Taquipnea persistente como manifestación inicial de hiperplasia de células neuroendocrinas: reporte de un caso clínico / Persistent tachypnea as initial manifestation of hyperplasia of neuroendocrine cells: case report

Se realiza revisión de la literatura y presentación de un caso clínico de Hiperplasia de Células Neuroendocrinas en paciente lactante masculino que inicia su padecimiento a los 3 meses de vida con dificultad respiratoria caracterizada por retracciones subcostales y taquipnea persistente, posterior-mente a los 8 meses de edad se agrega hipoxemia respirando aire ambiente que requiere uso de oxígeno suplementario continuo. Tiene antecedente de tres hospitalizaciones, con diagnóstico de Bronquiolitis y Neumonía atípica, realizándose panel viral respiratorio con reporte negativo. El paciente persiste con sintomatología respiratoria a pesar de tratamientos médicos, por lo que se deriva a neumología pediátrica, unidad de enfermedad pulmonar intersticial del lactante, iniciando protocolo de estudio, se realiza tomografía tórax de alta resolución, que evidencia imágenes en vidrio despulido en lóbulo medio y región lingular, además de atrapamiento aéreo. Se concluye el diagnóstico de Hiperplasia de Células neuroendocrinas con base a la clínica y hallazgos tomográficos. La Hiperplasia de Células Neuroendocrinas es una patología pulmonar intersticial poco frecuente, cuyo diagnóstico es clínico y radiológico, en la minoría de los casos se requiere biopsia pulmonar para confirmación. Puede ser fácilmente confundida con otras enfermedades respiratorias comunes, por lo que es importante sospecharla para realizar un diagnóstico precoz. La mayor parte de los casos evolucionan con declinación de los síntomas, mejorando espontáneamente en los primeros años de vida.

A review of the literature and presentation of a clinical case of Neuroendocrine Cell Hyperplasia in a male infant patient who begins his condition at 3 months of age with respiratory distress characterized by subcostal retractions and persistent tachypnea is presented. After 8 months of age hypoxemia is added requiring continuous oxygen therapy. He has a history of three hospitalizations, with a diagnosis of bronchiolitis and atypical pneumonia, respiratory viral panel has a negative report. The patient persists with respiratory symptoms despite medical treatments, so it is referred to pediatric pulmonology, initiating study protocol for interstitial lung disease of the infant. A high resolution chest tomography is performed, which evidences images in polished glass in the middle lobe and lingular region, in addition to air entrapment. The diagnosis of neuroendocrine cell hyperplasia is concluded based on clinical and tomographic findings. Neuroendocrine Cell Hyperplasia is a rare interstitial pulmonary pathology, whose diagnosis is clinical and radiological. Lung biopsy is required only in the minority of cases for confirming diagnosis. It can be easily confused with other common respiratory diseases, so it is important to suspect it to make an early diagnosis. Most cases evolve with decline in symptoms, improving spontaneously in the first years of life.

Resultado clínico y costo económico directo del tratamiento de la neumonía adquirida en la comunidad en niños mayores de 28 días y menores de 5 años: Un estudio observacional multicéntrico / Clinical outcome and direct economic cost of treatment of community-acquired pneumonia in children older than 28 days and younger than 5 years. A multicenter observational study

Introducción: La Neumonía Adquirida en la Comunidad (NAC) es considerada un problema de salud pública, afecta especialmente a niños menores de 5 años. Los episodios que requieren hospitalización generan importantes gastos económicos institucionales. El objetivo del presente estudio fue describir los resultados clínicos y el costo directo del tratamiento de la NAC en dos hospitales de referencia de Quito-Ecuador. Métodos: El presente estudio transversal, se realizó en niños >28 días y < 5 años, hospitali-zados en dos instituciones de salud pública en la ciudad de Quito, Ecuador, con NAC. Va-riables fueron: descripciones demográficas, resultado clínico, costo del tratamiento. Se presentan los datos con estadística descriptiva. Resultados: Se analizan 355 casos, 190 hombres (53.5%). Lactantes menores 95 casos (26.8%), lactantes mayores 130 casos (36.6%) y escolares 130 casos (36.6%). Los síntomas principales fueron la hipoxemia 353 casos (99.4%), taquipnea 239 casos (67.3%) y taquicardia 177 casos (49.9%). Con dificultas respiratoria leve 268 casos (75.5%). El tratamiento principalmente fue con analgésicos 345 casos (97.2%), antibióticos 335 casos (94.4%), nebulización con bronco dilatador 207 casos (58.3), líquidos parenterales 203 casos (57.2%) y oxígeno en 107 casos (30.1%). El costo promedio de la atención hospitalaria de una NAC fue de 736.18 ± 320.51 USD. No existió diferencia de costos entre instituciones (P >0.05). Conclusión: El costo sanitario de la atención médica en Ecuador es de aproximadamente 2 salarios mínimos vitales. Los tratamientos están ajustados a las guías de práctica médica vigentes.

