Síndrome hemolítico urémico secundario a Streptococcus pneumoniae. Reporte de un caso clínico

El síndrome hemolítico urémico secundario a Streptococcus pneumoniae (SHU-Sp) es una complicación poco frecuente de las enfermedades invasoras por S. pneumoniae. Presenta una alta morbimortalidad, con requerimiento de transfusiones de glóbulos rojos y plaquetas, terapia de sustitución de la función renal de inicio precoz y más prolongada, así como mayores complicaciones a largo plazo, comparado con las formas secundarias a infección entérica por Escherichia coli productora de toxina Shiga. Presentamos el caso clínico de una preescolar de dos años, previamente sana, vacunada con tres dosis de PCV13, que desarrolló una insuficiencia renal aguda, anemia hemolítica y plaquetopenia, en el contexto de una neumonía con empiema y bacteriemia por S. pneumoniae.

Streptococcus pneumoniae associated hemolytic uremic syndrome (Sp-HUS) is an uncommon complication of invasive pneumococcal infections. Patients with Sp-HUS have a higher mortality and long term morbidity than those due to HUS from Shiga toxin-producing Escherichia coli infections (STEC-HUS). They often require more red blood cells and platelet transfusions, and early initiation of renal substitution therapy, presenting a higher rate of arterial hypertension and chronic renal disease in the long term, compared to STEC-HUS. We report a healthy 2 year-old infant, vaccinated with three doses PCV13, that developed acute renal failure, hemolytic anemia and thrombocytopenia in the course of a complicated pneumococcal pneumonia with empyema and bacteremia.

Hematological disorders in preterm newborns born to mothers with pregnancy-induced hypertension / Alteraciones hematológicas en recién nacidos pretérmino de madres con enfermedad hipertensiva del embarazo

Abstract Background: Pregnancy-induced hypertension (PIH) has been related to impaired fetal growth, possibly by affecting hematopoiesis. This study aimed to analyze the most frequent hematological alterations in preterm infants born to mothers with PIH. Methods: We conducted a cross-sectional study in newborns born to mothers with PIH. We reviewed 130 hemograms of preterm infants: 45 from mothers with PIH, 71 with preeclampsia, and 14 with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Normality, cytosis conditions, or cytopenia values were adjusted for gestational ages. Differences between groups were analyzed with classical and Bayesian statistics (BF01 = null/alternative hypothesis ratio). Results: Anemia was found in only 1.2% of newborns. In the white blood cell count, the most frequent finding was lymphopenia (56.2%) and monocytosis (38.5%) (p = 0.6, FB01 = 249 y p = 0.81, FB01 = 19.9). Thrombocytopenia was found in 12.5% (p = 0.56, FB01 = 67). No significant differences were observed among PIH groups. Conclusions: Hematological alterations of newborns born to mothers with PIH are frequent and do not show a distinct pattern related to the severity of the affection in the mother. We recommend a full hematological evaluation in these preterm neonates.

Resumen Introducción: La enfermedad hipertensiva del embarazo (EHE) se ha relacionado con alteraciones en el crecimiento fetal, posiblemente porque afecta la hematopoyesis. El objetivo de este estudio fue analizar las alteraciones hematológicas más frecuentes en los recién nacidos prematuros hijos de madres con EHE. Métodos: Se llevó a cabo un estudio transversal en recién nacidos de madres con EHE. Se revisaron los hemogramas de 130 neonatos prematuros: 45 madres con hipertensión gestacional, 71 con pre-eclampsia y 14 con síndrome de HELLP (hemólisis, enzimas hepáticas elevadas y bajo recuento de plaquetas). Las cifras de normalidad, condiciones de citosis o citopenia fueron ajustadas a las edades gestacionales. Las diferencias entre los grupos se analizaron con estadística clásica y bayesiana (FB01= relación hipótesis nula/alterna). Resultados: Se encontró anemia en solo el 1.2% de los recién nacidos. En la serie blanca el hallazgo más frecuente fue la linfopenia (56.2%) y monocitosis (38.5%) (p = 0.6, FB01 = 249 y p = 0.81, FB01 = 19.9). La plaquetopenia se encontró en el 12.5% (p = 0.56, FB01 = 67). No se observaron diferencias significativas entre los grupos de EHE. Conclusiones: Las alteraciones hematológicas en recién nacidos de madres con EHE son frecuentes sin mostrar un patrón distinto con relación a la gravedad del padecimiento de la madre. Aun así, es recomendable la valoración hematológica en estos neonatos.

