Evolución clínica en pacientes con síndrome del túnel carpiano tratados con ultrasonido o infiltración con corticoesteroides / Clinical Evolution in Patients with Carpal Tunnel Syndrome Treated with Ultrasound or Corticosteroid Infiltration

Introducción. El Síndrome del túnel carpiano es la neuropatía periférica compresiva más común de la extremidad superior, que se produce por la compresión del nervio mediano. Los casos leves y moderados pueden tratarse con métodos conservadores como ultrasonido terapéutico o infiltración con corticoesteroides. Objetivo. Describir la evolución clínica de pacientes con síndrome de túnel carpiano tratados con terapia por ultrasonido e infiltración de corticoesteroides. Metodología. Ensayo clínico abierto, en pacientes con síndrome del túnel carpiano leve y moderado, que consultaron del 1 de octubre 2021 al 30 de mayo 2022. Se formaron dos grupos; el que recibió tratamiento con ultrasonido con 12 casos y el grupo tratado con infiltración con corticoesteroides con seis casos. Ambos grupos fueron intervenidos en la consulta inicial, y luego, en las cuatro y ocho semanas posteriores al inicio del tratamiento. Resultados. Se muestran los resultados descriptivos relacionados con la intensidad de dolor, valorada con la Escala Visual Numérica, la infiltración obtuvo dos casos sin dolor y cuatro con dolor moderado, contrario a ultrasonido que se mantuvo con cuatro casos leves, tres moderados y cinco intensos. En los síntomas, la infiltración redujo el número de casos en cuatro de los síntomas estudiados, en cambio el ultrasonido únicamente en dos. En severidad, valorada con el cuestionario de Boston para túnel carpal, con infiltración se obtuvieron dos casos asintomáticos y ninguno con ultrasonido. Respecto a los signos clínicos, el signo de Tinel desapareció en cuatro casos en ambos grupos, mientras que signo de Phalen desapareció en cuatro casos en ultrasonido y dos en infiltración. Conclusión. En intensidad de dolor y grado de severidad, la infiltración generó casos asintomáticos y redujo mayor cantidad de síntomas que el ultrasonido. Ambos tratamientos disminuyeron la presencia de signos clínicos

Introduction. Carpal tunnel syndrome is the most common compressive peripheral neuropathy of the upper extremity, which is caused by compression of the median nerve. Mild and moderate cases can be treated with conservative methods such as therapeutic ultrasound or corticosteroid infiltration. Objective. To describe the clinical evolution of patients with carpal tunnel syndrome treated with ultrasound therapy and corticosteroid infiltration. Methodology. A prospective open clinical trial was conducted in patients with mild and moderate carpal tunnel syndrome who consulted from October 1, 2021 to May 30, 2022. Two groups were formed: the group that received ultrasound treatment with 12 cases and the group treated with corticosteroid infiltration with six cases. Both groups were treated at the initial consultation and then at four and eight weeks after the start of treatment. Results. The descriptive results related to the intensity of pain, evaluated with the Visual Numeric Scale, are shown. Infiltration obtained two cases without pain and four with moderate pain, contrary to ultrasound which was maintained with four mild, three moderate and five intense cases. In symptoms, infiltration reduced the number of cases in four of the symptoms studied, while ultrasound reduced the number of cases in only two. In severity, assessed with the Boston carpal tunnel questionnaire, with infiltration, there were two asymptomatic cases and none with ultrasound. Regarding clinical signs, Tinel's sign disappeared in four cases in both groups, while Phalen's sign disappeared in four cases in ultrasound and two in infiltration. Conclusion. Infiltration produced asymptomatic patients and reduced more symptoms than ultrasonography in terms of pain intensity and severity. Clinical symptoms were less common with both treatments.

Hipoacusia en el síndrome de Vogt-Koyanagi-Harada: reporte de caso y revisión de la literatura / Hearing loss in Vogt-Koyanagi-Harada syndrome: case report and literature review

El síndrome de Vogt-Koyanagi-Harada (VKH) es una rara enfermedad granulomatosa multisistémica caracterizada por aparición de panuveítis grave bilateral y desprendimiento seroso de retina; puede acompañarse de un amplio espectro de síntomas extraoculares como los auditivos, y la afección más frecuente es la hipoacusia neurosensorial. Su etiología se reconoce como respuesta autoinmune mediada por células T contra antígenos de melanocitos presentes en coroides, meninges, cóclea y piel. Asimismo, factores genéticos del huésped se han identificado como predisponentes para su aparición, y es la presencia del alelo HLA-DR4, en particular el subtipo HLA-DRB1 0405, el más estudiado hasta la fecha. El tratamiento se basa en administración de corticosteroides sistémicos en dosis altas, sin embargo, es escasa la evidencia que evalúa específicamente la eficacia de estos medicamentos sobre sus manifestaciones audiovestibulares. Este artículo expone un caso de síndrome de VKH con compromiso auditivo concomitante y realiza una breve revisión narrativa de la literatura.

Vogt-Koyanagi-Harada syndrome (VKHS) is a rare multisystemic granulomatous disease, characterized by severe bilateral panuveitis and serous retinal detachment; it can be associated with a wide spectrum of extraocular symptoms, such as auditory symptoms, and the most common condition is sensorineural hearing loss. Its etio-logy is recognized as a T-cell-mediated autoimmune response against melanocyte antigens present in the choroid, meninges, cochlea, and skin. Likewise, host genetic factors have been identified as predisposing for its development, specifically the pre-sence of the HLA-DR4 allele, the HLA-DRB1 0405 subtype is the most studied up to date. Treatment is based on the administration of high doses of systemic corticos-teroids, however, there is not much evidence that specifically evaluates the efficacy of these medications on their audiovestibular manifestations. This article presents a clinical case of VKH syndrome with concomitant hearing impairment and carries out a short narrative review of the literature.

