Ovariectomy exacerbates glycerol-induced acute kidney injury in rats / A ovariectomia intensifica a lesão renal aguda induzida pelo glicerol em ratas

Objective: This study aimed to evaluate the effects of ovariectomy on glycerol-induced renal changes in rats. Methods: Twenty-four female Wistar rats were submitted to ovariectomized (OVX) or sham surgery. One week after surgery, the animals received an intramuscular injection (8ml/kg) of 50% glycerol or saline (0.15 M) solution. These animals were divided into the following groups (n=6 per group): Sham, sham-operated female rats injected with saline; OVX, ovariectomized female rats injected with saline; Sham+Gly, sham-operated female rats injected with glycerol; OVX+Gly, ovariectomized female rats injected with glycerol. All rats were euthanized 3 days after the injections and the kidneys were removed for histological and immunohistochemical studies. Blood and urine samples were also collected for renal function studies. Results: The OVX+Gly group presented higher creatinine serum levels, as well as greater fractional excretion of sodium and urinary flow than the Sham+Gly group. Histological lesions and tubulointerstitial staining for macrophages, nuclear factor-kappa B, and nitrotyrosine were more pronounced in the renal cortex of the OVX+Gly group compared to the Sham+Gly group. Conclusion: We conclude that ovariectomy aggravated changes in renal function and structure in glycerol-induced acute kidney injury by the intensification of the proinflammatory tissue response.

Objetivo: Avaliar os efeitos da ovariectomia nas alterações renais induzidas pelo glicerol em ratas. Métodos: Vinte e quatro ratas Wistar foram submetidas à ovariectomia (OVX) ou cirurgia sham (intervenção falsa). Uma semana após a cirurgia, os animais receberam injeção intramuscular (8ml/kg) de glicerol a 50% ou solução salina (0,15 M). As ratas foram divididas nos seguintes grupos (n=6 por grupo): Sham, fêmeas sham-operadas e injetadas com solução salina; OVX, fêmeas ovariectomizadas e injetadas com solução salina; Sham+Gly, fêmeas sham-operadas e injetados com glicerol; OVX+Gly, fêmeas ovariectomizadas e injetadas com glicerol. Todas as ratas foram eutanasiadas 3 dias após as injeções e os rins foram removidos para estudos histológicos e imuno-histoquímicos. Amostras de sangue e urina também foram coletadas para estudos de função renal. Resultados: O grupo OVX+Gly apresentou maiores níveis séricos de creatinina, assim como maiores fração de excreção de sódio e fluxo urinário do que o grupo Sham+Gly. As lesões histológicas e imunomarcação tubulointersticial para macrófagos, fator nuclear-kappa B e nitrotirosina foram mais pronunciadas no córtex renal do grupo OVX+Gly em comparação ao grupo Sham+Gly. Conclusão: Concluímos que a ovariectomia agravou as alterações na função e estrutura renal, na lesão renal aguda induzida por glicerol, pela intensificação da resposta tecidual pró-inflamatória.

Síndrome neuroléptico maligno asociado con intoxicación aguda por un organofosforado: reporte de caso / Neuroleptic malignant syndrome associated with acute organophosphate poisoning: Case report

El síndrome neuroléptico maligno es una condición clínica rara y potencialmente letal que frecuentemente se asocia con el uso de antipsicóticos. En la literatura especializada se encontró únicamente un reporte de caso relacionado con la ingestión de organofosforados. Se presenta un paciente con un cuadro clínico correspondiente al síndrome neuroléptico maligno posterior a la ingestión de clorpirifós. Como resultado de un intento de suicidio con el mencionado organofosforado, el hombre de 57 años presentó deterioro agudo del estado de consciencia, evolución neurológica tórpida e inestabilidad autonómica asociada a rigidez e hipertermia persistentes, así como incremento de la creatina-fosfocinasa (creatine phosphokinase, CPK). Se le administró tratamiento con bromocriptina, con lo cual el cuadro clínico remitió, y fue dado de alta sin secuelas. El diagnóstico del síndrome neuroléptico maligno es clínico y debe contemplarse en cualquier caso de exposición a sustancias que puedan resultar en una desregulación de la neurotransmisión dopaminérgica, con el fin de iniciar el tratamiento oportuno y contrarrestar efectivamente los efectos.

