Resumo Introdução: O uso de Rituximab (RTX) em doenças glomerulares (DG) aumentou nos últimos anos, embora ainda utilizado apenas em uma pequena fração de pacientes. Métodos: Conduzimos em nosso centro, de 2010-2020, um estudo retrospectivo de único centro de pacientes adultos com nefropatia membranosa (NM), glomeruloesclerose segmentar focal (GESF), nefrite lúpica (NL) e vasculite tratada com RTX como terapia de primeira ou segunda linha. Resultados: Identificamos 19 pacientes; 36,8% tinham NM; 25,0% cada apresentava GESF, NL e vasculite. RTX foi terapia de primeira linha em 26,3% dos pacientes e em 73,7% foi terapia de segunda linha. O tempo médio de acompanhamento foi 7,7 ± 7,2 anos. Em NM, 2 pacientes (28,6%) tiveram remissão completa (RC), 2 pacientes (28,6%) remissão parcial (RP), e 3 pacientes (42,9%) não tiveram resposta (NR). Na GESF, 2 pacientes (50,0%) apresentaram RC, 1 paciente (25,0%) não teve resposta e, 1 paciente, deterioração renal. Dois pacientes (50,0%) apresentaram NL classe IV com RC após RTX, 1 paciente com NL classe IIIC/V não teve resposta, e 1 paciente com NL classe II apresentou deterioração renal. Na vasculite, 3 pacientes (75,0%) apresentaram RC e 1 paciente RP. Reações à infusão ocorreram em 2 pacientes (10,5%) e um paciente apresentou múltiplas complicações infecciosas. Conclusões: A eficácia do RTX em tratar diferentes tipos de DG imunomediada tem sido demonstrada com diferentes taxas de resposta, mas com perfil geral seguro. Em nossa série de casos, os resultados também são encorajadores. Estudos longitudinais são necessários para compreender melhor o efeito do RTX na DG.

Abstract Introduction: The use of Rituximab (RTX) in glomerular diseases (GD) has increased in the past years, although it is still only used in a small fraction of patients. Methods: A single center retrospective study of adult patients with membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), lupus nephritis (LN), and vasculitis treated with RTX as first or second-line therapy was conducted at our center from 2010 to 2020. Results: We identified 19 patients; 36.8% had MN and 25.0% each had FSGS, LN, and vasculitis. RTX was first-line therapy in 26.3% of patients and in 73.7% it was second-line therapy. Mean follow-up time was 7.7 ± 7.2 years. In MN, 2 patients (28.6%) had complete remission (CR), 2 patients (28.6%) had partial remission (PR), and 3 patients (42.9%) had no response (NR). In FSGS, 2 patients (50.0%) presented CR, 1 patient (25.0%) had no response, and 1 patient had renal deterioration. Two patients (50.0%) had a LN class IV with a CR after RTX, 1 patient with LN class IIIC/V had no response, and 1 patient with LN class II had renal deterioration. In vasculitis, 3 patients (75.0%) presented CR and 1 patient had PR. Infusion reactions were present in 2 patients (10.5%) and one patient had multiple infectious complications. Conclusions: The efficacy of RTX in treating different types of immune-mediated GD has been demonstrated with different response rates, but an overall safe profile. In our case series, the results are also encouraging. Longitudinal studies are needed to better understand the effect of RTX in GD.

Abstract Curcumin, contained at Turmeric (Curcumalonga), can exert many beneficial pleiotropic activities in the gastrointestinal tract. This study evaluated the antioxidant and anti-inflammatory activity of C. longa on 5-fluorouracil (5-FU)-induced oral mucositis (OM) in hamsters. Phytochemical analysis of crude C. longa extract (CLE) was performed to detect the presence of curcumin by TLC and HPLC. Golden Syrian hamsters were orally pre-treated with CLE (5, 50, or 100mg/kg). Cheek pouch samples were subjected to macroscopic and histopathological evaluation. ELISA was performed to quantify the inflammatory cytokines IL-1β and TNF-α. Superoxide dismutase (SOD), glutathione (GSH) and malondialdehyde (MDA) levels were assessed by ultraviolet-visible spectroscopy analysis. Behavior analysis was conducted by the open field test. Curcumin content in the CLE was 0.55%m/m ± 0.0161 (2.84%). The group treated with 5mg/kg CLE showed healing evidence with macroscopic absence of ulceration (p<0.05) and microscopic aspect of re-epithelialization, discrete inflammatory infiltrate and absence of edema. Treatment with 5mg/kg CLE significantly increased GSH levels, and reduced MDA levels and SOD activity (p˂0.05), and decreased IL-1β (p˂0.05) and TNF-α (p˂0.01) levels. A significant reduction in walking distance, ambulation, speed, and rearing was observed for motor activity. Curcumin reduced oxidative stress, inflammation, and motor activity in hamsters with 5-FU-induced OM.

