Necrotizing fascitiis due to Streptococcus Pyogenes has a high mortality rate. Detection of the infection before it developes to the streptococcal toxic shock syndrome is quite challenging and its one of the main goals of its management because at this final stage the treatment is in most of the cases ineffective. In a secuence of events of the progression of the infection to shock, renal failure occurs before hipotension very often. We report the case of a 38-year-old patient affected by a fulminant necrotizing fascitiis by Streptococcus Pyogenes which presented at admission with lower leg cellulitis and acute renal failure.
Presence of central nervous system by extrapulmonary tuberculosis is an infrequent disease specially among non HIV infected patients, and it is associated with poor prognosis and high mortality rates. We report a case with a middle cerebral artery ischemic strocke as a first symptom of miliar tuberculosis.
CARTAS AL DIRECTORAN. MED.INTERNA (Madrid) masa exofítica (2) y mediante biopsia bronquial, transbronquial o transtorácica, se puede llegar al diagnóstico histológico, demostrando la presencia de células blásticas linfoides con fuerte actividad mitótica, claro indicativo de malignidad.El infiltrado linfoide invade estructuras bronquiales, vasculares y pleurales, siendo frecuente la necrosis.Como en nuestro caso, debido al alto grado de atipia, suelen ser necesarias técnicas inmunohistoquímicas para diferenciarlos de carcinomas, melanomas o sarcomas cuando existe marcada reacción fibroblástica (2).En comparación con el de bajo grado, el linfoma de alto grado tiene peor pronóstico.La media de supervivencia es de 8-10 años, siendo menor en pacientes con enfermedades de base (HIV, trasplantados).La progresión y la recidiva tanto local como a distancia son más frecuentes (2).El tratamiento se basa en la quimioterapia, siendo la pauta con CHOP (ciclofosfamida, doxorrubicina, vincristina y prednisona) combinada con la inmunoterapia con anticuerpos anti CD20 (Rituximab) la más difundida y con mayor tasa de respuestas (5).
Nowadays Palliative Medicine (PM) is changing from a specific point of view towards patients with advanced cancer, to another more generic that also keep in mind patients with advanced non malignant disease. Likewise it is more and more deeply rooted customs that the end-of-life care has become a fundamental right of our Society. But as a matter of fact, these patients with non-cancer diseases unusually go into a Palliative Care (PC) programme. It is known the difficulty to diagnosis the end of life clinical condition (EOLCC) in them. In this article we comment the justification and restriction of PC in patients with non-malignant cancer diseases, as well as the paradoxical situation to come out, in spite of the increasing programes of PC gradually. But above all we propose in a practical way resolve when a patient with non malignant organ advanced disease (NMOAD) could be subsidiary of PC. For that purpose we have to know the diagnosis and the prognostic factors in connection with the EOLCC of the NMOAD more common (advanced chronical pulmonary disease, advanced chronical heart failure, advanced cirrhosis hepatic, advanced chronical renal failure and very evolved dementia), to set up an appropriate make decisions keeping in mind the preferences and wishes of the patient and family, to document and record in the clinical history all those parameters and offerer to the patient the treatment more suitable with the intention to get a worthy death bearing in mind clinical, cultural and ethical standards. It is pointed out the necessity to carry out prospective studies to help setting up some inclusion criterions in PC programmes for patients with NMOAD.
Sarcoidosis is a multisystemic disease which diagnosis depends on the presence of nonnecrotizing granulomas in the biopsy. However there are variants such as necrotizing sarcoidal granulomas or nodular sarcoidosis which have atypical findings and make difficult the differential diagnosis with other infectious processes. We describe a case of a man who develops granulomas with extensive necrosis in a systemic sarcoidosis that affected the lung and the central nervous system. This finding made us to make the diagnosis of tuberculosis and delay the specific treatment.
