Síndrome de Chiari e Hidrossiringomielia com comprometimento neurológico: um relato de caso

A Malformação de Chiari (MC) pertence a um amplo grupo de raras deformidades estruturais da junção craniocerebelomedular. O tipo I da doença caracteriza-se pela herniação tonsilar ou amigdaliana cerebelar devido à anomalia da base do crânio e da parte superior da coluna cervical, além de a porção medial do lobo inferior do cerebelo pelo canal cervical também se protuberar através do forame magno, impedindo que o líquor flua normalmente através do canal. A real prevalência da doença é desconhecida, pois muitos pacientes com herniação cerebelar são assintomáticos e o problema agrava-se na fase adulta, com queixas de cefaleia intensa e, por vezes, parestesia. O objetivo deste estudo é relatar um caso de síndrome de Chiari (SC) em uma paciente de 53 anos, ao abordar sua apresentação clínica, diagnóstico e tratamento. Paciente do sexo feminino, 53 anos, foi admitida em um hospital da rede pública de referência se queixando de cefaleia occipital intensa e cervicalgia com irradiação da dor para os membros superiores, acompanhada de parestesia nos quatro segmentos. Relatou já sentir dor há 2 anos, mas apresentou piora do quadro clínico há 8 meses. Foi, também, observada incontinência urinária devido à dissinergia detrusora-esfincteriana por provável bexiga neurogênica. Foi, então, realizado exame de imagem de ressonância magnética (RNM) do crânio e da coluna cervical, com obtenção de sequências ponderadas em T1, T2 e STIR, nos planos sagital e transverso com contraste, o qual evidenciou leve alargamento medular, além de sinais de hidrossiringomielia difusa, com hipossinal na sequência T2 intramedular na altura de D1-D2 (coluna dorsal). Foi notada discreta herniação das tonsilas cerebelares junta ao forame magno, típica da SC, sendo, por fim, confirmado o diagnóstico. A paciente, no entanto, não apresentava hidrocefalia, mesmo com a interrupção do fluxo do líquido cefalorraquidiano (LCR) para o canal vertebral. Ela encaixou- se nos parâmetros de indicação cirúrgica, sendo realizada craniotomia occipital, com acesso ao plexo coroide do quarto ventrículo do tronco encefálico com o intuito de elevar as tonsilas cerebelares baixas, herniadas no canal espinhal cervical e bloqueando o fluxo do LCR. Após a descompressão craniocervical, o curso do líquor foi restaurado e a paciente foi, por fim, encaminhada à sala de recuperação pós-operatória. A SC é uma rara doença que apresenta quadro clínico e alterações radiológicas complexas e extensas e, por vezes, o diagnóstico é retardado devido à inespecificidade dos sintomas confundidos com cervicalgias e cefaleias comuns. A hipótese diagnóstica deve ser embasada nas queixas do paciente, na anamnese minuciosa, exame clínico e nos exames de imagens, sendo a prevalência desta patologia de difícil definição e com faixas etárias distintas

Plasma Cytokine Expression Is Associated with Cardiac Morbidity in Chagas Disease

Submitted by Nuzia Santos ([email protected]) on 2015-02-06T13:25:14Z No. of bitstreams: 1 2014_048.pdf: 2077033 bytes, checksum: 5c9786393949bf065beeeb0aad05f1bd (MD5)Approved for entry into archive by Nuzia Santos ([email protected]) on 2015-02-06T13:25:21Z (GMT) No. of bitstreams: 1 2014_048.pdf: 2077033 bytes, checksum: 5c9786393949bf065beeeb0aad05f1bd (MD5)Approved for entry into archive by Nuzia Santos ([email protected]) on 2015-02-06T14:27:57Z (GMT) No. of bitstreams: 1 2014_048.pdf: 2077033 bytes, checksum: 5c9786393949bf065beeeb0aad05f1bd (MD5)Made available in DSpace on 2015-02-06T14:27:57Z (GMT). No. of bitstreams: 1 2014_048.pdf: 2077033 bytes, checksum: 5c9786393949bf065beeeb0aad05f1bd (MD5) Previous issue date: 2014Universidade Federal de Minas Gerais. Faculdade de Medicina. Infectologia e Medicina Tropical. Belo Horizonte, MG, BrazilUniversidade Federal de Minas Gerais. Faculdade de Medicina. Infectologia e Medicina Tropical. Belo Horizonte, MG, Brazil/Universidade Federal de Minas Gerais. Instituto de Ciencias Biologicas. Departamento de Morfologia. Belo Horizonte, Minas Gerais, BrazilFundação Oswaldo Cruz. Centro de Pesquisas Rene Rachou. Laboratorio de Imunologia Celular e Molecular. Belo Horizonte, MG, BrazilUniversidade Federal de Minas Gerais. Instituto de Ciencias Biologicas. Departamento de Morfologia. Belo Horizonte, Minas Gerais, BrazilFundação Oswaldo Cruz. Centro de Pesquisas Rene Rachou. Laboratorio de Imunologia Celular e Molecular. Belo Horizonte, MG, BrazilUniversidade Federal de Minas Gerais. Instituto de Ciencias Biologicas. Departamento de Morfologia. Belo Horizonte, Minas Gerais, BrazilUniversidade Federal de Minas Gerais. Faculdade de Medicina. Infectologia e Medicina Tropical. Belo Horizonte, MG, BrazilFundação Oswaldo Cruz. Centro de Pesquisas Rene Rachou. Laboratorio de Imunologia Celular e Molecular. Belo Horizonte, MG, BrazilUniversidade Federal de Minas Gerais. Instituto de Ciencias Biologicas. Departamento de Morfologia. Belo Horizonte, Minas Gerais, BrazilFundação Oswaldo Cruz. Centro de Pesquisas Rene Rachou. Laboratorio de Imunologia Celular e Molecular. Belo Horizonte, MG, Brazil/Instituto Nacional de Ciencia e Tecnologia em Doenças Tropicais. Belo Horizonte, MG, BrazilUniversidade Federal de Minas Gerais. Faculdade de Medicina. Infectologia e Medicina Tropical. Belo Horizonte, MG, BrazilThe expression of immune response appears to be associated with morbidity in Chagas disease. However, the studies in this field have usually employed small samples of patients and statistical analyses that do not consider the wide dispersion of cytokine production observed in these patients. The aim of this study was to evaluate the plasma cytokine levels in welldefined clinical polar groups of chagasic patients divided into categories that better reflect the wide cytokine profile and its relationship with morbidity. Patients infected with Trypanosoma cruzi (T. cruzi) were grouped as indeterminate (IND) and cardiac (CARD) forms ranging from 23 to 69 years of age (mean of 45.6611.25). The IND group included 82 individuals, ranging from 24 to 66 years of age (mean of 39.6610.3). The CARD group included 94 patients ranging from 23 to 69 years of age (mean of 48612.52) presenting dilated cardiomyopathy. None of the patients have undergone chemotherapeutic treatment, nor had been previously treated for T. cruzi infection. Healthy non-chagasic individuals, ranging from 29 to 55 years of age (mean of 42.668.8) were included as a control group (NI). IND patients have a higher intensity of interleukin 10 (IL-10) expression when compared with individuals in the other groups. By contrast, inflammatory cytokine expression, such as interferon gamma (IFN-c), tumor necrosis factor alpha (TNF-a), interleukin 6 (IL-6), and interleukin 1 beta (IL-1b), proved to be the highest in the CARD group. Correlation analysis showed that higher IL-10 expression was associated with better cardiac function, as determined by left ventricular ejection fraction and left ventricular diastolic diameter values. Altogether, these findings reinforce the concept that a fine balance between regulatory and inflammatory cytokines represents a key element in the establishment of distinct forms of chronic Chagas disease

