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Universidade Estadual De Campinas Faculdade De Ciências Médicas UNIVERSIDADE ESTADUAL DE CAMPINAS FACULDADE DE CIÊNCIAS MÉDICAS MAÍRA MIGLIARI BRANCO PIMENTA ACIDENTES CAUSADOS POR CONTATO COM LARVAS DE LEPIDÓPTEROS (ERUCISMO) NA REGIÃO DE CAMPINAS -SP CAMPINAS 2018 MAÍRA MIGLIARI BRANCO PIMENTA ACIDENTES CAUSADOS POR CONTATO COM LARVAS DE LEPIDÓPTEROS (ERUCISMO) NA REGIÃO DE CAMPINAS -SP Dissertação de mestrado apresentada à Pós-Graduação da Faculdade de Ciências Médicas da Universidade Estadual de Campinas - UNICAMP para obtenção do título de Mestra em Ciências, área de concentração em Saúde da Criança e do Adolescente. ORIENTADOR: PROF. DR. FÁBIO BUCARETCHI ESTE EXEMPLAR CORRESPONDE À VERSÃO FINAL DA DISSERTAÇÃO DEFENDIDA PELA ALUNA MAÍRA MIGLIARI BRANCO PIMENTA, E ORIENTADA PELO PROF. DR. FÁBIO BUCARETCHI. CAMPINAS 2018 BANCA EXAMINADORA DA DEFESA DE MESTRADO MAÍRA MIGLIARI BRANCO PIMENTA Orientador (a) PROF(A). DR(A). FÁBIO BUCARETCHI MEMBROS: 1. PROF(A). DR(A). FÁBIO BUCARETCHI 2. PROF(A). DR(A). ANDRÉA DE MELO ALEXANDRE FRAGA 3. PROF(A). DR(A). FRANCISCO OSCAR DE SIQUEIRA FRANÇA Programa de Pós-Graduação em Saúde da Criança e do Adolescente da Faculdade de Ciências Médicas da Universidade Estadual de Campinas. Ata da Defesa, assinada pelos membros da Comissão Examinadora, consta no SIGA/Sistema de Fluxo de Dissertação/Tese e na Secretaria do Programa da Unidade. Data: 13 de novembro de 2018 DEDICATÓRIA Ao meu marido Wallace, meu companheiro de todas as jornadas; Aos meus pais, Pedro e Maura, por me incentivarem sempre a estudar; Aos meus irmãos, João, Luís e Laura, por todo apoio sempre; Às minhas amigas irmãs Mariana, Elen, Juliana, Ana Lourdes e Karinne, sempre ao meu lado; À minha filha Clarice por ter repartido o seu tempo comigo para que eu pudesse escrever a dissertação e para que ela tenha sempre vontade de aprender. AGRADECIMENTOS Ao Professor Doutor Fábio Bucaretchi, por todos os ensinamentos, e que soube me orientar mesmo à distância; À toda equipe do Centro de Informação e Assistência Toxicológica (CIATox) de Campinas, em especial às amigas Carla, Camila, Mariana, Daniela, Adriana e Sueli; Aos estagiários do CIATox que auxiliaram no preenchimento dos protocolos de atendimento; À minha querida amiga Luciane, que elaborou o protocolo de atendimento de lepidopterismo junto comigo e me ajudou na formatação da planilha dos atendimentos; Ao professor Roberto Henrique Pinto Moraes, pela recepção calorosa no Laboratório de Entomologia/Parasitologia do Instituto Butantan, e pelos ensinamentos básicos na identificação de lagartas de lepidópteros de importância médica na região de Campinas; Ao meu marido Wallace por me ajudar na formatação da dissertação; À Márcia, secretária do Programa de Pós-Graduação em Saúde da Criança e do Adolescente da FCM/Unicamp, sempre solícita e pronta a responder minhas dúvidas. Resumo Contexto: Estudos clínicos sobre acidentes com lagartas de mariposas (erucismo), incluindo acidentes com megalopigídeos, são pouco descritos no Brasil. Objetivo: Avaliar uma série de casos de erucismo admitidos na Unidade de Emergência Referenciada (UER) do Hospital de Clínicas da Unicamp e seguidos pelo Centro de Informação e Assistência Toxicológica de Campinas. Casuística e Métodos: Coorte prospectiva (janeiro de 2010 a abril de 2016). Critérios de inclusão: todos os casos de erucismo admitidos na UER. A intensidade da dor foi avaliada por escala numérica de notas de dor de 11 pontos (END 0-10). A dor foi classificada como grave na admissão na UER (T0) quando a nota atribuída foi ≥ 8. Resultados: No período de estudo, 278 casos de erucismo foram admitidos na UER (Podalia spp., n= 108; Megalopyge spp., n= 16; Automeris spp., n= 12; Lonomia spp., n= 3; Hylesia spp., n= 1; lagartas não trazidas para identificação ou não fotografadas, n= 138). A maioria dos acidentes ocorreu em homens (55,4%), com idade mediana de 40 anos, no verão (janeiro a março, 82,6%), na zona urbana (92,1%), e nos domicílios (61,3%). O intervalo mediano entre o acidente e a admissão na UER foi de 90 min. (IIQ: 45-150). Dor local foi a principal queixa reportada (95,3%), seguida de eritema local (82%), edema discreto (55,8%) e parestesia (21,9%). A intensidade da dor em T0 foi avaliada em 224 casos (82,7%), sendo classificada como grave em 124 casos (mediana= 8, IIQ: 6-10). Medicações para alívio da dor foram frequentemente usadas em T0, como anestesia local (40,3%) e analgésicos (76,4%), principalmente dipirona (54,7%) e opioides (14,4%). Analgesia adicional (T5 até alta da UER) foi utilizada em 80 pacientes (28,8%), em 34 casos pós-contato com megalopigídeos e, em 46 casos, com lagartas não identificadas. Em dois casos de lonomismo foi detectada coagulopatia, com um paciente sendo tratado com soro antilonômico. O tempo mediano de observação na UER foi