Enterocolitis neutropénica en el paciente oncológico pediátrico / Neutropenic enterocolitis in the pediatric cancer patient

Resumen La enterocolitis neutropénica (ECN) es una enfermedad heterogénea de foco digestivo, pero afectación sistémica, que corresponde a una condición clínica grave que amenaza la vida de pacientes inmunocomprometidos, particularmente oncológicos pediátricos. De patogenia aún poco definida y aunque de causa multifactorial, la ECN se asocia a los efectos citotóxicos de la quimioterapia empleada y se caracteriza por la triada clásica que incluye fiebre, neutropenia y dolor abdominal, donde la principal injuria se localiza en la mucosa intestinal, provocando su alteración como barrera y facilitando la invasión bacteriana intramural. La ECN constituye un reto diagnóstico para el equipo tratante, que requiere ser oportuno y contar con apoyo de un óptimo laboratorio general e imagenológico, para iniciar un completo manejo multidisciplinario en unidades y centros de alta complejidad. Se presenta una revisión actualizada del tema incorporando aspectos epidemiológicos, factores de riesgo, elementos de apoyo diagnóstico, consideraciones terapéuticas y medidas de prevención a fin de aportar en el conocimiento de esta patología, y reducir morbimortalidad en estos pacientes.

Abstract Neutropenic enterocolitis (NEC) is a heterogeneous disease of the gastrointestinal tract with systemic response, that corresponds to a severe and life-threatening clinical condition in immunocompromised patients, especially in childhood cancer. The pathologic features are poorly understood, although its multifactorial cause of NEC is well established and it is associated with the cytotoxic effects of the chemotherapy agents used and recognized by the classic triad of fever, neutropenia, and abdominal pain, secondary to gastrointestinal injuries that alters mucosal permeability and helps intramural bacterial invasion. NEC is truly a clinical challenge that requires an early diagnosis and a multidisciplinary approach including basic laboratory and imagological tests in high complexity centers. We present a current review, adding epidemiological aspects, risks factors, diagnostic support elements, therapeutic considerations, and preventive measures in order to provide knowledge of this disease and help to reduce morbidity and mortality associated with it.

Características clínicas y microbiológicas de infecciones del torrente sanguíneo en pacientes adultos neutropénicos / Clinical and microbiological characteristics of bloodstream infections in adult neutropenic patients

RESUMEN Las infecciones del torrente sanguíneo (IS) en pacientes oncológicos neutropénicos constituyen una patología de relevancia y se asocian a un aumento de la morbimortalidad. El objetivo de este estudio fue determinar las características epidemiológicas y microbiológicas de los episodios de IS en pacientes adultos neutropénicos con neoplasias hematológicas (NH) y neoplasias sólidas (NS). Se realizó un estudio retrospectivo en dos hospitales de tercer nivel entre 2009 y 2016. Se incluyeron todos los pacientes neutropénicos mayores de 18años con NH y NS que presentaron episodios de IS. Se excluyeron aquellos con neoplasias dermatológicas no melanoma. Se identificaron 143 episodios de IS, de los cuales el 80,4% fueron en personas con NH. El 97,9% de los pacientes tuvieron neutropenia de alto riesgo, sin diferencia entre los grupos NH y NS. Los orígenes más frecuentes de IS fueron bacteriemia primaria (46,9%) e infección asociada a catéter (21%), sin diferencias significativas entre grupos. El 74,1% de los aislamientos fueron bacilos gram negativos yEscherichiacolifue el microorganismo más frecuente (32,1%). El coco gram positivo más frecuentemente aislado fueStaphylococcusaureus(28,1%), seguido del grupo de los estafilococos coagulasa negativos (ECN), sin diferencias entre ambos tipos de neoplasias. El 67,5% de los ECN fueron multirresistentes; solo el 11,1% de los aislamientos deS. aureusfue resistente a la meticilina. El 17,6% de los aislamientos deE. coliy el 27,6% de los deKlebsiellapneumoniaefueron multirresistentes. No hubo diferencias en la frecuencia de aislamientos multirresistentes al comparar entre ambos tipos de neoplasia. Como conclusión, las IS en pacientes neutropénicos fueron más frecuentes en pacientes con NH y las causaron, principalmente, bacilos gram negativos. Se observó una elevada mortalidad en los pacientes neutropénicos con IS.

