{"id":6354,"date":"2023-07-05T22:15:13","date_gmt":"2023-07-06T01:15:13","guid":{"rendered":"https:\/\/www.ufrgs.br\/lacvet\/?p=6354"},"modified":"2024-02-15T15:06:14","modified_gmt":"2024-02-15T18:06:14","slug":"caso-clinico-176xw","status":"publish","type":"post","link":"https:\/\/www.ufrgs.br\/lacvet\/cc_interativos\/caso-clinico-176xw\/","title":{"rendered":"Caso Cl\u00ednico 176XW"},"content":{"rendered":"
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Identifica\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

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Esp\u00e9cie: Canina
Ra\u00e7a: SRD
Idade: 14 anos
Sexo: macho
Peso: 14,6 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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Aumento de volume na regi\u00e3o dorsal, lado esquerdo (dia 0). Foi relatado que o paciente apresentava tosse ap\u00f3s o exerc\u00edcio e h\u00e1bito de se co\u00e7ar e se morder. A tutora seguia um tratamento indicado previamente, com base em antiss\u00e9pticos e antibi\u00f3ticos de uso t\u00f3pico, al\u00e9m de furosemida (diur\u00e9tico). Ainda, relatou que o c\u00e3o apresentava comportamento normal, norm\u00faria, normodipsia, normofagia, normoquezia. Alimenta\u00e7\u00e3o \u00e0 base de ra\u00e7\u00e3o e comida caseira.<\/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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  • Escore corporal acima do ideal.<\/li>\n\n\n\n
  • Estado mental alerta.<\/li>\n\n\n\n
  • Hidratado, mucosas normocoradas.<\/li>\n\n\n\n
  • Temperatura retal de 38,5 \u00b0C (ref.: 37,5-39,3).<\/li>\n\n\n\n
  • Tempo de preenchimento capilar <2 segundos (sem altera\u00e7\u00f5es)<\/li>\n\n\n\n
  • Linfonodos sem altera\u00e7\u00f5es.<\/li>\n\n\n\n
  • No exame do sistema cardiorrespirat\u00f3rio foi constatado abafamento, sopro grau 2-3, frequ\u00eancia card\u00edaca de 143 bpm (ref.: 70-160).<\/li>\n\n\n\n
  • Presen\u00e7a de massa subcut\u00e2nea aderida ao t\u00f3rax medindo aproximadamente 15 cm por 7 cm.<\/li>\n<\/ul>\n\n<\/div>\n\t\t<\/div>\n\n
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    Exames complementares<\/strong><\/p>\n\t\t\t

    <\/span><\/div>\n\t\t<\/div>\n\t\t\t
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    Dia 0 – Citologia de massa subcut\u00e2nea: altera\u00e7\u00f5es sugestivas de neoplasia mesenquimal (lipossarcoma) ou paniculite, devido \u00e0 presen\u00e7a de c\u00e9lulas inflamat\u00f3rias.<\/p>\n\n\n\n

    Dia 14 – Ultrassonografia: bexiga apresentando conte\u00fado anec\u00f3ico com m\u00ednima quantidade de pontos hiperec\u00f3icos flutuantes. Rins assim\u00e9tricos com calcifica\u00e7\u00e3o bilateral de divert\u00edculos renais. F\u00edgado apresentando ao menos dois n\u00f3dulos hiperecog\u00eanicos com bordas definidas e outros v\u00e1rios n\u00f3dulos hipoecog\u00eanicos. Ves\u00edcula biliar repleta com conte\u00fado anec\u00f3ico e com grande quantidade de conte\u00fado hiperecog\u00eanico amorfo (lama biliar), com pelo menos duas estruturas hiperecog\u00eanicas (colelit\u00edase). Test\u00edculos apresentando n\u00f3dulos heterog\u00eaneos, o maior localizado em test\u00edculo direito. Apresenta n\u00f3dulo externo, extenso, em regi\u00e3o tor\u00e1cica esquerda.<\/p>\n\n\n\n

