{"id":6388,"date":"2023-09-24T18:29:23","date_gmt":"2023-09-24T21:29:23","guid":{"rendered":"https:\/\/www.ufrgs.br\/lacvet\/?p=6388"},"modified":"2025-08-05T10:50:00","modified_gmt":"2025-08-05T13:50:00","slug":"caso-clinico-1796h","status":"publish","type":"post","link":"https:\/\/www.ufrgs.br\/lacvet\/cc_interativos\/caso-clinico-1796h\/","title":{"rendered":"Caso Cl\u00ednico 1796H"},"content":{"rendered":"
\n
\n\t\t\t
\n\t\t\t

Identifica\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

<\/span><\/div>\n\t\t<\/div>\n\t\t\t
\n\n

Esp\u00e9cie: Canina
Ra\u00e7a: SRD
Idade: 5 anos
Sexo: f\u00eamea
Peso: 21,6 kg<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

\n\t\t\t
\n\t\t\t

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

<\/span><\/div>\n\t\t<\/div>\n\t\t\t
\n\n

H\u00e1 cinco dias, a paciente atacou um ouri\u00e7o. Os espinhos foram retirados pela tutora. A partir do dia seguinte, a paciente come\u00e7ou a apresentar letargia, anorexia, perda de peso, adipsia e epis\u00f3dios de \u00eamese.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

\n\t\t\t
\n\t\t\t

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

<\/span><\/div>\n\t\t<\/div>\n\t\t\t
\n\n

Estado mental: ap\u00e1tica
Temperatura retal: 37,3 \u00b0C\u2193<\/mark> (ref.: 37,5\u201339,2)
Mucosas normocoradas
Desidratada
Escore de condi\u00e7\u00e3o corporal: 5 (escala de 1 a 9; ideal=5)
Tempo de preenchimento capilar: <2 s (ref.: 1-2)
Frequ\u00eancia card\u00edaca: 132 bpm (val. ref.: 60\u2013160)
Apresentava les\u00e3o purulenta e ulcerada no focinho; apresentava tremores e presen\u00e7a de pulgas.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

\n\t\t\t
\n\t\t\t

Exames complementares<\/strong><\/p>\n\t\t\t

<\/span><\/div>\n\t\t<\/div>\n\t\t\t
\n\n

Dia 5 – Ultrassonografia<\/strong><\/p>\n\n\n\n

    \n
  • Gl\u00e2ndula adrenal esquerda: medindo, aproximadamente, 0,54 cm de espessura em seu polo caudal, com dimens\u00f5es e forma mantidas, contorno regular e homog\u00eaneo.<\/li>\n\n\n\n
  • Gl\u00e2ndula adrenal direita: n\u00e3o foi poss\u00edvel visualizar devido \u00e0 quantidade de conte\u00fado gasoso no trato gastrointestinal.<\/li>\n\n\n\n
  • Demais \u00f3rg\u00e3os abdominais visualizados sem altera\u00e7\u00f5es ecogr\u00e1ficas.<\/li>\n<\/ul>\n\n\n\n

    Dia 5 – Teste de estimula\u00e7\u00e3o com ACTH<\/strong><\/p>\n\n\n\n

      \n
    • Cortisol sangu\u00edneo basal: 0,01 \u00b5g\/dL\u2193<\/mark> (ref.: 0,5-6,0)<\/li>\n\n\n\n
    • Cortisol sangu\u00edneo ap\u00f3s estimula\u00e7\u00e3o com ACTH: 0,01 \u00b5g\/dL\u2193<\/mark> (ref.: 6-17).<\/li>\n<\/ul>\n\n<\/div>\n\t\t<\/div>\n\n
      \n\t\t\t
      \n\t\t\t