INTRODUCCIÓNLas enfermedades mielodisplásicas/mieloproliferativas (SMD/SMP) constituyen neoplasias clonales hematopoyéticas que reúnen características clínicas, de laboratorio y morfológicas que apoyan un diagnóstico tanto de síndrome mielodisplásico como de síndrome mieloproliferativo.Dentro de este grupo de hemopatías malignas, la clasificación OMS de los tumores hematopoyéticos y de los tejidos linfoides reconoce tres enfermedades con criterios definidos (leucemia mielomonocítica crónica, leucemia mieloide crónica atípica y leucemia mielomonocítica juvenil) y una cuarta, denominada enfermedad mielodisplásica/mieloproliferativa inclasificable, no encuadrable en las anteriores (1).Aunque no existen trabajos con una casuística amplia que describan las características clínicas y evolutivas de esta última entidad (2), es un hecho conocido la asociación de las enfermedades mielodisplásicas con complicaciones de tipo infeccioso (3).Sin embargo, la infección por Mycobacterium tuberculosis, local o diseminada, es muy infrecuente en pacientes con síndrome mielodisplásico, y las publicaciones que recogen esta asociación son ocasionales (4).Describimos a continuación el caso de un paciente diagnosticado de SMD/SMP inclasificable que presentó en su evolución un cuadro de tuberculosis diseminada que inicialmente simulaba una carcinomatosis peritoneal. CASO APORTADOVarón de 68 años de edad, con antecedentes personales de nefrectomía derecha por carcinoma renal de células claras, litiasis renal, hiperplasia prostática benigna y herpes zóster de repetición.
INTRODUCCIÓNLa obesidad es una enfermedad que se caracteriza por el exceso de grasa corporal.En función de la grasa corporal, podríamos definir como sujetos obesos a aquellos que presentan porcentajes de grasa corporal por encima de los valores considerados normales, que son del 12 al 20% en varones y del 20 al 30% en mujeres adultas (1).El índice de masa corporal (IMC) es el índice recomendado por diversas sociedades médicas para valorar la adiposidad en la mayoría de la población.En España se siguen las recomendaciones de la Sociedad Española para el Estudio de la Obesidad (SEEDO), que se establecieron en el año 1996 (2), que introdujo algunas variaciones a la clasificación propuesta por la Organización Mundial de la Salud (OMS) (3).El peso normal, varía entre 18,5-24,9 kg/m 2 , el sobrepeso comprende entre 25-29,9 kg/m 2 y la obesidad se define a partir de 30
The serotonin syndrome is a clinical condition associated with serotonin agonists. Is due to an overstimulation of central and peripheral serotonin receptors that leads to mental, autonomic and neuromuscular changes. Usually the disorder resolves within the first 24 hours after the medications are discontinued, however some patients progress to a multiple organ failure and die. We describe four elderly patients that presented with the classic triad. They presented the symptoms in average at the third day after the initiation or variation of the treatment with serotonin reuptake inhibitors. All had a favorable response with the suspension of medications and, in three cases, with the treatment with chlorpromazine. We believe it is a potentially fatal but reversible condition, probably underdiagnosed that requires a high index of suspicion.
To study the characteristics of major bleeding episodes into a closed space (BCS) of patients under chronic anticoagulation with either unfractionated heparin (HS) or coumadin (CM), and to determine the relationship, if any, of anticoagulation parameters (INR, PT and PTT) values at the time of bleeding with the episode. Finally, to determine risk factors for BCS and mortality in this population.Descriptive epidemiology of all cases of BCS seen in our hospital from 1995 to 2000 was obtained through the records and follow up visits of all patients under anticoagulation (HS or CM) during this period. A matched case-control study to determine risk factors for BCS was carried out. Cases and controls (1:2) were matched for age, gender, anticoagulant treatment and indication for anticoagulation. Cases were patients with a BCS while on anticoagulation (HS OR CM). Controls were patients under anticoagulation (HS or CM) without any bleeding episode during the study period that had anticoagulation parameter values (INR, PT or PTT) determined the very same day than the cases.During the study period, 225 patients under anticoagulation were prospectively followed (75 cases and 150 controls) amid a total of 1650 patients under anticoagulation, for a 4.5% prevalence of BCS. Reasons for