Wharton’s jelly absence: a possible cause of stillbirth

The umbilical cord is a structure that provides vascular flow between the fetus \ud and the placenta. It contains two arteries and one vein, which are surrounded \ud and supported by gelatinous tissue known as Wharton’s jelly. There are many \ud umbilical cord abnormalities that are related to the prognosis of fetus survival \ud and birth weight. The authors report a case of umbilical cord constriction due to \ud the localized absence of Wharton’s jelly, which was undiagnosed antenatally \ud and had a fatal outcome. A review of the association between the absence of \ud Wharton’s jelly and an unfavorable pregnancy outcome was undertaken

Hepatic necrosis associated with drug-induced hypersensitivity syndrome

Drug-induced hypersensitivity syndrome (DIHS; also known as drug reaction with eosinophilia and systemic symptoms [DRESS]) is a life-threatening condition first described by Chaikenetal. in 1950. It is characterized by extensive mucocutaneous rash; fever; lymphadenopathy; hepatitis; hematological abnormalities; damage to several organs such as kidney, heart, lungs, and pancreas; and possible reactivation of human herpesvirus-6 (HHV-6) or other herpes virus. Rare and severe cases may present hepatic necrosis, and about 15% of them result in death or liver transplantation. A hallmark of this syndrome is the late onset of symptoms after the drug exposure. The most common culprit drugs are the aromatic anticonvulsants (in almost 30% of the cases) and the antibiotics (which in some series represent 20% of the cases). The authors report a case of a 41-year-old female who presented to the emergency department with erythroderma, acute hepatitis, acute pancreatitis and acute renal failure, and was then treated with corticosteroid after the diagnosis of DIHS/DRESS. A specific culprit drug could not confidently be determined due to the presence of multiple drugs used by the patient. The clinical and laboratory outcome was apparently satisfactory, but unexpectedly, on the sixth day of hospitalization, the patient complained of nonspecific malaise, drowsiness, which progressed in a few hours with signs and symptoms of hepatic failure, refractory shock, and death. The autopsy findings showed submassive hepatic necrosis, and the immediate cause of death was attributed to hepatic failure

Blood flow velocity in monocular retinoblastoma assessed by color doppler

OBJECTIVE: To analyze the flow of retrobulbar vessels in retinoblastoma by color Doppler imaging. METHODS: A prospective study of monocular retinoblastoma treated by enucleation between 2010 and 2014. The examination comprised fundoscopy, magnetic resonance imaging, ultrasonography and color Doppler imaging. The peak blood velocities in the central retinal artery and central retinal vein of tumor-containing eyes (tuCRAv and tuCRVv, respectively) were assessed. The velocities were compared with those for normal eyes (nlCRAv and nlCRVv) and correlated with clinical and pathological findings. Tumor dimensions in the pathological sections were compared with those in magnetic resonance imaging and ultrasonography and were correlated with tuCRAv and tuCRVv. In tumor-containing eyes, the resistivity index in the central retinal artery and the pulse index in the central retinal vein were studied in relation to all variables. RESULTS: Eighteen patients were included. Comparisons between tuCRAv and nlCRAv and between tuCRVv and nlCRVv revealed higher velocities in tumor-containing eyes (

Strongyloides stercoralis disseminated infection and schistosomiasis in an AIDS patient

Strongyloides stercoralis hyperinfection syndrome is classically associated with impaired host response and implies in an overburden of larvae in its usual cycle. It has been recognized as a severe and potentially fatal condition in immunocompromised individuals, especially those using oral corticosteroids. Infection with Schistosoma mansoni not only increases the susceptibility to HIV infection, but also promotes progression to disease. The association of the most severe forms of strongyloidiasis and AIDS is scarcely described, even more when S. mansoni is also associated. The authors describe a case of a 34-year-old previously healthy male, admitted to the emergency department with a history of hematemesis associated with dyspnea, hemoptysis, and fever. He referred homosexual relations for 6 years. Physical examination showed an ill-looking patient, and was remarkable for tachycardia, tachypnea, diaphoresis, and pulse oximetry of 70% in room air. Lungs examination revealed the presence of rales in the left base. Chest radiography showed a diffuse and bilateral reticulo-nodular pattern. HIV serology was positive. Empirical antimicrobial therapy and corticosteroids were initiated. On the third day of hospitalization, petechiae appeared over the periumbilical area, but no further investigation was undertaken because the patient died soon after. The autopsy findings were compatible with S. stercoralis disseminated infection, a hepatic intestinal chronic form of schistosomiasis, and septic shock as the primary cause of death. The authors call attention to this infrequent association

Is 2-mm Punch Biopsy Useful in the Diagnosis of Malignant Eyelid Tumors?

