Síndrome urémico hemolítico del adulto / Adult hemolytic uremic syndrome

El síndrome urémico hemolítico (SUH), descripto en 1955, se caracteriza por la tríada de anemia hemolítica no inmunomediada, trombocitopenia y lesión renal aguda. En su patogenia interviene la toxina Shiga, producida con mayor frecuencia por E. coli O157:H. Puede manifestarse a cualquier edad, aunque es infrecuente en adultos, y se desarrolla en forma esporádica o en brote. Se presenta con un cuadro de dolor abdominal, diarrea, fiebre y vómitos. Puede afectar el sistema nervioso central, pulmones, páncreas y corazón. En adultos, el síndrome evoluciona tras un período de incubación de 1 semana posterior a la diarrea y tiene alta morbimortalidad, a diferencia de los casos pediátricos. Presentamos el caso de una paciente adulta, que cursó internación por síndrome urémico hemolítico. (AU)

Hemolytic uremic syndrome (HUS), described in 1955, is characterized by the triad of non-immune mediated hemolytic anemia, thrombocytopenia, and acute kidney injury. Shiga toxin, produced most frequently by E coli O157:H, is involved in its pathogenesis. Hus can manifest at any age, although it is rare in adults and develops sporadically or in outbreaks. HUS presents with a picture of abdominal pain, diarrhea, fever and vomiting. It can affect the central nervous system, lungs, pancreas, and heart.In adults, the syndrome evolves after an incubation period of 1 week after diarrhea, with high morbidity and mortality, unlike pediatric cases.We present the case of an adult patient who was hospitalized for hemolytic uremic syndrome. (AU)

Acidosis metabólica neonatal por síndrome de enterocolitis inducido por proteína de alimentos: reporte de caso / Neonatal metabolic acidosis caused by food proteininduced enterocolitis syndrome: a case report

El síndrome de enterocolitis inducido por proteínas de los alimentos (FPIES, por su sigla en inglés) es una reacción alérgica no mediada por inmunoglobulina E (IgE) con síntomas gastrointestinales, como vómitos y diarrea. El diagnóstico se basa en criterios clínicos y en una prueba de provocación para confirmarlo. Es una enfermedad desconocida en las unidades neonatales, debido a la inespecificidad de los síntomas en los recién nacidos. La cifra de metahemoglobina elevada es una opción sencilla de aproximación diagnóstica. Se describe el caso clínico de un recién nacido que ingresa al servicio de urgencias por deshidratación, letargia, vómitos, diarrea y acidosis metabólica grave con elevación de metahemoglobina, con mejora clínica y recuperación total tras el inicio del aporte de fórmula elemental. La sospecha diagnóstica se confirmó tras la prueba de provocación positiva.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated allergic reaction with gastrointestinal symptoms, such as vomiting and diarrhea. FPIES diagnosis is based on clinical criteria and on a food challenge test. It is an unknown disease in neonatal units due to its nonspecific symptoms in newborn infants. An elevated methemoglobin level is a simple way to approach diagnosis. Here we describe a clinical case of a newborn admitted to the emergency department because of dehydration, lethargy, vomiting, diarrhea, severe metabolic acidosis, and a high methemoglobin level. Clinical improvement and complete recovery was achieved after initiation of elemental formula. The diagnostic suspicion was confirmed after a positive challenge test.

Síndrome de Good, una causa infrecuente de diarrea crónica / Good Syndrome, a rare cause of chronic diarrhea

Chronic diarrhea is a frequent cause of consultation in daily clinical practice. There are multiple diagnostic algorithms that allow a staggered approach to the most frequent pathologies, leaving out some lesser-known ones. This article reports the case of a 66-year-old female patient with a history of arterial hypertension, dyslipidemia and resected AB thymoma and a history of chronic diarrhea of 8 weeks of evolution. The etiological study ruled out infectious causes, celiac disease and negative viral serology. Due to a history of thymoma, immunoglobulin count was performed, showing severe pan-hypogammaglobulinemia. Good's Syndrome is the combination of thymoma and hypogammaglobulinemia, where patients may present with diarrhea secondary to immunodeficiency. Hypogammaglobulinemia associated with the presence of a thymoma is a rare cause but widely described in the literature as Good's Syndrome. Therefore, it seems relevant to describe a case, its approach and subsequent management.

La diarrea crónica constituye una causa frecuente de consulta en la práctica clínica diaria. Existen múltiples algoritmos diagnósticos que permiten realizar un abordaje escalonado de las patologías más frecuentes y permiten descartar algunas menos conocidas. En el presente artículo se reporta el caso de una paciente de género femenino de 66 años, antecedentes de hipertensión arterial, dislipidemia y timoma AB resecado con historia de diarrea crónica de 8 semanas de evolución. Dentro del estudio etiológico se descartan las causas infecciosas, enfermedad celíaca y serologías virales negativas. Por antecedente de timoma, se realizó recuento de inmunoglobulinas, evidenciando una severa pan-hipogammaglobulinemia. El Síndrome de Good es la combinación de timoma e hipogammaglobulinemia, donde los pacientes podrían presentar diarreas secundarias a inmunodeficiencia. La hipogammaglobulinemia asociada a la presencia de un timoma es una causa poco frecuente pero ampliamente descrita en la literatura como Síndrome de Good. Por lo antes señalado, nos parece relevante describir un caso, su abordaje y manejo posterior.

