ABSTRACT Endometriosis is a common disease; however, unusual findings may cause diagnostic difficulties. We present herein three cases illustrating different morphological appearances of endometriosis: 1) endometriosis with atypical hyperplasia associated with bilateral ovarian carcinoma (mixed clear cell/endometrioid in the left ovary and endometrioid in the right ovary); 2) deep infiltrating endometriosis with intravascular spread, polypoid configuration in peritoneal surfaces, and involvement of a lymph node; and 3) decidualized endometriosis with prominent myxoid/mucinous change and multivacuolated (pseudoxanthoma) cells. Awareness of uncommon morphological manifestations of endometriosis is important to avoid improper consideration of malignancy.

RESUMO A gradual adoção de novas diretrizes curriculares afetou dramaticamente a atuação do professor de Patologia no curso médico. O resultado prático das mudanças adotadas foi a redução do espaço do ensino da Patologia na graduação e a perda de espaço do professor médico patologista no curso médico. Como consequência, os novos médicos compreendem menos os mecanismos envolvidos nas doenças, e, pelo menos em algumas regiões do mundo, a perda de visibilidade da Patologia como especialidade médica resultou em falta de patologistas dedicados à carreira acadêmica e à prática diagnóstica. Nesta revisão, discutimos o cenário internacional e comentamos como a nova realidade atingiu, na prática, o ensino da Patologia em duas escolas médicas tradicionais do Brasil.

ABSTRACT The gradual adoption of new directives in medical undergraduate curricula has dramatically changed the role of the pathologist in medical education. The practical consequences of these changes have been a reduction of space dedicated to pathology and the role of the pathology professor in the medical curriculum. As a result, new doctors have less knowledge of the basic mechanisms of diseases and, at least in some parts of the world, a loss of visibility of the specialty has led to a dwindling number of potential new pathology residents and more vacancies in academic and surgical/diagnostic pathology. This review discusses the international scenario and comments on how the new curriculum has affected Pathology Education in two traditional medical schools in Brazil.

Aim: considering the frequent consumption of fatrich diets by women of reproductive age, the aim of the present study was to investigate the effects of maternal consumption of a high-fat diet during the perinatal and/ or post-weaning period on the liver parameters and lipid metabolism of young rats. Methods: Wistar female rats were fed a high-fat (H) or control (C) diet during pregnancy and lactation. The offspring were allocated to four groups: Control Control (CC, n = 11), offspring fed a control diet after weaning; Control High-fat (CH, n = 10), offspring fed a high-fat diet after weaning; High-fat High-fat (HH, n = 10), offspring of mothers H fed a high-fat diet after weaning; and High-fat Control (HC, n = 9), offspring of mothers H fed with control diet after weaning. Results and discussion: the food intake did not differ among the groups, however, the relative weight of the adipose tissue was higher in animals from the HC, HH and CH groups (p ≤ 0.005). Liver steatosis was found in the CH and HH animals, which also exhibited hypercholesterolemia (p ≤ 0.05). The levels of the liver enzymes alanine aminotransferase (ALT) and gamma-glutamyl transpeptidase (GGT) were higher in the HH group, and the LDL level was higher in the CH group compared to the CC. The consumption of an obesogenic diet during critical periods of development may contribute to the occurrence of visceral obesity, liver steatosis and hypercholesterolemia in adult rats, even in the absence of changes in dietary intake.

