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XI-XIII En Which Is Your Diagnosis.P65 Qual o seu diagnóstico? Bruno Hochhegger1, Klaus Loureiro Irion2, Arthur Soares Souza Junior3, Adalberto Sperb Rubin1, Gláucia Zanetti4 Trabalho realizado no Laboratório de Pesquisa em Imagens Médicas da Universidade culdade de Medicina de São José do Rio Preto (Famerp) e Ultra-X, São José do Federal de Ciências da Saúde de Porto Alegre e Santa Casa de Porto Alegre, Porto Rio Preto, SP, Brasil. 4. Universidade Federal do Rio de Janeiro (UFRJ), Rio de Ja- Alegre, RS, Brasil. 1. Laboratório de Pesquisa em Imagens Médicas da Universidade neiro, RJ, Brasil. Endereço para correspondência: Dr. Bruno Hochhegger. Rua Ge- Federal de Ciências da Saúde de Porto Alegre e Santa Casa de Porto Alegre, Porto neral Neto, 315/404, Floresta. Porto Alegre, RS, Brasil, 90560-020. E-mail: Alegre, RS, Brasil. 2. Royal Liverpool University Hospital, Liverpool, England. 3. Fa- [email protected]. Hochhegger B, Irion KL, Souza Junior AS, Rubin AS, Zanetti G. Qual o seu diagnóstico? Radiol Bras. 2014 Set/Out;47(5):XI–XIII. Paciente do sexo masculino, 23 anos, usuário de drogas, esforços. Foi realizada radiografia do tórax em posteroan- com tosse seca e dispneia progressiva a grandes e médios terior e tomografia computadorizada do tórax (Figura 1). A B Figura 1. A: Radiografia do tórax em posteroanterior. B: Tomografia computadorizada com janela para parênquima pulmonar. Corte ao nível dos lobos superiores. Radiol Bras. 2014 Set/Out;47(5):XI–XIII XI 0100-3984 © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem http://dx.doi.org/10.1590/0100-3984.2014.47.5qd Descrição da imagem talcose e enfisema. Alguns usuários de drogas habitualmente Figura 1. Radiografia em posteroanterior e tomografia maceram comprimidos, dissolvem o pó resultante em água (40–42) computadorizada do tórax mostrando enfisema bolhoso nas e injetam esta solução por via intravenosa . Essas me- porções superiores dos pulmões, predominando à direita. dicações orais têm em comum a adição de um veículo inso- Diagnóstico: Enfisema bolhoso em paciente usuário lúvel (talco, celulose ou amido), para manter as partículas de cocaína fumada (crack). medicinais juntas e para atuar como lubrificante, impedindo que os comprimidos prendam-se nas máquinas ou entre si COMENTÁRIOS durante a sua manufatura(40,41). Dessa forma, a injeção A avaliação por métodos de imagem do sistema respi- resulta em êmbolos pulmonares microscópicos(40,42). As ratório tem sido motivo de uma série de publicações recen- partículas podem migrar para o interstício e causar reação tes na literatura radiológica nacional(1–16). A tomografia granulomatosa tipo corpo estranho(40,42). O mecanismo computadorizada (TC) de tórax revolucionou a importân- mais importante na formação do enfisema parece ser a cia dos exames de imagem em muitos aspectos da pneumo- presença do talco injetado diretamente no sistema vascu- logia e da cirurgia torácica. O uso da TC na investigação lar. A explicação fisiopatológica não é bem clara, mas qual- do câncer de pulmão, das doenças intersticiais e do enfi- quer que seja o mecanismo, o enfisema é um elemento de sema já faz parte da rotina de investigação pneumológica. extrema importância na fisiopatologia de algumas formas No enfisema, porém, o potencial da TC vem sendo subuti- da talcose pulmonar(40,42). lizado. Rotineiramente, o uso da TC continua sendo res- A principal diferença na TC entre as formas inalatórias trito à confirmação diagnóstica e à análise subjetiva da da talcose e a forma intravenosa (relacionada ao uso de dro- extensão e do tipo das lesões enfisematosas(17–26). gas orais injetadas por via venosa) é o desenvolvimento, na Atualmente, a TC de múltiplas fileiras de detectores última, de enfisema que afeta predominantemente os lobos encontra-se disponível na grande maioria dos centros de inferiores. A prevalência significativamente aumentada de diagnóstico por imagem. Esses equipamentos tornaram enfisema panacinar nos lobos inferiores é vista em viciados viável a realização de exames de TC de tórax com uma aqui- em drogas intravenosas que injetam metilfenidato (Rita- sição de todas as imagens durante uma única pausa respi- lina)(41,43,44). Este padrão é similar ao enfisema descrito em ratória. Essa capacidade técnica abriu novos caminhos na pacientes com deficiência de alfa-1-antitripsina(42,44). Em investigação das doenças pulmonares. Medidas objetivas do alguns usuários de Ritalina, enfisema é o único achado. volume pulmonar total e do volume de pulmão afetado por Barotrauma é outra complicação decorrente do hábito enfisema podem ser realizadas com elevada precisão(27–36). de fumar crack ou de inalar cocaína(45,46). Ele pode se ma- A quantificação de enfisema pela densitovolumetria nifestar como pneumotórax, pneumomediastino, pneumo- pulmonar por TC(27,37) é um processo no qual as áreas do pericárdio, ou enfisema subcutâneo(45,47). Nos usuários de pulmão com valores pré-determinados de densidade ou cocaína, aumento de pressão intratorácica pode ocorrer atenuação abaixo