{"id":6350,"date":"2023-07-05T22:00:10","date_gmt":"2023-07-06T01:00:10","guid":{"rendered":"https:\/\/www.ufrgs.br\/lacvet\/?p=6350"},"modified":"2024-02-15T15:05:58","modified_gmt":"2024-02-15T18:05:58","slug":"caso-clinico-176vc","status":"publish","type":"post","link":"https:\/\/www.ufrgs.br\/lacvet\/cc_interativos\/caso-clinico-176vc\/","title":{"rendered":"Caso Cl\u00ednico 176VC"},"content":{"rendered":"
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Identifica\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

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Esp\u00e9cie: Felina
Ra\u00e7a: Persa
Idade: 10 anos
Sexo: macho
Peso: 4 kg<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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Anamnese<\/strong><\/p>\n\t\t\t

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Paciente atendido no Dia 0 ap\u00f3s per\u00edodo de interna\u00e7\u00e3o pr\u00e9via em outra cl\u00ednica. Tutores relataram emagrecimento progressivo, v\u00f4mitos frequentes, inapet\u00eancia e prostra\u00e7\u00e3o, com in\u00edcio do quadro h\u00e1 duas semanas, quando houve o primeiro atendimento. Tamb\u00e9m, apresenta secre\u00e7\u00e3o nasal e estava recebendo antibi\u00f3tico (n\u00e3o identificado). Tutor relata que exames bioqu\u00edmicos pr\u00e9vios evidenciaram aumento das concentra\u00e7\u00f5es de ureia e de creatinina, e que hemograma pr\u00e9vio evidenciou anemia. Paciente vacinado, alimentado com ra\u00e7\u00e3o espec\u00edfica para ra\u00e7a Persa (sic), foi castrado ainda jovem e n\u00e3o tem acesso \u00e0 rua ou a outros animais.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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Exame f\u00edsico<\/strong><\/p>\n\t\t\t

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Dia 0<\/p>\n\n\n\n

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  • Desidrata\u00e7\u00e3o de grau moderado.<\/li>\n\n\n\n
  • Mucosas p\u00e1lidas.<\/li>\n\n\n\n
  • Algia \u00e0 palpa\u00e7\u00e3o abdominal, principalmente em topografia de rins, os quais pareciam aumentados.<\/li>\n\n\n\n
  • Ausculta cardiopulmonar revelou presen\u00e7a de sopro grau 2.<\/li>\n\n\n\n
  • Press\u00e3o arterial sist\u00f3lica (PAS) de 250 mmHg\u2191<\/mark> (ref.: 110-120).<\/li>\n<\/ul>\n\n<\/div>\n\t\t<\/div>\n\n
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    Exames complementares<\/strong><\/p>\n\t\t\t

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    Dia 0 – Ultrassonografia: rins com contornos levemente irregulares, cistos anecog\u00eanicos nas regi\u00f5es corticais, jun\u00e7\u00e3o cortico-medular mal definida e pelve renal direita apresentando material amorfo compat\u00edvel com c\u00e1lculo.<\/p>\n\n\n\n

    Dia 02 – Ecocardiografia: sem altera\u00e7\u00f5es sob o aspecto anat\u00f4mico. O estudo Doppler mostrou fluxo mitral com padr\u00e3o de relaxamento anormal, frequente em animais idosos.<\/p>\n\n\n\n

    Dia 373 – Urocultura\/antibiograma: Enterobacter<\/em> sp. (>100.000 UFC\/mL).<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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    Tratamento e evolu\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

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    Dia 0 ao dia 12: permaneceu internado, recebendo tratamento de suporte com fluidoterapia endovenosa com Ringer-lactato de s\u00f3dio (reposi\u00e7\u00e3o eletrol\u00edtica e hidrata\u00e7\u00e3o), cloridrato de metroclopramida (antiem\u00e9tico), ranitidina (protetor g\u00e1strico), eritropoietina (estimulante da eritropoiese) e mirtazapina (estimulante de apetite).<\/p>\n\n\n\n

    Dia 3: adicionado hidr\u00f3xido de alum\u00ednio (quelante de f\u00f3sforo) junto com as refei\u00e7\u00f5es. A PAS mostrou-se elevada mesmo ap\u00f3s adapta\u00e7\u00e3o do animal ao ambiente hospitalar e consequente redu\u00e7\u00e3o do fator estresse. Foram obtidos tr\u00eas registros separados de press\u00e3o arterial acima de 165 mmHg\u2191<\/mark>. Portanto, foi iniciado tratamento com anlodipino (controle da hipertens\u00e3o).<\/p>\n\n\n\n

