Bilateral diaphragmatic paralysis and Lyme neuroborreliosis. Ten-years of follow-up / Parálisis diafragmática bilateral y neuroborreliosis de Lyme. Diez años de seguimiento

Abstract Borrelia burgdorferi infection (Lyme disease) is one of the few identifiable causes of neuralgic amyotrophy (AN). Bilateral diaphragmatic paralysis is considered rare in borreliosis, and the pattern of long-term recovery of diaphragm function is also uncertain. Transdiaphragmatic pressure is the gold standard for diagnosing bilateral diaphragmatic paralysis, a study that has been reported on a few occasions. We pres ent a case of AN associated with borrelia infection and bilateral diaphragmatic paralysis that provides a detailed follow-up of the spirometric evolution, the maximum static pressures in the mouth, and the transdiaphragmatic pressure from the onset of symptoms and in the long term. This case allows us to know one of the possible evolutionary profiles of diaphragmatic dysfunction in AN due to borreliosis.

Resumen La infección por Borrelia burgdorferi (enfermedad de Lyme) es una de las pocas causas identificables de amiotrofia neurálgica. La parálisis diafragmática bilateral es considerada rara en la borreliosis y el patrón de recuperación a largo plazo de la función del diafragma también es incierto. La presión transdiafragmática es el patrón de oro para el diagnóstico de parálisis diafragmática bilateral, un estudio que ha sido informado en pocas ocasiones. Se presenta un caso de amiotrofia neurálgica asociado a infección por Borrelia y parálisis diafrag mática bilateral, que aporta un seguimiento detallado de la evolución espirométrica, de las presiones estáticas máximas en la boca y de la presión transdiafragmática desde el inicio de los síntomas y a largo plazo. Este caso permite conocer uno de los posibles perfiles evolutivos de la disfunción diafragmática en la amiotrofia neurálgica por borreliosis.

Hemidiaphragmatic paralysis with continuous interscalene block and diluted solutions of levobupivacaine / Bloqueo interescalénico y parálisis diafragmática con dosis diluidas de levobupivacaína

The continuous interscalene block represents the analgesic standard for shoulder surgery. However, the incidence of hemidiaphragmatic paralysis can reach up to 100% of cases. We hypothesized that more dilute local anesthetics would decrease the phrenic palsy at 24 hours. METHODS: Prospective series of patients undergoing arthroscopic shoulder surgery with continuous interscalene block. A 15-ml bolus of lidocaine 1%-levobupivacaine 0.25% plus an infusion of levobupivacaine 0.04% at an 8 mL/h rate plus 5 mL boluses on-demand with a 20-minutes lockout was used until discharge. Hemidiaphragmatic excursion was evaluated with M-mode ultrasound in the subcostal region before blocks, in the post-anesthetic unit, and at 24 h. The primary outcome was the presence of hemidiaphragmatic paralysis at 24 hours. Secondary outcomes included postoperative pain, amount of rescue boluses, postoperative opioids consumption, and side effects. RESULTS: Thirty patients were recruited and analyzed. The incidence of diaphragm paralysis at 24 h was 96.7%. The median [IQR] of pain at rest (patients with shoulder immobilizer) in a NRS from 0 to 10 at 0.5; 1; 3; 6; 12; 24; 48; 72 hours were 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2], respectively. The median [IQR] consumption of LA boluses was 1.5 [0-7]. There were no postoperative morphine requirements. The most frequent side effect was Horner´s syndrome. CONCLUSIONS: Continuous interscalene block with 0.04% levobupivacaine provides adequate analgesia for arthroscopic shoulder surgery but does not prevent hemidiaphragmatic paralysis at 24 hours under the conditions of this study.

