Tuberculosis of the breast is an uncommon disease. The authors present a case of an asymptomatic 64 year-old patient whose mammography showed a right breast nodule which needed aetiological investigation. Complementary diagnostic exams did not lead to a differential diagnosis between granulomatous lesion and breast carcinoma; nodule aspiration results suggested tuberculosis of the breast but were unclear and so tuberculosis antibiotics were initiated. No other tuberculosis infectious focus was found at clinical-laboratory evaluation. Imagiology progress was favourable, so patient continued treatment. The authors highlight the low rate of primary tuberculosis of the breast and make a brief reference to the pathology, which has a low rate of microbiological and pathological-anatomical identification.

A nocardiose pulmonar é uma doença rara. Neste contexto, os autores efectuam uma revisão bibliográfica desta patologia, a propósito de um doente, infectado pelo vírus de imunodeficiência humana (VIH), que apresentava um quadro clínico e imagiológico compatível com uma pneumonia de evolução arrastada, salientan-do-se a importância da realização de terapêutica de manutenção prolongada.

RESUMO: A Legionella pneumophila é uma bacteria comum do ambiente e um agente causal importante de pneumonias graves da comunidade. O diagnóstico em fase precoce da doença, nem sempre é fácil.Procedemos a um estudo retrospectivo, com o objectivo de caracterizar os doentes intemados na Unidade de Cuidados lntensivos Respiratórios (UCIR), com o diagnóstico de pneumonia a Legionella pneumophila (pLp), durante dez anos (1986-1996). Foram analisados doze processos clinicos que repre-sentavam 6,7% das pneumonias da comunidade intemados nesse perfodo. Comparam-se também as pneumonias a Legionella pneumophila com as outras pneumonias da comunidade, durante o mesmo perído de internamento. Onze doentes eram do sexo masculino e uma do sexo feminino, comidade média de 49,6±11, 9 anos. O TISS foi de 25,8±9,5, o APACHE II de 23,4±6,5 e o APS de 20,3±6,5. Apenas 1 doente não necessitou de ventilação medcânica, tendo sido o tempo médio de ventilação de 11,5±12,5 dias (min: 1 e máx: 44). Quatro pneumonias ocorreram fora da época sazonal habitual e só quatro doentes tinham história epidemiológica sugestiva. Apenas um doente, não tinha factores de risco. A confirmação diagnóstica foi feita por serologia e imunonuorescência directa das secreçõs brônquicas. Em relação às complicaçõoes, 9 doentes tiveram disfunção hepática, 7 insuficiência renal, 1 endocardite e 1 desenvolveu SDRA. A septicemia noscomial, ocorreu em 5 doentes. Faleceram 58,3% dos doentes que tinham índices de gravidade mais elevados.Os doentes com pLp, apresentavam maior gravidade que se traduziu por uma maior necessidade de suporte ventilatorio. A mortalidade embora mais elevada nos doentes com pLp (58,3% versus 31,8%), não foi significativamente diferente nos dois grupos quando consideramos apenas os doentes ventilados.Os autores concluem que a pneumonia da comunidade causada por Legionella pneumophila, é uma situaçã o grave que se acompanha de morbilidade e mortalidade consideraveis. Esta etiologia deve ser consideráveis, mesmo fora da epoca sazonal habitual, nas pneumonias graves do adulto sobretudo naqueles com factores de risco, pelo que a terapêutica antibiótica empírica deverá ter um espectro que inclua esta entidade.REV PORT PNEUMOL 1998; IV (2): 139-145 SUMMARY: Legionella pneumophila (LP) is a common bacteria of the environment, and it is an agent responsible for severe community acquired pneumonia (CAP). We analyzed the, 12 patients with Lp pneumonia admitted in our Respiratory ICU during the last 10 years (1986-1996). They represented 6,7% of CAP. Eleven patients were males and 1 female, with mean age 49,6±11,9 years. TISS was 25,8±9,5 and APACRE II 23,4±6,5. All, but 1 patient, were under mechanical ventilation (MV) during a mean period of 11,5±12,5 (min: 1, max:44) days.Four pneumonias occurred beyond the season, while only 4 patients had an epidemiological history. Only 1 patient had no risk factor. In all the others tobacco smoking and alcohol abuse were quite frequent. Diagnosis was based on serologic test and culture or direct fluorescent antibody staining of bronchial secretions.Eleven patients had a multisystemic disease with hepatic dysfunction in 9, renal failure in 7 (due to rhabdomyolysis in 4). One patient had a endocarditis and another developped ARDS. Nosocomial septicaemie occurred in 5 patients.Mortality rate was 58,3%. Deceased patients bad initially higher APACHE n, (A-a) 02, and lower natremia. Comparing Lp pneumonia with the other CAP (n=166), both submitted to MV, the higher mortality rate was not significant statisticly (58,3% versus 31,8%). In conclusion Lp pneumonia can occur all over the year. There was a high incidence of severe complications and outcome was similar to the other CAP when requiring MV.REV PORT PNEUMOL 1998; IV (2): 139-145 Key-words: Legionella pneumophila, Pneumonia, Mechanical ventilation, Palavras-chave: Legionella pneumophila, Pneumonia, Ventilação mecânica

