Síndrome de Guillain-Barré: epidemiologia, prognóstico e fatores de risco

Introduction. Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy and the principal cause of acute neuromuscular paralysis. The most prominent GBS subtypes are: acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor-sensory axonal neuropathy (AMSAN) and Fisher syndrome (FS). Differences in geographical distribution of variants have been reported. In Brazil, there are few studies describing the characteristics of GBS, but none on the frequency of GBS variants and their clinical manifestations. Infection-induced aberrant immune response resulting from molecular mimicry and formation of cross-reacting antibodies, contribute to complement activation. Functional biallelic polymorphism in immunoglobulin receptors that influence the affinity of IgG subclasses and the type of immune response have been described, suggesting genetic susceptibility to developing disease. It remains unclear whether individuals carrying different FCGR alleles have differential risk for GBS and⁄or disease severity. The goals of this study were: (1) To characterize GBS and describe the clinical findings in a cohort of patients with GBS from the state of Rio Grande do Norte, Brazil; (2) to determine whether polymorphism in FCGR were associated with development of GBS, and (3) to tease out whether the global gene expression studies could be a tool to identify pathways and transcriptional networks which could be regulated and decrease the time of disease. Methods. Clinical and laboratory data for 149 cases of GBS diagnosed from 1994 to 2013 were analyzed. Genomic DNA and total RNA were extracted from whole blood. Antigangliosides antibodies were determined in the sera. In addition, we also assessed whether FCGR polymorphism are present in GBS (n=141) and blood donors (n=364), and global gene expressions were determined for 12 participants with GBS. Blood samples were collected at the diagnosis and post-recovery. Results. AIDP was the most frequent variant (81.8%) of GBS, followed by AMAN (14.7%) and AMSAN (3.3%). The incidence of GBS was 0.3 ⁄ 100,000 people for the state of Rio Grande do Norte and cases occurred at a younger age. GBS was preceded by infections, with the axonal variant associated with episodes of diarrhea (P = 0.025). Proximal weakness was more frequent in AIDP, and distal weakness predominant in the axonal variant. Compared to 42.4% of cases with AIDP (P<0.0001), 84.6% of cases with the axonal variant had nadir in <10 days. Individuals with the axonal variant took longer to recover deambulation (P<0.0001). The mortality of GBS was 5.3%. A worse outcome was related to an axonal variant (OR17.063; P=0.03) and time required to improve one point in the Hughes functional scale (OR 1.028; P=0.03). The FCGR genotypes and allele frequencies did not differ significantly between the patients with GBS and the controls (FCGR2A p=0.367 and FCGR3A p=0.2430). Global gene expression using RNAseq showed variation in transcript coding for protein isoforms during acute phase of disease. Conclusions. The annual incidence of GBS was 0.3 per 100,00 and there was no seasonal pattern. A predominance of the AIDP variant was seen, and the incidence of the disease decreased with age. The distribution of weakness is a function of the clinical variants, and individuals with the axonal variant had a poorer prognosis. Early diagnosis and variant identification leads to proper intervention decreasing in long-term morbidity. FCGR polymorphisms do not seem to influence susceptibility to GBS in this population. This study found deregulated genes and signs of transcriptional network alterations during the acute and recovery phases in GBS. Identification of pathways altered during disease might be target for immune regulation and with potential to ameliorate symptoms.

Receptores de citocinas proinflamatórias na pré-eclâmpsia

Preeclampsia is a disease specific of human pregnancy that affects 3-8% of pregnant women, and it is one of the three leading causes of maternal mortality and morbidity. The disease is characterized by hypertension and proteinuria after the 20th week of gestation. The risk factors for this disease are not completely understood but appear to include dysregulation of the immune response arising from defects in placentation, environmental and genetic factors. This study aimed to determine whether the variation in the amount of proinflammatory cytokine receptors IL-1R2, IL-6R and TNF-αR1 would be involved in preeclampsia. They were recruited women with preeclampsia (n=24) and women who evolved during pregnancy without changes in blood pressure (n=12) were recruited. Clinical and laboratory data were collected. The cytokine receptors (IL-1R2, TNF-αR1 and IL-6R) were assessed in mononuclear cells isolated from peripheral blood using flow cytometry (Control = 8; PE = 24). C-reactive protein (CRP) was determined by CRP ultrasensitive method (Control = 7; PE = 18) was performed using sera pregnant women. Women with preeclampsia had higher weight at the beginning of the pregnancy (p=0.0171) and lower gestational age at delivery (0.0008). Classical monocytes were decreased in preeclampsia but not intermediate or non-classical monocytes. The frequency of IL-1R2 pro inflammatory cytokine receptors is decreased in women with PE only in the subpopulation of non-classical monocytes (p = 0.0011). TNF-αR1 receptor and IL-6R, had a decreased frequency in the three subpopulations of monocyte (classic, intermediate and non-classical) when compared to women with normal pregnancy. An increase in IL-1R2 receptor in TCD4+ lymphocytes, but a decrease in TNF-receptor and IL-6R in women with preeclampsia were found. No differences in the frequency of those receptors in CD3+/CD8+ in preeclampsia. There was no difference in C-reactive protein in preeclampsia. The reduction in the amount of IL-1R2, TNF- αR1 and IL-6R monocytes and lymphocytes can be involved in the regulation of inflammation observed in preeclampsia, contributing to disease.