Eficacia terapeútica de la dexametasona para la plaquetopenia en pacientes internadas en el servicio de obstetricia con síndrome de HELLP, Hospital Municipal Boliviano Holandes, gestión 2018 / Therapeutic efficacy of dexamethasone for plachetopenia in patients intermitted to the obstetrics service with HELLP syndrome, Municipal Hospital "Boliviano Holandés", management 2018

El síndrome de HELLP se caracteriza por anemia hemolítica microangiopática, disfunción hepática y trombocitopenia. OBJETIVO: determinar la eficacia terapéutica de la dexametasona para la plaquetopenia en pacientes internadas con síndrome de HELLP, en el servicio de Obstetricia del Hospital Municipal Boliviano Holandés, gestión 2018. MATERIAL Y METODOS: se realizó un estudio prospectivo, analítico y de corte dinámico desde el 1 de enero al 31 de diciembre de la gestión 2018, en el servicio de Obstetricia del Hospital Municipal Boliviano Holandés. Se incluyeron en el estudio pacientes internadas con el diagnóstico de HELLP; con edad gestacional mayor a 22 semanas y puérperas que estuvieron cursando los 7 días post parto, a quienes se administró dexametasona. RESULTADOS: se estudió 14 pacientes (100%), las cuales cumplieron los criterios de inclusión, a quienes se administró dexametasona EV (8mg c/12 hrs y 4mg c/12hrs). En relación a la edad, se presentó en mayores de 35 años (43%), teniendo el (71.4%) de las pacientes un nivel de instrucción secundario, de las cuales (50%) realizo menos de 3 controles prenatales durante su gestación. Respecto al recuento plaquetario existe un incremento de 34.500mm3 (p=0.00) tras 48 horas de tratamiento con dexametasona y disminución de enzimas hepáticas GOT (p=0.003) y GPT (p=0.017) respectivamente. CONCLUSION: este estudio demuestra que el uso de dexametasona en pacientes con síndrome de HELLP, es eficaz ya que incrementa el recuento plaquetario y reduce los niveles de transaminasas tras 48 horas de tratamiento

HELLP syndrome is characterized by microangiopathic hemolytic anemia, liver dysfunction, and thrombocytopenia. OBJETIVES: to determine the therapeutic efficacy of dexamethasone for thrombocytopenia in hospitalized patients with HELLP syndrome, in the Obstetrics service of the Municipal Hospital Boliviano Holandés, management 2018. MATERIALS AND METHODS: a prospective, analytical and dynamic study was carried out from January 1 to December 31 of the 2018 administration, in the Obstetrics service of the Holandés Boliviano Municipal Hospital. Hospitalized patients diagnosed with HELLP were included in the study; with gestational age greater than 22 weeks and puerperal women who were attending the 7 days postpartum, who were administered dexamethasone. RESULTS: we studied 14 patients (100%), who met the inclusion criteria, who were administered IV dexamethasone (8mg every 12 hours and 4mg every 12 hours). In relation to age, it was presented in patients older than 35 years (43%), with (71.4%) of the patients having a secondary education level, of which (50%) performed less than 3 prenatal controls during their pregnancy. Regarding the platelet count, there is an increase of 34,500mm3 (p=0.00) after 48 hours of treatment with dexamethasone and a decrease in liver enzymes GOT (p=0.003) and GPT (p=0.017), respectively. CONCLUSIONS: this study shows that the use of dexamethasone in patients with HELLP syndrome is effective since it increases platelet count and reduces transaminase levels after 48 hours of treatment.

