Mitos y realidades sobre el aporte de lácteos y calcio / Myths and facts about dairy foods and calcium supplementation

Desde una perspectiva histórica, el consumo de leche de otros mamíferos y sus derivados ha jugado un rol importante en el desarrollo de la sociedad humana. Sin embargo, en los últimos años se han planteado dudas respecto al real beneficio del consumo de productos lácteos y suplementos de calcio en la salud ósea. Más aún, se les han atribuido potenciales efectos adversos como el incremento del riesgo cardiovascular, aumento en la incidencia de cáncer, trastornos digestivos, nefrolitiasis y una mayor mortalidad. Si bien la evidencia disponible puede ser controversial, en la mayoría de los casos desmiente categóricamente estas afirmaciones.En esta revisión de la literatura, intentamos despejar las inquietudes respecto al beneficio y riesgo del consumo de lácteos, suplementos de calcio y Vitamina D.

From the historical perspective, milk and dairy product consumption has played an important role in the development of human society. However, in the recent years, some doubts have been raised regarding the benefits of dairy food consumption and calcium supplements on bone health. Additionally, potential adverse effects have been attributed to their use, such as increased cardiovascular risk, increased incidence of cancer, digestive troubles, nephrolithiasis and increased mortality rate. Although the available evidence may be controversial, in most cases it categorically refutes these statements.In this review of the literature, we try to address concerns regarding benefit and risks of consumption of dairy products, calcium and vitamin D supplements.

Diagnóstico diferencial de nódulos pulmonares cavitados: a propósito de un caso clínico / Differential diagnosis of cavitary pulmonary nodules: a propos of a clinical case

El diagnóstico diferencial de nódulos pulmonares cavitados constituye un gran desafo en el cual, la clínica, la imagenología y los exámenes de laboratorio permiten una orientación etiológica en cutro grandes grupos: infecciosa, neoplásica, reumatológica y miscelánea. Presentamos el caso de una paciente gran fumadora y portadora de una diabetes mellitus descompensada, con nódulos pulmonares cavitados, en la cual el contexto clínico obligaba a plantear ciertas etiologías como las infecciosas y neoplásicas, pero cuya biopsia fue compatible con Granulomatosis con Poliangeítis (ex Granulomatosis de Wegener), sin una clínica ni exámenes de laboratorio concordantes con dicho hallazgo.

The differential diagnosis of cavitary pulmonary nodules is a great challenge, where the clinical context in addition to the image studies and laboratory tests are part of the key tools to guide the diagnostic process through 4 major etiological groups: infectious, neoplastic, rheumatologic and miscellaneous. We describe a case of a heavy smoker and complicated diabetic patient with cavitary pulmonary nodules, with a clinical context that induces certain etiologies such as infectious and neoplastic, but whose biopsy was compatible with Granulomatosis with polyangiitis (ex Wegener 's granulomatosis), without a clinical exam nor laboratory tests suggesting this finding.

Miopatía necrotizante autoinmune (NAM): a propósito de un caso clínico / Necrotizing autoimmune myopathy (NAM): a propos of a clinical case

La miopatía inducida por estatinas es una reacción adversa que limita el uso de estos fármacos. Si bien su incidencia es baja, puede asociarse a cuadros severos e invalidantes. Habitualmente la miopatía es autolimitada y mejora con la suspensión del hipolipemiante, pero se han descrito casos en que el daño es persistente. en muchos de estos casos, la biopsia ha permitido demostrar una nueva entidad, denominada Miopatía Necrotizante Autoinmune (NAM) por estatinas, la cual se relaciona a una sobreexpresión del complejo mayor de histocompatibilidad tipo I y a la presencia de anticuerpos anti-HMGCoA reductasa. La NAM inducida por estatinas es una condición que responde al tratamiento esteroidal e inmunosupresor, pero puede dejar importantes secuelas. Por tal razón, su detección precoz y adecuado tratamiento resultan fundamentales. Presentamos el caso clínico de una mujer con esta entidad que refleja la dificultad diagnóstica y terapéutica.