Objetivo: teniendo en cuenta el consumo frecuente de dietas ricas en grasas por las mujeres en edad reproductiva, el objetivo del presente estudio fue investigar los efectos del consumo materno de una dieta alta en grasas durante el periodo perinatal y/o post-destete en el hígado y el metabolismo de los lipidos en ratas jóvenes. Métodos: ratas hembra Wistar fueron alimentadas durante el embarazo y la lactancia con un alto contenido de grasa (H) o de control (C). La descendencia se asignó a cuatro grupos: Control (CC, n = 11), descendencia alimentada con una dieta de control después del destete; Control de dieta alta en grasa (CH, n = 10), crias alimentadas con una dieta alta en grasas después del destete; Alta en grasas de alta en grasa (HH, n = 10), hijos de madres H alimentados con una dieta alta en grasas después del destete; y Control de alta en grasa (HC, n = 9), hijos de madres H alimentados con dieta de control tras el destete. Resultados y discusión: la ingesta de alimentos no difirio entre los grupos; sin embargo, el peso relativo del tejido adiposo fue mayor en los animales de los grupos HC, HH y CH (p ≤ 0,005). La esteatosis hepatica se encontro en los CH y HH, que tambien presentaban hipercolesterolemia (p ≤ 0,05). Los niveles de las enzimas hepaticas alanina aminotransferasa (ALT) y gamma-glutamil transpeptidasa (GGT) fueron mayores en el grupo de HH, y el nivel de LDL fue mayor en el grupo CH en comparación con el CC. El consumo de la dieta propicio la obesidad durante los periodos criticos del desarrollo y puede contribuir a la aparición de obesidad visceral, esteatosis hepatica e hipercolesterolemia en ratas adultas, incluso en ausencia de cambios en la ingesta dietética.

O uso de imunobiológicos no tratamento das doenças autoimunes é cada vez mais frequente na prática médica. Terapias anti-TNF têm sido cada vez mais utilizadas nas doenças autoimunes refratárias, especialmente na artrite reumatoide, com resultados promissores. Entretanto, o uso dessas terapias está relacionado ao aumento do risco do desenvolvimento de outras doenças autoimunes. Adicionalmente, o uso de agentes anti-TNF pode determinar repercussões pulmonares, como a reativação de infecções por micobactérias e fungos e o desenvolvimento de sarcoidose e de outras doenças pulmonares intersticiais (DPIs). A associação de DPI e uso dos agentes anti-TNF, em especial infliximabe e etanercepte, já foi descrita. O adalimumabe é a mais nova droga dessa classe, e algumas publicações sugerem que seu uso pode determinar a indução ou mesmo a exacerbação de DPIs preexistentes. Neste estudo, relatamos o primeiro caso de DPI aguda secundária à utilização de adalimumabe, em uma paciente portadora de artrite reumatoide sem DPI prévia no Brasil.

The use of immunobiological agents for the treatment of autoimmune diseases is increasing in medical practice. Anti-TNF therapies have been increasingly used in refractory autoimmune diseases, especially rheumatoid arthritis, with promising results. However, the use of such therapies has been associated with an increased risk of developing other autoimmune diseases. In addition, the use of anti-TNF agents can cause pulmonary complications, such as reactivation of mycobacterial and fungal infections, as well as sarcoidosis and other interstitial lung diseases (ILDs). There is evidence of an association between ILD and the use of anti-TNF agents, etanercept and infliximab in particular. Adalimumab is the newest drug in this class, and some authors have suggested that its use might induce or exacerbate preexisting ILDs. In this study, we report the first case of acute ILD secondary to the use of adalimumab in Brazil, in a patient with rheumatoid arthritis and without a history of ILD.

Leptospirosis in humans usually involves hypokalaemia and hypomagnesaemia and the putative mechanism underlying such ionic imbalances may be related to nitric oxide (NO) production. We previously demonstrated the correlation between serum levels of NO and the severity of renal disease in patients with severe leptospirosis. Methylene blue inhibits soluble guanylyl cyclase (downstream of the action of any NO synthase isoforms) and was recently reported to have beneficial effects on clinical and experimental sepsis. We investigated the occurrence of serum ionic changes in experimental leptospirosis at various time points (4, 8, 16 and 28 days) in a hamster model. We also determined the effect of methylene blue treatment when administered as an adjuvant therapy, combined with late initiation of standard antibiotic (ampicillin) treatment. Hypokalaemia was not reproduced in this model: all of the groups developed increased levels of serum potassium (K). Furthermore, hypermagnesaemia, rather than magnesium (Mg) depletion, was observed in this hamster model of acute infection. These findings may be associated with an accelerated progression to acute renal failure. Adjuvant treatment with methylene blue had no effect on survival or serum Mg and K levels during acute-phase leptospirosis in hamsters.