El bloqueo interescalénico representa el estándar analgésico para cirugía de hombro. No obstante, la incidencia de parálisis hemidiafragmática puede alcanzar 100% de los casos. Nuestra hipótesis es que infusiones con anestésicos locales más diluidos disminuirían la PHD 24 horas postbloqueo. MÉTODOS: Serie prospectiva de pacientes sometidos a cirugía artroscópica electiva de hombro con bloqueo interescalénico continuo. Un bolo de 15 mL de lidocaína 1%-levobupivacaína 0,5% más infusión postoperatoria de levobupivacaína al 0,04% a 8 ml/h más bolos a demanda de 5 mL con intervalo de 20 minutos hasta el alta. La excursión hemidiafragmática se evaluó con ultrasonido con transductor curvo 2-5 MHz en modo M en la región infracostal antes del bloqueo, en la unidad postanestésica y a las 24 h, antes del alta. El outcome primario fue la presencia de parálisis hemidiafragmática 24 horas postbloqueo. Los resultados secundarios incluyeron dolor postoperatorio, total de bolos de rescate, requerimiento de opioides postoperatorios y efectos secundarios. RESULTADOS: Treinta pacientes fueron reclutados y analizados. La incidencia de PHD a las 24 h fue 96,7%. La mediana [RIC] de dolor en reposo (pacientes con inmovilizador de hombro) medido en escala numérica de 0 a 10, a las 0,5; 1; 3; 6; 12; 24; 48; 72 horas fueron 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2] respectivamente. La mediana [RIC] de consumo de bolos de rescate fue 1,5 [0-7]. No hubo pacientes con requerimientos de morfina postoperatoria. El efecto colateral más frecuente fue el síndrome de Horner. CONCLUSIONES: El bloqueo interescalénico continuo con levobupivacaína 0,04% proporciona analgesia postoperatoria adecuada, pero no evita la PHD a las 24 h en las condiciones de esta serie.

Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study / Paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom: um estudo coorte prospectivo

Abstract Background and objectives: The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. Methods: Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. Results: Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale numerical rating scale (NRS) at 24 hours did not differ between groups. Conclusions: Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Resumo Justificativa e objetivos: O aparecimento frequente de paralisia hemidiafragmática durante o bloqueio interescalênico restringe seu uso em pacientes com insuficiência respiratória. O bloqueio supraclavicular pode ser uma opção segura e eficaz. Nosso objetivo primário foi avaliar a incidência de paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom e compará-lo com o bloqueio interescalênico. Métodos: Os adultos agendados para cirurgia eletiva do ombro sob anestesia regional (Hospital Universitário de Toulouse) foram prospectivamente incluídos neste estudo observacional, de maio de 2016 a maio de 2017. Vinte mililitros de ropivacaína a 0,375% foram injetados, preferencialmente objetivando a interseção da primeira costela e da artéria subclávia. A excursão diafragmática foi medida por ultrassonografia antes e 30 minutos após a anestesia regional. Uma redução ≥ 25% na excursão diafragmática durante um sniff test definiu a paralisia hemidiafragmática. Dispneia e hipoxemia foram registradas na sala de recuperação. Fatores preditivos de paralisia hemidiafragmática (sexo, idade, peso, tabagismo, capacidade funcional) foram explorados. A dor pós-operatória também foi avaliada. Resultados: Quarenta e dois e 43 pacientes dos grupos bloqueio supraclavicular e bloqueio interescalênico, respectivamente, foram avaliados. A incidência de paralisia hemidiafragmática foi de 59,5% no grupo bloqueio supraclavicular em comparação com 95,3% no grupo bloqueio interescalênico (p < 0,0001). O movimento paradoxal do diafragma foi mais comum no grupo bloqueio interescalênico (RR = 2, 95% IC 1,4-3; p = 0,0001). Uma variação semelhante na saturação de oxigênio foi registrada entre os pacientes com e sem paralisia hemidiafragmática (p = 0,08). Nenhum fator preditivo de paralisia hemidiafragmática pôde ser identificado. O consumo de morfina e o maior escore na escala numérica (NRS) em 24 horas não diferiram entre os grupos. Conclusão: Devido à frequente incidência de paralisia hemidiafragmática após bloqueio supraclavicular, essa técnica não pode ser recomendada para pacientes com função respiratória alterada.