McKittrick-Wheelock syndrome secondary to rectal adenocarcinoma

Introduction: McKittrick-Wheelock syndrome is a rare condition that arises from a hypersecretory state secondary to large colorectal tumors, mainly villous adenomas, leading to an electrolytic disorder associated with chronic diarrhea that usually persists for years. It is a relatively unknown disease that can lead to severe complications such as acute kidney injury, severe hyponatremia, and hypokalemia. In fact, it causes death in most untreated cases. Surgical removal of the tumor is the most successful treatment, and symptoms tend to disappear after proper management. Case Report: A 62-year-old man with a 2-year history of mucoid diarrhea preceded by abdominal pain presented with acute kidney injury, hyponatremia, and hypokalemia. A digital rectal examination and sigmoidoscopy were performed, and revealed a large laterally-spreading tumor in the rectum. Further investigation showed a rectal tubulovillous adenoma with secondary McKittrick-Wheelock syndrome. An anterior resection of the rectum with a colonic J-pouch and a diverting ileostomy were performed, and the patient improved with the resolution of the renal failure and electrolyte disturbances. The histopathological analysis revealed an invasive rectal adenocarcinoma. Discussion: McKittrick-Wheelock syndrome is a condition with a low incidence that needs early intervention and proper diagnosis. It is of extreme importance that this disease is included in the differential diagnoses for chronic diarrhea associated with an electrolytic disorder. (AU)

Vigilancia de diarreas agudas / Surveillance of acute diarrhea

Se presenta de manera breve la situación de diarreas agudas, en particular diarrea aguda sanguinolenta, hasta la Semana Epidemiológica 15 de 2022: notificaciones según tipo de efector, notificación de agentes etiológicos, y tasas según sexo y edad.

Caracterización clínico epidemiológica de la gastroenteritis por rotavirus. Estudio piloto. Hospital Pediátrico de Centro Habana. Noviembre 2017- abril 2018 / Clinical epidemiological characterization of rotavirus gastroenteritis. Pilot study. Paediatric Hospital of Centro Habana

La gastroenteritis causada por rotavirus constituye un importante problema de salud mundial, por lo que se recomienda incluir la vacunación contra el rotavirus en los programas de inmunización. Para evaluar el impacto de una futura introducción en Cuba de una vacuna contra este patógeno, resulta necesario crear una línea de base pre-vacunación de la carga de la gastroenteritis causada por este virus. Entre noviembre 2017 a abril 2018 se implementó en el Hospital Pediátrico de Centro Habana un sistema de vigilancia para la gastroenteritis causada por rotavirus. Se establecieron las definiciones para las categorías de caso sospechoso, probable y confirmado. Por cada niño captado se recogió una muestra de heces que se analizó con tiras rápidas y se confirmó la presencia de rotavirus por ELISA. Para determinar la severidad de la enfermedad se utilizó la escala de Vesikari. Los resultados fueron expresados en cifras absolutas y relativas, el análisis se realizó a través de la prueba de chi-cuadrado. Del total de ingresos por enfermedad diarreica aguda, el 26 por ciento cumplió los criterios de inclusión y el 46 por ciento resultó confirmado como rotavirus. El hacinamiento en el hogar y asistir al círculo infantil se comportaron como factores de riesgo. El servicio de gastroenterología absorbió la mayor carga de ingresos hospitalarios por esta causa. Los resultados mostrados validan la funcionalidad del sistema de vigilancia implementado y brindan nuevas evidencias sobre la carga de la enfermedad y la utilización de los servicios de un hospital pediátrico cubano, debido a la gastroenteritis provocada por rotavirus, lo que justifica la introducción de la vacuna(AU)

Gastroenteritis caused by rotavirus is a major global health problem, therefore it is recommended that vaccination against rotavirus be included in immunization programs. To evaluate the impact of a future introduction in Cuba of a vaccine against this pathogen, it is necessary to have a pre-vaccination baseline of the burden of gastroenteritis caused by rotavirus. Between November 2017 and April 2018, a surveillance system for gastroenteritis caused by rotavirus was implemented in the Paediatric Hospital of Centro Habana. Definitions were established for the categories of suspected, probable and confirmed cases. For each captured child, stool samples were collected, analyzed with rapid strips and confirmated by ELISA. To determine the severity of the disease, the Vesikari score was used. The results were expressed in absolute and relative figures; the analysis was performed through chi-square. Of the total admissions for acute diarrheal disease, 26 percent met the inclusion criteria and 46 percent were confirmed for rotavirus. Overcrowding at home and attending a day care center were risk factors. The gastroenterology service absorbed the greatest burden of hospital admissions for this cause. The results shown validate the role of the implemented surveillance system and provide new evidence on the burden of disease and use of services for rotavirus gastroenteritis in a cuban pediatric hospital(AU)

Enterite mesentérica como complicação rara do lúpus eritematoso sistêmico / Mesenteric enteritis as a rare complication of systemic lupus erythematosus

A dor abdominal no paciente com lúpus eritematoso sistêmico tem amplo espectro clínico, variando desde condições inespecí- ficas, como diarreia e vômitos, até eventos de importante morbi- mortalidade, como o abdome agudo inflamatório e/ou perfura- tivo. A seguir, descreve-se um caso de paciente do sexo feminino, de 23 anos, internada por dor abdominal associada a vômitos e à diarreia crônica e progressiva. Foi diagnosticada com lúpus eritematoso sistêmico há 2 anos. Durante a internação, evoluiu com quadro de abdome agudo, e foi realizada tomografia compu- tadorizada de abdome, revelando importante edema de parede intestinal difuso. Isso, somado a alterações clínico-laboratoriais, permitiu o diagnóstico de enterite lúpica. Foi realizado tratamen- to conservador, com corticoterapia e terapia de suporte com correção de distúrbios eletrolíticos severos, sendo iniciado ciclo- fosfamida, com resolução dos sintomas gastrintestinais.

