ABSTRACT
The case of a women 89 year old with an apparent partial intestinal obstruction is presented. The CT scan of abdomen and pelvis shows evident pneumatosis intestinalis (PI) within gas in the portal system. Expectant medical treatment was performed. Eight days later, a second CT scan showed almost complete remission of pneumatosis and gas in the portal system. The presence of gas in the bowel wall is a sign that can be find in benign to life threatening conditions. A review of the pathogenesis, radiological presentation and the different causes of PI are presented, based in the case report.
Presentamos el caso de una mujer de 89 años que ingresa por un probable cuadro de suboclusión intestinal. El estudio con TAC de abdomen y pelvis revela extensa neumatosis intestinal (NI) asociada a la presencia de gas en el sistema porta. Se realiza manejo médico de la paciente. Al octavo día se hace un control tomográfico, observándose regresión casi completa de la NI y del gas en sistema porta. La presencia de gas en la pared intestinal es un hallazgo que puede tener múltiples significados, desde lo más benigno hasta situaciones que ponen en riesgo la vida. A continuación revisamos las diferentes causas y teorías que explican la NI, su presentación radiológica e interpretación clínica, en base al presente caso clínico.
Subject(s)
Humans , Female , Aged, 80 and over , Pneumatosis Cystoides Intestinalis/etiology , Pneumatosis Cystoides Intestinalis , Pneumatosis Cystoides Intestinalis/therapy , Gases , Ischemia/pathology , Pneumatosis Cystoides Intestinalis/pathology , Pelvis , Radiography, Abdominal , Tomography, X-Ray Computed , Portal Vein/pathologyABSTRACT
Chronic organizing pneumonia (COP) has often been reported as a pulmonary manifestation of collagen vascular diseases, mainly rheumatoid arhritis, but the association of COP and dermatomyositis (DM) has rarely been documented. We report a 55 year-old woman with well-documented DM and a COP. She was refractory to steroids and two other immunosuppressive agents therapy (cyclophosphamide and azathioprine). Therefore, rituximab (2 x 1 g infusions) was used for treatment. During the following weeks her strength gradually increased while creatine kinase (CK), C reactive protein and erythrocyte sedimentation rate normalized. After 6 months, she had a relapse with increased muscle enzymes, fever and modérate muscle weakness. After a second course of rituximab (2 x 1 g infusions), the patient demonstrated a remarkable clinical response as indicated by an increase in muscle strength and moderate decline in creatine kinase levels. Lung abnormalities resolved significantly on high resolution chest CT sean. Thus, B-cell depletion therapy with rituximab used alone or in combination with other immunosuppressants may be a viable option in patients with polymyositis-dermatomyositis and pneumonia refractory to current therapies.
Subject(s)
Female , Humans , Middle Aged , Antibodies, Monoclonal/administration & dosage , Antirheumatic Agents/administration & dosage , Dermatomyositis/drug therapy , Immunosuppressive Agents/administration & dosage , Lung Diseases, Interstitial/etiology , Creatine Kinase , Dermatomyositis/complications , Dermatomyositis/diagnosis , Injections, Intravenous , Muscle Weakness/complicationsABSTRACT
Multiple myeloma is a low malignant, non-Hodgkin's lymphoma, which is characterized by infiltration of the bone marrow by clonal proliferation of atypical plasma cells. Extramedullary manifestations are relatively rare. Serous effusions in multiple myeloma are uncommon (6 percent of cases) but a myelomatous pleural effusion occurring in these patients is extremely rare. Plasma cell leukemia, occurring either de novo or in patients with long standing multiple myeloma, is the least common type of plasma cell dyscrasia. The authors describe the course of plasma cellular leukemia in a 63-year-old male patient where the first manifestation of the disease was a bacteremic pneumococcal pneumonia and a contralateral pleural exudate with a cytological finding of plasma cells. The exudate disappeared after the first cycle of chemotherapy (vincristine, adriamycin, dexamethasone). After the third cycle of chemotherapy remission of the disease was recorded which was, however, short. After three months' remission the disease recurred, consequently underwent autologous bone marrow transplantation. The patient has maintained complete remission for 12 months after diagnosis. Pleural effusion is an unusual but important complication of multiple myeloma and does not necessarily carry the grave prognosis implied in previous reports.
