{"id":7314,"date":"2023-10-12T11:56:02","date_gmt":"2023-10-12T14:56:02","guid":{"rendered":"https:\/\/www.ufrgs.br\/lacvet\/?p=7314"},"modified":"2023-11-01T11:04:52","modified_gmt":"2023-11-01T14:04:52","slug":"caso-clinico-179y7","status":"publish","type":"post","link":"https:\/\/www.ufrgs.br\/lacvet\/cc_interativos\/caso-clinico-179y7\/","title":{"rendered":"Caso Cl\u00ednico 179Y7"},"content":{"rendered":"
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Identifica\u00e7\u00e3o<\/strong><\/p>\n\t\t\t

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Esp\u00e9cie: Canina
Ra\u00e7a: Dachshund
Idade: 4 meses
Sexo: macho
Peso: 4,310 kg<\/mark><\/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 recentemente adotado, h\u00e1 duas semanas apresentava v\u00f4mito depois de ingerir ra\u00e7\u00e3o. Desde ent\u00e3o a tutora vinha oferecendo biscoitos e comida caseira ao animal. Em uma consulta anterior foi constatada eleva\u00e7\u00e3o da atividade s\u00e9rica de ALT (468 U\/L\u2191<\/mark>, ref.: <102). Tutora informou sobre a possibilidade de ter sido administrado antif\u00fangico, pois o paciente havia apresentado micose h\u00e1 3 meses. Foi mencionado tamb\u00e9m seu h\u00e1bito de comer objetos, com epis\u00f3dio de ingest\u00e3o de Sansevieria trifasciata <\/em>(Espada-de-S\u00e3o-Jorge).<\/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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Animal ativo e alerta
Temperatura retal 38,5 \u00b0C (37,4-39,0)
Escore corporal 3 (ref.: 1-5, ideal=3)
Discretamente desidratado
Mucosas normocoradas
Tempo de preenchimento capilar sem altera\u00e7\u00e3o (ref.: <2 s)
Frequ\u00eancia card\u00edaca: 135 bpm\u2191<\/mark> (ref.: 80\u2013120) <\/p>\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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An\u00e1lise de l\u00edquidos cavit\u00e1rios (dia 29)<\/strong>
Drenagem abdominal (ascite) classificada como efus\u00e3o de transudato puro ou pobre em prote\u00edna, composto por c\u00e9lulas epiteliais monom\u00f3rficas, com observa\u00e7\u00e3o de raros neutr\u00f3filos e macr\u00f3fagos.<\/p>\n\n\n\n

