Browsing by Author "Sousa, J"
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- Acute Bivalvular Left-Sided Methicillin-Resistant Staphylococcus Aureus Endocarditis with Cardiac, Cerebral, Renal and Septic ComplicationsPublication . Póvoas, D; Figueiredo, M; Murinello, A; Damásio, H; Ramos, A; Rodrigues, N; Sousa, J; Carvalho, F; Peres, H; Gomes, PInfective endocarditis (IE) is now rare in developed countries, but its prevalence is higher in elderly patients with prosthetic valves, diabetes, renal impairment, or heart failure. An increase in health-care associated IE (HCAIE) has been observed due to invasive maneuvers (30% of cases). Methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcus are the most common agents in HCAIE, causing high mortality and morbidity. We review complications of IE and its therapy, based on a patient with acute bivalvular left-sided MRSA IE and a prosthetic aortic valve, aggravated by congestive heart failure, stroke, acute immune complex glomerulonephritis, Candida parapsilosis fungémia and death probably due to Serratia marcescens sepsis. The HCAIE was assumed to be related to three temporally associated in-hospital interventions considered as possible initial etiological mechanisms: overcrowding in the hospital environment,iv quinolone therapy and red blood cell transfusion. Later in the clinical course,C. parapsilosis and S. marcescens septicemia were considered to be possible secondary etiological mechanisms of HCAIE.
- Blunt Trauma and Right Diaphragmatic Rupture: Unveiling the ImpactPublication . Alves, D; Sousa, J; Eurico Reis, J; Ribeiro, R; Calvinho, PTraumatic diaphragmatic ruptures are rare, yet blunt injuries tend to be more easily overlooked compared to penetrating trauma. The minimal evidence of external injuries makes a high index of suspicion key for diagnosis. We report the case of a right-sided thoracoabdominal blunt trauma that resulted in a diaphragmatic rupture and fractured rib. Although often approached through a midline laparotomy, a definitive right thoracotomy repair was exceptionally performed since the adjacent peritoneum remained uninjured.
- Henoch-Schönlein Purpura Associated with Pulmonary AdenocarcinomaPublication . Azevedo, A; Fernandes, V; Navarro, D; Ferreira, AC; Sousa, J; Viana, H; Carvalho, F; Nolasco, FIntroduction: The Henoch-Schönlein purpura (HSP) is an immunoglobulin A (IgA)-mediated smallvessel systemic vasculitis, rare in adults. The association with solid tumours has been described, especially with lung cancer. Case Report: We present the case of a 60-year-old Caucasian male, diagnosed with lung adenocarcinoma that underwent surgical resection without (neo)adjuvant theraphy. Two months latter he was admitted for abdominal pain, purpuric rash on his lower extremities and acute kidney injury, with serum creatinine (Scr) of 2 mg/dl. Urinalysis revealed haematuria and 24h proteinuria (P24h) of 1.5 g. The serum protein electrophoresis, complement components C3 and C4, circulating immune complexes, cryoglobulins, ANCA, ANA, anti-dsDNA and the remaining immunologic study as screening for viral infections (HCV, HBV and HIV) were negative. Renal ultrasound was normal and kidney biopsy revealed mild mesangial proliferation; 2 cellular glomerular crescents and 1 fibrinoid necrosis lesion; large amounts of red blood cell casts; lymphocytic infiltration in the intertubular interstitial capillaries; moderate arteriolar hyalinosis. Immunofluorescence demonstrated mesangial and parietal deposits of IgA. The diagnosis of HSP was assumed, and the patient started prednisolone 1 mg/kg/day. Ten months after diagnosis the patient’s baseline Scr is 1.4 mg/dl with P24h of 0.18g, without haematuria. Conclusion: Although this is a rare association and the exact mechanism behind the disease is yet unknown, physicians should be aware of it. The early recognition and treatment may prevent renal disease progression.
- HIV-Associated Facial Lipodystrophy: Experience of a Tertiary Referral Center With Fat and Dermis-Fat Compound Graft TransferPublication . Martins de Carvalho, F; Casal, D; Bexiga, J; Sousa, J; Martins, J; Teófilo, E; Maltez, F; Germano, I; Videira e Castro, JObjectives: HIV-associated lipodystrophy is a common comorbidity in HIV-infected patients, having a profound impact on every aspect of patients' lives, particularly when involving the face. Hence, it is of the utmost importance to evaluate the result of any potential therapies that may help solve HIV-associated facial lipodystrophy. The aim of this article was to evaluate the outcome of patients undergoing facial lipodystrophy correction surgery within our institution. Methods: A retrospective analysis of the clinical charts and iconographic information of patients regarding demographics, morphologic changes, surgical option, postoperative complications, results, and patient satisfaction assessed by a 1- to 10-point scale and by the Assessment of Body Change and Distress questionnaire. Results: Twenty-three patients were operated on from March 2011 to April 2015. Seventy-five percent of cases were treated with fat graft injection, whereas dermis-fat grafts were applied in 25% of patients. The former had their fat harvested more commonly from the abdomen, whereas in the latter case, the graft was harvested mostly from the inner aspect of arms. The mean volume of fat injected on each side of the face was 28.5 ± 22.7 mL. On a scale from 1 to 10, mean patient satisfaction was 7.7 ± 2.8. The Assessment of Body Change and Distress questionnaire revealed statistically significant improvements. Complications occurred in 25% of cases, the most frequent being significant reabsorption. No major complications occurred. Conclusions: Treatment of HIV-associated facial lipodystrophy with autologous fat or dermis-fat compound graft is a safe procedure with long-lasting results and unquestionable aesthetic and social benefits.