O carcinossarcoma de glândulas salivares é uma neoplasia rara na qual os componentes epitelial e estromal apresentam critérios microscópicos de malignidade. Setenta e quatro casos já foram relatados até o momento. Neste relato, descrevemos o caso de um paciente do sexo masculino, 81 anos, com carcinossarcoma da parótida, exibindo áreas de carcinoma indiferenciado e componente sarcomatoso constituído por condrossarcoma, sarcoma de alto grau e tumor de células gigantes. Revisamos e discutimos essa rara observação de carcinossarcoma de glândula salivar exibindo focos de tumor de células gigantes, descrito apenas em dois casos prévios.

Salivary gland carcinosarcoma is a rare neoplasm in which both stromal and epithelial components meet the microscopic criteria for malignancy. Seventy-four cases have been reported in English-language literature to date. In this study, we describe the case of an 81-year-old male patient with parotid gland carcinosarcoma featuring foci of undifferentiated carcinoma and sarcomatous components such as chondrosarcoma, high-grade undifferentiated sarcoma, and malignant giant cell tumor. We reviewed and discussed this rare occurrence of salivary gland carcinosarcoma with areas of malignant giant cell tumor, which had been reported only twice previously.

A doença de Rosai-Dorfman (DRD) consiste em histiocitose sinusal com linfadenopatia maciça. O envolvimento extranodal ocorre em até 43% dos casos. Entretanto, a DRD de partes moles de forma isolada é rara. A forma isolada de DRD mediastinal é muito rara, com apenas três relatos prévios. O envolvimento do mediastino posterior só foi descrito no contexto da DRD disseminada. Relatamos o caso de uma paciente de 49 anos de idade com história de dor e linfadenomegalia cervical há dois anos, com resolução espontânea. A TC revelou uma massa paravertebral à esquerda medindo 6 cm de diâmetro. A paciente foi submetida à ressecção cirúrgica da massa. O exame microscópico e estudo do imunofenótipo da peça cirúrgica definiram o diagnóstico de DRD. A paciente foi acompanhada por 12 meses, queixando-se de tosse discreta e dor torácica. O acompanhamento por imagem não detectou recorrência, e nenhuma linfadenomegalia cervical foi observada após a cirurgia.

Rosai-Dorfman disease (RDD) consists of sinus histiocytosis with massive lymphadenopathy. Extranodal involvement occurs in up to 43% of cases. However, isolated soft tissue RDD is rare. Isolated mediastinal RDD is exceedingly rare, and there have been only three previous reports. Involvement of the posterior mediastinum in RDD has been reported only in the context of disseminated RDD. Here, we report the case of a 49-year-old female patient with a two-year history of cervical pain and lymphadenomegaly, which resolved spontaneously. A CT scan revealed a left paravertebral mass with a diameter of 6 cm. The patient was submitted to surgical excision of the mass. Microscopic examination and immunophenotyping of the surgical specimen led to a diagnosis of RDD. During a 12-month follow-up period, the patient complained of mild cough and chest pain. Periodic imaging tests showed no sign of recurrence, and no postoperative cervical lymphadenomegaly was detected.

A literatura médica apresenta 28 relatos inequívocos de ossificação mesentérica heterotópica (OMH). A maioria apresenta-se como lesões mal definidas em estruturas intra-abdominais causando obstrução intestinal. Em apenas um caso a lesão apresentava-se como uma pequena massa bem delimitada, num paciente sem histórico de trauma. Apresentamos o caso de uma paciente de 67 anos com massa calcificada em topografia anexial esquerda. O conhecimento da entidade OMH previne eventual diagnóstico errôneo de osteossarcoma extraesquelético. Esse caso difere da maioria dos casos de OMH visto que é apenas o terceiro relatado no sexo feminino, e não apresentava envolvimento difuso levando aos sintomas obstrutivos.

There are 28 unequivocal reports of heterotopic mesenteric ossification (HMO) in the medical literature. Most cases are poorly defined lesions in intra-abdominal structures that cause intestinal obstruction. A small well-delineated solid mass was reported in only one patient with no previous history of trauma. We report herein the case of a 67 year-old female patient with calcified mass in the left adnexal region. The awareness of HMO may avoid an erroneous diagnosis of extraskeletal osteosarcoma. This case differs from most cases of HMO as it is the third one reported in females and does not present a diffuse involvement, which leads to obstructive symptoms.