Adrenal morphology and cortical function in patients with extrapulmonary tuberculosis: response to antituberculosis treatment

ABSTRACT Objective: Enlargement of the adrenal glands and variable adrenocortical function have been reported in patients with pulmonary tuberculosis and, in a few studies, in patients with extrapulmonary tuberculosis (EPTB). However, none of the studies have evaluated the course of the adrenal morphology in these patients. Subjects and methods: Prospective study including 37 patients with EPTB and 37 healthy age- and sex-matched controls. The adrenal function was evaluated by measurement of cortisol levels at baseline and after stimulation with ACTH (Acton Prolongatum) before and 6 months after antituberculosis treatment. The size of both adrenal glands was evaluated using 64-slice computed tomography (CT) scanning before and 6 months after treatment. The findings were compared with those in a group of healthy matched controls. Results: Clinical and biochemical parameters were comparable between groups. The mean baseline serum cortisol level was significantly lower in the EPTB group (397.1 ± 184.9 nmol/L) compared with the control group (696.3 ± 101.8 nmol/L). Compared with controls, patients with EPTB had significantly lower mean cortisol levels at baseline and 1 hour after ACTH, both before (397 ± 184.9 nmol/L and 750.7 ± 176.8 nmol/L, respectively) and after (529.7 ± 100.4 nmol/L and 1017.2 ± 119.7 nmol/L, respectively) antituberculosis treatment. Both the length and thickness of the right and left adrenal glands were greater in patients with EPTB than in controls but became comparable to those in controls after treatment completion. Conclusions: Patients with EPTB have an enlarged adrenal size and low baseline and stimulated serum cortisol levels. After treatment completion, cortisol levels increased significantly, and the adrenal size normalized in these patients.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study / Efeitos do corticoide antenatal na hemodinâmica fetal: um estudo longitudinal

Abstract Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Resumo Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Pharmacotherapy and clinical outcomes of hospitalized COVID-19 patients in Chile during the first wave of pandemic

Background: The largest growth in cases of COVID-19 worldwide during 2020 was in the Americas, and Chile was one of the most affected countries. Aim: To describe, characterize, and evaluate the use of drugs as treatment for COVID-19 in hospitalized patients in Chile during the first wave of the pandemic. Methods: We performed a multicenter, observational study that included 442 patients with confirmed SARS-CoV-2 infection admitted in Chilean hospitals between March 21 and September 22, 2020. The analysis included demographics, comorbidities, specific drug therapy, and outcomes over a 28-day follow-up period. Results: The median age of patients was 68 years (IQR 55-73), and 38.9% were women. The most common comorbidities were hypertension (57.7%) and diabetes (36.9%). Fifty-seven (12.9%) patients died. Hypertension (HR 2.99; CI 95% 1.43-6.26) and age ≥ 65 (2.14; CI 95% 1.10- 4.17) were the main predictors of mortality. Primary drugs were azithromycin (58.8%) and corticosteroids (51.1%). In this sample, azithromycin was a protective factor regarding mortality (HR 0.53; CI 95% 0.31-0.90), increasing clinical improvement and avoiding progression. Conclusions: The patterns of use of drugs to treat COVID-19 in Chile during the first wave of the pandemic were very dynamic and followed the international, evidence-based guidelines. The low mortality rate indicates that the clinical management of hospitalized patients was adequate.

Antecedentes: Durante 2020, el mayor incremento de casos de COVID-19 se observó en el continente americano, donde Chile fue uno de los países más afectados. Objetivos: Describir, caracterizar y evaluar el uso de fármacos indicados para tratar el COVID-19 en pacientes hospitalizados en Chile durante la primera ola de pandemia. Pacientes y Métodos: Un estudio multicéntrico observacional incorporó a 442 pacientes con infección confirmada por SARS- CoV-2 admitidos en hospitales chilenos entre el 21 de marzo y el 22 de septiembre de 2020. Se analizaron variables demográficas, comorbilidades, terapia farmacológica específica y desenlaces clínicos para un período de seguimiento de 28 días. Resultados: La mediana de la edad fue de 68 años (RIC 55-73), y un 38,9% fueron mujeres. Las comorbilidades más comunes fueron hipertensión (57,7%) y diabetes (36,9%). Cincuenta y siete (12,9%) de los pacientes murieron. Los principales predictores de mortalidad fueron la hipertensión (HR 2,99; IC 95% 1,43-6,26) y la edad ≥ 65 años (2,14; IC 95% 1,10- 4,17). Los fármacos más utilizados fueron azitromicina (58,8%) y corticosteroides (51,1%). En esta muestra, la azitromicina fue un factor de protección respecto a la mortalidad (HR 0,53; IC 95% 0,31-0,90), incrementando igualmente la mejoría y evitando la progresión. Conclusiones: Los patrones de uso de fármacos para tatar COVID-19 en Chile durante la primera ola de pandemia fueron muy dinámicos y siguieron las directrices internacionales basadas en la evidencia. La baja mortalidad sugiere que el manejo de los pacientes hospitalizados fue adecuado.

Actualización del consenso chileno SOCHINEP-SER para el manejo de las sibilancias recurrentes del preescolar / Update of the chilean consensus SOCHINEP-SER for the management of recurrent wheezing in preschool children

Las sibilancias recurrentes del preescolar son un problema prevalente. 50% de todos los niños tiene al menos un episodio de sibilancias en los primeros 6 años. Sin embargo, solo 4 % de los menores de 4 años tiene diagnóstico de asma. Por este motivo es fundamental realizar una adecuada anamnesis y examen físico tendientes a descartar causas secundarias, lo que debe ser complementado con exámenes de laboratorio de acuerdo con la orientación clínica. En la actualidad se recomienda indicar tratamiento de mantención con corticoides inhalados en aquellos niños que tengan episodios repetidos de obstrucción bronquial y que tengan una alta probabilidad de respuesta favorable a esta terapia. Se ha demostrado que aquellos pacientes que tienen un recuento de eosinófilos en sangre > 300 células por mm3 o aquellos que presentan una prueba cutánea positiva o IgE específicas positivas para alérgenos inhalados, responderán adecuadamente al tratamiento con esteroides inhalados.