- Leflunomide and Polyomavirus-Associated Nephropathy in Renal TransplantPublication . Ferreira, AC; Ferreira, A; Possante, M; Sousa, J; Viana, H; Carvalho, H; Nolasco, FPolyomavirus nephropathy is a major complication in renal transplantation, associated with renal allograft loss in 14 to 80% of cases. There is no established treatment, although improvement has been reported with a variety of approaches. The authors report two cases of polyomavirus infection in renal allograft recipients. In the first case, a stable patient presented with deterioration of renal function, worsening hypertension and weight gain following removal of ureteral stent placed routinely at the time of surgery. Ultrasound examination and radiology studies revealed hydronephrosis due to ureteral stenosis. A new ureteral stent was placed, but renal function did not improve. Urinary cytology revealed the presence of decoy cells and polyomavirus was detected in blood and urine by qualitative polymerase chain reaction. Renal biopsy findings were consistent with polyomavirus -associated nephropathy. In the second case, leucopaenia was detected in an asymptomatic patient 6 months after transplantation. Mycophenolate mophetil dosage was reduced but renal allograft function deteriorated, and a kidney biopsy revealed polyomavirus -associated nephropathy, also with SV40 positive cells. In both patients immunosuppression with tacrolimus was reduced, mycophenolate mophetil stopped and intravenous immune globulin plus ciprofloxacin started. As renal function continued to deteriorate, therapy with leflunomide (40 mg/day) was associated and maintained during 5 and 3 months respectively. In the first patient, renal function stabilised within one month of starting leflunomide and polymerase chain reaction was negative for polyomavirus after 5 months. A repeated allograft biopsy 6 months later showed no evidence of polyomavirus nephropathy. In the second patient, polyomavirus was undetectable in blood and urine by polymerase chain reaction after 3 months of leflunomide treatment, with no evidence of polyomavirus infection in a repeated biopsy 6 months after beginning treatment.
- Leukopenia in Kidney Transplant Patients with the Association of Valganciclovir and Mycophenolate MofetilPublication . Brum, S; Nolasco, F; Sousa, J; Ferreira, A; Possante, M; Pinto, JR; Barroso, E; Ribeiro Santos, JCytomegalovirus (CMV) is the most common viral infection after transplantation. Valganciclovir (VGC) is established for prophylaxis and treatment of CMV infections, but leukopenia which appears in 10% to 13% (severe in 4.9%) is the principal side effect. We have recently noted an increased incidence of leukopenia and severe neutropenia among our renal transplant patients and thought to identify the associated factors. We conducted a retrospective analysis of all kidney transplantations performed between January 2005 and December 2006. All patients received mycophenolate mofetil (MMF), tacrolimus, and steroids. VGC was used for targeted prophylaxis and preemptive therapy of CMV infection, with doses adjusted to renal function. Of the 64 patients undergoing renal transplantation 13 (20.3%) developed leukopenia within 3 +/- 2 months after transplantation with severe neutropenia in 5 (7.8%). All patients were on MMF and VGC (VGC 605 +/- 296 mg/d). Leukopenia was significantly associated with simultaneous liver-kidney transplantation and with second kidney transplantations (P < .01). The incidence of leukopenia was higher among patients under VGC since day 1 of transplantation (P = .008) with maximal incidence observed among patients prescribed 900 mg/d as opposed to those on lower doses (P < .01). There was no increase in CMV infection among patients with a low dose of VGC. No patient developed clinical CMV disease. In conclusion, VGC prophylaxis was associated with an increased frequency of leukopenia on MMF-tacrolimus treated patients or regimens. Low-dose VGC for CMV prophylaxis appeared to be as effective as high-dose treatment, and associated less frequently with leukopenia and neutropenia.