    Dia 14 – Radiografia: aumento de volume, com densidade de tecidos moles, em regi\u00e3o tor\u00e1cica dorsal e lateral esquerda sem envolvimento \u00f3sseo.<\/p>\n\n\n\n

    Dia 46 – Exame histopatol\u00f3gico: prolifera\u00e7\u00e3o neopl\u00e1sica maligna de adip\u00f3citos (lipossarcoma).<\/p>\n\n\n\n

    Dia 59 – Ultrassonografia: test\u00edculo direito com linha mediastinal ausente, apresentando imagens heterog\u00eanea, compat\u00edvel com neoplasia intratesticular, medindo 1,29 x 1,50 cm. Adrenal esquerda com dimens\u00f5es aumentadas.<\/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

    <\/span><\/div>\n\t\t<\/div>\n\t\t\t
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    Dia 0: tratamento \u00e0 base de furosemida (diur\u00e9tico, intensificador da excre\u00e7\u00e3o de urina e s\u00f3dio).<\/p>\n\n\n\n

    Dia 3: constatada insufici\u00eancia mitral leve com sinais iniciais de endocardiose.<\/p>\n\n\n\n

    Dia 29: retorno para realiza\u00e7\u00e3o do procedimento cir\u00fargico de retirada do tumor subcut\u00e2neo. Apresenta hiperglicemia (390 mg\/dL\u2191<\/mark>). Interna\u00e7\u00e3o para controle de glicemia e estabelecimento de dose de insulina NPH (insulina humana recombinante).<\/p>\n\n\n\n

    Dia 30: alta hospitalar com indica\u00e7\u00e3o de tratamento \u00e0 base de insulina NPH e observa\u00e7\u00e3o da ingesta de \u00e1gua.<\/p>\n\n\n\n

    Dia 44: interna\u00e7\u00e3o pr\u00e9-operat\u00f3ria e para controle glic\u00eamico. Administrada insulina NPH. Administrado tramadol (analg\u00e9sico) e carprofeno (anti-inflamat\u00f3rio).<\/p>\n\n\n\n

    Dia 46: realiza\u00e7\u00e3o do procedimento cir\u00fargico para retirada da neoplasia. Material enviado para exame histopat\u00f3logico: prolifera\u00e7\u00e3o neopl\u00e1sica maligna de adip\u00f3citos (lipossarcoma).<\/p>\n\n\n\n