Ultrassonografia abdominal (dias 7, 31, 58, 97 e 184)<\/strong>
Os quatro primeiros exames indicavam f\u00edgado com dimens\u00f5es mantidas e contornos regulares, moderadamente hiperecog\u00eanico (hepatopatia\/fibrose\/lipidose?), com diversos focos hiperecog\u00eanicos pequenos e arredondados, com aumento ac\u00fastico t\u00eanue (mineraliza\u00e7\u00e3o?). Presen\u00e7a tamb\u00e9m de moderada quantidade de l\u00edquido livre anecog\u00eanico na cavidade.
No dia 184 o f\u00edgado se apresentava com volume diminu\u00eddo e bordos irregulares. Par\u00eanquima heteroecog\u00eanico, apresentando aspecto nodular, com pontos hiperecog\u00eanicos de mineraliza\u00e7\u00e3o (hepatopatia cr\u00f4nica\/processo cirr\u00f3tico). Veias hep\u00e1ticas e portais pouco evidentes no Doppler colorido. No abd\u00f4men, caudal ao rim esquerdo, presen\u00e7a de vasos dilatados e tortuosos, apresentando fluxo turbulento em mosaico de n\u00facleos. Sugerida a possibilidade de envolvimento da veia testicular. Art\u00e9ria e veias de borda esquerda com origem aparentemente preservada. Imagem compat\u00edvel com desvios portossist\u00eamicos extra-hep\u00e1ticos e\/ou vasos sangu\u00edneos colaterais.<\/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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Ao longo de todo o per\u00edodo foram utilizados: silimarina (a\u00e7\u00e3o antioxidante, utilizada no tratamento de hepatopatias cr\u00f4nicas), adenosil metionina (tratamento da colestase e dist\u00farbios hep\u00e1ticos), omeprazol (redutor de secre\u00e7\u00e3o g\u00e1strica), ondansetrona (antiem\u00e9tico), Hepvet (auxiliar no metabolismo de gorduras e prote\u00ednas), vitamina K, espironolactona (diur\u00e9tico poupador de pot\u00e1ssio), metronidazol (derivado nitroimidazol com atividade antiprotozo\u00e1ria e antibacteriana). Ap\u00f3s institu\u00edda a terapia, o paciente se manteve est\u00e1vel, mas recorrentemente havia retorno dos quadros de v\u00f4mito e ascite.<\/p>\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><\/td>Dia <\/strong>22<\/strong><\/td>Dia <\/strong>52<\/strong><\/td>Dia <\/strong>319<\/strong><\/td><\/tr>
Eritr\u00f3citos (5,5-8,5 milh\u00f5es\/\u00b5L)<\/td>5,21\u2193<\/mark><\/td>4,10\u2193<\/mark><\/td>8,91\u2191<\/mark><\/td><\/tr>
Hemat\u00f3crito (37-55%)<\/td>32\u2193<\/mark><\/td>21\u2193<\/mark><\/td>50\u00a0<\/td><\/tr>
Hemoglobina (12-18 g\/dL)<\/td>9,8\u2193<\/mark><\/td>5,6\u2193<\/mark><\/td>16,6\u00a0<\/td><\/tr>
VCM (60-77 fL)<\/td>61,4\u00a0<\/td>51,2\u2193<\/mark><\/td>56,1\u2193<\/mark><\/td><\/tr>
CHCM (32-36%)<\/td>30,6\u2193<\/mark><\/td>26,7\u2193<\/mark><\/td>33,2\u00a0<\/td><\/tr>
Plaquetas<\/strong><\/td>\u00a0<\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
Quantidade (200-500 \u00d7103<\/sup>\/\u00b5L)<\/td>145\u2193<\/mark><\/td>100\u2193<\/mark><\/td>160\u2193<\/mark><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

Observa\u00e7\u00f5es (dia 52): hipocromasia (++); policromasia (+), anisocitose (+)<\/p>\n\n\n\n

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Leucograma<\/strong><\/td>Dia 22<\/strong><\/td>Dia 52<\/strong><\/td>Dia 319<\/strong><\/td><\/tr>
Leuc\u00f3citos totais (6.000-17.000\/\u00b5L)<\/td>26.300\u2191<\/mark><\/td>24.500\u2191<\/mark><\/td>15.400<\/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>0<\/td><\/tr>
Neutr. seg. (3.000-11.500\/\u00b5L)<\/td>18.147\u2191<\/mark><\/td>14.700\u2191<\/mark><\/td>9.086\u00a0<\/td><\/tr>
Bas\u00f3filos (<200\/\u00b5L)<\/td>0<\/td>0<\/td>0<\/td><\/tr>
Eosin\u00f3filos (100-1.250\/\u00b5L)<\/td>789<\/td>245<\/td>1.694\u2191<\/mark><\/td><\/tr>
Mon\u00f3citos (150-1.350\/\u00b5L)<\/td>789<\/td>1.715\u2191<\/mark><\/td>308<\/td><\/tr>
Linf\u00f3citos (1.000-4.800\/\u00b5L)<\/td>6.575\u2191<\/mark><\/td>7.840\u2191<\/mark><\/td>4.312<\/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 22<\/strong><\/td>Dia 52<\/strong><\/td>Dia 319<\/strong><\/td><\/tr>
Amostra<\/td>soro<\/td>soro<\/td>soro<\/td><\/tr>
Hem\u00f3lise<\/td>ausente<\/td>ausente<\/td>leve<\/td><\/tr>
AnticoagulanteA<\/sup><\/td>nenhum<\/td>nenhum<\/td>nenhum<\/td><\/tr>
Prote\u00ednas totaisB<\/sup> (60-80 g\/L)<\/td>38\u2193<\/mark><\/td>50\u2193<\/mark><\/td>66<\/td><\/tr>
Prote\u00ednas totaisC<\/sup> (54-71 g\/L)<\/td>n.d.<\/td>n.d.<\/td>n.d.<\/td><\/tr>
Albumina (26-33 g\/L)<\/td>22\u2193<\/mark><\/td>27<\/td>31<\/td><\/tr>
Globulinas (27-44 g\/L)<\/td>16\u2193<\/mark><\/td>23\u2193<\/mark><\/td>35<\/td><\/tr>
Colesterol total (135-270 mg\/dL)<\/td>n.d.<\/td>91\u2193<\/mark><\/td>74\u2193<\/mark><\/td><\/tr>
Ureia (21-60 mg\/dL)<\/td>20\u2193<\/mark><\/td>17\u2193<\/mark><\/td>12\u2193<\/mark><\/td><\/tr>
Creatinina (<1,4 mg\/dL)<\/td>n.d.<\/td>0,8<\/td>0,7<\/td><\/tr>
FA (<156 U\/L)<\/td>762\u2191<\/mark><\/td>286\u2191<\/mark><\/td>162\u2191<\/mark><\/td><\/tr>
ALT (<102 U\/L)<\/td>170\u2191<\/mark><\/td>114\u2191<\/mark><\/td>399\u2191<\/mark><\/td><\/tr>
TP*<\/sup> (<10 s)<\/td>8,2<\/td>8,9<\/td>7,4<\/td><\/tr>
TTPA*<\/sup> (15-20 s)<\/td>40,4\u2191<\/mark><\/td>26,1\u2191<\/mark><\/td>24,4\u2191<\/mark><\/td><\/tr>
Triglicer\u00eddeos (32-138 mg\/dL)<\/td>n.d.<\/td>37<\/td>28\u2193<\/mark><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