Ventilação elétrica: indicações e aspectos técnicos do implante cirúrgico do marca-passo de estimulação diafragmática / Electric ventilation: indications for and technical aspects of diaphragm pacing stimulation surgical implantation

OBJETIVO: Pacientes com lesão medular cervical alta em geral são dependentes de ventilação mecânica, que, embora salve vidas, está associada a complicações e redução da expectativa de vida devido a infecções respiratórias. A estimulação do diafragma por marca-passo, às vezes chamada de ventilação elétrica, induz a inspiração por estimulação dos músculos inspiratórios. Nosso objetivo foi destacar as indicações e alguns aspectos da técnica cirúrgica empregada no implante laparoscópico dos eletrodos, assim como descrever cinco casos de pacientes tetraplégicos submetidos à técnica. MÉTODOS: A seleção dos pacientes envolveu estudos de condução do nervo frênico por via transcutânea para determinar se os nervos estavam preservados. A abordagem cirúrgica foi laparoscopia clássica, com quatro trocartes. A técnica foi iniciada com o mapeamento elétrico para encontrar os "pontos motores" (pontos de contração máxima do diafragma). Se o mapeamento era bem-sucedido, dois eletrodos eram implantados na face abdominal de cada lado do diafragma para estimular ramos do nervo frênico. RESULTADOS: Dos cinco pacientes, três e um, respectivamente, eram capazes de respirar somente com o uso do marca-passo por períodos superiores a 24 e 6 h, enquanto um não era capaz. CONCLUSÕES: Embora seja necessário um acompanhamento mais longo para chegar a conclusões definitivas, os resultados iniciais são promissores, pois, no momento, a maioria dos nossos pacientes pode permanecer sem ventilação mecânica por longos períodos de tempo.

OBJECTIVE: Patients with high cervical spinal cord injury are usually dependent on mechanical ventilation support, which, albeit life saving, is associated with complications and decreased life expectancy because of respiratory infections. Diaphragm pacing stimulation (DPS), sometimes referred to as electric ventilation, induces inhalation by stimulating the inspiratory muscles. Our objective was to highlight the indications for and some aspects of the surgical technique employed in the laparoscopic insertion of the DPS electrodes, as well as to describe five cases of tetraplegic patients submitted to the technique. METHODS: Patient selection involved transcutaneous phrenic nerve studies in order to determine whether the phrenic nerves were preserved. The surgical approach was traditional laparoscopy, with four ports. The initial step was electrical mapping in order to locate the "motor points" (the points at which stimulation would cause maximal contraction of the diaphragm). If the diaphragm mapping was successful, four electrodes were implanted into the abdominal surface of the diaphragm, two on each side, to stimulate the branches of the phrenic nerve. RESULTS: Of the five patients, three could breathe using DPS alone for more than 24 h, one could do so for more than 6 h, and one could not do so at all. CONCLUSIONS: Although a longer follow-up period is needed in order to reach definitive conclusions, the initial results have been promising. At this writing, most of our patients have been able to remain ventilator-free for long periods of time.

Parálisis diafragmática y de cuerda vocal en un paciente cón Síndrome de Churg-Strauss: reporte de un caso / Diaphragmatic and vocal cord paralysis in Churg-Strauss syndrome: a case report

El Síndrome de Churg-Strauss es una vasculitis sistémica que afecta vasos de pequeño y mediano calibre y que suele presentarse con asma, fiebre, hipereosinofilia, insuficiencia cardiaca, daño renal y neuropatía periférica. esta última se observa en el 65 por ciento al 80 por ciento de los casos, siendo el compromiso de nervios craneales en una minoría, y aún más excepcional la parálisis de cuerdas vocales y el diafragma. Las neuropatías por vasculitis sistémicas pueden resultar en morbilidad grave e incluso la muerte, por esto la necesidad de instaurar un tratamiento temprano. Reportamos el caso de un paciente que padeció parálisis diafragmática y de cuerda vocal por síndrome de Churg-Strauss.

