Pedro Ferreira

Methods: A retrospective observational study was conducted at the intermediate medical care unit (IMCU) in São Francisco Xavier Hospital, a Portuguese hospital, in the period from January to December 2019. Patients with incomplete records or IMCU stays shorter than 24 hours were excluded. Scores were calculated using MDCalc, and statistical analysis was performed using SPSS version 27. Results: Of the 211 patients included in this analysis, 14.69% (n=31) died, with 16.1% (n=5) of these deaths occurring in the IMCU. The average age of non-survivors was significantly higher at 76.26 years (p < 0.001). Acute Physiology and Chronic Health Evaluation (APACHE II) and Simplified Acute Physiology Score (SAPS III) scores demonstrated good discrimination, with AUCs of 0.79 and 0.83, respectively, but both scores tended to overestimate mortality. Sequential Organ Failure Assessment (SOFA) showed the lowest discrimination performance with an Area Under the Curve (AUC) of 0.74. Conclusion: APACHE II and SAPS III provided good mortality prediction in the IMCU, with SAPS III showing the highest AUC. However, both scores overestimated mortality, indicating the need for calibration for IMCUs. The SOFA score was less effective due to its focus on organ failure. Further research is needed to adapt these models or develop new ones tailored specifically for IMCUs to improve predictive accuracy and clinical utility.

Immune-mediated necrotizing myopathy (IMNM) is a rare form of inflammatory myopathy characterized by severe muscle weakness, elevated serum creatine kinase (CK) levels, and myofiber necrosis with minimal inflammatory infiltrates. IMNM is frequently associated with autoantibodies, particularly anti-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), and is often linked to statin use. However, it can also develop in statin-naïve patients, especially following viral infections. We present the case of a 47-year-old woman who developed anti-HMGCR-positive IMNM without prior statin exposure, following a viral respiratory infection and subsequent dengue fever. She initially presented with proximal muscle weakness and elevated CK levels, which worsened after contracting dengue. Diagnostic testing confirmed the presence of anti-HMGCR antibodies, and a muscle biopsy revealed necrotizing myopathy. Treatment with methylprednisolone, intravenous immunoglobulin, and rituximab resulted in significant clinical improvement. This case underscores the need to consider IMNM in patients with unexplained muscle weakness and elevated CK levels, even in the absence of statin use. Viral infections may trigger IMNM, highlighting the importance of early recognition and aggressive immunosuppressive therapy to prevent severe complications. Further research is required to better understand the pathophysiology of IMNM and optimize treatment approaches.

Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect almost every organ. Lupus protein-losing enteropathy (PLE) is one of the rarest manifestations of gastrointestinal involvement. Lupus flare as initial presentation is rare and the disease can act as a trigger to other pathologic immune syndromes like Hemophagocytic Lymphohistiocytosis (HLH), although this association is rare. We report the case of a previously healthy African 39-year-old female patient, with a recent history of cesarean section. Admitted to the Emergency Department (ED) with diffuse abdominal pain and fever, having completed a cycle of antibiotic therapy for initially suspected endometritis. The clinical picture progressed with sustained high fever, new-onset lymphadenopathies, systemic rash, acute pulmonary edema and seizures. Laboratory findings included hyperferritinemia, hypertriglyceridemia, proteinuria and hypoalbuminemia. The auto-immune panel was positive for antinuclear antibodies (ANA), anti-dsDNA, anti-SSA and anti-SSB, anti-PL7, anti-RNP, anti-U1-SnRNP, and anti-Pm-Scl75. She also presented hypocomplementemia. An inaugural flare of SLE with multisystemic involvement and concomitant secondary Hemophagocytic Syndrome was considered and therapy with methylprednisolone pulses, Anakinra and Cyclophosphamide was started. By the end of the first cycle of cyclophosphamide, the patient presented clinical worsening with abdominal pain recrudescence and profuse diarrhea. After the exclusion of an infectious process, a Lupus PLE was assumed and Cyclophosphamide protocol was resumed, with sustained clinical improvement after the induction protocol. Despite initially suspected gynecological infection, the clinical progression with multisystemic involvement together with the auto-immune panel made the diagnosis of SLE possible, with other laboratory findings raising the suspicion of HLH. This case represents a rare report of severe SLE with multiple organ involvement accompanied by HLH. Gastrointestinal involvement with PLE added rarity and morbidity to the clinical picture. The case reinforces the idea that when organ dysfunction is due to a severe autoimmune response, supportive treatment can be lifesaving until immunosuppressive drugs reach their full effect.

Breast cancer may metastasize to the lung, liver, bone, brain, and skin, with especially high rates of metastasis to skin sites. These skin metastases are called malignant wounds. Patients with malignant wounds often report multiple symptoms, and pain is one of the most common and distressing among them. Despite the availability of multiple guidelines about treatment to relieve pain, almost half of all cancer patients still receive inappropriate care for pain. A multidisciplinary approach can improve outcomes in terms of symptom control and quality of life and enable the detection of previously unmet needs of both patients and caregivers. Palliative care is a multidisciplinary therapy that aims to alleviate physical, psychological, and emotional suffering in patients at any stage of the disease. We present the case of a 53-year-old male with a three-year history of stage IV breast cancer. He was admitted to the internal medicine ward in July 2021 with uncontrolled pain related to a malignant wound in the left hemithorax. This was a case with physical, emotional, social, and existential factors contributing to severe pain, necessitating a multidisciplinary approach for adequate relief. Opioid titration and insomnia and anxiety treatment were initiated. Dressing care was applied with metronidazole impregnation and aminocaproic acid for hemorrhagic spots, followed by fat gauze. He was proposed to undergo antalgic radiotherapy, which was unfortunately associated with new onset of symptoms. Psychological support was provided for the patient and his family. We managed to control the pain and stabilize the wound; however, cachexia become evident with the disease progression. In the last week of his life, the patient still believed he would be able to undergo chemotherapy. He died in the emergency room, where he had gone to seek relief for uncontrolled symptoms. Even though the patient had an incurable disease associated with immense suffering since early 2019, he was only referred to the palliative care team during the last three months of his life. Existential suffering was an important dimension of this patient’s pain and was present until his death despite receiving psychological support. Late referral to palliative care is unfortunately frequent and often associated with poor quality of life and inability to plan or make end-of-life care decisions. Radiotherapy was proposed for pain control but was associated with serious side effects. In a palliative care setting, decision-making always needs careful consideration related to benefit versus harm and must involve the patient and his family. Living with stage IV cancer is an everyday challenge for patients, and clinicians may also find managing such patients very arduous and stressful. Symptoms must be actively studied and evaluated from a multidimensional perspective. Managing expectations throughout this process while maintaining hope is a delicate balancing act and should be undertaken by specialized palliative care teams.