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Resumen La hipercalcemia maligna mediada por péptido relacionado con hormona paratiroidea (PR-PTH) es una manifestación poco común en tumores neuroendocrinos. Presentamos dos pacientes con tumores neuroendocrinos de páncreas con metástasis a hígado pero sin compromiso óseo en quienes se evidenció hipercalcemia maligna asociada a elevación de PR-PTH, con PTH suprimida. En ambos casos se logró normalizar temporalmente la calcemia con el uso de análogos de somatostatina, pero durante la evolución se requirió adición de bisfosfonatos en uno de ellos. Con la discusión de estos casos, la revisión de la literatura y de los casos similares publicados esperamos contribuir al mejor conocimiento de esta enfermedad. Abstract Parathyroid hormone-related peptide-mediated hypercalcaemia (PTH-rp) is rare in patients with neuroendocrine tumours. The clinical cases are thus presented on two patients with pancreatic neuroendocrine tumours with liver metastases, but without bone involvement and with hypercalcaemia associated with elevated PTH-rp and with PTH suppressed. In both cases, it was possible to temporarily bring the calcium levels back to normal with the use of somatostatin analogues, but during the course of the disease, the addition of bisphosphonates was required in one of them. With the discussion of these cases and the review of the literature and similar published cases, it is hoped to contribute to provide better knowledge of this disease.

SUMMARY Hypercalcemia associated with silicone-induced granuloma is a rare disease. Diagnosis can be tricky as it is established after ruling out other hypercalcemia-causing entities. In addition, management is customized depending on the patient's wishes and possible solutions. We present a male bodybuilder, in his thirties, with multiple silicone injections in his upper extremities, who developed hypercalcemia and urinary symptoms. Advanced laboratory tests ruled out various causes of hypercalcemia and CT imaging revealed nephrocalcinosis. A biopsy of the upper arm showed granulomatous tissue and inflammation. The patient necessitated two sessions of dialysis and corticosteroids were given to relieve symptoms and reverse laboratory abnormalities. Silicone-induced hypercalcemia should be on high alert because of the increasing trend of body contour enhancements with injections, implants and fillers. Treatment should be optimized depending on the patient's needs and condition. RESUMO A hipercalcemia associada ao granuloma induzido por silicone é uma doença rara. O diagnóstico pode ser complicado, pois é estabelecido depois de eliminadas outras entidades que causam hipercalcemia. Além disso, o gerenciamento é personalizado, dependendo dos desejos do paciente e das possíveis soluções. Apresentamos um fisiculturista masculino, com trinta e poucos anos, múltiplas injeções de silicone nas extremidades superiores, que desenvolveu hipercalcemia e sintomas urinários. Testes laboratoriais avançados descartaram várias causas de hipercalcemia e a imagem da TC revelou nefrocalcinoses. Uma biópsia da parte superior mostrou tecido granulomatoso e inflamação. O paciente exigiu duas sessões de diálise e foram administrados corticosteroides para aliviar os sintomas e reverter as anormalidades laboratoriais. A hipercalcemia induzida por silicone deve estar em alerta elevado devido à crescente tendência de aprimoramentos do contorno corporal com injeções, implantes e enchimentos. O tratamento deve ser otimizado de acordo com as necessidades e condições do paciente.

Resumen: Las estrategias nutrieionales para prematuros extremos con alto aporte de proteínas, han mostrado alteraciones metabólicas con hipofosfemia precoz, especialmente en el grupo de pacientes con res tricción de crecimiento intrauterino (Rein). También se presenta hipofosfemia tardía, característica de la enfermedad metabólica ósea. En este artículo se revisan y actualizan conceptos en relación a la fisiopatología del metabolismo del fósforo en recién nacidos prematuros y uso de parenterales preco ces en el contexto de enfermedad metabólica ósea. Los artículos fueron identificados en base de datos electrónicas como Pubmed y Rima. Fueron incluidos artículos en inglés y español. Fueron filtrados por título y resumen. La literatura actual propone diversas estrategias de nutrición precoz que per mitan asegurar una adecuada cantidad de nutrientes para continuar con el crecimiento y desarrollo extrauterino. En pacientes con nutrición parenteral pero con diferentes aportes de fósforo, o relación calcio: fósforo inadecuada, a mayor contenido de aminoácidos, se presenta hipofosfemia, hipercalcemia, hipomagnesemia, hipokalemia e hiperglicemia, especialmente en casos de Rein. Estas alteraciones se asocian a prolongación de ventilación mecánica, mayor riesgo de displasia broncopulmonar y aumento de sepsis tardía. La hipofosfemia tardía, descrita ya hace muchos años, se presenta con normocalcemia y aumento de fosfatasas alcalinas, en la enfermedad metabólica ósea del prematuro, con alteración de la mineralización en distintos grados, secundaria a un inadecuado aporte de este mineral para los altos requerimientos de estos pacientes. Esta presentación de hipofosfemia precoz y tardía en el prematuro alerta sobre el control oportuno de fosfemia para ajustar el aporte nutricional. En el prematuro con nutrición parenteral precoz, el control en conjunto con la calcemia en la primera semana de vida, especialmente en Rein, permite tratar la hipofosfemia y prevenir sus complicacio nes. En hipofosfemia tardía, el seguimiento semanal o quincenal desde las 4 semanas a los prematuros con riesgo, permite lograr un aporte óptimo de minerales. Abstract: New nutritional approaches to treat extreme premature babies have demonstrated relevant eviden ce of metabolic disturbances with early hypophosphatemia, especially in patients with intrauterine growth restriction (IUGR). They have shown late hypophosphatemia, as well, which is characteristic in the metabolic bone disease. A sytematic search of literature describing metabolic disturbances of phosphorus in preterm newborns is presented, related to the use of early parenteral nutrition and also in the context of metabolic bone disease. The articles were gathered from electronic data bases, such as PubMed and Rima. We include articles in english and spanish which were selected by titles and abstracts. Several strategies for early nutrition have been proposed in order to ensure an adequate amount of nutrients to accomplish the development and growth of preterm babies. Patients with parenteral nutrition support with different doses of phosphate, or inadequate calcium phosphate relation, or an increased amino acid content, may present hypophosphatemia, hypercalcemia, hy pomagnesemia, hypokalemia and hyperglycemia, all of these are additionally noteworthy in the pre sence of intrauterine growth restriction. Furthermore, said alterations are associated with prolonged mechanical ventilation, as well as bronchopulmonary dysplasia and increase in late onset sepsis. The late hypophosphatemia, described several years ago, arises as normocalcemia and as an increment of alkaline phosphatases in the metabolic bone disease in preterm babies, and also with an inadequate mineralization in different grades, secondary to an inadequate supply due to high nutritional requi rements in these patients. When early or late hypophosphatemia appears in preterm babies, it shall require timely control of phosphemia and will need to adjust the nutritional intake in order to correct it. In case of preterm babies with early parenteral nutrition it will also need a control of calcemia in the first week of birth, especially if those belonging to the IUGR group. Adjustment must be made along with metabolic follow up, as well. In late hypophosphatemia, a weekly or every two weeks fo llow up will be a must for all preterm babies in risk and they should be given supplements to get an optimum mineral supply.

Resumen: La necrosis grasa subcutánea es una paniculitis poco frecuente, autorresolutiva, que afecta generalmente neonatos de término en las primeras semanas de vida. Se han identificado ciertos factores de riesgo para su desarrollo como asfixia perinatal, hipotermia y aspiración de meconio. Sus complicaciones son infrecuentes, dentro de éstas se destaca la hipercalcemia por su gravedad. Se presenta el caso de un recién nacido que presentó necrosis grasa subcutánea. El diagnóstico se realizó en base a la clínica y el estudio histopatológico. El paciente evolucionó favorablemente con regresión de las lesiones sin complicaciones. Summary: Subcutaneous fat necrosis is a rare, self-limiting panniculitis, which usually affects full term infants in the first weeks of life. There are several risk factors for its development such as perinatal asphyxia, hypothermia and meconium aspiration. Its complications are unusual, hypercalcemia being the most severe one among all. The study reports the case of a full term new born that presented subcutaneous fat necrosis. The diagnosis was based on clinical findings and histopathological study. The patient improved with regression of lesions, without complications.

