Tuberculosis asociada a antagonistas del factor de necrosis tumoral alfa, presentación de un caso y análisis de los casos reportados en Colombia / Tuberculosis associated with tumor necrosis factor-α antagonists, case description and analysis of reported cases in Colombia

Resumen El factor de necrosis tumoral alfa (FNTα) es una citocina fundamental en la reacción inmunitaria frente al cáncer y a infecciones tales como la tuberculosis. Esta molécula también desempeña un papel fundamental en la patogenia de enfermedades complejas y de difícil tratamiento, como la artritis reumatoidea, la espondilitis anquilosante, la enfermedad de Crohn, la psoriasis y la colitis ulcerativa, condiciones que suelen requerir el uso de medicamentos que antagonizan la función del factor de necrosis tumoral alfa, el cual se ha relacionado con un incremento del riesgo de desarrollar tuberculosis, micosis y otras infecciones graves. Se reporta el caso de un hombre de 68 años de edad con diagnóstico de enfermedad de Crohn, a quien se le administró tratamiento con antagonistas del FNTα, debido a lo cual desarrolló tuberculosis diseminada. El diagnóstico se hizo con base en los hallazgos histológicos y mediante pruebas de biología molecular. Se discuten la presentación clínica y el manejo del caso, y se hace un análisis comparativo de los casos de tuberculosis asociados al tratamiento con antagonistas del FNTα reportados en Colombia durante los últimos diez años, con especial énfasisen la detección y el tratamiento de la tuberculosis latente.

Abstract Tumor necrosis factor-α (TNF-α) is an important fundamental cytokine during the immune response against cancer and infections such as tuberculosis. This molecule also plays a key pathogenic role in complex and difficult-to-treat diseases such as rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, psoriasis and ulcerative colitis. The treatment of these diseases frequently needs TNF-αantagonists, which has been related to an increased risk of developing tuberculosis, mycoses, and other severe infections. We report the case of a 68-year-old man with Crohn's disease, who developed disseminated tuberculosis due to anti-TNF-α immunosuppressive therapy. The diagnosis was based on the histopathological findings and molecular biology assays. We discuss the clinical presentation and workup of this case, and we present a comparative analysis of tuberculosis cases associated with anti-TNF-α reported in Colombia during the last 10 years emphasizing on the diagnosis and treatment of latent tuberculosis.

Doenças inflamatórias intestinais: considerações fisiológicas e alternativas terapêuticas / Inflammatory bowel diseases: physiological considerations and alternative therapies

Com o advento da industrialização e a mudança nos hábitos de vida mundial foi possível observar uma tendência para o surgimento de doenças, que passaram de maioria infecciosa para maioria inflamatória. Com o trato gastrointestinal não seria diferente, assim as doenças inflamatórias intestinais (DII) se tornaram mais comuns no mundo atual, sendo ainda mais presentes em países desenvolvidos e em desenvolvimento. Dentre as DII mais importantes destacam-se a Doença de Cronh (DC) e a Retocolite Ulcerativa (RCU), ambas de patogenia desconhecida, sem cura, sem padrão ouro para diagnóstico e que levam a pré-disposição ao câncer coloretal. Sabe-se apenas que o tabagismo, uso de contraceptivos orais, anti-inflamatórios não esteroidais, dieta, status social e geográfico, stress, flora entérica, alterações na permeabilidade intestinal e apendicectomia são fatores que predispõe ao surgimento dessas doenças. Ambas DII apresentam os sintomas de febre, dores abdominais, sangramento do cólon, diarreia e grave perda de peso. Sabe-se também que resultam de uma resposta imune inadequada em indivíduos geneticamente suscetíveis, aliado a complexas interações com fatores ambientais, microbianos e do sistema imune entérico. No Brasil não existe um levantamento do número de pacientes acometidos pelas DII. Isso aliado a ausência de um padrão ouro de diagnóstico para essas doenças leva a crer que há uma subestimação da quantidade real de casos. Diante de tantas incertezas esse artigo de revisão tem por objetivo apresentar as principais diferenças entre a DC e a RCU e mostrar os principais tratamentos existentes hoje.

With industrialization and the change in global lifestyle, a tendency for the emergence of diseases can be observed, with changes from mostly infectious to mostly inflammatory. With the gastrointestinal tract it is no different. Therefore, inflammatory bowel diseases (IBD) have become more common in today's world, being even more present in developed and developing countries. Among the most important IBD there are the Cronh's disease (CD) and ulcerative colitis (UC), both of unknown pathogenesis, with no cure, no gold standard for diagnosis, and leading to predisposition for colorectal cancer. It is only known that smoking, the use of oral contraceptives, non-steroidal anti-inflammatory drugs, diet, social and geographical status, stress, enteric flora, changes in intestinal permeability and appendectomy are factors that predispose to the emergence of these diseases. Both IBDs present symptoms of fever, abdominal pain, bowel bleeding, diarrhea and severe weight loss. It is also known that they result from an inappropriate immune response in genetically susceptible individuals, combined with complex interactions with environmental and microbial factors, as well as the enteric immune system. In Brazil, there is no survey on the number of patients affected by IBD. This, combined with the absence of a diagnostic gold standard for these diseases, suggests that there is an underestimation of the actual number of cases. With so many uncertainties, this review article aims to present the main differences between CD and UC and show the main existing treatments at the moment.

Esclerosis sistémica progresiva en una mujer joven / Progressive systemic sclerosis in a young woman

Se presenta el caso clínico de una fémina de 23 años de edad, con diagnóstico clínico y radiográfico de enfermedad de Cronh desde hacía 2 años aproximadamente, quien fue ingresada en el Servicio de Medicina Interna del Hospital General Docente "Dr. Juan Beuno Zayas Alfonso'' de Santiago de Cuba, por presentar síndrome febril prolongado, cefalea intensa, mialgias, artralgia y poliserositis, con una evolución desfavorable, además de complicaciones que fueron apareciendo posteriormente (insuficiencias cardíaca, renal y respiratoria). Los resultados de los exámenes complementarios efectuados y de los estudios histopatológicos, reafirmaron la presencia de esclerosis sistémica progresiva, lo cual se confirmó luego mediante biopsia de piel. Se indicó el tratamiento, según las diferentes eventualidades clínicas y finalmente la paciente logró reincorporarse a la vida social, pero con ciertas limitaciones.

The case report of a 23 years female patient with clinical and radiographic diagnosis of Cronh disease for approximately 2 years who was admitted in the Internal Medicine Service of "Dr. Juan Bruno Zayas Alfonso" Teaching General Hospital in Santiago de Cuba is presented for presenting prolonged feverish syndrome, intense migraine, myalgias, artralgia and polyserositis, with an unfavorable clinical course, besides complications that were emerging later on (heart, renal and respiratory failures). The results of the complementary exams and of pathological and histological studies carried out, reaffirmed the presence of progressive systemic sclerosis, which was confirmed later by means of skin biopsy. The treatment was indicated, according to the different clinical events and finally the patient was could be reinserted to the social life, but with certain limitations.