Abdominal pain in patients with systemic lupus erythematosus has a broad clinical spectrum, ranging from nonspecific symp- toms, such as diarrhea and vomiting, to events of significant morbidity and mortality, such as acute inflammatory and/or per- forating abdomen. This article describes a case of a 23-year-old female patient hospitalized for abdominal pain, associated with vomiting and progressive chronic diarrhea. She was diagnosed with systemic lupus erythematosus 2 years ago. During hospita- lization, the patient progressed with acute abdomen, and an ab- dominal computed tomography scan was performed, revealing major diffuse intestinal wall edema. This, added to clinical and laboratories alterations, allowed the diagnosis of lupus enteritis. A conservative treatment with corticotherapy and supportive therapy with correction of severe electrolyte disturbances were initiated, as well as the prescription of cyclophosphamide, with resolution of gastrointestinal symptoms.

Irritable bowel syndrome in Indonesian adolescents

Abstract Objective: Irritable bowel syndrome is a frequent functional gastrointestinal disorder. The aims of this study were to investigate its epidemiology, focusing on the role of intestinal mucosal integrity and to evaluate the impact on the quality of life. Methods: A community-based survey applying a comparative cross sectional approach was conducted in six high schools in Palembang. Subjects were recruited using multistage random sampling divided in two groups. Rome III criteria were used to establish a diagnosis of IBS in combination with a questionnaire to determine risk factors. Determination of fecal alpha-1-antitrypsin and calprotectin levels was performed to determine impaired intestinal mucosal integrity. A questionnaire was used to evaluate how quality of life was affected by irritable bowel syndrome. Results: The survey was performed in 454 14−18 years old adolescents, of whom 30.2% fulfilled the Rome III criteria for IBS, with the following subtypes: 36.5% diarrhea, 18.9% constipation, 21.9% mixed, and 22.6% unclassified. Major risk factors were female gender, bullying, age 14-16 years, history of constipation and diarrhea, eating nuts, and drinking coffee, tea, and soft drinks. There was a significant association with intestinal inflammation (p = 0.013). A significantly impaired quality of life was found (p = 0.001). Conclusions: The prevalence of irritable bowel syndrome in adolescents was high, with bullying, female gender, age 14-16 years, constipation and diarrhea, and dietary consumption of soft drinks, coffee, and tea as risk factors. A significant association with intestinal inflammation was found.

Alterações gastrointestinais durante o acompanhamento nutricional de pacientes oncológicos em acompanhamento ambulatorial de quimioterapia / Gastrointestinal changes during nutritional follow-up of cancer patients undergoing outpatient chemotherapy

ABSTRACT BACKGROUND: Cancer patients may have gastrointestinal changes that influence nutritional status. OBJECTIVE: To investigate the occurrence of gastrointestinal changes resulting from outpatient chemotherapy treatment in cancer patients. METHODS: In a retrospective longitudinal study, the nutritional status and chemotherapy gastrointestinal changes (nausea, vomit, diarrhea, constipation, mucositis, dysphagia, xerostomia, inappetence, dysgeusia and heartburn) in cancer patients (n=187) were investigated in an outpatient follow-up. For the study of the parameters over time, the generalized estimating equation (GEE) method was used. Kruskal-Wallis, Mann-Whitney tests and Spearman coefficient, at a significance level of 5% were also used. RESULTS: The majority of the patients were female (63.64%) and the mean age was 57.5±12.1 years. The most frequent symptoms were nausea (18.54%); inappetence (18.31%); intestinal constipation (11.58%); diarrhea (7.98%); xerostomia (7.59%) and vomiting (7.43%). The nutritional status did not exhibit any relevant changes (P=0.7594). However, a higher prevalence of eutrophy was observed, followed by overweight; vomiting exhibited a significant difference (P=0.0211). The nausea symptom exhibited a significant difference with a higher prevalence of colorectal neoplasia when compared to breast neoplasia (P=0.0062); as well as vomiting in lung and colorectal neoplasias (P=0.0022), and dysphagia, in head and neck neoplasia, when compared to other neoplasms (P<0.001). There was a statistically significant difference between the number of medical appointments and gender (P=0.0102) and between dysphagia and gender (P<0.0001). CONCLUSION: The study findings enhance the need for signs and symptoms follow up, as well as nutritional status follow up of patients undergoing outpatient chemotherapy.