ABSTRACT Bloodstream infections (BI) are relevant in neutropenic patients because they are associated with an increased number of complications and death. The objective was determinate the epidemiologic and microbiologic features of the BI in neutropenic patients with solid neoplasm (SN) and hematologic neoplasm (HN). Retrospective study in two third level hospitals between 2009 and 2016. They were included all the patients older than 18 years-old with active oncologic disease and neutropenia, who had BI. Patients with dermatologic cancer other than melanoma where excluded. A total of 143 BI in neutropenic were observed, of which 80.4% occurred in HN. Around 97.9% of the patients had a high-risk neutropenia without differences between both groups. The most frequent site of BI was primary bacteremia (46.9%) and catheter-associated infection (21%), without significant differences between the two groups. The gram negatives bacilli (GNB) predominated over the gram positive cocci (GPC) and they represented 74.1% of the isolated bacteria, beingEscherichia colithe most frequent (32.8%). Among the gram positive cocci,Staphylococcus aureus(28.1%) was the most frequent isolated, followed by coagulase-negativeStaphylococci(CNS). There were no differences in microbiological isolates between both groups. With regard to the antimicrobial susceptibility 67.5% of the CNS, 17.6% of theE. coliand 27.6% of theKlebsiella pneumoniaewere multiresistant with no differences between both groups. Only 11.1% of S. aureus isolates were methicillin resistant. In conclusion BI of the neutropenic patients where most frequents within patients with HN, GNB were the main microbiological isolates. High mortality was observed in neutropenic patients with BI.

Neutropenia febril asociada a la ingesta de metimazol: reporte de caso / Febrile neutropenia associated with methimazole ingestion: case report

La neutropenia se define como un recuento absoluto de neutrófilos menor a 1500 células /µL. Se debe a la disminución en la producción de granulocitos o al aumento en su destrucción, ya sea a nivel medular o periférico. Según la clasificación de la Organización Mundial de la Salud (OMS) los grados de neutropenia van de 0 a IV, de acuerdo a la magnitud de la disminución del recuento de neutrófilos. El grado IV es el de mayor riesgo y corresponde a recuentos por debajo de 500 células/µL. El impacto en la morbimortalidad asociada a la neutropenia no está vinculado con la disminución directa del recuento celular, sino con los procesos infecciosos asociados a los que son propensos los pacientes que la presentan. Existen diversas condiciones por las que se puede desarrollar neutropenia, entre las que se encuentran las infecciones, las malignidades y los fármacos. Estos últimos pueden generar eventos adversos por mecanismos dosis dependiente, como en el caso de la quimioterapia citotóxica o por una reacción idiosincrática. Se presenta el caso de una paciente femenina de 37 años de edad, con antecedentes de tirotoxicosis, tratada con propanolol y metimazol durante cuatro semanas, quien además de manifestaciones tóxicas, presentó neutropenia febril muy grave, que mejoró luego de suspensión del antitiroideo. Se pretende resaltar la asociación de neutropenia febril como complicación de uso de tionamidas y la importancia del seguimiento con exámenes de laboratorios para un diagnóstico oportuno(AU)

Neutropenia is defined as an absolute neutrophil count less than 1500 cells / μL. It is due to the decrease in the production of granulocytes or increase in their destruction, either at the medullary or peripheral level. According to the classification of the World Health Organization (WHO) the degrees of neutropenia range from 0 to IV, taking into account the magnitude of the decrease in the neutrophil count. Grade IV is the highest risk and corresponds to counts below 500 cells /μL. The impact on morbidity and mortality associated with neutropenia is not linked to the direct reduction of the cell count, but to the associated infectious processes to which patients who present it are prone. There are several conditions under which neutropenia can develop, including infections, malignancies and drugs. The latter can generate adverse effects by dose-dependent mechanisms, as in the case of cytotoxic chemotherapy or an idiosyncratic reaction. Next, the case of a female patient of thirty-seven years of age, with a history of thyrotoxicosis, treated with propanolol and methimazole for four weeks, who in addition to toxic manifestations, presents very severe febrile neutropenia that improves after suspension of the antithyroid. We aim to highlight the association of febrile neutropenia as a complication of thionamide use and the importance of follow-up with laboratory tests for an opportune diagnosis(AU)

Micosis invasivas agudas: presentaciones atípicas / Acute invasive mycosis: atypical presentations / Micose invasiva aguda: apresentações atípicas

INTRODUCCIÓN: Las micosis invasivas agudas son infecciones rápidamente progresivas con una alta tasa de morbimortalidad. Se presentan principalmente en pacientes neutropénicos. La neutropenia puede clasificarse en cuantitativa (en neoplasias hematológicas, SIDA, inmunodepresión secundaria a transplantes) o cualitativa (en diabéticos mal controlados). Existen dos formas de presentación: Rinosinusal y extrasinusal. En esta última se describen tres subtipos: Rinoorbitaria (mayor frecuencia), rinocerebral y de partes blandas cervicofaciales. OBJETIVO: Describir dos casos clínicos de pacientes con presentaciones atípicas en las micosis invasivas agudas.