Neuroleptic malignant syndrome is a rare and potentially fatal clinical condition frequently associated with the use of antipsychotics. In the literature, there is only one case report associated with the intake of organophosphates. We present the case of a patient who presented with a clinical picture compatible with neuroleptic malignant syndrome, after the ingestion of an organophosphate (chlorpyrifos). A 57-year-old man who consulted for attempted suicide, acute deterioration of consciousness, torpid neurological evolution, and associated autonomic instability associated with rigidity, persistent hyperthermia, and elevated CPK. Bromocriptine treatment was offered, which resolved the clinical picture. The association with the ingestion of an organophosphate was established, and he was discharged without sequelae. The diagnosis of neuroleptic malignant syndrome is clinical and should be considered in any case of exposure to substances that may lead to dysregulation of dopaminergic neurotransmission in order to initiate timely therapy and impact outcomes.

Downer cow syndrome causing rhabdomyolysis and acute renal failure in a 17-month-old Guzerá heifer / Síndrome da vaca caída causando rabdomiólise e insuficiência renal aguda em uma novilha Guzerá de 17 meses

The downer cow syndrome (DCS) is characterized by an alert cow showing inability or reluctance to stand for 12 hours or more. This paper reported clinical, laboratory, and pathological findings in a Guzerá heifer with rhabdomyolysis, pigmenturia and acute renal failure following DCS. A 17-month-old Guzerá heifer was transported via a 350-km ride in a truck and showed sternal recumbency and severe difficulty in standing and walking. Neurological examination was unremarkable, and the heifer presented normal response to cranial nerves and spinal cord tests. Rectal palpation revealed a 5-month gravid uterus. No other abnormalities were noted in the pelvis or around the coxofemoral joints. Biochemical abnormalities included extremely high muscular enzyme activities (creatine phosphokinase and aspartate aminotransferase) and high creatinine levels. Urinalysis revealed blackish and cloudy urine, proteinuria, and a positive occult blood test. Spinal cord ultrasonography showed no abnormalities. This report highlighted an uncommon clinical presentation (myoglobinuria) and pathological findings in a heifer with DCS as a consequence of severe compressive muscle damage. Practitioners and producers must be aware of the risk of careless road transportation for long distances of cattle, especially obese cows, avoiding unnecessary suffering and expenses due to DCS.

A síndrome da vaca caída (SVC) é caracterizada por um bovino alerta que mostra incapacidade ou relutância em permanecer em estação por 12 horas ou mais. O objetivo deste trabalho é relatar os achados clínicos, laboratoriais e patológicos em uma novilha Guzerá com rabdomiólise, pigmentúria e insuficiência renal aguda após a SVC. Uma novilha da raça Guzerá, de 17 meses de idade, foi transportada de caminhão por 350 km e apresentou decúbito esternal, grande dificuldade para assumir estação e caminhar. O exame neurológico não demonstrou alterações, e a novilha possuía resposta normal aos testes de nervos cranianos e medula espinhal. A palpação retal revelou útero grávido de cinco meses. Nenhuma outra anormalidade foi observada na pelve ou na região das articulações coxofemorais. As anormalidades bioquímicas incluíram atividades de enzimas musculares (creatina fosfoquinase e aspartato aminotransferase) extremamente aumentadas e níveis elevados de creatinina. A urinálise revelou urina enegrecida e turva, proteinúria e teste de sangue oculto positivo. O exame ultrassonográfico da medula espinhal não apresentou anormalidades. Este relato evidencia uma apresentação clínica (mioglobinúria) e achados patológicos incomuns em uma novilha com SVC em consequência de extensa lesão muscular compressiva. Veterinários e produtores devem estar atentos aos riscos do transporte rodoviário descuidado por longas distâncias de bovinos, especialmente vacas obesas, evitando assim sofrimento e despesas desnecessárias decorrentes da SVC.