de um determinado limiar são mascara- durante o ato de fumar devido a tosse vigorosa ou produ- das por uma cor sólida, de modo que o observador possa ção intencional de uma manobra de Valsalva para aumen- prontamente identificar as áreas de alteração na densidade tar a absorção e maximizar o efeito da droga(46). Os alvéo- pulmonar ou enfisema. Em 1995, foi sugerida a fixação do los hiperdistendidos podem romper-se para o interstício e, limiar de –950 UH para a separação do pulmão normal eventualmente, para o mediastino, produzindo pneumome- versus pulmão enfisematoso (quantificação de enfisema)(38), diastino(45,48). Aspiração vigorosa após inalação de cocaína sendo este o limiar mais frequentemente utilizado. Com o pode causar pneumomediastino por um mecanismo simi- advento da tomografia helicoidal, foi possível calcular o lar(46,49). O barotrauma é geralmente diagnosticado com volume real (cm3) em vez da área (cm2), sendo introduzida radiografias de tórax, mas a TC pode auxiliar no diagnóstico a quantificação volumétrica do enfisema por TC. Tais téc- quando a radiografia de tórax não é conclusiva. Em indiví- nicas têm permitido o diagnóstico precoce e o monitora- duos jovens, a presença de ar no mediastino, em ausência mento desses pacientes(21,28,31). Esses trabalhos pioneiros de uma história de outros fatores etiológicos, deve levantar inspiraram muitos outros autores, que expandiram a apli- a suspeita de uso de cocaína(45). cação clínica da TC para além da análise subjetiva dos as- Enfisema também tem sido relatado em usuários de pectos anatômicos das imagens. Agora, já se reconhece que drogas fumadas ou inaladas, geralmente afetando homens a densitovolumetria pulmonar por TC é mais precisa e sen- jovens. Alguns trabalhos descreveram alterações bolhosas sível que os testes de função pulmonar tradicionais e é graves associadas à cocaína fumada. A TC identifica bolhas considerada método de escolha para avaliação não invasiva e enfisema centrolobular nos lobos superiores, especial- e precisa de alterações patológicas no enfisema, mostrando mente na periferia, poupando as porções centrais dos pul- boa correlação com os achados histopatológicos(39). mões(45,47), como observado no paciente neste relato. O uso de drogas ilícitas pode causar lesões pulmona- res por diferentes mecanismos. Um mecanismo importante REFERÊNCIAS de agressão pulmonar é a utilização de medicamentos fei- 1. Yamanari MGI, Mansur MCD, Kay FU, et al. Bullet embolism of tos para uso oral injetados por via intravenosa, causando pulmonary artery: a case report. Radiol Bras. 2014;47:128–30. XII Radiol Bras. 2014 Set/Out;47(5):XI–XIII 2. Zanetti G, Nobre LF, Mançano AD, et al. Pulmonary paracoccidioido- 27. Hochhegger B, Marchiori E, Irion K, et al. Accuracy of measurement mycosis. Radiol Bras. 2014;47(1):xi–xiii. of pulmonary emphysema with computed tomography: relevant 3. Fernandes MC, Zanetti G, Hochhegger B, et al. Rhodococcus equi points. Radiol Bras. 2010;43:260–5. pneumonia in an AIDS patient. Radiol Bras. 2014;47(3):xi–xiii. 28. Irion KL, Marchiori E, Hochhegger B, et al. CT Quantification of 4. Mançano AD, Santos Neto RC, Silva KCC. Williams-Campbell syn- emphysema in young subjects with no recognizable chest disease. drome. Radiol Bras. 2014;47(2):xi–xii. AJR Am J Roentgenol. 2009;192:W906. 5. Ceratti S, Pereira TR, Velludo SF, et al. Pulmonary tuberculosis in 29. Hochhegger B, Irion KL, Marchiori E, et al. Reconstruction algo- a patient with rheumatoid arthritis undergoing immunosuppressive rithms and their influence in emphysema CT measurements. Acad treatment: case report. Radiol Bras. 2014;47:60–2. Radiol. 2010;17:674. 6. Bispo IGA, Nascimento DT, Ferreira KO, et al. Brain metastasis as 30. Hochhegger B, Marchiori E, Irion KL, et al. Are we measuring pul- initial presentation of papillary adenocarcinoma of the lung: case monary emphysema? Respir Med. 2010;104:1073. report. Radiol Bras. 2013;46:313–6. 31. Hochhegger B, Irion KL, Marchiori E, et al. Reconstruction algo- 7. Eifer DA, Arsego FV, Torres FS. Unilateral pulmonary veins atresia: rithms influence the follow-up variability in the longitudinal CT evaluation by computed tomography. Radiol Bras. 2013;46:376–8. emphysema index measurements. Korean J Radiol. 2011;12:169– 8. Amorim VB, Rodrigues RS, Barreto MM, et al. Computed tomogra- 75. phy findings in patients with H1N1 influenza A infection. Radiol 32. Hochhegger B, Marchiori E, Irion K, et al. Visual vs automated as- Bras. 2013;46:299–306. sessment of emphysema. Chest. 2011;140:1384. 9. Carneiro DS, Arantes JH, Souza GV, et al. Heterotaxy syndrome: a 33. Hochhegger B, Marchiori E, Irion KL, et al. Iodinated contrast media case report. Radiol Bras. 2013;46:181–3. and its influence in emphysema CT measurements. Clin Imaging. 10. Zanetti G, Nobre LF, Mançano AD, et al. Nodular reversed halo sign 2012;36:160. caused by pulmonary tuberculosis, confirmed by sputum culture. 34. Hochhegger B, Irion KL, Marchiori E. Reconstruction algorithms Radiol Bras. 2013;46(6):ix–x.
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