Correlation analysis between plasma IL-10 levels and echocardiographic variable markers of cardiac morbidity.

<p>Correlation analysis between plasma IL-10 levels and cardiac function variables (LVEF and LVDD) in the IND (n = 82, first column) and CARD (n = 94, second column) groups. Correlation analysis was performed using the Spearman correlation coefficient, and results were considered significant when <i>P</i><0.05. Significant differences (<i>P</i>-value) are indicated in each graph together with the <i>r</i> value.</p

Establishing the concept of low, medium and high cytokine producers.

<p>A) Representative scatter plot graph of plasma IL-10 used to establish the cut-off to define low, medium, and high cytokine producers. B) Representative scatter plot graph of plasma IFN-γ used to establish the cut-off edge to define low, medium, and high cytokine producers. C) Representative scatter plot graph of plasma TNF-α used to establish the cut-off to define low, medium, and high cytokine producers. D) Representative scatter plot graph of plasma IL-6 used to establish the cut-off to define low, medium, and high cytokine producers. E) Representative scatter plot graph of plasma IL-1β used to establish the cut-off to define low, medium, and high cytokine producers. Low cytokine producers were defined by values of lower than the first tertile. Medium cytokine producers were defined by values equal to or lower than the second tertile, while high cytokine producers were defined by values higher than or equal to the second tertile. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0087082#s3" target="_blank">Results</a> were considered significant with a <i>P</i>-value<0.05.</p

Analyses of plasma cytokine levels and their association with cardiac morbidity expressed by the clinical classification.

<p>The analysis of plasma levels was performed as described in the material and methods section. The groups evaluated were: NI (n = 24, white box), IND (n = 82, light gray box), and CARD (n = 94, dark gray box). The results were expressed by mean intensity of fluorescence (MIF). (A) Plasma IL-10 levels in NI, IND, and CARD groups and their association with cardiac morbidity. (B) Plasma IFN-γ levels in NI, IND, and CARD groups and their association with cardiac morbidity. (C) Plasma TNF-α levels in NI, IND, and CARD groups and their association with cardiac morbidity. (D) Plasma IL-6 levels in NI, IND, and CARD groups and their association with cardiac morbidity. E) Plasma IL-1β levels in NI, IND, and CARD groups and their association with cardiac morbidity. Significant differences (<i>P</i>-value<0.05) in the charts are identified by connecting lines and the symbol (*) for comparisons between the groups.</p

Correlation analysis between plasma IFN-γ, TNF-α, IL-6 levels, and echocardiographic variable markers of cardiac morbidity.

<p>A) Correlation analysis between plasma IFN-γ and cardiac function variables in the IND (n = 82, first column) and CARD (n = 94, second column) groups. B) Correlation analysis between plasma TNF-α and cardiac function variables in the IND (n = 82, first column) and CARD (n = 94, second column) groups. C) Correlation analysis between plasma IL-6 and cardiac function variables in the IND (n = 82, first column) and CARD (n = 94, second column) groups. Correlation analysis was performed using the Spearman correlation coefficient, and results were considered significant when <i>P</i><0.05. Significant differences (<i>P-</i>value) are indicated in each graph together with the <i>r</i> value.</p