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r e v b r a s r e u m a t o l. 2 0 1 7;5 7(6):596-604 w w w. r e u m a t o l o g i a. c o m. b r Antiemetics Chemotherapy Cystitis a b s t r a c t Cyclophosphamide is an alkylating agent widely used for the treatment of malignant neo-plasia and which can be used in the treatment of multiple rheumatic diseases. Medication administration errors may lead to its reduced efficacy or increased drug toxicity. Many errors occur in the administration of injectable drugs. The present study aimed at structuring a routine for cyclophosphamide use, as well as creating a document with pharmacotherapeu-tic guidelines for the patient. The routine is schematized in three phases: pre-chemotherapy, administration of cyclophosphamide, and post-chemotherapy, taking into account the drugs to be administered before and after cyclophosphamide in order to prevent adverse effects, including nausea and hemorrhagic cystitis. Adverse reactions can alter laboratory tests; thus, this routine included clinical management for changes in white blood cells, platelets, neutrophils, and sodium, including cyclophosphamide dose adjustment in the case of kidney disease. Cyclophosphamide is responsible for other rare-but serious-side effects, for instance, hepatotoxicity, severe hyponatremia and heart failure. Other adverse reactions include hair loss, amenorrhea and menopause. In this routine, we also entered guidelines to post-chemotherapy patients. The compatibility of injectable drugs with the vehicle used has been described, as well as stability and infusion times. The routine aimed at the rational use of cyclophosphamide, with prevention of adverse events and relapse episodes, factors that may burden the health care system. (K.A. Teles), pmedeirossouza@uol.com.br (P. Medeiros-Souza). http://dx.doi.org/10.1016/j.rbre.2016.09.008 2255-5021/© 2016 Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). r e v b r a s r e u m a t o l. 2 0 1 7;5 7(6):596-604 597 Rotina de administração de ciclofosfamida em doenças autoimunes reumáticas: uma revisão Palavras-chave: Ciclofosfamida Antieméticos Quimioterapia Cistite r e s u m o A ciclofosfamida é um agente alquilante vastamente usado para o tratamento de neoplasias malignas e pode ser usado no tratamento de diversas doenças reumatológicas. O erro de administração de medicamentos pode levar à diminuição da eficácia ou ao aumento da toxicidade medicamentosa. Diversos erros ocorrem na administração de medicamentos injetáveis. O trabalho objetivou a estruturação de uma rotina do uso de ciclofosfamida, bem como a criação de um documento de orientaç ões farmacoterapêuticas para o paciente. A rotina foi esquematizada em três fases, a pré-quimioterapia, a administração da ciclofos-famida e a pós-quimioterapia, que levaram em consideração os medicamentos que devem ser administrados antes e depois da ciclofosfamida para prevenção aos efeitos adversos, incluindo náusea e cistite hemorrágica. As reaç ões adversas podem alterar os exames...

RESUMOO lúpus induzido por drogas (LID) é descrito como o desenvolvimento de sintomas semelhantes ao do lúpus eritematoso sistêmico idiopático, temporalmente relacionado à exposição a drogas, havendo, comumente, a resolução do quadro com a suspensão do medicamento desencadeante. A associação mais clássica é feita com a procainamida e a hidralazina. Recentemente, com a introdução de novas drogas na prática clínica, tem sido relatado um aumento no número de medicamentos implicados como causadores da doença, e a lista atual inclui quase uma centena de drogas relacionadas à ocorrência de LID. Embora descrito há mais de 60 anos, o mecanismo imunológico básico do LID ainda não está totalmente compreendido. Há várias hipóteses para o processo de indução de auto-imunidade pelas drogas, e o fenômeno geralmente é interpretado como uma inapropriada ativação do sistema imunitário. Entre as diversas teorias propostas, as mais aceitas são: a inibição da metilação do ácido desoxirribonucléico (DNA) por algumas drogas, o que permitiria a ativação das células T; a oxidação de certas substâncias pelos monócitos, gerando metabólitos ativos que ocasionariam ativação das células apresentadoras de antígenos e/ou a interferência dos metabólitos de determinadas drogas com a tolerância do sistema imune. Novos estudos são necessários para a melhor compreensão da imunopatogenia do LID, objetivando desenvolver tratamentos específicos com base no melhor conhecimento dos mecanismos patogênicos.Palavras-chave: lúpus induzido por drogas, imunologia, lúpus eritematoso sistêmico, droga, auto-imunidade. ABSTRACTDrug-induced lupus (DIL) has been described as the development of idiopathic systemic lupus erythematous-like symptoms, temporarily associated to the exposition to drugs, and as a rule, the condition is improved with the suspension of the triggering medication. The most classical association is with procainamide and hydralazine. Recently, with the introduction of new drugs in the clinical practice, an increase on the number of medications associated with the occurence of the disease has been reported, and the current list includes almost one hundred drugs associated to the occurrence of DIL. The basic DIL immunologic mechanism, although described for more than 60 years, is not yet fully understood. There are several hypotheses for the druginduced autoimmunity process, and the phenomenon is generally interpreted as an inappropriate activation of the immune system. Among the several theories proposed, the most accepted ones are: the inhibition of the DNA methylation by some drugs, what would allow the activation of T-cells; the oxidation of some substances by monocytes, what would generate active metabolites that in turn would lead to the activation of antigen-presenting cells and/or the interference of the metabolites of some drugs with the immune system tolerance. Further studies should be conducted in order to elucidate the DIL immunopathogeny with the objective of developing specific treatments based on the better knowledge on the pathog...