Avaliação da adaptação marginal de diferentes tipos de restaurações obtidas por CAD/CAM e métodos convencionais

The past few decades have brought many changes to the dental practice and the technology has become ready available. The result of a satisfactory rehabilitation treatment basically depends on the balance between biological and mechanical factors. The marginal adaptation of crowns and prosthetic structures is vital factor for long-term success. The development of CAD / CAM technology in the manufacture of dental prostheses revolutionized dentistry, this technology is capable of generating a virtual model from the direct digital scanning from the mouth, casts or impressions. It allows the planning and design of the structure in a computered software. The virtual projects are obtained with high precision and a significant reduction in clinical and laboratory time. Thus, the present study (Chapters 1, 2 and 3) computed microtomography was used to evaluate, different materials, different CAD/CAM systems, different ways of obtaining virtual model (with direct or indirect scanning), and in addition, also aims to evaluate the influence of cementing agent in the final adaptation of crowns and copings obtained by CAD / CAM. Furthermore, this study (Chapter 4, 5 and 6) also aims to evaluate significant differences in vertical and horizontal misfits in abutment-free frameworks on external hexagon implants (HE) using full castable UCLAs, castable UCLAs with cobalt-chromium pre-machined bases and obtained by CAD / CAM with CoCr or Zirconia by different scanning and milling systems. For this, the scanning electron microscopy and interferometry were used. It was concluded that the CAD / CAM technology is capable to produce restorations, copings and screw-retained implant-supported frameworks in different materials and systems offering satisfactory results of marginal accuracy, with significative reduction in clinical and laboratory time.

The Feasibly of Functionally Guided Intensity Modulated Radiation Therapy Treatment Planning Using Perfluoropropane-Enhanced MRI for Lung Cancer

Radiotherapy is commonly used to treat lung cancer. However, radiation induced damage to lung tissue is a major limiting factor to its use. To minimize normal tissue lung toxicity from conformal radiotherapy treatment planning, we investigated the use of Perfluoropropane(PFP)-enhanced MR imaging to assess and guide the sparing of functioning lung. Fluorine Enhanced MRI using Perfluoropropane(PFP) is a dynamic multi-breath steady state technique enabling quantitative and qualitative assessments of lung function(1).

Imaging data was obtained from studies previously acquired in the Duke Image Analysis Laboratory. All studies were approved by the Duke IRB. The data was de-identified for this project, which was also approved by the Duke IRB. Subjects performed several breath-holds at total lung capacity(TLC) interspersed with multiple tidal breaths(TB) of Perfluoropropane(PFP)/oxygen mixture. Additive wash-in intensity images were created through the summation of the wash-in phase breath-holds. Additionally, model based fitting was utilized to create parametric images of lung function(1).

Varian Eclipse treatment planning software was used for putative treatment planning. For each subject two plans were made, a standard plan, with no regional functional lung information considered other than current standard models. Another was created using functional information to spare functional lung while maintaining dose to the target lesion. Plans were optimized to a prescription dose of 60 Gy to the target over the course of 30 fractions.

A decrease in dose to functioning lung was observed when utilizing this functional information compared to the standard plan for all five subjects. PFP-enhanced MR imaging is a feasible method to assess ventilatory lung function and we have shown how this can be incorporated into treatment planning to potentially decrease the dose to normal tissue.