RESUMO CONTEXTO: Pacientes oncológicos podem apresentar alterações gastrointestinais que influenciam o estado nutricional. OBJETIVO: Investigar a ocorrência de alterações gastrointestinais decorrentes do tratamento ambulatorial de quimioterapia, em pacientes oncológicos. MÉTODOS: Num estudo longitudinal retrospectivo, investigou-se o estado nutricional e as alterações gastrointestinais (náuseas, vômito, diarreia, constipação, mucosite, disfagia, xerostomia, inapetência, disgeusia e pirose) de pacientes oncológicos (n=187), em acompanhamento ambulatorial de quimioterapia. Para o estudo dos parâmetros ao longo do tempo, utilizou-se o método das equações de estimação generalizadas (EEG). Também foram utilizados os testes de Kruskal-Wallis, Mann-Whitney e o coeficiente de Spearman, com nível de significância de 5%. RESULTADOS: A maioria dos pacientes era do sexo feminino (63,64%) e a média de idade foi 57,5±12,1 anos. Os sintomas mais frequentes foram náuseas (18,54%); inapetência (18,31%); constipação intestinal (11,58%); diarreia (7,98%); xerostomia (7,59%) e vômito (7,43%). O estado nutricional não apresentou alterações relevantes (P=0,7594). No entanto, observou-se maior prevalência de eutrofia, seguido do sobrepeso e o vômito apresentou diferença significativa (P=0,0211). O sintoma de náusea apresentou diferença significativa com maior prevalência na neoplasia colorretal, quando comparado à neoplasia de mama (P=0,0062); assim como o vômito nas neoplasias de pulmão e colorretal (P=0,0022). E a disfagia, na neoplasia de cabeça e pescoço, quando comparada às demais neoplasias (P<0,001). Houve diferença estatisticamente significante entre o número de consultas médicas e sexo (P=0,0102) e entre disfagia e sexo (P<0,0001). CONCLUSÃO: Os achados encontrados no estudo permitem reforçar a necessidade do acompanhamento de sinais e sintomas, bem como do estado nutricional, de pacientes em acompanhamento ambulatorial de quimioterapia.

Panorama histórico de la enfermedad diarreica aguda en México y el futuro de su prevención / Historical overview of acute infectious diarrhea in Mexico and future preventive strategies

Resumen: Objetivo: Revisar los aspectos epidemiológicos de la enfermedad diarreica aguda (EDA) a través de la historia de México y analizar las estrategias que potencialmente podrán prevenir su aparición en la población mexicana. Material y métodos: Se realizó una búsqueda sistematizada utilizando los siguientes descriptores de las ciencias de la salud: diarrea, morbilidad, mortalidad, México y promoción de la salud de los últimos 20 años (1878-2018). Resultados: Se obtuvieron más de 8 600 artículos que fueron evaluados en función de los objetivos de la presente publicación. Conclusión: Como resultado de una revisión sistemática se observó que, gracias a las estrategias implementadas a lo largo del tiempo, se ha logrado graduar los matices de riesgo de la EDA; ello permite ahora plantear estrategias que guiarán a la prevención de ese padecimiento, de la mano de políticas que incluyan aspectos higiénico-dietéticos, innovaciones farmacéuticas y aplicaciones tecnológicas en medidas sanitarias.

Abstract: Objective: To analyze the epidemiological aspects of AID through Mexican history and the potential strategies to prevent AID in Mexican population. Materials and methods: A systematic review was performed exploring the key words, diarrhea, morbidity, mortality, Mexico, health promotion for the last 20 years (1978-2018). Results: Over 8 600 articles were obtained; all of them were evaluated to consider those follow the aim of the present work. Conclusion: The result of the performed systematic review denoted the influence of AID in Mexican public health policy the adopted actions diminished the AID's associated risks and allowed future strategies to prevent it; those actions must include hygienic and dietetic measures, pharmaceutical innovations and technological tools applied to health policies.

Family COVID-19 cluster analysis of an infant without respiratory symptoms

Abstract Diagnosing cases of coronavirus disease (COVID-19) with only non-respiratory symptoms has been challenging. We reported the diagnosis of a child who tested positive for COVID-19 with abdominal pain/diarrhea and tracked his family cluster. One member of the family tested positive for COVID-19 on real-time reverse-transcription polymerase chain reaction assay and three other family members had anti-SARS-CoV-2 antibodies.

Neuroendocrine tumor in a child with common variable immunodeficiency / Tumor neuroendócrino em criança com imunodeficiência comum variável

ABSTRACT Objective: To report a case of a child with primary immunodeficiency who at eight years developed digestive symptoms, culminating with the diagnosis of a neuroendocrine tumor at ten years of age. Case description: One-year-old boy began to present recurrent pneumonias in different pulmonary lobes. At four years of age, an immunological investigation showed a decrease in IgG and IgA serum levels. After the exclusion of other causes of hypogammaglobinemia, he was diagnosed with a Common Variable Immunodeficiency and started to receive monthly replacement of human immunoglobulin. The patient evolved well, but at 8 years of age began with epigastrium pain and, at 10 years, chronic persistent diarrhea and weight loss. After investigation, a neuroendocrine tumor was diagnosed, which had a rapid progressive evolution to death. Comments: Medical literature has highlighted the presence of gastric tumors in adults with Common Variable Immunodeficiency, emphasizing the importance of early diagnosis and the investigation of digestive neoplasms. Up to now there is no description of neuroendocrine tumor in pediatric patients with Common Variable Immunodeficiency. We believe that the hypothesis of digestive neoplasm is important in children with Common Variable Immunodeficiency and with clinical manifestations similar to the case described here in the attempt to improve the prognosis for pediatric patients.