Recurrent wheezing in preschoolers has a high prevalence. 50% of all children have at least one wheezing episode in the first six years of life. However, only 4% of children under four years of age are diagnosed with asthma. Therefore, it is essential to carry out an adequate medical history and physical examination to rule out secondary causes, which must be complemented with laboratory tests in accordance with clinical guidance. It is recommended to indicate maintenance treatment with inhaled corticosteroids to those children who have repeated episodes of wheezing and who have a high probability of a good response to this therapy. It has been demonstrated that those patients who have blood eosinophil count > 300 cells per mm3 or those who have a positive skin test or positive specific IgE for inhaled allergens will have a good response to inhaled corticosteroids.

Actualización del consenso chileno SOCHINEP-SER para el manejo de las sibilancias recurrentes del preescolar / Update of the chilean consensus SOCHINEP-SER for the management of recurrent wheezing in preschool children

Las sibilancias recurrentes del preescolar son un problema prevalente. 50% de todos los niños tiene al menos un episodio de sibilancias en los primeros 6 años. Sin embargo, solo 4% de los menores de 4 años tiene diagnóstico de asma. Por este motivo es fundamental realizar una adecuada anamnesis y examen físico tendientes a descartar causas secundarias, lo que debe ser complementado con exámenes de laboratorio de acuerdo con la orientación clínica. En la actualidad se recomienda indicar tratamiento de mantención con corticoides inhalados en aquellos niños que tengan episodios repetidos de obstrucción bronquial y que tengan una alta probabilidad de respuesta favorable a esta terapia. Se ha demostrado que aquellos pacientes que tienen un recuento de eosinófilos en sangre > 300 células por mm3 o aquellos que presentan una prueba cutánea positiva o IgE específicas positivas para alergenos inhalados responderán adecuadamente al tratamiento con esteroides inhalados.

Recurrent wheezing in preschoolers has a high prevalence. 50% of all children have at least one wheezing episode in the first six years of life. However, only 4% of children under four years of age are diagnosed with asthma. Therefore it is essential to carry out an adequate medical history and physical examination to rule out secondary causes, which must be complemented with laboratory tests in accordance with clinical guidance. It is recommended to indicate maintenance treatment with inhaled corticosteroids to those children who have repeated episodes of wheezing and who have a high probability of a good response to this therapy. It has been demonstrated that those patients who have blood eosinophil count > 300 cells per mm3 or those who have a positive skin test or positive specific IgE for inhaled allergens will have a good response to inhaled corticosteroids.

Systemic lupus erythematosus: Pharmacological differences between women and men and among age groups and geographical regions

Systemic lupus erythematosus (SLE) is a chronic and potentially fatal autoimmune disease. There are clinical differences between women and men and among age groups. Its treatment involves a heterogeneous group of drugs. The objective was to determine the pharmacological treatment patterns in a group of patients with SLE and compare them according to sex, age group and geographic region. This was a cross-sectional study that identified outpatient drugs used in patients with SLE from a population database of Colombians affiliated with the Colombian Health System. Sociodemographic and pharmacological variables were considered. Descriptive and bivariate analyses were performed. A total of 4307 patients with SLE were identified (median age, 44.2 years; 89.4% women). Disease-modifying antirheumatics were the most prescribed drugs (90.5%), especially chloroquine (54.4%), which predominated in all age groups and geographical regions. Hydroxychloroquine and methotrexate were the predominant prescribed drugs for women, while corticosteroids, chloroquine, azathioprine, and mycophenolate were the predominant prescribed drugs for men. The use of corticosteroids (prednisolone and prednisone) decreased with increasing age. Differences were found in the prescription of drugs for patients with SLE between women and men and among geographic regions and age groups. The use of chloroquine predominated over hydroxychloroquine, contrasting with clinical practice guidelines.

El lupus eritematoso sistémico (LES) es una enfermedad autoinmune crónica y potencialmente mortal. Existen diferencias clínicas entre mujeres y hombres, y entre grupos de edad. Su tratamiento involucra un grupo heterogeneo de medicamentos. El objetivo fue determinar los patrones de tratamiento farmacológico de un grupo de pacientes con LES y compararlos según el sexo, los grupos de edad y las regiones geograficas. Estudio de corte transversal que identifico los medicamentos de uso ambulatorio empleados en pacientes con LES, a partir de una base de datos poblacional de colombianos afiliados al Sistema de Salud de Colombia. Se consideraron variables sociodemográficas y farmacologicas. Se realizo un análisis descriptivo y bivariado. Se identificó a 4.307 pacientes con LES, con una mediana de edad 44,2 an˜ os y un 89,4% mujeres. Los medicamentos modificadores de enfermedad reumatica fueron los mas prescritos (90,5%), en especial cloroquina (54,4%), el cual predomino en todos los grupos de edad y las regiones geográficas. La hidroxicloroquina y el metotrexato predominaron en mujeres, mientras que los corticosteroides, la cloroquina, la azatioprina y el micofenolato, en hombres. Con el aumento de la edad disminuyo el uso de corticoides (prednisolona y prednisona). Se encontraron diferencias en la prescripción de los medicamentos empleados en los pacientes con LES entre mujeres y hombres, regiones geográficas y grupos etarios. El uso de cloroquina predomino sobre la hidroxicloroquina, en contraste con lo recomendado por las guías de practica clínica.

O que mudou entre os períodos de pico e de platô durante a primeira onda do SARS-CoV-2? Estudo multicêntrico português em unidades de cuidados intensivos / What changed between the peak and plateau periods of the first COVID-19 pandemic wave? A multicentric Portuguese cohort study in intensive care