Seawater carbonate chemistry and biological processed during experiments with corals Porites sp. & Stylophora pistillata, 2010

Uptake of anthropogenic CO2 by the oceans is altering seawater chemistry with potentially serious consequences for coral reef ecosystems due to the reduction of seawater pH and aragonite saturation state (omega arag). The objectives of this long-term study were to investigate the viability of two ecologically important reef-building coral species, massive Porites sp. and Stylophora pistilata, exposed to high pCO2(or low pH) conditions and to observe possible changes in physiologically related parameters as well as skeletal isotopic composition. Fragments of Porites sp. and S. pistilata were kept for 6-14 months under controlled aquarium conditions characterized by normal and elevated pCO2 conditions, corresponding to pHTvalues of 8.09, 7.49, and 7.19, respectively. In contrast with shorter, and therefore more transient experiments, the long experimental timescale achieved in this study ensures complete equilibration and steady state with the experimental environment and guarantees that the data provide insights into viable and stably growing corals. During the experiments, all coral fragments survived and added new skeleton, even at seawater omega arag <1, implying that the coral skeleton is formed by mechanisms under strong biological control. Measurements of boron (B), carbon (C) and oxygen (O) isotopic composition of skeleton, C isotopic composition of coral tissue and symbiont zooxanthellae, along with physiological data (such as skeletal growth, tissue biomass, zooxanthellae cell density and chlorophyll concentration) allow for a direct comparison with corals living under normal conditions and sampled simultaneously. Skeletal growth and zooxanthellae density were found to decrease, whereas coral tissue biomass (measured as protein concentration) and zooxanthellae chlorophyll concentrations increased under high pCO2 (low pH) conditions. Both species showed similar trends of delta11B depletion and delta18O enrichment under reduced pH, whereas the delta13C results imply species-specific metabolic response to high pCO2 conditions. The skeletal delta11B values plot above seawater delta11B vs. pH borate fractionation curves calculated using either the theoretically derived deltaB value of 1.0194 (Kakihana et al., Bull. Chem. Soc. Jpn. 50(1977), 158) or the empirical deltaB value of 1.0272 (Klochko et al., EPSL 248 (2006), 261). However, the effective deltaB must be greater than 1.0200 in order to yield calculated coral skeletal delta11B values for pH conditions where omega arag >1. The delta11B vs. pH offset from the literature seawater delta11B vs. pH fractionation curves suggests a change in the ratio of skeletal material laid down during dark and light calcification and/or an internal pH regulation, presumably controlled by ion-transport enzymes. Finally, seawater pH significantly influences skeletal delta13C and delta18O. This must be taken into consideration when reconstructing paleo-environmental conditions from coral skeleton

Seawater carbonate chemistry and clownfish Amphiprion percula size and otholith development during experiments, 2011

Calcification in many invertebrate species is predicted to decline due to ocean acidification. The potential effects of elevated CO2 and reduced carbonate saturation state on other species, such as fish, are less well understood. Fish otoliths (earbones) are composed of aragonite, and thus, might be susceptible to either the reduced availability of carbonate ions in seawater at low pH, or to changes in extracellular concentrations of bicarbonate and carbonate ions caused by acid-base regulation in fish exposed to high pCO2. We reared larvae of the clownfish Amphiprion percula from hatching to settlement at three pHNBS and pCO2 levels (control: ~pH 8.15 and 404 µatm CO2; intermediate: pH 7.8 and 1050 µatm CO2; extreme: pH 7.6 and 1721 µatm CO2) to test the possible effects of ocean acidification on otolith development. There was no effect of the intermediate treatment (pH 7.8 and 1050 µatm CO2) on otolith size, shape, symmetry between left and right otoliths, or otolith elemental chemistry, compared with controls. However, in the more extreme treatment (pH 7.6 and 1721 µatm CO2) otolith area and maximum length were larger than controls, although no other traits were significantly affected. Our results support the hypothesis that pH regulation in the otolith endolymph can lead to increased precipitation of CaCO3 in otoliths of larval fish exposed to elevated CO2, as proposed by an earlier study, however, our results also show that sensitivity varies considerably among species. Importantly, our results suggest that otolith development in clownfishes is robust to even the more pessimistic changes in ocean chemistry predicted to occur by 2100.