    Dia 12: alta hospitalar, tendo o paciente ganho 400 g de massa corporal. Recomendada a manuten\u00e7\u00e3o da fluidoterapia via subcut\u00e2nea (Ringer-lactato de s\u00f3dio), da famotidina (protetor g\u00e1strico), do hidr\u00f3xido de alum\u00ednio simultaneamente \u00e0s refei\u00e7\u00f5es, do anlodipino e da eritropoietina.<\/p>\n\n\n\n

    Dia 373: ap\u00f3s um ano, a tutora relata epis\u00f3dios de mic\u00e7\u00e3o em locais inapropriados, sugestivo de cistite. Em face da detec\u00e7\u00e3o de Enterobacter<\/em> sp. na urocultura, institu\u00eddo tratamento com amoxicilina+clavulanato de pot\u00e1ssio (antibacteriano).<\/p>\n\n\n\n

    Dia 440: apresentou inapet\u00eancia e prostra\u00e7\u00e3o, tendo sido hospitalizado novamente para fluidoterapia e estabiliza\u00e7\u00e3o do quadro.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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    Hemogasometria<\/strong><\/p>\n\t\t\t

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    Sangue VENOSO<\/strong><\/td>Dia 388<\/strong><\/td><\/tr>
    pH (7,277-7,409)<\/td>7,33<\/td><\/tr>
    pCO2<\/sub> (32,7-44,7 mmHg)<\/td>40,3<\/td><\/tr>
    pO2<\/sub> (47,9-56,3 mmHg)<\/td>26\u2193<\/mark><\/mark><\/td><\/tr>
    BEecf (-3 a 2 mmol\/L)<\/td>-5\u2193<\/mark><\/mark><\/td><\/tr>
    HCO3<\/sub>–<\/sup> (18-23 mmol\/L)<\/td>21,3<\/td><\/tr>
    tCO2<\/sub> (mmol\/L)<\/td>23<\/td><\/tr>
    sO2<\/sub> (%)<\/td>44<\/td><\/tr>
    Na (145-157 mmol\/L)<\/td>153<\/td><\/tr>
    K (3,6-5,5 mmol\/L)<\/td>3,5\u2193<\/mark><\/mark><\/td><\/tr>
    iCa (1,07-1,50 mmol\/L)<\/td>1,31<\/td><\/tr><\/tbody><\/table><\/figure>\n\n<\/div>\n\t\t<\/div>\n\n
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    Hemograma<\/strong><\/p>\n\t\t\t

