ABC | Volume 112, Nº6, June 2019

Anatomopathological Correlation Arq Bras Cardiol. 2019; 112(6):793-802 Issa and Benvenuti Pulmonary infiltrate and left ventricular apex obliteration in a young man Table 2 – Laboratory evolution 30 Oct 15 Nov 30 Nov 6 Dec Red blood cells (millions/mm³) 4.3 2.8 2.2 3.1 Hemoglobin (g/dL) 12 7.9 6.4 9.3 Hematocrit (%) 37% 26 22 29 Leukocytes/mm³ 26,210 9,650 9,210 26,970 Neutrophils (%) 91 97 87 78 Eosinophils (%) 0 0 0 0 Lymphocytes (%) 6 2 11 20 Monocytes (%) 3 1 2 2 Platelets/mm³ 276,000 69,000 101,000 83,000 Creatinine (mg/dL) 1.36 2.98 4.94 2.64 Urea (mg/dL0 68 189 256 120 Sodium (mEq/L) 135 146 155 139 Potassium (mEq/L) 4.2 4.4 5.1 4.8 Lactate (mg/dL) 23 37 11 35 PT (INR) 1.2 1.1 1.3 1.2 APTT (rel) 0.86 0.85 1.04 0.98 CRP (mg/L) 15.90 124 109 AST (U/L) 90 37 ALT (U/L) 211 359 PT: prothrombin time; APPT: partially activated thromboplastin time; CRP: C-reactive protein; AST: aspartate aminotransferase; ALT: Alanine aminotransferase. Toxoplasma sp and resistant acid-fast bacilli were negative and there was no growth of bacteria or fungi in the cultures. The cell count was 11 cells /mm 3 - 31% lymphocytes, 66% monocytes and 3%macrophages; protein level was 475mg/dL; glycorrhachia was 105 mg/dL. Skull (November 29, 2011) and abdomen CT (November 30, 2011) showed normal results. A new high-resolution chest tomography (November 30, 2011) disclosed persistence of the diffuse and symmetrical interstitial-alveolar infiltrate, characterized by diffuse ground-glass parenchymal attenuation and multiple nodular and micronodular opacities, predominantly centrilobular, sometimes confluent and delineating a tree-in-bud pattern, with a predominant distribution in the pulmonary medulla, compatible with alveolar filling. Further findings suggestive of inflammatory or infectious processes associated with edema or alveolar hemorrhage were described. There was no pleural effusion. Blood culture was positive for Staphylococcus haemolyticus , sensitive to vancomycin and teicoplanin, and urine culture was positive for Pseudomonas aeruginosa , sensitive to piperacillin /tazobactam. A subsequent culture of urine disclosed growth of Candida non-albicans. He was initially treated with vancomycin and piperacillin/ tazobactam and, subsequently, imipenem and meropenem, teicoplanin, amphotericin, fluconazole, caspofungin, and acyclovir. Due to the presence of signs suggestive of pulmonary alveolar hemorrhage and hematuria, there was a diagnostic suspicion of Goodpasture Syndrome and the investigation was initiated. The search for neoplastic markers (July 10, 2004) disclosed - alpha-fetoprotein=1.9 ng/mL, CA-125=401.4U/mL, CA-15.3 =14.9U/mL, CA-19.9=20.1, carcinoembryonic antigen (CEA) = 2.7 ng/mL. The search for antinuclear and antimitochondrial antibodies, and antineutrophil cytoplasmic antigen (ANCA) was negative. The C3 fraction of the complement was 18 mg/dL, and the C4 fraction was 10 mg/dL. The evolutive results of the laboratory tests are shown in table 2. The patient developed worsening of the pulmonary and hemodynamic picture, anemia (received packed red blood cell transfusion), thrombocytopenia and renal failure (was submitted to dialysis) and underwent a cardiorespiratory arrest with pulseless electrical activity; initially, he was successfully resuscitated, but had a recurrence and died (December 7, 2011). Clinical aspects This is the case of a young, male patient, smoker, who had hypothyroidism post-treatment with radioactive iodine, who sought medical care due to symptoms of dyspnea and cough for a week; these complaints had been preceded by chest pain at exertion two weeks before. The medical evaluation at the first consultation was notable for the presence of tachycardia and mild leukocytosis in the whole blood count. The chest X-ray was normal despite the presence of dyspnea at rest. Interestingly, the ECG performed during a routine medical evaluation 11 months before symptom onset showed signs suggestive of heart disease, with left chamber overload. 797