Resumo O brentuximab vedotina está aprovado pela Food and Drug Administration (FDA) e pela European Medicines Agency (EMA) para o tratamento de doentes adultos com linfomas cutâneos primários de células T CD30+, refratários a pelo menos uma linha terapêutica prévia. Os autores reportam dois casos clínicos de linfoma cutâneo primário de células grandes anaplásicas, tratados com brentuximab vedotina, com respostas clínicas distintas. Não obstante, o brentuximab vedotina poderá constituir uma alternativa terapêutica válida para o tratamento destas patologias.

Abstract Brentuximab vedotin is approved by the Food and Drug Administration (FDA) and by the European Medicines Agency (EMA) for the treatment of adult patients with CD30-positive primary cutaneous T-cell lymphomas, refractory to at least one previous line of therapy. The authors report two clinical cases of primary cutaneous anaplastic large-cell lymphoma treated with brentuximab vedotin, with different clinical responses. Nevertheless, brentuximab vedotin may be a valid therapeutic alternative for the treatment of these pathologies.

RESUMO A substituição dos dentes ausentes, por próteses implanto retidas, é uma forma previsível de reabilitação na população como um todo. Devido à similaridade da doença periodontal com a periimplantite, infere-se a hipótese de que pacientes com histórico de doença periodontal seriam mais suceptíveis a periimplantite. Este conceito vem sendo discutido e suportado por novas evidencias científicas.O objetivo desta revisão é avaliar se pacientes historicamente periodontalmente comprometidos apresentam relação com maior perda óssea peri-implantar. A literatura pertinente conclui que a reabilitação por meio de implantes em pacientes com histórico de doença periodontal é previsível e com índice de sucesso semelhantes pacientes sem histórico de periodontite.

ABSTRACT The replacement of missing teeth by implant retained prostheses is a predictable form of rehabilitation in the population as a whole. Due to thesimilarity between periodontal disease and peri-implantitis, the hypothesis is inferred that patients with a history of periodontal disease would be more susceptible to peri-implantitis. This concept has been discussed and supported by new scientific evidence. The purpose of this review was to evaluate whether there is any relationship between periodontitis and greater peri-implant bone loss in periodontally compromised patients. The pertinent literature has concluded that rehabilitation by means of implants in patients with a history of periodontal disease was predictable and has shown success rates similar to those obtained in patients with no history of periodontitis.

Chronic kidney disease (CKD) is associated to significant infection incidence and severity, the cause of death of, approximately, 20% of end-stage renal disease patients. Close to 80% of all infections in these patients can be related to organ or tissue other than vascular access, reflecting immune system dysfunction related to several mechanisms. Strongyloides stercoralis is an endemic nematode found especially in tropical and subtropical areas. The clinical manifestations of stercoralis infection vary according to the acuity of infection and the host response, from asymptomatic to the disseminated presentation, frequently lethal. Risk factors for severe presentations are related to immunosuppression states. The authors report a case of a patient with advanced CKD of unknown etiology, who developed an exuberant eczema, respiratory symptoms and severe hypereosinophilia. The etiological study revealed a disseminated form of Strongyloides stercoralis infection with myocardia involvement, diagnosed solely by serologic testing, despite microbiological tests to identify the infective agent. In this case, the patient has evolved favorably, with remission of symptoms and cardiac features, after adequate anti-helminthic treatment. The importance of parasitic colonization and its potential harm becomes clinically more relevant when patients become immunosuppressed, as in CKD progression or in the immunosuppressive therapy setting, such as solid organ transplant rejection therapy. A brief literature review related to strongyloidiasis and immunosuppression in the CKD setting is also presented