Introduction: Community-acquired pneumonia (CAP) is a public health problem mainly affecting children under five. Episodes that require hospitalization generate high institutional financial costs. The objective of this study was to describe the clinical results and the direct cost of CAP treatment in two reference hospitals in Quito-Ecuador. Methods: This cross-sectional study was conducted in children >28 days and <5 years hospitalized in two public health institutions in Quito, Ecuador, with CAP. Variables were demographic descriptions, clinical outcomes, and cost of treatment. The data are presented with descriptive statistics. Results: A total of 355 cases were analyzed, including 190 men (53.5%). Younger infants had 95 cases (26.8%), older infants 130 cases (36.6%), and schoolchildren 130 cases (36.6%). The main symptoms were hypoxemia in 353 cases (99.4%), tachypnea in 239 cases (67.3%), tachycardia in 177 cases (49.9%), and mild respiratory difficulties in 268 cases (75.5%). Treatment was mainly with analgesics in 345 cases (97.2%), antibiotics in 335 cases (94.4%), bronchodilator nebulization in 207 cases (58.3), par-enteral fluids in 203 cases (57.2%), and oxygen in 107 cases (30.1%). The average cost of hospital care for CAP was 736.18 ± 320.51 USD. There was no cost difference between institutions (P >0.05). Conclusion: The health cost of medical care in Ecuador is approximately two times the minimum living wage, and treatments are adjusted to current medical practice guidelines.

¿Polipnea o taquipnea? Esa es la cuestión / Compliance with the recommendations for physical activity set by the WHO by public bicycle users in a Spanish municipality

RESUMEN Introducción: Polipnea y taquipnea tienen significados diferentes en diversos textos y los estudiantes de Medicina se desorientan al estudiar la Semiología de la disnea. Objetivo: Elucidar la disparidad semántica entre polipnea y taquipnea. Material y Métodos: Se realizó una revisión bibliográfica utilizando los descriptores en ciencias de la salud taquipnea y polipnea. Se realizó una búsqueda en quince textos de Semiología Médica y en otros libros y revistas, impresos y electrónicos, entre ellos, la Revista Española de Cardiología (enero 1997 a diciembre 2020) en Archivos de Bronconeumología(diciembre 1964 a diciembre 2020); y se hizo el análisis etimológico de las palabras estudiadas, en Medigraphic (2012-21). Resultados: Seis de quince textos de Semiología consideran sinónimos polipnea y taquipnea; cuatro, solo emplean polipnea; y dos, taquipnea. Tres distinguen taquipnea como aumento de la frecuencia respiratoria; de polipnea, respiración superficial y rápida; dos definen taquipnea como aumento de la frecuencia respiratoria simple o con disminución de la amplitud (respiración superficial) y polipnea o hiperpnea, como aumento de la profundidad respiratoria con incremento de la frecuencia. En revistas científicas, taquipnea apareció en 192 artículos como respiración rápida y superficial; con igual significado se encontró polipnea, en 27. Según origen, taquipnea significa aceleración del ritmo respiratorio; polipnea, respiración muy frecuente y superficial, sin relación con polýpnóoos: "que sopla con fuerza" e hiperpnea significa incremento de la velocidad y amplitud de los movimientos respiratorios. Conclusiones: Polipnea y taquipnea deben considerarse equivalentes de respiración rápida y superficial; taquipnea simple, si la amplitud respiratoria es normal; e hiperpnea denomina la respiración muy frecuente y profunda.

ABSTRACT Introduction: Polypnea and tachypnea have different meanings in several texts, and medical studentsmay get confusedwith just the study of the semiology of dyspnea. Objective: Toelucidatethe semantic gap between polypnea and tachypnea. Material and Methods: A bibliographic review was conducted usinghealth science descriptors such as tachypnea and polypnea; a search was performed in 15 texts of Medical Semiology and other printed or electronic books and journals, among them, theRevista Española de Cardiología(fromJanuary 1997 to December 2020) andArchivos de Bronconeumología (from December 1964 toDecember 2020); in addition, the etymological analysis of these words was carried out in Medigraphic (2012-2021). Results: Six out of fifteen texts on semiology consider that the termspolypnea and tachypnea are synonymous; fourtexts only use polypnea; and two use the term tachypnea. Three texts distinguish tachypnea as increased respiratory rate, andpolypnea as arapid, shallow breathing; two texts define tachypnea as a simple increase in the respiratory rateor a decrease in the respiratory amplitude (shallow breathing); and polypnea or hyperpnea as the increasein depth and rate of breathing.In scientific journals, the term tachypnea was usedin 192 papersto refer to rapid, shallow breathing; andpolypnea had the same meaning in 27 articles. According to its origin, tachypnea means rapid respiratory rate; Polypnea is presented as very frequent and shallow breathing, unrelated to polýpnoos: "that blows forcefully"; while hyperpneameans an increase in the speed and amplitude of respiratory movements. Conclusions: Polypnea and tachypnea should be considered as equivalents of rapid andshallow breathing; simple tachypneaif the respiratory amplitude is normal; and hyperpnea designs a very frequent and deep breathing.

Taquipnea persistente de la infancia: hiperplasia de células neuroendocrinas, una revisión / Persistent tachypnea of infancy: neuroendocrine cell hyperplasia, a review

La hiperplasia de células neuroendocrinas de la infancia (HCNEI) constituye una de las enfermedades intersticiales más frecuentes en pediatría. Tanto su etiología como los mecanismos fisiopatológicos involucrados son inciertos. Suele presentarse en pacientes por lo demás sanos, durante los primeros meses de vida con taquipnea, retracciones costales, rales e hipoxemia. En la tomografía axial computada de tórax de alta resolución (TACAR) presenta imágenes características en vidrio esmerilado de distribución central y zonas de atrapamiento aéreo. Para el diagnóstico, además de la clínica y la TACAR, podemos recurrir a la biopsia en casos atípicos. Los hallazgos histológicos reflejan una arquitectura pulmonar normal y un aumento en el número de células neuroendocrinas. El manejo global es con medidas de sostén, ya que no se cuenta con un tratamiento específico. La sintomatología suele mejorar con la edad y el pronóstico es favorable.