A Legionella pneumophila é uma bacteria comum do ambiente e um agente causal importante de pneumonias graves da comunidade. O diagnóstico em fase precoce da doença, nem sempre é fácil.

A situação patológica mais importante na circulação pulmonar é o desenvolvimeoto da Hipertensão Arterial Pulmonar, que pode resultar de doença parenquimatosa pulmonar, alterações da parede vascular ou da obstrução do lúmen por trombose ou embolia.

A toracoscopia é uma técnica médico-cirúrgica com fmalidade diagoóstica e/ou terapêutica. O aperfeiçoamento da qualidade dos instrumentos e a experiência cad a vez maior, vão permitir a realização da técnica em muitas situações actualmente praticadas por toracotomia. 0 alargamento do âmbito da toracoscopia, sem o intuito de a hipervalorizar relativamente à toracotomia, vai contribuir não só para a in intervenção mais precoce como para a melhoria da qualidade de vida do doente. Pelo sucesso da toracoscopia em várias patologias pleuroparenquimatosas, os AA decidiram fazer uma breve revisão teórica realçando os resultados descritos na literatura e uma amostra da experiência da Unidade de Endoscopia Respiratória (U.E.R.) do Hospital Santa Maria (H.S.M.).

A retrospective study was performed in 107 patients with pneumonia in a total of 2231 who were admitted in a Medicine ward, of an University Hospital in Lisbon during 1990. From the studied patients, 50 (46,7%) were females and 57 (53,3%) males. The mean age was 70,7 +/- 15,3 years, with a mean of 12.8 admission days. In the past history it was identified 43 (40%) patients with respiratory illness. In this, the chronic obstructive airways disease were the more prevalent disease in 22 (20.5%) patients. In the other chronic debilitating diseases, registered in 90 (84.1%), we reported in 58 (54.2%) patients among cardiovascular illness, hypertension (H) in 17 (15.8%) cases and H with diabetes mellitus II (DMII) in 14 (13.1%). The most common radiographic pattern was bronchopneumonia in 56 (52.3%) cases and in the respiratory functional study, the partial respiratory insufficiency occurred in 25 (23.4%) cases. In blood test at admission, it was found anaemia in 35 (32.7%) patients, leukocytosis in 72 (67.3%), elevated sedimentation rate in 70 (65.4%), renal dysfunction in 12 (11.2%) and hyperglycemia in 67 (62.6%). Concerning therapeutics, the ampicillin was the most used antimicrobial therapy in 50 (46.7%) cases and the oxygenotherapy was necessary in 45 (42%). Only 29 (27.1%) needed bronchodilators and 3 (2.8%) required mechanical ventilatory support. The evolution was good in 76 (71%) cases and 31 (29%) patients died. The authors conclude that the pneumonia is a frequent disease in the Internal Medicine Clinics, either as admission cause either as complication of other comorbid medical condition and has a high mortality rate. The most important factors for the prognosis were the age of patients and previous diseases. The aim of the authors is to enhance prevention infection in lower respiratory tract, principally in the weak constitutions patients and the prescription of the appropriate therapy according with the judgment presumption and if possible with the isolated microorganism. Identify with the retrospective study, important elements in the clinical process for interpretation of diagnosis and therapeutic attitude and to learn with the preceding experience for future orientation.