Manifestaciones hematologicas en pacientes adultos con lupus eritematoso sistémico / Hematological manifestations in adult patients with systemic lupus erythematosus

Introducción: el lupus erimatoso sistémico (LES) puede afectar las tres series celulares de la sangre. Objetivo: describir las alteracoines hematológicas y los marcadores de actividad en pacientes adultos con LES. Metodología: estudio observacional descriptivo realizado en pacientes con LES en el Hospital Nacional en 2017-2018. Se excluyeron a los pacientes con inmunosupresores (ciclofosfamida, rituzimab), pacientes con LES medicamentoso, pacientes con síndrome de superposición, pacientes con otras enfermedades autoinmunes. Resultados: se incluyeron 88 pacientes, con edad media 27±15 años. Hubo predominio de mujeres (89%). Se detectó anemia en 55%, leucopenia en 13%, linfopenia en 32%, plaquetopenia en 11%. Los valores de ANA estaban elevados en 92% y anti DNA en 22%. Conclusión: la afectación hematológica más frecuente en pacientes adultos con LES fue la anemia, seguida por la leucopenia y la plaquetopenia.

Introduction: systemic lupus erythematosus (SLE) can affect the three celular series of the blood. Objective: to describe hematological alterations and activity markers in adult patients with SLE. Methodology: descriptive observational study performed in patients with SLE of the National Hospital in 2017-2018. Were excluded patients with immunosuppressants (cyclophosphamide, rituzimab), patients with drugs induled SLE, patients with overlap syndrome, patients with other autoimmune diseases. Results: 88 patients were included, with an average age of 27 ± 15 years. There was a predominance of women (89%). Anemia was detected in 55%, leukopenia in 13%, lymphopenia in 32%, thrombocytopenia in 11%. ANA values were high in 92% and anti DNA in 22%. Conclusion: the most frequent haematological compromise in adult patients with SLE was anemia, followed by leukopenia and thrombocytopenia.

A propósito de un caso de hemorragia intracerebral secundaria a trombocitopenia / By the way a case of intracerebral hemorrhage secondary to thrombocytopenia

Se trata de un paciente joven que presenta trastorno del sensorio, alza térmica, lesiones petequiales y necróticas en piel, con plaquetopenia y leucocitosis que desarrolla una hemorragia intracerebral y luego distress respiratorio, es intubado, recibe antibioticoterapia y corticoides, es operado y mejora lentamente.

It is a patient with sensory impairment, high temperature, with petechial and necrotic lesions in skin, with disminish of platelets and increase of white blood cells, that developed an intracerebral hemorrhage, after a respiratory distress, was intubated and receive steroids and antibiotics, after was operated and improved slowly.

Características clínicas de pacientes hospitalizados durante un brote epidémico de dengue

