Tuberculosis miliar en pacientes en tratamiento con adalimumab, una asociación no tan frecuente en pediatría / Miliary tuberculosis in patients treated with adalimumab, an association not so frequent in pediatrics

Los antagonistas del Factor de Necrosis Tumoral-α, son medicamentos que en los últimos años han tenido un incremento de su uso en pacientes con condiciones inflamatorias inmunomediadas en pediatría, como la Artritis Idiopática Juvenil y la Enfermedad Inflamatoria Intestinal. El uso de estos medicamentos en adultos tiene una fuerte asociación con la primoinfección o reactivación por Mycobacterium tuberculosis, pero en niños la evidencia es limitada. Se presentan 2 casos de pacientes tratados con adalimumab, quienes, a pesar de un buen control de su enfermedad y una prueba de tuberculina negativa al inicio de la terapia, desarrollaron tuberculosis miliar en el seguimiento, con importantes implicaciones para su salud. El tamizaje de tuberculosis latente con tuberculina/IGRAS (Interferón-γ release assays, por sus siglas en inglés) y un alto índice de sospecha de tuberculosis, son las herramientas disponibles para una adecuada identificación de la tuberculosis en pacientes que reciben crónicamente estas terapias.

Tumor Necrosis Factor-α antagonists are drugs that in recent years have seen an increase in their use in patients with immune-mediated inflammatory conditions in pediatrics such as Juvenile Idiopathic Arthritis and Inflammatory Bowel Disease. The use of these drugs in adults has a strong association with primary infection or reactivation by mycobacterium tuberculosis, but in children the evidence is limited. We present 2 cases of patients treated with adalimumab who, despite good control of their disease and a negative tuberculin test at the beginning of therapy, developed miliary tuberculosis during follow-up with important implications for their health. Screening for latent tuberculosis with tuberculin / IGRAS (Interferón-γ release assays) and a high index of suspicion for tuberculosis are the tools available for an adequate identification of tuberculosis in patients who receive these therapies chronically.

Expression of CD14 and toll-like receptors 2 and 4 by milk neutrophils in bovine mammary glands infected with Corynebacterium bovis / Expressão de CD14 e dos receptores do tipo toll 2 e 4 por neutrófilos lácteos provenientes de glândulas infectadas por Corynebacterium bovis

This study evaluated the expression of CD14, toll-like receptor (TLR) 2 and TLR4 on the surface of milk neutrophils in bovine mammary glands infected with Corynebacterium bovis. Here, we used 23 culture-negative control quarters with no abnormal secretion on the strip cup test and milk somatic cell count lower than 1x105 cells/mL, and 14 C. bovis infected quarters. The identification of neutrophils, as well as, the percentage of neutrophils that expressed CD14, TLR2 and TLR4 were analyzed by flow cytometry using monoclonal antibodies. The present study encountered no significant difference in the percentages of milk neutrophils that expressed TLR2 and TLR4 or in the expression of TLR4 by milk neutrophils. Conversely, a lower median fluorescence intensity of TLR2 in milk neutrophils was observed in C. bovis-infected quarters. The percentage of neutrophils that expressed CD14 and the median fluorescence intensity of CD14 in milk neutrophils was also lower in C. bovis-infected quarters...

O presente estudo objetivou avaliar alterações na expressão de CD14, e dos receptores do tipo toll (TLR) 2 e 4 na superfície de neutrófilos lácteos provenientes de glândulas mamárias infectadas por Corynebacterium bovis. O presente estudo utilizou 23 quartos negativos no exame bacteriológico, sem alterações na prova de fundo escuro e com contagem automática de células somáticas menor que 1 x105 células/mL, e 14 quartos mamários infectados por C. bovis A identificação de neutrófilos, assim como a porcentagem de neutrófilos lácteos que expressaram CD14, TLR2 e 4 foram avaliadas por citometria de fluxo utilizando anticorpos monoclonais. A porcentagem de neutrófilos que expressaram TLR2 e TLR4 nos quartos mamários infectados por C. bovis não diferiu dos quartos mamários sadios, assim como na expressão de TLR4. No entanto, a intensidade de fluorescência do TLR2 na superfície dos neutrófilos foi menor nos quartos mamários infectados por C. bovis. A porcentagem de neutrófilos que expressaram CD14 e a intensidade de fluorescência da molécula de CD14 foi menor na superfície dos neutrófilos lácteos dos quartos infectados por C. bovis...

Bronquiolitis: artículo de revisión / Bronchiolitis: review

Bronchiolitis is a common childhood disease and is the leading cause of hospitalization in children under 2 years, lower respiratory tract infection. It is characterized by upper respiratory symptoms which lead to lower respiratory symptoms for primary infection or reinfection with a viral pathogen, more identified is the respiratory syncytial virus. Despite the frequency and importance of this disease, there is still much controversy regarding the most appropriate treatment protocol. Its definition and treatment remain the subject of ongoing debate and the subject of study, seeking to reach a global consensus on the appropriate approach to this entity, so this article is a practical approach to bronchiolitis, based on the available scientific evidence to epidemiology, clinical manifestations, diagnosis, treatment and prevention of bronchiolitis. The implementation of a treatment algorithm is feasible and can help reduce operating errors and the rate of inadequate prescription of steroids and antibiotics in children with bronchiolitis.