Neuroendocrine cell hyperplasia of infancy (NEHI) is one of the most common interstitial lung diseases of childhood. The etiology and pathophysiological mechanisms involved are uncertain. It usually presents in otherwise healthy patients during the first months of life with tachypnea, rib retractions, crackles, and hypoxemia. High-resolution chest computed tomography (HRCT) shows ground-glass opacities of central distribution and areas of air trapping. For diagnosis purposes, in addition to clinical and HRCT features, a lung biopsy is indicated for atypical cases. Histological findings reflect normal architecture and an increased number of neuroendocrine cells. The management consists of supportive and preventive care, since there is no specific treatment. Symptoms usually improve with age and the prognosis is favorable.

Proteinose alveolar pulmonar: Relato de caso / Pulmonary alveolar proteinosis: Case report

A proteinose alveolar pulmonar (PAP) é rara e caracterizada por preenchimento alveolar com material lipoproteináceo. A proteinose alveolar é caracterizada por um alvéolo com material eosinofílico, acelular, finamente granular, com fendas de colesterol. Este relato de caso descreve um paciente do sexo masculino, 2 anos, portador de hipogamaglobulinemia. O paciente foi internado com quadro compatível com Stevens- Johnson após uso de amoxicilina e clavulanato para quadro de otite média aguda. Posteriormente, foi encaminhado à unidade de terapia intensiva devido à piora respiratória clínica e radiológica. Biópsia pulmonar: proteinose alveolar com alvéolos distendidos por material proteináceo, eosinofílico e grumoso com infiltrado linfo- histiocitário local. A proteinose alveolar pulmonar é rara e o diagnóstico correto deve ser realizado para que seja realizado tratamento adequado e acompanhamento da evolução. Deve-se atentar para complicações, especialmente infecções oportunistas.

Pulmonary alveolar proteinosis (PAP) is rare and it is characterized by alveolar filling with lipoproteinaceous material. Alveolar proteinosis is characterized by an alveolus with eosinophilic, acellular, finely granular material, with cholesterol cracks. This case report describes a 2-yearold male patient with hypogammaglobulinemia. The patient was hospitalized with Stevens-Johnson-compatible condition after use of amoxicillin and clavulanate for acute otitis media. Subsequently, he was referred to the intensive care unit due to worsening clinical and radiological breathing. Lung biopsy: alveolar proteinosis with alveoli distended by proteinaceous, eosinophilic and lumpy material with local lymphohistiocytic infiltrate. Pulmonary alveolar proteinosis is rare and the correct diagnosis must be made in order to carry out an appropriate treatment and follow-up of the evolution. Attention should be paid to complications, especially opportunistic infections.

Hiperplasia de células neuroendocrinas: reporte de caso / Neuroendocrine cell hyperplasia: case report

A clinical case of Neuroendocrine Cell Hyperplasia is presented with a bibliographic review. An infant patient with respiratory distress syndrome, characterized by nasal flaring, retractions, and tachypnea with temporary resolution with the use of bronchodilators. However, the patient requires oxygen. With complementary examinations (negative viral panel twice) and epidemiology it is classified as a viral Bronchiolitis. Without improvement, extrapulmonar pathologies were suspected, discarding hearth disease, epilepsy, pathological gastroesophageal reflux. New tests were performed to rule out other pathologies, including immunological disorders. Those results were normal, so a high-resolution chest tomography was done which allowed the diagnosis of Neuroendocrine Cell Hyperplasia. During the follow up the child had improved and required oxygen until he was two years old. Neuroendocrine Cell Hyperplasia belongs to a huge group of less common interstitial disorders, which diagnosis is clinical and radiological. It can easily be confused with common respiratory disorders. For this reason, it is important to know about this disease to make an early diagnosis. Most of the cases had a gradual (months to years) improvement.

Se presenta un caso clínico de Hiperplasia de Células Neuroendocrinas y la revisión de la literatura. Paciente lactante menor con cuadro de dificultad respiratoria, caracterizado por aleteo nasal, retracciones y taquipnea persistente acompañada de desaturación. Sin adecuada respuesta al uso de broncodilatadores. Por exámenes complementarios, panel viral negativo en dos ocasiones y epidemiología, se le diagnostica una bronquiolitis viral. Por no presentar mejoría se completan estudios, descartándose neumonía atípica, cardiopatía, epilepsia, reflujo gastroesofágico patológico y compromiso inmunológico. El diagnóstico fue determinado en base a la clínica, junto con imágenes en vidrio esmerilado característicos en lóbulo medio y língula. En su seguimiento mejora paulatinamente, requiriendo soporte de oxígeno hasta los dos años. La Hiperplasia de Células Neuroendocrinas es una patología intersticial pulmonar poco frecuente, cuyo diagnóstico es clínico y radiológico. Puede ser fácilmente confundida con desórdenes respiratorios comunes, por lo que es importante sospecharla para realizar un diagnóstico precoz. La mayor parte de los casos evolucionan con declinación de los síntomas, mejorando espontáneamente en meses o en los primeros años de vida.