Vitamin D intoxication caused by the irregular consumption of medications is a major concern in geriatric health. Due to errors in administering such vitamins and medical malpractice, many patients lack the proper management of vitamin supplementation, considering what is actually prescribed. The present study, which aims to report on intoxication by this vitamin, describes an elderly couple who lived alone and divided their household tasks. The wife, who is the main focus of the report, was lucid but suffered musculoskeletal disorders and used a wheelchair, while the husband could function physically. The wife was hospitalized with a clinical profile of delirium. Intoxication is a major cause of metabolic encephalopathy, which explains how the case developed. The co-adjuvant was the husband, who suffered apparent mild cognitive impairment, and modified the doctor's dosage of vitamin D alone, contradicting the guidance of the family. The family monitored the health status of the couple through weekly telephone calls to check if their medications were being taken properly. After investigation with new anamneses and a review of medical records, intoxication was confirmed due to an error in the amount of the drug administered over a prolonged period. It is extremely important to be aware of the clinical profile of hypercalcemia and how to treat the same. In geriatrics, diagnosis should involve both clinical treatment and special care to understand the daily routine of elderly persons in order to avoid further repercussions. Resumo A intoxicação por vitamina D merece ser destacada em geriatria devido ao consumo irregular de medicamentos. Muitos pacientes não têm manejo competente da suplementação vitamínica comparada a real prescrição, tanto na administração quanto por negligência médica. Este artigo, que tem como objetivo relatar sobre a intoxicação por essa vitamina, mostra o cenário de um casal de idosos que moravam sozinhos, dividindo as tarefas domiciliares, sendo que a esposa tinha uma mente lúcida e o marido um corpo funcionante, para que se estabelecesse a vivência. A esposa, alvo principal do relato, possuía distúrbios osteomusculares em condição de cadeirante, assim a vitamina D se fazia necessária, e se apresentou na internação com o quadro clínico de delirium. Destaca-se que essa intoxicação é importante causa de encefalopatia metabólica, o que explica o seguimento do caso. O coadjuvante foi o marido, com aparente distúrbio cognitivo leve, que modificou por conta própria a posologia da vitamina D indicada pelo médico, apesar da orientação da família. A família fazia controle da situação da saúde do casal através de ligações telefônicas semanais, conferindo se as medicações estavam sendo apropriadamente tomadas. Após investigação com novas anamneses e revisão de prontuário, ficou confirmada a intoxicação devido a um erro de quantidade de administração da droga por tempo prolongado. É de extrema importância que se tenha conhecimento sobre o quadro clínico da hipercalcemia e como manuseá-lo. Em geriatria, o diagnóstico deve ter a solução clínica somada a um cuidado especial de entender o que ocorre no cotidiano da pessoa idosa para que assim se evite novas repercussões.

New nutritional approaches to treat extreme premature babies have demonstrated relevant eviden ce of metabolic disturbances with early hypophosphatemia, especially in patients with intrauterine growth restriction (IUGR). They have shown late hypophosphatemia, as well, which is characteristic in the metabolic bone disease. A sytematic search of literature describing metabolic disturbances of phosphorus in preterm newborns is presented, related to the use of early parenteral nutrition and also in the context of metabolic bone disease. The articles were gathered from electronic data bases, such as PubMed and Rima. We include articles in english and spanish which were selected by titles and abstracts. Several strategies for early nutrition have been proposed in order to ensure an adequate amount of nutrients to accomplish the development and growth of preterm babies. Patients with parenteral nutrition support with different doses of phosphate, or inadequate calcium phosphate relation, or an increased amino acid content, may present hypophosphatemia, hypercalcemia, hy pomagnesemia, hypokalemia and hyperglycemia, all of these are additionally noteworthy in the pre sence of intrauterine growth restriction. Furthermore, said alterations are associated with prolonged mechanical ventilation, as well as bronchopulmonary dysplasia and increase in late onset sepsis. The late hypophosphatemia, described several years ago, arises as normocalcemia and as an increment of alkaline phosphatases in the metabolic bone disease in preterm babies, and also with an inadequate mineralization in different grades, secondary to an inadequate supply due to high nutritional requi rements in these patients. When early or late hypophosphatemia appears in preterm babies, it shall require timely control of phosphemia and will need to adjust the nutritional intake in order to correct it. In case of preterm babies with early parenteral nutrition it will also need a control of calcemia in the first week of birth, especially if those belonging to the IUGR group. Adjustment must be made along with metabolic follow up, as well. In late hypophosphatemia, a weekly or every two weeks fo llow up will be a must for all preterm babies in risk and they should be given supplements to get an optimum mineral supply.

O adenocarcinoma das glândulas apócrinas dos sacos anais em cães é uma neoplasia de carácter maligno, com taxas de metastização de 36 até 96%. O objectivo deste estudo foi comparar os métodos de condução de casos de adenocarcinoma das glândulas apócrinas dos sacos anais num hospital de referência, em cirurgia de tecidos moles, no Reino Unido, com a metodologia descrita na literatura de evidência médica atual. O presente estudo incluiu a documentação de 4 casos de cães presentes à consulta de especialidade cirúrgica com queixa compatível com adenocarcinoma das glândulas apócrinas dos sacos anais no hospital veterinário Rosemary Lodge. Dois dos pacientes eram da raça Labrador Retriever, que pode ter sido devido à popularidade da raça em Inglaterra. A maioria dos sinais clínicos não eram específicos nem sistémicos, no entanto todos os pacientes apresentaram hipercalcémia nas análises clínicas, o que está descrito como um síndrome paraneoplásico neste tipo de tumor. Neste estudo constatou-se que os casos de AGASA foram conduzidos apenas com uma abordagem cirúrgica, não tendo sido submetidos a tratamento adjuvante segundo as guidelines recomendadas pelos especialistas em Oncologia. Conclui-se que é necessário consciencializar a comunidade veterinária, de forma a que os casos oncológicos sejam uniformemente referenciados para tratamentos adjuvantes ou coadjuvantes como descritos na literatura médica., Apocrine gland anal sac adenocarcinoma (AGASAC) in dogs is a malignant neoplasm with metastatic rates described from 36 to 96%. The goal of this study was to compare the approach on cases of apocrine glands of the anal sac adenocarcinoma from a Soft Tissue Referral hospital, in the United Kingdom, with the approach described in the evidence-based literature. The present study consisted on the description of 4 canine clinical cases that were presented to a Soft Tissue Surgery referral consultation at the Veterinary Hospital Rosemary Lodge with a complaint compatible with apocrine glands anal sac adenocarcinoma. Two pacients were of the Labrador Retriever breed, which may have been due to the breed popularity in United Kingdom. Clinical signs were often nonspecific nor systemic, although all the pacients presented hypercalcemia in the blood work, which has been described as a paraneoplasic syndrome in this type of tumour. In this study, it was found that the cases of AGASAC were conducted on a surgical approach only, and didn´t receive adjuvant treatment following the current oncology guidelines. Is has been sugested that it is necessary to increase awareness, so that oncology cases should be referred for adjuvant treatments as described in medical literature., Orientação: Joana de Oliveira ; co-orientação: Ana Rita Serras

Orientador: Marcelo Lopes de Lima Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas Resumo: Introdução: O hiperparatireoidismo é uma complicação comum da doença renal crônica e pode persistir em 20 a 50% dos casos após o transplante renal, manifestando-se com hipercalcemia e hipofosfatemia. O hiperparatireoidismo persistente está associado com aumento da incidência de eventos cardiovasculares, fratura e morte. As opções terapêuticas atualmente disponíveis são a cirurgia de paratireoidectomia e a terapia medicamentosa com o agente calcimimético cinacalcete. Métodos: Estudo retrospectivo controlado de centro único incluindo receptores adultos de transplante renal que desenvolveram hipercalcemia devido ao hiperparatireoidismo persistente. Critérios para tratamento: aumento do PTH com cálcio sérico maior que 11 mg/dl a qualquer momento após o transplante ou cálcio sérico persistentemente acima de 10,2 mg/dl um ano após o transplante renal. Os pacientes tratados com cinacalcete (n=46) foram comparados com pacientes tratados com paratireoidectomia (n=30). O período de seguimento foi de um ano. Foram analisados dados demográficos e laboratoriais. No grupo cinacalcete também foram analisados episódios de rejeição aguda e a tolerância ao medicamento. Resultados: A paratireoidectomia controlou a calcemia mais rapidamente e alcançou níveis significativamente menores; a paratireoidectomia levou a níveis significativamente maiores de fosforo sérico e normalizou o PTH. O cinacalcete, apesar de controlar o cálcio e o fósforo, não corrigiu o PTH. Não houve diferença na resposta ao cinacalcete quando subgrupos estratificados pelo PTH (? 700 pg/ml vs. > 700 pg/ml) ou tamanho da glândula paratireoide (< 1,0 cm vs. > 1,0 cm) foram analisados. Pacientes tratados com cinacalcete tiveram melhor função renal ao final do período de seguimento. A droga foi bem tolerada e nenhum episódio de rejeição foi documentado. Conclusões: A paratireoidectomia foi superior ao cinacalcete para corrigir os distúrbios metabólicos do hiperparatireoidismo; entretanto, esteve associada com pior função renal ao longo do seguimento e alta incidência de hipoparatireoidismo pós-cirúrgico. O cinacalcete se mostrou seguro e bem tolerado Abstract: Background: Hyperparathyroidism is a frequent complication in chronic kidney disease and may persist after transplant in 20 to 50% of cases, manifest by hypercalcemia and hypophosphatemia. Persistent disease is associated with an increase in the incidence of cardiovascular events, fracture and death. Therapeutic options currently available are parathyroidectomy (PTX) and therapy with calcimimetic agent cinacalcet. Methods: Single-center retrospective study including adult renal transplant recipients who developed hipercalcemia due to persistent hyperparathyroidism. Criteria for treatment: Elevated PTH with serum calcium > 11 mg/dL at any time after transplantation or serum calcium persistently higher than 10.2 mg/dl one year after transplantation. Patients treated with cinacalcet (n = 46) were compared to patients treated with parathyroidectomy (n = 30). The follow up period was 1 year. Demographic and laboratory data were analyzed. In the cinacalcet group, episodes of rejection and medication tolerance were also analyzed. Results: PTX controlled the calcemia faster and reached significantly lower levels in the long term; PTX showed significantly higher levels of serum phosphate and returned PTH to normal levels. Cinacalcet, despite of controlling calcium and phosphorus in the long term, did not correct PTH. There was no difference in response to cinacalcet when subgroups were stratified by PTH (? 700 pg/ml vs. > 700 pg/ml) or parathyroid gland size (< 1,0 cm vs. > 1,0 cm). Patients treated with cinacalcet had better renal function. The drug was well tolerated and no rejection episode was detected. Conclusions: Parathyroidectomy was superior to cinacalcet to correct the metabolic disorders of hyperparathyroidism; however, it was associated with worse renal function in the long term and high incidence of post-surgical hypoparathyroidism. Cinacalcet proved to be a safe and well tolerated drug Mestrado Fisiopatologia Cirúrgica Mestre em Ciências