    Dia 57: Durante o per\u00edodo de interna\u00e7\u00e3o ocorreu deisc\u00eancia dos pontos e o animal recebeu fluidoterapia com solu\u00e7\u00e3o fisiol\u00f3gica (reposi\u00e7\u00e3o eletrol\u00edtica e hidrata\u00e7\u00e3o), metadona (analg\u00e9sico opioide), tramadol, dipirona (analg\u00e9sico e antit\u00e9rmico), carprofeno, metoclopramida (antiem\u00e9tico), ondansetrona (antiem\u00e9tico), citrato de maropitant (antiem\u00e9tico), omeprazol (anti-ulceroso), sucralfato (anti-\u00e1cido e antiulceroso), cefalotina (antibi\u00f3tico), amoxicilina+clavulanato (antibi\u00f3ticos), lactulose (regulador intestinal) e insulina NPH. Alta hospitalar com indica\u00e7\u00e3o de tratamento \u00e0 base de insulina e recomenda\u00e7\u00e3o de quimioterapia. Com a utiliza\u00e7\u00e3o da insulina, o paciente apresentou diminui\u00e7\u00e3o nos n\u00edveis de glicemia no decorrer dos dias.<\/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 29<\/strong><\/td><\/tr>
    pH (7,351-7,443)<\/td>7,44<\/td><\/tr>
    pCO2<\/sub> (33,6-41,2 mmHg)<\/td>31,7\u2193<\/mark><\/td><\/tr>
    pO2<\/sub> (47,9-56,3 mmHg)<\/td>30,0\u2193<\/mark><\/td><\/tr>
    BE (-3 a 2 mmol\/L)<\/td>-2<\/td><\/tr>
    HCO3<\/sub> (21-25 mmol\/L)<\/td>21,8<\/td><\/tr>
    tCO2<\/sub> (mmol\/L)<\/td>23<\/td><\/tr>
    sO2<\/sub> (%)<\/td>61<\/td><\/tr>
    Na (140-155 mmol\/L)<\/td>138\u2193<\/mark><\/td><\/tr>
    K (3,5-5,7 mmol\/L)<\/td>4,7<\/td><\/tr>
    iCa (1,3-1,5 mmol\/L)<\/td>1,17\u2193<\/mark><\/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 30<\/strong><\/td>Dia 57<\/strong><\/td>Dia 91<\/strong><\/td><\/tr>
    Eritr\u00f3citos (5,5-8,5 milh\u00f5es\/\u00b5L)<\/td>7,67\u00a0<\/td>4,04\u2193<\/mark><\/td>6,10\u00a0<\/td><\/tr>
    Hemat\u00f3crito (37-55%)<\/td>48\u00a0<\/td>32\u2193<\/mark><\/td>43\u00a0<\/td><\/tr>
    Hemoglobina (12-18 g\/dL)<\/td>16,0<\/td>9,8\u2193<\/mark><\/td>14,6\u00a0<\/td><\/tr>
    VCM (60-77 fL)<\/td>62,6\u00a0<\/td>80,0\u2191<\/mark><\/mark><\/td>70,5\u00a0<\/td><\/tr>
    CHCM (32-36%)<\/td>33,3\u00a0<\/td>28,1\u2193<\/mark><\/td>33,9\u00a0<\/td><\/tr>
    RDW (14-17%)<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>12,7\u2193<\/mark><\/td><\/tr>
    Metarrubr\u00edcitos (\/100 leu)<\/td>ausente\u00a0<\/td>4\u2191<\/mark><\/td>ausente\u00a0<\/td><\/tr>
    Plaquetas<\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
    Quantidade (200-500 \u00d7103<\/sup>\/\u00b5L)<\/td>600\u2191<\/mark><\/td>n.d.*<\/td>1.368\u2191<\/mark><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

    Observa\u00e7\u00f5es: n.d.: n\u00e3o determinado. *Presen\u00e7a de agrega\u00e7\u00e3o plaquet\u00e1ria.<\/p>\n\n\n\n