Rabdomiólise em paciente com infecção por dengue: relato de caso / Rabdomyolysis in patient with dengue infection: case report / Rabdomiolisis en paciente con infección por dengue: reporte de un caso

A rabdomiólise como complicação da dengue é subnotificada e pouco descrita na literatura. O presente caso traz um alerta para recordar tal possibilidade, principalmente devido à alta incidência da dengue no Brasil e da importância do manejo inicial, que pode evitar um desfecho desfavorável. Este relato trata de um paciente de 54 anos que iniciou com quadro agudo de fraqueza, com dor intensa em membros inferiores, dor abdominal, náuseas, vômitos e anúria. Foi observada evidente disfunção renal aguda em urgência dialítica com acidose metabólica grave, além de hiperuricemia, hiponatremia, hipocalcemia e hipercalemia, com valores de creatinofosfoquinase (CPK) de 125.010 e de mioglobina, 318,28. O paciente necessitou de três sessões de hemodiálise e recebeu alta com recuperação da função renal. O resultado da sorologia IgM para dengue foi positivo após um mês e dez dias da admissão hospitalar.

Reports on rhabdomyolysis as a complication of dengue are scarce in the literature. This study warns about such a possibility, especially considering the high incidence of dengue in Brazil and the importance of early management to avoid an unfavorable outcome for the patient. The case consists of a 54-year-old patient admitted to the hospital with complains of acute weakness, severe lower limb pain, abdominal pain, nausea, vomiting, and anuria. Clinical evaluation indicated acute renal dysfunction in dialysis emergency with severe metabolic acidosis, as well as hyperuricemia, hyponatremia, hypocalcemia, and hyperkalemia, with creatine phosphokinase (CPK) values equal to 125.010 and myoglobin to 318.28. The patient was discharged with recovery of renal function after three hemodialysis sessions. Serology results were positive for dengue IgM one month and ten days after hospital admission.

La rabdomiólisis como complicación del dengue está poco implementada en la literatura y poco reportada, y este caso trae una advertencia para recordar esta posibilidad, principalmente por la alta incidencia del dengue en el país en el que vivimos y la importancia del manejo inicial, evitando un desfavorable resultado para el paciente. Se trata de un paciente de 54 años que inicia debilidad aguda, dolor severo en miembros inferiores, dolor abdominal, náuseas, vómitos y anuria. Se evidenció disfunción renal aguda en urgencia de diálisis con acidosis metabólica severa, además de hiperuricemia, hiponatremia, hipocalcemia e hiperpotasemia, con valores de creatinfosfoquinasa (CPK)de 125.010 y mioglobina de 318,28. El paciente requirió tres sesiones de hemodiálisis y fue dado de alta con recuperación de la función renal. El resultado de la serología IgM para el dengue fue positivoun mes y diez días después del ingreso hospitalario.

Rabdomiólisis tardía secundaria a infección por SARS-CoV-2 / Late rhabdomyolysis secondary to SARS-CoV-2 infection

Resumen El SARS-CoV-2, la causa de la enfermedad por el nuevo coronavirus de 2019 (COVID-19), ha demostrado producir una variedad de manifestaciones extra pulmonares. La rabdomiólisis debida a la infección por SARS-CoV-ha sido reportada principalmente en el curso temprano de la enfermedad. En el pre sente informe, presentamos el caso de una paciente con infección confirmada por SARS-CoV-2 que se recuperó de neumonía por COVID-19 y posteriormente desarrolló una rabdomiólisis de inicio tardío que fue manejada con éxito con corticosteroides orales e hidratación enérgica durante el curso de la hospitalización. El reconocimiento y diferenciación oportuna de esta subdiagnosticada entidad y las manifestaciones constitucionales usuales du rante el COVID-19, podrían ayudar a prevenir y tratar tempranamente complicaciones posteriores potencialmente mortales.

Abstract SARS-CoV-2, the cause of 2019 novel coronavirus disease (COVID-19), has shown to produce a variety of extrapulmonary manifestations. Rhabdomyolysis due to SARS-CoV-2 infection has been reported mainly in the early course of the disease. In this report, we present the case of a female patient with confirmed SARS-CoV-2 infection who recovered from respiratory compromise and developed a late-onset rhabdomyolysis successfully managed with oral corticoste roids and aggressive hydration. Prompt recognition of this underdiagnosed entity could help prevent subsequent life-threatening complications.