Inflammatory signs and epileptic crisis in patients admitted in an emergency unit / Signos inflamatorios y crisis epiléptica en pacientes admitidos en una unidad de emergencia / Sinais inflamatórios e crise epiléptica em pacientes admitidos em unidade de emergência

ABSTRACT Objective: To evaluate inflammatory signs presented in medical records of patients with a main diagnosis of epileptic seizures, admitted in an emergency unit. Method: Cross-sectional and retrospective study. The sample was composed of 191 medical records, from children, adolescents, adults, and elders, with a clinical diagnosis of epileptic seizures, admitted between June 2016 and June 2017 at the emergency unit of a hospital in Porto Alegre/RS. Results: The prevalent inflammatory signs were tachypnea (33.5%) and/or fever (27.2%) associated with leukocytosis (P=0.030). Children/adolescents had seizures less frequently (P=0.010) and these were due to fever (P=0.000). Adults presented seizures more frequently (P=0.006), which were related to medication/intoxication (P=0.000). In elders, seizures occurred due to metabolic or circulatory abnormalities (P=0.000), less often due to fever (P=0.005). Conclusion: Seizures are related to fever and tachypnea, being caused by different etiologies according to age, being more frequent in adults. Fever is related to leukocytosis, regardless of age.

RESUMEN Objetivo: Evaluar signos inflamatorios registrados en prontuarios de pacientes con diagnóstico principal de crisis epilépticas, admitidos en unidad de emergencia. Método: Estudio transversal, retrospectivo. Muestra compuesta por 191 prontuarios de pacientes pediátricos, adolescentes, adultos y ancianos, diagnosticados con crisis epilépticas, admitidos entre junio de 2016 a junio de 2017 en unidad de emergencia de un hospital de Porto Alegre/RS. Resultados: Prevalencia del taquipnea (33,5%) y/o fiebre (27,2%) como signos inflamatorios, fiebre relacionada a leucocitosis (P=0,030). Niños/adolescentes tienen crisis menos frecuentes (P=0,010) de origen febril (P=0,000). Los adultos presentaron mayor número de eventos (P=0,006), provocados por medicamentos/intoxicaciones (P=0,000). En ancianos, crisis ocurrieron debido a disturbios metabólicos/circulatorios (P=0,000),menor ocurrencia de fiebre (P=0,005). Conclusión: Crisis epilépticas están relacionadas a fiebre y taquipnea, presentando diferentes etiologías según grupo de edad, con mayor ocurrencia entre adultos. Fiebre relacionada con el leucocitosis, independientemente de la edad.

RESUMO Objetivo: Avaliar os sinais inflamatórios registrados em prontuários de pacientes com diagnóstico principal de crise epiléptica, admitidos em unidade de emergência. Método: Estudo transversal, retrospectivo. Amostra composta por 191 prontuários de pacientes pediátricos, adolescentes, adultos e idosos, com diagnóstico clínico de crise epiléptica, admitidos entre junho de 2016 a junho de 2017, na unidade de emergência de um hospital de Porto Alegre/RS. Resultados: Prevalência do relato de taquipneia (33,5%) e/ou febre (27,2%) como sinais inflamatórios, estando febre relacionada à leucocitose (P=0,030). Crianças/adolescentes tiverem crises menos frequentes (P=0,010) ede origem febril (P=0,000). Adultos apresentaram maior número de eventos (P=0,006), provocados por medicações/intoxicações (P=0,000). Nos idosos, crises ocorreram por distúrbios metabólicos/circulatórios (P=0,000), com menor ocorrência de febre (P=0,005). Conclusão: Crises epilépticas estão relacionadas à presença de febre e taquipneia, apresentando diferentes etiologias conforme faixa etária, com maior frequência de ocorrência entre adultos. Febre está relacionada à leucocitose, independentemente da idade.

Paciente com Chikungunya evoluindo com Síndrome de Angústia Respiratória do Adulto grave / Chikungunya evolving with SRDA Chikungunya patient progressing to severe Adult Respiratory Distress Syndrome

Objetivo: Demonstrar casos de Chikungunya cujos paciente evoluíram com Síndrome da Angústia Respiratória do Adulto. Métodos: Estudo descritivo e documental cuja a amostra foi composta por pacientes internados em um hospital no município de Campos dos Goytacazes, diagnosticados com sorologia IgM positiva para febre do vírus Chikungunya, que evoluíram para Síndrome da Angústia Respiratória do Adulto. Foram feitas análises de prontuários e de imagens radiológicas, além de revisão de literatura. Resultados: Foram incluídos três pacientes no estudo, sendo que um evoluiu ao óbito e os outros dois obtiveram recuperação de suas funções após o quadro agudo da doença. Conclusão: A Chikungunya é uma doença recente em território nacional, com possível evolução para quadros graves, especialmente em sua fase aguda. Por essa razão, estudos aprofundados são necessários para maior conhecimento e entendimento da patologia e de suas factíveis complicações.

