Neumonía intersticial linfoidea asociada a inmunodeficiencia común variable / Interstitial lymphoid pneumonia associated with common variable immunodeficiency

La neumonía intersticial linfoidea (NIL) es una rara entidad, descripta como hiperplasia no neoplásica del tejido linfoide pulmonar y clasificada dentro de las enfermedades intersticiales idiopáticas. Se la ha descripto asociada a infección por HIV, fenómenos autoinmunes, hipergamaglobulinemia policlonal o menos frecuentemente a hipogammaglobulinemia. Presentamos una paciente de 66 años de edad con diabetes mellitus, síndrome de Sjögren e hipertensión arterial, derivada a nuestro centro por tos seca y disnea clase funcional II-III. En el examen físico presentaba rales tipo “velcro” bibasales y esplenomegalia. Los estudios de laboratorio evidenciaron plaquetopenia (50 000/mm³) e hipogammaglobulinemia; la tomografía axial computarizada (TAC) de tórax mostró compromiso intersticial bibasal, con nódulos peribroncovasculares menores a un centímetro. Se realizó una videotoracoscopia con biopsia pulmonar, la anatomía patológica mostró hallazgos compatibles con neumonía intersticial linfoidea. Se inició tratamiento con metilprednisona 40 mg/día vía oral e infusión endovenosa de gammaglobulina 500 mg/kg, mensual, evolucionando con mejoría clínico-radiológica. Por persistencia de plaquetopenia, asociada a hiperesplenismo, se realizó esplenectomía con buena respuesta. En la anatomía patológica no se observo clonalidad linfoide.

The interstitial lymphoid pneumonia (LIP) is an uncommon disorder, described as non-neoplastic lung lymphoid tissue hyperplasia and classified as an interstitial lung disease. It has been described in association with HIV infection, autoimmune disorders, policlonal hypergammaglobulinemia and less frequently, with hypogammaglobulinemia. We report the case of a 66 year old female patient with a history of diabetes, Sjögren syndrome and hypertension. She was referred to our hospital due to a dry cough and dyspnea (FC II-III). The physical examination showed bilateral dry crackles and splenomegaly. Laboratory studies showed thrombocytopenia (50 000/ mm³) and hypogammaglobulinemia. A computed tomography thoracic scan showed interstitial bilateral basal lung infiltrates with small peribroncovascular nodules. A lung biopsy was made by thoracoscopy and reported LIP. Initial treatment consisted of oral methilprednisone, 40 mg daily, and once a month intravenous gammaglobulin 500 mg/kg, with good clinical and radiological response. A splenectomy was done due to persistent thrombocytopenia associated with hypersplenism, with good response of the platelets counts. No lymphoid clonal or other associated disease was detected.

Características de acceso al tratamiento con presión positiva en el síndrome de apneas del sueño y su relación con el cumplimiento y el abandono en un hospital de comunidad / Characteristics of access to treatment with positive pressure in the sleep apnea syndrome and its relationship to compliance and neglect in a community hospital

Objetivos: Describir las características de acceso al tratamiento con presión positiva y su cumplimiento en el síndrome de apneas del sueño (SAHOS), en un hospital de comunidad. Métodos: Datos obtenidos por encuesta telefónica a pacientes derivados para tratamiento en el período de dos años. Se interrogó acerca de: cobertura de salud, provisión, compra o alquiler de equipos, tipos, abandono y motivos del mismo. Resultados: Desde julio de 2006 a julio de 2008 se indicó tratamiento con presión positiva en la vía aérea superior a 58 pacientes con SAHOS severo o moderado. Fue posible encuestar a 54. Todos tuvieron cobertura de salud (13 obras sociales y 7 empresas de medicina prepaga). El 25 por ciento (14/54 pacientes) habían abandonado al momento de ser encuestados. El 51.8 por ciento (n=28) compró el equipo (refiriendo falta de cobertura por la empresa de salud) y en el 13 por ciento (n=7) el financiador cubrió el 50 por ciento. En el 18.5 por ciento de los pacientes (n=10) la cobertura entregó el equipo en comodato (todos correspondieron a obras sociales y ninguno a empresa de medicina prepaga), y 5 pacientes continuaban usando equipos en alquiler permanente. De aquellos que compraron el equipoo lo obtuvieron en comodato (n=38), 4 (10 por ciento) abandonaron, comparados con los 11 pacientes que lo hicieron mientras alquilaban, y con el 25 por ciento de abandono global. Conclusiones: El grupo equipo propio, por compra o comodato mostró menor abandono (p= 0.0001). La cobertura fue diferente para obras sociales que para empresas demedicina prepaga, y la tasa mas alta de abandono se presentó durante el alquiler del equipo (78 por ciento).

Objective: To determine the impact of factors which hamper the treatment of obstructive sleep apnea (OSA) in a private hospital. Methods: We conducted a retrospective telephonic survey of adults referred for treatment of OSA during a two year period. The questionnaire included data about health insurance system, type and methods of acquisition (purchase or rental) of the continuous positive airway pressure (CPAP) equipment, compliance with treatment and reasons for abandonment if it occurred. Results: From July 2006 to July 2008, treatment with CPAP was prescribed to 58 patients with severe or moderate OSA; 54 of them could be interviewed. All of them had healthinsurance coverage (with 13 labor union dependent systems and 7 different private health insurance systems). Twenty-five percent of the patients (n=14) had abandoned treatmentat the moment of being interviewed; 51.8 percent of the patients (n=28) had purchased the CPAP equipment (because it was not included in their health insurance coverage) and 13 percent (n=7) had paid 50 percent of the cost of the equipment. In 18.5 percent of patients (n=10) the health insurance system delivered the equipment as a loan (only labor union dependent systems) and 5 patients rented the CPAP equipment in a permanent way at their own cost. Among the patients who had purchased the equipment or obtained it as a loan(n=38), 4 patients abandoned treatment (10 percent) vs 11 patients (78 percent) in the group who had rented it (p= 0.0001).Conclusions: The patients who had paid for their own equipment or had received it as a loan had a significantly lower rate of abandonment . The benefit of the provision of the CPAP equipment differs between private and labor union health insurance systems. Renting the CPAP equipment results in the highest rates of abandonment of treatment.

Embolismo pulmonar tumoral: Reporte de dos casos / Pulmonary tumor embolism: Report of two cases

Dyspnea and hypoxemia in a patient with cancer may have several causes, including infections, thromboembolism, metastases, and pulmonary injuries by drugs. We report a 47-year-old female with breast cancer and a 70-year-old male with urinary bladder cancer who were admitted for dyspnea, hypoxemia and pulmonary hypertension. Chest X rays and CT scans were normal. The ventilation-perfusion scintigram was highly suspicions of thromboembolism in the female. The male died 16 hours after admission and the post mortem examination revealed the presence of tumor cells in the pulmonary vasculature.