Background and aims: Clostridium difficile infection (CDI) constitutes an important cause of antibiotic-associated diarrhea. Recurrence after first-line treatment with antibiotics is high and fecal microbiota transplantation (FMT) may be effective for refractory and recurrent CDI. This series aims to describe the efficacy of FMT in the treatment of refractory and recurrent CDI. Methods: A prospectively recorded single-centre case series of patients with persistent or recurrent CDI treated with FMT between June 2014 and March 2015 was analyzed. Primary and secondary outcomes were defined as resolution of diarrhea without recurrence of CDI within 2 months after one or more FMT, respectively. A descriptive analysis was performed. Results: 8 FMT were performed in 6 patients, 3 with refractory CDI and 3 with recurrent CDI. The median age of recipients was 71 years and 66.7% were women. One FMT was delivered through colonoscopy and the remaining 87.5% through esophagogastroduodenoscopy. One upper FMT was excluded due to recurrence of CDI after antibiotic exposure for a respiratory infection. The overall cure rate of FMT was total with lower route and 83.3% with upper route. Primary cure rate was achieved in 83.3% of patients and secondary cure rate was achieved in all patients. Median time to resolution of diarrhea after FMT was 1 day and no complications were reported during follow-up. Conclusion: FMT appears to constitute a safe and effective approach in the management of refractory and recurrent CDI. Difference between primary and secondary cure rates may result of insufficient restoration of intestinal microbiota with a single FMT.

A enteroscopia por cápsula é um dos principais métodos de diagnóstico de lesões do intestino delgado, em especial no contexto da hemorragia digestiva obscura. A enteroscopia por cápsula revolucionou a avaliação do intestino delgado e a deteção e tumores. No entanto, os tumores do intestino delgado nem sempre são diagnosticados por enteroscopia por cápsula. Vários artigos que comparam a enteroscopia por cápsula com outros métodos de diagnóstico, como a enteroscopia por duplo balão ou a enterografia por tomografia computorizada/ressonância colocam em causa o elevado valor preditivo negativo da cápsula endoscópica na deteção de tumores do intestino delgado. Os autores descrevem o caso de uma doente com hemorragia digestiva obscura manifesta devido a um GIST diagnosticado por enterografia por TC abdominal após realização de duas enteroscopias por cápsula que foram negativas. Este caso demonstra que a enteroscopia por cápsula pode não diagnosticar lesões com significado clinico e realça a importância de utilizar outros métodos de diagnóstico, especialmente em doentes com elevado índice de suspeição de tumores do intestino delgado ou hemorragia persistente/recorrente.

Capsule endoscopy is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases, especially in the setting of obscure gastrointestinal bleeding. It has revolutionized small bowel examination and has improved the detection of small bowel tumors. However, small bowel tumors are sometimes missed by capsule endoscopy. Furthermore, there are several recent reports comparing capsule endoscopy with other diagnostic modalities, such as double balloon enteroscopy and CT/RM enterography, that challenge the reportedly high negative predictive value of capsule endoscopy in detecting small bowel tumors. We report the case of a patient with overt obscure gastrointestinal bleeding due to a gastrointestinal stromal tumor diagnosed by CT enterography after two negatives capsule endoscopies. This case shows that capsule endoscopy may overlook significant life threatening lesions and highlights the importance of using other diagnostic modalities after a negative capsule endoscopy, especially in patients with a high index of suspicion for small bowel tumoral pathology or persistent/recurrent bleeding.