Purpose: Two-millimeter punch biopsy is a swift and practical diagnostic tool in the outpatient setting. However, few studies have evaluated the efficacy of the method for diagnosis of malignant eyelid tumors. Methods: This was an observational study of patients with suspicion of malignant eyelid tumor attending the Ocular Plastic Surgery Center at Hospital das Clinicas, University of Sao Paulo School of Medicine. Following standard procedures, preoperative biopsies were taken with a 2-mm trephine and surgical excision was performed with safety margins, followed by reconstruction. Anatomopathologic analysis of the surgical specimen was used as gold standard to evaluate the accuracy of diagnosis by punch biopsy. Results: The study included 50 periocular tumors with suspicion of malignancy. The indicators of efficacy in the identification of malignancy by 2-mm punch biopsy were: sensitivity 88%, specificity 100%, positive predictive value 100%, and negative predictive value 64%. Accuracy was 90% for malignancy and 80% for histologic type. The. index of agreement between the diagnostic methods was 0.722 (p < 0.001). Conclusion: A positive result with 2-mm punch biopsy is a safe indication for surgical excision of the tumor, whereas a negative result does not necessarily imply benignity. In cases of high clinical suspicion, a second biopsy should be taken from a different part of the tumor to rule out malignancy. (Ophthal Plast Reconstr Surg 2012;28:282-285

Lesão palpebral como manifestação primária do lúpus eritematoso discóide

O lúpus eritematoso discóide é uma desordem autoimune que geralmente afeta áreas da pele expostas ao sol. A apresentação de lesões palpebrais na ausência de outras anormalidades cutâneas é incomum, sendo o envolvimento da pálpebra inferior prevalente em apenas 6% dos pacientes com lúpus eritematoso cutâneo crônico. Relatamos o caso de uma paciente do sexo feminino de 40 anos, com hiperemia, madarose e ulceração na pálpebra inferior do olho esquerdo refratária ao tratamento para blefarite. Inicialmente, outra lesão semelhante havia sido descrita na pálpebra superior do olho direito. No entanto, as biópsias incisionais mostraram-se inconclusivas. Diante de uma lesão migratória palpebral de características semelhantes à primeira, a hipótese clínica de lúpus eritematoso discóide foi aventada e o diagnóstico confirmado por meio de revisão histopatológica. Uma forte suspeita clínica e o reconhecimento precoce podem evitar erros diagnósticos, complicações clínicas e tratamentos inapropriados, como descrito neste caso de lesão palpebral como manifestação primária do lúpus eritematoso discóide

Lesão palpebral como manifestação primária do lúpus eritematoso discóide Eyelid lesion as a primary manifestation of discoid lupus erythematosus

O lúpus eritematoso discóide é uma desordem autoimune que geralmente afeta áreas da pele expostas ao sol. A apresentação de lesões palpebrais na ausência de outras anormalidades cutâneas é incomum, sendo o envolvimento da pálpebra inferior prevalente em apenas 6% dos pacientes com lúpus eritematoso cutâneo crônico. Relatamos o caso de uma paciente do sexo feminino de 40 anos, com hiperemia, madarose e ulceração na pálpebra inferior do olho esquerdo refratária ao tratamento para blefarite. Inicialmente, outra lesão semelhante havia sido descrita na pálpebra superior do olho direito. No entanto, as biópsias incisionais mostraram-se inconclusivas. Diante de uma lesão migratória palpebral de características semelhantes à primeira, a hipótese clínica de lúpus eritematoso discóide foi aventada e o diagnóstico confirmado por meio de revisão histopatológica. Uma forte suspeita clínica e o reconhecimento precoce podem evitar erros diagnósticos, complicações clínicas e tratamentos inapropriados, como descrito neste caso de lesão palpebral como manifestação primária do lúpus eritematoso discóide.The discoid lupus erythematosus is an autoimmune disorder which generally affects the sun-exposed skin. Presentation of lesions on the eyelids in the absence of any other cutaneous abnormality is uncommon and the lower-eyelid involvement is seen in 6% of patients with cronic cutaneous lupus erythematosus. We have reported the case of a 40 year-old, woman who presented hyperemia, madarosis and ulceration on the lower eyelid of the left eye. She was treated for blepharitis without resolution. Before that, another similar lesion had been described on the upper eyelid of the right eye. Nevertheless, the incisional biopsies of that eyelid were inconclusive. Faced with a migratory lesion similar to the first one, the clinical hypothesis of discoid lupus erythematosus was suggested and diagnosis was confirmed by histopathological review. A high index of suspicion and early recognition may prevent misdiagnosis, clinical complications and inappropriate treatment, as described in the case of eyelid lesion as a primary manifestation of discoid lupus erythematosus