Early Hepatic Encephalopathy after a Transjugular Intrahepatic Portosystemic Shunt Procedure: Case Report

Patients with decompensated hepatic cirrhosis may present systemic alterations and dysfunction of multiple organs. Ascites, portal hypertension, esophageal varices, and hepatic encephalopathy are common complications arising from cirrhosis. The aim of this paper is to report a case of a patient with liver cirrhosis and the complications of a transjugular intrahepatic portosystemic shunt. Male, elderly, and ex-alcoholic, diagnosed with liver cirrhosis, ascites, and esophageal varices. He underwent transjugular intrahepatic portosystemic shunt due to portal hypertension and returned to the hospital after 24 hours with agitation and mental confusion. He had a bowel movement stop, neurological worsening, loss of renal function, hepatic hydrothorax, hepatic encephalopathy, hypernatremia, hypocalcemia, and hypophosphatemia. He underwent a new procedure to occlude the transjugular intrahepatic portosystemic shunt, showing improvement of the mental status and ascites. However, continued with decompensation and hydro-electrolytic disorders. He evolved with worsening of the ventilatory pattern, and neurological and renal function, with a fatal outcome. Esophageal varices due to portal hypertension can be corrected with the transjugular intrahepatic portosystemic shunt. However, complications such as hypernatremia, hepatic hydrothorax, and hepatic encephalopathy may occur. Therefore, there is a need for reintervention to shunt or reduce its caliber. Thus, for patients with advanced age and decompensated cirrhosis, the potential risks and benefits of this procedure should be carefully evaluated due to the risk of complications and death.

Approach to Paroxysmal Atrial Fibrillation Type Arrhythmia in a Cardiology Service:A Case Report

Atrial fibrillation is a cardiac arrhythmia of high prevalence in the population, especially in the elderly. Its main electrical characteristics are the interval between two successive irregular R waves, absence of P waves and presence of f waves between QRS complexes. The most common symptoms of atrial fibrillation are irregular palpitations associated with dyspnea, dizziness, feeling tired, fatigue and general malaise, but not all patients have any symptoms. The present report presents the history of an elderly patient who arrived at the hospital’s emergency department with irregular heart rhythm and palpitations. The patient’s symptoms, associated with the electrocardiogram results, indicated paroxysmal atrial fibrillation. Electrical cardioversion was performed, and after, cardiac ablation via the femoral vein at the hospital’s cardiology service. There were no complications during the procedure. As a routine imaging exam after ablation, control esophagogastroduodenoscopy was requested to verify that there was no formation of atrio-esophageal fistula developed by the invasive ablation procedure and electrocardiogram, which showed normal sinus rhythm. The patient remained in the cardiac intensive care unit for observation for 24 hours. After the electrical cardioversion and catheter ablation procedures, the patient improved his clinical picture of atrial fibrillation and was discharged after 24 hours of hospitalization. He received treatment to perform at home, to reduce acid reflux into the esophagus and to prevent thrombosis. He did not present pulmonary thromboembolism after hospital discharge. It is believed, therefore, that this form of treatment and management of paroxysmal atrial fibrillation is effective for the solution of the proposed problem and can also serve as a reference for other professionals within the cardiology service.

Opportunistic Infections in Late Kidney Transplantation with Death Outcome: Case Report