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

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
      \n\n

      Dia 0<\/strong>: paciente internada e iniciada a fluidoterapia (Ringer-lactato). Iniciado o tratamento com cloridrato de tramadol (analg\u00e9sico), cloridrato de ondansetrona (antiem\u00e9tico), cloridrato de ranitidina (bloqueador H2<\/sub>, anti\u00e1cido), meloxicam (anti-inflamat\u00f3rio n\u00e3o-esteroide, analg\u00e9sico e antipir\u00e9tico) e citrato de maropitant (antiem\u00e9tico). Durante os dois primeiros dias a paciente apresentou hipoglicemia (<65 mg\/dL) e elevada frequ\u00eancia card\u00edaca (>120 bpm), bem como epis\u00f3dios de hipotermia (<37,4\u00b0C) ao longo da interna\u00e7\u00e3o.<\/p>\n\n\n\n

      Dia 2:<\/strong> suspenso o uso dos analg\u00e9sicos cloridrato de tramadol e meloxicam.<\/p>\n\n\n\n

      Dia 5<\/strong>: suspensa a fluidoterapia pelo turno da manh\u00e3. Durante o turno da tarde, mostrou not\u00e1vel piora apresentando hipotermia (<37,4\u00b0C), bradicardia (<80 bpm), TPC maior que dois segundos e PAS (Press\u00e3o Arterial Sist\u00f3lica) de 65 mmHg (ref.: 110\u2013120). Administrado sulfato de atropina (antiespasm\u00f3dico e anticolin\u00e9rgico).\u00a0 Realizada fluidoterapia (NaCl 0,9%). Administrados os mesmos f\u00e1rmacos do dia 0, al\u00e9m de acetato de hidrocortisona (glicocorticoide), dexametasona (glicocorticoide), omeprazol (inibidor da bomba de pr\u00f3tons; anti\u00e1cido) e sucralfato (antiulcerativo).<\/p>\n\n\n\n

      Dia 8:<\/strong> paciente recebeu alta com prescri\u00e7\u00f5es de acetato de fludrocortisona (esteroide sint\u00e9tico), prednisona (glicocorticoide), cloridrato de ranitidina, omeprazol, sucralfato e cobamamida+cloridrato de ciproeptadina (estimulante de apetite) por tempo determinado.<\/p>\n\n\n\n

      Dia 103:<\/strong> tutora relatou que havia trocado o acetato de fludrocortisona original pelo f\u00e1rmaco manipulado e que h\u00e1 uma semana a paciente estava ap\u00e1tica, sem apetite, apresentando epis\u00f3dios de v\u00f4mito e muitos tremores. Administrou prednisona e, ao notar que n\u00e3o houve melhora, buscou atendimento. No exame cl\u00ednico foi verificada desidrata\u00e7\u00e3o, TPC >2 s e extremidades frias. Durante a consulta foram realizados fluidoterapia e administrado dexametasona. A paciente foi encaminhada ao domic\u00edlio com novas prescri\u00e7\u00f5es de acetato de fludrocortisona e prednisona e seguiu com o quadro estabilizado e acompanhamento peri\u00f3dico.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

      \n\t\t\t
      \n\t\t\t

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

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
      \n\n
      Sangue VENOSO<\/strong><\/td>Dia 5<\/strong><\/td>Dia 103<\/strong><\/td><\/tr>
      pH (7,351-7,443)<\/td>7,26\u2193<\/mark><\/td>7,33\u2193<\/mark><\/td><\/tr>
      pCO2<\/sub> (33,6-41,2 mmHg)<\/td>33,8<\/td>37<\/td><\/tr>
      pO2<\/sub> (47,9-56,3 mmHg)<\/td>33\u2193<\/mark><\/td>n.d.<\/td><\/tr>
      BE (-3 a 2 mmol\/L)<\/td>-12\u2193<\/mark><\/td>-6,5\u2193<\/mark><\/td><\/tr>
      HCO3<\/sub> (21-25 mmol\/L)<\/td>15,3\u2193<\/mark><\/td>18\u2193<\/mark><\/td><\/tr>
      tCO2<\/sub> (mmol\/L)<\/td>16<\/td>19,2<\/td><\/tr>
      sO2<\/sub> (%)<\/td>56<\/td>60<\/td><\/tr>
      Na (140-155 mmol\/L)<\/td>125\u2193<\/mark><\/td>144<\/td><\/tr>
      K (3,5 a 5,7 mmol\/L)<\/td>8,4\u2191<\/mark><\/mark><\/mark><\/td>4,7<\/td><\/tr>
      Rela\u00e7\u00e3o Na:K (>30)<\/td>14,9\u2193<\/mark><\/td>30,6<\/td><\/tr><\/tbody><\/table><\/figure>\n\n<\/div>\n\t\t<\/div>\n\n
      \n\t\t\t
      \n\t\t\t

