Dr. Artur da Rocha Corrêa Fernandes

Apresentação em tema: "Dr. Artur da Rocha Corrêa Fernandes"— Transcrição da apresentação:

1 Dr. Artur da Rocha Corrêa Fernandes
Germe Gustavo Ribas Orientador Dr. Artur da Rocha Corrêa Fernandes Setembro 04, 2014

2 Quadro Clínico M.A.F, feminina, 83 anos
Dor intensa nos membros superiores há 2 meses Edema e força grau III superiores e IV nos inferiores CPK 2700, FAN 1/640, anti-Jo1, ENA, ANCA, antiDNA, FR, HIV, CMV e hepatite B e C negativos Hipertensa e diabética desde 98, sinvastatina 40mg Câncer de mama há 5 anos (mastectomia total) DM mal controlado 227 mg/dL em 19/08/2013. CPK VR (26-192)

3 OUTUBRO DE 2013 T1

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21 Hipoteses diagnósticas
Hipóteses: Miopatia inflamatória idiopática Infarto muscular por diabetes Miopatia droga induzida (estatinas)

22 Conduta Internação Controle da glicemia Suspensão da sinvastatina
Prednisona Atualmente: Redução progressiva da CPK 46 U/L Remissão da dor e fraqueza muscular

23 Infarto muscular (diabetes)
Longa evolução, mal controlado e associado a retino, nefro e/ou neuropatia Agudo e ausência de febre ou leucocitose Histopatologia: Necrose muscular com edema associados a oclusão arteriolar e capilar Ressonância magnética: Edema e aumento do volume muscular Músculos não contíguos compartimento anterior da coxa Regiões centrais sem ou com pouco realce Compartimento anterior com relativa preservação do reto femoral e do sartório. Diabetes musculoskeletal complications and their imaging mimics. RG 2012; 32:

24 Infarto muscular (diabetes)
T1 PÓS CONTRASTE DMI in a 40-year-old man with poorly controlled diabetes who presented after several weeks of severe right thigh pain and swelling. (a, b) Axial T1-weighted (a) and T2-weighted fat-suppressed (b) MR images of the thighs reveal subcutaneous, fascial, and intramuscular edema and muscle enlargement, findings that are most pronounced in the right anterior compartment. The asymmetric distribution of the findings and the involvement of noncontiguous muscles are characteristic of this condition. (c, d) Contrast material–enhanced T1-weighted fat- suppressed (c) and subtraction (d) MR images show patchy peripheral enhancement with central nonenhancement and serpentine areas of signal void in the right vastus lateralis muscle (arrow). Symptoms resolved with conservative management, which included glycemic control and analgesics; no antibiotics were administered. T2 SUBTRAÇÃO Diabetes musculoskeletal complications and their imaging mimics. RG 2012; 32:

25 Miopatia inflamatória idiopática
Dermatopolimiosite: adolescência e neoplasia Polimiosite: anos Insidioso, simétrico e proximal Progressão para membros superiores, pescoço e músculos faríngeos Histopatológico: Infiltrado inflamatório Ressonância magnética: Edema muscular ou miofascial irregular e difuso Infiltração gordurosa tardiamente The role of MRI in assessment of polymyositis and dermatomyositis. Rheumatology 2007; 46: Diagnostic imaging. Musculoskeletal: non-traumatic disease. Amirsys 2010

26 Miopatia inflamatória idiopática
(Left) Coronal STIR MR shows bilateral, symmetric abnormally high signal intensity involving all the muscles of the anterior and adductor compartments of the thighs. In this case, the muscles are diffusely involved. (Right) Coronal T1 Wl C+ FS MR, same case, shows diffuse and apparently symmetric enhancement =:I in a typical case of polymyositis. Even though there appears to be diffuse involvement, clinical signs may be less impressive. MR often shows earlier and more widespread involvement than is expected clinically. STIR T1 PÓS CONTRASTE Diagnostic imaging. Musculoskeletal: non-traumatic disease. Amirsys 2010