Churg-Strauss syndrome is a systemic vasculitis of the small and medium sized vessels that usually occurs with asthma, fever, hypereosinophilia, cardiac failure, renal damage and peripheral neuropathy. The latter affects 65 percent to 80 percent of patients, cranial nerves involvement is rare while vocal cord and diaphragmatic paralysis are exceptional. Neuropathies due to systemic vasculitis may result in significant disability and death, therefore the importance to institute an early treatment. We report here a patient who suffered diaphragmatic and vocal cord paralysis due to Churg-Strauss syndrome.

Polymyositis presenting with respiratory failure.

Polymyositis is a systemic autoimmune disorder characterised by inflammatory myopathy of the skeletal muscles predominantly affecting the proximal muscles and associated with extra-muscular manifestations like dysphagia and skin involvement. In this case report, we describe the occurrence of diaphragmatic weakness and respiratory failure due to polymyositis with relatively well preserved power in limb muscles.

Chilaiditi's sign possibly associated with malposition of chest tube placement.

Although diaphragmatic paralysis is a rare recognized complication of chest tube malposition, Chilaiditi's sign occurring as a result of this complication has never been reported in literature to the best of our knowledge. We describe one such case, which had an interesting clinical sequence of events and radiographic findings and suggest that the medial end of the chest tube should be positioned at least 2 cm from the mediastinum on the frontal chest radiograph to avoid these complications.

Incidencia de parálisis diafragmática después de cirugía cardíaca / Incident of paralysis diafragmática after heart surgery

El daño del nervio frénico debido a cirugía cardíaca es la principal causa de parálisis diafragmática en los niños. Determinamos la incidencia de esta afección después de cirugía cardíaca y evaluamos la evolución clínica y tratamiento quirúrgico aplicados a estos pacientes. Se realizó un análisis retrospectivo de 8 pacientes con parálisis diafragmática operados en un período de 26 meses. La incidencia de parálisis diafragmática fue de 8/651(1,2 por ciento). La fístula de Blalock Taussig fue el proceder quirúrgico causante en 4 (50 por ciento) pacientes, lo cual representa una incidencia de 4/63 (6,3 por ciento). El 42,8 por ciento de los pacientes había recibido una cirugía torácica previa. Se realizó plicatura diafragmática a 5 pacientes (62,5por ciento). El tiempo mediano entre cirugía cardíaca y plicatura fue de 3 días (rango 2-23 días). La mediana del tiempo de ventilación mecánica después de cirugía cardíaca fue de 10 días (rango 5-33 días) en los pacientes con plicatura y de 6 días (rango 19 horas-12 días) en los pacientes sin plicatura (p = 0,39). La edad mediana de los pacientes que requirieron plicatura fue 1 mes (rango 10 días-18 meses), mientras que en los restantes fue de 84 meses (rango 4-100 meses) (p = 0,04). El tiempo mediano entre plicatura y extubación exitosa fue de 3,5 días (rango 3-10 días). La mortalidad en pacientes con parálisis diafragmática fue del 25 por ciento (2 pacientes). La parálisis diafragmática fue una complicación frecuente, y fue la fístula sistémico-pulmonar el proceder quirúrgico asociado más importante. La mortalidad fue elevada a pesar de que la plicatura diafragmática se realizó con relativa precocidad.