INTRODUCTION: Acute invasive mycosis can be a rapidly progressing infection that exhibits high rates of morbidity and mortality. Most commonly occurs in individuals with hematologic malignancies, particularly in patients who have received bone marrow transplantation. Other compromised patient populations at risk are those on chronic steroids, poorly controlled diabetics, patients with AIDS, and those undergoing chemoradiation therapy. Presentation forms can be rinosinusal and extrasinusal, this last one divided into: Rhinorbital, rhinocerebral and soft tissue affectation. OBJECTIVE: Describe two clinical cases of atypical presentation of acute invasive mycosis.

INTRODUÇÃO: Infecções fúngicas invasivas agudas são rapidamente progressivas, com alta taxa de morbidade e mortalidade. Eles ocorrem principalmente em pacientes neutropênicos. A neutropenia pode ser classificada como quantitativa (em neoplasias hematológicas, AIDS, imunossupressão secundária a transplantes) ou qualitativa (em diabéticos pouco controlados). Existem duas formas de apresentação: Rinossinusal e extrasinusal. Neste último, são descritos três subtipos: rino-orbitário (maior freqüência), tecido mole cervicofacial e rinocerebral. OBJETIVO: Descrever dois casos clínicos de pacientes com apresentações atípicas em micoses invasivas agudas e realizar uma revisão bibliográfica da referida patologia.

Feohifomicosis nasal por Curvularia spicifera en un paciente pediátrico con neutropenia y leucemia mieloide aguda / Nasal phaeohyphomycosis by Curvularia spicifera in pediatric patient with neutropenia and acute myeloid leukemia

There are very few reports of pediatric patients with infections by dematiaceous filamentous fungi. In this publication we report a case of invasive fungal infection of the nasal septum by Curvularia spicifera in a pediatric patient with acute myeloid leukemia. The patient presented with a painful scabby wound in the nasal vestibule. Culture and universal PCR were consistent with Curvularia spicifera. Early management with surgical debridement and bi-associated antifungal therapy achieved complete resolution of the lesions, with no evidence of dissemination and relapses. Clinical management of these fungal infections represents a challenge as the antifungal selection and duration of therapy is not yet well stablished.

Existen pocos reportes de infecciones por hongos dematiáceos en pediatría. Comunicamos el caso de una infección fúngica invasora del tabique nasal en un niño con una leucemia mieloide aguda, que se presentó como una lesión costrosa dolorosa en el vestíbulo nasal. Se realizó desbridamiento quirúrgico precoz y recibió tratamiento antifúngico biasociado, lográndose resolución completa de las lesiones, sin diseminación ni recaídas. El cultivo y la RPC universal fueron compatibles con Curvularia spicifera. El manejo de estas infecciones fúngicas representa un desafío, considerando que la elección del agente antifúngico y la duración de la terapia no están completamente establecidas.

Primary cutaneous aspergillosis and idiopathic bone marrow aplasia

Abstract: We describe the case of a 9-year-old boy with idiopathic bone marrow aplasia and severe neutropenia, who developed skin ulcers under cardiac monitoring electrodes. The diagnosis of primary cutaneous aspergillosis was made after the second biopsy and culture. Imaging investigation did not reveal internal fungal infection. The child was treated, but did not improve and died 3 months after admission. The report highlights and discusses the preventable risk of aspergillus skin infection in immunocompromised patients.

Bone Marrow Suppression and Hemophagocytic Histiocytes Are Common Findings in Korean Severe Fever with Thrombocytopenia Syndrome Patients

The causes of cytopenia in patients with severe fever with thrombocytopenia syndrome (SFTS) are not fully understood until now. We reviewed the bone marrow (BM) findings of patients with SFTS to unravel the cause of the cytopenia. Three Korean SFTS were enrolled in this study. Thrombocytopenia, neutropenia, and anemia were detected in all three patients. Severe hypocellular marrow (overall cellularity <5%) and a decreased number of megakaryocytes were noted in one patient, and hypo-/normocellular marrow and an increased number of hemophagocytic histiocytes were observed in two patients. Megakaryocytes were relatively preserved in two patients. Although a limited number of cases are available, our observations suggest that both BM suppression and peripheral destruction or sequestration are causes of cytopenia of patients with SFTS. To the best of our knowledge, this is the first well documented pathologic evaluation of Korean SFTS.