Introducción: el dengue es una enfermedad dinámica, multisistémica, de etiología viral, con cuatro serotipos, endémica en el Paraguay. Se presenta con espectro clínico variable. Entre los meses de febrero y abril de 2015 se registró un brote epidémico en la ciudad de Coronel Oviedo (Paraguay), por lo cual se incrementó el número de consultas y casos de pacientes que necesitaron ser hospitalizados. Objetivos: determinar las características clínicas de los pacientes durante el brote epidémico de 2015. Metodología: estudio observacional, transversal, retrospectivo, descriptivo, no probabilístico, con componente analítico. Fueron revisadas historias clínicas de mujeres y varones mayores de 18 años internados en el área destinada a los pacientes con dengue en el Hospital Regional de Coronel Oviedo entre los meses de febrero y abril de 2015. Resultados: la edad media de los enfermos fue 42,1 ±18,6 años, 70,43% fueron mujeres. El 100% de los pacientes presentaban cuadro clínico compatible con dengue; en 77,05% de los casos el antígeno NS1 dio positivo y en 59,02% hubo nexo epidemiológico. El 77,05% presentaron signos de alarma, siendo la trombocitopenia el más frecuente (65,57%). Durante la fase crítica de la enfermedad se internaron el 80,33% de los pacientes. La hipertensión arterial fue la comorbilidad asociada más frecuente (39,34%). Se halló una correlación negativa débil entre el recuento plaquetario y los valores de enzimas hepáticas. La media de días de hospitalización fue 4,49±1,93 días. Conclusiones: la edad media fue 42,13 ±18,66 años, la mayoría fueron mujeres. El 100% de los pacientes presentaban cuadro clínico compatible con dengue; en la mayoría de los casos el Ag NS1 dio positivo y un alto porcentaje se confirmó por nexo epidemiológico. El 77,05% presentaron signos de alarma, siendo la trombocitopenia el más frecuente, durante la fase crítica de la enfermedad se internaron el 80,33% de los pacientes.

Introduction: Dengue is a dynamic multisystemic viral disease with four serotypes and is endemic in Paraguay. It has a variable clinical spectrum. Between February and April 2015, there was an outbreak in the city of Coronel Oviedo (Paraguay), which increased the number of consultations and cases of patients that needed hospitalization. Objective: To determine the clinical characteristics of patients, during the 2015 outbreak. Methodology: This was an observational cross-sectional retrospective descriptive non-probabilistic study with an analytical component. The clinical records of women and men older than 18 years old and admitted into the area of dengue patients at the Regional Hospital of between February and April 2015 were evaluated. Results: Mean age of the patients was 42.1 ±18.6 years and 70.43% was women. Hundred percent of patients presented clinical symptoms compatible with dengue; in 77.05% of the cases NS1 antigen was positive and in 59.02% there was an epidemiological link. The 77.05% presented signs of alarm being thrombocytopenia the most frequent (65.57%). During the critical phase of the disease, 80.33% of the patients were hospitalized. Arterial hypertension was the most frequent associated comorbidity (39.34%). A weak negative correlation was found between platelets counting and values of hepatic enzymes. The mean of hospitalization days was 4.49±1.93. Conclusions: The mean age was 42.13 ±18.66 years and most of the patients were women. Hundred percent of the patients presented clinical symptoms compatible with dengue, NS1 antigen was positive in most cases and a high percentage was confirmed by epidemiologic link. A 77.05% presented alarm signs being thrombocytopenia the most frequent; during the critical phase of the disease 80.33% of the patients were hospitalized.

Dengue en un paciente anticoagulado

Presentamos un caso de un paciente de sexo masculino de 73 años de edad con dengue siendo portador de una prótesis mecánica en posición aórtica y anticoagulado con acenocumarol. Ingresó con plaquetopenia por lo que se suspendió acenocumarol y fue anticoagulado con enoxaparina. Evolucionó favorablemente por lo que fue dado de alta nuevamente con acenocumarol.

We present the case of a 73-year-old man with dengue who had a mechanical prosthesis in aortic position and was anticoagulated with acenocoumarol. As he was admitted with thrombocytopenia, acenocoumarol was suspended and anticoagulated instead with enoxaparin. The patient showed a favorable evolution and was discharged and restarted on acenocoumarol.

Plaquetopenia grave em paciente etilista com infecção por vírus da imunodeficiência humana / Severe thrombocytopenia in an alcoholic patient with human immunodeficiency virus infection

A infecção por vírus da imunodeficiência humana e síndrome da imunodeficiência adquirida constituem importantes problemas de saúde pública em todo o mundo e a plaquetopenia tem sido um achado frequente nesse grupo populacional. Os mecanismos da citopenia são multifatoriais e ainda não estão completamente esclarecidos. Fatores que agravam a plaquetopenia incluem coinfecção por hepatite C e cirrose hepática. O objetivo desse relato é exemplificar o caso de um paciente com o vírus, cirrose alcoólica e plaquetopenia grave, abaixo de 5.000/mm3, corrigida com a administração de corticosteroide.