RESUMO Objetivo: Analisar e comparar as características de pacientes críticos com a COVID-19, a abordagem clínica e os resultados entre os períodos de pico e de platô na primeira onda pandêmica em Portugal. Métodos: Este foi um estudo de coorte multicêntrico ambispectivo, que incluiu pacientes consecutivos com a forma grave da COVID-19 entre março e agosto de 2020 de 16 unidades de terapia intensiva portuguesas. Definiram-se as semanas 10 - 16 e 17 - 34 como os períodos de pico e platô. Resultados: Incluíram-se 541 pacientes adultos com mediana de idade de 65 [57 - 74] anos, a maioria do sexo masculino (71,2%). Não houve diferenças significativas na mediana de idade (p = 0,3), no Simplified Acute Physiology Score II (40 versus 39; p = 0,8), na pressão parcial de oxigênio/fração inspirada de oxigênio (139 versus 136; p = 0,6), na terapia com antibióticos na admissão (57% versus 64%; p = 0,2) ou na mortalidade aos 28 dias (24,4% versus 22,8%; p = 0,7) entre o período de pico e platô. Durante o período de pico, os pacientes tiveram menos comorbidades (1 [0 - 3] versus 2 [0 - 5]; p = 0,002); fizeram mais uso de vasopressores (47% versus 36%; p < 0,001) e ventilação mecânica invasiva na admissão (58,1% versus 49,2%; p < 0,001), e tiveram mais prescrição de hidroxicloroquina (59% versus 10%; p < 0,001), lopinavir/ritonavir (41% versus 10%; p < 0,001) e posição prona (45% versus 36%; p = 0,04). Entretanto, durante o platô, observou-se maior uso de cânulas nasais de alto fluxo (5% versus 16%; p < 0,001) na admissão, remdesivir (0,3% versus 15%; p < 0,001) e corticosteroides (29% versus 52%; p < 0,001), além de menor tempo de internação na unidade de terapia intensiva (12 versus 8 dias; p < 0,001). Conclusão: Houve mudanças significativas nas comorbidades dos pacientes, nos tratamentos da unidade de terapia intensiva e no tempo de internação entre os períodos de pico e platô na primeira onda da COVID-19.

ABSTRACT Objective: To analyze and compare COVID-19 patient characteristics, clinical management and outcomes between the peak and plateau periods of the first pandemic wave in Portugal. Methods: This was a multicentric ambispective cohort study including consecutive severe COVID-19 patients between March and August 2020 from 16 Portuguese intensive care units. The peak and plateau periods, respectively, weeks 10 - 16 and 17 - 34, were defined. Results: Five hundred forty-one adult patients with a median age of 65 [57 - 74] years, mostly male (71.2%), were included. There were no significant differences in median age (p = 0.3), Simplified Acute Physiology Score II (40 versus 39; p = 0.8), partial arterial oxygen pressure/fraction of inspired oxygen ratio (139 versus 136; p = 0.6), antibiotic therapy (57% versus 64%; p = 0.2) at admission, or 28-day mortality (24.4% versus 22.8%; p = 0.7) between the peak and plateau periods. During the peak period, patients had fewer comorbidities (1 [0 - 3] versus 2 [0 - 5]; p = 0.002) and presented a higher use of vasopressors (47% versus 36%; p < 0.001) and invasive mechanical ventilation (58.1 versus 49.2%; p < 0.001) at admission, prone positioning (45% versus 36%; p = 0.04), and hydroxychloroquine (59% versus 10%; p < 0.001) and lopinavir/ritonavir (41% versus 10%; p < 0.001) prescriptions. However, a greater use of high-flow nasal cannulas (5% versus 16%, p < 0.001) on admission, remdesivir (0.3% versus 15%; p < 0.001) and corticosteroid (29% versus 52%, p < 0.001) therapy, and a shorter ICU length of stay (12 days versus 8, p < 0.001) were observed during the plateau. Conclusion: There were significant changes in patient comorbidities, intensive care unit therapies and length of stay between the peak and plateau periods of the first COVID-19 wave.

Evaluation of the impact of subepithelial corneal infiltrates on corneal biomechanics after epidemic keratoconjunctivitis / Avaliação do impacto de infiltrados sub-epiteliais corneanos na biomecânica corneana após ceratoconjuntivite epidêmica

ABSTRACT Purpose: To examine the effect of subepithelial corneal infiltrates on corneal biomechanical properties after epidemic keratoconjunctivitis compared to that in healthy controls. Methods: The cross-sectional study included consecutive patients with bilateral subepithelial corneal infiltrates after epidemic keratoconjunctivitis and healthy controls. Best corrected visual acuity corneal subepithelial infiltrate scoring Fantes grading scale, and central corneal thickness were measured. Corneal hysteresis corneal resistance factor Goldmann correlated intraocular pressure and corneal compensated intraocular pressure were assessed using an ocular response analyzer. Results: This study included 66 eyes of 33 patients with subepithelial corneal infiltrates following epidemic keratoconjunctivitis and randomly selected 37 eyes of 37 healthy volunteers. The mean Fantes and CSIS scores were 1.8 ± 0.8 and 2.9 ± 1.3, respectively, in the first involved eyes and 1.3 ± 1.1 and 1.9 ± 1.7, respectively, in the fellow eyes (p=0.009 and p=0.002, respectively). The first (526.1 ± 28.1 µm; p=0.005) and second involved eyes (523.4 ± 38.1 µm; p=0.044) had significantly thinner corneas compared to that in healthy controls (557.0 ± 38.1 µm). While best-corrected visual acuity showed a positive correlation with corneal resistance factor (r=0.363, p=0.045) and corneal hysteresis (r=0.414, p=0.021), corneal subepithelial infiltrate scoring showed a negative correlation with Goldmann correlated intraocular pressure (r=-0.479, p=0.006) and corneal compensated intraocular pressure (r=-0.413, p=0.021). Conclusion: Eyes with subepithelial corneal infiltrates had significantly thinner corneas compared to that in healthy controls. A positive correlation of the corneal resistance factor and corneal hysteresis with best-corrected visual acuity and a negative correlation of the Goldmann correlated intraocular pressure and corneal compensated intraocular pressure with corneal subepithelial infiltrate scoring should be taken into account when measuring intraocular pressure values in patients with subepithelial corneal infiltrates.

