Síndrome de Churg-Strauss - Vasculite Cutânea como Forma de Apresentação Clínica

A síndrome de Churg-Strauss (SCS) ou angeíte granulomatosa alérgica é uma doença rara caracterizada pela presença de asma, eosinofilia e vasculite dos pequenos e, por vezes, dos médios vasos. O pulmão, coração, pele e nervos periféricos são frequentemente atingidos. Os autores descrevem o caso clínico de uma doente do sexo feminino de 47 anos de idade, internada por lesões purpúricas dolorosas com uma semana de evolução, localizadas nas superfícies extensoras dos membros inferiores. Nos antecedentes pessoais destacava-se asma brônquica com 7 anos de evolução, rinite alérgica e sinusite. A avaliação laboratorial revelou leucocitose com eosinofilia e elevação dos parâmetros de inflamação. Os anticorpos citoplasmáticos anti-neutrófilos eram negativos. A avaliação neurológica e o estudo electroneuromiográfico mostraram uma polineuropatia periférica assimétrica. A biopsia cutânea revelou uma vasculite necrotizante com infiltrado perivascular rico em eosinófilos. O diagnóstico de SCS foi apoiado pelos achados clínicos e histopatológicos, pelo que se iniciou corticoterapia sistémica que resultou numa melhoria clínica marcada. As manifestações cutâneas podem ser uma forma de apresentação clínica do SCS, sendo o seu reconhecimento essencial para a instituição precoce de terapêutica e para a prevenção de lesões irreversíveis em órgãos vitais.

Vasculite Sistémica com Envolvimento das Coronárias numa Adolescente. Qual o Diagnóstico?

As vasculites sistémicas são raras na idade pediátrica. Apresenta-se o caso de uma adolescente de 14 anos com febre, mialgias, púrpura e edema dos membros, que apresentava leucocitose, velocidade de sedimentação e PCR elevadas. O ecocardiograma mostrou insuficiência mitral, dilatação e aneurisma da artéria coronária esquerda e posteriormente insuficiência cardíaca com hipertensão e pancardite. Detectaram-se também enfartes renais e cerebrais. As biópsias cutâneas foram inconclusivas, e a serologia para Influenza A foi positiva. A investigação para doenças auto-imunes foi inconclusiva, incluindo ANCAc e p negativos. Foi administrada imunoglobulina endovenosa com evolução favorável, mantendo aneurisma cardíaco. O diagnóstico diferencial entre poliarterite nodosa e doença de Kawasaki (DK) na adolescência pode ser difícil. Apesar de não se poder excluir DK atípica, pela sua raridade nesta idade, a vigilância desta doente a longo prazo é mandatória.

"Etude rétrospective des cas de vasculite cutanée identifiés au laboratoire de dermopathologie du CHUV de 2006 à 2010"

CONTEXTE Les vasculites représentent un groupe de maladies inflammatoires touchant tous les vaisseaux, des grosses artères aux artères de plus petit calibre, en passant par les capillaires et les veines, de toutes tailles également. La taille des vaisseaux atteints est d'une importance cruciale pour le diagnostic puisque la classification actuelle en dépend. Sur le plan histopathologique, la vasculite est une réaction inflammatoire qui atteint la paroi de vaisseaux, et qui va entraîner alors une ischémie, puis une nécrose du vaisseau lui-­‐ même voire des structures environnantes ; les caractéristiques microscopiques de ces lésions permettent souvent d'aider à préciser le groupe auquel appartient la vasculite. Cependant, il n'est pas toujours facile ni possible d'obtenir un échantillon de tissu, une biopsie, selon l'endroit concerné (cerveau, régions profondes et difficilement accessibles...). OBJECTIFS Dans les atteintes de type « vasculite », la peau est fréquemment un organe cible. Le grand avantage est son accès direct et aisé, notamment dans le but de pratiquer un examen histopathologique par le biais d'une biopsie, qui peut se pratiquer de manière superficielle ou profonde, révélant alors des vaisseaux de différents calibres. Face à un tableau clinique parfois complexe et menaçant, il est important de pouvoir orienter le diagnostic rapidement. L'objectif de ce travail est donc de déterminer quelles sont l'utilité et l'apport de la biopsie cutanée dans le diagnostic des vasculites, et autrement dit de déterminer s'il vaut la peine de pratiquer ce genre d'examen, ou s'il vaut mieux privilégier d'autres approches plus rentables sur ce plan-­‐là. METHODES Grâce à l'aide des dermatologues et à la base de données du Service de dermatopathologie du CHUV, nous nous proposons de faire une étude rétrospective et systématique, sur les 5 années passées, de toutes les biopsies cutanées compatibles avec le diagnostic de vasculite. RESULTATS ESCOMPTES Ils sont de deux ordres : déterminer d'une part si le résultat de la biopsie était compatible avec le diagnostic clinique retenu chez les patients ayant subi ce type d'examen. Cela nous permettra alors d'établir des recommandations pour la réalisation éventuelle d'une biopsie cutanée dans ce type de situation. Il sera en effet capital de savoir si ce geste est utile et, le cas échéant, s'il faut demander une biopsie profonde ou si une biopsie superficielle est suffisante. Ce travail nous permettra d'autre part de revoir les caractéristiques cutanées -­‐ sur le plan histopathologique -­‐ des vasculites, et de déterminer aussi leur fréquence. Dans l'idéal, ce travail devrait permettre de faire la revue et la mise à jour des connaissances dans le domaine des vasculites cutanées, utiles aux praticiens notamment.