INTRODUÇÃO: O ensino da Patologia tem papel fundamental na formação médica, por ser o principal elo entre as ciências básicas e a prática clínica, assim como referência para a pesquisa científica. A Patologia insere-se no grupo de disciplinas que passam por um processo de mudanças curriculares e incorporação de novas tecnologias, sendo tal processo iniciado há duas décadas nos EUA, Austrália e Europa. OBJETIVO: Discutir as vantagens e desvantagens das mudanças que atingem o ensino da Patologia no País, a partir da experiência internacional. RESULTADOS: Na presente revisão, discutimos preocupações atuais, que incluem a marginalização da Patologia no currículo médico, a falta de contato dos estudantes com a Anatomia Patológica e as possíveis lacunas na formação do futuro médico. CONSIDERAÇÕES FINAIS: A ausência de contato com a Anatomia Patológica no curso médico, ou sua participação meramente ilustrativa, cria os problemas adicionais de pouco incentivo à escolha desta especialidade médica e gera a dificuldade dos novos médicos em lidar com solicitações e interpretações de laudos anatomopatológicos.

BACKGROUND: Teaching of General Pathology plays a central role in basic medical education, because it forms the main link between the basic sciences and clinical practice, besides serving as a reference for scientific research. Pathology is one of a group of disciplines that have undergone important curriculum changes and incorporated new technologies, in a process that began 20 years ago in the United States, Australia, and Europe. OBJECTIVE:To discuss the advantages and disadvantages of changes in Pathology as part of medical education in Brazil, in light of the international experience. RESULTS:This review discusses current concerns, including the marginalization of Pathology in the medical curriculum, students' lack of contact with Pathological Anatomy, and resulting gaps in the training of future physicians. CONCLUSIONS:Students' lack of contact with Pathological Anatomy during rotation in medical school (or merely cursory participation on their part) creates additional problems, such as limited incentives for choosing this medical specialty as a career and difficulty by young physicians in ordering and reading pathology reports.

OBJETIVO: Avaliar modificações implementadas recentemente num curso de Patologia Geral (PG), com vistas a incentivar a auto-instrução dos alunos por meio de recursos eletrônicos. METODOLOGIA: Estudantes do curso de PG da Escola Bahiana de Medicina e Saúde Pública foram solicitados a preencher um questionário sobre modificações implementadas na disciplina, entre elas a utilização de um CD-ROM elaborado e distribuído pela disciplina. RESULTADOS: Foram avaliados 288 estudantes. A importância média dada ao CD-ROM foi de 8,45 ± 1,79, numa escala de 0 a 10, sendo esta a principal fonte de estudo utilizada por 97,2% dos estudantes para a prova prática. Os alunos que estudaram pelo CD apresentaram menor freqüência de notas baixas - consideradas inferiores a 6,0 (39,9% x 87,5%, P = 0,010) - e referiram conseguir identificar os processos gerais com maior freqüência (99,3% x 87,5%, P = 0,012) em relação aos que não utilizaram este método. 95,8% dos alunos acharam que o curso melhorou sua capacidade de reconhecer tecidos e órgãos ao microscópio. CONCLUSÕES: O CD-ROM utilizado oferece recursos que podem facilitar o processo ensino-aprendizagem, representando uma alternativa para o ensino integrado de PG.

AIM: To evaluate the modifications implemented in a General Pathology (GP) course, seeking to motivate self-instruction of the students through electronic resources. METHODS: Students of the Escola Bahiana de Medicina e Saúde Pública were requested to answer a questionnaire in order to evaluate the modifications implemented in this discipline, specially the use of a CD-ROM elaborated and distributed in the course. RESULTS: 288 students participated in the study. The mean importance given to the CD-ROM was of 8.45 ± 1.79, in a scale from 0 to 10. It was also the main study source for the practical evaluation, used by 97.2% of the students. The students who used the CD-ROM got low scores - considered inferior to 6.0 (39.9% x 87.5%, P = 0.010) - less frequently, and reported to be able of identifying the general pathologic processes more frequently (99.3% x 87.5%, P = 0.012) than the students that did not use this method. 95.8% of the students thought that the course improved their capacity to recognize tissues or organs under the microscope. CONCLUSIONS: The CD-ROM offers resources that can facilitate the teaching-learning process, representing an alternative for the integrated teaching of GP.