Introduction: Primary hyperparathyroidism in pregnancy is rare. Increased risk of fetal death, miscarriage, preterm delivery, preeclampsia and hypocalcemia of the neonate are potential complications. Cure is obtained with parathyroidectomy in the 2nd trimester but correction of hypercalcemia is essential. Case presentation: We present a case of a 31-year-old woman with a history of renal lithiasis, high PTH (171.4 pg/mL), hypercalcemia (11.3 mg/dL), and hypophosphatemia (1.9 mg/dL), with no parathyroid localization in the cervical ultrasound. Bone densitometry and scintigraphy were requested but the patient did not perform those exams because of unexpected pregnancy. Despite strict hydration and forced diuresis, the hypercalcemia got worse and the patient became more symptomatic. Exploratory surgery was refused and therefore, medical management was explored. The patient was treated with pamidronate, with consequent normalization of serum calcium and improvement of symptoms. A female child was born at 37 weeks of gestation without complications. The parathyroid scintigraphy with Tc99m-sestambi performed after delivery showed a focus of increased tracer uptake inferiorly to the left lobe of the thyroid gland. The patient was submitted to a radioguided parathyroidectomy. The pathological anatomy examination revealed a parathyroid adenoma. Conclusions: The pregnancy raised difficulties in locating the anomalous parathyroid(s). After the surgical option was eliminated, the difficulty was to choose the most balanced medical treatment to control the maternal calcium levels without fetal harm. The use of loop diuretics and bisphosphonates had been shown to be effective in controlling hypercalcemia until the end of pregnancy.

Hypercalcemia is a rare metabolic disorder in children and is potentially fatal. It has a wide differential diagnosis, including cancer. Here, we report the case of a previously healthy 3-year-old who was admitted to the emergency room with fatigue, hyporeactivity, fever and limping gait that had evolved over 5 days and that was progressively worsening. On examination the patient was unconscious (Glasgow coma score: 8). Laboratory tests indicated severe hypercalcemia (total calcium 21.39mg/dL, ionized calcium 2.93mmol/L) and microcytic anemia. Hyperhydration was initiated, and the child was transferred to the pediatric intensive care unit. Continuous venovenous hemodiafiltration with calcium-free solution was instituted, which brought progressive normalization of serum calcium and an improved state of consciousness. Zoledronate was administered, and metabolic and infectious causes and poisoning were excluded. The bone marrow smear revealed a diagnosis of acute lymphoblastic leukemia. Hypercalcemia associated with malignancy in children is rare and occurs as a form of cancer presentation or recurrence. Continuous venovenous hemodiafiltration should be considered in situations where there is imminent risk to life.

Los hallazgos de hipercalcemia, lesiones líticas craneales, anemia de trastornos crónicos y lesión renal aguda, suelen ser característicos del mieloma múltiple. En el presente documento se describe un caso interesante de linfoma anaplásico de células grandes con características que imitaban un mieloma múltiple., The findings of hypercalcemia, cranial lytic lesions, anemia of chronic disorders and acute renal injury are often characteristic of multiple myeloma. Here we describe an interesting case of large cell anaplastic lymphoma with features mimicking multiple myeloma.

A previously healthy 24 yo male presented with a two-month history of epigastric pain, nausea, vomiting, fatigue and malaise. He reported abuse of different substances, including an injectable veterinary vitamin compound, which contains high doses of vitamin A, D and E, and an oily vehicle that induces local edema and enhances muscle volume. Serum creatinine was 3.1 mg/dL, alanine transaminase 160 mg/dL, aspartate transaminase 11 mg/dL, total testosterone 23 ng/dL, 25-OH-vitamin D >150 ng/mL (toxicity >100), 1,25-OH-vitamin D 80 pg/mL, vitamin A 0.7 mg/dL, parathormone 150 ng/mL (toxicidade > 100), 1,25-OH-vitamina D 80 pg/mL, vitamina A 0,7 mg/dL, paratormônio < 3 pg/mL, cálcio total 13,6 mg/dL, cálcio urinário de 24h 635 mg/24h (VR 42-353). Uma ultrassonografia do trato urinário demonstrou sinais de nefropatia parenquimatosa. O diagnóstico foi hipercalcemia e insuficiência renal aguda secundária a intoxicação por vitamina D. Ele foi tratado inicialmente com hidratação intravenosa, furosemida e prednisona. No quinto dia de hospitalização uma dose de pamidronato dissódico foi adicionada. O paciente evoluiu com normalização do cálcio sérico e da função renal. Trinta dias depois ele apresentou testes clínicos e laboratoriais normais, exceto a 25-OH-vitamina D que estava persistentemente elevada (107 ng/mL), já que ela pode demorar vários meses para normalizar. Este relato de caso é um alerta aos riscos relacionados ao uso de substâncias veterinárias para fins estéticos.

Resumen Se presenta el caso de un masculino de 25 años de edad, conocido sano, trabajador en un piñera, con un cuadro de 3 semanas de evolución de malestar general, adinámia, astenia, síntomas gastrointestinales y pérdida de peso. Fue valorado en el servicio emergencias de un hospital rural donde se describió que presentaba fascies de crónicamente enfermo, los laboratorios evidenciaron calcio en 21,10 g/dl, diagnosticándosele hipercalcemia maligna de probable etiología neoplásica e insuficiencia renal aguda, presentó cuadro de convulsiones generalizadas y falleció el mismo día que ingresó. El carcinoma de paratiroides es un tumor infrecuente con una incidencia menor a 1 en 1 millón, su clínica se basa en los efectos por la excesiva secreción de hormona paratiroidea y por niveles elevados de calcio en sangre como en el presente caso. Abstract We report the case of a 25-year-old male, known as a healthy, hard-working worker, with a 3-week history of malaise, adynamia, asthenia, gastrointestinal symptoms and weight loss. It was evaluated in the emergency service of a rural hospital where it was described that it presented fascies of chronically ill, the laboratories evidenced calcium in 21,10 g / dl, being diagnosed malignant hypercalcemia of probable neoplastic etiology and acute renal failure, he presented generalized convulsions and died the same day he entered. Parathyroid carcinoma is an uncommon tumor with an incidence of less than 1 in 1 million. Its clinical features are based on the effects of excessive secretion of parathyroid hormone and elevated levels

Introduction: Granulomatous interstitial nephritis is a rare condition, in which renal involvement is uncommon. Its etiology is variable, and may be medicinal, infectious or inflammatory origin. Case report: This is a 65-year-old male patient with renal lesions of unknown etiology, associated with hypercalcaemia. During the investigation, cardiac insufficiency with diastolic dysfunction and interstitial lung involvement on chest tomography were evidenced. Renal function (glomerular filtration rate) has partially improved with clinical measures. Renal biopsy was performed, which showed moderate interstitial lesion with tuberculoid granulomas without caseous necrosis. Conclusion: The objective of the article was to describe a case of NIG and to alert to the importance of its clinical investigation. In this case, renal biopsy, associated with systemic clinical manifestations, contributed to the diagnosis of sarcoidosis. RESUMO Introdução: a nefrite intersticial granulomatosa é uma condição rara, na qual o envolvimento renal é incomum. Sua etiologia é variável e pode ter origem medicinal, infecciosa ou inflamatória. Relato de caso: trata-se de um paciente do sexo masculino, com 65 anos de idade, com lesões renais de etiologia desconhecida, associadas à hipercalcemia. Durante a investigação, evidenciaram-se insuficiência cardíaca com disfunção diastólica e envolvimento pulmonar intersticial à tomografia torácica. A função renal (taxa de filtração glomerular) melhorou parcialmente com medidas clínicas. Foi realizada biópsia renal, que apresentou lesão intersticial moderada com granulomas tuberculoides sem necrose caseosa. Conclusão: o objetivo do artigo foi descrever um caso de GIN e alertar para a importância de sua investigação clínica. Neste caso, a biópsia renal, associada a manifestações clínicas sistêmicas, contribuiu para o diagnóstico de sarcoidose.

