Bone is a frequent site of metastases and typically indicates a short-term prognosis in cancer patients. Once cancer has spread to the bones it can rarely be cured, but often it can still be treated to slow its growth. The majority of skeletal metastases are due to breast and prostate cancer. Bone metastasis is actually much more common than primary bone cancers, especially in adults. The diagnosis is based on signs, symptoms and imaging. New classes of drugs and new interventions are given a better quality of life to these patients and improved the expectancy of life. It is necessary a multidisciplinary approach to treat patients with bone metastasis. In this paper we review the types, clinical approach and treatment of bone metastases.

In the advanced stages of illness, patients often face challenging decisions regarding their treatment and overall medical care. Terminal ill patients are commonly affected by infections. However, in palliative care, the use of antimicrobials can be an ethical dilemma. Deciding whether to treat, withhold, or withdraw the antimicrobial treatment for an infection can be difficult. Antimicrobial administration can lead to adverse outcomes but the two main benefits, longer survival and symptom relief, are the main reasons why physicians prescribe antimicrobial when treating terminally ill patients. For the patient who has an irreversible advanced heart or lung disease, or an advanced dementia, or a metastatic cancer, it is easier the decision of withholding mechanical ventilation, tube feeding, and dialysis than antibiotherapy. To characterize infections, agents, and their treatments in palliative care, we conducted a review of the literature. We also included some tips to help health professionals to guide their clinical approach.

Homem, 88 anos, recorre à urgência por astenia generalizada, anorexia e diminuição do débito urinário. Estava febril, hipotenso e com auscultação cardiopulmonar normal. Analiticamente apresentava leucocitose, creatinina de 3,1 mg/dL e leucocitúria. O doente foi internado por lesão renal aguda e medicado com ciprofloxacina assumindo uma infeção urinária. Foi isolada uma Escherichia coli na urocultura e 2 amostras de hemoculturas e o antibiótico foi alterado para meropenem de acordo com o antibiograma. Pela febre persistente e aumento dos parâmetros inflamatórios, foi realizado ecocardiograma transtorácico ao dia 14 de internamento, que revelou uma vegetação na válvula mitral, tendo-se adicionado à antibioterapia a gentamicina e vancomicina. Um acidente vascular cerebral isquémico, com transformação hemorrágica e plegia esquerda, e uma perfuração severa da válvula mitral posterior, complicaram o curso clínico. O estado clínico gradualmente melhorou e o doente transitou para uma unidade de reabilitação ao fim de 59 dias de internamento.Este caso pretende exemplificar como a endocardite é ainda uma entidade muitas vezes de difícil diagnóstico associada a complicações graves e obrigando a internamento prolongado.

Cocaine is a highly addictive substance. Its poisoning can lead to potentially fatal multi-organ dysfunction. We report a case of cocaine overdose with severe multi-organ dysfunction. A healthy 51-year-old man was admitted to the emergency room due to behaviour changes and seizure after inhaling crack. Multiple dysfunctions were developed, with emphasis on liver and kidney dysfunction, due to their severity. The patient had marked hepatic cytolysis with a peak on the third day with alanine aminotransferase (ALT) and aspartate aminotransferase (AST): 7941 and 4453 IU/L, respectively with mild coagulopathy and hyperbilirubinemia. Underwent empirical treatment with acetylcysteine ​​with good clinical response. Also developed anuric AKIN3 acute kidney injury secondary to rhabdomyolysis, requiring treatment with intermittent haemodialysis. The approach to a case with severe multiorgan dysfunction is described, with special emphasis on the use of acetylcysteine. The good evolution of the patient can corroborate the use of this drug as a potential modifier of prognosis.

Cryptococcosis is a life-threatening fungal infection that affects immunocompromised patients, causing predominantly meningoencephalitis and pneumonia. Lymph node involvement is rare and its identification may not be obvious. We report the case of a patient recently diagnosed with AIDS and previously treated for cryptococcal meningitis who developed multifocal cryptococcal disease despite antifungal treatment, expressed as cervical and mediastinal lymphadenitis and constitutional symptoms. The difficulty of the diagnosis was based on the fact that cryptococcal meningitis was resolved after treatment, and the new manifestations were more typical of other conditions such as tuberculosis and malignancy. Final diagnosis was established after fine-needle aspiration cytology of a lymph node with Cryptococcus identification. Such cases may be difficult to manage, and the possibility of clinical relapse versus cryptococcal immune reconstitution inflammatory syndrome is discussed. Induction therapy was restarted and maintained for a longer period, and the total duration was based on clinical response.