Factores de riesgo de colonización por Enterococcus spp resistente a vancomicina en pacientes pediátricos hospitalizados con patología oncológica / Risk factor of intestinal colonization with vancomycin resistant Enterococcus spp in hospitalized pediatric patients with oncological disease

Background: The isolation of vancomycin-resistant Enterococcus spp (ERV) has increased significantly within the last few years, along with the risk of infection and dissemination of these bacteria. Our aim was to determine risk factors (RF) for intestinal colonization in hospitalized pediatric patients with oncological disease at Hospital de Niños Roberto del Río. Methods: Between January 2012 and December 2013 a transversal study was performed with 107 rectal swabs and processed with a PCR for ERV. The patients were classified as "colonized with ERV" and "not colonized with ERV" and we evaluated possible RF for intestinal colonization in both groups. Results: VRE colonization was found in 51 patients (52%). The median of time elapsed between oncological diagnosis and VRE colonization was 35 days. The significant RF associated with VRE colonization were days of hospitalization prior to study, neutropenia and treatment with antibiotics within 30 days prior to study and mucositis. Conclusions: According to the RF revealed in this study we may suggest prevention standards to avoid ERV colonization. This is the first investigation in our country in hospitalized pediatric patients with oncological disease and processed with a multiplex PCR for ERV, therefore it is a great contribution about this subject in Chile.

Introducción: El aislamiento de Enterococcus spp resistentes a vancomicina (ERV) ha presentado un incremento significativo en los últimos años, aumentando el riesgo de infección por esta bacteria y favoreciendo su diseminación. Nuestro objetivo es determinar los factores de riesgo (FR) de colonización intestinal de ERV en pacientes oncológicos internados en el Hospital de Niños Roberto del Río. Método: Entre enero de 2012 y diciembre de 2013 se realizó un estudio transversal de colonización rectal por ERV mediante muestras de hisopado rectal obtenidas en 107 pacientes efectuando RPC múltiple para ERV. Se dividió en grupo "portador" y "no portador" y se evaluó los posibles FR para colonización por ERV. Resultados: Se encontró colonización por ERV en 51 pacientes (52%). El tiempo transcurrido desde el diagnóstico oncológico y la colonización presentó una mediana de 35 días. Los FR encontrados con asociación significativa fueron el número de días de hospitalización previa, neutropenia, uso de antimicrobianos 30 días previos y mucositis. Conclusión: De acuerdo a los FR encontrados podemos sugerir medidas de prevención para colonización por ERV. Esta es la primera investigación realizada en nuestro país en pacientes oncológicos pediátricos y que utiliza la técnica de RPC múltiple para ERV, lo que permite un aporte significativo sobre este tema en Chile.

Probable fusariosis diseminada en pacientes con malignidades hematológicas / Probable disseminated fusariosis in patients with hematologic malignancies

Se describen dos casos de Probable Fusariosis Diseminada (PFD) en pacientes con malignidades hematológicas atendidos en el Hospital Médico-Quirúrgico y Oncológico del ISSS (HMQ-O-ISSS). El caso 1 presentó una respuesta satisfactoria al tratamiento con Voriconazole, mientras que el caso 2 a pesar del tratamiento temprano con Voriconazole falleció. En ambos casos no logró aislarse el hongo en hemocultivos, pero si se logró visualizar en el estudio histopatológico. Fusariosis diseminada debe ser tomada en cuenta en el diagnóstico diferencial de infecciones fúngicas invasivas que se presentan en pacientes con malignidades hematológicas. Para nuestro conocimiento son los primeros casos reportados en El Salvador

We described two cases of Probable Disseminated Fusariosis in patients with hematological neoplasms who were being treated at the HMQ-O-ISSS. The first case had satisfactory response to treatment with Voriconazol, while case 2 died despite early Voriconazol treatment. In both cases, we failed to isolate fungus in blood cultures, but it was displayed on histopathology. Disseminated Fusariosis should be taken into account in the differential diagnosis of invasive fungal infections that appear in patients with hematologic malignancies. For our knowledge, these are the first two cases reported in El Salvador

Aspergilosis pulmonar secundaria a neutropenia inducida por metimazol: reporte de un caso / Pulmonary aspergillosis due to methimazole-induced neutropenia: a case report

Se reporta el caso de una paciente de 48 años de edad con diagnóstico reciente de enfermedad de Graves, quien acudió a emergencia por presentar fiebre, palpitaciones y dolor faríngeo. Su tratamiento regular incluía metimazol. Al ingreso, los análisis mostraron TSH suprimido, T4 libre elevado y neutropenia. La paciente fue hospitalizada, se administraron antibióticos y factor estimulante de colonia. Después de diez días de tratamiento, la paciente presentó leucocitosis, fiebre y hemoptisis. La tomografía de tórax mostró una cavidad con múltiples nódulos en el lóbulo superior derecho. Los cultivos fueron positivos a Aspergillus fumigatus y Aspergillus flavus. Se inició tratamiento con anfotericina B y luego se cambió a voriconazol, a pesar de lo cual no hubo mejoría del cuadro. La paciente falleció por falla multiorgánica.

