Hemorragia alveolar pulmonar como presentación poco frecuente de infección por Leptospira spp: una enfermedad ocupacional del personal militar en zonas tropicales / Pulmonary alveolar hemorrhage as an unusual presentation of Leptospira spp: an occupational-disease of military personnel in tropical zones

Resumen La leptospirosis es una de las zoonosis endémicas más importantes en el mundo con un aumento de la incidencia en los últimos años. En el personal militar podría ser catalogada como una enfermedad ocupacional dado sus actividades específicas en áreas rurales. Su presentación clínica es variable siendo en la mayoría de los casos una enfermedad febril autolimitada. De acuerdo con diversos factores dependientes del patógeno y del hospedero pueden presentarse manifestaciones severas de la enfermedad dentro de la cual destaca el compromiso pulmonar con una alta tasa de mortalidad. Existe evidencia del uso de esteroide sistémico como parte del tratamiento de esta complicación. Presentamos el caso de un paciente joven, militar, que debuta con síndrome de hemorragia alveolar difusa secundario a leptospirosis y presenta una excelente respuesta al tratamiento con altas dosis de metilprednisolona, con una discusión del proceso diagnóstico y aspectos fisiopatológicos de esta condición.

Leptospirosis is one of the most important endemic zoonoses in the world with an increase in incidence in recent years. In military personnel it could be classified as an occupational disease given their specific activities in rural areas. Its clinical presentation is variable being in most cases a self-limited febrile disease. According to various factors dependent on the pathogen and the host, severe manifestations of the disease may occur within which the pulmonary involvement with a high mortality rate stands out. There is evidence of systemic steroid use as part of the treatment of this complication. We present a case of a young, military patient who debuts with diffuse alveolar hemorrhage syndrome secondary to leptospirosis and presents an excellent response to treatment with high doses of methylprednisolone, with a discussion of the diagnostic process and pathophysiological aspects of this condition.

Leptospirosis, una zoonosis que impacta a la salud: diagnóstico, tratamiento y nuevas alternativas de control / Leptospirosis a zoonosis that impacts health: diagnosis, treatment and new alternatives of control

La leptospirosis es una zoonosis con potencial epidémico y de difícil diagnóstico que requiere un manejo integral para orientar las medidas de prevención y control; sin embargo, una de las dificultades es la existencia de más de 300 serovares, la supervivencia de la bacteria en el ambiente por más de 180 días y la importancia del agua como vehículo de transmisión. Esto asociado con los efectos adversos de los antibióticos y su efecto sobre la multirresistencia generada por la mayoría de las bacterias, hace que se evalúen nuevas alternativas a partir de la biodiversidad. Por lo tanto, el objetivo de este artículo es abordar la leptospirosis y su diagnóstico enfatizando en el control convencional de la infección y las alternativas de tratamiento a partir del uso de plantas medicinales. Para esto se realizó una revisión exhaustiva de artículos en bases de datos. La información encontrada permitió establecer los aspectos relevantes de la enfermedad, su diagnóstico y tratamiento, tanto con antimicrobianos convencionales como frente a nuevas alternativas de origen natural. Se concluye que es importante realizar investigaciones orientadas hacia la búsqueda de principios activos que puedan contribuir al control de Leptospira spp., agente causal de la leptospirosis, una de las zoonosis más importantes por su impacto en salud humana, veterinaria y del ecosistema(AU)

Leptospirosis is a potentially epidemic zoonosis of difficult diagnosis which requires comprehensive management to indicate appropriate prevention and control measures. However, some of the difficulties are the existence of more than 300 serovars, survival of the bacteria in the environment for more than 180 days, and the role of water as a route of transmission. The above situation, alongside the adverse effects of antibiotics and their effect on the multi-drug resistance developed by most bacteria, lead to the search for new alternatives based on biodiversity. The purpose of the study was therefore to address leptospirosis and its diagnosis highlighting conventional control of the infection as well as treatment options based on the use of medicinal plants. To achieve this end, an exhaustive review was conducted of papers included in databases. The information obtained made it possible to determine the relevant aspects of the disease, its diagnosis and its treatment with conventional antimicrobials as well as new alternatives of a natural origin. Conclusions point to the importance of conducting research aimed at the search for active principles potentially contributing to control of Leptospira spp., the causative agent of leptospirosis, one of the most relevant zoonoses in terms of its impact on the health of humans, animals and the ecosystem(AU)

