RESUMO O relato descreve três casos de síndrome de sicca, inicialmente suspeitos de serem a síndrome de Sjögren, que foram negados pela investigação clínica e laboratorial. O primeiro associado ao uso de isotretinoína, um ácido retinóico, o segundo ao uso de esteroides androgênicos anabolizantes e o terceiro relacionado ao adenoma da hipófise secretora da prolactina, todos manifestaram sicca, incluindo a síndrome do olho seco após esses eventos e as manifestações persistem. A ressonância magnética revelou atrofia bilateral da glândula lacrimal. Eles eram uma mulher de 24 anos, um homem de 32 anos e uma mulher de 77 anos com sintomas crônicos da síndrome de sicca, incluindo a síndrome do olho seco. A história médica, o exame ocular, os exames laboratoriais e a ressonância magnética foram confirmados como síndrome do olho seco, no entanto, todos os exames foram negativos para a síndrome de Sjögren. A glândula lacrimal estava ausente na ressonância magnética nos três casos. A história clínica revelou que sinais e sintomas se manifestaram após exposição crônica ao ácido retinóico, esteróides anabolizantes androgênicos e adenoma secretivo da prolactina hipofisária, respectivamente. Isotretinoína crônica, esteroides anabólicos androgênicos e adenoma hipofisário secretor de prolactina ou, neste último caso, seu tratamento inibitório pode ser a causa da atrofia da glândula lacrimal, síndrome da sicca e síndrome do olho seco e diagnóstico diferencial da síndrome de Sjögren. Estudos adicionais sobre doses, duração e outras suscetibilidades aos efeitos adversos duradouros do ácido retinóico, esteroides androgênicos anabólicos e repercussões do adenoma da hipófise secretora da prolactina são necessários para confirmar e detalhar essas associações.

ABSTRACT This report is of three cases of sicca syndrome, initially suspected to be Sjögren’s syndrome, which was ruled out by clinical and laboratory investigations. The patients were a 24-year-old woman, a 32-year-old man, and a 77-year-old woman with chronic symptoms of sicca syndrome, including dry eye syndrome. The first case was associated with the use of isotretinoin, a retinoic acid. The second was associated with the use of anabolic androgenic steroids, and the third was related to a prolactin- secreting pituitary adenoma. All cases manifested sicca, including dry eye syndrome, after those events, and the manifestations persisted. Magnetic resonance imaging revealed bilateral atrophy of the lacrimal gland. The medical history, ocular examinations, laboratory exams, and magnetic resonance images confirmed dry eye syndrome; however, the exams were all negative for Sjögren’s syndrome. The lacrimal gland was absent on magnetic resonance imaging in all three cases. The clinical history revealed that the signs and symptoms appeared after chronic exposure to retinoic acid, anabolic androgenic steroids, and a prolactin-secreting pituitary adenoma, respectively. Chronic isotretinoin, anabolic androgenic steroids, and prolactin-secreting pituitary adenoma or, in this last case, its inhibitory treatment, can cause lacrimal gland atrophy, sicca syndrome, and dry eye syndrome, and a differential diagnosis of Sjögren’s syndrome. Further studies on doses, time, and other susceptibilities to the long-lasting adverse effects of retinoic acid, anabolic androgenic steroids, and the repercussions of prolactin-secreting pituitary adenoma are necessary to confirm and expand upon these associations.

ABSTRACT The Choosing Wisely Initiative aims to collect statements from medical societies all over the world on medical interventions that result in no benefit to patients, with the potential to cause harm. In this article we present the views of the Diagnostic Laboratory Group at the Brazilian Society of Infectious Diseases (SBI). Ten experts from SBI were asked to list 10 diagnostic tests that were perceived as unnecessary in the field of infectious diseases. After voting for the more relevant topics, a questionnaire was sent to all SBI members, in order to select for the most important items. A total of 482 votes were obtained, and the top 10 results are shown in this manuscript. The Choosing Wisely statements of SBI should facilitate clinical practice by optimizing the use of diagnostic resources in the field of infectious diseases.