Efeito da tibolona sobre parâmetros doplervelocimétricos das artérias oftálmica e retiniana

OBJETIVO: avaliar o efeito do uso da tibolona sobre os parâmetros doplervelocimétricos das artérias oftálmica e retiniana. MÉTODOS: realizou-se ensaio clínico, prospectivo, longitudinal, aleatorizado, controlado com placebo, duplo-cego, no qual dentre 100 mulheres na menopausa, 50 usaram o princípio ativo tibolona 2,5 mg (Grupo Tib) e 50, o placebo para formar o grupo controle (Grupo Plac). No Grupo Tib, das 50 mulheres que iniciaram o estudo, 44 retornaram após 84 dias para a finalização dos exames. No Grupo Plac retornaram 47 delas. As artérias oftálmica e retiniana foram estudadas, determinando-se o índice de resistência (IR), índice de pulsatilidade (IP) e relação sístole/diástole (S/D). As aferições foram feitas antes e 84 dias após a medicação. Utilizou-se o teste t de Student para amostras independentes na comparação das medianas entre os grupos e para amostras dependentes na comparação entre as medianas dentro do mesmo grupo. RESULTADOS: as características das mulheres nos dois grupos foram semelhantes em relação à idade, ao tempo de menopausa, ao índice de massa corporal, à pressão arterial, à paridade e à freqüência cardíaca. O Grupo Tib apresentou as seguintes medianas: IR(pré)=0,71±0,05, IR(pós)=0,72±0,08 (p=0,43); IP(pré)=1,29±0,22, IP(pós)=1,30±0,25 (p=0,4) e SD(pré)=3,49±0,77, SD(pós)=3,65±0,94 (p=0,32). Na artéria retiniana foram obtidas as seguintes medianas na artéria oftálmica: IR(pré)=0,67±0,09, IR(pós)=0,69±0,10 (p=0,7); IP(pré)=1,20±0,29, IP(pós)=1,22±0,3 (p=0,2) e SD(pré)=3,29±0,95, SD(pós)=3,30±1,07 (p=0,3). Os grupos tibolona e controle não apresentaram diferenças significantes nos índices quando avaliados ao final do estudo. CONCLUSÕES: a tibolona, na dose de 2,5 mg, não apresenta efeitos sobre os índices doppler das artérias oftálmica e retiniana.

Factores pronósticos en la agudeza visual final de pacientes con oclusión venosa retiniana tratados con terapia antiangiogénica

Objetivo: determinar los diferentes factores clínicos y de imagen pronósticos para la agudeza visual final a los 3, 6 y 12 meses en los pacientes con oclusiones venosas retinianas tratados con terapia antiangiogénica. Material y métodos: estudio longitudinal de una cohorte de 60 pacientes con oclusión venosa retiniana tratados con terapia antiangiogénica intravitrea con ranibizumab y bevacizumab tomados retrospectivamente entre 2010 y 2012. Posteriormente se realizó un estudio analítico de cohorte retrospectiva, para establecer la asociación y predicción de los cambios de la agudeza visual. Resultados: se encontró una diferencia estadísticamente significativa entre la línea base, 3, 6 y 12 meses post tratamiento. (p < 0.001, prueba de Friedman). En el modelo explicativo de los cambios de la agudeza visual a los 3, 6 y 12 meses con la línea base, se encontró asociación significativa la presencia de IS/OS a los 3 meses con los cambios de la agudeza visual a los 6 meses (r2=.232, p< 0.001) y a los 12 meses (r2=.506, p< 0.001), en este último también se encontró asociado el género masculino (r2=.277 p< 0.001). Tomando los valores de la agudeza visual a los 3,6 y 12 meses y como covariable la agudeza visual inicial se encontró asociación significativa en los tres momentos, 3 meses (r2=0.697, p< 0.001), 6 meses (r2=745, p< 0.001) y 12 meses y (r2=786, p< 0.001), se encontró asociación significativa el presentar oclusión venosa de rama comparada con oclusión central con los cambios de la agudeza visual a los 6 meses (r2=.662, p=0.04) Conclusión: la presencia de IS/OS a los 3 meses y la agudeza visual inicial tienen una alta capacidad predictora de la agudeza visual a los 6 y 12 meses, el género masculino tiene relación con mejoría de la agudeza visual final y la oclusión de rama tiene relación con la mejoría de la agudeza visual a 6 meses.