Construção de um Referencial de Competências dos Técnicos de Análises Clínicas e Saúde Pública

O presente estudo teve como objectivo construir e validar um referencial de competências dos Técnicos de Análises Clínicas e Saúde Pública. Para a concretização deste objectivo construi-se uma entrevista estruturada com 15 questões de resposta aberta aplicada a uma amostra de 10 Técnicos de Análises Clínicas e Saúde Pública. Os dados foram recolhidos, culminaram num questionário de resposta fechada constituído por 36 competências e aplicado a 100 técnicos. Dos resultados do tratamento deste, derivou um outro questionário com 26 competências, relativamente às quais, além da classificação das mesmas, era solicitado emissão de opinião técnica. Este instrumento foi aplicado a 10 peritos (professores que ministraram ou ministram na Licenciatura de Análises Clínicas e Saúde Pública e/ou investigadores desta área de estudos). Daí resultaram 22 competências que foram sujeitas a validação semântica e que constituíram o referencial de competências. O conjunto que competências a que se chegou foi trabalhado em clusters de competências pessoais, interpessoais e instrumentais e para se verificar a sua fiabilidade interna aplicou-se o Alfa de Cronbach. O referencial de competências constituído foi validado através de um Focus Group de técnicos. A construção do referencial de competências dos Técnicos de Análises Clínicas e Saúde Pública permitiu dar a conhecer as competências essenciais à apresentação de um bom desempenho profissional, quando sujeitos a avaliação por competências, e o desenvolvimento de estudos acerca desta profissão. / The following paper aimed to develop and validate a reference of the Clinical Analysis and Public Health technicians’ competences. In order to achieve this purpose it was put together a structured interview based on fifteen open-response questions. This interview was applied to a sample of ten Clinical Analysis and Public Health technicians. The collected data of this interview led to a closed response questionnaire including thirty-six competences, which was then administered to a hundred technicians. Subsequently, the data collected in this questionnaire let to another different questionnaire composed of twenty-six competences. This time, besides their classification it was required to issue a technical opinion. This research instrument was then administered to ten experts (teachers who minister or ministered the Degree of Clinical Analysis and Public Health and / or researchers in this field of study). This last resulted into twenty-two competences which were subjected to semantic validation and afterwards composed the reference of competences. The reached reference of competences was then worked on to clusters of personal, interpersonal and instrumental competences whose liability was checked through the Cronbach's Alpha. The reference of competences was then validated through a technician’s Focus Group. The building of this Clinical Analysis and Public Health technicians’ reference of competences was important to acknowledge the important competences necessary to perform this Job well and professionally.

Sonolência Diurna Excessiva e Otimismo em Estudantes do 1º Ano do Ensino Superior

Os principais objetivos do presente estudo são analisar a prevalência da sonolência diurna excessiva (SDE) em estudantes do Ensino Superior (ES), bem como os seus níveis de otimismo. Participaram no presente estudo 162 estudantes universitários de várias faculdades de ES privado, de ambos os sexos, com idades compreendidas entre os 17 e os 46 anos (M=20,49; DP=5,153) e que frequentavam diferentes cursos (Psicologia, Ciências da Comunicação, Análises Clínicas, Ciências Farmacêuticas e Fisioterapia). O protocolo de recolha de dados foi constituído por um questionário sociodemográfico, dois itens do Questionário do Estado de Saúde (SF-36), a Escala de Sonolência de Epworth (ESE) e a Escala de Orientação para a Vida (LOT-R). A ESE apresentou um valor de alfa de Cronbach de α=0,68 e o LOT-R um valor de alfa de Cronbach de α=0,84. Os principais resultados descritivos mostram uma pontuação média na ESE de 8,98 (DP=3,85), que corresponde a uma prevalência de 32,1% (n=52) de SDE. A pontuação média obtida com a LOT-R foi de 14,3 (DP=4,77), que corresponde a 65,4% (n=106) de estudantes otimistas. Foram encontradas correlações estatisticamente significativas entre a idade e a SDE, mas não entre a SDE e as variáveis de perceção de saúde. Os resultados diferenciais não apresentaram significância estatística na SDE, quando o sexo, o curso e a situação de residência foram tidos em consideração. A idade foi assumida, nas análises de regressão linear, como variável preditora explicativa de 3% da variância dos resultados da ESE. Relativamente ao otimismo, este mostrou-se correlacionado com a perceção do estado de saúde no momento, mas não com a SDE, idade e transição de saúde. Não foi encontrada significância estatística no otimismo quando o sexo, o curso e a situação de residência foram considerados. As análises de regressão linear identificaram como modelo preditor explicativo de cerca de 12% da variação total do LOT-R o modelo que integra a idade e a perceção do estado de saúde no momento. Estudos posteriores devem ser realizados para se aferir a prevalência de SDE e caraterizar o otimismo em estudantes universitários, bem como a relação entre ambos e com outras variáveis relevantes, de foma a apoiar, adequadamente a intervenção.

