest of the population, the increased ischemic events rate (ischemic stroke and systemic embolism) did not reached statistical significance (3.7% vs. 1.9%, p=0.5), but it did for hemorrhagic events (major bleeding and hemorrhagic stroke) (6.1% vs 0.6%, p=0.01) On multivariate analysis, even after considering adjustment for age, Katz and CHAD2VAS2C scores, renal function and DOAC prescribed, DOAC underdosing was associated with a higher risk of both ischemic and hemorrhagic events (HR = 3.51, 95% CI 1.08–11.38). However, it lost its independent negative effect regarding mortality (HR 1.32, 95% CI 0.87–1.99). Survival and event rate in underdosed Conclusions There is a significant proportion of frail and elderly patients with AF that are underdosed. This subset has a significant survival disadvantage, eventually reflecting prescription bias. However, underdosed patients have also a higher event rate of both ischemic and hemorrhagic events, suggesting that underdosing fragile patients is not an effective strategy and that instead it may be hazardous.