RESUMO Objetivo: Relatar um caso de criança portadora de imunodeficiência primária que, aos oito anos, desenvolveu sintomas digestivos, culminando com o diagnóstico de tumor neuroendócrino aos dez anos de idade. Descrição do caso: Menino, com um ano de idade, começou a apresentar pneumonias de repetição em diferentes lobos pulmonares. Aos quatro anos, a investigação imunológica mostrou diminuição dos níveis séricos de IgG e IgA. Após exclusão de outras causas de hipogamaglobulinemia, teve diagnóstico de imunodeficiência comum variável, passando a receber reposição mensal de imunoglobulina humana. Evoluiu bem, porém, aos oito anos, começou com epigastralgia e, aos dez anos, diarreia crônica persistente e perda de peso. O quadro culminou com o diagnóstico de tumor neuroendócrino intestinal, de rápida progressão, com óbito do paciente. Comentários: A literatura tem chamado a atenção para tumores gástricos em adultos com imunodeficiência comum variável, alertando para a importância do diagnóstico precoce e da pesquisa de neoplasias digestivas. Até o momento, não há descrição de tumor neuroendócrino em pacientes pediátricos portadores de imunodeficiência comum variável. Acredita-se ser importante a hipótese de neoplasia digestiva diante de crianças com imunodeficiência comum variável e com manifestações clínicas semelhantes ao caso descrito, na tentativa de melhorar o prognóstico para pacientes pediátricos.

Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome

OBJECTIVES: To assess the outcomes of pediatric patients with laboratory-confirmed coronavirus disease (COVID-19) with or without multisystem inflammatory syndrome in children (MIS-C). METHODS: This cross-sectional study included 471 samples collected from 371 patients (age<18 years) suspected of having severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The study group comprised 66/371 (18%) laboratory-confirmed pediatric COVID-19 patients: 61 (92.5%) patients tested positive on real-time reverse transcription-polymerase chain reaction tests for SARS-CoV-2, and 5 (7.5%) patients tested positive on serological tests. MIS-C was diagnosed according to the criteria of the Center for Disease Control. RESULTS: MIS-C was diagnosed in 6/66 (9%) patients. The frequencies of diarrhea, vomiting, and/or abdominal pain (67% vs. 22%, p=0.034); pediatric SARS (67% vs. 13%, p=0.008); hypoxemia (83% vs. 23%, p=0.006); and arterial hypotension (50% vs. 3%, p=0.004) were significantly higher in patients with MIS-C than in those without MIS-C. The frequencies of C-reactive protein levels >50 mg/L (83% vs. 25%, p=0.008) and D-dimer levels >1000 ng/mL (100% vs. 40%, p=0.007) and the median D-dimer, troponin T, and ferritin levels (p<0.05) were significantly higher in patients with MIS-C. The frequencies of pediatric intensive care unit admission (100% vs. 60%, p=0.003), mechanical ventilation (83% vs. 7%, p<0.001), vasoactive agent use (83% vs. 3%, p<0.001), shock (83% vs. 5%, p<0.001), cardiac abnormalities (100% vs. 2%, p<0.001), and death (67% vs. 3%, p<0.001) were also significantly higher in patients with MIS-C. Similarly, the frequencies of oxygen therapy (100% vs. 33%, p=0.003), intravenous immunoglobulin therapy (67% vs. 2%, p<0.001), aspirin therapy (50% vs. 0%, p<0.001), and current acute renal replacement therapy (50% vs. 2%, p=0.002) were also significantly higher in patients with MIS-C. Logistic regression analysis showed that the presence of MIS-C was significantly associated with gastrointestinal manifestations [odds ratio (OR)=10.98; 95%CI (95% confidence interval)=1.20-100.86; p=0.034] and hypoxemia [OR=16.85; 95%CI=1.34-211.80; p=0.029]. Further univariate analysis showed a positive association between MIS-C and death [OR=58.00; 95%CI=6.39-526.79; p<0.0001]. CONCLUSIONS: Pediatric patients with laboratory-confirmed COVID-19 with MIS-C had a severe clinical spectrum with a high mortality rate. Our study emphasizes the importance of investigating MIS-C in pediatric patients with COVID-19 presenting with gastrointestinal involvement and hypoxemia.

Updated analysis of irritable bowel syndrome: a review of the literature / Análisis actualizado del síndrome de intestino irritable: una revisión de la literatura

Irritable bowel syndrome (IBS) is a chronic pathology with disorders of the bowel-brain interaction, characterized by abdominal pain localized anywhere in the abdomen as well as bowel habit alteration (constipation, diarrhea or mixed), in the absence of any disease that can cause these symptoms. With the updated concepts according to the latest meeting of experts in Rome 2016, our goal is to raise awareness about irritable bowel syndrome, by reviewing the literature regarding definition, classification, pathophysiology, clinical aspects, treatment, prognosis and the future. IBS is a chronic pathology, characterized by abdominal pain, at least 1 day per week in the last 3 months, associated with the alteration of the intestinal bowel habits. With a classification based on the alteration of intestinal bowel movements and in addition to constipation induced by opioids or narcotics, the etiology and pathophysiology are not well explained or well-known so far. The clinical aspects are based on the Rome IV criteria. A good doctor-patient relationship is key to reassuring the patient's doubts about his illness, which increases the chances of adherence to individualized treatment from patient to patient depending on the sing and symptoms that may manifest in those that include: dietary advice, psychological support, in some cases pharmacological prescription, suspension of medications or change medications, minimize the dose of drugs or suspend, according to the needs of the patient as is the case of opioids. The prognosis is still uncertain, and a promising future to illustrate new definitions, classifications, pathophysiologies, clinical aspects and treatments according to the type of clinical manifestation of each patient.

