Hipersensibilidad a corticoides y manejo en asma severa. A propósito de un caso / Hipersensitivity to corticosteroids and management of severe bronchial asthma. Case study

Resumen Las reacciones de hipersensibilidad a corticoides son raras en la población general, se dividen en dos categorías: Inmediatas, típicamente mediadas por Inmunoglobulina E (IgE), donde se incluye la anafilaxia luego de la administración de un fármaco en un corto período. Su prevalencia descrita es de 0,3-0,5%. Otra reacción es la 'no inmediata', que se manifiesta en un tiempo mayor de una hora después de la administración del fármaco. Se revisó la literatura con el objetivo de mejorar y aclarar el tratamiento en pacientes asmáticos que poseen esta condición. Se encontró que las vías posibles para generar estas reacciones son intranasal, aerosol por inhalador, oral y parenteral. Frente a esta condición se requiere una evaluación estrecha y detallada de la historia clínica, síntomas y reacciones secundarias al fármaco sospechoso. Finalmente, al momento de elegir tipo de corticoide a usar es primordial la seguridad del paciente logrando, además, el control de la enfermedad.

Hypersensitivity reactions to corticosteroids are rare in the general population, they fall into two categories: 'immediate', typically mediated by immunoglobulin E (IgE), which includes anaphylaxis after administration of a drug in a short period of time. Its reported prevalence is 0.3-0.5%. Another reaction is 'not immediate', which manifests itself in a time longer than one hour after the administration of the drug. We reviewed the literature with the aim of improving and clarifying the treatment in asthmatic patients with this condition. It was found that the possible routes to generate these reactions are intranasal, aerosol by inhaler, oral and parenteral. Facing this condition requires a close and detailed evaluation of the clinical history, symptoms and side reactions to the suspected drug. Finally, when choosing which corticosteroid to use, the patient's safety is paramount, and control of the disease is also essential.

Traqueobroncomegalia: a propósito de un caso clínico-radiológico / Tracheobronchomegaly: a case report

Tracheobronchomegaly corresponds to the anomalous diffuse dilatation of the trachea and main bronchi, usually accompanied by bronchiectasis, which predisposes to recurrent infections. The imaging study is essential to recognize this entity. A case of a 40-year-old woman, with suspicion of bronchial asthma is presented. Imaging study and bronchofiberscopy confirmed the diagnosis of tracheobronchomegaly in this patient.

La traqueobroncomegalia corresponde a la dilatación anómala y difusa de la tráquea y bronquios principales, acompañado habitualmente de bronquiectasias, lo que predispone a infecciones recurrentes. El estudio radiológico resulta fundamental para reconocer esta entidad. Se presenta un caso de una mujer de 40 años en estudio por sospecha de asma bronquial en que el estudio de imágenes (Rx y TAC) y lafibrobroncoscopia confirmó el diagnóstico de traqueobroncomegalia.

Prueba de caminata en seis minutos en sujetos chilenos sanos de 20 a 80 años / Reference values for the 6-minutes walking test in healthy subjects 20-80 years old

Background: The six minute walking distance test (6MWD) is widely used to evaluate exercise capacity in several diseases due to its simplicity and low cost. Aim: To establish reference values for 6MWD in healthy Chilean individuals. Material and methods: We studied 175 healthy volunteers aged 20-80 years (98 women) with normal spirometry and without history of respiratory, cardiovascular or other diseases that could impair walking capacity. The test was performed twice with an interval of 30 min. Heart rate, arterial oxygen saturation (with a pulse oxymeter) and dyspnea were measured before and after the test. Results: Walking distance was 576 ± 87 m in women and 644 ± 84 m in men (p < 0.0001). For each sex, a model including age, height and weight produced 6MWD prediction equations with a coefficient of determination (R²) of 0.63 for women and 0.55 for men. Conclusions: Our results provide reference equations for 6MWD that are valid for healthy subjects between 20 and 80 years old.

Dermatomiositis refractaria asociada a neumonía en organización tratada con rituximab: Reporte de un caso / Refractory dermatomyositis associated with chronic organizing pneumonia treated with rituximab: Report of one case

Chronic organizing pneumonia (COP) has often been reported as a pulmonary manifestation of collagen vascular diseases, mainly rheumatoid arhritis, but the association of COP and dermatomyositis (DM) has rarely been documented. We report a 55 year-old woman with well-documented DM and a COP. She was refractory to steroids and two other immunosuppressive agents therapy (cyclophosphamide and azathioprine). Therefore, rituximab (2 x 1 g infusions) was used for treatment. During the following weeks her strength gradually increased while creatine kinase (CK), C reactive protein and erythrocyte sedimentation rate normalized. After 6 months, she had a relapse with increased muscle enzymes, fever and modérate muscle weakness. After a second course of rituximab (2 x 1 g infusions), the patient demonstrated a remarkable clinical response as indicated by an increase in muscle strength and moderate decline in creatine kinase levels. Lung abnormalities resolved significantly on high resolution chest CT sean. Thus, B-cell depletion therapy with rituximab used alone or in combination with other immunosuppressants may be a viable option in patients with polymyositis-dermatomyositis and pneumonia refractory to current therapies.