Introdução: O hiperparatiroidismo primário é uma doença rara na idade pediátrica e define-se como uma alteração primária das glândulas paratiroideias, que condiciona uma produção excessiva de hormona paratiroideia. Caso Clínico: Adolescente do sexo masculino com doze anos de idade admitido na Urgência pediátrica por lombalgia tipo cólica e disúria. A ecografia renal evidenciou litíase renal. A investigação laboratorial realizada revelou hipercalcémia, elevação sérica da hormona paratiroideia e hipercalciúria. Estabelecido o diagnóstico de hiperparatiroidismo primário, realizou ecografia cervical e cintigrafia das glândulas tiroideias e paratiroideias que foi sugestiva de adenoma da paratiroideia inferior direita. Submetido a paratiroidectomia inferior direita com normalização dos valores da calcémia e da hormona paratiroideia pós-cirurgia. O exame histológico revelou hiperplasia das células principais. O estudo genético realizado foi negativo. Conclusão: O hiperparatiroidismo primário deve ser considerado no diagnóstico diferencial de litíase renal, de forma a permitir uma intervenção precoce determinante na prevenção de lesão de órgão-alvo., NASCER E CRESCER - BIRTH AND GROWTH MEDICAL JOURNAL, Vol 26, No 2 (2017)

Hypercalcemia is a rare condition in childhood; the most common causes are primary hyperparathyroidism, malignancy, prolonged immobilisation, thyrotoxicosis, thiazide diuretic, supplements containing calcium, milk-alkali syndrome, vitamin D intoxication, infections and idiopathic. We present three cases of severe hypercalcemia of unusual causes in children. The first patient had high fever, poor general condition, weight loss and myalgia. Extensive preliminary investigation did not define the etiology, but a review of medical history revealed prolonged contact with pet bird and a positive serology for Chlamydia confirmed the diagnosis of psittacosis. The second patient had generalized lymphadenopathy and hepatosplenomegaly with fever a month ago. Paracoccidioides brasiliensis was identified in myelogram; the patient showed partial improvement with the use of co-trimoxazole, with subsequent emergence of multiple osteolytic lesions. A smear of gastric lavage was positive for Mycobacterium tuberculosis and the patient was treated with rifampicin, isoniazid, ethambutol and pyrazinamide, with improvement of clinical condition. The third patient was treated by hypercalciuria and idiopathic hypomagnesiuria with daily use of cholecalciferol; the patient had a two quilograms of weight loss in the past two months. No cause of hypercalcemia could be detected in laboratory workout. The capsules of cholecalciferol were analyzed and presented an amount of 832,000 IU of vitamin D per capsule. Acute hypercalcemia in childhood may be due to exogenous vitamin D intoxication, as well as infectious causes. The possible causal relationship between psittacosis and occurrence of hypercalcemia alert to the need for detailed investigation of the epidemiological antecedents. Resumo A hipercalcemia é uma condição pouco comum na infância; dentre as causas mais comuns destacam-se hiperparatireoidismo primário, neoplasia, imobilização prolongada, tireotoxicose, diurético tiazídico, suplementos contendo cálcio, síndrome leite-álcali, intoxicação por vitamina D, infecções e causa idiopática. Apresentamos três casos de hipercalcemia grave por causas incomuns em crianças. O primeiro paciente tinha história de febre alta acompanhada de queda do estado geral, emagrecimento e mialgia. Extensa investigação preliminar não definiu a etiologia, porém uma revisão da história clínica revelou contato prolongado com ave de estimação e uma sorologia positiva para clamídia confirmou o diagnóstico de psitacose. O segundo paciente apresentava adenomegalia generalizada e hepatoesplenomegalia acompanhadas de febre por um mês, tendo sido identificado Paracoccidioides brasiliensis no mielograma; o paciente apresentou melhora parcial com uso de sulfametoxazol+trimetoprima, com posterior surgimento de múltiplas lesões osteolíticas. Uma baciloscopia do lavado gástrico foi positiva para Mycobacterium tuberculosis, tratado com rifampicina, isoniazida, pirazinamida e etambutol, com boa evolução. O terceiro paciente já era acompanhado por hipercalciúria e hipomagnesiúria idiopáticas e fazia uso diário de colecalciferol; perdeu dois quilogramas nos últimos dois meses. Nenhuma causa de hipercalcemia pôde ser detectada nos exames laboratoriais. As cápsulas de colecalciferol foram analisadas e encontrou-se uma quantidade de 832.000 UI de vitamina D. A hipercalcemia aguda na infância pode ser decorrente de intoxicação exógena por vitamina D, bem como de causas infecciosas. A possível relação causal entre psitacose e ocorrência da hipercalcemia alerta para a necessidade de investigação detalhada dos antecedentes epidemiológicos.

Introdução: O hiperparatiroidismo primário é uma doença rara na idade pediátrica e define-se como uma alteração primária das glândulas paratiroideias, que condiciona uma produção excessiva de hormona paratiroideia. Caso Clínico: Adolescente do sexo masculino com doze anos de idade admitido na Urgência pediátrica por lombalgia tipo cólica e disúria. A ecografia renal evidenciou litíase renal. A investigação laboratorial realizada revelou hipercalcémia, elevação sérica da hormona paratiroideia e hipercalciúria. Estabelecido o diagnóstico de hiperparatiroidismo primário, realizou ecografia cervical e cintigrafia das glândulas tiroideias e paratiroideias que foi sugestiva de adenoma da paratiroideia inferior direita. Submetido a paratiroidectomia inferior direita com normalização dos valores da calcémia e da hormona paratiroideia pós-cirurgia. O exame histológico revelou hiperplasia das células principais. O estudo genético realizado foi negativo. Conclusão: O hiperparatiroidismo primário deve ser considerado no diagnóstico diferencial de litíase renal, de forma a permitir uma intervenção precoce determinante na prevenção de lesão de órgão-alvo. Introduction: Primary hyperparathyroidism is a rare disease in the pediatric age group and a rare cause of nephrolithiasis. It results from an excessive production of the parathyroid hormone due to abnormalities within the parathyroid glands. Case report: The patient was a twelve-year-old male admitted in the paediatrics emergency department with intermitent flank pain and dysuria. An abdominal ultrassound identified nephrolithiasis. Laboratorial tests showed hypercalcemia, an increased serum level of parathyroid hormone and hypercalciuria. A primary hyperparathyroidism was diagnosed and the ultrassound plus scintigraphy of both thyroid and parathyroid glands revealed a right lower parathyroid adenoma. A right lower parathyroidectomy was performed with regularization of the calcium and parathyroid hormone levels. The histopathology revealed main cells hyperplasia and genetic tests were negative. Conclusion: Primary hyperparathyroidism should be considered in the differential diagnosis of nephrolithiasis to allow an early intervention and prevent organ damage.

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A previously healthy 24 yo male presented with a two-month history of epigastric pain, nausea, vomiting, fatigue and malaise. He reported abuse of different substances, including an injectable veterinary vitamin compound, which contains high doses of vitamin A, D and E, and an oily vehicle that induces local edema and enhances muscle volume. Serum creatinine was 3.1 mg/dL, alanine transaminase 160 mg/dL, aspartate transaminase 11 mg/dL, total testosterone 23 ng/dL, 25-OH-vitamin D >150 ng/mL (toxicity >100), 1,25-OH-vitamin D 80 pg/mL, vitamin A 0.7 mg/dL, parathormone

Primary bone manifestation associated with hypercalcemia is an infrequent presentation of acute lymphoblastic leukemia (ALL) in children. An 8-year-old girl was admitted with bone and abdomen pain, vomiting, fever, headache, anemia, elevated serum calcium and normal parathyroid hormone levels. Bone radiographs: osteolytic lesions. Bone marrow biopsy showed an infiltration by ALL with immunohistochemical positivity for CD45, CD20, CD79a, TdT and CD10, clinically characterized by hypercalcemia, multifocal osteolytic lesions and single cytopenia. Bone marrow biopsy was a relevant aid in establishing the diagnosis of multifocal osteolytic lesions, associated with hypercalcemia. RESUMO Apresentação óssea primária associada à hipercalcemia é manifestação clinicolaboratorial infrequente de leucemia linfoblástica aguda (LLA) em crianças. Relatamos o caso de uma criança do sexo feminino, 8 anos, admitida com dores ósseas e no abdômen associadas a vômitos, febre, cefaleia, anemia, hipercalcemia e níveis de paratormônio normais. Radiografias ósseas apresentaram lesões osteolíticas. Biópsia de medula óssea demonstrou infiltração por LLA com positividade imuno-histoquímica para CD45, CD79a, TdT e CD10, clinicamente caracterizada por hipercalcemia, lesões osteolíticas multifocais e citopenia única. A biópsia de medula óssea é importante ferramenta no estabelecimento do diagnóstico de lesões osteolíticas multifocais associada à hipercalcemia.