Rabdomiólisis inducida por consumo crónico de bebidas energizantes asociado a ejercicio físico de baja intensidad: reporte de caso / Rhabdomyolysis induced by long-term consumption of energy drinks associated with low intensity physical exercise: case report

RESUMEN Introducción: Un riesgo potencialmente mortal es el hábito de consumo de bebidas energizantes, porque puede producir un síndrome caracterizado por la necrosis muscular que promueve la liberación de enzimas y mioglobina proveniente del interior del miocito hacia la circulación, creando una peroxidación lipídica llegando a generar lesión renal aguda e hyperkalemia; conocido como rabdomiólisis. La rabdomiólisis la esperaríamos encontrar entre 24 y 48 h después de actividades extenuantes, aún más con un índice de Borg modificado mayor o igual a 5 puntos; sin embargo, las bebidas energizantes por su alto contenido de cafeína y otros componentes pueden generar este evento adverso poco conocido. Caso clínico: Paciente de 37 arios, obeso, que ingresó al servicio de urgencias por cuadro clínico de mialgia y orina oscura que apareció 24h después de 4 días de ejercicio muscular de baja intensidad, asociado a consumo diario de bebida energizante por 2 años. El diagnóstico de rabdomiólisis se confirmó por hiperCKemia e hipertrasaminemia; no fue posible medir los niveles de mioglobina. El paciente fue tratado con fluidoterapia agresiva. Nunca presentó complicaciones renales ni hidroelectrolíticas. Conclusión: Nuestro caso destaca la aparición de rabdomiólisis aguda en pacientes sometidos a ejercicios de baja intensidad no descartando como causa principal el consumo crónico de bebidas energizantes. Son pocos casos actualmente reportados en la literatura. Gracias al tratamiento oportuno se evitó la progresión a lesión renal aguda.

ABSTRACT Introduction: The habit of consuming energy drinks is a life-threatening risk, because it can produce a syndrome characterised by a muscle necrosis. This promotes the release of enzy mes and myoglobin from inside the myocyte into the circulation, creating lipid peroxidation and leading to acute kidney injury, and hyperCKemia, together producing rhabdomyolysis. Rhabdomyolysis can be expected to be found within 24 to 48 h after strenuous activities, even more so with a modified Borg index greater than or equal to 5 points. However, energy drinks, due to their high content of caffeine and other components, can generate this little known adverse event. Clinical case: A 37-year-old patient admitted to the emergency department due to clinical symptoms of myalgia, and dark urine that appeared 24 h after four days of low-intensity muscular exercises, and was associated with daily consumption of an energizing drink for 2 years. The diagnosis of rhabdomyolysis was confirmed by increased creatine kinase and transaminases. It was not possible to measure myoglobin levels. The patient was treated with aggressive fluid therapy. He never presented with any renal or electrolyte complica tions. Conclusion: This case highlights the appearance of acute rhabdomyolysis in patients taking low intensity exercises, and not ruling out long-term consumption of energy drinks as the main cause. There are few cases currently reported in the literature. Owing to the timely treatment, progression to acute kidney injury was avoided.

Rabdomiólisis como presentación inicial de COVID-19: caso Clínico / Rhabdomyolysis as the presentation form of COVID-19 infection: report of one case

COVID-19 infection causes a systemic inflammatory response, which mainly presents as a febrile syndrome with respiratory involvement. We report a 37-year-old male who consulted for myalgia, nausea and epigastric pain lasting three days. On admission, he had crepitations at the lung bases. The initial laboratory showed a creatine kinase of 62,768 U/L, a LDH of 1,110 IU/L, a creatinine a 2.1 mg/dL, an aspartate aminotransferase of 1,347 IU/L, a D-dimer of 1,140 ng/mL, a ferritin of 1,201 ng/mL and a lymphocyte count of 810 cells/mm3. The chest CT scan was compatible with multifocal pneumonia, suggesting a COVID-19 infection. COVID-19 PCR was positive. The patient was managed with hydration, sodium bicarbonate, ceftriaxone, and azithromycin, with a good clinical response.

