Our results indicate that EOC is associated with and increases the risk of depression among caregivers of HD patients. We propose that strategies aiming to strengthen POC and diminish EOC can be applied to minimize depressive feelings.

Systemic lupus erythematosus (SLE) is a pathology capable of affecting several organs and systems of the human body, including the central nervous system. The most common psychiatric manifestations addressed in studies are acute confusional state, mood disorders, cognitive dysfunction, psychosis, among others. However, there are few documented case reports associating lupus with an episode of mania, mainly because this neuropsychiatric symptom usually precedes the onset of typical SLE symptoms, such as malar rash or arthralgias. The objective of this study is to describe the case of a patient hospitalized for diagnostic investigation of SLE who presented with mania.

BACKGROUNDSystemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by periods of exacerbations, interspersed with remissions. It has variable manifestations which can affect different systems of the human body. Regarding cardiac involvement, the most classic manifestations consist of pericarditis, myocarditis, cardiac block and endocarditis. However, it is observed that cardiac tamponade (CT), although rarer, is potentially fatal in patients with SLE. CASE REPORTA 22-year-old female diagnosed 1 year ago with SLE with cutaneous-articular involvement, without follow-up, using prednisone 40 mg/day for 8 months. She was hospitalized with dyspnea at rest, oliguria and foamy urine for 5 days. She also had fever and arthralgia of her wrists and elbows for 15 days. Physical examination: blood pressure 101/69 mmHg, heart rate 133 bpm, systolic murmur in the mitral focus (4+/6+) and aortic (4+/6+), turgid jugular, bilateral basal crackles and positive Skoda's sign . Laboratory showed hemoglobin 6.8g/dL; creatinine 4.8 mg/dL; urea 178 mg/dL; albumin 2.2 g/dL, hypocomplementemia; urine with 3+ proteinuria, 2+ erythrocytes; 24-h urine with 1.8 g protein/day, characterizing nephritis lupus. Radiography showed bilateral pleural effusion with significant cardiomegaly. The patient developed acute hypervolemic pulmonary edema, indicating dialysis therapy. After 23 days, she presented hypotension, muffled heart sounds and worsening of jugular turgescence, pericardiocentesis was performed with the output of 460 mL of blood fluid, increased cellularity, predominance of neutrophils and glucose consumed. Five days later, she presented Beck's triad again, and a pericardial pleural window with pericardial biopsy was performed. Absence of vegetation ruled out infectious endocarditis. Empirical treatment with COXCIP-4 was initiated due to the possibility of pericardial tuberculosis, subsequently suspended due to lack of clinical response and signs of drug induced hepatitis. In addition, the patient had a tonic-clonic seizure, treated with pulse therapy with immunoglobulin for 5 days and pulse therapy with cyclophosphamide due to compatible neurolupus. After being hospitalized for 3 months, she was discharged with established renal and cyclophosphamide pulse therapy planned for another 6 months. CONCLUSIONIn SLE, CT has a prevalence of only 1%. Also, there are few cases in the literature of patients with this condition. However, this report reinforces the importance of CT being remembered as a possible differential diagnosis of complications in patients with SLE. In addition, our case emphasizes the importance of early diagnosis and treatment, aiming to avoid dramatic cases like this.

No abstract

BACKGROUNDDown syndrome (DS) is a genetic disease with trisomy of chromosome 21, associated to a higher prevalence of autoimmune disorders. However, the presence of rheumatic diseases in patients with this trisomy is unusual. This case describes a patient with DS diagnosed with mixed connective tissue disease (MCTD), characterized by overlapping symptoms of more than one collagenous disease. CASE REPORTA 39-year-old woman previously diagnosed with DS and hypothyroidism came to the clinic reporting that 2 years ago she started showing hypopigmentation, thickening, skin dryness, with difficulty to walk. She also reported myasthenia, difficulty moving her hands and mouth, and arthralgia in small and large joints. Physical exam showed hypo/achromic macules on lower and upper limbs, with leukomelanoderma, violaceous peripalpebral lesion, diffuse skin thickening and alopecia. Raynaud's phenomenon, telangiectasis, synovitis on the wrists, thinning of the distal phalanges and sclerodactyly were observed. Tests showed ANA (1:320) with a mixed nucleolar and fine dotted nuclear pattern, negative anticardiolipin, CH50 (137.2), anti-DNA, anti-SM, anti-RO, anti-LA, anti-SCL-70, antibeta-2-GPI, anticentromere, lupus anticoagulant, C-ANCA, and atypic ANCA were not reagent, anti-RNP (45.4), antimyeloperoxidase (359), and P-ANCA (1/40) were reagent. In addition, she presented normocytic anemia and leukopenia. ESR, CRP, and CPK were high. Therefore, an echocardiogram, hand and wrist X-rays, upper digestive endoscopy, high-resolution computed tomography (HRCT), and muscle enzymes were requested due to the suspicion of CTED or ES. On her return, she reported cough with sputum and presented an echocardiogram with moderate pericardial effusion without signs of diastolic restriction and a pulmonary artery systolic pressure of 33 mmHg. X-rays of the hands with amorphous calcifications of mottled soft tissue in the distal third of the first right clinodactyly and distal and middle third of the left. X-rays of the right wrist without changes and of the left wrist with amorphous hyperdense material in the carpal bones and calcification in soft tissue adjacent to the ulna. HRCT suggestive of tuberculosis. In view of this, investigation for infectious disease was initiated. CONCLUSIONMCTD is a multifaceted disease, requiring careful investigation. In this case, the diagnosis was built from the clinical picture associated with a positive anti-RNP in the absence of other specific antibodies for SLE and ES. However, since there are few reports that address a patient with DS and MCTD, this case is important to make professionals aware of this connection that may be present in clinical practice.