El síndrome del intestino irritable (SII) es una patología crónica con desordenes de la interacción cerebro intestino, caracterizado por dolor abdominal localizado en cualquier parte del abdomen además de alteración del hábito intestinal como (constipación, diarrea o mixto), en ausencia de alguna enfermedad que pueda causar estos síntomas. Con los conceptos actualizados conforme en la última reunión de expertos en Roma 2016, nuestra meta es dar a conocer más sobre el síndrome del intestino irritable, mediante revisión de la literatura en cuanto a definición, clasificación, fisiopatología, aspectos clínicos, tratamiento, pronóstico y el futuro. El SII es una patología crónica, caracterizado por dolor abdominal, por lo menos 1 día por semana en los últimos 3 meses, asociado a la alteración del hábito intestinal. Con una clasificación basada en la alteración de los hábitos intestinales y además de constipación inducida por opioides o narcóticos, la etiología y fisiopatología no están bien explicadas ni se conocen bien hasta el momento. Los aspectos clínicos son basados en los criterios de Roma IV. Una buena relación médico-paciente es clave para tranquilizar las dudas del paciente sobre su enfermedad, lo que aumenta las posibilidades de adherencia al tratamiento individualizado de paciente a paciente dependiendo de las sintomatologías y signos que puedan manifestar en los que incluyen: asesoramiento dietético, apoyo psicológico, en algunos casos cambiar medicación, disminuir al mínimo la dosis del medicamento o suspender, según las necesidades del paciente como son los casos de los opiodes. El pronóstico todavía incierto, y un futuro prometedor para ilustrar nuevas definiciones, clasificaciones, fisiopatologías, aspectos clínicos, tratamientos posiblemente de acuerdo con el tipo de manifestación clínica de cada paciente.

Detection of enteric agents into a cats' shelter with cases of chronic diarrhea in Southern Brazil / Detecção de agentes enteropatogênicos associados à diarreia crônica em um gatil no Sul do Brasil

This study carried out a survey about enteropathogenic agents in domestic cats' shelter as a stage of investigation for the intermittent chronic diarrhea. Individual fecal samples from 39 cats with free access to the external environment were submitted to parasitological examination, parvovirus, and coronavirus by PCR, and Cryptosporidium spp., Giardia spp. and Tritrichomonas foetus by real-time PCR. From the cats evaluated, 30 (76.9%) were positive for one or more enteric agents, and coinfections were observed in 11 cats samples (28.2%). Helminth eggs were observed in 48.7% of cats (19/30), 16 (41%) were positive for parvovirus or coronavirus and 25.6% (10/30) were infected by protozoa. From the positives for protozoa, five cats were positive to T. foetus (12.82%). The first finding of this protozoan through PCR was in the southern Brazil, and the second was in the whole country. Chronic diarrhea in cats may be multifactorial in shelter animals where the population density is high and the control of parasitic, and viral infections are deficient. Moreover, it is due to poor hygiene conditions in these shelters. The factors associated with the proliferation of infectious diseases in shelters are correlated with new pathogens infections such as T. foetus.(AU)

Uma pesquisa de agentes enteropatogênicos em gatos domésticos de um abrigo foi realizado como etapa da investigação das causas de diarreias crônicas intermitentes. Amostras fecais individuais de 39 gatos, com livre acesso ao ambiente externo, foram obtidas para pesquisa de helmintos através do exame parasitológico, investigação de parvovírus e coronavírus e de Cryptosporidium spp., Giardia spp. e Tritrichomonas foetus através de PCR em tempo real. Dos gatos avaliados, 30 (76,9%) foram positivos para algum ou mais de um destes agentes entéricos. Desses, 11 (28,2%) apresentaram co-infecções parasitárias. Ovos de helmintos foram observados em 48,7% dos gatos (19/30), 16 felinos (41%) foram positivos para parvovírus ou coronavírus e 25,6% (10/30) estavam infectados por protozoários. Dos positivos para protozoários, cinco apresentaram Tritrichomonas foetus (12,82%), um organismo pouco relatado no Brasil, sendo este o primeiro relato de detecção deste protozoário através de PCR em fezes de gatos no Sul do Brasil e o segundo no país. A diarreia crônica em gatos pode ser multifatorial em animais de abrigo onde a densidade populacional é elevada e os meios de controle parasitário e viral são deficitários, além das condições de higiene precárias. Os fatores associados à proliferação de doenças infecciosas em abrigos promovem o surgimento de infecções por novos patógenos como o Tritrichomonas foetus, até então pouco relatado no Brasil.(AU)

Linfangiectasia intestinal primaria: primer reporte de caso en Perú / Primary intestinal lymphangiectasia: first case report in Peru

La linfangiectasia intestinal primaria es una entidad clínica poco común de etiología desconocida. La edad típica de presentación de esta enfermedad es durante los 3 primeros años de vida, pero también se han reportado casos en adultos. Posee sintomatología variable, pero la manifestación clínica principal es el edema, puede presentarse también diarrea y pérdida de peso. La pérdida de fluido linfático en el tracto gastointestinal conlleva también a hipoproteinemia y linfopenia. El diagnóstico se establece en base a la clínica, a los estudios de laboratorio, al estudio endoscópico y se confirma con la evaluación histológica de la biopsia realizada. El manejo se da mediante una dieta rica en proteínas, baja en grasas y triglicéridos de cadena media. A continuación, se presenta el caso de un paciente varón de 1 año de edad que presenta edema generalizado, con predominio de miembros inferiores, y diarrea. Los exámenes de laboratorio muestran la presencia de hipoproteinemia marcada. Posteriormente, se realiza una endoscopía digestiva alta y una biopsia duodenal. El estudio histológico confirma el diagnóstico de linfangiectasia intestinal primaria. El paciente recibe el tratamiento establecido para esta enfermedad y, finalmente es dado de alta.