Insuficiencia renal aguda secundaria a rabdomiolisis como manifestación de infección por SARS-CoV-2 / Acute kidney injury caused by rhabdomyolysis as a SARS-CoV-2 infection manifestation: report of one case

SARS-CoV-2 infection has a wide spectrum of clinical manifestations secondary to the impairment of different organs, including kidney. Rhabdomyolysis is produced by disintegration of striated muscle and the liberation of its contents to the extracellular fluid and bloodstream. This may produce hydro electrolytic disorders and acute kidney injury. We report a 35-year-old female with a history of SARS-CoV-2 infection who was hospitalized because of respiratory failure and developed renal failure. The etiologic study showed elevated total creatine kinase levels and a magnetic resonance imaging confirmed rhabdomyolysis. The patient required supportive treatment with vasoactive drugs, mechanic ventilation and kidney replacement therapy. She had a favorable evolution with resolution of respiratory failure and improvement of kidney function.

Bee sting envenomation severe cases in Manaus, Brazilian Amazon: clinical characteristics and immune markers of case reports

Abstract Bee venom is a natural toxin composed of several peptides. Massive envenoming causes severe local and systemic reactions. We report two cases of severe bee envenomation, of which one was fatal. We also describe clinical characteristics and immune markers. Both victims suffered from respiratory distress, renal failure, rhabdomyolysis, and shock. They required invasive mechanical ventilation, vasoactive drugs, and renal replacement therapy. Moreover, serum levels of chemokines, cytokines, and cell-free circulating nucleic acids demonstrated an intense inflammatory process. Massive envenoming produced systemic injury in the victims, with an uncontrolled inflammatory response, and a more significant chemotactic response in the fatal case.

Trametinib and dabrafenib induced rhabdomyolysis, renal failure, and visual loss. Report of one case

ABSTRACT MEK- and BRAF-inhibitors trametinib and dabrafenib are successfully used for BRAF-mutated, metastasizing melanoma, but these compounds may induce side effects. We report a 50 years old female with BRAF-mutated metastasizing melanoma who received trametinib (2 mg/d) and dabrafenib (200 mg/d) after using interferon without benefit. Shortly after starting trametinib/dabrafenib, she experienced an inability to abduct the left eye. Eight days after starting this therapy the patient experienced loss of appetite, vomiting, diarrhea, vertigo, and fever of 40°C. Two days later she experienced visual loss, requiring permanent support for her daily activities. Two further days later myoglobinuria appeared in the absence of myalgias or muscle weakness but accompanied by marked tiredness and inactivity. She could not eat or drink during four days prior to admission. The patient suspected an adverse effect of trametinib/dabrafenib and discontinued it 2 days prior to admission. Thereafter, she experienced an almost complete remission of the deficits except for ocular muscle weakness and visual impairment.

Los inhibidores de MEX and BRAF como trametinib y dabrafenib se usan en el melanoma metastásico con mutación BRAF, pero pueden tener efectos secundarios. Informamos una paciente de 50 años con un melanoma metastásico con la mutación BRAF que recibió trametinib (2 mg/día) y dabrafenib (200 mg/día) después de usar interferón sin beneficio. Después de iniciar esta terapia la paciente notó una incapacidad de abducir el ojo izquierdo. Ocho días después de iniciar el tratamiento, tuvo falta de apetito, vómitos, diarrea, vértigo y fiebre de 40°C. Dos días después notó pérdida de su agudeza visual, requiriendo asistencia para efectuar sus actividades de vida diaria. Dos días después apareció coluria, en ausencia de mialgias o debilidad muscular, pero acompañadas de fatiga. Ella no pudo comer o tomar líquidos por cuatro días antes de ingresar al hospital. La paciente sospechó que estaba experimentando efectos secundarios de los medicamentos y los suspendió dos días antes del ingreso, experimentando una casi completa remisión de sus síntomas, con excepción de la debilidad de musculatura ocular y déficit visual.