RESUMO Objetivo: Examinar o efeito de infiltrados sub-epiteliais corneanos nas propriedades biomecânicas da córnea após ceratoconjuntivite epidêmica, em comparação com controles saudáveis. Métodos: Este estudo transversal incluiu pacientes consecutivos com infiltrados sub-epiteliais corneanos bilaterais após ceratoconjuntivite epidêmica e controles saudáveis. Foram medidas a melhor acuidade visual corrigida, uma pontuação do infiltrado sub-epitelial da córnea, a escala de graduação de Fantes e a espessura central da córnea. A histerese da córnea, o fator de resistência da córnea, a pressão intraocular correlacionada à tonometria de Goldmann e a pressão intraocular compensada da córnea foram avaliados com o Ocular Response Analyzer. Resultados: Este estudo incluiu 66 olhos de 33 pacientes com infiltrados corneanos sub-epiteliais após ceratoconjuntivite epidêmica e selecionou aleatoriamente 37 olhos de 37 voluntários saudáveis. As pontuações médias da escala de Fantes e dos infiltrados sub-epiteliais corneanos nos primeiros olhos acometidos foram respectivamente de 1,8 ± 0,8 e 2,9 ± 1,3. Nos olhos contralaterais, foram respectivamente de 1,3 ± 1,1 e 1,9 ± 1,7 (p=0,009 e p=0,002, respectivamente). O primeiro e o segundo olhos envolvidos tinham córneas significativamente mais finas (respectivamente 526,1 ± 28,1 µm; p=0,005 e 523,4 ± 38,1 µm; p=0,044) em comparação com os controles saudáveis (557,0 ± 38,1 µm). Embora a acuidade visual melhor corrigida tenha mostrado uma correlação positiva com o fator de resistência da córnea (r=0,363, p=0,045) e com a histerese da córnea (r=0,414, p=0,021), a pontuação dos infiltrados sub-epiteliais corneanos mostrou uma correlação negativa com a pressão intraocular correlacionada à tonometria de Goldmann (r=-0,479, p=0,006) e com a pressão intraocular compensada da córnea (r=-0,413, p=0,021). Conclusão: Os olhos com infiltrados corneanos sub-epiteliais tinham córneas significativamente mais finas em comparação com os controles saudáveis. Ao se medirem os valores de pressão intraocular em pacientes com infiltrados sub-epiteliais corneanos, deve-se levar em consideração tanto as correlações positivas do fator de resistência da córnea e da histerese da córnea com a melhor acuidade visual corrigida quanto as correlações negativas da pressão intraocular correlacionada à tonometria de Goldmann e da pressão intraocular compensada da córnea com a pontuação do infiltrado sub-epitelial da córnea.

Persistence of behavioral abnormalities following corticosteroid therapy in children with initial episode of idiopathic nephrotic syndrome: a prospective longitudinal observation / Persistência de anormalidades comportamentais após corticoterapia em crianças com episódio inicial de síndrome nefrótica idiopática: uma observação longitudinal prospectiva

Abstract Introduction: Treatment of nephrotic syndrome with corticosteroid can cause several side- effects including behavioral abnormalities. The objectives of the study were to observe the proportion of non-relapsers having persistence of behavioral abnormalities after completion of treatment of initial episode and compare the abnormalities with relapsers, and to determine risk factors for persistence. Methods: Seventy-five children with a first episode of idiopathic nephrotic syndrome and 60 normal children were rated by parents for behavioral problems using the Child Behavior Checklist. The Parenting Stress Index was also evaluated. The children were rated before treatment and 12 and 36 weeks after. Results: Both relapsers and non-relapsers showed abnormalities in internalizing and externalizing domains at 12 weeks of steroid therapy. Non-relapsers had abnormal scores in the internalizing domain in 63.5 % and externalizing domain in 48.1% of cases at 36 weeks. Relapsers had abnormal scores in all the three behavior domains, but a significantly higher proportion of relapsers had abnormal scores regarding total behavior (65.2% vs 28.8%, p<0.01) and child domains (100% vs 57.7%, p<0.001) of Parenting Stress Index in comparison to non-relapsers at 36 weeks. Occurrence of relapse increased the risk (odds ratio 5.76, 95% CI 1.35-10.76, p< 0.001) for persistence of abnormal total behavior at 36 weeks follow-up. Conclusion: Persistence of abnormalities was observed not only in relapsers but also in non-relapsers. Relapse was found to be a significant risk factor for persistence of abnormal behaviors in these patients.

Resumo Introdução: O tratamento da síndrome nefrótica com corticosteroide pode causar vários efeitos colaterais, incluindo anormalidades comportamentais. Os objetivos do estudo foram observar a proporção de não-recidivos com persistência de anormalidades comportamentais após conclusão do tratamento do episódio inicial, comparar as anormalidades com os recidivos, e determinar fatores de risco para persistência. Métodos: 75 crianças com primeiro episódio de síndrome nefrótica idiopática e 60 crianças normais foram avaliadas pelos pais por problemas comportamentais usando o Checklist de Comportamento Infantil. O Índice de Estresse Parental também foi avaliado. As crianças foram avaliadas antes do tratamento, 12 e 36 semanas após. Resultados: Tanto recidivos quanto não recidivos mostraram anormalidades nos domínios de internalização e externalização às 12 semanas de terapia com esteroides. Não-recidivos apresentaram pontuações anormais no domínio de internalização em 63,5%, e no domínio de externalização, em 48,1% dos casos em 36 semanas. Recidivos tiveram pontuações anormais em todos os três domínios de comportamento, mas uma proporção significativamente maior de recidivos apresentou pontuações anormais em relação ao comportamento total (65,2% vs 28,8%, p<0,01) e domínios infantis (100% vs 57,7%, p<0,001) do Índice de Estresse Parental em comparação com não recidivos às 36 semanas. A ocorrência de recidiva aumentou o risco (odds ratio 5,76, 95% IC 1,35-10,76, p< 0,001) de persistência de comportamento total anormal em 36 semanas de acompanhamento. Conclusão: A persistência de anormalidades foi observada não apenas em recidivos, mas também em não recidivos. A recidiva foi um fator de risco significativo para a persistência de comportamentos anormais nesses pacientes.