La bronquiolitis, es una enfermedad frecuente en la infancia y constituye la principal causa de ingreso hospitalario en los menores de 2 años, por infección del tracto respiratorio inferior (ITRI). Se caracteriza por síntomas respiratorios superiores que conducen a síntomas respiratorios inferiores por la infección primaria o la reinfección con un patógeno viral, el más identificado es el virus respiratorio sincicial (VRS). A pesar de la frecuencia e importancia de esta enfermedad, aún existen grandes controversias en cuanto al protocolo terapéutico más adecuado. Su definición y tratamiento siguen siendo tema de constantes debates y motivo de estudio, buscando llegar a un consenso mundial sobre el adecuado abordaje de esta entidad, por lo que este artículo es un enfoque práctico de la bronquiolitis, basado en la evidencia científica disponible en cuanto a la epidemiología, manifestaciones clínicas, diagnóstico, tratamiento y prevención de la bronquiolitis. La implementación de un algoritmo terapéutico es factible y puede ayudar a reducir los errores de manejo y la tasa de prescripción de esteroides y antibióticos, inadecuados en niños con bronquiolitis.

Resección quirúrgica de aspergiloma en paciente inmunosuprimido: presentación de un caso clínico / Surgical resection of aspergilloma in immunosupressed patient: a case report

Aspergillosis refers to the spectrum of disease caused by Aspergillus species. The aspergilloma is the most common and best-recognized form of pulmonary involvement due to Aspergillus; usually developing in a preformed lung cavity and the principal association is with Tuberculosis. The true incidence of aspergilloma is not known. Although frequently asymptomatic, the presence of a fungus ball due to Aspergillus may cause hemoptysis and in cases can be fatal, with a variable mortality ranging between 9 to 30 percent. Aspergilloma usually comes to clinical attention as an incidental finding, thus the diagnosis involve clinical and radiological findings confirmed by pathology. There is no consistent evidence that aspergilloma. Responds to antifungal agents, and these drugs rarely achieve the minimal inhibitory concentrations within the lung cavities. Surgical resection, despite a high morbidity, is the only proven therapy for these cases.

La aspergilosis se refiere al espectro de enfermedades ocasionadas por la especie de Aspergillus. El aspergiloma es la forma más reconocida y común de la afección pulmonar relacionada a dicha especie, generalmente se desarrolla en una cavidad pulmonar pre-existente, la principal asociación es con secuelas de tuberculosis. Se desconoce la incidencia a nivel mundial. La mayoría de los pacientes se manifiestan asintomáticos; en raras ocasiones, debutan con hemoptisis mayor, con una mortalidad variable que oscila entre el 9 a 30 por ciento. El diagnóstico se basa en los hallazgos clínicos, imagenología y confirmados por patología. El tratamiento farmacológico no ha demostrado ser de gran utilidad, en tanto que, la cirugía a pesar de una elevada morbilidad podría ser el tratamiento de elección.

Determinação sérica de colesterol e triglicérides em cavalos soroprodutores alimentados com concentrados com teores de 15 ou 22 de proteína bruta / Serum evaluation of cholesterol and triglycerides of serum-producing horses fed concentrate with 15 or 22 of crude protein

A produção de soro-hiperimune em eqüinos ainda é fundamental para obtenção do soro utilizado no tratamento de algumas enfermidades como o tétano e a difteria. Para verificar o possível benefício da utilização de concentrados hiperprotéicos na dieta dos cavalos soroprodutores da Fazenda São Joaquim do Instituto Butantan-SP, foram analisados os teores séricos de colesterol e triglicérides de 32 animais, pertencentes ao plantel de produção de soro antidiftérico. Estes foram distribuídos, ao acaso, em dois grupos de 16 eqüinos. Os animais do grupo A receberam concentrado com 15% de proteína bruta (PB) e os animais do grupo B receberam concentrado com 22% de PB. As amostras de soro foram obtidas em dois ciclos de produção nos momentos anteriores à inoculação do antígeno, antes das sangrias de produção e nos dias 15, 30 e 45 de descanso. As concentrações de triglicérides foram maiores no grupo Bno dia 58 do primeiro ciclo (p<0,001) e, no segundo ciclo, foram maiores no grupo A nos dias 95 e 137 (p<0,04) e no grupo B no dia 109 (p<0,04). Não houve diferença entre os grupos para as concentrações séricas de colesterol. Este trabalho concluiu que embora as concentrações séricas de triglicérides e colesterol sejam sensíveis ao processo de produção de plasma-hiperimune antidifitérico, os resultados encontrados não foram suficientes para afirmar se hábenefício ou não na utilização de concentrado hiperprotéico(22% PB) em cavalos produtores de soro-hiperimune anti-difteria em dois ciclos de produção.

The hyperimmune serum production in horses is still fundamental to obtain the serum used in the treatment of some diseases like tetanus and diphtery. In order to determine the benefit of the utilization of high-protein concentrate in serum-producing horses dietary of Butantan Institute, the serum concentrations of cholesterol and triglycerides were screened from a group of 32 anti-diphteric serum-producing horses. Those horses were distributed occasionally in two groups of 16 equines. The animals of group A were fed with a concentrate with 15% of crude protein (CP) and the animals of group B were fed with a concentrate with 22% of CP. The serum samples were obtained in two immunization periods, in moments previous to the antigen inoculation, before the bleeding of production and with a delay of 15, 30 and 45 days after the last bleeding. The serum concentrations of triglycerides were higher in group B in day 58 of the first period (p<0,001) and in the second period were higher in group A in days 95 and 137 (p<0,04) and in group B in day 109(p<0,04). There was no difference between the groups for cholesterol serum concentrations. We concluded that although the triglycerides and cholesterol serum concentrations be sensitive to the process ofanti-diphteric hyperimmune plasma production, the results found were not enough to affirm weather there is or not a benefit in the utilization of high-protein concentrate (22% CP) in anti-diphteric serum-producing horses based on two periods of production.