Kidney transplantation with donors in severe acute kidney injury. Should we use these organs? Retrospective Case Series / Transplante renal com doadores em lesão renal aguda severa. Devemos utilizar esses órgãos? Série de casos retrospectiva

ABSTRACT Introduction: The number of incident and prevalent patients on dialysis has increased, as well as the number of candidates for renal transplantation in Brazil, without a proportional increase in the number of organ donors. The use of expanded kidneys, as to renal function, may be an alternative to increase the supply of organs. Objective: to discuss the feasibility of using expanded kidneys for renal function, which are in severe acute renal injury. Methods: All cases of renal transplantation of deceased donors performed at the Hospital das Clínicas de Botucatu of UNESP, from January 2010 to June 2018, totaling 732 cases were evaluated. Cases with final donor creatinine greater than 6 mg/dL were selected. Results: four patients were selected, of whom all donors were in severe acute kidney injury (AKI). These donors presented rhabdomyolysis as a probable cause of severe AKI, were young, with no comorbidities and had decreased urinary volume in the last 24 hours. The clinical evolution of all the recipients was satisfactory, with a glomerular filtration rate after transplantation ranging from 48 to 98 mL/min/1.73 m2. Conclusion: this series of cases shows the possibility of using renal donors in severe AKI, provided the following are respected: donor age, rhabdomyolysis as the cause of AKI, and implantation-favorable biopsy findings. Additional studies with better designs, larger numbers of patients and longer follow-up times are needed.

RESUMO Introdução: O número de pacientes incidentes e prevalentes em diálise tem aumentado, assim como o número de candidatos ao transplante renal no Brasil, sem um aumento proporcional do número de doadores de órgãos. O uso de rins expandidos, quanto à função renal, pode ser uma alternativa para aumentar a oferta de órgãos. Objetivo: discutir a viabilidade do uso de rins expandidos quanto à função renal, que estejam em lesão renal aguda severa. Métodos: foram avaliados todos os casos de transplante renal de doador falecido realizados no Hospital das Clínicas de Botucatu da UNESP, de janeiro de 2010 a junho de 2018, totalizando 732 casos. Selecionou-se os casos com creatinina final do doador maior do que 6 mg/dL. Resultados: quatro pacientes foram selecionados, dos quais todos os doadores estavam em lesão renal aguda (LRA) severa. Esses doadores apresentavam rabdomiólise como provável causa de LRA severa, eram jovens, sem comorbidades e apresentavam diminuição de volume urinário nas últimas 24 horas. A evolução clínica de todos os receptores foi satisfatória, com taxa de filtração glomerular após o transplante variando entre 48 a 98 mL/min/1,73m2. Conclusão: essa série de casos mostra a possibilidade de utilização de doadores renais em LRA severa, desde que respeitadas as condições seguintes: idade do doador, rabdomiólise como causa de LRA e achados de biópsia favoráveis à implantação. Estudos adicionais com melhores desenhos, maior número de pacientes e maiores tempos de seguimento são necessários.

Miositis viral, reporte de un caso pediátrico / Viral myositis, a pediatric case report

La miositis viral aguda es una complicación posterior a una infección viral causada, principalmente, por virus influenza A y B. Se caracteriza por ser un proceso inflamatorio transitorio, súbito, autolimitado y benigno. Generalmente, afecta a niños preescolares y escolares, que presentan dolor bilateral y sensibilidad en los grupos musculares de los miembros inferiores sin alteración en el examen neurológico. Puede generar alteración de la marcha o de la bipedestación. Su principal complicación es la rabdomiólisis, por lo que se debe hacer un seguimiento clínico y de los valores de la creatinfosfoquinasa. Se presenta el caso de un niño en edad escolar con diagnóstico de miositis viral aguda. Debido a que es poco frecuente y su incidencia en Latinoamérica es desconocida, se considera importante el reporte del caso y la revisión del tema, ya que su curso es benigno, de fácil manejo, y su conocimiento evita estudios y hospitalizaciones innecesarias.