Infection with human immunodeficiency virus infection and acquired immunodeficiency syndrome is a serious public health issue worldwide, and thrombocytopenia has been a frequent finding among this group of patients. The mechanisms of this cytopenia are multifactorial and have not been completely understood. Factors that worsen thrombocytopenia include hepatitis C coinfection and hepatic cirrhosis. The aim of this report is to describe the case of an human immunodeficiency virus infection patient with alcoholic cirrhosis and severe thrombocytopenia, above 5,000/mm3, which was treated with corticosteroid use.

Síndrome de Wiskott-Aldrich / Wiskott - Aldrich syndrome

Objetivo: Descrever um caso de síndrome de Wiskott-Aldrich, enfatizandoa importância do diagnóstico precoce de uma imunodeficiênciarara, para seu tratamento adequado.Descrição do caso: Criança do sexo masculino, que aos seismeses de idade apresentou eczema em face e pescoço. Três mesesapós, evoluiu com piora, sendo internado com infecção secundária doeczema. Aos dez meses foi novamente internado por otite média comsecreção sanguinolenta, sangramento oral e lesões em pele com sufusõeshemorrágicas. Com um ano foi internado pela terceira vez, devidoà diarreia sanguinolenta, evoluindo com sepse. Exames laboratoriaisevidenciaram plaquetopenia e anemia, além de número reduzido delinfócitos T CD4+ e CD8+. A pesquisa para proteína da síndrome deWiskott-Aldrich foi ausente.Discussão: A Síndrome de Wiskott-Aldrich (WAS) é uma imunodeficiênciarara, ligada ao X, com manifestações clínicas característicasque incluem trombocitopenia com plaquetas pequenas, eczema, infecçõesrecorrentes e incidência aumentada de manifestações autoimunese malignidades. O diagnóstico precoce é muito importante para umtratamento adequado. Até o momento, a única terapia curativa é otransplante de células tronco.

Objective: Describe a case of Wiskott-Aldrich syndrome, emphasizingthe importance of early diagnosis of a rare immunodeficiency, for itsappropriate treatment.Case description: Male child, who at six months of age presentedeczema in face and neck. Three months later, progressed to worse,being admitted with secondary infection of the eczema. At ten monthswas again hospitalized due to otitis media with drainage of blood, oralbleeding and skin lesions with hemorrhagic suffusions. With one yearold was hospitalized for the third time, due to bloody diarrhea, evolvingto sepsis. Laboratory tests showed anemia and thrombocytopenia, andreduced number of CD4 and CD8 T lymphocytes. The search for theWiskott-Aldrich syndrome protein was absent.Discussion: The Wiskott-Aldrich Syndrome (WAS) is a rareimmunodeficiency, X-linked, with clinical features that includethrombocytopenia with small platelets, eczema, recurrent infections andincreased incidence of autoimmune manifestations and malignancies.Early diagnosis is very important for appropriate treatment. So far, theonly curative therapy is the transplantation of stem cells.

Valor predictivo del hemograma en la sepsis neonatal / Predictive value of the complete blood count (CBC) in neonatal sepsis