Background: Despite well-documented risks, injectable supplements containing high doses of vitamins are commonly used. Objectives: To describe acute kidney injury (AKI) as a complication of vitamin intoxication. Methods: Our series consisted of 16 patients with kidney complications resulting from the use of veterinary intramuscular injection supplements of vitamin A, D and E. The patients were admitted to two referral hospitals in Fortaleza (Brazil) between January 2010 and January 2015. Results: Patients’ mean age was 28.3 ± 8.9 years (19-53 years), and 11 (68.7%) were male. Main signs and symptoms upon admission were nausea (68.7%), vomiting (62.5%), weight loss (43.7%), epigastric pain (31.2%) and headache (31.2%). At hospital admission the mean laboratory values were: hemoglobin 10 ± 2.0 g/dL (6.1-14.2), leukocytes 10,542 ± 4871/mm3 (4100-15,100), creatinine 3.9 ± 5.2 mg/dL (0.7-22) and urea 91 ± 88 mg/dL (22-306), respectively. Serum calcium was 12 ± 2.2 mg/dL (8.8-15.5), 24-h urine calcium was 575 ± 329 mg (10.7-1058), serum PTH was 55 ± 141 pg/mL (2-406), and serum vitamin D concentration was 135 ± 75 ng/mL (22-265). Using KDIGO criteria, AKI was diagnosed in 13 patients (81.2%), classified as stage 1 (n = 3), stage 2 (n = 3) or stage 3 (n = 7). No deaths occurred in the study period. Conclusions: Excessive use of veterinary vitamin supplements containing high doses of vitamin A, D and E was associated with AKI. Hypercalcaemia, which was a common finding, appears to be a contributing factor to the development of this type of AKI. Resumen Antecedentes: Suplementos inyectables que contienen altas dosis de vitaminas son utilizados con frecuencia, a pesar de los riesgos bien documentados. Objetivo: Describir la ocurrencia de daño renal agudo (IRA) como complicación de intoxicación por suplementos vitamínicos. Métodos: Esta es una serie de 16 pacientes con complicaciones renales resultantes de la utilización de inyección intramuscular de suplementos veterinarios con vitaminas A, D y E. Los pacientes fueron ingresados en 2 hospitales de referencia en Fortaleza (Brasil), entre enero de 2010 y enero de 2015. Resultados: La edad media de los pacientes fue de 28,3 ± 8,9 años (19-53 años) y 11 (68,7%) eran varones. Signos y síntomas principales al ingreso fueron náuseas (68,7%), vómitos (62,5%), pérdida de peso (43,7%), dolor epigástrico (31,2%) y cefalea (31,2%). Al ingreso en el hospital los valores medios de laboratorio fueron: hemoglobina 10 ± 2,0 g/dL (6,1-14,2), leucocitos 10.542 ± 4.871/mm3 (4.100-15.100), creatinina 3,9 ± 5,2 mg/dL (0,7-22) y urea 91 ± 88 mg/dL (22-306), respectivamente. El nivel de calcio sérico fue de 12 ± 2,2 mg/dL (8,8-15,5), el de calcio en orina de 24 h fue de 575 ± 329 mg (10,7-1.058), el de PTH sérico fue de 55 ± 141 pg/mL (2-406) y el nivel de vitamina D sérica fue de 135 ± 75 ng/mL (22-265). Utilizando criterios KDIGO, se diagnosticó IRA en 13 pacientes (81,2%); fueron clasificadas como clase 1 (n = 3), clase 2 (n = 3) y clase 3 (n = 7). No hubo muertes en el período de estudio. Conclusiones: El uso excesivo de suplementos vitamínicos veterinarios que contienen altas dosis de vitamina A, D y E se asoció con IRA. La hipercalcemia, un hallazgo común, parece ser un factor que contribuye al desarrollo de este tipo de IRA.

Hypercalcemia is a rare condition in childhood; the most common causes are primary hyperparathyroidism, malignancy, prolonged immobilisation, thyrotoxicosis, thiazide diuretic, supplements containing calcium, milk-alkali syndrome, vitamin D intoxication, infections and idiopathic. We present three cases of severe hypercalcemia of unusual causes in children. The first patient had high fever, poor general condition, weight loss and myalgia. Extensive preliminary investigation did not define the etiology, but a review of medical history revealed prolonged contact with pet bird and a positive serology for Chlamydia confirmed the diagnosis of psittacosis. The second patient had generalized lymphadenopathy and hepatosplenomegaly with fever a month ago. Paracoccidioides brasiliensis was identified in myelogram; the patient showed partial improvement with the use of co-trimoxazole, with subsequent emergence of multiple osteolytic lesions. A smear of gastric lavage was positive for Mycobacterium tuberculosis and the patient was treated with rifampicin, isoniazid, ethambutol and pyrazinamide, with improvement of clinical condition. The third patient was treated by hypercalciuria and idiopathic hypomagnesiuria with daily use of cholecalciferol; the patient had a two quilograms of weight loss in the past two months. No cause of hypercalcemia could be detected in laboratory workout. The capsules of cholecalciferol were analyzed and presented an amount of 832,000 IU of vitamin D per capsule. Acute hypercalcemia in childhood may be due to exogenous vitamin D intoxication, as well as infectious causes. The possible causal relationship between psittacosis and occurrence of hypercalcemia alert to the need for detailed investigation of the epidemiological antecedents.

El Cáncer está considerado como una de las enfermedades con más incidencia e índice de mortalidad del mundo, siendo previsible que aumenten el número de casos en un 70% en los años venideros. Estos casos requieren una gran demanda de atención en un servicio de urgencia hospitalaria a pesar de no considerarse la causa principal de atención en este tipo de servicios. La hipercalcemia está considerada la urgencia oncológica más común afectando al 20%-30% de los pacientes con algún tipo de neoplasia, por ello la atención desde el personal de enfermería debe ser precisa y sistemática, fomentando el autocuidado del paciente y basándose en la evidencia científica. Para ello, el empleo de los Planes de Cuidados permite al personal de enfermería estandarizar las actuaciones, ayudando al establecimiento de prioridades, sistematización de actividades y ayuda a la toma de decisiones. La falta de trabajos sobre el uso de planes de cuidados enfermeros en los servicios de urgencias hospitalarias en el ámbito del paciente oncológico, como las prácticas inadecuadas en el servicio de urgencias olvidándose de la integridad como persona del paciente, hace que la calidad asistencial se vea disminuida. En el presente trabajo se propone un plan de cuidados para el paciente oncológico en situación de urgencias con hipercalcemia. Cancer is considered a disease which has one of the highest mortality rates of the world, and the numbers of cases are expected to increase by 70% in the years to come. These cases require a high demand for care in a hospital emergency service, despite not being considered the main cause of care in this type of service. Hypercalcemia is considered the most common oncological urgency affecting 20-30% of patients with neoplasia, so care from nursing staff must be accurate and systematic, encouraging self-care and based on the scientific evidence. To do this, the use of care plans allows nurses to standardize actions, helping to prioritize, systematize activities and help to make decisions. The lack of investigation on the use of nursing care plans at the hospital emergency service in the field of cancer patients, such as inadequate practices in the emergency service forgetting the integrity of the patient, decreases the quality of caring service. In the present work, a plan of care for the oncological patient in an emergency situation with hypercalcemia is proposed. Grado en Enfermería

Introducción: La paratohormona es una hormona encargada de la homeostasis del calcio, el hiperparatiroidismo es una patología con manifestaciones renales y óseas, el Tumor Pardo es una rara presentación de esta enfermedad. Caso clínico: Hombre de 35 años con dolor y paresia en extremidad superior izquierda, fue resecado parte del húmero por un diagnóstico de Tumor de Células Gigantes; reingresa con dolor pélvico derecho, malestar general, astenia y estreñimiento. Se descubre un nódulo cervical derecho e hipersensibilidad en la pelvis derecha. Los exámenes de laboratorio muestran hiperparatiroidismo; la biopsia de la lesión pélvica es diagnóstica de Tumor Pardo, encontrándose además una hipercaptación paratiroidea derecha. Operado, el diagnóstico histopatológico fue: Adenoma paratiroideo derecho y un micro carcinoma papilar tiroideo; en el post-operatorio desarrolló un Síndrome de Bone Hunger, el cual fue superado y dado de alta. Discusión y conclusiones: El Tumor Pardo no es una verdadera neoplasia; producido por intensa actividad osteoclástica, tiene características histológicas y radiológicas inespecíficas y su diagnóstico se realiza por datos clínicos y bioquímicos. El hiperparatiroidismo puede llevar a la formación de Tumores Pardos; se sugiere realizar estudios de la glándula tiroides en pacientes con hiperparatiroidismo.