A retrospective study was performed in 107 patients with pneumonia in a total of 2231 who were admitted in a Medicine ward, of an University Hospital in Lisbon during 1990. From the studied patients, 50 (46,7%) were females and 57 (53,3%) males. The mean age was 70,7 +/- 15,3 years, with a mean of 12.8 admission days. In the past history it was identified 43 (40%) patients with respiratory illness. In this, the chronic obstructive airways disease were the more prevalent disease in 22 (20.5%) patients. In the other chronic debilitating diseases, registered in 90 (84.1%), we reported in 58 (54.2%) patients among cardiovascular illness, hypertension (H) in 17 (15.8%) cases and H with diabetes mellitus II (DMII) in 14 (13.1%). The most common radiographic pattern was bronchopneumonia in 56 (52.3%) cases and in the respiratory functional study, the partial respiratory insufficiency occurred in 25 (23.4%) cases. In blood test at admission, it was found anaemia in 35 (32.7%) patients, leukocytosis in 72 (67.3%), elevated sedimentation rate in 70 (65.4%), renal dysfunction in 12 (11.2%) and hyperglycemia in 67 (62.6%). Concerning therapeutics, the ampicillin was the most used antimicrobial therapy in 50 (46.7%) cases and the oxygenotherapy was necessary in 45 (42%). Only 29 (27.1%) needed bronchodilators and 3 (2.8%) required mechanical ventilatory support. The evolution was good in 76 (71%) cases and 31 (29%) patients died. The authors conclude that the pneumonia is a frequent disease in the Internal Medicine Clinics, either as admission cause either as complication of other comorbid medical condition and has a high mortality rate. The most important factors for the prognosis were the age of patients and previous diseases. The aim of the authors is to enhance prevention infection in lower respiratory tract, principally in the weak constitutions patients and the prescription of the appropriate therapy according with the judgment presumption and if possible with the isolated microorganism. Identify with the retrospective study, important elements in the clinical process for interpretation of diagnosis and therapeutic attitude and to learn with the preceding experience for future orientation.

Pleural effusions can be a manifestation of several nosological entities. Etiologic diagnosis involves a good clinical history, followed by thoracocentesis with pleural biopsy and eventually bronchoscopy or thoracoscopy. The differentiation between transudates and exudates, by the biochemical characteristics of the pleural effusions, can orientate the underlying disorder. It is known that there are more than 35 different etiological entities of exudative pleural effusions. However, pneumonia, malignancies, pulmonary embolism, abdominal disease and tuberculosis are the major causes (around 90%). Transudative effusions are more frequently due to congestive heart failure, renal or hepatic failure. The AA present a clinical situation of pleural effusion, the etiology of which was initially attributed to congestive heart failure, with a good response, clinical and radiological response to the treatment established. However the laboratory alteration persisted (anaemia, renal failure, acute inflammation). The subsequent study showed the existence of a rare syndrome, a Myeloma Ig M lambda that can lead to differential diagnosis with Waldenström's Macroglobulinemia, about which the authors make some theoretical considerations showing the difficulty in etiologic diagnosis of some pleural effusions.

Pleural effusions can be a manifestation of several nosological entities. Etiologic diagnosis involves a good clinical history, followed by thoracocentesis with pleural biopsy and eventually bronchoscopy or thoracoscopy. The differentiation between transudates and exudates, by the biochemical characteristics of the pleural effusions, can orientate the underlying disorder. It is known that there are more than 35 different etiological entities of exudative pleural effusions. However, pneumonia, malignancies, pulmonary embolism, abdominal disease and tuberculosis are the major causes (around 90%). Transudative effusions are more frequently due to congestive heart failure, renal or hepatic failure. The AA present a clinical situation of pleural effusion, the etiology of which was initially attributed to congestive heart failure, with a good response, clinical and radiological response to the treatment established. However the laboratory alteration persisted (anaemia, renal failure, acute inflammation). The subsequent study showed the existence of a rare syndrome, a Myeloma Ig M lambda that can lead to differential diagnosis with Waldenström's Macroglobulinemia, about which the authors make some theoretical considerations showing the difficulty in etiologic diagnosis of some pleural effusions.

We present the case of a 64-year-old woman who, in the past 5 years, complained of constipation/diarrhea, hyposudoresis, xerostomia and xerophthalmia, dysuria and orthostatic hypotension. Cardiovascular reflexes analysis revealed sympathetic and parasympathetic failure. Norepinephrine was markedly reduced, both lying and after tilt. Norepinephrine infusion determined a significant rise in blood pressure, allowing the diagnosis of denervation hypersensitivity. The diagnosis of pure autonomic failure was made. Therapy with 9 alpha fludrocortisone and metoclopramide was initiated with marked and sustained symptomatic effect.

We present the case of a 64-year-old woman who, in the past 5 years, complained of constipation/diarrhea, hyposudoresis, xerostomia and xerophthalmia, dysuria and orthostatic hypotension. Cardiovascular reflexes analysis revealed sympathetic and parasympathetic failure. Norepinephrine was markedly reduced, both lying and after tilt. Norepinephrine infusion determined a significant rise in blood pressure, allowing the diagnosis of denervation hypersensitivity. The diagnosis of pure autonomic failure was made. Therapy with 9 alpha fludrocortisone and metoclopramide was initiated with marked and sustained symptomatic effect.