Statins induced myotoxicity, constitutes sometimes a major barries to the use of these drugs. Although a low incidece, may be associated with severe disease and disability. Usually this myopathy is self-limited and improves with the removal of lipid-lowering agent, but has been reported patients with persistent disease. In many of this cases, the muscle biopsy has demonstrated a new entity called autoimmune necrotizing myopathy (NAM) for statins, which is characterized by an up-regulation of major histocompatibility complex type I (MHC I) and the presence of anti-HMGCoA reductase antibodies. NAM caused by statins in difficult to manage and can cause important damage. by this reason, early detection and treatment is crucial. We report a case of a woman with this condition, which reflects the difficulty in diagnosis and therapy.

Hombre joven con déficit motor y lesiones inflamatorias intracerebrales: reporte de un caso clínico de Neuro-Behcet / Young man with motor deficit and intracerebral inflammatory lesions: a Neuro-Behcet case report

La enfermedad de Behçet (EB) es una patología inflamatoria vascular, multisistémica y recurrente. El fenómeno subyacente es una perivasculitis que afecta el territorio arterial y venoso. La mayor prevalencia de la enfermedad se encuentra en el Oriente y cuenca del Mediterráneo, en la llamada “Ruta de la Seda”. La prevalencia en Chile es desconocida. Las manifestaciones clínicas más frecuentes son úlceras orales y genitales recurrentes, uveítis, artritis, compromiso de sistema nervioso y vascular. El compromiso de SNC (Neuro-Behçet) varía entre 5 por ciento y 13 por ciento, y se divide en dos tipos: Intra-axial o parenquimatoso, más frecuente, más grave, con lesiones inflamatorias en tronco del encéfalo, en unión meso-diencefálica y región pontobulbar. Puede extenderse hacia diencéfalo, bulbo y médula espinal. El compromiso hemisférico es menos frecuente. Extra-axial, que se presenta como trombosis de senos venosos, y aneurismas, estenosis y disección arterial. El tratamiento del Neuro-Behçet intra-axial se basa en esteroides en dosis altas asociados a inmunosupresores, entre ellos, y dependiendo de la severidad, Metotrexato, Azatioprina, Ciclofosfamida, Micofenolato, y Anti-TNFα en casos refractarios o severos.

The highest prevalence of the disease is found in the East and the Mediterranean basin, in the so called “Silk Road”. The prevalence in Chile is unknown. The most frequent clinical manifestations are recurrent oral and genital ulcers, uveitis, arthritis, and CNS involvement (Neuro-Behçet). Neurological disease varies between 5 percent and 13 percent, and it can be divided into two types: Intra-axial or parenchymatous: more frequent, more severe, with inflammatory lesions involving the brainstem, midbrain, diencephalon and pontobulbar regions. It may extend into the spinal cord. Involvement of the brain hemispheres is less common. Extra-axial: also called “Neurovasculo Behçet”, less common and with better prognosis. It can manifests as venous sinus thrombosis, and aneurysm, stenosis, or arterial dissection of intracerebral or extracranial arteries. Treatment of Intra-axial Neuro-Behçet is based on high-dose steroids associated with immunosuppressive agents like: Methotrexate, Azathioprine, Cyclophosphamide, Mycophenolate, and anti α-TNF in refractory or severe disease.

Nódulos pulmonares cavitados y vasculitis ANCA asociada: secundarios a infección por zigomicetos / Cavitated pulmonary nodules and associated ANCA vasculitis: secondary to zygomycetes infection

La presencia de nódulos pulmonares cavitados nos obliga a plantear varios diagnósticos diferenciales. El diagnóstico definitivo hay que definirlo en base a lo que nos aportan los exámenes serológicos, imagenológicos e histológicos, y correlacionar con la forma de presentación clínica. Un diagnóstico importante que debe ser considerado es la Granulomatosis de Wegener (GW) que corresponde a una vasculitis, en la mayoría de los casos sistémica y en la que encontramos anticuerpos anticitoplasma de neutrófilos de histología compatible con vasculitis. Las patologías infecciosas son otra causa importante de lesiones nodulares en pulmón. Si estamos ante pacientes con algún grado de inmunosupresión, no debemos olvidar la etiología micótica y dentro de esta la infección causada por hongos del grupo Zigomicetes (mucormicosis), sobre todo por la urgencia de realizar tratamiento agresivo y su alta mortalidad.