The phrenic nerve injury due to cardiac surgery is the main cause of diaphragmatic paralysis in children. The incidence of this affection after cardiac surgery was determined, and the clinical evolution and surgical treatment applied to these patients were evaluated. A retrospective analysis of 8 patients with diaphragmatic paralysis operated on in a period of 26 months was made. The incidence of diaphragmatic paralysis was 8/651 (1.2 percent). Blalock Taussing’s shunt was the causing surgical procedure in 4 patients (50 percent), accounting for an incidence of 4/63 (6.3 percent). 42.8 percent of the patients had underwent previous thoracic surgery. Diaphragmatic plication was carried out in 5 patients (62.5 percent). The mean time between heart surgery and plication was 3 days (range 2-23 days). The mean time of mechanical ventilation after heart surgery was 10 days (range 5-33 days) among patients with plication, and of 6 days (range 19 hours-12 days) in patients without plication (p = 0.39). The mean age of the patients requiring plication was 1 month (range 10 days – 18 months), whereas in the rest it was 84 months (range 4-100 months) (p = 0.04). The mean time between plication and successful extubation was 3.5 days (range 3-10 days). The mortality in patients with diaphragmatic paralysis was 25 percent (2 patients). Diaphragmatic paralysis was a common complication, and the systemic-pulmonary shunt was the most important associated surgical procedure. Mortality was high in spite of the fact that diaphragmatic plication was performed early.

Right hemidiaphragm paralysis as a rare complication of a central venous port catheter insertion

Central Venous Port Catheters are increasingly used in critically ill patients for intravenous treatments and nutrition, and lately, a main focus of oncology patients receiving chemotherapy. Besides all advantages they have also added a new set of challenges. In this case report we describe the acute presentation of a right hemidiaphragm paralysis in an oncology patient with recurrent breast ductal carcinoma as an immediate rare complication of a right subclavian vein catheterization and port insertion.

Unusual complications of empyema thoracis: diaphragmatic palsy and Horner's syndrome.

We report here a 3 month old child with empyema thoracis, who developed complications of diaphragmatic palsy and Horner's syndrome. These complications of empyema thoracis have not been reported earlier. We discuss the possible mechanisms for these complications.

Hemidiaphragmatic paralysis: a rare complication of cervical herpes zoster.

Herpes zoster, a sequel of the reactivation of the varicella zoster virus, usually presents with cutaneous eruptions associated with intense pain and burning sensation in the affected dermatomes. Motor weakness, however, can sometimes complicate herpes zoster. In this report we present a case that had diaphragmatic motor weakness as a sequel of herpes zoster lesions in the neck.

Neuromuscular respiratory failure in Guillain-Barre Syndrome: evaluation of clinical and electrodiagnostic predictors.

Guillain-Barre Syndrome (GBS) has an unpredictable clinical course with up to 30% of patients requiring assisted ventilation during the course of their illness. Successful management mandates anticipation, prompt recognition and optimal treatment of neuromuscular respiratory failure in GBS. AIMS: To identify clinical and electrodiagnostic predictors of neuromuscular respiratory paralysis in GBS. MATERIALS AND METHODS: Forty six patients of GBS were studied over a 6 year period, the study being 2 year retrospective and 4 year prospective. Clinical and electrodiagnostic data were compared between ventilated (28) and non-ventilated (18) patients. The clinical parameters assessed were median age, gender, antecedent infection, prior lung disease, time to peak disability, bifacial weakness, upper limb weakness, bulbar paralysis, neck weakness and autonomic dysfunction. Electrodiagnostic studies included motor nerve conduction studies in 11 ventilated and 13 non-ventilated patients, done prior to maximum disability in each group. Multiple logistic regression analysis was used to compare the two groups. RESULTS: Comparing the clinical data in the ventilated and non-ventilated groups, 'early peak disability', autonomic dysfunction and bulbar weakness predicted the onset of respiratory paralysis. Age, gender, neck or bifacial weakness, upper limb paralysis, or preceding infection did not influence the development of neuromuscular respiratory weakness. Electrodiagnostic testing revealed abnormal H reflex and F waves to be the commonest abnormality in either group. Although data was not sufficient for statistical analysis, the presence of markedly attenuated Compound Muscle Action Potentials inexcitable motor nerves and denervation changes on the electromyography, was commoner in the ventilated group. Thirty six patients received treatment with either plasmapheresis (12) or intravenous immunoglobulin (24). Overall mortality was 5, all 5 patients being on assisted ventilation. CONCLUSION: Early progression to peak disability, bulbar dysfunction and autonomic instability predicted the development of neuromuscular respiratory paralysis in GBS. Early electrodiagnostic studies in this series suggest axonopathic GBS as a predictor of respiratory paralysis, a finding that needs to be evaluated with sufficient data to permit statistical analysis.