Background: Capsule endoscopy is a first line examination to evaluate obscure gastrointestinal bleeding. The identification of factors associated with the detection of lesions by capsule endoscopy could improve resource utilization and patient selection. Objectives: To identify factors associated with positive capsule endoscopy findings in patients with obscure gastrointestinal bleeding. Methods: Retrospective, single-center study, including 203 patients (214 capsule endoscopy procedures) submitted to capsule endoscopy in the setting of obscure gastrointestinal bleeding. Type of obscure gastrointestinal bleeding, number of units of packed red blood cells transfused, type of positive finding, number of endoscopy studies performed prior to capsule endoscopy, comorbidities, medication and Charlson index were evaluated. Overt bleeding was subdivided into ongoing and previous gastrointestinal bleeding. Only lesions with high hemorrhagic potential (P2) were classified as positive findings. Results: The mean age was 62.2 years and 59.7% of patients were female. Most patients were referred for occult gastrointestinal bleeding (64.5%), while 35.5% were referred for overt gastrointestinal bleeding (63.2% previous-overt gastrointestinal bleeding). The most frequent positive findings included ulcers/erosions (34%) and angioectasias (32%). In univariate analysis, the identification of positive findings was significantly higher in those with ongoing-overt bleeding (p < 0.001), advanced age (p = 0.003), increasing number of pre-capsule endoscopies (p < 0.001), increasing transfusion requirements (p < 0.001), moderate/severe renal disease (p = 0.009) and antiplatelet drugs (p = 0.021) and NSAID intake (p = 0.005). In multivariate analysis, positive findings were significantly higher only in those with ongoing-overt bleeding (odds ratio [OR] 18.68, 95% confidence interval [CI] 3.98-85.6, p < 0.001), higher transfusion requirements (OR 1.23, 95% CI 1.1-1.4, p < 0.001) and NSAID intake (OR 5.9, 95% CI 2.1-17.3, p = 0.001). Conclusions: Capsule endoscopy should be used early in obscure gastrointestinal bleeding. Ongoing-overt bleeding, higher transfusion requirements and NSAIDs intake were associated with positive findings on capsule endoscopy.

O pólipo fibróide inflamatório (PFI) é uma lesão subepitelial (LSE) gastrointestinal incomum e benigna. As características dos PFIs gástricos na ultrassonografia endoscópica (EUS) foram esporadicamente descritas em relatos de casos clínicos e séries pequenas. No entanto, o diagnóstico diferencial e tratamento são frequentemente um desafio. Apresentamos um caso invulgar de uma LSE gástrica volumosa, com sintomas obstrutivos face ao seu efeito valvular sobre o piloro (‘‘ball valve syndrome’’) e anemia por erosão da mucosa. Na avaliação por EUS observou-se uma LSE hipoecogénica mas heterogénea no antro distal, com 50 mm, e pedículo longo na dependência da segunda e terceira camadas (mucosa profunda e submucosa). Estava mantida a integridade da quarta camada (muscular), e não foram observadas adenopatias peri-lesionais. Optou-se pela exérese endoscópica face à sintomatologia referida. A análise histológica com estudo imuno-histoquímico foi compatível com PFI. Os PFIs raramente atingem estas dimensões ou causam sintomas. Apesar da sua etiologia benigna, a ressecção endoscópica foi importante para estabelecer um diagnóstico histológico bem como tratamento. Destaca-se a importância da EUS no diagnóstico diferencial desta lesão. A literatura sobre PFIs é revista.

Inflammatory fibroid polyp (IFP) is an unusual benign gastrointestinal subepithelial tumor (SET). The endosonographic (EUS) features of IFPs were sporadically reported on imagingtips or small case series study. However, the differential diagnosis and optimal treatment of gastric IFP is still challenging. We report an unusual case of a large erosioned and prolapsing gastric submucosal lesion, presenting primarily with obstructive symptoms (‘‘ball valve syndrome’’) and anemia. On EUS examination, a 50mm SET in the distal antrum was seen, with hypoechoic but heterogeneous echo-pattern, located in the second and third sonographic layers of the gastric wall (deep mucosal and submucosal). The fourth (muscle) layer was intact; no peri-lesional adenopathies were identified. A decision was made to proceed to endoscopic treatment because of the mentioned symptoms. Histopathologic evaluation of the resected specimen with immunohistochemical staining was consistent with the diagnosis of IFP. IFP rarely reach these large dimensions or cause symptoms. Despite its benign etiology, endoscopic resection was important in both establishing a histologic diagnosis and treatment. EUS was crucial in the differential diagnosis. The literature concerning IFP is also reviewed.