Centros subcorticais dos sistemas visual primário e óptico acessório no mocó (kerodon rupestris): caracterização pela projeção retiniana e citoarquitetura.

The primary and accessory optic systems comprise two set of retinorecipient neural clusters. In this study, these visual related centers in the rock cavy were evaluated by using the retinal innervations pattern and Nissl staining cytoarchigtecture. After unilateral intraocular injection of cholera toxin B subunit and immunohistochemical reaction of coronal and sagittal sections from the diencephalon and midbrain region of rock cavy. Three subcortical centres of primary visual system were identified, superior colliculus, lateral geniculate complex and pretectal complex. The lateral geniculate complex is formed by a series of nuclei receiving direct visual information from the retina, dorsal lateral geniculate nucleus, intergeniculate leaflet and ventral lateral geniculate nucleus. The pretectal complex is formed by series of pretectal nuclei, medial pretectal nucleus, olivary pretectal nucleus, posterior pretectal nucleus, nucleus of the optic tract and anterior pretectal nucleus. In the accessory optic system, retinal terminals were observed in the dorsal terminal, lateral terminal and medial terminal nuclei as well as in the interstitial nucleus of the superior fasciculus, posterior fibres. All retinorecipient nuclei received bilateral input, with a contralateral predominance. This is the first study of this nature in the rock cavy and the results are compared with the data obtained for other species. The investigation represents a contribution to the knowledge regarding the organization of visual optic systems in relation to the biology of species.

Caracaterização do núcleo pré-geniculado do sagüi (Callithrix jacchus) :projeção retiniana, neuroquímica e atividade celular (expressão de FOS)

In rodents, the suprachiasmatic nucleus (SCN) and the intergeniculate leaflet (IGL) are the main components of the circadian system. The SCN is considerate the site of an endogenous biological clock because can to generate rhythm and to synchronize to the environmental cues (zeitgebers) and IGL has been related as one of the main areas that modulate the action of SCN. Both receive projections of ganglion cells of retina and this projection to SCN is called retinohypothalamic tract (RHT). Moreover, the IGL is connected with SCN through of geniculohypothalamic tract (GHT). In primates (include humans) was not still demonstrated the presence of a homologous structure to the IGL. It is believed that the pregeniculate nucleus (PGN) can be the answer, but nothing it was still proven. Trying to answer that question, the objective of our study is to do a comparative analysis among PGN and IGL through of techniques immunohystochemicals, neural tracers and FOS expression after dark pulses. For this, we used as experimental model a primate of the new world, the common marmoset (Callithrix jacchus). Ours results may contribute to the elucidation of this lacuna in the circadian system once that the IGL is responsible for the transmission of nonphotic information to SCN and participate in the integration between photic and nonphotic stimulus to adjust the function of the SCN. In this way to find a same structure in primates represent an important achieve in the understanding of the biological rhythms in those animals

A Zona Incerta no sagüi (Callithrix jacchus): Análise Citoarquitetônica, Neuroquímica e Projeção Retiniana

The retinal projections in mammals usually reach, classically, three major functional systems: the primary visual system, the accessory optic system, and the circadian timing system. But the retinal projections also reach areas classically considered non-visual, one of which groups the neurons of the zona incerta (ZI), target this study. The primary visual system includes thalamic lateral geniculate complex is formed by the dorsal lateral geniculate nucleus, intergeniculate leaflet and the ventral lateral geniculate nucleus and other Components. The accessory optic system is composed of the small nuclei: nuclei terminal dorsal, lateral, medial and the interstitial nucleus of the superior posterior fasciculus. These nuclei are involved in visuo-motor activities. The circadian timing system is comprised of the suprachiasmatic nucleus of the hypothalamus, that act as master circadian pacemaker, entraining pathways and efferents pathways to the efectors, and the intergeniculate leaflet, that seems to act as a modulator of the pacemaker. The retinal projections too reach classically considered non-visual areas, including the zona incerta. This region is localized in the ventral thalamus and has been implicated in various functional properties including nociceptive and somatosensory processing, motor response, sociosexual behaviour, feeding and drinking, in symptoms of neurodegenerative diseases, arousal and attention. It also displays connection with several areas of central nervous system. The aim of this study was characterize the retinal projection in the zona incerta of Callithrix jacchus (sagüi), a primate of the New World through the anterograde axonal transport of the cholera toxin subunit b and analyze the citoarchicteture using Nissl and NeuN, and neurochemical substances such as serotonin, GABA, VIP, VP, GFAP and binding-calcium proteins. The zona incerta showed a different division of the literature in citoarquitetura, both by means of Nissl as neurochemical by NeuN, with a subdivision ventrolateral and dorsomedial. The neurochemical to the other substances corroborate with this subdivision. The GFAP was almost completely negative for the zona incerta, result non evidenced in previous studies yet. The 16 retinal projection in sagüi, unlike other primates and rodents, reached the caudal portion only. This work helps to make further studies are conducted based on this subdivision and the localization of the neurochemical substances associated with possible behaviors that the zona incerta is involved