Dissertação de Mestrado Integrado em Medicina Veterinária Canine primary hyperparathyroidism (PHPTH) is an endocrine disorder, where one or more parathyroid glands autonomously produce and secrete parathyroid hormone (PTH), which results in hypercalcaemia (Feldman, 2010). Diagnosis of PHPTH is achieved when there are inappropriate PTH concentrations (normal or increased) in the presence of elevated ionised calcium (iCa) concentration with no other identifiable cause (Skelly, 2012). iCa is the only active fraction of calcium and does not always correlate to total calcium, which is why iCa should be used to assess serum calcium status (Schenck & Chew, 2008). PHPTH is usually diagnosed after detection of hypercalcaemia in a blood analysis performed for unrelated reasons, as clinical signs are often not perceived by the owners (Feldman, Hoar, Pollard, & Nelson, 2005; Feldman, 2015a). Treatment by parathyroidectomy, percutaneous ultrasound-guided ethanol ablation or percutaneous ultrasound-guided heat ablation is curative and prognosis is excellent for treated dogs, but hypocalcaemia is a frequent postoperative complication (Caplan, 2013; Feldman, 2015a; Flanders, 2003; Nelson, 2009; Rasor, Pollard, & Feldman, 2007; Séguin & Brownlee, 2012). The retrospective study had the objective of characterising a sample of six dogs diagnosed with PHPTH at Anderson Moores Veterinary Specialists and analyse the procedures and tests conducted in the clinical approach to previously identified hypercalcaemia. RESUMO - Hiperparatiroidismo primário canino: abordagem clínica à hipercalcémia - O hiperparatiroidismo primário canino (PHPTH) é uma doença endócrina, na qual uma ou mais glândulas paratiróides produzem e secretam hormona paratiroideia ou paratormona (PTH) autonomamente, o que resulta em hipercalcémia (Feldman, 2010). O diagnóstico de PHPTH é efectuado quando existem concentrações de PTH inapropriadas (normais ou aumentadas) na presença de concentrações aumentadas de cálcio ionizado (iCa) sem outra causa identificável (Skelly, 2012). O iCa é a única fracção activa do cálcio e nem sempre se correlaciona com o cálcio total, motivo pelo qual o iCa deve ser utilizado para avaliar o cálcio em circulação (Schenck & Chew, 2008) O PHPTH é normalmente diagnosticado após a detecção de hipercalcémia numa análise sanguínea efectuada por motivos não relacionados, uma vez que os sinais clínicos normalmente não são identificados pelos donos (Feldman, Hoar, Pollard, & Nelson, 2005; Feldman, 2015a).. O tratamento com paratiroidectomia, ablação percutânea com etanol guiada por ultra-som ou ablação percutânea com calor guiada por ultra-som é curativo e tem um prognóstico excelente para animais tratados, embora a hipocalcémia seja uma complicação póscirurgica frequente (Caplan, 2013; Feldman, 2015a; Flanders, 2003; Nelson, 2009; Rasor, Pollard, & Feldman, 2007; Séguin & Brownlee, 2012). O estudo retrospectivo deste trabalho teve como objectivo a caracterização de uma amostra de seis cães diagnosticados com PHPTH na Anderson Moores Veterinary Specialists e analizar os procedimentos e testes efectuados na abordagem clínica à hipercalcémia previamente identificada. N/A

Fibromyalgia (FM) and hyperparathyroidism may present similar symptoms (musculoskeletal pain, cognitive disorders, insomnia, depression and anxiety), causing diagnostic confusion. Objectives: To determine the frequency of asymptomatic hyperparathyroidism in a sample of patients with FM and to evaluate the association of laboratory abnormalities to clinical symptoms. Methods: Cross-sectional study with 100 women with FM and 57 healthy women (comparison group). Parathyroid hormone (PTH), calcium and albumin levels were accessed, as well as symptoms in the FM group. Results: In FM group, mean serum calcium (9.6 ± 0.98 mg/dL) and PTH (57.06 ± 68.98 pg/mL) values were considered normal, although PTH levels had been significantly higher than in the comparison group (37.12 ± 19.02 pg/mL; p = 0.001). Hypercalcemic hyperparathyroidism was diagnosed in 6% of patients with FM, and 17% of these women exhibited only high levels of PTH, featuring a normocalcemic hyperparathyroidism, with higher frequencies than those expected for their age. There was no significant association between hyperparathyroidism and FM symptoms, except for epigastric pain, which was more frequent in the group of patients concomitantly with both diseases (p = 0.012). Conclusions: A high frequency of hyperparathyroidism was noted in women with FM versus the general population. Normocalcemic hyperparathyroidism was also more frequent in patients with FM. Longitudinal studies with greater number of patients are needed to assess whether this is an association by chance only, if the increased serum levels of PTH are part of FM pathophysiology, or even if these would not be cases of FM, but of hyperparathyroidism.

Introduction: The persistence of mineral metabolism disorders after renal transplant (RT) appears to possess a negative impact over graft and patient's survival. Objectives: To evaluate the parameters of mineral metabolism and the persistence of hyperparathyroidism (HPT) in transplanted patients for a 12-month period after the procedure. Methods: Retrospective analysis of 41 transplants (18 women- 44%, mean age of 39 ± 15 years) performed in a University Hospital, evaluating changes of calcium (Ca), phosphorus (P) and parathyroid hormone (PTH) and the prevalence of persistent HPT. The patients were divided into two groups accordingly to PTH levels prior to Tx: Group 1 with PTH ≤ 300 pg/mL (n = 21) and Group 2 with PTH > 300 pg/mL (n = 20). The persistency of HPT after transplant was defined as PTH ≥ 100 pg/mL. The evolution of biochemical parameters and the persistency of HPT were analyzed in each group after 1 year of transplant. Results: After a one-year of follow up, 5% of the patients presented hypophosphatemia (p < 2.7 mg/dL), 24% hypercalcemia (Ca > 10.2 mg/dL) and 48% persistency of HPT (PTH ≥ 100 pg/mL). There was a positive correlation between the PTH pre and post Tx (r = 0.42/p = 0.006) and a negative correlation between PTH and Ca pre-Tx (r = -0.45/p = 0.002). However, there was no significant difference among groups 1 and 2 regarding PTH levels pre and post Tx. Conclusion: The findings in this article suggest that mineral metabolism alterations and the persistency of HPT may occur after one year of renal Tx, mainly in patients which present high PTH levels prior toTx. Resumo Introdução: A persistência de distúrbios do metabolismo mineral ósseo após o transplante renal (Tx) parece possuir um impacto negativo sobre a sobrevida do enxerto e do paciente. Objetivos: avaliar os parâmetros do metabolismo mineral e a persistência de hiperparatiroidismo (pHPT) 12 meses após o Tx. Métodos: Análise retrospectiva de 41 transplantes (18 mulheres- 44%, idade de 39 ± 15 anos) realizados em um Hospital Universitário, avaliando cálcio (Ca), fósforo (P), hormônio da paratireóide (PTH) e a prevalência de pHPT. Pacientes foram divididos em dois grupos de acordo com os níveis de PTH pré Tx: Grupo 1: PTH ≤ 300 pg/ml (n = 21) e Grupo 2: PTH > 300 pg/ml (n = 20). pHPT foi definida como PTH ≥ 100pg/mL após o Tx. A evolução dos parâmetros bioquímicos e a pHPT foram analisadas após 1 ano de Tx. Resultados: após um ano, 5% dos pacientes apresentaram hipofosfatemia (p < 2,7mg/dL), 24% hipercalcemia (Ca > 10,2 mg/dL) e 48% persistência de HPT (PTH ≥ 100 pg/mL ). Houve correlação positiva entre PTH pré e pós Tx (r = 0,42/p = 0,006) e correlação negativa entre PTH e Ca pré-Tx (r = -0,45/p = 0,002). Entretanto, não houve diferença significativa entre os grupos 1 e 2 em relação aos níveis de PTH pré e pós-Tx. Conclusão: Os resultados sugerem que alterações do metabolismo mineral e a pHPT podem ocorrer após um ano do Tx, principalmente em pacientes com níveis elevados de PTH pré-Tx.