Bilateral endogenous endophthalmitis is a rare condition initiated by infection by microbes in the bloodstream, such as those arising from a foci of infective endocarditis. We report a case and discuss the diagnostic aspects and the clinical outcome of a patient with characteristic findings of the disease. The patient was a 49 year old white male who had a metallic aortic valve implanted 7 months previously, and who presented to the hospital with 10 days of fever, cough and dyspnea, then diarrhea and mental confusion. On the second day of hospitalization, he experienced sudden loss of vision in both eyes. A Gram-positive coccobacillus was isolated from the bloodstream, he was treated with fluoroquinolone with disappearance of fever, decreased ocular inflammation, and improvement in his vision to light perception. He later underwent valve replacement surgery but died during the procedure. We review the occurrence of ocular signs and symptoms and their importance in patients with endocarditis.

RESUMO Foram avaliados os prontuários de 249 pacientes portadores de retinoblastoma vistos no Hospital A. C. Camargo da Fundação Antônio Prudente no período de janeiro de 1975 a dezembro de 1989; desses, 164 (65,9%) eram unilaterais e 85 (34,1%) eram bilaterais. A idade de aparecimento dos primeiros sinais variou de presente ao nascimento aos 113 meses; a idade de encaminhamento ao Serviço variou de 0 a 115 meses, podendo-se constatar uma demora no encaminhamento principalmente nas faixas de menor idade. O tumor era intra-ocular ao diagnóstico em 156 (63,9%) e extra-oculares em 88 (36,1%). Verificamos uma tendência à diminuição de encaminhamentos nos estádios extra-oculares nos últimos anos. A freqüência total de óbitos foi de 26,6%; observou-se diminuição dessa taxa a partir de 1982, tanto nos tumores intra como nos extra-oculares. Acreditamos que o diagnóstico e o encaminhamento precoces a centros especializados de tratamento são fatores essenciais para o progresso na cura desta doença.

SUMMARY Charts of 249 on line retinoblastoma patients from A. C. Camargo Hospital/Antonio Prudente Fundation/São Paulo were reviewed. We founded 65,9% of unilateral cases and 34,1% of bilateral. The age at which signs were noticed ranged from birth to 113 months, and the referral age ranged from less than 1 month to 115 months. The tumors were intraocular (IO) in 63,9% and had extraocular (EO) extension in 36,1%. The death rate was 26,6% of the total cases; among the IO it was 5,1% and among the EO it was 64,8%. We believe that an early diagnosis and referral to specialized centers are the main factors related to progress in treatment and cure of this disease.

RESUMO Este estudo analisa os resultados das culturas obtidas de material de úlceras de córnea em 263 pacientes no período de setembro de 1986 a fevereiro de 1989. Confirma estudos anteriores de que o isolamento de bactérias (41,8%) é mais freqüente que o de fungos (3,8%). Neste período, pela primeira vez foram isoladas 2 cepas de Acanthamoeba sp. como agente etiológico de úlcera de córnea. Entre as bactérias Gram positivas, Staphylococcus aureus foi a mais freqüentemente isolada (22,1%), e entre as bactérias Gram negativas, Pseudomonas sp. foi a mais encontrada (7,6%). Entre as ceratites micóticas, os fungos mais freqüentemente Isolados foram Aspergillus sp. e Fusarium sp. Foram demonstradas alterações nos perfis de sensibilidade das bactérias aos antibióticos testados em relação a estudo realizado neste mesmo Laboratório de Microbiologia Ocular da Escola Paulista de Medicina. Houve aumento de resistência bacteriana à cefalotina, tobramicina e amicacina, enquanto a gentamicina apresentou níveis de sensibilidade semelhantes em relação ao estudo anterior.

SUMMARY Some ethiological aspects of corneal ulcers in 263 patients that were submitted to corneal culture in the Laboratório de Microbiologia Ocular da Escola Paulista de Medicina were analysed. Positive cultures were obtained in 132 of the samples, where bacterias were isolated in 41,8% and fungy in 3,8%. Acanthamoeba sp. was isolated in 2 samples. Staphylococcus aureus was the most frequent bacteria isolated (22,1%) and among Gram negative bacteria, Pseudomonas sp. was isolated in 7,6%. Comparing the results of this study with those performed before at the same laboratory, we demonstrate an increase of bacterial resistency to antibiotics like cefalotin, tobramicin and amicacin, while gentamicin keeps the some level of sensibility.