Glucocorticoides en hemorragia alveolar por leptospira / Glucocorticoids in leptospira alveolar hemorrhage

Resumen Se presentan los casos clínicos de dos pacientes que ingresaron en la guardia de Emergencias del HIGA San Martín de La Plata con un cuadro clínico compatible con leptospirosis, que evolucionaron con insuficiencia respiratoria y hemorragia alveolar. En ambos se administraron glucocorticoides con buena evolución. Se realizó una búsqueda bibliográfica de artículos publicados desde 2005 en castellano e inglés y la revisión del tema. Basada en la evidencia actual no se puede hacer una clara recomendación para el uso de corticoides en la leptospirosis grave. La bibliografía publicada es escasa y de baja calidad. Aparentemente habría un beneficio en el uso de corticoides en los casos de afectación pulmonar por leptospirosis grave. Se necesitan estudios de alta calidad para realizar recomendaciones con evidencia científica, para verificar la dosis adecuada de corticoides, tiempo de inicio, duración del tratamiento y los casos en los que se debería administrar esta terapéutica.

Abstract We present the clinical cases of two patients who were admitted to the HIGA San Martín de La Plata emergency ward with a clinical picture compatible with leptospirosis, who evolved with respiratory failure and alveolar hemorrhage. In both, glucocorticoids were administered with good evolution. A bibliographic search of articles published since 2005 in Spanish and English and a review of the topic was carried out. Based on the current evidence, no clear recommendation can be made for the use of corticosteroids in severe leptospirosis. The published bibliography is scarce and of low quality. There would appear to be a benefit in the use of corticosteroids in cases of pulmonary involvement due to severe leptospirosis. High-quality studies are needed to make recommendations with scientific evidence, to verify the adequate dose of corticosteroids, time of initiation, duration of treatment and the cases in which this therapy should be administered.

Leptospirosis en pediatría, un diagnóstico a tener en cuenta / Leptospirosis in pediatrics, a diagnosis to be considered

Resumen La leptospirosis humana es una importante causa de enfermedad febril aguda que afecta con mayor frecuencia las zonas tropicales. Su principal reservorio es los roedores por lo que la infección está vinculada con factores de pobreza, déficit sanitario, actividades recreativas y laborales que favorecen el contacto con la orina de animales infectados, agua o suelos contaminados. Las infecciones por Leptospira spp tienen una presentación inespecífica desde cuadros asintomáticos hasta un compromiso multisistémico con alta mortalidad, siendo la sospecha clínica y la presencia de factores de riesgo las variables iniciales para el diagnóstico de la enfermedad. Entre los métodos disponibles para el diagnóstico microbiológico se destaca la observación directa, el cultivo, la reacción de polimerasa en cadena y la serología que permiten la confirmación de éste. El tratamiento de leptospirosis en niños se basa en medidas de soporte y en el inicio de antimicrobianos β-lactámicos o macrólidos. Las medidas de prevención de la enfermedad son fundamentales en la población expuesta al riesgo siendo recursos esenciales intervenciones generales, quimioprofilaxis y vacunación. El conocimiento, la consideración diagnóstica y el tratamiento oportuno en el paciente pediátrico, acelera la recuperación y limita la aparición de complicaciones que pueden impactar en la calidad de vida.

Abstract Human leptospirosis is an important cause of acute febrile disease that most frequently affects tropical areas. Its main reserve is rodents, so the infection is limited by factors of poverty, health deficit, recreational and work activities that favor contact with the urine of infected animals, contaminated water or soil. Leptospira spp infections have a non-specific presentation, ranging from asymptomatic to multisystem compromise with high mortality; being the clinical suspicion and the presence of risk factors the initial variables for the diagnosis of the disease. Among the available methods for microbiological diagnosis, direct observation, culture, polymerase chain reaction and serology that allows confirmation of this are highlighted. The treatment of leptospirosis in children is based on clinical support measures and the antibiotic initiation of β-lactams or macrolides. Disease prevention measures are fundamental in the population exposed to risk being essential resources general interventions, chemoprophylaxis and vaccination. The knowledge, diagnostic consideration, and timely treatment in pediatric patients accelerate recovery and limit the appearance of complications that can impact the quality of life