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    Eritrograma<\/strong><\/strong><\/td>Dia 0<\/strong><\/td>Dia 3<\/strong><\/td>Dia 270<\/strong><\/td>Dia 373<\/strong><\/td>Dia 440<\/strong><\/td><\/tr>
    Eritr\u00f3citos (5-10 milh\u00f5es\/\u00b5L)<\/td>4,7\u2193<\/mark><\/mark><\/td>3,0\u2193<\/mark><\/mark><\/td>7,3\u00a0<\/td>6,3\u00a0<\/td>5,5\u00a0<\/td><\/tr>
    Hemat\u00f3crito (24-45%)<\/td>22\u2193<\/mark><\/mark><\/td>14\u2193<\/mark><\/mark><\/td>29\u00a0<\/td>24\u00a0<\/td>23\u2193<\/mark><\/mark><\/td><\/tr>
    Hemoglobina (8-15 g\/dL)<\/td>6,4\u2193<\/mark><\/mark><\/td>4,2\u2193<\/mark><\/mark><\/td>8,7\u00a0<\/td>7,8\u2193<\/mark><\/mark><\/td>7,0\u2193<\/mark><\/mark><\/td><\/tr>
    VCM (39-55 fL)<\/td>46,5\u00a0<\/td>46,5 \u00a0<\/td>39,9<\/td>38,3\u2193<\/mark><\/mark><\/td>41,7\u00a0<\/td><\/tr>
    CHCM (31-35%)<\/td>29\u2193<\/mark><\/mark><\/td>30\u2193<\/mark><\/mark><\/td>30\u2193<\/mark><\/mark><\/td>32\u00a0<\/td>30\u2193<\/mark><\/mark><\/td><\/tr>
    RDW (17-22%)<\/td>24,3\u2191<\/mark><\/td>22,6\u00a0<\/td>16,0\u2193<\/mark><\/mark><\/td>20,2<\/td>18,8\u00a0<\/td><\/tr>
    Plaquetas<\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
    Quantidade (200-600 \u00d7103<\/sup>\/\u00b5L)<\/td>420<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>280<\/td>360<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n
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    Leucograma<\/strong><\/td>Dia 0<\/strong><\/td>Dia 3<\/strong><\/td>Dia 270<\/strong><\/td>Dia 373<\/strong><\/td>Dia 440<\/strong><\/td><\/tr>
    Leuc\u00f3citos totais (5.000-19.500\/\u00b5L)<\/td>24.800\u2191<\/mark><\/td>10.900\u2191<\/mark><\/td>4.900\u2193<\/mark><\/td>5.600\u00a0<\/td>6.300\u00a0<\/td><\/tr>
    Miel\u00f3citos (0\/\u00b5L)<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td><\/tr>
    Metamiel\u00f3citos (0\/\u00b5L)<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td><\/tr>
    Neutr. bast. (<300\/\u00b5L)<\/td>992\u2191<\/mark><\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td><\/tr>
    Neutr. seg. (2.500-12.500\/\u00b5L)<\/td>19.840\u2191<\/mark><\/td>7.739\u00a0<\/td>3.087\u00a0<\/td>3.360\u00a0<\/td>5.103\u00a0<\/td><\/tr>
    Bas\u00f3filos (<100\/\u00b5L)<\/td>0\u00a0<\/td>0\u00a0<\/td>49<\/td>112<\/td>0\u00a0<\/td><\/tr>
    Eosin\u00f3filos (100-1.250\/\u00b5L)<\/td>0\u2193<\/mark><\/td>327\u00a0<\/td>686\u00a0<\/td>560\u00a0<\/td>441\u00a0<\/td><\/tr>
    Mon\u00f3citos (<850\/\u00b5L)<\/td>1.984\u2191<\/mark><\/td>1.190\u2191<\/mark><\/td>147\u00a0<\/td>56\u00a0<\/td>63\u00a0<\/td><\/tr>
    Linf\u00f3citos (1.500-7.000\/\u00b5L)<\/td>1.984\u00a0<\/td>1.635\u00a0<\/td>931\u2193<\/mark><\/td>1.512\u00a0<\/td>693\u2193<\/td><\/tr><\/tbody><\/table><\/figure>\n\n<\/div>\n\t\t<\/div>\n\n
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    Bioqu\u00edmica sangu\u00ednea<\/strong><\/p>\n\t\t\t

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    <\/td>Dia 0<\/strong><\/td>Dia 03<\/strong><\/td>Dia 270<\/strong><\/td>Dia 373<\/strong><\/td>Dia 440<\/strong><\/td><\/tr>
    Amostra<\/td>soro<\/td>soro<\/td>soro<\/td>soro<\/td>soro<\/td><\/tr>
    Hem\u00f3lise<\/td>ausente<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td><\/tr>
    AnticoagulanteA<\/sup><\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td><\/tr>
    Prote\u00ednas totaisB<\/sup> (60-80 g\/L)<\/td>n.d.\u00a0<\/td>70\u00a0<\/td>84\u2191<\/mark><\/td>80\u00a0<\/td>80\u00a0<\/td><\/tr>
    Prote\u00ednas totaisC<\/sup> (54-78 g\/L)<\/td>72\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Albumina (21-33 g\/L)<\/td>26\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Globulinas (26-51 g\/L)<\/td>46\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Ureia (43-64 mg\/dL)<\/td>172\u2191<\/mark><\/td>86\u2191<\/mark><\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Creatinina (<1,6 mg\/dL)<\/td>6,1\u2191<\/mark><\/td>3,6\u2191<\/mark><\/td>4,3\u2191<\/mark><\/td>4,9\u2191<\/mark><\/td>5,1\u2191<\/mark><\/td><\/tr>
    F\u00f3sforo (2,7-6,2 mg\/dL)<\/td>16,1\u2191<\/mark><\/td>9,4\u2191<\/mark><\/td>9,0\u2191<\/mark><\/td>10,6\u2191<\/mark><\/td>8,8\u2191<\/mark><\/td><\/tr>
    FA (<93 U\/L)<\/td>15\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    ALT (<83 U\/L)<\/td>46\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

    B<\/sup>Estimadas por refratometria; C<\/sup>Determinadas por espectrofotometria.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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    Urin\u00e1lise<\/strong><\/p>\n\t\t\t

