Objective: To describe a case of congenital syphilis with a late diagnosis and identify missed opportunities at diverse phases/levels of healthcare, which led to late diagnosis. Case description: Boy, 34 days of life, referred from a basic healthcare unit to a tertiary hospital due to enlarged abdominal volume and progressive jaundice for 2 weeks, fecal hypocholia, hepatosplenomegaly, anemia, low platelet count and elevated liver enzymes. At physical examination, the infant presented with erythematous-exfoliative lesions on the palms and soles, macular rash in the inguinal region, ascitis, palpable liver 5 cm below the right costal margin and a palpable spleen 3 cm from the left costal margin. Infant serology: reactive CMIA (chemiluminescent microparticle immunoassay), VDRL (Venereal Diseases Research Laboratory) 1:1024 and reactive TPHA (Treponema pallidum Hemagglutination). Maternal serology: reactive CMIA and TPHA, VDRL 1:256. Radiography of the long bones showed symmetric periostitis, periosteal thickening, and lucent bands in the femur, humerus, ulna and tibia. After treatment with crystalline penicillin, the infant showed clinical and laboratory improvement, receiving hospital discharge at the 18th hospitalization day.Comments: This case shows that congenital syphilis is occasionally diagnosed late as a result of failed strategies to prevent this disease, both in the basic and secondary/tertiary levels of care. The application of interventions recommended by the Ministry of Health and identification of the situation in which there is ineffective implementation of these measures are important to assess routine care in all levels of healthcare and diverse units responsible for newborn and infant health care.
BackgroundDifferential diagnosis of inflammatory bowel disease is often very challenging. Paracoccidioidomycosis is a fungal disease that can mimic manifestations of Crohn’s disease.Case presentationWe report a case of a 13-year-old Caucasian boy with abdominal pain for 1.5 years associated with nausea, diarrhea, and weight loss of 10 kg. He presented increased C-reactive protein and an increased erythrocyte sedimentation rate. A colonoscopy showed deep serpiginous ulcers throughout his entire colon and rectum, which suggested Crohn’s disease. He received one dose of infliximab, which is an anti-tumor necrosis factor-α, and showed no improvement. After the second dose, he got worse and started to have bloody diarrhea. A new colonoscopy was performed and pathological examination revealed ulcerative chronic inflammation with non-caseating granulomas and fungal structures (budding forms) compatible with Paracoccidioides brasiliensis. He underwent intravenously administered and then orally administered trimethoprim-sulfamethoxazole treatment. Due to drug intolerance, he was treated with amphotericin B and itraconazole, then he showed clinical improvement and mucosal healing with good outcome.ConclusionParacoccidioidomycosis must be part of the differential diagnosis of inflammatory bowel diseases in endemic areas and must be excluded before starting immunosuppressive therapy.
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