27 Miopatia inflamatória idiopática
STIR Fig. 4 —42-year-old man with known dermatomyositis. Axial STIR image shows diffuse hyperintensity in some thigh muscles (arrowhead, vastus lateralis muscle). Note also increased signal in subcutaneous tissue septa (arrow) and skin thickening T1 MRI findings in inflammatory muscle diseases and their noninflammatory mimics. AJR 2009; 192:

28 Miopatia paraneoplásica
Risco aumentado de neoplasia em DM e outras MII Dermatopolimiosite: Ovário, mama, pulmão, estomago, colorretal e linfoma Polimiosite: Pulmão, bexiga e linfoma Antes, durante ou após a MII Reação cruzada: remissão e recidiva relacionadas Pacientes mais velhos, sintomas cutâneos e musculares mais graves (miopatia necrotizante), agudos e acometimento distal mais frequente Paraneoplastic myopathy. Current Opinion in Rheumatology. 2009; 21:594-98

29 Miopatia paraneoplásica
CPK normal ou pouco elevada * Risco 6-7 vezes maior se Anti-Jo1 e Mi-2 negativos Anti-155/140 positivo (OR: 23,2) Anti-Jo1/Mi2 negativo e anti-155/140 positivo MII: 94% de sensibilidade DM: 100% de sensibilidade Anti155/140 descrito em 2006 Paraneoplastic myopathy. Current Opinion in Rheumatology. 2009; 21:594-98

30 Miopatia droga induzida
Diagnóstico de exclusão Efeito adverso das estatinas Fisiopatologia desconhecida Dose dependente Miopatia: qualquer sintoma muscular (1%) Mialgia: sintomas e ausência de > CPK Miosite: > CPK Rabdomiólise: > CPK 10 vezes e nefropatia (0,2%) Imagem de aspecto inespecífico Imaging features of therapeutic drug-induced musculoskeletal abnormalities. RG 2012; 32:

31 Miopatia droga induzida
Figure 20. Myositis in a 63-year-old man undergoing long-term statin therapy. Axial T2-weighted MR image of both thighs shows a region of high signal intensity in the right vastus intermedius (arrowheads), with subtle inflammatory changes in muscle in the left thigh. These findings are nonspecific, but when considered in conjunction with the patient’s medical history they are suggestive of drug-induced myositis. Figure 5 Statin-induced myositis. A 55-year-old patient taking simvastatin for hypercholesterolemia presented with gradual onset but progressively worsening muscle pains in both arms and shoulders. This T2 sagittal magnetic resonance image shows diffuse increased signal intensity in the upper arm musculature confirming myositis. T2 T2 Imaging features of therapeutic drug-induced musculoskeletal abnormalities. RG 2012; 32: The myositides: The role of imaging in diagnosis and treatment. Semin Musculoskelet Radiol 2010;

32 Resumo Diagnóstico indefinido
Etiologia paraneoplásica versus droga induzida Chamar atenção para o diagnóstico diferencial de miopatia paraneoplásica Tentativa de surpreender neoplasia oculta

33 Referências Baker J et al. Diabetes musculoskeletal complications and their imaging mimics. Radiographics 2012; 32: Studynková J et al. The role of MRI in assessment of polymyositis and dermatomyositis. Rheumatology 2007; 46: Manaster J. Diagnostic imaging. Musculoskeletal: non-traumatic disease. Amirsys 2010. Schulze M et al. MRI findings in inflammatory muscle diseases and their noninflammatory mimics. AJR 2009; 192: Dankó K et al. Paraneoplastic myopathy. Current Opinion in Rheumatology. 2009; 21:594-98 Sidhu H et al. Imaging features of therapeutic drug-induced musculoskeletal abnormalities. Radiographics 2012; 32: Bashir W and O´Dennell P. The myositides: The role of imaging in diagnosis and treatment. Semin Musculoskelet Radiol 2010;

34 Obrigado !