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    Leucograma<\/strong><\/td>Dia 30<\/strong><\/td>Dia 57<\/strong><\/td>Dia 91<\/strong><\/td><\/tr>
    Leuc\u00f3citos totais (6.000-17.000\/\u00b5L)<\/td>11.000\u00a0<\/td>18.500\u2191<\/mark><\/td>8.700\u00a0<\/td><\/tr>
    Miel\u00f3citos (0\/\u00b5L)<\/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><\/tr>
    Neutr. bast. (<300\/\u00b5L)<\/td>0\u00a0<\/td>185\u00a0<\/td>0\u00a0<\/td><\/tr>
    Neutr. seg. (3.000-11.500\/\u00b5L)<\/td>8.910\u00a0<\/td>16.280\u2191<\/mark><\/td>5.394\u00a0<\/td><\/tr>
    Bas\u00f3filos (<200\/\u00b5L)<\/td>0\u00a0<\/td>0\u00a0<\/td>0\u00a0<\/td><\/tr>
    Eosin\u00f3filos (100-1.250\/\u00b5L)<\/td>110\u00a0<\/td>370\u00a0<\/td>1.218\u00a0<\/td><\/tr>
    Mon\u00f3citos (150-1.350\/\u00b5L)<\/td>660\u00a0<\/td>555\u00a0<\/td>783\u00a0<\/td><\/tr>
    Linf\u00f3citos (1.000-4.800\/\u00b5L)<\/td>1.320\u00a0<\/td>1.110\u00a0<\/td>1.305\u00a0<\/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 30<\/strong><\/td>Dia 57<\/strong><\/td>Dia 91<\/strong><\/td><\/tr>
    Amostra<\/td>soro<\/td>soro<\/td>soro<\/td><\/tr>
    Hem\u00f3lise<\/td>ausente<\/td>n.d.<\/td>n.d.<\/td><\/tr>
    AnticoagulanteA<\/sup><\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td><\/tr>
    Prote\u00ednas totaisB<\/sup> (60-80 g\/L)<\/td>48\u2193<\/mark><\/td>62\u00a0<\/td>68\u00a0<\/td><\/tr>
    Prote\u00ednas totaisC<\/sup> (54-71 g\/L)<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Albumina (26-33 g\/L)<\/td>37\u2191<\/mark><\/td>24\u2193<\/mark><\/td>n.d.\u00a0<\/td><\/tr>
    Globulinas (27-44 g\/L)<\/td>11\u2193<\/mark><\/td>38\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Glicose (65-118 mg\/dL)<\/td>n.d.\u00a0<\/td>431\u2191<\/mark><\/td>n.d.\u00a0<\/td><\/tr>
    Colesterol total (135-270 mg\/dL)<\/td>n.d.\u00a0<\/td>201\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Ureia (21-60 mg\/dL)<\/td>n.d.\u00a0<\/td>31\u00a0<\/td>34\u00a0<\/td><\/tr>
    Creatinina (<1,4 mg\/dL)<\/td>0,74\u00a0<\/td>0,88\u00a0<\/td>1,0\u00a0<\/td><\/tr>
    FA (<156 U\/L)<\/td>n.d.\u00a0<\/td>889\u2191<\/mark><\/td>374\u2191<\/mark><\/td><\/tr>
    ALT (<102 U\/L)<\/td>n.d.\u00a0<\/td>505\u2191<\/mark><\/td>225\u2191<\/mark><\/td><\/tr>
    Frutosamina (170-338 \u00b5mol\/L)<\/td>652\u2191<\/mark><\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
    Triglicer\u00eddeos (32-138 mg\/dL)<\/td>n.d.\u00a0<\/td>115\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

    <\/span><\/div>\n\t\t<\/div>\n\t\t\t
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    <\/td>Dia 29<\/strong><\/td><\/tr>
    M\u00e9todo de coletaA<\/sup><\/td>cat<\/td><\/tr>
    Sedimento urin\u00e1rioB<\/sup><\/strong><\/td>\u00a0<\/td><\/tr>
    C\u00e9lulas epiteliais<\/td>escamosas (2), transi\u00e7\u00e3o (4)<\/td><\/tr>
    Cilindros<\/td>ausentes<\/td><\/tr>
    Hem\u00e1cias<\/td>ausentes<\/td><\/tr>
    Leuc\u00f3citos<\/td><5<\/td><\/tr>
    Bacteri\u00faria<\/td>leve\u2191<\/mark><\/td><\/tr>
    Outros<\/td>aglomera\u00e7\u00e3o de c\u00e9lulas de transi\u00e7\u00e3o<\/td><\/tr>
    Exame qu\u00edmico<\/strong><\/td>\u00a0<\/td><\/tr>
    pH (5,5-7,0)<\/td>6,0\u00a0<\/td><\/tr>
    Corpos cet\u00f4nicosC<\/sup><\/td>++\u2191<\/mark><\/td><\/tr>
    GlicoseD<\/sup><\/td>++++\u2191<\/mark><\/td><\/tr>
    BilirrubinaE<\/sup><\/td>+\u2191<\/mark><\/td><\/tr>
    Urobilinog\u00eanio (<1 mg\/dL)<\/td>\u22480,2\u00a0<\/td><\/tr>
    Prote\u00ednaF<\/sup><\/td>tra\u00e7os\u2191<\/mark><\/td><\/tr>
    SangueG<\/sup><\/td>ausente\u00a0<\/td><\/tr>
    RPCUH<\/sup><\/td>n.d.<\/td><\/tr>
    Exame f\u00edsico<\/strong><\/td>\u00a0<\/td><\/tr>
    Dens. espec. (1,015-1,045)<\/td>1,044\u00a0<\/td><\/tr>
    Cor<\/td>amarela<\/td><\/tr>
    Consist\u00eancia<\/td>fluida<\/td><\/tr>
    Aspecto<\/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