Acute renal failure (ARF) is one of the most common complications of leptospirosis although the causal mechanisms are still unclear. Diverse mechanisms are implicated in leptospiral nephropathy and new data supports the role of peculiar ion transport defects. Besides antibiotic therapy, ARF management in leptospirosis requires dialytic therapy which is most efficient when started early. Dialysis is the standard supportive therapy even though recent evidence suggests clinical benefit from alternative treatments such as plasmapheresis and hemofiltration. Renal recovery is achieved soon after clinical improvement. The comprehension of the primary mechanisms of renal dysfunction will be helpful in the development of additional therapeutic tools for improving supportive therapy for leptospiral nephropathy. This review discusses new insights into mechanisms implicated in leptospiral ARF and recent advances in treatment.

A reposição hormonal para alívio dos sintomas menopausais é amplamente utilizada em todo o mundo. A evolução do conhecimento sobre os riscos deste tratamento sempre foi mais lenta do que sua aplicação na prática clínica. Na década de 70, um aumento de incidência de câncer do endométrio ocorreu nos países desenvolvidos sendo que a terapia de estrógenos exógenos na menopausa foi o principal fator relacionado. Nas décadas de 80 e 90, a combinação entre estrógenos e progestínicos passou a ser largamente utilizada com base na premissa de que apresentava efeitos benéficos sobre os sistemas cardiovascular e osteoarticular, sem aumento no risco de câncer uterino. Entretanto, relatos recentes novamente questionam a segurança da reposição hormonal e, desta vez, apontam para o risco maior de câncer total e doença cardiovascular nos esquemas combinados. Concluímos neste trabalho que os riscos recentemente relacionados à terapia combinada têm grande potencial de impacto na Saúde Pública, e este esquema não é indicado para proteção do risco de carcinoma endometrial uma vez que seus riscos superam os benefícios.

Hormone replacement therapy (HRT) has been used worldwide to relieve menopausal symptoms. The evolution in clinical knowledge of its risks has lagged persistently behind its application in clinical practice. In the 1970s, endometrial cancer incidence increased in developed countries, and exogenous estrogen therapy in postmenopausal women was the most important factor. In the 1980s and 90s, combined estrogen-progesterone therapy was prescribed on a large scale, based on its potential beneficial effects on the musculoskeletal and cardiovascular systems without increasing the risk of endometrial carcinoma. However, once again, recent reports argue against the safety of HRT, and the most important issues are now the increased risk of cardiovascular disease and total cancer in combined formulations. We conclude that the recently reported risks on combined HRT may have a significant public health impact, and that this treatment regimen should not be prescribed to protect postmenopausal women from endometrial carcinoma, since the risks outweigh the benefits.

A reposição hormonal para alívio dos sintomas menopausais é amplamente utilizada em todo o mundo. A evolução do conhecimento sobre os riscos deste tratamento sempre foi mais lenta do que sua aplicação na prática clínica. Na década de 70, um aumento de incidência de câncer do endométrio ocorreu nos países desenvolvidos sendo que a terapia de estrógenos exógenos na menopausa foi o principal fator relacionado. Nas décadas de 80 e 90, a combinação entre estrógenos e progestínicos passou a ser largamente utilizada com base na premissa de que apresentava efeitos benéficos sobre os sistemas cardiovascular e osteoarticular, sem aumento no risco de câncer uterino. Entretanto, relatos recentes novamente questionam a segurança da reposição hormonal e, desta vez, apontam para o risco maior de câncer total e doença cardiovascular nos esquemas combinados. Concluímos neste trabalho que os riscos recentemente relacionados à terapia combinada têm grande potencial de impacto na Saúde Pública, e este esquema não é indicado para proteção do risco de carcinoma endometrial uma vez que seus riscos superam os benefícios.

Hormone replacement therapy (HRT) has been used worldwide to relieve menopausal symptoms. The evolution in clinical knowledge of its risks has lagged persistently behind its application in clinical practice. In the 1970s, endometrial cancer incidence increased in developed countries, and exogenous estrogen therapy in postmenopausal women was the most important factor. In the 1980s and 90s, combined estrogen-progesterone therapy was prescribed on a large scale, based on its potential beneficial effects on the musculoskeletal and cardiovascular systems without increasing the risk of endometrial carcinoma. However, once again, recent reports argue against the safety of HRT, and the most important issues are now the increased risk of cardiovascular disease and total cancer in combined formulations. We conclude that the recently reported risks on combined HRT may have a significant public health impact, and that this treatment regimen should not be prescribed to protect postmenopausal women from endometrial carcinoma, since the risks outweigh the benefits.