A 48-year old woman with a recent diagnosis of Graves’ disease arrived at the emergency room with fever, palpitations, and a sore throat. Her regular treatment included methimazole. On admission, laboratory results showed suppressed TSH, elevated free thyroxine, and neutropenia. She was admitted and started on antibiotics and granulocyte-macrophage colony stimulating factor (gm-csf). After ten days, the patient developed leukocytosis, fever, and hemoptysis. Chest CT scan showed a lung cavity with multiple nodules in the upper right lobe. Cultures from a lung biopsy were positive for Aspergillus Fumigatus and Aspergillus Flavus. Amphotericin B was started but then switched to voriconazole, with both treatments failing to result in clinical improvement. The patient died of multi-organ failure.

Chest computed tomography findings in severe influenza pneumonia occurring in neutropenic cancer patients

OBJECTIVE: To describe the chest computed tomography findings for severe influenza H1N1 infection in a series of hospitalized neutropenic cancer patients. METHODS: We performed a retrospective systematic analysis of chest computed tomography scans for eight hospitalized patients with fever, neutropenia, and confirmed diagnoses of influenza H1N1. The clinical data had been prospectively collected. RESULTS: Six of eight patients (75%) developed respiratory failure and required intensive care. Prolonged H1N1 shedding was observed in the three mechanically ventilated patients, and overall hospital mortality in our series was 25%. The most frequent computed tomography findings were ground-glass opacity (all patients), consolidation (7/8 cases), and airspace nodules (6/8 cases) that were frequently moderate or severe. Other parenchymal findings were not common. Five patients had features of pneumonia, two had computed tomography findings compatible with bronchitis and/or bronchiolitis, and one had tomographic signs of chronicity. CONCLUSION: In this series of neutropenic patients with severe influenza H1N1 infection, chest computed tomography demonstrated mainly moderate or severe parenchymatous disease, but bronchiolitis was not a common feature. These findings associated with febrile neutropenia should elicit a diagnosis of severe viral infection.

Sudden Atelectasis and Respiratory Failure in a Neutropenic Patient: Atypical Presentation of Pseudomembranous Necrotizing Bronchial Aspergillosis

Pseudomembranous necrotizing bronchial aspergillosis (PNBA) is a rare form of invasive aspergillosis with a very poor prognosis. The symptoms are non-specific, and the necrotizing plugs cause airway obstruction. Atelectasis and respiratory failure can be the initial manifestations. Recently, we treated an immunocompromised patient with PNBA, who presented with a sudden onset of atelectasis and acute respiratory failure. There were no preceding signs except for a mild cough and one febrile episode. Bronchoscopy revealed PNBA, and Aspergillus nidulans was cultured from the bronchial wash.

Ecocardiograma na investigação e acompanhamento de paciente neurotropênico febril com diagnóstico de aspergilose cardíaca / Echocardiogram in the investigation and attendance of the febrile neutropenic patient with diagnosis of cardiac aspergillosis

Neste relato, é apresentada a história clínica de um paciente jovem, portador de aplasia medular, em propedêutica para neutropenia febril. Ecocardiograma transesofágico revelou massa intra-atrial esquerda de grandes dimensões, com alto risco de embolização sistêmica. Foi submetido a cirurgia para ressecção da massa atrial, sendo o material enviado para o exame anatomopatológico, o qual revelou trombo infectado por Aspergillus sp (endocardite fúngica). Ecocardiogramas realizados no 7º dia pós-operatório revelaram rápida recidiva da massa intra-atrial. Paciente evoluiu com piora clínica, insuficiência respiratória, parada cardiorrespiratória e óbito.

We present here a young patient’s clinical history, bearer of medular aplasy, in the investigation for febrile neutropenia. Transesophagealechocardiogram showed an intra-left atrial mass of great dimensions with high risk of systemic embolization. He underwent to surgery for ressection of the atrial mass and the material was sent to anatomopathology study that revealed infected thrombus by Aspergillus sp (fungal endocarditis). Echocardiogram accomplished in 7th postoperative day revealed fast recurrence of the intra-atrial mass. Patient developed with clinical worsening, breathing insufficiency, cardiorespiratory arrest and death.