Classic and current concepts in adrenal steroidogenesis: a reappraisal

ABSTRACT Adrenal steroid biosynthesis and its related pathology are constant evolving disciplines. In this paper, we review classic and current concepts of adrenal steroidogenesis, plus control mechanisms of steroid pathways, distribution of unique enzymes and cofactors, and major steroid families. We highlight the presence of a "mineralocorticoid (MC) pathway of zona fasciculata (ZF)", where most circulating corticosterone and deoxycorticosterone (DOC) originate together with 18OHDOC, under ACTH control, a claim based on functional studies in normal subjects and in patients with 11β-, and 17α-hydroxylase deficiencies. We emphasize key differences between CYP11B1 (11β-hydroxylase) and CYP11B2 (aldosterone synthase) and the onset of a hybrid enzyme - CYP11B1/CYP11B2 -, responsible for aldosterone formation in ZF under ACTH control, in "type I familial hyperaldosteronism" (dexamethasone suppressible). In "apparent MC excess syndrome", peripheral conversion of cortisol to cortisone is impaired by lack of 11β-hydroxysteroid dehydrogenase type 2, permitting free cortisol access to MC receptors resulting in severe hypertension. We discuss two novel conditions involving the synthesis of adrenal androgens: the "backdoor pathway", through which dihydrotestosterone is formed directly from androsterone, being relevant for the fetoplacental setting and sexual differentiation of male fetuses, and the rediscovery of C19 11-oxygenated steroids (11-hydroxyandrostenedione and 11-ketotestosterone), active androgens and important markers of virilization in 21-hydroxylase deficiency and polycystic ovaries syndrome. Finally, we underline two enzyme cofactor deficiencies: cytochrome P450 oxidoreductase which partially affects 21- and 17α-hydroxylation, producing a combined clinical/hormonal picture and causing typical skeletal malformations (Antley-Bixler syndrome), and PAPSS2, coupled to SULT2A1, that promotes sulfation of DHEA to DHEAS, preventing active androgens to accumulate. Its deficiency results in reduced DHEAS and elevated DHEA and androgens with virilization. Future and necessary studies will shed light on remaining issues and questions on adrenal steroidogenesis.

Gastritis eosinofílica: a propósito de un caso

Introducción: La gastritis eosinofílica es una enfermedad infrecuente caracterizada por la presencia de eosinofilia hística, que afecta las diferentes capas de la pared intestinal. Este tipo de gastritis se caracteriza por una infiltración eosinofílica intensa que puede afectar solo la mucosa gástrica o todas sus capas hasta la serosa. La presentación clínica difiere de la posición y la extensión de la infiltración del eosinófilo, así como también su profundidad a través de la pared del intestino. Objetivo: Presentar el caso de un paciente diagnosticado y tratado como una gastritis eosinofílica. Caso clínico: Paciente masculino, raza blanca, de 47 años de edad, que acudió al Servicio de Gastroenterología del Hospital Universitario Manuel Ascunce Domenech, de la provincia Camagüey; en octubre de 2019. Refirió que durante los dos últimos meses había consultado en atención primaria de forma esporádica por molestias epigástricas, estos episodios cedían con pautas cortas de antiácidos. Los síntomas comenzaron agudizarse y se hicieron más resistentes al tratamiento, apareciendo náuseas, vómitos y pérdida de peso marcada. Se decidió comenzar la realización de estudios analíticos al paciente. Conclusiones: El resultado del estudio histológico fue infiltrado inflamatorio crónico severo con presencia de eosinófilos más del 50 % que se extiende a todas las capas con epitelio glandular reactivo, concluyó como una gastritis eosinofílica.

Introduction: Eosinophilic gastroenteritis is a rare disease characterized by the presence of tissue eosinophilia, which affects the different layers of the intestinal wall.This type of gastritis is characterized by an intense eosinophilic infiltration that can affect only the gastric mucosa or all its layers up to the serosa. The clinical presentation differs on the position and extent of the eosinophil infiltration, as well as its depth through the bowel wall. Objective: To present the case of a patient diagnosed and treated as eosinophilic gastritis. Case report: A 47-year-old white male patient from Camagüey province, who attends the Gastroenterology Service of the Manuel Ascunce Domenech University Hospital, Camagüey province; in October 2019. He reported that during the last two months he had consulted primary care sporadically due to epigastric discomfort, these episodes subsided with short courses of antacids. The symptoms began to worsen and became more resistant to treatment, with nausea, vomiting and marked weight loss appearing. It was decided to start performing analytical studies on the patient. Conclusions: The result of the histological study was a severe chronic inflammatory infiltrate with the presence of eosinophils more than 50% that extends to all layers with reactive glandular epithelium, concluding it as eosinophilic gastritis.

Diagnosis and treatment of 21-hydroxylase deficiency with testicular adrenal rest tumors:a report of three cases and literature review / 中华内科杂志

Objective:To provide insight into the diagnosis for clinicians, the clinical characteristics, diagnosis and treatment history of 3 patients with 21-hydroxylase deficiency (21-OHD) and testicular adrenal rest tumors (TART) were analyzed.Methods:The clinical, laboratory and imaging data of 3 male patients with 21-OHD and TART, confirmed with CYP21 gene sequencing, from May 2010 to May 2021 in the First Medical Center of Chinese PLA General Hospital were analyzed retrospectively. The treatment strategy and clinical outcome were followed up.Results:All the 3 patients were first diagnosed with bilateral adrenal mass at the age of 27-42 years old. They were 145-162 cm tall. The levels of progesterone, 17-hydroxyprogesterone, and adrenocorticotropic hormone (ACTH) of the 3 patients were relatively high, and that of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) of the 3 patients were low. Testosterone level of 1 patient was significantly elevated, and that of the other 2 patients was below the lower limit of normal range. Testicular ultrasound showed heterogeneous hyperechoic masses in both testes. CT of the adrenal glands showed bilateral adrenal enlargement with mass. All 3 patients were treated with dexamethasone. After 4-96 months of follow-up, 17-hydroxyprogesterone level was kept above the median normal level. One of the patients got married and had a baby after treatment. The sizes of adrenal hyperplasia and testicular masses reduced to various degrees with the change of the testicular masses being proportional to that of adrenal hyperplasia.Conclusions:Patients with 21-OHD are prone to have TART, leading to the impaired testicular function. Early glucocorticold therapy is beneficial to the reduction of TART and restoration of testicular function.