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Early diagnosis of rheumatoid arthritis is essential for its proper management. Currently, the initial phase of rheumatoid arthritis is known to provide a window of therapeutic opportunity. Although the diagnosis is primarily clinical, the development and improvement of laboratory and imaging methods have contributed to earlier diagnosis and determination of procedures in early rheumatoid arthritis. In this article, the authors review the role of the major imaging methods used for assessing early rheumatoid arthritis, especially conventional radiography, ultrasonography, and magnetic resonance imaging.

1. Residente do 2º ano de Reumatologia, Brasília, DF 2. Médica estagiária em Reumatologia, Brasília, DF 3. Médico reumatologista, Brasília, DF 4. Médicos reumatologista assistente do Hospital Universitário de Brasília, Brasília,DF 5. Residente do 1º ano de Reumatologia, Brasília,DF introdução A vasculite reumatoide (VR) é uma condição rara e grave. Os achados cutâneos podem ser bastante variados. Descrevemos um raro caso de vasculite reumatoide com evolução cutânea grave. relato de casoMulher, 49 anos, com diagnóstico de AR há 15 anos, em tratamento com metotrexato 15 mg/semana e prednisona 10 mg/dia. Procurou o HUB, relatando, há oito dias, edema e manchas violáceas em perna direita, confluentes, intensamente dolorosas, com vesículas e bolhas de conteúdo seroso. O quadro sugeria erisipela bolhosa, sendo iniciada antibioticoterapia. Em três dias as lesões progrediram para grandes bolhas e úlceras com exsudação e material necrótico. Exames laboratoriais: hemoglobina de 7,7 g/dl, leucometria de 16.400, VHS:60 mm/h e PCR: 35 mg/dl. Biópsia da lesão: intenso infiltrado neutrofílico na derme profunda e tecido subcutâneo, sinais de vasculite neutrofílica em pequenos vasos (necrose fibrinóide da parede, trombose e hemorragia). A cultura de fragmento cutâneo, bem como a hemocultura mostraram Acinetobacter baumanii. Diante do diagnóstico de VR cutânea, com quadro infeccioso subjacente, iniciou-se prednisona 1 mg/kg/dia, ciclofosfamida, via oral, e pentoxifilina. O esquema antimicrobiano foi alterado para imipenem e vancomicina. Houve rápida piora do quadro cutâneo, com necrose extensa dermo-epidérmica e ampla exposição de fáscia e planos musculares profundos, em toda a extensão de membro inferior direito, abaixo do joelho. Optou-se por pulsos de metilprednisolona 500mg/dia por três dias, indicado desbridamento cirúrgico amplo das lesões, além de oxigenioterapia hiperbárica. Após um mês da terapia, houve surgimento de tecido de granulação, o que possibilitou o planejamento de terapia cirúrgica (enxertia) para recobrir a extensa área de necrose.

Paraneoplastic syndromes are characterized by the set of signs and symptoms of an underlying cancer, frequently occult, due to a variety of remote tumor effects unrelated to the mechanical impact of the tumor mass or distant metastasis [1,2]. Among these syndromes, paraneoplastic vasculitis are very rare, especially necrotizing systemic vasculitis. It is estimated that 2-5% of all causes of vasculitis are paraneoplastic, with the most common presentation being leukocitoclastic cutaneous vasculitis related to hematological malignancies [1,3,4], and fewer cases related to solid organ tumors as an underlying cause.There are some reports of paraneoplastic ANCA-associated vasculitis (AAV), especially granulomatosis with polyangiitis associated with hematological malignancies and with solid organ tumors such as lung and renal carcinomas [5]. We report a case of eosinophilic granulomatosis with polyangiitis (EGPA) associated to chromophobe renal cell carcinoma (chCRR), an unusual form of malignant renal neoplasm, with complete remission of vasculitis after tumor resection.It is important to be aware of the rare association between vasculitis and cancer, since early recognition could provide proper treatment and better prognosis. A 62 year-old man presented with painful palpable purpura on lower limbs and palms, dry cough, dyspnea and fever four weeks prior to admission. He had a long medical history of hypertension and diabetes, and lifetime tobacco exposure of 35 packyears.There was also a severe persistent asthma starting three years before. Weight loss, abdominal pain and urinary symptoms were absent. On physical examination, there were skin lesions (Figure 1), wheezing on chest auscultation and a body mass index of 27.2 kg/m 2 . Laboratory tests showed marked eosinophilia (5,700 cells/mm 3 at admission, peaking 15,520 cells/mm 3 during hospital stay), elevated erythrocyte sedimentation rate (80 mm/h) and C-reactive protein (2,6 mg/dL, NR <0,5 mg/dL). Renal function and urine analysis were normal. Skin biopsy demonstrated eosinophilic leukocitoclastic vasculitis of small vessels with fibrinoid necrosis and eosinophilic perivascular infiltrates (Figure 2). Antinuclear antibody and antineutrophil cytoplasmic antibodies (ANCA) tested negative. Serological tests for hepatitis B and C viruses and acquired human immunodeficiency virus were negative. At admission, chest radiography revealed pulmonary infiltrates.A computerized tomography (CT) scan was performed, showing bilateral alveolar infiltrates and a small indeterminate solid nodule on left lower lobe. Daily oral prednisone was started (up to 1 mg/kg) with no improvement. The patient evolved with respiratory insufficiency, with severe hypoxemia, and then intravenous (IV) methylprednisolone 1 g/day was prescribed for three days. There was a striking improvement, with normalization of eosinophil count and complete resolution of respiratory symptoms. However, the cutaneous vasculitis not only persisted, but also progressed some days after the IV glucocorticoid therapy, ...