The presence of cavitated pulmonary nodules obliges one to pose various differential diagnoses. A definite diagnosis must be defined based on serological, imagenological and histological exams, and contrast these with the clinical manifestation. An important diagnosis that must be considered is Wegener’s granulomatosis, which corresponds to a Vasculitis, usually systemic, in which we find antineutrophil cytoplasmic antibodies and histology compatible with Vasculitis. Infectious pathologies are an important cause of pulmonary nodular lesions. If faced with a patient with a degree of immunosuppression, we must not forget the mycotic etiology, and within this the infection caused by fungi from the Zygomycetes group (mucomycosis), above all due to the urgency of aggressive treatment and its high mortality rate.

Concomitancia de anticuerpos antimembrana basal y ANCA en el síndrome riñón-pulmón / Concomitance of glomerular basement membrane antibodies and ANCA in pulmonary - renal syndrome

La enfermedad antimembrana basal glomerular (anti-MBG) es una condición que se manifiesta clínicamente como glomerulonefritis rápidamente progresiva y hemorragia alveolar, también llamada Síndrome Riñón- Pulmón. Se asocia a la presencia de autoanticuerpos dirigidos contra el colágeno tipo IV de la membrana basal glomerular. Las vasculitis sistémicas asociadas a ANCA también pueden manifestarse como Síndrome Riñón-Pulmón, cuadro clínico a veces indistinguible de la enfermedad anti-MBG. La concomitancia de ANCA y anticuerpos anti-MBG en el Síndrome Riñón-Pulmón es del orden de un 30 por ciento, según distintos reportes de la literatura. El perfil clínico, el pronóstico y el rol fisiopatológico de cada anticuerpo en este grupo de pacientes todavía son materia de investigación. El mecanismo patogénico inicial parece ser el daño mediado por ANCA, que puede inducir la aparición de anticuerpos anti-MBG, los que perpetúan el daño en el glomérulo.

Anti-glomerular basement membrane (anti-MBG) disease is a condition that is manifested clinically as rapidly progressive glomerulonephritis and alveolar hemorrhage, also known as Pulmonary-Renal Syndrome. It is associated with the presence of autoantibodies directed against type IV collagen of the glomerular basement membrane. Systemic vasculitis associated with ANCA may also manifest as Pulmonary-Renal Syndrome, sometimes clinically indistinguishable from the anti-MBG disease.The concomitance of ANCA and anti-MBG antibodies in the Pulmonary-Renal Syndrome is about 30 percent, according to various reports in literature. The clinical profile, prognosis and physiopathologic roles of each antibody in this group of patients is still under investigation. The pathogenic mechanism appears to be the initial damage mediated by ANCA, which may induce the appearance of anti-MBG, those who perpetuate the glomerulus damage.

Síndrome POEMS: reporte de un caso clínico / POEMS syndrome: report of a clinical case

El síndrome POEMS se caracteriza por la presencia de Polineuropatía, Organomegalia, Endocrinopatía, Gammapatía Monoclonal y Cambios en la Piel. Muchas otras manifestaciones clínicas del síndrome no están incluidas en este acrónimo, como las lesiones óseas osteoescleróticas, edema de papila, sobrecarga de volumen extravascular, trombocitosis, policitemia, acropaquia, hipertensión pulmonar, baja de peso, fatiga, diarrea, compromiso renal y artralgias. Es una patología infrecuente, de mayor prevalencia en varones, con una relación 2:1, preferentemente entre la quinta y sexta década de la vida. Es una enfermedad de curso crónico y tiene sobrevida promedio de 13,8 años en algunas series. La patogenia es desconocida y no existe en la actualidad consenso respecto al tratamiento ni estudios randomizados y controlados que comparen los resultados de diferentes terapias en esta enfermedad.

POEMS syndrome is characterized by the presence of Polyneuropathy, Organomegaly, Endocrinopathies, Monoclonal Gammopathy and Skin changes. Many other clinical manifestations of the syndrome are not included in this acronym, as the osteosclerotic lesions, papillary edema, extravascular volume overload, thrombocytosis, polycythemia, acropaquia, pulmonary hypertension, weight loss, fatigue, diarrhea, arthralgia, and renal involvement. It is an infrequent disease, more prevalent in males with a 2:1 ratio, mostly between the fifth and sixth decades of life. It has a chronic course with an average survival of 13.8 years in some series. The pathogenesis is unknown and currently there is no consensus regarding the treatment or randomized controlled studies comparing the outcomes of different therapies in this disease.