Neuroleptospirosis con pericarditis y colestasis intrahepática (Síndrome de Weil) / Neuroleptospirosis with Pericarditis and Intrahepatic Cholestasis (Weil syndrome)

Introducción: El síndrome de Weil es una forma grave de la infección bacteriana causada por la bacteria Leptospira, conocida como leptospirosis. Este se caracteriza por la disfunción de múltiples órganos, entre ellos, hígado, riñón, músculos, serosas o el sistema neurológico, en este caso denominado neuroleptospirosis, genera una mortalidad muy elevada cuando no se brinda diagnóstico y tratamiento adecuado. Objetivo: Describir las manifestaciones clínicas, paraclínicos complementarios y tratamiento de un paciente con síndrome de Weil, una condición poco frecuente. Caso clínico: Paciente de 23 años quien consulta en el contexto de síndrome febril agudo asociado con neuritis óptica, dolor torácico y paraclínicos que evidenciaron afectación hepática y cardíaca. Se confirma el diagnóstico de síndrome de Weil dado por neuroleptospirosis, pericarditis y colestasis intrahepática. Conclusiones: mediante un caso clínico de síndrome de Weil, se describe la afectación multisistémica de complicaciones asociadas con leptospirosis, con manifestaciones poco habituales como neuroleptospirosis, pericarditis y colestasis intrahepática(AU)

Introduction: Weil syndrome is a serious form of the bacterial infection caused by the Leptospira bacterium; this is known as leptospirosis. This is characterized by multiple organ dysfunction; for example, the liver, kidney, muscles, of serous type, or the neurological system, in this case called neuroleptospirosis, which produces a very high mortality when adequate diagnosis and treatment are not provided. Objective: To describe the clinical manifestations, complementary paraclinic practice and treatment of a patient with Weil syndrome, as a rare condition. Clinical case: 23-year-old patient who presents with acute febrile syndrome associated with optic neuritis, chest pain, and paraclinical symptoms obviously consistent liver and cardiac involvement. The diagnosis of Weil syndrome is confirmed, specifically defined by neuroleptospirosis, pericarditis, and intrahepatic cholestasis. Conclusions: Through a clinical case of Weil syndrome, the multisystem involvement of complications associated with leptospirosis is described, along with its unusual manifestations, such as neuroleptospirosis, pericarditis, and intrahepatic cholestasis(AU)

Ionic imbalance and lack of effect of adjuvant treatment with methylene blue in the hamster model of leptospirosis

Leptospirosis in humans usually involves hypokalaemia and hypomagnesaemia and the putative mechanism underlying such ionic imbalances may be related to nitric oxide (NO) production. We previously demonstrated the correlation between serum levels of NO and the severity of renal disease in patients with severe leptospirosis. Methylene blue inhibits soluble guanylyl cyclase (downstream of the action of any NO synthase isoforms) and was recently reported to have beneficial effects on clinical and experimental sepsis. We investigated the occurrence of serum ionic changes in experimental leptospirosis at various time points (4, 8, 16 and 28 days) in a hamster model. We also determined the effect of methylene blue treatment when administered as an adjuvant therapy, combined with late initiation of standard antibiotic (ampicillin) treatment. Hypokalaemia was not reproduced in this model: all of the groups developed increased levels of serum potassium (K). Furthermore, hypermagnesaemia, rather than magnesium (Mg) depletion, was observed in this hamster model of acute infection. These findings may be associated with an accelerated progression to acute renal failure. Adjuvant treatment with methylene blue had no effect on survival or serum Mg and K levels during acute-phase leptospirosis in hamsters. .

Informe ultrarrápido de evaluación de tecnología sanitária: profilaxis antibiótica para la leptospirosis en caso de desastre natural (inundación) / Ultra-rapid report health technology assessment: antibiotic prophylaxis for leptospirosis in the event of a natural disaster (flood)