Objective: To report cases of Chikungunya that progressed with Acute Respiratory Distress Syndrome. Methods: This is a descriptive and documental study, the sample of which consisted of patients who were hospitalized, in the city of Campos dos Goytacazes, diagnosed with positive IgM serology for Chikungunya fever, which progressed to Acute Respiratory Distress Syndrome. Medical records and radiological images were analyzed, and literature reviewed. Results: Three patients were included in the study, with one of them progressing to death, and the other two having their functions recovered after acute illness. Conclusion: Chikungunya is a recent disease in the national territory, with possible progression to severe conditions, especially on its acute phase. For this reason, in-depth studies are necessary for a better knowledge and understanding of the pathology and its likely complications

Trombo serpiginoso em átrio direito: apresentação atípica de tromboembolismo pulmonar. Relato de caso / Serpiginous thrombus in right atrium: atypical presentation of pulmonary thromboembolism. Case report

O tromboembolismo pulmonar é um grave problema de saúde pública devido ao subdiagnóstico e às elevadas morbidade e mortalidade. Quando a embolia pulmonar é maciça com repercussão hemodinâmica importante e a terapia adequada não ocorre nas primeiras horas, a mortalidade é superior a 85%. Na suspeita clínica de tromboembolismo pulmonar, a avaliação ecocardiográfica pode ter papel fundamental na avaliação da mobilidade e da estrutura do ventrículo direito, presença de hipertensão pulmonar e documentação da presença de trombo. A detecção ecocardiográfica de trombo móvel nas câmaras cardíacas direitas permite identificar um grupo de pacientes de alto risco, com mortalidade muito elevada, quando comparada ao tromboembolismo pulmonar em geral. Além da terapia clínica clássica, com heparinas e trombolíticos, as terapêuticas endovascular e cirúrgica devem ser consideradas e podem contribuir para o prognóstico desses pacientes. Relata-se um caso de uma paciente de 33 anos de idade admitida em uma unidade de emergência da no 8o dia de pós-operatório de apendicectomia, com queixas de dor torácica e dispneia de início súbito. Ecocardiograma transtorácico evidenciou presença de trombo serpiginoso solto em átrio direito, que ocluía intermitentemente a valva tricúspide durante o ciclo cardíaco. Diante das características ecocardiográficas atípicas do trombo e da significativa chance de embolização maciça, optou-se por intervenção cirúrgica de emergência.

Pulmonary thromboembolism is a serious public health problem due to misdiagnosis and high morbidity and mortality. When pulmonary embolism is massive with important hemodynamic repercussion, and the appropriate therapy does not take place in the early hours, mortality is higher than 85%. If there is clinical suspicion of pulmonary thromboembolism, an echocardiographic evaluation may have a key role in the evaluation of mobility and structure of the right ventricle, presence of pulmonary hypertension, and documentation of the presence of thrombus. Echocardiographic detection of mobile thrombus in right cardiac chambers allows the identification of a group of high-risk patients with very high mortality when compared to pulmonary thromboembolism in general . In addition to the classical clinical therapy with heparins and thrombolytics, endovascular and surgical therapy should be considered and may contribute to these patients' prognosis. A case is reported of a 33-year-old female patient admitted to an Emergency Unit at 8th postoperative day (POD) of appendectomy, with complaints of chest pain and dyspnea of sudden onset. Transthoracic echocardiography showed the presence of a floating serpiginous thrombus in the right atrium, which intermittently occluded the tricuspid valve during the cardiac cycle. Due to the atypical echocardiographic features of the thrombus, and significant chance of massive embolization, an emergency surgery was chosen.

Mecanismos fisiopatológicos de taquipnea / Physiopathological mechanisms of tachypnea

Tachypnea is a common symptom in respiratory diseases, generally triggered for metabolic compensation purposes. Its presence results from integrated complex mechanisms, both physiological and pathological; for a good clinical approach, it is indispensable to know these mechanisms.

La taquipnea es la manifestación más común de las enfermedades respiratorias y obedece generalmente a una respuesta de compensación metabólica. Su presencia resulta de mecanismos de integración complejos tanto fisiológicos como patológicos que es necesario conocer para el mejor abordaje clínico de un paciente.

Síndrome de hiperatividade simpática paroxística causada por síndrome da embolia gordurosa / Paroxysmal sympathetic hyperactivity syndrome caused by fat embolism syndrome

RESUMO A hiperatividade simpática paroxística representa uma complicação incomum, com potencial risco à vida, de lesões cerebrais graves, mais comumente de origem traumática. Seu diagnóstico clínico se baseia na manifestação recorrente de taquicardia, hipertensão, diaforese, taquipneia e, às vezes, febre, além de posturas distônicas. Os episódios podem ser induzidos por estímulos ou ocorrer de forma espontânea. É comum que ocorra subdiagnóstico desta síndrome, e o retardamento de seu reconhecimento pode aumentar a morbidade e a incapacidade em longo prazo. Evitar os desencadeantes e a farmacoterapia podem ter muito sucesso no controle desta complicação. A síndrome da embolia gordurosa é uma complicação rara, mas grave, das fraturas de ossos longos. Sinais neurológicos, petéquias hemorrágicas e insuficiência respiratória aguda são as características que constituem seu quadro clínico. O termo "embolia gordurosa cerebral" é estabelecido quando predomina o envolvimento neurológico. O diagnóstico é clínico, porém achados específicos de neuroimagem podem confirmá-lo. As manifestações neurológicas incluem diferentes graus de alteração da consciência, défices focais ou convulsões. Seu tratamento é de suporte, porém são possíveis desfechos favoráveis, mesmo nos casos com apresentação grave. Relatamos dois casos de hiperatividade simpática paroxística após embolia gordurosa cerebral, uma associação muito incomum.