Severity in biliary peritonitis

Objective. To analyze clinical and laboratory findings in order to find variables predictive of severity of Biliary Peritonitis (BP). Patients and methods. Physical findings, course of illness, imaging and laboratory data were evaluated in 42 patients with BP, and statistically analysed to assess their prognostic significance. Results. Serious illness and worse outcome were associated with: age ≥ 60 years (P=0.034), long time between onset of symptoms and treatment (P=0.025), fever > 38°C (P=0.009), WBC count > 17,000 cell/mm³ (P=0.043), diffuse abdominal pain (P=0.034), and infected bile (P=0.048). Conclusions. Most patients become severely ill due to supervening infection, while early bile drainage avoids serious complications. In addition, abdominal pain, fever and WBC count are also predictive of severity of BP.

Agentes etiológicos de infecções urinárias em ambulatório

As infeções do trato urinário (ITU), depois das infeções respiratórias, são as mais comuns na comunidade, sendo a Escherichia coli o principal agente etiológico. Afeta predominantemente o sexo feminino e, anualmente, estima-se que ocorram em todo o Mundo cerca de 150 milhões de episódios de ITU, sendo responsável por 15% dos antibióticos prescritos em ambulatório. Os objetivos deste estudo foram caracterizar os agentes etiológicos das ITU e determinar o seu padrão de resistência aos antimicrobianos na região litoral norte de Portugal, de modo a contribuir para o uso racional na terapêutica empírica. Foi realizado um estudo observacional, descritivo e transversal, sendo obtidos 80 967 resultados de uroculturas de um Laboratório de Análises Clínicas de prestação de serviços à comunidade, relativos ao período entre Abril de 2007 e Março de 2015. Registaram-se 13 541 bacteriúrias positivas (16,72%). Escherichia coli foi o microrganismo mais isolado (71,62%), seguida de Klebsiella pneumoniae (12,41%), Proteus mirabilis (7,84%), Enterococcus. faecalis (3,97%) e Pseudomonas aeruginosa (1,42%), tendo-se observado diferenças estatisticamente significativas entre sexos e idades. Verificou-se uma diminuição da resistência aos antimicrobianos a partir do ano de 2012. E. coli apresentou em 2015 a menor taxa de resistência respetivamente de 4,46% e 12,37% para a fosfomicina e nitrofurantoína. A combinação de amoxicilina+ácido clavulânico registou uma taxa de resistência superior a 20% (22,03%). O baixo nível de resistência à fosfomicina permite que este antibiótico se apresente como a opção terapêutica de primeira linha no tratamento empírico de ITU não complicada na mulher em ambulatório, pelo que, estes resultados permitem corroborar as indicações de 2011 da Direção Geral de Saúde sobre a substituição de fluoroquinolonas por fosfomicina.

Prótese obturadora palatina

Nos pacientes com defeitos ósseos palatinos congénitos ou adquiridos, quando a possibilidade de reconstrução cirúrgica não existe, poderá ter de se utilizar uma prótese obturadora palatina, com vista ao restabelecimento das funções do sistema estomatognático, tais como, a fonética, deglutição e mastigação. Contudo, esta necessidade não é só funcional mas também estética e psicológica, com vista a melhorar a qualidade de vida dos pacientes. As próteses obturadoras palatinas têm vindo a desenvolver há alguns séculos, com o aprimoramento das técnicas de confecção e materiais dentários que auxiliam na elaboração, cada vez mais eficientes, principalmente no que se refere a sua adaptação. Neste trabalho realizou-se uma revisão narrativa da literatura sobre próteses obturas palatinas utilizando as palavras-chave: maxillary birth bony defects; maxillary acquired bony defects; obturator prosthesis; prosthetic rehabilitation in maxillary defects; inflatable hollow obturator; prosthodontic rehabilitation of maxillary defects. Os objectivos deste trabalho foi o de conhecer os diferentes tipos de próteses obturadoras palatinas utilizadas na reabilitação de pacientes com defeitos ósseos palatinos, bem como, as suas indicações, contra-indicações, os cuidados de utilização e o protocolo clínico e laboratorial de confecção. As próteses obturadoras palatinas são assim uma solução possível na reabilitação funcional de um número grande de pacientes com defeitos ósseos palatinos, no entanto, o seu sucesso está dependente do correcto planeamento e da execução clínica e laboratorial cuidadosa.