La leptospirosis es una zoonosis bacteriana causada por especies del género Leptospira que afectam a humanos y animales. Su reservorio lo constituyen los roedores y animales domésticos principalmente, y su transmisión ocurre por la contaminación de suelos y agua con la orina de estos animales. Su distribucción es amplia en países tropicales incluyendo la región del Caribe, América Central y paises de Amércia del Sur. La mayoría de las infecciones son subclínicas o leves, pero puede ocasionar cuadros clínicos graves e incluso fatales. Situaciones particularmente graves de riesgo de infección las constituyen las inundaciones, ya que aumenta el contacto con aguas contaminadas por la orina de los animales vectores. Se realizó un informe ultrarrápido de evaluación de tecnología sobre las profilaxis antibiótica para la leptospirosis en caso de inundación a pedido de las autoridades del Ministerio de Salud de la Provincia de Burenos Aires. Conclusiones: La evidencia analizada no permite determinar si existen beneficios claros en relación al uso de doxiciclina 200 ms semanal en forma profiláctica para evitar la infección por leptospirosis en caso de inundación, luego de la exposición al factor de risgo. En cambio sí se observó aumento de efectos adversos leves (náuseas y vómitos) con el empleo de dicho antibiótico. Se necesitan nuevos ensayos clínicos controlados y aleatorizados de alta calidad metodológica para poder esclarecer la efectividad de la quimioproflaxis de casos de leptospirosis epidémica relacionados a inundaciones. Intervención no recomienda evidencia heterogénea impide extraer conclusiones sobre beneficio clínico en este momento.

Títulos de anticorpos aglutinantes induzidos por vacinas comerciais contra leptospirose bovina / Agglutinating antibody titers induced by commercial vaccines against bovine leptospirosis

No presente estudo, 100 fêmeas bovinas foram divididas em cinco grupos de 20 animais cada. Os grupos experimentais receberam quatro diferentes vacinas comerciais (B, C, D e E), e um grupo permaneceu como controle. Amostras foram colhidas no dia da aplicação da primeira dose e nos dias 3, 7, 14, 21, 28, 35, 42, 49, 56, 63, 70, 77, 84, 91, 120, 150 e 180 pós-vacinação (PV). A triagem dos animais foi feita pela análise sorológica com 6 antígenos de leptospiras, escolhendo-se os animais não reagentes. Os títulos de anticorpos foram monitorados pela soroaglutinação microscópica (SAM) com os sorovares Canicola, Grippotyphosa, Hardjo, Icterohaemorrhagiae, Pomona e Wolffi. Todas as vacinas induziram, aos 3 dias PV, títulos de anticorpos aglutinantes para os sorovares Hardjo e Wolffi, que persistiram até o 150º dia PV. Os sorovares Hardjo e Wolffi induziram os maiores títulos de anticorpos aglutinantes. A vacina D, apesar de não possuir o sorovar Wolffi em sua composição foi capaz de induzir anticorpos aglutinantes contra este sorovar. Somente foram detectados anticorpos contra o sorovar Canicola nos animais vacinados com a bacterina D. A vacina que induziu os maiores títulos médios de anticorpos, considerando todos os sorovares testados foi a D.

In the investigation 100 heifers were used, divided into 5 groups of 20 animals each. The four experimental groups were vaccinated using distinct commercial polyvalent bacterines: B, C, D and E, and A group was the control. Samples were collected at days 0, 3, 7, 14, 21, 28, 35, 42, 49, 56, 63, 70, 77, 84, 91, 120, 150 and 180 from the first injection of the vaccine. The selection of the animals for the experimental groups was done based on a serological screening with 6 antigens of Leptospira sp. constituted by non-reagent animals. The vaccine titers were monitored using the microscopic agglutination test (MAT) for Canicola, Grippotyphosa, Hardjo, Icterohaemorrhagiae, Pomona and Wolffi serovars. All vaccines used were capable to product agglutinins for the Hardjo and Wolffi serovars observed at 3 days after vaccination, remaining until the 150th day; those serovars induced the highest titres of agglutinins. Vaccine D, in spite of not containing the Wolffi serovar, induced the production of agglutinins to this serovar. Agglutinins to the Canicola serovar were only observed in the animals vaccinated with the D bacterine. Vaccine D induced the highest average titers of antibodies to all tested serovars.

Hemorrhagic pulmonary leptospirosis: three cases from the Yucatan peninsula, Mexico / Leptospirose hemorrágica pulmonar: três casos na península de Yucatán, México

Three leptospirosis cases with lung involvement are reported from the Yucatan Peninsula, Mexico. All three patients were admitted to the intensive care unit due to acute respiratory failure. Treatment with antibiotics resulted in favorable evolution despite the negative prognosis. Leptospirosis should be included in the differential diagnosis of patients with fever and lung involvement.