ABSTRACT Paroxysmal sympathetic hyperactivity represents an uncommon and potentially life-threatening complication of severe brain injuries, which are most commonly traumatic. This syndrome is a clinical diagnosis based on the recurrent occurrence of tachycardia, hypertension, diaphoresis, tachypnea, and occasionally high fever and dystonic postures. The episodes may be induced by stimulation or may occur spontaneously. Underdiagnosis is common, and delayed recognition may increase morbidity and long-term disability. Trigger avoidance and pharmacological therapy can be very successful in controlling this complication. Fat embolism syndrome is a rare but serious complication of long bone fractures. Neurologic signs, petechial hemorrhages and acute respiratory failure constitute the characteristic presenting triad. The term cerebral fat embolism is used when the neurological involvement predominates. The diagnosis is clinical, but specific neuroimaging findings can be supportive. The neurologic manifestations include different degrees of alteration of consciousness, focal deficits or seizures. Management is supportive, but good outcomes are possible even in cases with very severe presentation. We report two cases of paroxysmal sympathetic hyperactivity after cerebral fat embolism, which is a very uncommon association.

Impact of A/H1N1 influenza in children at a Brazilian University Hospital

ABSTRACT Background A/H1N1 influenza is a viral disease that affects a significant part of the population mainly in winter, leading to increased number of medical consultations, hospitalizations and consequently care spending in emergency. Methods This is a case-series retrospective study, involving patients admitted to a tertiary hospital in southern Brazil in 2016 with a clinical diagnosis of acute respiratory infection of the influenza type and laboratory confirmation of influenza A/H1N1. Results 64 patients were included, mostly male, median age of 48.3 months. Chronic underlying diseases were found in 73% of the patients, and these patients evolved to the most unfavorable outcome. About vaccination, of the 57 patients with an age range for vaccination, only 28% had complete vaccination coverage. The main clinical manifestations found in the included patients were fever, cough, intercostal indrawing, wheezing, tachypnea and pulmonary crackles. These patients were mainly followed-up with laboratory tests and chest X-ray. Consolidation was evident in 43% of patients followed by interstitial infiltrate in 33%. A five-day course of neuraminidase inhibitor was prescribed for all patients, as recommended by the WHO, but due to the complications, 73% of the patients required antibiotic therapy, and 61% oxygen therapy. The majority of patients had a favorable outcome, but 11 required intensive care and one died. Conclusions A/H1N1 influenza persists as an important public health problem, mainly due to high morbidity and hospitalization rates. It is important to identify patients with A/H1N1 influenza and clinical situations with higher risk of complications. Through this study, it is possible to analyze the characteristics of pediatric patients with A/H1N1 influenza and mainly to emphasize assistance of populations with comorbidities, since they present higher rates of complications and death.

Bronchiolitis severity according to the infected viruses

PURPOSE: The aim of this study was to evaluate the severity of disease in children with acute bronchiolitis according to the type of infected virus. METHODS: From November 2007 to May 2015, 768 patients under 2 years of age who underwent real time-polymerase chain reaction of nasopharyngeal aspirates admitted to the Department of Pediatrics of Dongguk University Ilsan Hospital for acute bronchiolitis were enrolled. Severe bronchiolitis was defined as presence of one or more kinds among tachypnea, chest retraction, needs of O2 inhalation or ventilator care. RESULTS: The severity of bronchiolitis was increased with shorter fever duration (P < 0.001) and previous wheezing episodes (P = 0.005). In the case of single infection, respiratory syncytial virus (RSV) A only increased the severity of acute bronchiolitis (P = 0.012). However, the severity of illness decreased when RSV A coinfected with adenovirus (P = 0.034), human rhinovirus (P = 0.038), or human coronavirus NL63 (P = 0.042). On the other hand, when human rhinovirus was coinfected with enterovirus (P = 0.013) or parainfluenza 3 (P = 0.019), the severity was increased. When human metapneumovirus coinfected with human bocavirus, the severity was increased (P = 0.038). CONCLUSION: Acute bronchiolitis was associated with increased severity only when RSV A infected solely, but several viruses increased or decreased the severity when coinfection occurred. Therefore, it may be helpful in predicting the course of the acute bronchiolitis according to the affected virus.

Clinical Features of Critical Congenital Heart Disease in Term Infants with Hypoxemia: A Single-Center Study in Korea

PURPOSE: This study was performed to determine the clinical features of full-term infants with hypoxemia detected by pulse oximetry and to establish the diagnosis of critical congenital heart disease (CCHD). METHODS: We retrospectively reviewed the medical records of neonates who had been admitted to the neonatal intensive care unit within 2 weeks of birth at Korea University Ansan Hospital between January 2013 and October 2017 (n=450). We classified these neonates based on the presence of hypoxemia at admission and investigated neonatal characteristics, initial symptoms, echocardiographic findings, and final diagnosis associated with hypoxemic diseases. RESULTS: Of 450 term infants, 265 infants (58.9%) were identified hypoxemia by pulse oximetry at admission. The most common symptoms of them were cyanosis and tachypnea. Among them, 80.1% of infants (214/265) were diagnosed with respiratory tract disease and 8.3% of infants (22/265) had congenital heart disease. Thirteen infants (13/265, 4.9%) had CCHD and were treated with urgent surgery or transcatheter intervention within 28 days of birth. Majority of infants with respiratory tract disorder were transferred from hospital immediately after birth, but 46.1% of infants (6/13) with CCHD remained asymptomatic after birth and were admitted after 48 hours after birth. In addition, other hypoxemic illnesses were identified as neonatal infectious and neurological diseases. CONCLUSION: This study showed the importance of assessment in neonates with hypoxemia, including those diagnosed with CCHD. The possibility of CCHD should be considered in the differential diagnosis in neonates demonstrating hypoxemia after 48 hours of birth. A larger prospective study is needed to assess the effectiveness and outcomes of pulse oximetry for neonatal screening in Korea.