El mieloma múltiple es una neoplasia maligna de células plasmáticas que invade la médula ósea y otros tejidos. Las manifestaciones extramedulares son relativamente raras. El derrame pleural en el mieloma múltiple es poco frecuente (6 por ciento de los casos), y el derrame pleural neoplásico es extremadamente raro. La leucemia de células plasmáticas, que se produce de novo o en pacientes con mieloma múltiple, es la variedad menos común de discrasia de células plasmáticas. Los autores describen el cuadro clínico de un paciente de 63 años con leucemia de células plasmáticas, donde la primera manifestación de la enfermedad fue una neumonía neumocócica bacteriémica asociado a un derrame pleural contralateral, que correspondió a un exudado predominio mononuclear. El examen citológico reveló abundantes células plasmáticas inmaduras en el líquido pleural y la sangre periférica. El derrame pleural desapareció después del primer ciclo de quimioterapia (vincristina, adriamicina, dexametasona). Después de tres meses de remisión, la enfermedad neoplásica recidivó, siendo el paciente sometido a trasplante autólogo de médula ósea. El paciente se ha mantenido en remisión completa un año después del diagnóstico. El derrame pleural es una complicación poco común, pero importante, del mieloma múltiple y no necesariamente conlleva un mal pronóstico.
Subject(s)
Humans , Male , Middle Aged , Pleural Effusion/etiology , Multiple Myeloma/surgery , Multiple Myeloma/complications , Multiple Myeloma/drug therapy , Drug Therapy, Combination , Pleural Effusion/surgery , Pleural Effusion/drug therapy , Dexamethasone/therapeutic use , Doxorubicin/therapeutic use , Leukemia, Plasma Cell , Remission Induction , Transplantation, Autologous , Treatment Outcome , Vincristine/therapeutic useABSTRACT
During the past two decades there has been a resurgence ofinvasive group A streptococcal (GAS) infection, specially pneumonia and bacteremia. We report a 35 year-old female previously subjected to a thyroidectomy for a thyroid cáncer, that five days after operation, presented with a severe community-acquired pneumonia caused by Streptococcus pyogenes (Lancefield Group A Streptococcus) that was complicated by acute respiratory failure and septic shock. She was treated with a combination of 3 g/day of cefotaxime and 1.8 g/day of clindamycin with a good clinical response and discharged from the hospital in good conditions. Although this microorganism is an uncommon cause of community-acquired pneumonia, previously healthy individuals may be infected and the clinical course may be fulminant. Patients with invasive GAS infection admitted to ICU have a high mortality rate. Treatment of choice of Group A streptococcal infection is penicillin. However, clindamycin should be added in severe infections.
Subject(s)
Adult , Female , Humans , Pneumonia, Bacterial/microbiology , Shock, Septic/microbiology , Streptococcal Infections/microbiology , Streptococcus pyogenes/isolation & purification , Community-Acquired Infections/microbiologyABSTRACT
La neumonía adquirida en la comunidad (NAC) constituye una causa frecuente de consulta ambulatoria, hospitalización y muerte en la población adulta de los países desarrollados y en vías de desarrollo. El espectro de gravedad de la enfermedad es muy variable, fluctuando desde pacientes jóvenes sin comorbilidad ni factores de riesgo de manejo ambulatorio hasta pacientes críticamente enfermos que requieren hospitalización en unidades de cuidado crítico. La evaluación clínica sistemática (anamnesis y examen físico) y los exámenes de laboratorio básicos (hemograma, proteína C reactiva, pruebas de función renal, radiografía de tórax) disponibles en la unidad de emergencia permiten que el médico establezca el diagnóstico clínico-radiográfico y evalúe la gravedad del enfermo, lo que le permitirá decidir el lugar de manejo, la extensión del estudio microbiológico y el tratamiento específico. Además, la identificación y el tratamiento de las complicaciones de la neumonía y la sepsis acompañante deberían ser considerados por el médico de la unidad de emergencia al evaluar pacientes críticamente enfermos.
Pneumonia is one of the most common conditions for which patients seek emergency care. It is a challenging infection in that the spectrum of illness ranges from the nontoxic patient appropriate for outpatient antibiotics treatment to the critically ill patient requiring intensive care hospitalization. Current data and diagnostic technology provide the emergency physician with the tools for an appropriately rapid evaluation and consideration of the differential diagnosis. The rational application of severity assessment tools and local clinical guidelines recently published allow for optimal empirical antibiotic treatment and risk stratification for the best disposition. Although antibiotic-resistant organisms increasingly are being identified, patients continue to benefit from early institution of standard emergency department treatment. Finally, identification and early treatment of the complications of pneumonia and accompanying sepsis must be considered by the emergency physicians when evaluating critically ill patients.