Analisamos três casos de leptospirose com envolvimento pulmonar na Península Yucatán, México. Os três pacientes com seqüelas pulmonares entraram na unidade de cuidados intensivos devido à insuficiência respiratória grave. Todos os casos evoluíram favoravelmente ao tratamento com antibióticos, apesar do prognóstico negativo. Leptospirose deve ser incluída no diagnóstico diferencial de pacientes com febre e comprometimento pulmonar.

Renal involvement in leptospirosis: new insights into pathophysiology and treatment: [review]

Acute renal failure (ARF) is one of the most common complications of leptospirosis although the causal mechanisms are still unclear. Diverse mechanisms are implicated in leptospiral nephropathy and new data supports the role of peculiar ion transport defects. Besides antibiotic therapy, ARF management in leptospirosis requires dialytic therapy which is most efficient when started early. Dialysis is the standard supportive therapy even though recent evidence suggests clinical benefit from alternative treatments such as plasmapheresis and hemofiltration. Renal recovery is achieved soon after clinical improvement. The comprehension of the primary mechanisms of renal dysfunction will be helpful in the development of additional therapeutic tools for improving supportive therapy for leptospiral nephropathy. This review discusses new insights into mechanisms implicated in leptospiral ARF and recent advances in treatment.

Isolation of Leptospira canicola from a dog in Iran: first report

A 5-year-old male cross-bred guard dog with signs of anorexia, vomiting and jaundice was referred to Small Animal Hospital, Faculty of Veterinary Medicine, University of Tehran. Initial diagnostic laboratory tests revealed leukocytosis, thrombocytopenia, haemoconcentration, azotaemia, high liver enzyme activities, proteinuria and bilirubinuria. Aggressive therapeutic procedures failed to improve the animal deteriorated condition and finally the animal died. After necropsy, specimens were collected for microscopic examination as part of completing diagnostic procedures. Results of urine bacterial culture confirmed leptospirosis as a causative agent. Furthermore, numerous large spiral bacteria were also observed under dark-field microscope. This article summarizes and characterizes the historical and physical findings, laboratory data, bacterial culture and pathological diagnostic features of leptospirosis in the cross-bred dog. Based on published data, this is the first case of confirmed Leptospira isolation from a dog in Iran

The incidence and clinical characteristics of the immune phase eye disease in treated cases of human leptospirosis.

BACKGROUND: Uveitis is increasingly being reported from south India following epidemics of leptospirosis. The incidence of eye involvement in treated patients has not been investigated properly in prospective studies. AIMS: To determine the incidence, clinical spectrum and risk factors for Leptospiral uveitis in antibiotic-treated patients. SETTINGS AND DESIGN: A prospective cohort study conducted among the patients treated for leptospirosis at Calicut Medical College between July and November 2002 and a seroprevalence study among sewage workers. Materials And Methods: As many as 360 patients admitted with suspected leptospirosis were studied by clinical examination, baseline ophthalmic survey, laboratory investigations and Leptospira serology (Microagglutination test - MAT; and IgM and IgG using ELISA) during the epidemic. Of the 282 seropositive and antibiotic-treated cases, 174 patients who completed 30 months of regular follow-up were analyzed. A cross-sectional serosurveillance also was performed among 50 sewage workers to determine the baseline MAT titer. Statistical Analysis: Univariate analysis and logistic regression. RESULTS: Thirty-two patients (18.4%) developed the eye disease during follow-up. The mean age was 43.9 years and the sex ratio was equal. Twenty-one patients (65.6%) had anterior uveitis. Only six patients (18.8%) had visual symptoms. Median duration for developing anterior uveitis was 4 weeks. Recurrent uveitis was not seen following treatment. None had vision-threatening eye disease. Clinical and laboratory abnormalities during the acute phase did not pose risk for development of the eye disease later. Forty-six sewage workers (92%) showed a MAT titer of 1/25. CONCLUSIONS: Uveitis is common following acute leptospirosis. Antibiotic-treated patients during the acute phase of illness developed only mild uveitis.

Leptospirosis: clinical presentation and correlation with serovars.