OBJETIVO: Verificar o efeito do sildenafil na pressão arterial (PA) e freqüência cardíaca (FC) de indivíduos portadores de miocardiopata chagásica (MCC) e de disfunção ventricular sistólica grave (FE<40%) submetidos à atividade física. MÉTODOS: Foram avaliados 12 homens com fração de ejeção<40% e MCC confirmada por sorologia. Foi realizado o Teste de 6 minutos (T6M) antes e após a ingestão de sildenafil 50 mg, com intervalo de 30 minutos. Antes e depois de cada T6M aferiram-se a freqüência cardíaca (FC) e a pressão arterial sistólica (PAS) e diastólica (PAD). Para análise estatística, o estudo foi dividido em 4 etapas: Antes do T6M realizado antes do Sildenafil (T1); após o T6M, antes do Sildenafil (T2); após o sildenafil, antes do T6M (T3); após o Sildenafil, após o T6M (T4). RESULTADOS: A idade dos participantes variou entre 47 e 68 anos (57,6±6,4). PAS e PAD após o T6M e uso do sildenafil (T4) mostraram-se menores do que antes do fármaco (T2): 134,2±15,1 versus 125,5±14,0 e 88,4±12,4 versus 83,0±10,8, respectivamente. Nenhum indivíduo referiu sintomas durante a realização do T6M. Não houve diferença na distância total percorrida no T6M antes e depois do uso do sildenafil (487,5±15,22 versus 505,3±18,45 metros, respectivamente) - p=0,056, e na FC (antes sildenafil 75,5±8,79 e 96,8±10,36 bpm e após 77,1±9,81 e 96,1 ± 12,97 bpm). CONCLUSÃO: Observou-se significante diminuição da PA após atividade física sob uso do sildenafil. Entretanto, durante o Teste de 6 minutos, não foram relatados sintomas pelos pacientes, sugerindo, então, que esse efeito parece não ser suficiente para causar manifestações clínicas entre os portadores de MCC e insuficiência cardíaca.

OBJECTIVE: To accurately verify the effect of Sildenafil on blood pressure (BP) and heart rate (HR) in individuals with Chagasic myocardiopathy (CMC) and severe systolic ventricular dysfunction (EF<40%) submitted to physical activity. METHODS: Twelve men with ejection fractions <40% and CMC confirmed by a serological test were assessed. The six-minute walk test (6MWT) was performed before and after administration of 50 mg of Sildenafil, with a 30 minute interval. Heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure were taken and compared before and after each 6MWT. For statistical analysis purposes, the study was divided into four stages: before the 6MWT and administration of Sildenafil (S1); after the 6MWT but before the administration of Sildenafil (S2); after the administration of Sildenafil but before the 6MWT (S3); and after the administration of Sildenafil and the 6MWT (S4). RESULTS: Participant ages ranged from 47 to 68 years (57.6 ± 6.4). SBP and DBP after the 6MWT and the administration of Sildenafil (S4) were lower than before taking the drug (S2): 134.2 ± 15.1 versus 125.5 ± 14.0 and 88.4 ± 12.4 versus 83.0 ± 10.8, respectively. None of the patients reported any symptoms during the 6MWT. There were no differences in the distances walked during the 6MWT before or after taking Sildenafil (487.5±15.22 versus 505.3±18.45 meters, respectively)-p=0.056, or in HR (before Sildenafil 75.5 ± 8.79 and 96.8 ± 10.36 bpm and after 77.1 ± 9.81 and 96.1 ± 12.97 bpm). CONCLUSION: Based on these results, it can be concluded that both prediction equations significantly overestimated HRmax measured during maximal GXT in Brazilian elderly women, a finding that may have important implications when prescribing exercise intensity for this population. In addition, HRmax was inversely related to the volunteers’ age, suggesting that the chronotropic reserve continues to decline after age 60.