Objetivo: Realizar un análisis del hemograma, herramienta de diagnóstico accesible en los hospitales públicos y valorar su utilidad en la sepsis neonatal. Metodología: Estudio de pruebas diagnósticas, desarrollado en el Hospital General Pediátrico Niños de Acosta Ñu, del 1 de enero del 2008 al 31 de diciembre de 2009. Resultados: Desde enero del 2008 a diciembre del 2009 ingresaron 209 RN en Urgencias y Terapia Intensiva Pediátrica del HGP. Tuvieron hemocultivo positivo 30 pacientes ingresados al estudio. Presentaron leucopenia 13 % (4/30) en el grupo de sepsis vs 10% (4/40) en el grupo control, leucocitosis 23% (7/30) en el grupo sepsis vs 35 % (14/40) en el grupo control. La leucopenia tuvo una S = 13% E= 90% VPP 50% y VPN 58%. El CP+ de 3 y CP- de 0,96. Solo 13 % presento neutropenia 4/30 del grupo sepsis y 12,5% (5/40) del grupo control, neutrofilia (>17500) se observo en el 41 %, (13/30) grupo sepsis y 40% (16/40) del grupo control. Considerando la S,E VPP,VPN y CP para cada uno de los puntos de cortes, se tuvo, para neutropenia S 13%, E 87%, VPP 44% VPN 57%; CP+ 1;CP- 1. Neutrofilia S 43 %, E 80 %; VPP 44% VPN 58% CP+ 2; CP- 0,71. Las plaquetas también fueron analizadas, se encontró plaquetopenia (<150000) en el 20 %, (11/30) en el grupo sepsis, y frente a 7,5% (3/40) en el grupo control). Las plaquetas en promedio en el grupo con sepsis fue 200.000±139.897 vs grupo control 340.825± 15.0417 (p= 0,0002) Para la plaquetopenia la S 36%, E de 92 %; VPP 78%; VPN 66%; CP+ 4,5 y CP- de 0,6. El análisis de los verdaderos positivos y los falsos positivos con la curva ROC mostró un área bajo la curva para los leucocitos de 0,50 (IC95% 0,36 - 0,65), para los neutrófilos 0,57 (IC 95% 0,43 - 0,71) y para las plaquetas 0,76 (IC 95% 0,64 - 0,88)...

Introduction: Diagnosis of neonatal sepsis remains a challenge. There is no single laboratory test to confirm diagnosis. In recent years the usefulness of various markers has been investigated, but always in conjunction with blood count values (white count, neutrophils etc.). Objective: The purpose of this study is to analyze the complete blood count, a diagnostic tool available in almost all public hospitals, and assess its usefulness in neonatal sepsis. Methodology: A study of diagnostic tests performed at the Niños of Acosta Nu General Pediatric Hospital between January 1, 2008 and December 31, 2009. We analyzed the medical records of newborns clinically diagnosed with sepsis and confirmed by two positive blood cultures. The CBC taken was analyzed as an auxiliary method of diagnosis. Results: 209 newborns were admitted through the hospital’s emergency or pediatric multidisciplinary intensive care units. A study group was formed of the 30 patients with positive blood cultures and a control group from 40 patients with no suspected infection. In the sepsis group leucopenia was shown in 13% (4/30) vs. 10% (4/40) in the control group while leukocytosis was seen in 23% (7/30) of the sepsis group vs. 35% (14/40) in the control group. For leukopenia sensitivity was 13%, specificity 90%, positive predictive value (PPV) 50%, and negative predictive value (NPV) 58%. The positive probability ratio was 3 and negative probability ratio 0.96. In the sepsis group, only 13% (4/30) presented neutropenia vs. 12.5% (5/40) in the control group; neutrophilia (>17500) was observed in 41% (13/30) of the sepsis group and 40% (16/40) of the control group, while in regard to the cutoff points, for neutropenia sensitivity was 13%, specificity 87%, PPV 44%, NPV 57%, positive probability ratio 1, and negative probability ratio 1, while for neutrophilia sensitivity was43%, specificity 80%, PPV 44%, NPV 58% positive probability ratio 2, and negative probability ratio 0.71...