Potencial fisiológico de sementes de soja enriquecidas com molibdênio no armazenamento e sua influência na atividade de enzimas do metabolismo do nitrogênio

Molybdenum is one of the essential micronutrients for soybeans, acting directly on nitrogen metabolism as enzyme cofactor of nitrogenase. Usually, this nutrient is supplied to the plants through seed treatment or foliar application. The aim of this study was to evaluate the molybdenum effects by foliar in the physiological potential of soybean seeds and verify its interference in the enzyme activities involved in nitrogen metabolism. Soybean seeds of BMX Turbo cultivar were used, produced in Erechim, RS, harvest 2013, from plants treated with the following Mo concentrations: 0; 25; 50 and 75 g ha-1, supplied through two commercial products (Biomol and Molybdate) and stored during 0 and 6 months in uncontrolled conditions. The first experiment was conducted in Seedtes Seed Analysis Laboratory in Pato Branco, PR. The used design was completely randomized in a factorial analysis 4 x 2 x 2 with four replications each. The physiological potential of the seeds was evaluated by the germination test, seedling growth, accelerated aging and emergence on the soil. The second experiment was conducted in a greenhouse, where the seeds derived from treatments with different concentrations of Mo: 0; 25; 50 and 75 g ha-1 supplied through two commercial products (Biomol and Molybdate) were grown in vases. The used design was completely randomized in a factorial analysis 4 x 2 with four replications. Evaluations were performed when the plants reached the R1 phenological stage concerning the nodulation, dry matter of root and shoot of the plants and the determination of the activity of the enzymes glutamine synthetase and glutamate synthetase and the content of total soluble proteins. The data were submitted to variance analysis and when significant they were assessed by Tukey’s test for comparison of products and seed storage and with regression study to the concentrations at 5% probability. Analyses were performed using SISVAR statistical software. The soybean seed storage under uncontrolled conditions affected the seed vigour produced with Mo, regardless of the commercial product used during production. The application of Mo through foliar positively influences the production of soya beans which presented increasing responses in the germination and vigour with the application of Mo above 25 g ha-1 . The enrichment of Mo through foliar did not affect the nodulation of plants of the next generation, however, the use of Mo above 25 g ha-1 provided an increase in the activity of enzymes involved in nitrogen metabolism as well as on the total protein content.

Haemophagocytic Syndrome in a 19-Year-Old Male with Plasmodium falciparum Malaria

Objectives: Infectious agents triggering haemophagocytic lymphohistiocytosis (HLH) primarily involve the herpes virus group. We report a case of HLH precipitated by Plasmodium falciparum. Materials and methods: Clinical and laboratory findings in a patient presenting with fever were collected. After confirmation of acute malaria, anti-malarial treatment was administered. Results: Despite initial favourable evolution, the patient developed fever again together with a worsening of the haematological parameters and increased ferritin levels. A bone marrow biopsy confirmed the diagnosis of HLH. Conclusion: This case illustrates that HLH should be considered in the differential diagnosis of acute malaria in patients with persisting fever and pancytopenia.

Severe Statin-induced Rhabdomyolysis following Cholestatic Hepatitis induced by Amoxicillin-clavulanate

We report the case of an 86-year-old man with a past history of coronary disease admitted to our internal medicine department for severe asthenia and weakness due to rhabdomyolysis. Three days earlier, he had been discharged from a gastroenterology unit with a diagnosis of amoxicillin–clavulanate-induced acute cholestatic hepatitis. A review of his drugs revealed that he had taken atorvastatin 10 mg daily in the previous six years, without clinical or laboratory signs of myopathy. Atorvastatin was therefore stopped, with gradual improvement of the rhabdomyolysis. All concomitant drug therapy needs to be reassessed in elderly patients, especially when they become acutely ill.

Eosinophilic Fasciitis: an Atypical Presentation of a Rare Disease

Objectives: We report an atypical presentation of eosinophilic fasciitis and provide a concise overview of the literature. Materials and Methods: Clinical and laboratory findings in a patient presenting with fever and skin induration were recorded. A deep muscle biopsy was performed in order to confirm the diagnosis. Results: A spontaneous favourable clinical and radiological evolution was observed. Conclusion: The diagnosis of eosinophilic fasciitis is challenging due to the lack of pathognomonic signs and symptoms. As spontaneous resolution has been described, watchful waiting is defendable depending on the clinical presentation. Although magnetic resonance imaging (MRI) can be useful in establishing the diagnosis, a deep muscle biopsy remains the gold standard diagnostic tool.