Myasthenia gravis and acute respiratory muscle paralysis following wasp sting.

A 34-year-old lady presented with generalised weakness of body, indistinguishable from myasthenia gravis within 24 hours of a wasp sting. Respiratory muscle paralysis leading to respiratory failure developed and mechanical ventilatory support was required. The patient made an uneventful recovery.

Respiratory paralysis in Sjogren syndrome with normal renal function.

We report a 28-year-old woman who presented with quadriparesis and respiratory failure, and had severe hypokalaemia and distal renal tubular acidosis. She recovered completely on potassium and alkali supplementation. Biopsy and scintigraphy of the minor salivary glands confirmed the presence of Sjogren syndrome. A 6-month course of prednisolone did not correct the distal renal tubular acidosis.

Hypokalemic respiratory paralysis in Bartter's syndrome.

Life threatening hypokalemia can be a mode of presentation in renal salt wasting (Group-1) patients of Bartter's syndrome causing hypokalemic respiratory paralysis. Treatment on an emergent basis is required. In the long run, such patients may require higher doses of supplementary potassium and potassium sparing diuretics.

Associaçäo de paralisia diafragmática bilateral e paralisia da cintura escapular após correçäo de aneurisma de aorta: relato de caso / Association between bilateral diaphragmatic paralysis and scapular girdle paralysis after aortic aneurysm correction: case report

A associaçäo de paralisia diafragmática bilateral e paralisia da cintura escapular é uma complicaçäo rara após correçäo de aneurisma de aorta ascendente. Esta associaçäo leva à uma forma grave de insuficiência respiratória cujo sucesso do desmame da ventilaçäo mecânica é dependente da capacidade da musculatura respiratória remanescente em compensar o trabalho respiratório excedente. Fisioterapia respiratória intensiva com treinamento da musculatura, correçäo dos distúrbios metabólicos, tratamento das infecçöes respiratórias associadas à ventilaçäo mecânica e otimizaçäo do suporte nutricional foram fundamentais para o sucesso do desmame

Cuando la retirada de la ventilación mecánica es dificultosa en la UCIP: caso clínico / When the weaning from mechanical ventilation is difficult in the UCIP: report of a case

Paciente de 22 meses que presenta como complicación postquirúrgica, de cirugía torácica, sección del nervio frénico derecho con la consiguiente parálisis hemidiafragmática. Se comentan algunos aspectos fisiopatológicos de tal afección y se discuten las estrategias ante un weaning dificultoso

Parálisis diafragmática iatrogénica y persistencia de ducto arterioso en un hijo de madre diabética / Diaphragmatic paralysis iatrogenic and patent ductus arterioso in child of moter diabetica

Introducción. La parálisis diafragmática neonatal se ha asociado a las siguientes causas: traumatismos obstétricos, venodisección yugular interna, aplicación de la sonda torácica y a cirugía intratorácica. Caso clínico. Se presenta el caso de un neonato de 34 semanas de gestación, masculino, de 3,00 g, que al tercer día de vida extrauterina presentó neumotórax derecho, manejándose con sonda en el tórax, la que fue colocada inadecuadamente. Simultáneamente presentó persistencia del conducto arterioso (PAC) practicándose ligadura quirúrgica y posteriormente plicatura diafragmática derecha, al décimo día y décimo séptimo día de vida, respectivamente. Su evolución fue favorable y egresó al mes de edad. Conclusión. La parálisis diafragmática iatrogénica y la PCA son dos patologías que con frecuencia requieren manejo quirúrgico. En este caso coexistieron ambas entidades