Patient: Male, 63-year-old Final Diagnosis: Spontaneous knot formation in central venous catheter Symptoms: Central venous catheter whit any flow • associated with pain at the insertion site of the access Medication: — Clinical Procedure: Central venous catheterization Specialty: General and Internal Medicine • Surgery Objective: Challenging differential diagnosis Background: Central venous catheterization (CVC) is indispensable in the management of critically ill patients in the emergency room and intensive care units, either to avoid the various peripheral punctures and vasoactive drugs administration in decompensated patients, or even to administer parenteral nutrition. CVC is an invasive procedure with possible mechanical, infectious, and thrombotic complications. The complete knotting of a catheter is a rare complication. The aim of this study is to report a case of a simple tight knot 2 cm from the catheter tip. We provide insights for early identification of catheter knotting, as well as its management. Case Report: A 63-year-old man with a previous history of angioplasty and non-pharmacological coronary stent in a marginal branch of the circumflex coronary artery evolved to junctional bradycardia and cardiogenic shock and was transferred to the reference hospital. He had a CVC inserted in the right jugular vein; however, it did not have any blood flow. The hypothesis of catheter knotting was suggested and confirmed through a chest X-ray. Venotomy was performed and it was successfully removed. Conclusions: Knotting in CVC obstruction is a rare complication. Recognition of this complication is essential to avoid major complications, such as catheter fragmentation and venous injury. Radiological follow-up after the procedure in patients with difficult anatomy is essential, and echo-guided catheterization should be encouraged when available. Despite the rarity of a knotted intravascular catheter, it is important to note this possible late complication that must be considered in the absence of catheter blood flow.

Background Immunobiological antibodies to tumor necrosis factor alpha (TNFα), act by decreasing the proinflammatory cytokine TNFα. In this context, patients using these biologicals may develop an immunocompromised state (1). TNFα is important in the activation, differentiation and recruitment of different immune cells, with an important role in the formation and maintenance of granulomas, in response to intracellular organisms (2), such as tuberculosis (TB), whose reports occur, on average, 12 weeks after onset of the biological (1). Neurotuberculosis (NT) is the most severe form of TB (3), being responsible for 5 to 7% of cases of extra-pulmonary involvement (4,5). Its diagnosis being based on suspicious symptoms, biochemical analysis of the cerebrospinal fluid (CSF) and confirmed by the detection of the TB bacillus in the CSF. TB in the central nervous system (CNS) is usually due to the spread of pulmonary infection, and rarely occurs in isolation as in this case we are reporting. Methods This study aims to report a case of NT was described in patient with Ulcerative Colitis (UC), 4 years after the start of therapy with biological, and discuss clinical aspects, diagnosis, management and prognosis. Results 34-year-old woman with UC since the age of 20, using adalimumab for 4 years, presented with progressive headache for 20 days, associated with daily afternoon fever (38⁰C). She denied any contact or familiar with TB. Analysis of CSF revealed TB culture positive. On brain MRI, there were small cortical lesions in the left frontal lobe and two larger lesions, with post-contrast enhancement, in the left temporal lobe and in the right frontal lobe, both measuring about 10 mm (Figure 1). She was in sustained deep remission with adalimumab for 4 years (Figure 2). She has had a chest X-ray and a tuberculin test every year, all of which are negative for TB. The initial management was discontinuing adalimumab, treatment with rifampicin, isoniazid, ethambutol, pyrazinamide and prednisone. The patient showed clinical and neurological improvement. Currently, 12 months after the diagnosis, she is asymptomatic and without neurological sequelae. Conclusion The reported case assumes importance because this patient has isolated TB in the CNSDigitar texto without pulmonary involvement who has UC and was using adalimumab. Screening tests for TB can ignore latent infection, especially in patients undergoing immunosuppression (anti-TNF, steroids and HIV). The possibility of TB should always be considered in the presence of fever of unknown origin in patients on anti-TNFα therapy, even for a long period. Early recognition, suspension and appropriate treatment are important steps towards therapeutic success, avoiding neurological sequelae and mortality.

Aim Analysis of the twitter activity on #Crohns, identifying individuals with interest in Crohn´s disease on Twitter. Methods A historic cohort study about Twitter activity evaluation of #Crohns, analyzed over a period of 9 years. For the twitter analysis, a health care social media analytics tool, Symplur Signals, was adopted. Results Since 2011 until 2019, 627.000 tweets of #Crohns were detected, with 276.380 retweets by 109.937 users, of these users 32.4% are patients advocate and 12.6% doctors. There was a pattern of annual peak activity of the #Crohns, mainly in May and December, and less activity, usually in July. Of all tweets, 52.5% were categorized as positive and 47.5% as negative. Conclusion Social media, especially Twitter, represents an important information tool, but it is still underutilized by gastroenterologists. This study suggests a significant interference of international awareness campaigns about IBD in the activity of #Crohns on Twitter, denoting an increase in debating this topic on the platform. Discussions on the subject by health professionals are still below expectations regarding the importance of the theme.

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Objective:Rare disease Background:Tuberculosis (TB), a global public health problem, is a disease with a high incidence and prevalence worldwide.The risk of developing TB increases after starting anti-tumor necrosis factor (TNF) therapy in the management of ulcerative colitis (UC). Isolated neurotuberculosis (NTB) without other manifestations is a rare form of infection in these patients. This article reports a case of a severe UC patient with isolated NTB following long-term therapy with adalimumab and discusses the clinical aspects, diagnosis, management, and prognosis. Case Report:A 34-year-old female patient with severe UC with pancolitis reported continuous and progressive holocranial headaches associated with a daily fever of 38°C and night sweats after 4 years of using adalimumab and after being in deep remission. Annually, she was screened for latent TB with chest X-rays and a Mantoux tuberculin skin test, and she always had negative results for TB. On cerebral magnetic resonance imaging with postcontrast sequences, small cortical lesions in the left frontal lobe and 2 larger lesions were visualized and were suggestive of tuberculomas. The initial management consisted of the suspension of immunosuppressive therapy and treatment with rifampicin, isoniazid, ethambutol, pyrazinamide, and prednisone. The patient showed clinical and neurological improvement and was clinically asymptomatic, with no changes in laboratory tests. Also, she had no neurological sequelae and was taking maintenance therapy with prednisone as indicated by the neurologist. Conclusions:Early recognition of symptoms of neurological involvement of TB, suspension of anti-TNF and adequate treatment are fundamental steps to prevent complications.

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