Primary intestinal lymphangiectasia is a rare clinical condition of unknown etiology. The common age of presentation is during the first 3 years of life, but cases in adults have also been reported. It has a variable symptomatology, but the main clinical manifestation is edema, also diarrhea and weight loss can occur. The loss of lymph fluid into the gastrointestinal tract also leads to hypoproteinemia and lymphopenia. Diagnosis is based on clinical manifestations, laboratory and endoscopic findings, and is confirmed on histopathological examination of biopsy. The main treatment is a protein rich, low in fat and medium chain triglyceride diet. We present the case of a 1-year-old male patient who presents with generalized edema, predominantly in lower limbs, and diarrhea. Laboratory findings show the presence of marked hypoproteinemia. Then an endoscopy and a duodenal biopsy are performed, and the histopathological study confirms the diagnosis of primary intestinal lymphangiectasia. The patient is treated and after a satisfactory evolution, is discharged.

Estrongiloidiasis gastrointestinal en paciente inmunocompetente: a propósito de un caso / Gastrointestinal strongyloidosis in an immunocompetent patient: a case report

Intestinal parasitic infections cause a not insignificant number of chronic diarrhea in children, however, with the sociodemographic change that our country has experienced, the number of cases and new parasites (immigration from tropical endemic areas) could increase. We report the case of an immunocompetent patient who presents with chronic diarrhea associated with Strongyloides stercoralis infection. The patient migrated two years ago from an endemic area for this helminth. The diagnosis is challenging, and the chances of a successful outcome depend on the administration of the antiparasitic.

Las infecciones parasitarias intestinales provocan un número no despreciable de causas de diarrea crónica en niños, sin embargo, con el cambio sociodemográfico que ha vivido nuestro país se podría incrementar el número de casos y de nuevos parásitos (inmigración de áreas endémicas tropicales). Reportamos el caso de un paciente inmunocompetente, que presenta cuadro de diarrea crónica asociada a infección por Strongyloides stercoralis. El paciente habría migrado hace dos años desde zona endémica para este helminto. El diagnóstico es desafiante y las posibilidades de un resultado exitoso dependen de la administración del antiparasitario.

Diarrea aguda en el lactante y preescolar / Acute diarrhea in toddlers and infants

Acute diarrhea (AD) is the increase in frequency and volume of bowel movements with decrease in their consistency that lasts less than 14 days. AD is a major public health problem and is still nowadays a cause of significant morbidity and mortality during childhood, especially in children with nutritional deficits. At a younger age, there is a greater susceptibility to diarrhea, which is more intense and more likely cause dehydration. The prevention and management of dehydration is the mainstay of treatment. The use of medications must be used with caution, analyzing individual cases and based on the best available evidence. We will analyze the subject with special emphasis on treatment according to scientific evidence.

La diarrea aguda (DA) se define como el aumento en la frecuencia y volumen de las deposiciones con disminución de la consistencia y que dura menos de 14 días. La DA es un gran problema de salud pública y es aún hoy en día una causa de importante morbimortalidad durante la infancia en especial en niños con déficits nutricionales. A menor edad hay mayor susceptibilidad de presentar diarrea, siendo ésta de mayor intensidad y con mayores posibilidades de producir deshidratación. La prevención y el manejo de la deshidratación es el pilar fundamental del tratamiento. El uso de medicamentos debe ser criterioso, analizando cada caso individual y basado en la mejor evidencia disponible. Analizaremos el tema con especial énfasis en el tratamiento según evidencia científica.

Diagnóstico y manejo de la colitis microscópica / Diagnosis and management of microscopic colitis

Microscopic colitis (MC) is a clinical condition characterized by chronic watery diarrhea, normal colonic mucosa and characteristic histological findings. It is composed of two main entities: collagenous colitis (CC) and lymphocytic colitis (LC). Its incidence has been increasing, currently accounting for between 8 to 16% of studies for chronic diarrhea. It is more frequent in elderly women and is strongly associated with other autoimmune disorders. Its pathogenesis is not very well understood, but it supposes the immune activation secondary to the exposure of the colonic mucosa to different luminal antigens, mainly drugs. Management includes suspension of the potential causative agent and the use of anti-diarrheal medications. Oral budesonide has proven to be effective in induction and maintenance of remission, but with a high rate of recurrence upon discontinuation. Immune-modulators drugs such as azatioprine and metrotrexate have been tested in patients dependent to corticoids with variable results. Antibodies against tumor necrosis factors (TNF) are under studies, with promising results.