anticoagulation were: atrial fibrillation in 79 (35.3%), valvular heart disease in 59 (25.9%), pulmonary embolism or deep venous thrombosis in 48 (21.4%), dilated cardiomyopathy in 26 (11.6%) and vascular cerebral stroke in 13 (5.8%). Mean age of cases was 70.5 (SD 9.5) years and 41 (55%) were women, values similar to the controls. At the time of BCS 39 patients were on CM and 36 on HS. The mean INR value in the CM group at the time of the episode of BCS was 5.3 (SD + 7.5) while the PTT value was 2,25 (SD 0.95) in the HS group. There was previous antecedent bleeding in 24 (32%) cases. The most common sites of BCS were: muscular (40%), CNS (30.6%), retroperitoneal (18,6%) and articular (10.6%). Muscular (abdominal or thoracic wall) and retroperitoneal BCS were higher in the HS group (10 and 12 in the HS group versus 5 and 2 in the CM group, respectively; p < 0.0001). In contrast, CNS bleeding was commoner in the CM group (20 in CM versus 3 in HS; p < 0.001). BCS related mortality rate was 14.6% (11/75) and higher in the CM group (p = 0.04). Comparative analysis of the case-control study revealed that anticoagulation values in the CM group at the time of bleeding were within the recommended range in 38.5% of cases vs. 75% of the controls (p < 0.001). Also, there were significant differences in mean INR values between cases and controls (5.3 + 7.5 vs. 2.6 + 0.9, p < 0.029) In the HS group no differences were present in PTT values at the time of bleeding between cases and controls. In BCS cases, a previous bleeding episode was more frequent than in the control group (32% versus 1.3%, p < 0.001). Likewise, mortality was higher in cases (18,6%) than in controls (11.4%), p = 0.01.In our study, the majority of patients under anticoagulation with CM had INR values above the recommended range at the time of BCS, in contrast with those on HS that had a PTT within the therapeutic range at the time of the BCS. A previous bleeding episode was an independent risk factor for a BCS episode. Bleeding was a late complication in the CM group and frequently in the CNS, while BCS was more frequently associated with muscular or retroperitoneal sites in the HS treated group. BCS related mortality was 15%. Close monitoring of INR is crucial to minimize bleeding complications.
INTRODUCCIÓNEl síndrome febril de origen desconocido en el paciente inmunodeprimido es un cuadro frecuente en los Servicios de Urgencias de todo el mundo (1-4).La etiología más frecuente es la infecciosa, existiendo otras causas de gran prevalencia, particularmente de tipo neoplásico, metabólico, inmunológico, etc. Sin embargo, a pesar de todo, hay causas poco frecuentes y que en muchas ocasiones pasan desapercibidas en las fases iniciales de la anamnesis y exploración física del paciente.Es el caso de la leishmaniasis (5).Se trata de una parasitosis, producida por un grupo de protozoos, cuyo reservorio son cánidos y roedores y cuya transmisión se produce al hombre, en nuestro medio, mediante mosquitos del género Phlebotomus (6,7).Existen varias especies patógenas para el hombre, con diferencias en cuanto a la clínica y la distribución geográfica.Leishmania infantum es la principal responsable de la clínica en nuestro medio, de tipo viscerotropa, pro-
INTRODUCCIÓNLa disfunción de cuerdas vocales (DCV) se caracteriza por la aducción de las mismas durante la inspiración, lo que resulta en una limitación al flujo aéreo a nivel de la laringe (1).La primera descripción se atribuye a Dunglison (2), quien en 1842 describió un desorden de los músculos laríngeos en mujeres con histeria, denominándolo "croup histérico".Si bien la DCV, es la expresión que mejor explica este síndrome, existen otras denominaciones a saber: estridor de Munchausen, pseudoasma, obstrucción de la vía aérea superior (VAS) no orgánica o funcional, asma facticio, croup espasmódico, sibilancias laríngeas emocionales, obstrucción de VAS psicógena, disquinesia laríngea episódica, laringoespasmo paroxístico episódico, estridor laríngeo funcional, laringoespasmo inducido por ejercicio y síndrome de laringe irritable (1,3).La verdadera incidencia y el curso clínico de la enfermedad son desconocidos.Los síntomas más comunes son sibilancias, tos, disnea episódica, estridor inspiratorio, disfonía, y dolor torácico (3).Históricamente se atribuyo esta enfermedad a distintos desordenes psicológicos, en los últimos años se han encontrado múltiples causas orgánicas entre las que se encuentra el reflujo gastroesofágico (RGE).Se han descrito hasta la fecha aproximadamente 1.500 casos (1,3).Se presentan dos pacien-