Introducción: Con mayor aporte de proteínas y energía en la primera semana se ha observado hipofosfemia en prematuros extremos. Los menores niveles de fósforo se han presentado en prematuros con antecedentes de restricción de crecimiento intrauterino. Objetivos: Caracterizar los niveles plasmáticos bioquímicos en el cordón de prematuros extremos, nacidos adecuados (AEG) y pequeños para edad gestacional (PEG) y la relación con calcemia y fosfemia en la primera semana de vida. Pacientes y método: Estudio clínico realizado en Neonatología del Hospital Doctor Sótero del Río, en los años 2013 y 2014. Se analiza el perfil bioquímico en el cordón y la calcemia y fosfemia en los primeros 7 días de vida, registrados en la ficha clínica según fueran AEG o PEG, según las curvas de Alarcón-Pittaluga. Análisis con significación de p < 0,05. Resultados: Los niveles de colesterol, transaminasas, albúmina y creatinina fueron similares para los PEG y AEG. Los niveles de pH, fósforo, calcio, y fosfatasas alcalinas fueron menores en los PEG. El nitrógeno ureico, el ácido úrico y los triglicéridos fueron mayores en los PEG. Los PEG muestran marcada reducción de fosfemia en la primera semana, la calcemia tiende a subir proporcionalmente al descenso de la fosfemia. Conclusiones: En prematuros extremos la desnutrición intrauterina se expresa en modificación de los niveles plasmáticos de calcio, fósforo, fosfatasas alcalinas, nitrógeno ureico, ácido úrico y triglicéridos. Posnatalmente, al recibir aporte nutricional, se manifiesta una disminución de la fosfemia y un aumento de calcemia, concordante con aportes insuficientes de fósforo durante el período. Introduction: The use of greater amounts of protein and energy during the first week of life is associated with hypophosphataemia in extreme preterm babies. The lowest phosphorus levels are described in intrauterine growth restricted (IUGR) babies. Objectives: To describe biochemistry levels in cord blood plasma in extreme premature, adequate and small for gestational age babies (AGA/SGA) and their relationship with plasma calcium and phosphorus levels during the first week of life. Patients and method: A descriptive clinical study was performed in the Neonatology Service at Hospital Dr. Sótero del Río during 2013 and 2014. A biochemical analysis of cord blood was performed on 43 premature babies, as well as plasma calcium and phosphorus levels during the first week. The adequacy for gestational age was obtained using Alarcón- Pittaluga growth curves. Statistical significance was P < .05. Results: Cholesterol, transaminases, albumin and creatinine levels were similar for both AGA and SGA babies. Levels of pH, phosphorus, calcium and alkaline phosphatase were significantly lower in SGA babies. Urea nitrogen, uric acid and triglycerides levels were higher in SGA. The analysis during the first week showed a strong reduction in phosphorus levels, as well as an increase in calcium levels in proportion to the decrease in phosphorus in the SGA sub- group. Conclusions: Intrauterine malnutrition in preterm babies is expressed in the modulation of plasma levels of calcium, phosphorus, alkaline phosphatase, urea nitrogen, uric acid and triglycerides. During post-natal life, when nutritional intake begins, a decrease in phosphorus and an increase in calcium levels appear, consistent with insufficient phosphorus intake during this period.

O tumor marrom do hiperparatireoidismo primário (HPP) é assim denominado por sua coloração característica, proveniente da hemorragia intralesional e do depósito de hemossiderina em seu interior (MARTINS et al, 2010). A ocorrência do tumor marrom é três vezes mais frequente em mulheres acima de 50 anos. Os sintomas podem ser dor, edema duro, deformidade, ou ser totalmente assintomático (PINTO et al, 2010). Este relato é sobre um paciente do sexo masculino procurou o serviço de saúde devido à fratura de fêmur direito após queda da própria altura. No exame físico inicial foi evidenciada fratura em diáfise de fêmur direito e tumoração sólida em tíbia esquerda. O diagnóstico histopatológico foi compatível com tumor de células gigantes. Realizou-se, então, investigação laboratorial para distúrbios do metabolismo ósseo, cintilografia óssea e de paratireoides. Chegou-se a conclusão de que o paciente apresentava alteração no terço médio da tíbia esquerda compatível com tumor marrom devido ao hiperparatireoidismo primário decorrente de adenoma da paratireoide inferior esquerda. Baseado em Souza et al, 2005, este caso serviu para relatar sobre um tipo de lesão, que é relativamente rara tendo sua importância definida como o diagnóstico de uma doença sistêmica através dos dados coletados e de uma lesão local.

Introducción: La calcifilaxis (CFX) es un síndrome caracterizado por depósito de calcio en la capa íntima y media de los vasos, proliferación, fibrosis y trombosis luminal, isquemia y necrosis tisular. Su reporte inicial y descripciones posteriores estuvieron asociados a la insuficiencia renal crónica terminal (IRCT). Hay poca información sobre el efecto que la recuperación de la función renal secundaria al trasplante renal produce en la incidencia de esta patología. Material y métodos: Estudio retrospectivo unicéntrico. Se realizó un análisis retrospectivo de la cohorte de los 448 pacientes trasplantados de riñón y riñón y páncreas entre el 1 de enero de 2001 y el 1 de enero de 2014 en nuestro Servicio. Resultados: Tres pacientes presentaron CFX confirmada por biopsia. En los 3 pacientes la CFX se asoció a hipercalcemia (calcemia promedio 11.5 mg/dl), en 2 de ellos al momento del diagnóstico. La Paratohormona intacta (PTHi) al momento del diagnóstico fue 2pg/ml, 62,3pg/ ml y 3561pg/ml respectivamente. Dos pacientes eran diabéticos. Se halló hipoalbuminemia en los 3 pacientes. Sólo un paciente presentó obesidad, hiperfosfatemia y anticoagulación como factores de riesgo agregados. En todos los casos la biopsia proporcionó el diagnóstico de certeza para CFX. La mediana de la creatininemia en el momento del diagnóstico de CFX fue de 1,5 mg/ dl (1,2mg/dl; 1,2mg/dl y 2mg/dl respectivamente) y el promedio de tiempo entre el trasplante y el desarrollo de CFX fue de 32 meses. En todos los casos se realizó un estricto control del fósforo, la hipercalcemia, las lesiones dérmicas y se administró tiosulfato de sodio IV durante 7 meses promedio. Se observó hipercalcemia al año post trasplante en el 19,59 % de los 448 pacientes estudiados, la evolución fue favorable dos pacientes, con control de la calcemia y mejoría de las manifestaciones cutáneas, y conservación de la función renal. Conclusiones: La prevalencia de CFX luego de un TxR sobre un total de 448 pacientes trasplantados de riñón y de riñón y páncreas para el periodo 2001/2014 fue del 0,66%, inferior a los reportes de incidencia de CFX en diálisis. Los factores asociados a CFX en nuestros pacientes fueron la hipercalcemia al año post trasplante y al momento del evento, la hipoalbuminemia, la diabetes y los desórdenes de la glándula paratiroidea. La persistencia de la hipercalcemia al año post-trasplante renal debe ser un elemento de alta sospecha clínica de esta complicación. Introduction: Calciphylaxis (CFX) is a syndrome characterized by deposition of calcium in the intima and media of vessels, intimal proliferation, fibrosis, luminal thrombosis, tissue ischemia and necrosis. Its initial report and subsequent descriptions were associated with chronic renal failure. There is little information regarding the possible effect of the recovery of renal function secondary to kidney transplantation in the incidence of this disease. Methods: Center retrospective study. We analyze in this report the three cases of patients who developed CFX after a renal transplant within a cohort of 448 kidney and kidney-pancreas transplant patients from January 1th 2001 to January 1th 2014 in our Hospital. Results: Three patients were found to have CFX. All of them had hypercalcemia (serum calcium average 11.5 mg/dl) at first year post transplant and 2 patients at diagnosis of CFX. PTHi in the three CFX patients was 2 pg/ml, 62,3pg/ml and 3561pg/ml respectively. Hypoalbuminemia was found in all patients. Two patients were diabetic. Only one patient was obese and under anticoagulation treatment. In all cases a biopsy provided the diagnosis of certainty for calciphylaxis. Median serum creatinine at diagnosis was 1.5 mg/dl (1.2 mg/dl 1.2 mg/dl and 2 mg/dl, respectively) and the average time between transplantation and calciphylaxis diagnosis was 32 months. In all cases, strict control of phosphorus and hypercalcemia and sodium IV thiosulfate treatment was performed. The evolution was successful in two patients, controlling blood calcium and improving cutaneous manifestations with preservation of renal function. Conclusions: CFX prevalence in a cohort of 448 kidney and kidney-pancreas transplant patients from 2001 to 2014 was 0.66%, less than reported in dialysis patients. Factors associated with CFX in our patients were hypercalcemia in the first year after renal transplant and at the time of the event, hypoalbuminemia, diabetes and disorders of the parathyroid gland. The persistence of hypercalcemia in the first year after renal transplant should be an element of high clinical suspicion of this complication in the kidney transplant recipients.

