Male patient, 30 years old, white, born and living in Rio de Janeiro, RJ, Brazil,\ncomplained of intense pruritus followed by disseminated erythematous lesions with onset\nless than 24 hours before. He had no history of associated diseases, use of any\nmedications or any other associated factors. On the first inspection we noted small\nerythematous papules and some petechiae that assumed a linear pattern located on the\ntrunk, lower and upper limbs. There were no mucosal abnormalities, fever or any other\nsystemic symptoms ( and ). Based on the peculiar rash, the patient was\nquestioned about the ingestion of shiitake and confirmed he had eaten a\nlarge amount of raw mushrooms five hours before the cutaneous lesions appeared, leading\nus to the diagnosis of flagellate erythema due to shiitake\ningestion.
A 53-year-old man presented with unstable angina due to the severe stenosis of the left anterior descending coronary artery and obtuse marginalis, although the right coronary artery was normal. Laboratory findings, including a complete blood count, erythrocyte sedimentation rate, and C reactive protein, were normal. Chest X-ray revealed no abnormal findings, and there was no valvular abnormality on preoperative echocardiography. The patient had no co-morbid disorders, but his left ventricular ejection fraction was reduced (40–45%).\nThe intraoperative course was uneventful. There were no findings of pericarditis. On physical examination, there was no respiratory distress, blood pressure was 130/80 mm Hg, heart rate was 80 beats per minute, respiratory rate was 23 per minute, the neck veins were not distended, and there was no ankle edema. Cardiovascular system examination showed regular first and second heart sounds with no gallop or murmur. The electrocardiogram (ECG) demonstrated a Q wave in the precordial leads. For temporary coronary artery occlusion, 4/0 Viline sutures and a Bulldog Clamp were used, and warm blood was employed to de air the graft. Temporary coronary artery occlusion was not prolonged, and the electrocardiogram and hemodynamic variables and objective data showed no signs of ischemia or contractile dysfunction. The operation was uneventful. No intra-coronary shunt was utilized.\nThe patient left the operating room without any inotropic support. Six hours later, however, he developed low cardiac output. At exploration, cardiac tamponade was excluded and flowmetry showed that the graft had adequate function. There were no findings as regards pericarditis, and the patient’s postoperative erythrocyte sedimentation rate, C-reactive protein, and cardiac enzymes were normal. A high dose of adrenalin and dobutamine was administered, and an intra-aortic balloon pump was used.\nIntraoperative transesophageal echocardiography demonstrated a depression in the left ventricular function due to an akinetic lateral left ventricular wall in the region of the obtuse marginalis. After hemodynamic stabilization, the patient left the Intensive Care Unit without an intra-aortic balloon pump and inotropic support. On the fifth postoperative day, a coronary angiogram demonstrated patent grafts and correct anastomotic sites ( & ). On the seventh postoperative day, the akinetic lateral wall of the left ventricle changed to dyskinesia. Finally, after hospital discharge on the thirtieth postoperative day, an echocardiogram showed a normal left ventricular function without regional wall motion abnormalities.