Motivos de la prescripción inadecuada de antibióticos en un hospital pediátrico de alta complejidad / Reasons for inappropriate prescribing of antibiotics in a high-complexity pediatric hospital

Objetivo. Describir el estado de la aplicación de la norma relacionada con la prohibición de la venta de antibióticos sin prescripción médica en farmacias de Bogotá, Colombia. Métodos. Estudio descriptivo transversal, en el cual se utilizó la técnica de simulación de compra en farmacias (droguerías) de Bogotá. La muestra de 263 farmacias se calculó con una precisión de 5% y un factor de corrección de 2% mediante estratificación (farmacias de cadena e independientes) y asignación aleatoria simple en cada estrato. Resultados. Del total de farmacias estudiadas, 80,3% no cumplen la norma que establece la venta de antibióticos con receta. En 20,1% de los casos, el expendedor indagó la edad del paciente o sus síntomas o ambos, con el fin de ofrecer otros medicamentos o para cambiar el antibiótico. En ninguna oportunidad se preguntó por antecedentes personales de alergia a los antibióticos. En los casos en los cuales hubo intención de venta del antibiótico, la presentación genérica fue la más comúnmente ofrecida (81,2%). Algunos expendedores de medicamentos hicieron recomendaciones inapropiadas. Las localidades con mayor incumplimiento de la norma coinciden con aquellas que tienen altas tasas de necesidades básicas insatisfechas. Conclusiones. A cinco años de adopción de la norma orientada a contrarrestar la venta libre de antibióticos, su cumplimiento es mínimo y la entrega no se realiza de acuerdo a los parámetros establecidos. El personal de farmacia no suministra la información requerida de acuerdo con sus competencias.

Objective. Describe the implementation status of a regulation prohibiting antibiotic sales without a medical prescription in pharmacies of Bogotá, Colombia. Methods. A cross-sectional descriptive study was conducted using the simulated purchase technique in Bogotá pharmacies (drugstores). The sample of 263 pharmacies was calculated by stratification (chain pharmacies and independent pharmacies) with 5% accuracy and a 2% correction factor. Simple randomization was assigned in each stratum. Results. Out of the total pharmacies studied, 80.3% did not comply with the regulation established for prescription sales of antibiotics. In 20.1% of the cases, the dispenser asked about the patient’s age, symptoms, or both age and symptoms in order to offer other drugs or change the antibiotic. There were no inquiries about a medical history of allergy to antibiotics. In cases in which there was the intention to sell antibiotics, the generic format was most commonly offered (81.2%). Some drug dispensers made inappropriate recommendations. The locations with the highest levels of noncompliance with the regulation were also those with high rates of unmet basic needs. Conclusions. Five years after passage of a regulation to halt the unrestricted sales of antibiotics, there is minimal compliance, and dispensing does not conform to the established parameters. Pharmacy personnel do not provide the required information according to their responsibilities.

Miliaria-rash after neutropenic fever and induction chemotherapy for acute myelogenous leukemia / Miliária 'rash' após neutropenia febril e quimioterapia de indução para a leucemia mielóide aguda

Miliaria is a disorder of the eccrine sweat glands which occurs in conditions of increased heat and humidity. It can be associated with persistent febrile states as well as with certain drugs. We presented a 40 year-old female with myelodysplastic syndrome and progression to acute myelogenous leukemia who was admitted to the hospital for chemotherapy induction. The patient was treated with idarubicin and cytarabine. She became pancytopenic and developed neutropenic fever and was started on vancomycin and cefepime, but was persistently febrile with night sweats. Five days into her fevers, she developed diffuse, nonpruritic and fragile vesicles together with drenching nightsweats. The patient's exanthem was diagnosed as Miliaria crystallina, most probably induced by neutropenic fever and idarubucin exposure.

Miliária é uma desordem das glândulas sudoríparas écrinas, que ocorre em condições de aumento de calor e umidade. Miliária pode ser associada com estados febris persistentes bem como com certos medicamentos. Apresentamos o caso de uma mulher de 40 anos com síndrome mielodisplásica e progressão para leucemia mielóide aguda que foi admitida no hospital para quimioterapia de indução. A paciente foi tratada com idarrubicina e citarabina. Ela se tornou pancitopênica e desenvolveu neutropenia febril. Iniciou tratamento com vancomicina e cefepime, mas a febre com sudorese noturna continou. Cinco dias depois a paciente desenvolveu vesículas difusas, não pruríticas e frágeis juntamente com a persistência de sudorese noturna. O exantema do paciente foi diagnosticado como Miliária cristalina, provavelmente induzida por neutropenia febril e exposição a idarubucin.