O Núcleo genuíno lateral dorsal do tálamo do sagüi (callithrix jacchus): Pprojeção retiniana, caracterização citoarquitetônica e neuroquimica da principal estação visual primária.

The thalamus plays an important role in the sensorial processing information, in this particular case, the visual information. Several neuronal groups have been characterized as conductors and processors of important sensorial information to the cerebral cortex. The lateral geniculate complex is one to them, and appears as a group very studied once it is responsible, in almost all totality, for the processing of visual information. Among the nuclei that constitute the lateral geniculate complex we highlight the dorsal lateral geniculate nucleus of the thalamus (DLG), the main thalamic relay for the visual information. This nucleus is located rostral and lateral to medial geniculate nucleus and ventral to thalamic pulvinar nucleus in most of the mammals. In the primates humans and non-humans, it presents as a laminate structure, arranged in layers, when observed in coronal sections. The objective of this work was to do a mapping of the retinal projections and a citoarchictetonic and neurochemical characterization of DLG in the marmoset (Callithrix jacchus), a New World primate. The retinal projections were traced by anterograde transport of subunit b of cholera toxin (CTb), the citoarchicteture was described by Nissl method, and to neurochemical characterization immunohistochemicals technical were used to examine the main neurotransmitters and neuroatives substances present in this neural center. In DGL of marmoset thalamus, in coronal sections labeled by Nissl method, was possible to visualize the division of this nucleus in four layers divided in two portions: magnocellular and parvocellular. The retinal projections were present being visualized fibers and terminals immunorreactives to CTb (IR-CTb) in the DLG ipsilateral and contralateral. And through the immunohistochemicals techniques was observed that DLG contain cells, fibers and/or terminals immunoreactives against neuronal nuclear protein, subunits of AMPA 15 glutamate receptors (GluR1, GluR2/3, GluR4), choline acetyltransferase, serotonin, glutamic acid decarboxylase, binding calcium proteins (calbindin, parvalbumin and calretinin), vasopressin, vasoactive intestinal polypeptide, and an astrocyte protein, glial fibrillary acidic protein.

Projeção retiniana, caracterização citoarquitetônica e neuroquímica da zona incerta do moco (Kerodon rupestris)

The Zona Incerta (ZI) is embryologically derived from the ventral thalamus, in continuity with the reticular nucleus of the thalamus. Studies usingneural tracers technics have allowed identify a complex connectional map including the ZI. Futhermore, cytochemical, molecular and functional data have shown abundant variability in the neurochemical contend in the ZI, as well as,the involvement of the ZI in the modulation of nociception, attention, alertness, control and maintenance of posture and control of visceral activity. This work aims to characterize the cytoarchitecture, neurochemical content of the ZI in the rock cavy (Kerodon rupestris), and a direct retinal-ZI pathway present in this species. The Nissl staining is effective for the delineation and characterization of ZI citoarchitecture. ZIc receives a contralateral retinal projection showing varicosities, suggesting a modulatory character of photic information. The ZI in the rock cavy, as in others rodents and primates, is characterized by a complex neurochemical signature. The ZI neurochemistry presents great diversity, especially in the medial portion of ZIr, where we have found immunoreactivity of all neuroactive substances investigated, and that NOS-IR, GFAP and CR helped the delimitation of middle ZI in ZId and ZIv. Nevertheless, just 5-HT-IR fibers are present in all subdivisions of the ZI. These data demonstrate the great wealth of the neurochemistry of rock cavy s ZI and a direct retinal modulation in the ZI, helping to explain it s broad functional repertory

Vasculite necrosante na glomerulonefrite difusa aguda pós-infecciosa

Os autores relatam dois casos de glomerulonefrite difusa aguda pós-infecciosa com evolução clinicomorfológica incomum. As biópsias renais mostraram alterações características de glomerulonefrite difusa aguda associada à extensa necrose fibrinóide e infiltrado inflamatório leucocitário na parede de arteríolas e artérias interlobulares. Foram também observadas crescentes. Ambos os pacientes cursaram com insuficiência renal aguda severa, sendo que um dos pacientes recuperou a função renal e outro evoluiu para insuficiência renal crônica e óbito.