Eficacia del tratamiento antibiótico en la bronquitis aguda / Efficacy of antibiotic treatment in acute bronchitis

Partiendo de una viñeta clínica la autora plantea el siguiente interrogante: ¿En pacientes mayores de 65 años con diag-nóstico probable de bronquitis aguda, el uso de antibióticos produce mejora en algún parámetro clínico?Luego de realizar una busqueda bibliográfica se resumen la evidencia publicada en una reciente revisión sistemática, la cual concluye que si bien existen beneficios estadísticamente significativos en algunos resultados de interés, estos no parecen tener impacto clínico teniendo en cuenta la naturaleza habitualmente autolimitada y benigna de esta enfermedad y la posibilidad de efectos colateales relacionados con el tratamiento. Es importante destacar sin embargo que la eviden-cia resultó limitada para abordar cabalmente a la población anciana afectada por este problema. (AU)

Moved by a clinical vignette, the author propose the following question: In patients over 65 with probable diagnosis of acute bronchitis, does the use of antibiotics produce improvement in any clinical outcome?After carrying out a bibliographic search, the evidence published in a recent systematic review is summarized, which concludes that although there are statistically significant benefits in some results of interest, these do not seem to have clinical impact, tak-ing into account the usually self-limited and benign nature of this disease and the possibility of collateral effects related to the treatment. It is important to highlight, however, that the evidence was limited to fully address the elderly population affected by this problem. (AU)

Causes of Transfer of Neonates (Born after ≥34 Weeks of Gestation) to the Neonatal Intensive Care Unit Owing to Respiratory Distress and their Clinical Features

PURPOSE: Respiratory morbidity is the most common problem among neonates admitted to neonatal intensive care units. Therefore, the aim of this study was to make a differential diagnosis between transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), and pneumonia through comparison of clinical features and test results. METHODS: This retrospective study was conducted in 86 infants with TTN, RDS, or pneumonia. These were infants who had respiratory distress, were born after ≥34 weeks of gestation, and transferred to the neonatal intensive care unit of Kosin University Gospel Hospital between June 1, 2011 and June 30, 2016. RESULTS: The numbers (percentage) of infants with TTN, RDS, and pneumonia were 51 (59.3%), 20 (23.3%), and 15 (17.4%), respectively. Late-preterm and early-term newborns accounted for 65.1% of the infants. Tachypnea was observed in 74.4% of the neonates. The median age at admission was 4 hours (0 to 116) after birth. The infants with RDS had significantly lower birth weights, pH levels, base excess and oxygen saturation levels at admission, longer duration of total ventilator therapy, and hospital stay than those in the other two groups. The infants with pneumonia showed significantly high initial high-sensitivity C-reactive protein levels and significant chest radiographic findings. CONCLUSION: Early differential diagnosis for TTN, RDS, and pneumonia is challenging because they show similar respiratory symptoms at an early stage. Clinical features and test results can be used to determine the etiology of respiratory distress and early antibiotic treatment.

Pediatric Case Report on an Interstitial Lung Disease with a Novel Mutation of SFTPC Successfully Treated with Lung Transplantation

Mutations of the surfactant protein (SP)-C gene (SFTPC) have been associated with neonatal respiratory distress syndrome (RDS) and childhood interstitial lung disease (ILD). If accurate diagnosis and proper management are delayed, irreversible respiratory failure demanding lung transplantation may ensue. A girl was born at term but was intubated and given exogenous surfactant due to RDS. Cough and tachypnea persisted, and symptoms rapidly progressed at 16 months of age despite treatment with antibiotics, oral prednisolone, methylprednisolone pulse therapy, and intravenous immunoglobulin. At 20 months, she visited our hospital for a second opinion. A computed tomography scan showed a diffuse mosaic pattern with ground-glass opacity and subpleural cysts compatible with ILD. A video-assisted thoracoscopic lung biopsy revealed ILD with eosinophilic proteinaceous material and macrophages in the alveolar space. Bilateral lung transplant from a 30-month-old child was done, and she was discharged in room air without acute complications. Genetic analysis revealed a novel c.203T>A, p.Val68Asp mutation of SP-C, based on the same exon as a known pathogenic mutation, p.Glu66Lys.

Idiopathic type-4 hiatal hernia in a middle-aged cat / 대한수의학회지

A 6-year-old female domestic short hair cat presented with acute onset of vomiting, anorexia, lethargy, and tachypnea. The cat was apparently healthy prior to presentation without history of trauma. On diagnostic imagings, the entire stomach and spleen were detected in the thoracic cavity. An emergent celiotomy was performed, and a type-4 hiatal hernia was confirmed; the stomach, spleen, pancreas, and duodenum were herniated through the esophageal hiatus. It was corrected using phrenicoplasty, esophagopexy, and left-sided gastropexy and there was no recurrence 16 months after surgery. This is the first case report of an idiopathic type-4 hiatal hernia in a cat.