Estudio de Infecciones diseminadas por candida en pacientes con neutropenia febril asociada a enfermedades hemato-oncológicas / Study disseminated Candida infections in patients with febrile neutropenia associated with hemato-oncological diseases

Mundialmente, en las últimas dos décadas se ha observado un incremento en la frecuencia de las infecciones micóticas diseminadas, con alta morbi-mortalidad, particularmente importante en las infecciones por Candida. El objetivo es determinar la frecuencia de candidiasis diseminada, en pacientes con enfermedades hemato-oncológicas o aplasia medular que ingresaron a los servicios de medicina interna del hospital universitario de caracas, con fiebre y neutropenia, entre enero y septiembre de 2010, realizándose evaluación exhaustiva y tomándose muestras de sangre, además de otras muestras en caso de presencia de lesiones, para el diagnóstico micológico. Se evaluaron 48 pacientes en el período del estudio, diagnósticandose 21 casos (43,75%) de micosis diseminadas, catalogadas como infecciones probadas en 13 y probables en 8 casos. De las infecciones probadas 8 (38%) correspondieron a infecciones por Candida: en uno se aisló Candida albicans y en 7, Candida no albicans: 2 pacientes con candida tropicalis, 2 con candida glabatra y uno con candida guillermondii. Dos cepas fueron informadas como candida spp, y 5 por otros hongos. Las infecciones micóticas diseminadas contribuyen sustancialmente a la morbimortalidad de los pacientes con neutropenia, por lo tanto es fundamental la sospecha y diagnóstico temprano de estas entidades en los pacientes con cáncer de origen hematológico y aplasia medular.

Wordwide, there has been an increase in the incidence of disseminated fungal diseases during the last two decades, with high morbidity and mortality particularly importante in Candida infections. To determine the frequency of disseminated candidiasis in patients with hemato-oncological diseases or bone marrow aplasia and febrile neutropenia. A descriptive, prospective and analytical study was conducted. Patients with hemato-oncological diseases or bone marrow aplasia who were hospitalized at the internal medicine service of the hospital universitrio de caracas, with fever and neutropenia, between january and september, 2010 were included, making torough assessment and taking blook samples as well as other clinical specimen when other lesions were present, for mycological diagnosis. During the study period, 48 patients were evaluated. Twenty one cases were diagnosed (43.75%) as disseminated fungal disease. They were classified as proven in 13 cases and probable in 8. From the proven diseases, 8 (38%) corresponded to Candida infections: in one, Candida albicans was isolated and in 7, Candida non-albicans: 2 patients with Candida tropicalis were found, 2 with Candida glabrata and one with Candida guillermondii. Two were reported as Candida spp. In 5 patients other fungi were found. Dissemiated fungal infections substantially contribute to morbidity and mortality in neutropenic patients. For this reason, awareness and early diagnosis of this disease are crucial are crucial in patients with hematological cancer and bone marrow aplasis.

The outcome of febrile neutropenic episodes in paediatric oncology at the Wendy Fitzwilliam Paediatric Hospital / La evolución clínica de los episodios neutropénicos febriles en la oncología pediátrica en el Hospital Pediátrico Wendy Fitzwilliam

OBJECTIVES: To evaluate the incidence, presentation, treatment and outcome of febrile neutropenic episodes of patients treated at the Wendy Fitzwilliam Paediatric Hospital (WFPH) in Trinidad and Tobago. METHODOLOGY: Using a retrospective cohort method, the records of all the patients registered at the Paediatric Oncology Unit at The WFPH, receiving chemotherapy for haematological or solid tumour malignancies from May 2001 to April 2008 and having episodes of febrile neutropenia were analysed. RESULTS: Seventy one episodes of febrile neutropenia were analysed from the 36 patient records. Episode frequency ranged from 1 to 5. The mean duration of febrile neutropenic episodes was 5. 01 days (± SD 5. 2), with range from 1 - 25 days. Acute Lymphoblastic Leukaemia (ALL) accounted for 43. 7%. The mean WBC for the study population was 0. 88 x 10(9)/L (± SD 0. 61), with the mean absolute neutrophil count (ANC) at 0. 16 x 10(9)/L (± SD 0. 23). Antifungal therapy was used in 6 cases and the incidence of blood culture positive sepsis was 8. 5%. Complete resolution occurred in 65 episodes CONCLUSIONS: Febrile neutropenia episodes treated at the WFPH have a very favourable outcome (91. 5%). The further analysis of the relationships found in this study between the total white blood cell count at presentation and the duration of antimicrobial therapy, the duration of the febrile neutropenic episodes and outcome is needed.