The efficacy and safety comparison of transperitoneal laparoscopic adrenalectomy and retroperitoneal laparoscopic adrenalectomy for adrenocortical carcinoma / 中华泌尿外科杂志

Objective:To compare the efficacy and safety of retroperitoneal laparoscopic adrenalectomy (RLA) and transperitoneal laparoscopic adrenalectomy (TLA) in the treatment of localized adrenocortical carcinoma (ACC).Methods:The data of 22 patients with stage Ⅰ/Ⅱ ACC underwent laparoscopic adrenalectomy in our institution from January 2009 to December 2018 were retrospectively analyzed. According to the different surgical approaches, these patients were divided into RLA and TLA groups. Eleven patients underwent RLA and 11 patients underwent TLA. There were no significant differences between the RLA group and the TLA group in terms of age at first diagnosis[44 (35, 54) vs. 46(41, 55) years, P= 0.793], sex (male/female: 3/8 vs. 4/7, P = 1.00), secreting tumor ratio (3/11 vs. 4/11, P = 1.00), tumor location (left/right: 6/6 vs. 7/4, P = 1.00), with hypertension or diabetes mellitus (4/11 vs. 3/11, P = 1.00). However, RLA has significantly smaller tumor size [3.0(2.5, 8.4) cm vs. 7.7(5.2, 8.4)cm, P= 0.001], and more stage Ⅰ patients [90.9%(10/11) vs. 18.2%(2/11), P=0.002], compared with those in TLA group. The perioperative indicators and oncology prognosis outcomes were collected and compared between the two groups. The Kaplan-Meier method was performed to calculate the overall survival (OS) and disease-free survival (DFS). Results:Compared with TLA, RLA had shorter operation time[90(70, 100) vs. 110 (90, 120) min, P = 0.005] and postoperative drainage tube removal time [2 (2, 3) vs. 3 (2, 6) day, P = 0.002), and the difference was statistically significant. In the TLA group, one patient was converted to open operation due to intraoperative tumor capsule rupture. For postoperative complications, one patient in the TLA group suffered with wound infection. There were no perioperative deaths in either group. All postoperative pathological examinations confirmed ACC, and there was no significant difference in Ki-67 index between the two groups [10%(3%, 35%) vs. 10%(9%, 25%), P = 0.484]. The median follow-up was similar in the two groups [48(26, 98) vs. 31(18, 49) months, P=0.237]. The local recurrence and metastasis rates were 36.4% for RLA group and 63.6% for TLA group ( P = 0.395). Survival analysis showed no statistically significant difference in DFS [5-year DFS rate: 33.6% vs. 73.2%, P = 0.118] between the two groups. The 5-year OS rates for RLA group versus TLA group were 58.3% vs. 45.5% ( P=0.485). Conclusions:For localized (stage Ⅰ/Ⅱ) ACC, both RLA and TLA seem safe and feasible, based on the similar long-term oncological prognosis. However, compared with TLA, RLA has the advantage of shorter operation time and postoperative drainage tube removal time. Due to the small number of cases included in this study, further multi-center, large-sample studies are required to demonstrate clear benefit of one surgical approach in the future.

Progress on pathogenesis and treatment of ocular cicatricial pemphigoid / 国际眼科杂志(Guoji Yanke Zazhi)

@#Ocular cicatricial pemphigoid(OCP)is a special manifestation of mucosal pemphigoid(mucous membrane pemphigoid, MMP), and the pathogenesis is not clear at present. It can be caused by variety factors such as antigen-antibody reaction, inflammation cell infiltration, the action of various cytokines, elevated calcium ion levels and susceptibility genes. In the early period of diseases, conjunctival present chronic progressive fibrotic inflammation, later the corneal opacity and the neovascularization will eventually lose vision. Therefore, it is particularly important to carry out clinical standardized treatment for OCP patients in a timely manner. To use medicine to control the inflammation and delay the progression of the disease, for example, dapsone, intravenous immunoglobulin(IVIG), rituximab(RTX), tumor necrosis factor antagonists and adrenocorticoids. Surgical treatment can be considered appropriately when OCP patients are complicated by severe trichiasis, corneal disease and cataract.

Effect of etomidate and dexamethasone on cortisol secretion in elderly patients undergoing general anesthesia / 中华麻醉学杂志

Objective:To evaluate the effects of dexamethasone and etomidate on cortisol secretion in elderly patients undergoing general anesthesia.Methods:One hundred and twenty-five elderly patients of either sex, aged 66-90 yr, of American Society of Anesthesiologists physical statusⅠ-Ⅲ, undergoing minor and medium elective surgeries under general anesthesia, were allocated into 4 groups using a random number table method: propofol and normal saline group (group PN, n=31), propofol and etomidate group (group PD, n=31), etomidate and normal saline group (group EN, n=33) and etomidate and dexamethasone group (group ED, n=30). In PN and EN groups, propofol (2 mg/kg) was used to induce and maintain anesthesia, and normal saline 2 ml and dexamethasone 0.1 mg/kg were intravenously injected, respectively, at 5 min before anesthesia induction.In PD and ED groups, etomidate (0.2 mg/kg) was used to induce and maintain anesthesia, and normal saline 2 ml and dexamethasone 0.1 mg/kg were intravenously injected, respectively, at 5 min before anesthesia induction.The serum cortisol concentrations were measured at 8: 00 after entering the operating room on the morning of operation (T 1), 1 h after the start of anesthesia (T 2), 2 h after the start of anesthesia (T 3), 8: 00 on the next day ofoperation (T 4) and 8: 00 on the 2nd day of operation (T 5). Blood glucose concentrations were measured at T 1-T 3, and the hypotension during the peri-anesthesia period, nausea and vomiting in post-anesthesia care unit, and nausea and vomiting scores were recorded at 24 h after operation. Results:A total of 122 patients completed the trial.Compared with PN group, the concentration of serum cortisol was significantly decreased at T 2-T 5, blood glucose concentrations were increased at T 2 and T 3 ( P<0.05), and no significant change was found in the incidence of hypotension, nausea and vomiting and nausea and vomiting scores in PD group ( P>0.05), and the concentration of serum cortisol was significantly decreased at T 2-T 4, the incidence of hypotension was decreased ( P<0.05), and no significant change was found in the blood glucose concentrations, incidence of nausea and vomiting or nausea and vomiting scores in EN group ( P>0.05). Compared with ED group, the serum cortisol concentration was significantly increased at T 2 and T 3, the incidence of hypotension was increased, the incidence of nausea and vomiting and nausea and vomiting scores were decreased ( P<0.05), and no significant change was found in the blood glucose concentrations in PD group ( P>0.05), and the serum cortisol concentration was significantly decreased at T 2 and T 3 and increased at T 4 and T 5, the serum cortisol concentration was decreased at T 2 and T 3, and no significant change was found in the incidence of hypotension, nausea and vomiting and nausea and vomiting scores in EN group ( P>0.05). Conclusions:Combination of etomidate and dexamethasone significantly enhances the duration and degree of inhibition of cortisol secretion in elderly patients than etomidate or dexamethasone alone.