- MPO-ANCA-Associated Necrotizing Glomerulonephritis in Rheumatoid Arthritis; a Case Report and Review of LiteraturePublication . Góis, M; Messias, A; Carvalho, D; Carvalho, F; Sousa, H; Sousa, J; Nolasco, FBACKGROUND: Renal involvement in rheumatoid arthritis (RA) is common and has a negative impact on patient survival. Only few cases have been reported of necrotizing glomerulonephritis (GN) associated with myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) in patients with RA. CASE PRESENTATION: We report a patient with RA who developed a necrotizing GN associated with ANCA-MPO, treated with rituximab (RTX). A 55-year-old man with a 27-year history of RA under secukinumab was referred to our nephrology clinic with worsening renal function associated with microhematuria and proteinuria. Our laboratory evaluation showed hypocomplementemia and positive titers for MPO-ANCA (615 U/mL). A renal biopsy demonstrated pauci-immune necrotizing GN. The patient was treated with 3 consecutive pulses of methylprednisolone followed by oral prednisolone (1 mg/Kg) and rituximab (1000 mg, repeated 14 days later). After a 10-month follow-up, the arthritis remains well-controlled, renal function stabilized, proteinuria improved and MPO-ANCA titer normalized (6.3 U/mL). CONCLUSIONS: Necrotizing GN is a rare but a serious condition and an early diagnosis is essential to treatment. This is the first case of necrotizing GN (without extra-renal manifestations of vasculitis) in a patient with active RA, successfully treated with RTX.
- Peritoneal Dialysis in HIV Infected Patients. A Good Option?Publication . Ferreira, AC; Fernandes, V; Sousa, J; Vila Lobos, A; Nolasco, F
- Renal Involvement in Rheumatoid Arthritis: Analysis of 53 Renal BiopsiesPublication . Góis, M; Carvalho, F; Sousa, H; Ferreira, AC; Sousa, J; Nolasco, FBackground: Rheumatoid arthritis (RA) is a systemic inflammatory disorder characterized by joint inflammation, associated with autoantibody production. Renal involvement arises as a complication of treatment or can be related to the disease itself. Methods: 53 biopsies from patients with RA from 1989 to 2015 were reviewed. Histologic diagnosis, age, gender, duration of RA, drug therapy, renal function, proteinuria and haematuria were analyzed. Results: Amyloidosis was the most common renal histologic pattern (21 patients). Membranous Nephropathy (MN) was found in 12 patients, followed by Mesangial Proliferative Glomerulonephritis (n=4) and Focal and Segmental Glomerulosclerosis (n=4), IgA Nephropathy (n=3), Necrotizing Glomerulonephritis (n=3), Chronic Interstitial Nephritis (n=3), Endocapillary Proliferative Glomerulonephritis (n=2) and Minimal Change Disease (n=1). Amyloidosis correlated with long duration RA (14.9±6.66 years vs 8.84±6.37 years; p<0.001), presenting with nephrotic proteinuria in the majority of the cases (5.11±2.94 g/24h vs 3.52±2.71 g/24h p=0.03), which correlates with dominant glomerular amyloid deposition (7.0±2.28 g/24h vs 3.04±2.08 g/24h; p<0.001). In patients with MN, renal function was preserved (serum creatinine 0.83±0.21mg/dl vs 2.03±0.21mg/dl; p<0.001) and one third of the cases presented with haematoproteinuria. Disease modifying antirheumatic drugs (DMARDs) could be related with MN in six cases. Patients with Necrotizing Glomerulonephritis had a severe renal involvement, as did patients with Chronic Interstitial Nephritis. Conclusion: We found a wide spectrum of histological lesions that cannot be predicted with only clinical and laboratory findings. Thus, renal biopsy is essential to ensure correct diagnosis in RA patients who present with urinary abnormalities or deteriorated renal function.
- Seasonal Impact in Burn Profiles in a Dedicated Burn UnitPublication . Mata Ribeiro, L; Vieira, L; Sousa, J; Silva Guerra, AIntroduction: The number of burns in Portugal remains considerably large and therefore constitutes a major public health problem. There is a shortage of studies describing the epidemiological and clinical impact of seasonality on burn centre admissions, particularly in high income countries. Methods: This retrospective analysis included all patients (>18 years old) with acute burns admitted to a specialized Burn Center in Lisbon (Hospital São José) between 20 of September 2010 and 19 of September 2017 (7 years). Clinical data was obtained from electronic medical records. The patients were categorized into four groups, according to each season. Results: Six hundred and sixteen (616) patients were included in this analysis, the majority being male (55.2%). There were no significant differences between the number of patients admitted in each season nor in gender distribution. Older patients were admitted during winter. Hospitalisation time was higher for patients admitted in the winter and surface area injured was higher for those admitted during summer. Fire burns were the most common aetiology in all seasons. Work related burns and suicide attempts were more frequent in the summer. Most patients had more than one anatomical area affected (73.9%) and winter was specifically associated with more frequent isolated lower limb burns. Winter and fire burns were associated with deeper injuries. More patients underwent surgery during winter (80.7%) than in the remaining seasons (average 65%) but the average number of surgeries per season did not change significantly. The overall mortality rate was 6.8% and the need for mechanical ventilation was 28.9%. Concerning both variables we did not find major differences across seasons. Mortality was associated with older patients, deeper and more extensive burns and need for mechanical ventilation. Conclusion: Winter seems to be associated with older patients and with the most severe burns (deeper and more often needing surgery). This study was designed to fill the gap in seasonal burn profile in Portugal and it helps in establishing preventive strategies and better resource allocation.