Cytomegalovirus (CMV) and Pneumocystis jirovecii fungus are the main opportunistic microorganisms that affect transplanted individuals. Immunosuppressive drugs administered to prevent organ rejection leave the immune system vulnerable to these infections. The present report is about a kidney transplanted patient using immunosuppressants who was diagnosed with cytomegalovirus and pneumocystosis requiring admission to the intensive care unit (ICU). Female patient, 57 years old, a kidney transplanted three years ago, with comorbidities, such as systemic arterial hypertension, hypertriglyceridemia and type 2 diabetes mellitus. She was admitted to the hospital in January 2020 with a history of diarrhea, cough, malaise and weight loss of seven kg in a month. She made continuous use of the immunosuppressants tacrolimus® and mycophenolate sodium (MFS). After five days of hospitalization, she was transferred to the ICU due to refractory diarrhea, worsening renal function and respiratory pattern, requiring mechanical ventilation. Chest tomography showed changes that led to the diagnostic hypothesis of CMV pneumonia or Pneumocystis jirovecii. Treatment with Ganciclovir® and Bactrim® was started. The bronchial lavage polymerase chain reaction test confirmed the infectious condition for CMV and Pneumocystis jirovecii. Despite the drug therapy instituted, there was no improvement in the infectious condition. The patient started to present a general and progressive worsening of the clinical picture with loss of renal graft function, respiratory failure, metabolic acidosis, hemodynamic instability and severe distributive shock, evolving to death. In the present report, it was observed that after late kidney transplantation the fragility of the immune system caused by the use of immunosuppressants contributed to the development of a severe infection with CMV and Pneumocystis jirovecii. Adjusting the doses of immunosuppressants to individual needs can be an important measure for maintaining the proper immune system and consequently avoiding late opportunistic infections and death outcomes.

Non-Hodgkin’s Lymphoma Associated with Metastatic Lung Cancer: Case Report

Lymphomas are neoplastic transformations that affect lymphoid cells. Diffuse large B-cell non-Hodgkin’s lymphoma has a high degree of cell proliferation, accounting for 30% of all lymphomas. Lung cancer is the leading cause of death worldwide and the recommended treatment is chemotherapy. Among the main complications resulting from non-Hodgkin’s lymphoma, lung cancer and chemotherapy used in their treatment, we can mention sepsis, acute kidney injury and febrile neutropenia. Febrile neutropenia can occur by suppressing the production of neutrophils. Sepsis, a widespread infection, is the main cause of acute kidney injury, which can also be caused by hydroelectrolytic complications or by nephrotoxicity. This is a report of a smoking patient with metastatic lung cancer who sought care due to progressive dysphagia, cough with chest pain, fever, and lower airways critical obstruction due to mediastinal lymphadenopathy, being diagnosed with diffuse large B-cell non-Hodgkin’s lymphoma. The patient evolved to death because of a significant worsening of the ventilatory pattern of multifactorial cause, mainly due to sepsis, acute kidney injury, and febrile neutropenia. The patient had mostly classic characteristics of her comorbidities, however, the overlapping of interrelated comorbidities led to the outcome of death. What is unusual about the present case report is that the patient’s characteristics, such as age, sex, and ethnicity, are opposite to those described as risk factors for diffuse large B-cell non-Hodgkin’s lymphoma.

Advanced Stage Stuck Gland Adenocarcinoma:Case Report

Parotid gland adenocarcinoma is commonly a tumor of low malignancy and low incidence worldwide. The reported case shows the rapid progression of this tumor in an elderly patient and infrequent effects, such as a presentation of facial edema not commonly described in the medical literature. Patient was admitted to hospital in November 2019 with secretion and partial hearing loss in the right ear and infiltrative and stone lesion with initial skin ulceration in the right cervical region. After 42 days, he returned and was admitted to the intensive care unit with significant swelling of the face, hardened and hyperemic neck, difficulty in speech and inability to open the eye. He presented changes in the mobility of the speech and hearing organs, reduced laryngeal mobility, vocal changes, speech with altered articulation and severe oropharyngeal dysphagia with risk of bronchoaspiration. The patient was diagnosed in September 2019 with a parotid tumor (salivary gland adenocarcinoma T4). The medical team requested computed tomography, computed tomography angiography of the chest and cervical vessels and computed tomography of the neck, in addition to evaluation by the head and neck surgery service and general surgery. After analyzing the results, the medical team suggested a hypothesis of tumor invasion that could result in obstruction of local lymphatic drainage, something unusual in the evolution of this type of tumor. In addition, it was not possible to adhere to radiotherapy treatment due to the extent of the lesion and there was also no confirmation of metastases. The reported case shows us that parotid gland adenocarcinoma, when diagnosed in an advanced stage, can limit the approach to treatment. It was chosen in agreement with the family to proceed with palliative care without invasive measures. Palliative care may be the best option for cases like this, bringing some comfort to the patient and his family.