OBJETIVO: Evaluar la incidencia, presentación, tratamiento y evolución clínica de los episodios neutropénicos febriles de pacientes tratados en el Hospital Pediátrico Wendy Fitzwilliam (WFPH) en Trinidad y Tobago. METODOLOGÍA: Mediante un método de cohorte retrospectivo, se analizaron las historias clínicas de todos los pacientes inscritos en la Unidad de Oncología Pediátrica en WFPH, que recibieron quimioterapia para el tratamiento de neoplasias hematológicas o tumores malignos sólidos desde mayo de 2001 a abril de 2008 y tuvieron episodios de neutropenia febril. RESULTADOS: Se analizaron setenta y un episodios de neutropenia febril de las historias clínicas de 36 pacientes. La frecuencia de los episodios osciló entre 1 y 5. La duración promedio de los episodios neutropénicos febriles fue 5. 01 días (± SD 5. 2), con un rango de 1 a 25 días. La leucemia linfoblástica aguda (LLA) representó el 43, 7% de los casos. El promedio del conteo de glóbulos blancos (WBC) para la población de estudio fue 0. 88 X 10(9)/L (± SD 0, 61), con el promedio del conteo absoluto de neutrófilos (CAN) en 0. 16 X 10(9)/L (± SD 0. 23). La terapia antifúngica fue utilizada en 6 casos y la incidencia de la sepsis confirmada por cultivo positivo de la sangre fue 8. 5%. En 65 episodios (91. 5%) hubo resolución completa con 6 muertes. CONCLUSIONES: Los episodios de neutropenia febril tratados en la WFPH tienen una evolución clínica muy favorable (91. 5%). Se necesita profundizar en el análisis de las relaciones encontradas en este estudio entre el conteo total de glóbulos blancos en la presentación y la duración del tratamiento con antibióticos, la duración de los episodios neutropénicos febriles y la evolución clínica.

Neutropenia febril asociada a LES: reporte de un caso clínico / Systemic lupus erythematosus-associated febrile neutropenia: a case report

Introducción: Fiebre de Origen Desconocido (FOD) es una entidad clínica poco prevalente y amplio es el repertorio patologías conocidas como causales. Caso clínico. Se describe el caso de una mujer de 43 años, hipertensión arterial y "sífilis" tratada en 1994. Dos meses con Síndrome Febril Prolongado, baja de peso, poliartritis y compromiso del estado general progresivo, vómitos y diarrea. Destacaba en el examen físico temperatura axilar de 39°C, candidiasis oral, evidentemente enflaquecida y sensibilidad difusa del abdomen sin signos de alarma. Estudio revelo neutropenia febril y parámetros inmunológicos alterados, compatibles con Lupus Eritematoso Sistémico. Discusión.

Clinical Features, Risk Factors and Outcomes of Bacteremia due to Enterococci with High-Level Gentamicin Resistance: Comparison with Bacteremia due to Enterococci without High-Level Gentamicin Resistance

High-level gentamicin resistance (HLGR) in enterococci has increased since the 1980s, but the clinical significance of the resistance and its impact on outcome have not been established. One hundred and thirty-six patients with bacteremia caused by enterococci with HLGR (HLGR group) were compared with 79 patients with bacteremia caused by enterococci without HLGR (non-HLGR group). Hematologic malignancy, neutropenia, Enterococcus faecium infection, nosocomial infection and monomicrobial bacteremia were more common in the HLGR group than the non-HLGR group, and APACHE II scores were also higher (P<0.05, in each case). Neutropenia, monomicrobial infection, stay in intensive care at culture, and use of 3rd generation cephalosporin, were independent risk factors for acquisition of HLGR enterococcal bacteremia. Fourteen-day and 30-day mortalities were higher in the HLGR group than the non-HLGR group in univariate analysis (37% vs. 15%, P=0.001; 50% vs. 22%, P<0.001). However, HLGR was not an independent risk factor for mortality due to enterococcal bacteremia in multivariate analysis. Therefore, HLGR enterococcal bacteremia is associated with more severe comorbid conditions and higher mortality than non-HLGR enterococcal bacteremia but the HLGR itself does not contribute significantly to mortality.