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    <\/td>Dia 373<\/strong><\/td>Dia 387<\/strong><\/td><\/tr>
    M\u00e9todo de coletaA<\/sup><\/td>cist<\/td>n.i.<\/td><\/tr>
    Sedimento urin\u00e1rioB<\/sup><\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
    C\u00e9lulas epiteliais<\/td>escamosas (1), transi\u00e7\u00e3o (1)<\/td>escamosas (2)<\/td><\/tr>
    Cilindros<\/td>ausentes<\/td>ausente<\/td><\/tr>
    Hem\u00e1cias<\/td>ausentes<\/td>70\u2191<\/mark><\/strong><\/td><\/tr>
    Leuc\u00f3citos<\/td>1<\/td>1<\/td><\/tr>
    Bacteri\u00faria<\/td>leve\u2191<\/mark><\/td>ausente<\/td><\/tr>
    Exame qu\u00edmico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
    pH (6,0-7,0)<\/td>5,0\u2193<\/mark><\/td>6,5\u00a0<\/td><\/tr>
    Corpos cet\u00f4nicosC<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
    GlicoseD<\/sup><\/td>tra\u00e7os\u2191<\/mark><\/td>+++\u2191<\/mark><\/td><\/tr>
    BilirrubinaE<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
    Urobilinog\u00eanio (<1 mg\/dL)<\/td>\u22480,2\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Prote\u00ednaF<\/sup><\/td>tra\u00e7os\u2191<\/mark><\/td>tra\u00e7os\u2191<\/mark><\/td><\/tr>
    SangueG<\/sup><\/td>ausente\u00a0<\/td>+++\u2191<\/mark><\/td><\/tr>
    RPCUH<\/sup><\/td>n.d.<\/td>n.d.<\/td><\/tr>
    Exame f\u00edsico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
    Dens. espec. (1,015-1,060)<\/td>1,012\u2193<\/mark><\/td>1,008\u2193<\/mark><\/td><\/tr>
    Cor<\/td>amarela p\u00e1lida<\/td>amarela p\u00e1lida<\/td><\/tr>
    Consist\u00eancia<\/td>fluida<\/td>fluida<\/td><\/tr>
    Aspecto<\/td>l\u00edmpido<\/td>l\u00edmpido<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

    A<\/sup>mic, mic\u00e7\u00e3o natural \u25cf cat, cateteriza\u00e7\u00e3o \u25cf cist, cistocentese \u25cf out, outros (especificar em \u201cObserva\u00e7\u00f5es\u201d)
    B<\/sup>N\u00famero m\u00e9dio de elementos por campo de 400 x
    C<\/sup>tra\u00e7os, \u22485 mg\/dL \u25cf +, \u224815 mg\/dL \u25cf ++, \u224840 mg\/dL \u25cf +++, \u224880 md\/dL \u25cf ++++, \u2265160 mg\/dL
    D<\/sup>tra\u00e7os, \u2248100 mg\/dL \u25cf +, \u2248250 mg\/dL \u25cf ++, \u2248500 mg\/dL \u25cf +++, \u22481000 mg\/dL \u25cf ++++, \u22652000 mg\/dL
    E<\/sup>+, leve \u25cf ++, moderada \u25cf +++, alta
    F<\/sup>+, \u224830 mg\/dL \u25cf ++, \u2248100 mg\/dL \u25cf +++, \u2248300 mg\/dL \u25cf ++++, \u22652000 mg\/dL
    G<\/sup>nh, n\u00e3o hemolisado \u25cf h, hemolisado \u25cf +, leve \u25cf ++, moderada \u25cf +++, alto
    H<\/sup>RPCU, rela\u00e7\u00e3o prote\u00edna\/creatinina urin\u00e1ria (na aus\u00eancia de sedimento ativo)
    – Caninos: <0,2, n\u00e3o protein\u00farico \u25cf 0,2 a 0,5, protein\u00faria lim\u00edtrofe \u25cf >0,5, protein\u00farico
    – Felinos: <0,2, n\u00e3o protein\u00farico \u25cf 0,2 a 0,4, protein\u00faria lim\u00edtrofe \u25cf >0,4, protein\u00farico
    – Equinos: <0,93, n\u00e3o protein\u00farico
    n.d.: n\u00e3o determinado<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

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    Discuss\u00e3o e refer\u00eancias bibliogr\u00e1ficas<\/strong><\/p>\n\t\t\t

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    Devem ser discutidos os achados laboratoriais alterados (referentes a urin\u00e1lise, bioqu\u00edmica sangu\u00ednea e hemograma), estabelecendo as correla\u00e7\u00f5es relevantes com o quadro cl\u00ednico do paciente. N\u00e3o deve ser discutido o tratamento realizado. As altera\u00e7\u00f5es nos achados laboratoriais devem ser justificadas com base nas informa\u00e7\u00f5es contidas na literatura especializada. \u00c9 sugerido organizar a discuss\u00e3o nos seguintes grandes t\u00f3picos:<\/p>\n\n\n\n