Introduction: Subcutaneous fat necrosis is a rare transient disorder of adipose tissue mostly affecting term or post-term newborns with perinatal complications.Case report: Full-term neonate, large for gestational age, with a complicated vaginal birth, requiring resuscitation. Skin lesions compatible with NGTS, which resolved without complications, were noted at 13 days of life.Discussion: We report a case of subcutaneous fat necrosis with a benign evolution, just to remind this uncommon entity. The pathogenesis is poorly understood and although it tends to resolve spontaneously, an eventful associated hypercalcaemia >may have a fatal outcome., Introdução: A necrose gorda do tecido subcutâneo (NGTS) é uma patologia transitória rara do tecido adiposo, que afeta sobretudo recém-nascidos de termo ou pós-termo com um período perinatal complicado.Caso clínico: Recém-nascido de termo, grande para a idade gestacional, nascido por parto vaginal complicado, com necessidade de reanimação. Aos 13 dias de vida surgiram lesões cutâneas compatíveis com NGTS, que resolveram sem complicações.Discussão: Relatamos um caso de NGTS que apresentou uma evolução benigna, para relembrarmos esta entidade incomum. A patogenia é mal compreendida e, embora geralmente resolva espontaneamente, pode complicar-se de hipercalcemia condicionando uma evolução desfavorável.

Antecedentes: La hipercalcemia durante el embarazo es un hallazgo raro. La exposición prolongada a los altos niveles de calcio puede llevar a calcificaciones en distintos órganos maternos y en el feto puede llevar a abortos espontáneos y mortinatos. Caso clínico: Paciente primípara, con gestación de 20+4 semanas, remitida por falla renal aguda e hipertensión arterial. Ella reportó ingesta excesiva de queso, leche y multivitamínicos. Con calcio de 9,2 mg/dL y relación BUN/Creatinina de 6,8 se diagnostica intoxicación alimentaria y nefrocalcinosis medular por alta ingesta de calcio. Al cuarto día de hospitalización presenta sangrado vaginal y debido a las condiciones de la madre se termina el embarazo. Posteriormente presenta una mejoría clínica significativa y se da de alta. Discusión: La relevancia de este caso es que la presencia de hipercalcemia en el embarazo y su no identificación, aumenta el riesgo de aborto, y de hipocalcemia neonatal, que a su vez puede causar muerte materna. En este cuadro se pueden presentar varias complicaciones, siendo una de las más frecuentes la nefrocalcinosis, identificada en este reporte. Conclusión: La ingesta de calcio excesiva en gestantes puede causar nefrocalcinosis. Es importante la educación para evitar ésta y otras complicaciones. Background: Hypercalcemia during pregnancy is a strange finding. The long exposure to high calcium levels can take to calcifications in different maternal organs and it can lead to miscarriage and stillborn. Case presentation: A woman with 20+4 weeks' gestation, who was remitted because of an acute renal failure and hypertension. She reported excessive intake of cheese, milk and multivitaminics. With a calcium level of 9.2 mg/dL and BUN/Creatinine of 6.8, diagnosed with food poisoning and medullary nephrocalcinosis as a result of the high calcium intake. At the fourth day at the hospital she presented vaginal bleeding and due to the conditions of the mother the pregnancy was ended. Afterwards she presented a significant clinical improvement and she was discharged from the hospital. Discussion: The relevance of this case is that the presence of hypercalcemia during pregnancy and not identifying it elevates the risk of miscarriage and neonatal hypocalcemia, which can cause maternal death. In this aspect, many complications can develop, being one of the most important the nephrocalcinosis, identified in this report. Conclusion: The excessive calcium intake in pregnant women can cause nephrocalcinosis. It is important to educate them to avoid this and other complications.

info:eu-repo/semantics/publishedVersion

Trabalho Final de Mestrado Integrado, Ciências Farmacêuticas, Universidade de Lisboa, Faculdade de Farmácia, 2016 Submitted by Repositório FFUL (repositorio@ff.ul.pt) on 2018-12-07T16:20:25Z No. of bitstreams: 1 MICF_Ana_Carolina_Pereira.pdf: 729734 bytes, checksum: 5fca5b345c593ad150b0056fdf92aa4f (MD5) Made available in DSpace on 2018-12-10T17:25:13Z (GMT). No. of bitstreams: 1 MICF_Ana_Carolina_Pereira.pdf: 729734 bytes, checksum: 5fca5b345c593ad150b0056fdf92aa4f (MD5) Previous issue date: 2016

Small cell carcinoma of the ovary, hypercalcemic type is a rare and aggressive tumor affecting young women. The mechanism of development is unclear and there have been relatively few clinical studies reported in literature. The authors present a clinical case of a 15-year-old girl with a small cell carcinoma of the ovary

Introduction: The mineral bone disorder, particularly secondary hyperparathyroidism, in chronic kidney disease (CKD) has a systemic impact affecting not only bone metabolism. Therefore its correction is important to prevent cardiovascular, inflammatory and immune diseases. Objective To assess the effectiveness and safety of intravenous paricalcitol administered over a 6 month period for the treatment of secondary hyperparathyroidism (SHPT) in patients undergoing conventional hemodialysis, with close follow-up of treatment response. Methods: A phase 4 clinical trial was performed comparing clinical and laboratory data before and after 6 months of treatment. SHPT patients undergoing hemodialysis who were naïve to vitamin D metabolites or had failed to current therapy were included. Clinical and laboratory characteristics were analyzed. Efficacy analyses were based on intact parathyroid hormone (iPTH) levels and were performed using data from patients who completed 6 months of treatment. Results: Nineteen of the 26 patients enrolled completed 6 months of treatment. All patients exhibited reduced baseline iPTH levels (mean reduction, 371.8 pg/mL; 95% CI, 273.3-470.2 pg/mL]; 17 patients (89.5%) had reductions exceeding 30%. Twelve patients (63%) achieved therapeutic success (defined as iPTH serum levels 150-300 pg/mL), with a median time of 2 months from the beginning of treatment. All reported episodes of hypercalcemia (n = 2) and hyperphosphatemia (n = 34) were asymptomatic. No major therapy-related serious AEs were reported. Conclusion: Paricalcitol was safely administered and was associated with significant decreases in iPTH levels over the study period. Resumo Introdução: A doença metabólica óssea, em particular o hiperparatireoidismo secundário, na doença renal crônica (DRC) tem um impacto sistêmico que afeta nem só o metabolismo ósseo. Por tanto, sua correção é importante para prevenir as doenças do sistema imunitário, inflamatório e cardiovascular. Objetivo: Avaliar a eficácia e a segurança do paricalcitol intravenoso administrado durante um período de 6 meses no tratamento do hiperparatireoidismo secundário (SHPT) em pacientes submetidos a hemodiálise convencional, com acompanhamento de perto da resposta do tratamento. Métodos: Realizou-se um ensaio clínico de fase 4 que comparava os dados clínicos com os dados do laboratório antes e depois dos 6 meses de tratamento. Incluíram-se os pacientes SHPT em hemodiálise sem experiência com os metabólitos da vitamina D ou que fracassaram com a terapia em uso. Analisaram-se as características clínicas e de laboratório. As análises de eficácia se basearam nos níveis do hormônio da paratireóide intacto (iPTH) e foram realizadas usando dados dos pacientes que completaram os 6 meses de tratamento. Resultados: Dezenove dos 26 pacientes registrados completaram os 6 meses de tratamento. Todos os pacientes mostraram níveis de referência iPTH reduzidos (redução média, 371,8 pg/mL; 95% CI, 273,3-470.2 pg/mL]; 17 pacientes (89,5%) tiveram reduções superiores a 30%. Doze pacientes (63%) conseguiram o sucesso terapêutico (definido como níveis de soros iPTH de 150-300 pg/mL), com um tempo médio de 2 meses a partir do início do tratamento. Todos os episódios de hipercalcemia (n = 2) e de hiperfosfatemia (n = 34) reportados foram assintomáticos. Não se informaram AEs graves importantes relacionados à terapia. Conclusão: O paricalcitol foi administrado de forma segura e se associou às reduções significativas nos níveis de iPTH durante o período do estudo.

A necrose adiposa subcutânea do recém-nascido é uma paniculite rara do período neonatal. Surge, geralmente, em recém-nascidos de termo ou pós-termo, nas primeiras 4 semanas de vida, e em associação com trauma obstétrico. Caracteriza-se pelo aparecimento de placas ou nódulos subcutâneos duros, localizados ao tronco, nádegas ou coxas. O seu curso é, geralmente, benigno e autolimitado, embora possa acompanhar-se de hipercalcemia, o que obriga a uma vigilância periódica até à resolução das lesões cutâneas. Os autores descrevem 2 casos de necrose adiposa subcutânea do recém-nascido, um num recémnascido de termo, outro num prematuro, ambos associados a partos traumáticos e a sofrimento fetal Subcutaneous fat necrosis of the newborn is an uncommon disorder occurring during the prenatal stage. Generally occurring in full-term neonates or during the first four weeks after a traumatic delivery, the disorder is characterized by the appearance of hard subcutaneous nodules or plaques on the trunk, buttocks or thighs. It is normally a benign and transient condition, although it may be complicated by hypocalcemia, which requires close monitoring until skin lesions are cured. The authors describe two cases of subcutaneous fat necrosis of the newborn, one occurring in a full-term neonate and the other in a premature newborn, both related to traumatic delivery and fetal distress