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

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
      \n\n
      Eritrograma<\/strong><\/td>Dia 0<\/strong><\/td>Dia 5<\/strong><\/td>Dia 102<\/strong><\/td><\/tr>
      Eritr\u00f3citos (5,5-8,5 milh\u00f5es\/\u00b5L)<\/td>6,88<\/td>4,28\u2193<\/mark><\/td>7,32<\/td><\/tr>
      Hemat\u00f3crito (37-55%)<\/td>45<\/td>30\u2193<\/mark><\/td>48<\/td><\/tr>
      Hemoglobina (12-18 g\/dL)<\/td>14,7<\/td>10,2\u2193<\/mark><\/td>15,4<\/td><\/tr>
      VCM (60-77 fL)<\/td>65<\/td>70<\/td>65<\/td><\/tr>
      CHCM (32-36%)<\/td>33<\/td>34<\/td>32<\/td><\/tr>
      Plaquetas<\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      Quantidade (200-500 \u00d7103<\/sup>\/\u00b5L)<\/td>312<\/td>160\u2193<\/mark><\/td>340<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n
      \n\n\n\n
      Leucograma<\/strong><\/td>Dia <\/strong>0<\/strong><\/td>Dia <\/strong>5<\/strong><\/td>Dia <\/strong>102<\/strong><\/td><\/tr>
      Leuc\u00f3citos totais (6.000-17.000\/\u00b5L)<\/td>23.100\u2191<\/mark><\/mark><\/mark><\/td>13.000<\/td>34.400\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      Miel\u00f3citos (0\/\u00b5L)<\/td>0<\/td>0<\/td>0<\/td><\/tr>
      Metamiel\u00f3citos (0\/\u00b5L)<\/td>0<\/td>0<\/td>0<\/td><\/tr>
      Neutr. bast. (<300\/\u00b5L)<\/td>0<\/td>0<\/td>344\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      Neutr. seg. (3.000-11.500\/\u00b5L)<\/td>13.167\u2191<\/mark><\/mark><\/mark><\/td>8.320<\/td>28.552\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      Bas\u00f3filos (<200\/\u00b5L)<\/td>0<\/td>0<\/td>0<\/td><\/tr>
      Eosin\u00f3filos (100-1.250\/\u00b5L)<\/td>3.465\u2191<\/mark><\/mark><\/mark><\/td>910\u00a0<\/td>0<\/td><\/tr>
      Mon\u00f3citos (150-1.350\/\u00b5L)<\/td>1.848\u2191<\/mark><\/mark><\/mark><\/td>260\u00a0<\/td>2.064\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      Linf\u00f3citos (1.000-4.800\/\u00b5L)<\/td>4.620<\/td>3.510<\/td>3.440<\/td><\/tr><\/tbody><\/table><\/figure>\n\n<\/div>\n\t\t<\/div>\n\n
      \n\t\t\t
      \n\t\t\t