Compromiso cardiovascular en el lupuseritematoso sistémico / Cardiovascular involvement in patient with systemic lupus erythematosus

Lupus erythematosus is a multisystemic disease that compromises principally women in fertile age. The principal affected organs are kidney, SNC, bone marrow and serous membranes. Cardiovascular affection includes pericardium, conduction system, myocardium, valves and coronary arteries. The most frequent valve disease is Libman-Sacks endocarditis, although valvulitis or valve dysfunction can exist as well. The mitral valve is the most affected, followed by the aortic valve. The most frequent valve abnormality is slight to moderate aortic insufficiency, while serious insufficiency or valve disruption is very rare. A physical examination has limited efficacy in the diagnosis of valve disease. A high degree of suspicion associated with echocardiography helps to establish the diagnosis. If surgery is not needed, antiplatelet therapy is recommended for asymptomatic patients, and oral anticoagulation treatment is advised for those with valve disease and evidence of thromboembolic phenomena. Recurrence of the disease has been observed in biological grafts, which makes the use of mechanical prostheses advisable when valve replacement indication exists. The following case shows the clinical evolution of a female patient with a rare but very serious lupus erythematosus complication.

Estudio de la eficacia del condroitín 4 y 6 sulfato en los síntomas de la artrosis de rodilla / Study of the effectiveness of condroitín 4 and 6 sulphate in the symptoms of the artrosis of knee

We developed a prospective, open study to evaluate the efficacy of chondroitin sulfate in the treatment of kneeosteoarthritis. Methodology: We studied 61 patients with primary knee osteoarthritis. They were given 800mg/day chondroitin 4-and 6- sulfate (Condrosulf, IBSA, Switzerland) for a period of three months. Patients were controlled every 30 days using the Lequesne index and the visual analogue pain scale. Medication was suspended after 90 days and patients were reevaluated 90 days later. Only Paracetamol was allowed as analgesic. Results: After 90 days a significant improvement of45 percent was observed in the Lequesne index, and 59 percent for knee pain. Once medication is suspended, the effect tends to slowly revert, with final study results significantly better than basal levels. Residual effect is better in patients under age 65 and in those with less basal radiological damage. Subjective opinion of both patient and doctor concurs with results. Conclusions: Chondroitin 4-and 6- sulfate is effective for the symptomatic treatment of knee osteoarthritis. Its effect lasts several months after drug suspension.

Artritis por Cryptococcus neoformans en un adulto mayor: Presentación de un caso y revisión / Cryptococcus neoformans arthritis in elderly adult: Case report and review

Cryptococcal infection is not frequent in immunocompetent patients. The most commonly involved sites are the lungs and the central nervous system. Cryptococcal osteomyelitis occurs in 5-10 percent of patients with disseminated cryptococcosis with few reports of cryptococcal arthritis in elderly adults. We describe the case of a 92-year-old woman with a Cryptococcus neoformans knee joint infection associated to osteomyelitis.

La infección por Cryptococcus neoformans es infrecuente, los sitios más comunes de presentación son pulmón y SNC. La osteomielitis criptococóccica ocurre en 5 a 10 por ciento de los pacientes con criptococcosis diseminada. La mayoría de casos ocurre entre 21 y 59 años de edad, hay pocos reportes de artritis criptococóccica en adultos mayores.

Anticuerpos anticélulas endoteliales en enfermedades sistémicas / Anti-endothelial cell autoantibodies in systemic diseases

Anti-endothelial cell autoantibodies (AECA), first described more then 30 years ago, represent a heterogeneous group of autoantibodies directed against poorly characterized antigens located in endothelial cell membranes, and have been reported in a variety of sistemic diseases. Although most of the target antigens for AECA are still not well identified, and AECA have been considered an epiphenomenon of vascular injury, new evidence suggests a pathogenic role, specially by inducing endothelial cell activation and apoptosis. The presence of AECA has been correlated with disease activity in SLE and systemic vasculitis such as Wegener's granulomatosis, Takayasu arteritis, and behçet's disease, and they could be valuable markers of disease activity. Other potential areas of clinical interest in diseases associated to AECA could be the serum thrombomodulin level, as marker of endothelial cell injury in neuropsychiatric lupus, and other vasculitides; and the determination of anti-heat shock protein antibodies including the Hsp60, as a new, non traditional risk factor for atherosclerosis in patient with lupus.