de 75 minutos (IIQ: 45-120). Conclusões: Dor local foi a principal queixa associada com erucismo, causado, em sua maioria, por megalopigídeos do gênero Podalia. Infiltração anestésica local e analgésicos foram os procedimentos mais utilizados para controle da dor na UER. Palavras-chave: Erucismo; Megalopygidae; Podalia spp; Dor; Escala numérica de dor. Abstract Context: Clinical studies of erucism (envenomation caused by dermal contact with larval forms of moths), including megalopigids, have been rarely described in Brazil. Objective: To evaluate a case series of erucism admitted to the Emergency Department (ED) of a public university teaching hospital and followed by the Campinas Poison Control Center. Patients and methods: Prospective cohort study (January 2010 to April 2016). Inclusion criteria: all cases of erucism admitted to our ED. A Numeric Pain Rating Scale (NPRS 0-10) was used to assess pain intensity in the ED. Pain was considered as severe upon ED admission (T0) when the NPRS was ≥ 8. Results: In the study period 278 cases of erucism were admitted to our ED (Podalia spp., n=108; Megalopyge spp., n=16; Automeris spp., n=12; Lonomia spp., n=3; Hylesia spp., n=1; caterpillars not brought for identification or not photographed, n=138). Most of the cases occurred in men (55.4%), with a median age of 40 years, during the summer (January to March 82.6%), in an urban setting (92.1%) and in households (61.3%). The median time between the dermal contact and admission to the ED was 90 min. (IQI: 45-150). Local pain was the main complaint reported (95.3%), followed by local erythema (82%), mild edema (55.8%) and paresthesia (21.9%). Pain intensity at T0 was assessed in 224 cases (82.7%) and was classified as severe in 124 cases (median= 8, IQI: 6-10). Medications to relief pain were frequently used at T0, such as local anesthesia (40.3%) and analgesics (76.4%), the latter involving mainly dipyrone (54.7%) and opioids (14.4%). Additional analgesia (from T5 until discharge) was required in 80 patients (28.8%), post-contact with megalopigids (n=34) and by caterpillars not brought for identification (n=46). Two cases of lonomism developed coagulopathy, with one being treated with antilonomic antivenom. The median length of the ED stay was 75 min (IQI: 45-120). Conclusion: Pain was the main complaint associated with erucism, mainly related to megalopigids of the genus Podalia. Local anesthesia and analgesics were frequently used for the management of pain. Keywords: Erucism; Megalopygidae; Podalia spp; Pain; Numeric Pain Rating Scale Lista de Ilustrações Figura 1: Distribuição dos casos de erucismo atendidos na Unidade de Emergência Referenciada do Hospital de Clínicas da Unicamp de acordo com os meses do ano. ........................................ 24 Figura 2: Imagens de três casos da presente série mostrando dermatite local pós-contato com cerdas urticantes ........................................................................................................................... 27 Figura 3: Fluxograma de seleção dos casos para análise do controle da dor grave em uma série casos de erucismo admitidos na UER/HC/Unicamp.. ................................................................... 29 Figura 4: Gráficos em “box plots” mostrando a evolução da dor grave de acordo com os tratamentos utilizados. ................................................................................................................. 33 Lista de Tabelas Tabela 1: Aspectos demográficos dos 278 casos de erucismo admitidos na UER/HC/Unicamp no período de janeiro de 2010 a abril de 2016 de acordo com o gênero da lagarta. ....................... 28 Tabela 2: Manifestações clínicas observadas à admissão de 278 casos de erucismo na UER/HC/Unicamp, de acordo com o gênero da lagarta. .............................................................. 29 Tabela 3: Avaliação evolutiva da intensidade da dor de acordo com o tempo, usando a escala numérica de notas de dor, e do tempo de observação na UER, em 278 casos de erucismo de acordo com o gênero da lagarta. .................................................................................................. 30 Tabela 4: Procedimentos analgésicos empregados para controle da dor em 278 casos de erucismo admitidos na UER/HC/Unicamp de acordo com o gênero da lagarta. ......................... 31 Tabela 5: Aspectos demográficos e procedimentos empregados para controle da dor grave em 55 casos de erucismo admitidos na UER/HC/Unicamp. ............................................................... 34 ABREVIATURAS UTILIZADAS ABRACIT Associação Brasileira dos Centros de Informação e Assistência Toxicológica e Toxicologistas Clínicos CIATox Centro de Informação e Assistência Toxicológica DATATOX Sistema Brasileiro de Dados de Intoxicações END
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