Acute viral myositis is a complication after a viral infection mainly caused by Influenza A and B viruses. It is characterized as a transitory, sudden, self-limiting and benign inflammatory process. It usually affects preschool and school children presenting bilateral pain and sensitivity in the muscle groups of the lower limbs without alteration in the neurological examination. It can affect the gait or standing. The main complication is rhabdomyolysis, which is why clinical followup and values of creatine phosphokinase must be done. We present the case of a school-age child diagnosed with acute viral myositis. Because it is not a frequent entity and its incidence in Latin America is unknown, we consider important to report the case and review the topic, as its clinical course is benign, easily treated, and its knowledge can avoid unnecessary studies and hospitalizations.

Rigidez muscular, trastorno de sensorio y antipsicóticos: Reporte de caso / Muscle rigidity, sensory disorder and antipsychotics: a case report

En los servicios de emergencias que atienden a una gran población, muchas veces se encuentran cuadros aislados, como deshidratación severa, hipernatremia o hiponatremia, injuria renal aguda, trastorno de sensorio, entre otras. Sin embargo, muchos de estos cuadros forman parte de una sola patología, y si no se hace una unidad clínica en el momento adecuado, la morbimortalidad se puede incrementar drásticamente. Sobre todo, en enfermedades con baja frecuencia, muy raras o poco habituales, como la que se narrará a continuación, podría empeorar el estado crítico del paciente si no se detecta a tiempo o no se maneja adecuadamente. Este caso clínico es el de una paciente mujer de 74 años, con antecedente de patología psicótica con tratamiento irregular que, tras ingerir carbamazepina y risperidona, presenta los síntomas típicos y poco frecuentes del síndrome neuroléptico maligno (SNM).

In emergency rooms with large numbers of assigned population, we often see isolated conditions, such as severe dehydration, hypernatremia or hyponatremia, acute kidney injury, sensory disorder, among others. However, many of these conditions are part of a single disease and, if they are not gathered together as a medical unit at the right time, morbidity and mortality may drastically increase, especially in the event of diseases with a very rare or unusual frequency. Such is the case of the following disorder, which could worsen the critical condition of the patient if it is not detected on time or not treated appropriately. This clinical case addresses a 74-year-old female patient who reports a history of psychotic disorder with irregular treatment and, after the intake of carbamazepine and risperidone, presents the typical and infrequent symptoms of neuroleptic malignant syndrome (NMS).

Micetismos: Parte 2: Síndromes con sintomatología demorada y latencia muy larga / Mushroom poisonings. Part 2: Delayed-onset syndromes with very long latency time

En este trabajo se analizan los micetismos menos comunes, caracterizados por la aparición demorada de síntomas y por tiempos de latencia muy largos. Estas intoxicaciones son provocadas por especies de hongos ectomicorrícicos poco comunes. Se analizan: a) Toxíndrome nefrotóxico demorado o retrasado. Micetismo orellánico o por orellanina. b) Toxíndrome con rabdomiólisis. Micetismos por Tricholoma equestre y Tricholoma terreum. c) Toxíndrome encefalopático o neurotóxico retrasado. Micetismo por Pleurocybella porrigens. d) Toxíndrome cardiovascular. Micetismo por Trogia venenata. Se discuten el tiempo de incubación, las características sintomatológicas, el curso clínico, las toxinas responsables de cada micetismo y su mecanismo de acción, y el tratamiento que ha resultado efectivo para la recuperación de los pacientes.

Less common mycetisms, characterized by delayed-onset and very long latency times are analyzed. These intoxications are caused by rare ectomycorrhizal fungal species. The following syndromes have been taken into account: (a) Delayed nephrotoxic syndrome. Orellanic mycetism or mycetism due to orellanin. (b) Syndrome with rhabdomyolysis. Mycetisms by Tricholoma equestre, and Tricholoma terreum. (c) Delayed encephalopathic or neurotoxic syndrome. Mycetism by Pleurocybella porrigens. (d) Cardiovascular syndrome. Mycetism by Trogia venenata. The incubation time, symptom characteristics, clinical course, toxins responsible for each mycetism and their mechanism of action, and treatment that has shown to be effective for patient recovery are discussed.