      Bioqu\u00edmica sangu\u00ednea<\/strong><\/p>\n\t\t\t

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
      \n\n
      <\/td>Dia 0<\/strong><\/td>Dia 2<\/strong><\/td>Dia 5<\/strong><\/td>Dia 102<\/strong><\/td>Dia 103<\/strong><\/td><\/tr>
      Amostra<\/td>soro<\/td>soro<\/td>soro<\/td>soro<\/td>soro<\/td><\/tr>
      Hem\u00f3lise<\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/td>ausente<\/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>74<\/td>n.d.<\/td>60<\/td>78<\/td>n.d.<\/td><\/tr>
      Albumina (26-33 g\/L)<\/td>35\u2191<\/mark><\/mark><\/mark><\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>36\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      Glicose (65-118 mg\/dL)<\/td>63\u2193<\/mark><\/td>75<\/td>93<\/td>n.d.<\/td>102<\/td><\/tr>
      Ureia (21-60 mg\/dL)<\/td>158\u2191<\/mark><\/mark><\/mark><\/td>50<\/td>n.d.<\/td>n.d.<\/td>73\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      Creatinina (<1,4 mg\/dL)<\/td>3,4\u2191<\/mark><\/mark><\/mark><\/td>1,5\u2191<\/mark><\/mark><\/mark><\/td>1,3<\/td>5,1\u2191<\/mark><\/mark><\/mark><\/td>0,8<\/td><\/tr>
      C\u00e1lcio (9,0-11,3 mg\/dL)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>16,8\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      F\u00f3sforo (2,6-6,2 mg\/dL)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>5,4<\/td><\/tr>
      FA (<156 U\/L)<\/td>43<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>40<\/td><\/tr>
      ALT (<102 U\/L)<\/td>175\u2191<\/mark><\/mark><\/mark><\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>27<\/td><\/tr>
      Pot\u00e1ssio (4,4-5,3 mmol\/L)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>9,6\u2191<\/mark><\/mark><\/mark><\/td>n.d.<\/td><\/tr>
      S\u00f3dio (141\u2013152 mmol\/L)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>121\u2193<\/mark><\/td>n.d.<\/td><\/tr>
      Rela\u00e7\u00e3o Na:K (>30)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td>12,6<\/td>n.d.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

      B<\/sup>Estimadas por refratometria; n.d., n\u00e3o determinado.<\/p>\n\n<\/div>\n\t\t<\/div>\n\n

      \n\t\t\t
      \n\t\t\t

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

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
      \n\n
      <\/td>Dia 1<\/strong><\/td>Dia 103<\/strong><\/td><\/tr>
      M\u00e9todo de coletaA<\/sup><\/td>cist<\/td>cist<\/td><\/tr>
      Sedimento urin\u00e1rioB<\/sup><\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      C\u00e9lulas epiteliais<\/td>escamosas (1)<\/td>escamosas (1), transi\u00e7\u00e3o (2)<\/td><\/tr>
      Cilindros<\/td>ausente<\/td>ausente<\/td><\/tr>
      Hem\u00e1cias<\/td>ausente<\/td>5\u2191<\/mark><\/mark><\/mark><\/td><\/tr>
      Leuc\u00f3citos<\/td>ausente<\/td>ausente<\/td><\/tr>
      Bacteri\u00faria<\/td>ausente<\/td>ausente<\/td><\/tr>
      Exame qu\u00edmico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      pH (5,5-7,0)<\/td>6,0\u00a0<\/td>6,0\u00a0<\/td><\/tr>
      Corpos cet\u00f4nicosC<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
      GlicoseD<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
      BilirrubinaE<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
      Urobilinog\u00eanio (<1 mg\/dL)<\/td>n.d.\u00a0<\/td>n.d.\u00a0<\/td><\/tr>
      Prote\u00ednaF<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
      SangueG<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
      RPCUH<\/sup><\/td>0,05<\/td>0,02<\/td><\/tr>
      Exame f\u00edsico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
      Dens. espec. (1,015-1,045)<\/td>1,008\u2193<\/mark><\/td>1,018\u2193<\/mark><\/td><\/tr>
      Cor<\/td>amarelo claro<\/td>amarelo claro<\/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

      \n\t\t\t
      \n\t\t\t

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

      <\/span><\/div>\n\t\t<\/div>\n\t\t\t
      \n\n

      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