Púrpura trombocitopênica imune da criança: experiência de 12 anos em uma única instituição brasileira / Childhood immune thrombocytopenic purpura: 12-year experience of a single Brazilian institution

O objetivo deste trabalho foi determinar a frequência dos quadros clínicos da púrpura trombocitopênica imune e sua associação com contagem de plaquetas, taxa de resposta à esplenectomia e fatores preditivos do desfecho e da evolução para a cronicidade. Realizou-se estudo retrospectivo com 187 crianças diagnosticadas no Hospital das Clínicas da UFMG, entre 04/1988 e 12/2001. Quadros assintomáticos e leves corresponderam a 76 por cento do total. Hemorragias exclusivamente cutâneas ocorreram em 96 por cento dos casos sintomáticos. A gravidade dos sintomas associou-se à intensidade da plaquetopenia. Evolução aguda foi apresentada por 123 pacientes (70,7 por cento) e crônica por 51 (29,3 por cento). A apresentação insidiosa (26,2 por cento) associou-se a um maior número de esplenectomias (p=4x10-7), a uma menor taxa de resposta à corticoterapia (p=0,003) e constituiu-se, juntamente com a ausência de resposta à corticoterapia (p<1x10-7), em fator preditivo da cronicidade (p=1x10-7). Taxa de resposta de 74,5 por cento foi alcançada com a esplenectomia. Remissão foi o desfecho final em 80,2 por cento dos pacientes. Foram preditivos de remissão final: gênero masculino (p=0,02), número baixo de plaquetas ao diagnóstico (p=0,004), resposta à corticoterapia (p=0,003) e ocorrência de uma primeira remissão (p<1x10-7). Confirmou-se que a doença na criança é benigna e autolimitada. Houve associação entre gravidade dos sintomas e intensidade da plaquetopenia. Constituíram-se fatores preditivos da cronicidade: apresentação insidiosa e ausência de resposta à corticoterapia. Constituíram-se fatores associados à remissão final: gênero masculino, número mais baixo de plaquetas ao diagnóstico, resposta à corticoterapia inicial e ocorrência de uma primeira remissão.

The objective of this work was to determine the frequency of clinical manifestations of immune thrombocytopenic purpura and its association with platelet count, response to splenectomy and predictive factors for response and chronicity. This retrospective study included 187 children diagnosed at Hospital das Clínicas, Federal University of Minas Gerais, Brazil, between April 1988 and December 2001. About 76 percent of the cases had asymptomatic or clinically mild disease. Cutaneous bleeding alone was seen in 96 percent of the symptomatic cases. Severity of symptoms was associated with low platelet count. The acute disease was observed in 123 patients (70.7 percent) and 51 (29.3 percent) developed the chronic disease. Insidious presentation (26.2 percent) was associated with a larger number of splenectomies (p=4x10-7) and with a reduced response to steroids (p=0.003). Additionally, the lack of response to steroids (p<1x10-7) and insidious presentation were predictive factors for chronicity (p=1x10-7). Splenectomy resulted in remission in 74.5 percent. Remission was the final outcome for 80.2 percent of patients. Remission-associated factors included being male (p=0.02), a lower platelet count at diagnosis (p=0.004), response to steroids (p=0.003), and the occurrence of a first remission (p<1x10-7). The disease in childhood is benign and self-limiting with severity of symptoms being associated with a low platelet count.

Características clínicas, laboratoriais e epidemiológicas de pacientes com suspeita de febre hemorrágica em um centro de referência em doenças infecciosas / Clinical, laboratorial and epidemiologic characteristics of patients under suspicion of hemorrhagic fever in an infectious-disease referral hospital

A epidemiologia da febre hemorrágica (FH) não epidêmica tem sido pouco explorada no Brasil. Adotando-se uma definição sindrômica ampla para a doença, foram estudados 55 casos suspeitos de FH internados em um centro de referência em doenças infecciosas em Minas Gerais, durante período de um ano. Os pacientes tinham idade entre 14 e 70 anos (mediana 37 anos) e 80% deles eram homens. Observamos plaquetopenia sem sangramento em 34 (61,8%) casos e evidência de sangramento espontâneo em 16 (29,1%) pacientes. Os sinais e sintomas mais freqüentes foram febre, náusea/vômito, sangramento e icterícia. O diagnóstico foi estabelecido em 78,2% (43/55) dos casos, sendo que em três pacientes uma doença não infecciosa foi reconhecida. As etiologias infecciosas encontradas foram: dengue (13), leptospirose (9), malária (5), sepse bacteriana (6), leishmaniose (4), meningite aguda (2) e infecção aguda pelo HIV (1). Alteração da função renal foi observada em 13 pacientes, 4 deles necessitaram de hemodiálise. A letalidade hospitalar foi de 11%. A presença de icterícia e exantema se relacionaram aos diagnósticos de leptospirose e dengue, respectivamente.

