Caso 1 - Homem de 59 anos com obesidade acentuada, hipertensão arterial, insuficiência cardíaca e submetido a anticoagulação para fibrilação atrial, apresentou acidente vascular cerebral e septicemia

Abstract

Laboratory assessment (March 8, 2001) showed hemoglobin = 14.4 g/dL, hematocrit = 43%, uric acid = 9 mg/dL, creatinine = 1.6 mg/dL, potassium = 4.4 mEq/L, sodium =145 mEq/L, fasting glycemia = 148 mg/dL, total cholesterol = 121 mg/dL, triglycerides = 57 mg/dL; urinalysis showed proteinuria of 0.25 g/L, with no other alterations. TSH was 5.28 U/mL, free T4 was 1.1 ng/dL, leptin was 31 ng/mL (normal range =3.8±1.8 ng/mL), testosterone = 336 ng/mL, FSH = 2.6 UI/L, LH = 2.0 UI/L, estradiol = 40.2 pg/mL, insulin = 7.9 Ul/mL, urinary cortisol = 261 g/24 h and DHEAS = 1457 ng/mL.The echocardiogram (April 26, 2001) showed septum and posterior wall thickness of 10 mm, aortic diameter of 32 mm, left atrial diameter of 52 mm, left ventricular (LV) diastolic diameter of 70 mm and LV systolic diameter of 57 mm, with ejection fraction of 46%, due to accentuated diffuse hypokinesis. The patient presented moderate mitral regurgitation.The kidney ultrasonography disclosed normal-sized kidneys, both with 12.1 cm in length, whereas the liver showed signs of steatosis; there were signs suggestive of cholelithiasis.The patient was medicated with 40 mg of enalapril, 40 mg of furosemide, 25 mg of chlorthalidone, 5 mg of amlodipine, 500 mg of methyldopa, 25 mg of spironolactone, 100 mg of acetylsalicylic acid and 1,700 mg of metformin daily, in addition to dietary recommendations of a low-salt, lowcalorie diet for type II diabetes. The patient's adherence to treatment, together with dietary changes, resulted in a weight loss of 28 kg, symptom improvement and BP decrease to 150/90 mm Hg.Three years later the patient weighed 149 kg and the BP was 180/130 mm Hg.The fundoscopy showed retinal exudates in the temporal region, abnormal arteriovenous crossings with venous stasis and arterial reflex narrowing, compatible with hypertensive retinopathy.Laboratory assessment (February 2004) showed cholesterol = 172 mg/dL, HDL-cholesterol = 41 mg/dL, LDL-cholesterol = 114 mg/dL, triglycerides = 87 mg/dL, creatinine = 1.1 mg/dL, urea = 29 mg/dL and glycemia = 126 mg/dL.The metformin dose was increased to 2550 mg and the furosemide dose to 80 mg/day; the patient was then referred to bariatric surgery.The patient evolved with few symptoms until April 2006, when he presented syncope and was admitted at the hospital A 59-year-old obese male patient was admitted at the hospital with left hemiplegia. He had been first admitted at the age of 54, due to intense dyspnea and arterial hypertension.He was diagnosed with arterial hypertension at 44 years, when he presented intense dyspnea and arterial hypertension with blood pressure (BP) levels of 220/120 mm Hg. He sought emergency medical care and was medicated. The patient evolved with dyspnea, intense sudoresis and retrosternal pressure, triggered by moderate exertion. His adherence to treatment was irregular. He started to present episodes of intense snoring during sleep and a sensation of suffocation upon awakening. The patient knew he had been obese since a young age, but his weight had progressively inc...