Estudio Descriptivo: Neumonía y Complicaciones en Niños en el Hospital de Especialidades José Carrasco Arteaga. Enero - Diciembre 2015 / Desciptive Research: Pneumonia and Complications in Children at José Carrasco Arteaga Specialty Hospital. January - December 2015

INTRODUCCIÓN: La neumonía es la primera causa de morbi ­ mortalidad en los países en desarrollo, según la Organización Mundial de la Salud representa aproximadamente el 19 % de todas las muertes en menores de 5 años. El objetivo del presente estudio fue determinar las características clínicas y complicaciones de niños con neumonía en un Hospital de Especialidades en la zona sur de Ecuador. MÉTODOS: El presente estudio es descriptivo retrospectivo de corte trasversal con recolección de información obtenida de historias clínicas de los pacientes hospitalizados por neumonía de Enero a Diciembre de 2015 en el Hospital de Especialidades José Carrasco Arteaga de la ciudad de Cuenca-Ecuador. Se analizaron las variables demográficas de la población estudiada y sus complicaciones. Se presentan datos en frecuencias y porcentajes. RESULTADOS: En los 6 meses de estudio se revisaron 573 historias clínicas de los cuales 142 casos se registraron como neumonía (24.78 %). La edad media fue 4 a 3.57 años, y es el sexo femenino el más afectado (53.53 %). La tos (91.55 %), alza térmica (87.32 %), taquipnea (70.42 %), estertores (47.18 %), fueron las características clínicas más comunes. La neumonía bacteriana típica (62.68 %), es el tipo de neumonía más frecuente y la que mayor complicación presenta como: derrame pleural (7.04 %), sepsis (6.34 %), fallecimiento (6.34 %), empiema (4.23 %), absceso pulmonar (2.11 %), fistula broncopulmonar (2.11 %). CONCLUSIONES: La neumonía es una patología frecuente de hospitalización en pediatría, la edad más afectada fue de 1 a 3 años, las características clínicas como tos, alza térmica, y taquipnea fueron las más comunes. La neumonía bacteriana típica, es el tipo más grave y las complicaciones que presentaron fueron: derrame pleural, empiema, sepsis, con mortalidad de 5.63 %. (AU)

BACKGROUND: Pneumonia is the leading cause of morbidity and mortality in developing countries, according to the World Health Organization, accounting for approximately 19 % of all deaths in children under 5 years of age. The aim of the present study was to determine the clinical characteristics and complications of children with pneumonia at a Specialty Hospital in the southern area of Ecuador. METHODS: The present study is a descriptive retrospective cross-sectional study with data collection from clinical records of patients hospitalized for pneumonia from January to December 2015 at the José Carrasco Arteaga Specialty Hospital in the city of Cuenca, Ecuador. We analyzed the demographic variables of the studied population and their complications. Data are presented in frequencies and percentages. RESULTS: In the 6-month study, 573 medical records were reviewed, of which 142 cases were recorded as pneumonia (24.78 %). The mean age was 4 a 3.57 years, and the female sex was the most affected (53.53 %). Cough (91.55 %), thermal rise (87.32 %), tachypnea (70.42 %), rales (47.18 %) were the most common clinical features. The most common type of pneumonia is pneumonia (62.68 %), which presents as pleural effusion (7.04 %), sepsis (6.34 %), death (6.34 %), empyema (4.23 %), abscess pulmonary (2.11 %), bronchopulmonary fistula (2.11 %) CONCLUSIONS: The Pneumonia is a pathology frequent pediatrics of hospitalization; the most affected age was 1 to 3 years and clinical characteristics most common such as: cough, fever, and tachypnea. Typical bacterial pneumonia is the most severe type for disease children's and the complications frequents presented were pleural effusion, empyema, and sepsis, with mortality of 5.63 %.(AU)

Short-term clinical outcomes of neonates of secundiparous mothers: a single-center cohort study / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To investigate the short-term clinical outcomes of neonates of secundiparous mothers, and to provide a reference for the clinical practice after the change in birth policy.</p><p><b>METHODS</b>A cohort study was performed for the parturients and their neonates born in Yongkang Maternal and Child Health Care Hospital in Zhejiang, China between June 2015 and April 2016. According to the parity of the mother, the neonates were divided into primiparous group and secundiparous group. The short-term clinical outcomes of neonates were compared between the two groups.</p><p><b>RESULTS</b>A total of 4 091 neonates who met the inclusion criteria were enrolled, and there were 2 023 neonates in the primiparous group and 2 068 in the secundiparous group. In the secundiparous group, most mothers (57.16%) were aged 26-34 years, and 16.49% were aged above 35 years. Compared with the primiparous group, the secundiparous group had a significantly higher rate of births by cesarean section (42.55% vs 25.06%; P<0.05). The percentages of neonatal respiratory distress syndrome (NRDS; 8.6% vs 3.4%) and transient tachypnea of the newborn (TTN; 7.2% vs 2.6%; P<0.05) in hospitalized neonates from the secundiparous group were significantly higher than in those from the primiparous group.</p><p><b>CONCLUSIONS</b>Elderly parturient women are not the major population of secundiparous parturients. The neonates of secundiparous mothers have a higher rate of births by cesarean section, which might be associated with increased percentages of NRDS and TTN in hospitalized neonates from the secundiparous mothers.</p>