Neste trabalho, analisam-se micetismos menos comuns, caracterizados pelo aparecimento retardado de sintomas e tempos de latência muito longos. Essas intoxicações são causadas por espécies raras de fungos ectomicorrízicos. São analisados os seguintes: (a) síndrome de toxicidade nefrotóxica retardada ou atrasada. Micetismo orelânico ou micetismo por orelanina. (b) Toxíndrome com rabdomiólise. Micetismo por Tricholoma equestre e Tricholoma terreum. (c) Toxicidade tardia encefalopática ou neurotóxica. Micetismo por Pleurocybella porrigens. (d) Síndrome cardiovascular. Miceticismo por Trogia venenata. O tempo de incubação, as características sintomatológicas, o curso clínico, as toxinas responsáveis por cada micetismo e seu mecanismo de ação e o tratamento efetivo para a recuperação dos pacientes são discutidos.

Rabdomiólisis por hipopotasemia severa en paciente con síndrome de Conn / Rhabdomyolysis and profound hypokalemia in a patient with Conn´s syndrome

El Síndrome de Conn o hiperaldosteronismo primario se caracteriza por hipertensión, hipopotasemia con alcalosis metabólica y una masa adrenal. La rabdomiólisis puede ser secundaria a traumatismos, excesiva actividad muscular, enfermedades musculares hereditarias y otras causas médicas, como la hipopotasemia. Presentamos el caso de un hombre de 46 años con rabdomiólisis secundaria e hipopotasemia severa como expresión de hiperaldosteronismo primario por un adenoma suprarrenal(AU)

Conn's syndrome or primary hyperaldosteronism is characterized by hypertension, hypokalemia with metabolic alkalosis and the presence of an adrenal mass. Rhabdomyolysis can be secon- dary to trauma, excessive muscle activity, hereditary muscle diseases and other medical causas, such as hypokalemia. We present the case of a 46-year-old man with secondary rhabdomyolisis and hypokalemia as an-expresión of primary hyperaldosteronism due to an adrenal adenoma(AU)

Rabdomiólisis intraoperatoria en cirugía de resección de osteosarcoma de fémur: Reporte de caso y discusión / Case report: Intraoperative rhabdomyolisis after femur osteosarcoma resection

Rhabdomyolysis is a pathology that rarely has causes in the perioperative period, where it has been commonly related as a complication of malignant hyperthermia, prolonged patient positioning with intraoperative muscle compression, in the postoperative period of bariatric surgery and in children. The purpose of this review is to present the case of a 49 year-old male patient, who underwent limb salvage surgery for treatment of a left femur osteosarcoma, with reconstruction via bone transplant and joint prosthesis. During the procedure hyperkalemia and elevation of Creatine-Phosphokinase (CPK) enzyme levels where detected, without changes compatible with renal failure, which required repeated treatment to normalize and that, after ruling out other causes, it was attributed to skeletal muscle destruction during the procedure. Rhabdomyolysis is a phenomenon inherent to this sort of procedures and may manifest initially as laboratory findings and that, if not diagnosed in time, may lead to fatal arrhythmias and acute renal failure.

La rabdomiólisis es una patología que rara vez tiene origen en el período perioperatorio, donde comúnmente se le ha relacionado como complicación de la hipertermia maligna, de decúbitos prolongados con compresión muscular intraoperatoria, del posoperatorio de la cirugía bariátrica y en niños. El objetivo de este trabajo es presentar el caso de un hombre de 49 años, sometido a resección de un osteosarcoma de fémur izquierdo con reconstrucción mediante trasplante óseo y prótesis articular, durante el cual se detectan hiperpotasemia y aumento de la Creatin-Fosfokinasa (CPK), sin alteraciones compatibles con fallo renal, que requirió reiterados tratamientos para la normalización de los valores de kalemia, y que tras descartar otras causas se atribuyó a la destrucción de musculoesquelético durante el procedimiento. La rabdomiólisis es un fenómeno inherente a este tipo de procedimientos y puede manifestarse inicialmente con alteraciones analíticas que, de no ser diagnosticadas en tiempo y forma, pueden llevar a arritmias fatales y fallo renal agudo.