A total of 2400 patients with pyrexia of unknown origin and or suspected leptospirosis were included in this study. Dark field microscopy detected Leptospira in 690 cases, Leptospira serological Investigations proved positive in 570 out of these 690 patients. Among them 212 had the classical icteric and the other 358 had anicteric type of presentation. Notably eptospira interrogans serovar ictero haemorrhagiae infection was encountered in 212 patients. In 30 patients, who had multi organ dysfunction which included renal failure, hepatic dysfunction or meningitis was due to Leptospira interrogans Serovar cannicola. Coexsistense of leptospirosis and hepatitis B virus infection were noted in 15 patients. Antibody to Leptospira interrogans was demonstrated by Micro agglutination test (MAT) in addition to dark field microscopy positivity in these cases. Similarly HIV antibody was demonstrated in 30 of the 330 anicteric patients. 554 out of 570 cases responded to intra venous penicillin (216), and oral Doxycycline (182) and Augmentin (156), and the remaining 16 patients succumbed to death.

Leptospirosis: puesta al día / Leptospirosis: a literature review

Se revisan los aspectos clínicos, diagnóstico de laboratorio y alternativas terapéuticas para la leptos-pirosis. Destaca en la epidemiología el riesgo ocupa-cional y laboral y la falta de datos, por no haber constituido en Chile tema de vigilancia epidemiológica hasta el año 2000. Los datos clínicos evidencian una notable heterogeneidad de manifestaciones, muchas veces inespecíficas. La complejidad del diagnóstico diferencial que plantea hace necesario incluirlo en el análisis causal de múltiples situaciones clínicas. El diagnóstico de laboratorio es aún complejo y poco accesible. Aunque es todavía controvertido, el análisis de la literatura apoya el beneficio del tratamiento antimicrobiano con varias alternativas de elección.

We review epidemiological, clinical, laboratory and therapeutic aspects of leptospirosis. In relation to the epidemiology it is worth noting the importance of recreational and occupational risk factors, as well as the lack of date available in Chile before the year 2000, when leptospirosis became the object of epidemiological surveillance. There are many forms of clinical presentations for this disease and often signs and symptoms may be nonspecific. Thus, differential diagnosis must include many clinical entities. Laboratory diagnosis, on the other hand, is complex and not widely available. Although still controversial, a literature review supports antimicrobial treatment, with different antibiotics to choose from.

A case of severe leptospirosis with pancytopaenia

Pancytopaenia is a rare clinical presentation of severe leptospirosis. We would like to report a case of severe leptospirosis that progressed to pancytopaenia despite initial penicillin therapy. The patient needed a second course of antibiotic with doxycycline to improve his persistent symptoms and cytopaenia. Persistent pancytopaenia in severe leptospirosis and its management were reviewed.

Evaluation of penicillin therapy in patients with leptospirosis and acute renal failure

The effectiveness of specific antibiotic treatment in severe leptospirosis is still under debate. As part of a prospective study designed to evaluate renal function recovery after leptospirosis acute renal failure (ARF) (ARF was defined as Pcr > or = 1.5 mg/dL), the clinical evolutions of 16 treated patients (T) were compared to those of 18 untreated patients (nT). Treatment or non-treatment was the option of each patient's attending infectologist. The penicillin treatment was always with 6 million IU/day for 8 days. No difference was found between the two groups in terms of age, gender, number of days from onset of symptoms to hospital admission, or results of laboratory tests performed upon admission and during hospitalization, but proteinuria was higher in the treated group. There were no significant difference in the other parameters employed to evaluate patients' clinical evolution as: length of hospital stay, days of fever, days to normalization of renal function, days to total bilirubins normalized or reached 1/3 of maximum value and days to normalization of platelet counts. Dialytic treatment indication and mortality were similar between group T and nT. In conclusion, penicillin therapy did not provide better clinical outcome in patients with leptospirosis and ARF

Leptospirosis: comunicacion de un caso / Leptospirosis: a case report

La leptospirosis es una enfermedad infecciosa causada por un tipo de espiroquetas, grupo de microorganismos cuyos distintos serotipos pueden causar manifestaciones clínicas diversas.Entre ellos los más relevantes son la meningitis aséptica y el síndrome de Weil, caracterizado por fiebre ictericia, insuficienciarenal y hemorragias. En chile, son pocos los casos comunicados, al ser una patología infrecuente en nuestro medio. Se presenta el caso de un paciente diagnosticado y tratado con éxito en el Hospital Dr. G. Fricke