Compromiso pleural en la leucemia de células plasmáticas: reporte de un caso / Pleural effusion in plasma cell leukemia: a case report

Multiple myeloma is a low malignant, non-Hodgkin's lymphoma, which is characterized by infiltration of the bone marrow by clonal proliferation of atypical plasma cells. Extramedullary manifestations are relatively rare. Serous effusions in multiple myeloma are uncommon (6 percent of cases) but a myelomatous pleural effusion occurring in these patients is extremely rare. Plasma cell leukemia, occurring either de novo or in patients with long standing multiple myeloma, is the least common type of plasma cell dyscrasia. The authors describe the course of plasma cellular leukemia in a 63-year-old male patient where the first manifestation of the disease was a bacteremic pneumococcal pneumonia and a contralateral pleural exudate with a cytological finding of plasma cells. The exudate disappeared after the first cycle of chemotherapy (vincristine, adriamycin, dexamethasone). After the third cycle of chemotherapy remission of the disease was recorded which was, however, short. After three months' remission the disease recurred, consequently underwent autologous bone marrow transplantation. The patient has maintained complete remission for 12 months after diagnosis. Pleural effusion is an unusual but important complication of multiple myeloma and does not necessarily carry the grave prognosis implied in previous reports.

El mieloma múltiple es una neoplasia maligna de células plasmáticas que invade la médula ósea y otros tejidos. Las manifestaciones extramedulares son relativamente raras. El derrame pleural en el mieloma múltiple es poco frecuente (6 por ciento de los casos), y el derrame pleural neoplásico es extremadamente raro. La leucemia de células plasmáticas, que se produce de novo o en pacientes con mieloma múltiple, es la variedad menos común de discrasia de células plasmáticas. Los autores describen el cuadro clínico de un paciente de 63 años con leucemia de células plasmáticas, donde la primera manifestación de la enfermedad fue una neumonía neumocócica bacteriémica asociado a un derrame pleural contralateral, que correspondió a un exudado predominio mononuclear. El examen citológico reveló abundantes células plasmáticas inmaduras en el líquido pleural y la sangre periférica. El derrame pleural desapareció después del primer ciclo de quimioterapia (vincristina, adriamicina, dexametasona). Después de tres meses de remisión, la enfermedad neoplásica recidivó, siendo el paciente sometido a trasplante autólogo de médula ósea. El paciente se ha mantenido en remisión completa un año después del diagnóstico. El derrame pleural es una complicación poco común, pero importante, del mieloma múltiple y no necesariamente conlleva un mal pronóstico.

Neumonía grave por Streptococcus pyogenes: reporte de un caso / Community-acquired pneumonia caused by Streptococcus pyogenes: report of one case

During the past two decades there has been a resurgence ofinvasive group A streptococcal (GAS) infection, specially pneumonia and bacteremia. We report a 35 year-old female previously subjected to a thyroidectomy for a thyroid cáncer, that five days after operation, presented with a severe community-acquired pneumonia caused by Streptococcus pyogenes (Lancefield Group A Streptococcus) that was complicated by acute respiratory failure and septic shock. She was treated with a combination of 3 g/day of cefotaxime and 1.8 g/day of clindamycin with a good clinical response and discharged from the hospital in good conditions. Although this microorganism is an uncommon cause of community-acquired pneumonia, previously healthy individuals may be infected and the clinical course may be fulminant. Patients with invasive GAS infection admitted to ICU have a high mortality rate. Treatment of choice of Group A streptococcal infection is penicillin. However, clindamycin should be added in severe infections.

La prueba de caminata en seis minutos en la evaluación de la capacidad de ejercicio en pacientes con enfermedad pulmonar obstructiva crónica / Six minutes walk for the assessment of patients with chronic obstructive pulmonary disease

Exercise capacity can be evaluated in patients with chronic obstructive pulmonary disease (COPD), measuring the distance that patients are able to walk in 6 minutes (six-minute walk distance test; 6WDT). This test is simple to perform, inexpensive, reproducible and safe. It has been frequently employed for the assessment of COPD patients due to its high prognostic valué of mortality and its usefulness to evalúate long-term of therapeutic interventions. In severe stages of the disease, the declining results of the best are useful to detect worsening. This review describes the method, standardization and reference valúes for the 6WDY and the results obtained with different therapeutic interventions, based on data from the literature and from the authors experíence. We also review its predictive valué for mortality and its valué in the assessment of patients with more severe COPD.