Carcinoma de corteza suprarrenal. Presentación de un caso y revisión de la literatura

RESUMEN El carcinoma suprarrenal es un tumor raro pero devastador, esto se debe fundamentalmente a que en la mayoría de los casos se encuentra en estadios avanzados en el momento del diagnóstico. Tiene una incidencia de 0,5-2 casos por un millón habitantes al año. Entre el 40 y el 70 % de los pacientes tienen metástasis cuando se inicia el estudio. Se presenta de manera general en adultos, aunque también afecta a los niños. La mediana de edad en el momento del diagnóstico es 46 años, siendo más frecuente en el sexo masculino. Se presenta el caso de una paciente con antecedentes de hipertensión arterial de un año de evolución, ante los síntomas presentados se le realizan estudios por imágenes y de laboratorio diagnosticándose un tumor suprarrenal izquierdo. Se le realizó supraadrenalectomía izquierda obteniéndose como resultado histopatológico un carcinoma adenocortical suprarrenal. Se presenta este caso porque el carcinoma suprarrenal representa una entidad poco frecuente y es relevante exponer esta experiencia para el manejo de este tipo de neoplasia.

ABSTRACT Adrenal carcinoma is a rare devastating tumor, mainly because in most cases it is in advanced stages at the time of diagnosis. It has an incidence of 0.5-2 cases per one million inhabitants per year, in which 40 to 70 % of patients have metastases when the study begins. It occurs mainly in adults, although it also affects children. The median age at the time of diagnosis is 46 years, being more frequent in males. The case of a patient with a history of arterial hypertension of one year of evolution is presented. In view of the symptoms presented, imaging and laboratory studies are performed, diagnosing a left adrenal tumor. A left supraadrenelectomy was performed, obtaining an adenocortical adrenal carcinoma as a histopathological result.

Presentación diversa de las enfermedades de la corteza adrenal

RESUMEN Introducción: Las glándulas suprarrenales se dividen en corteza y médula. La corteza secreta tres clases de hormonas diferentes: los glucocorticoides, mineralocorticoides y andrógenos; la médula produce las catecolaminas. Todas ellas intervienen en múltiples funciones corporales. Objetivo: Mostrar diferentes formas de presentación de algunas de las enfermedades de la corteza adrenal. Presentación de los casos: Paciente 1: escolar de 7 años, antecedentes de hipotiroidismo controlado, presenta decaimiento y escaso crecimiento pondoestatural. Cortisol en ayunas 86 nmol/L y ACTH 154 pg/ml. Se diagnostica insuficiencia adrenal primaria. Reingresa a los 9 años, por mantener escaso crecimiento. Edad ósea: 2 años y 8 meses. Test de clonidina: alterado, confirma déficit de hormona del crecimiento. Paciente 2: escolar de 8 años, antecedentes de hiperplasia adrenal congénita por déficit de 21 hidroxilasa, forma virilizante simple. Presenta aceleración del desarrollo genital. Se incumplió tratamiento con hidrocortisona, durante 5 años. Se comprobó elevada la 17 hidroxiprogesterona 189 ng/dl. Se diagnosticó pubertad precoz periférica y virilización de los genitales. Paciente 3: lactante de 5 meses con obesidad de 3 meses de evolución. Tomografía axial computarizada de abdomen contrastado confirma lesión tumoración de 5 cm en proyección de la suprarrenal derecha. Cortisol en ayunas 892 nmol/L, cortisol 11 pm 920 nmol/L. Se realizó cirugía y se diagnosticó síndrome de Cushing por carcinoma adrenal productor de cortisol. Conclusiones: En la práctica clínica diaria podemos encontrar pacientes con síntomas y signos tan comunes como el decaimiento, vómitos o el aumento brusco de peso y ellos ser secundario a enfermedades de la glándula suprarrenal.

ABSTRACT Introduction: The adrenal glands are divided into cortex and marrow. The cortex secretes three different classes of hormones: glucocorticoids, mineralocorticoids and androgens; the marrow produces catecholamines. All of them are involved in multiple corporal functions. Objective: Show different forms of presentation of some of the diseases of the adrenal cortex. Presentation of cases: Patient 1: 7-year-old school boy, history of controlled hypothyroidism, and presenting decay and poor pondostatural growth. Cortisol level in fasting 86 nmol/L and ACTH 154 pg/ml. Primary adrenal insufficiency is diagnosed. Re-admitted at age 9 for maintaining little growth. Bone age: 2 years and 8 months. Clonidine test: altered, it confirms growth hormone deficiency. Patient 2: 8-year-old schoolboy, history of congenital adrenal hyperplasia due to 21 hydroxylase deficiency, simple virilizing form. He presents acceleration of genital development. Hydrocortisone treatment was missed for 5 years. 17 hydroxyprogesterone was found to be elevated to 189 ng/dl. Peripheral precocious puberty and virilization of the genitals were diagnosed. Patient 3: 5-month-old infant with obesity of 3 months of evolution. Contrasted computed axial tomography of the abdomen confirms tumor lesion of 5 cm in projection of the right adrenal. Cortisol level in fasting 892 nmol/L, cortisol 11 pm 920 nmol/L. Surgery was performed and Cushing's syndrome was diagnosed due to cortisol-producing adrenal carcinoma. Conclusions: In daily clinical practice we can find patients with symptoms and signs as common as decay, vomiting or sudden weight gain and they are secondary to diseases of the adrenal gland.