Dengue hemorrágico sin hemorragias: otra categoría? / Hemorrhagic dengue without hemorrhaging: a novel diagnostic category?

Objetivo: Comparar el comportamiento clínico del dengue clásico (DC) y dengue hemorrágico (DH). Material y métodos: Estudio transversal en casos seropositivos de la Delegación Veracruz Norte del Instituto Mexicano del Seguro en 2004. Se analizaron antecedentes epidemiológicos, sintomatología, parámetros clínicos y evolución. Se obtuvieron frecuencias, proporciones y promedios. Se compararon datos clínicos y tiempos de evolución. Resultados: Estudiamos 404 pacientes integrados en tres grupos: 75 con DC, 120 con DH y 212 sin datos hemorrágicos pero con plaquetopenia (DcP). Los síntomas generales fueron menos frecuentes en los casos de dengue; el dolor abdominal, hepatomegalia y esplenomegalia fueron más comunes en los que presentaron hemorragias. El escape de líquidos y hemorragias ocurrieron en 75 y 46% de este último grupo. Los antecedentes de infección previa fueron semejantes. Todos los enfermos de DH presentaron plaquetopenia y 3%, hemoconcentración. La media del hematócrito fue menor (p=0.02) y el conteo plaquetario mayor (p<0.01) en los de DC. La hemoglobina no mostró diferencias. El promedio entre el inicio de la enfermedad y la aparición de plaquetopenia fue similar en los casos con DH (4.3±1.6 días) y DcP (4.3±1.6); aunque, a diferencia de éstos, en los primeros el escape de líquidos (3.7±1.8) y hemorragias (3.4±1.7) se identificaron previamente. Conclusiones: Los resultados demuestran la presencia de casos con una evolución atípica, sin datos hemorrágicos externos pero con trombocitopenia importante que puede pasar desapercibida y predisponer el agravamiento del cuadro.

OBJECTIVE: Compare the clinical course of Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF). MATERIAL AND METHODS: Cross-sectional study among seropositive cases reported by the Northern Veracruz District IMSS Office in 2004. We analyzed the epidemiology, symptomology, clinical findings and disease progression. We calculated frequencies, proportions and averages. Clinical data and disease progression were compared. RESULTS: We studied 404 patients, divided into three groups: 75 with CD, 120 DHF and 212 cases with no hemorrhagic data although displaying Dengue with Thrombocytopenia (DwT). General symptoms were much less common among Dengue cases. Abdominal pain, hepatomegaly and splenomegaly were more frequent among patients with DHF. Fluid leakage and hemorrhaging were observed in 75% and 46%, respectively, of the latter group. The history of prior infection was proportional. All patients presenting DHF showed thrombocytopenia, though only 3% showed hemoconcentration. The mean value for hematocrit was low (p=0.02) and the platelet count greater (p<0.001) among Dengue cases. Hemoglobin concentration showed no difference. The average time between disease onset and appearance of thrombocytopenia was similar in DHF cases (4.3+/- 1.6 days) and Dengue with Thrombocytopenia (4.3+/-1.6); even though, contrary to these, in the first group fluid leakage (3.7+/-1.8) and hemorrhaging (3.4+/-1.7) were previously identified. CONCLUSIONS: Our results confirm the presence of cases showing atypical disease course, without external hemorrhaging data but showing significant thrombocytopenia that may go unnoticed and worsen disease progression.