Enfermedad pulmonar difusa asociada al consumo de tabaco / Smoking related interstitial lung disease: case report

The relationship between cigarette smoke and interstitial lung diseases (ILD) is not clear. Respiratory bronchiolitis (RB), usually found as an incidental histologic abnormality in otherwise asymptomatic smokers, is characterized by the accumulation of cytoplasmic golden-brown-pigmented macrophages within respiratory bronchioles. A small proportion of smokers have a more exaggerated response that, in addition to the bronchiole-centered lesions, provokes interstitial and air spaces inflammation and fibrosis extending to the nearby alveoli. This set of histologic changes is called RB-ILD, and it results in clinical symptoms. Desquamative interstitial pneumonia (DIP) is characterized by panlobular involvement, diffuse mild-to-moderate interstitial fibrosis, and massive alveolar filling with macrophages. It is well known that the histopathologic patterns of RB-IID and DIP may overlap, and that the key features for differentiating these disorders are the distribution and the extent of the lesions: bronchiolocentric in RB-IID and diffuse in DIP. It has been proposed that RB, RB-IID and DIP may be different components of the same histopathologic disease spectrum, representing various degrees of severity of the same process caused by chronic smoking, although this is still controversial. To illustrate the problem, we present the clinical case of a heavy-smoker patient with progressive dyspnea and radiographic pulmonary infiltrates suggesting of smoking related interstitial lung disease.

La enfermedad pulmonar difusa asociada al consumo de tabaco no ha sido claramente definida, la bronquiolitis respiratoria (RB) es un hallazgo morfológico frecuente en fumadores asintomáticos, se caracteriza por la acumulación de macrófagos pigmentados en los bronquiolos respiratorios. Sólo una pequeña proporción de los sujetos fumadores presenta una respuesta inflamatoria exagerada que compromete el intersticio y espacio alveolar, lo cual corresponde a la bronquiolitis respiratoria asociada a enfermedad pulmonar difusa (RBIID), que se manifiesta por disnea de esfuerzos y tos. La neumonía intersticial descamativa (DIP) se caracteriza por compromiso panlobular, fibrosis intersticial discreta e infiltración masiva del espacio aéreo por macrófagos. El patrón histopatológico de RBIID y DIP se pueden sobreponer, siendo los principales elementos diferenciadores entre ambas entidades, la distribución y extensión de las lesiones: compromiso bronquiolo-céntrico en RBIID y difuso en DIP. Se ha planteado que la RB, RBIID y DIP pueden constituir diferentes fases de una misma enfermedad asociada al consumo de tabaco, lo cual aún es motivo de controversia. Con el propósito de ilustrar este problema, se presenta el caso clínico de un paciente fumador que consultó por disnea progresiva, tos e infiltrados pulmonares bilaterales sugerentes de enfermedad pulmonar difusa asociada al tabaquismo.

Impacto de la evaluación infectológica en el uso racional de antimicrobianos en pacientes con bacteriemia por Streptococcus pneumoniae / Impact of infectious diseases specialist evaluation on the rational use of antibiotics in patients with Streptococcus pneumoniae bacteremia

The increasing reporting of Streptococcus pneumoniae resistance to penicillin has lead to the recommendation of third generation cephalospirins for the treatment of serious pneumococcal infections. As a consequence, clinicians usually do not prescribe first line antibiotics despiste the availability of susceptibility studies. Whit the aim to evaluate the impact of the infectious diseases specialist evaluation in the apropriate use oh the susceptibility studies, two series were compared: a historic control one (1998-2002, n = 50) and a prospectuve group that had the advisement of one infectious diseases specialist (2003-2006, n = 60). In both series, pneumonia stood out as the source of the bacteremia, and -alcoholism/hepatic insufficiency as associated factor. In the first series, 48 isolates resulted susceptible to penicillin by agar diffusion, and 1 out of 36 patients with pneumonia had a change in the antibiotic therapy to penicillin. In the prospective series, we found 56 susceptible isolates, and the remaining four were classified as intermediate susceptibility according to the MIC value. Antibiotics were changed in 36 out of 50 patients with bacteremic pneumococcal pneumonia (p < 0.05). The infectious diseases specialist evaluation had a positive impact on the use of the microbiological information for therapeutics purposes.

La descripción creciente de Streptococcus pneu-moniae resistente a penicilina, ha llevado a la recomendación de emplear cefalosporinas de tercera generación para el tratamiento de las infecciones neumo-cócicas graves. Como consecuencia, los médicos clínicos no prescriben, usualmente, antimicrobianos de primera línea, a pesar de disponer de estudios de susceptibilidad in vitro. Con el propósito de evaluar el impacto de la asesoría del infectólogo para el uso adecuado de los estudios de susceptibilidad, se compararon dos series: un control histórico (1998-2002, n = 50) y un grupo prospectivo en que sí hubo asesoría infectológica (2003-2006, n = 60). En ambas series, la neumonía fue el foco principal de bacteriemia y alcoholismo/falla hepática los factores asociados más frecuentes. En el primer grupo, 48 aislados resultaron susceptibles a penicilina por prueba de difusión en agar y en uno de 36 pacientes con neumonía, se efectuó cambio en la terapia antimicrobiana a bencilpeni-cilina. En el grupo prospectivo, hubo 56 cepas susceptibles y las cuatro restantes fueron clasificadas como de susceptibilidad intermedia, de acuerdo con los valores de CIM. Se cambió de antimicrobiano en 36 de 50 pacientes con neumonía neumocóccica bacteriémica (p < 0,05). La evaluación hecha por el infectólogo tuvo un impacto positivo en el uso de información micro-biológica con fines terapéuticos.