La colitis microscópica (CM) es una condición clínica caracterizada por diarrea crónica acuosa con mucosa colónica normal y hallazgos histológicos característicos. Está compuesta por dos entidades principales: la colitis colágena (CC) y la colitis linfocítica (CL). Su incidencia ha ido en aumento, siendo en la actualidad la responsable del 8 a 16% de los casos por diarrea crónica. Es más frecuente en mujeres de edad avanzada con una fuerte asociación a otras enfermedades autoinmunes. Su etiopatogenia no es del todo conocida, pero se cree juega un rol la activación inmune secundaria a la exposición de la mucosa colónica a diferentes antígenos luminales, principalmente fármacos. Dentro del manejo se incluye la suspensión del potencial agente causal y el uso de fármacos antidiarreicos. La budesonida oral ha demostrado alta efectividad en la inducción y mantención de la remisión, pero con una alta tasa de recurrencia al suspenderla. Fármacos inmunomoduladores como azatioprina y metrotrexato se han probado en pacientes corticodependendientes con resultados variables. El uso de anticuerpos monoclonales anti factor de necrosis tumoral (TNF) se encuentra en estudio, con resultados prometedores.

Indicadores de saúde ambiental nos assentamentos do município de Cáceres: faixa fronteiriça Brasil/Bolívia / Environmental health indicators in the settlements of the county of Cáceres: border strip Brazil/Bolivia / Indicadores de salud ambiental em los asentamientos del município de Cáceres: banda fronteriza Brasil/Bolívia

Objetivo: propor e avaliar indicadores de saúde ambiental dos assentados na faixa fronteiriça cacerense. Método: utilizou-se o estudo descritivo, explicativo, quanti-qualitativo e censo, abrangendo todos os responsáveis pelas propriedades (lotes) dos assentamentos Jatobá, Nova Esperança, Rancho da Saudade, Sapicuá, Corixo, Bom Sucesso e Katira. Para coleta de dados foi aplicado um formulário semiestruturado, no período de março a julho de 2016, a 136 agricultores. Na construção dos indicadores utilizou-se a abordagem derivada do modelo Pressão-Estado-Impacto-Resposta. Os indicadores propostos foram: destinação do lixo, qualidade da água e casos de diarreia em crianças. As fontes de captação de água foram submetidas a quatro análises físico-química e microbiológica. Resultados: na destinação do lixo doméstico predominou a categoria queima com 80,9%, seguida das categorias enterra com 8,8% e queima e enterra com 10,3%. Verificou-se que a água não atende as exigências do Ministério da Saúde, devido à presença de Coliformes Totais. O número de crianças nos assentamentos foi 69, destas 88,40% consomem água dos poços coletivos, 52,45% apresentaram episódios de diarreia. Conclusão: os indicadores mostraram-se eficazes, sendo necessárias ações coletivas de orientações referentes aos cuidados com a destinação do lixo e o isolamento no entorno dos poços, e análises periódicas das águas destes assentamentos.(AU)

Objective: to propose and evaluate indicators of environmental health of the settlers in the border area of Caceres. Method: the descriptive, explanatory, quantitative-qualitative and census study was used, covering all those responsible for the properties (lots) of the Jatobá, Nova Esperança, Rancho da Saudade, Sapicuá, Corixo, Bom Sucesso and Katira settlements. For data collection, a semistructured form was applied, from March to July 2016, to 136 farmers. In the construction of the indicators we used the approach derived from the Pressure-State-Impact-Response model. The proposed indicators were: waste disposal, water quality and cases of diarrhea in children. The sources of water abstraction were submitted to four physical-chemical and microbiological analyzes. Results: domestic waste disposal predominated in the category burned with 80.9%, followed by the categories burial with 8.8% and burning and burial with 10.3%. It was verified that the water does not meet the requirements of the Ministry of Health, due to the presence of Total Coliforms. The number of children in the settlements was 69, of whom 88.40% consume water from the collective wells, 52.45% had episodes of diarrhea. Conclusion: the indicators were effective, requiring collective actions of guidelines regarding waste disposal and isolation in the vicinity of the wells, and periodic analysis of the waters of these settlements.(AU)

Objetivo: proponer y evaluar indicadores de salud ambiental de los asentados en la franja fronteriza cacerense. En el presente trabajo se analizaron los resultados obtenidos en el análisis de los resultados obtenidos en el análisis de los resultados obtenidos. Método: para la recolección de datos se aplicó un formulario semiestructurado, en el período de marzo a julio de 2016, a 136 agricultores. En la construcción de los indicadores se utilizó el abordaje derivado del modelo Presión-Estado-Impacto-Respuesta. Los indicadores propuestos fueron: destino de la basura, calidad del agua y casos de diarrea en niños. Las fuentes de captación de agua se sometieron a cuatro análisis físico-químicos y microbiológicos. Resultados: en la destinación de la basura doméstica predominó la categoría quema con 80,9%, seguida de las categorías enterra con 8,8% y quema y enterra con el 10,3%. Se verificó que el agua no atiende las exigencias del Ministerio de Salud, debido a la presencia de Coliformes Totales. El número de niños en los asentamientos fue 69, de estas 88,40% consumen agua de los pozos colectivos, 52,45% presentaron episodios de diarrea. Conclusión: los indicadores se mostraron eficaces, siendo necesarias acciones colectivas de orientaciones referentes a los cuidados con la destinación de la basura y el aislamiento en el entorno de los pozos, y análisis periódicos de las aguas de estos asentamientos.(AU)