B<\/sup>Estimadas por refratometria; C<\/sup>Determinadas por espectrofotometria
TP, tempo de protrombina; TTPA, tempo de tromboplastina parcial ativada
Observa\u00e7\u00f5es: *amostras de plasma com citrato<\/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 91<\/strong><\/td>Dia 319<\/strong><\/td><\/tr>
M\u00e9todo de coletaA<\/sup><\/td>n\u00e3o informado<\/td>cat<\/td><\/tr>
Sedimento urin\u00e1rioB<\/sup><\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
C\u00e9lulas epiteliais<\/td>escamosas (2), transi\u00e7\u00e3o (3)<\/td>escamosas (raras), transi\u00e7\u00e3o (raras)<\/td><\/tr>
Cilindros<\/td>ausentes<\/td>presentes\u2191<\/mark><\/td><\/tr>
Hem\u00e1cias<\/td>60\u2191<\/mark><\/td>0<\/td><\/tr>
Leuc\u00f3citos<\/td><5<\/td>raros<\/td><\/tr>
Bacteri\u00faria<\/td>severa\u2191<\/mark><\/td>leve\u2191<\/mark><\/td><\/tr>
Outros<\/td>Urato de am\u00f4nio (++)<\/td>Urato de am\u00f4nio (+)<\/td><\/tr>
Exame qu\u00edmico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
pH (5,5-7,0)<\/td>8,0\u2191<\/mark><\/td>7,0<\/td><\/tr>
Corpos cet\u00f4nicosC<\/sup><\/td>ausente\u00a0<\/td>ausente\u00a0<\/td><\/tr>
GlicoseD<\/sup><\/td>ausente<\/td>tra\u00e7os\u2191<\/mark><\/td><\/tr>
BilirrubinaE<\/sup><\/td>+\u2191<\/mark><\/td>+++\u2191<\/mark><\/td><\/tr>
Urobilinog\u00eanio (<1 mg\/dL)<\/td>\u22480,2\u00a0<\/td>\u22480,2\u00a0<\/td><\/tr>
Prote\u00ednaF<\/sup><\/td>+\u2191<\/mark><\/td>+\u2191<\/mark><\/td><\/tr>
SangueG<\/sup><\/td>++\u2191<\/mark><\/td>ausente<\/td><\/tr>
RPCUH<\/sup><\/td>n.d.<\/td>n.d.<\/td><\/tr>
Exame f\u00edsico<\/strong><\/td>\u00a0<\/td>\u00a0<\/td><\/tr>
Dens. espec. (1,015-1,045)<\/td>1,034\u00a0<\/td>1,030\u00a0<\/td><\/tr>
Cor<\/td>Amarela escura<\/td>Amarela<\/td><\/tr>
Consist\u00eancia<\/td>Fluida<\/td>Fluida<\/td><\/tr>
Aspecto<\/td>Discretamente turvo<\/td>\u00a0Turvo<\/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