Tuberculosis diseminada con afectación grave del sistema nervioso central poco sintomática / Almost symptom free disseminated tuberculosis severely affecting the central nervous system

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[Acalculous cholecystitis: an uncommon form of presentation of Q fever]. / Colecistitis alitiásica: una forma infrecuente de presentación de fiebre Q.

Acute acalculous cholecystitis is a very rare clinical presentation of Q fever. We report the case of a 38-year-old man who presented with fever associated with elevation of liver enzyme levels and thickening of the gallbladder wall on abdominal ultrasonography and who was initially diagnosed with acute acalculous cholecystitis. Due to the persistence of fever and transaminase elevation despite antibiotic treatment, a liver biopsy was performed. Characteristic "doughnut" epithelioid granulomas were observed, suggesting a diagnosis of granulomatous hepatitis caused by Q fever, which was confirmed by serological methods. Treatment with doxycycline was commenced and the patient subsequently showed rapid clinical improvement, with disappearance of fever and normalization of liver enzyme levels. We review 8 cases of acute cholecystitis associated with Q fever published in the literature and stress the importance of liver biopsy in the etiological diagnosis of patients with prolonged fever and abnormal liver function tests.

Colecistitis alitiásica: una forma infrecuente de presentación de fiebre Q / Acalculous cholecystitis: an uncommon form of presentation of Q fever

La colecistitis aguda alitiásica es una forma infrecuente depresentación de la fiebre Q. Se expone el caso clínico de unpaciente varón de 38 años con un síndrome febril asociado aalteraciones en las pruebas de función hepática y un engrosamientode la pared vesicular en la ecografía abdominal,que permitió establecer un diagnóstico inicial de colecistitisalitiásica. La falta de respuesta al tratamiento habitual, juntocon la persistencia de la fiebre e hipertransaminasemia,motivó la realización de una biopsia hepática que mostró lapresencia de granulomas de células epitelioides «en rosquilla» típicos de la hepatitis granulomatosa por fiebre Q. Eldiagnóstico se confirmó posteriormente mediante serología.El tratamiento con doxiciclina fue altamente efectivo, conrápida desaparición de la fiebre y normalización de laspruebas de función hepática.Además, se realiza una revisión de los 8 casos de colecistitisaguda asociada a fiebre Q descritos en la bibliografía y sesubraya el papel de la biopsia hepática en el diagnósticoetiológico de los cuadros de fiebre prolongada asociada a alteracionesen el perfil hepático

Acute acalculous cholecystitis is a very rare clinical presentationof Q fever. We report the case of a 38-year-old manwho presented with fever associated with elevation of liverenzyme levels and thickening of the gallbladder wall on abdominalultrasonography and who was initially diagnosedwith acute acalculous cholecystitis. Due to the persistence offever and transaminase elevation despite antibiotic treatment,a liver biopsy was performed. Characteristic «doughnut epithelioid granulomas were observed, suggesting adiagnosis of granulomatous hepatitis caused by Q fever,which was confirmed by serological methods. Treatmentwith doxycycline was commenced and the patient subsequentlyshowed rapid clinical improvement, with disappearanceof fever and normalization of liver enzyme levels.We review 8 cases of acute cholecystitis associated with Q feverpublished in the literature and stress the importance ofliver biopsy in the etiological diagnosis of patients with prolongedfever and abnormal liver function tests

[Bacteremia in the elderly: associated and prognostic factors]. / Bacteriemia en el anciano: factores asociados y pronósticos.

BACKGROUND: Bacteremia is associated with high morbidity and mortality rates and its prevalence increases with age. The objective of the present investigation was to know the epidemiology, associated factors and prognosis in patients with bacteremia in our environment and in relation with age. METHODS: Two hundred and twenty-nine episodes of bacteremia were prospectively studied; 97 (42%) cases corresponded to patients aged > 70 years. The prognostic factors were evaluated by the univariate and multivariate analysis in the whole cohort and univariate study of associated factors for an age > 70 years. RESULTS: The etiology, infectious sources, nosocomial acquisition, and complications apart from shock (p = 0.02) were similar in the elderly patients. The associations of diabetes (p = 0.05), COPD and/or heart disease (p = 0.01), and exitus were higher for patients > 70 years. The main independent prognostic factor in the series was disseminated intravascular coagulation (p < 0.001, multivariate OR 14.2). CONCLUSIONS: Patients older than 70 years have a higher incidence of shock and mortality associated with infection. The higher overall mortality rate in the series was associated with disseminated intravascular coagulation and multisystemic failure irrespective of age.

Temporal arteritis in polymyalgia rheumatica: immune complex deposits and the role of the leukocyte elastase in the pathogenesis.

Immunohistochemical studies were performed on the temporal artery of 34 patients with clinically established polymyalgia rheumatica (PR) or temporal arteritis, 6 patients with vasculitis, and 25 patients with various diseases. The combined immunofluorescence and peroxidase-anti-Peroxidase Methode zeigte Immunoglobulin- und C3-Ablagerunin histologically affected and to some degree also in unaffected arteries of patients with PR and in all patients with temporal arteritis. The deposits were found both inter- and intracellularly, and contained IgA and to a lesser extend IgG, IgM, and C3. Linear deposits of leukocyte elastase were found along the fragmented internal lamina, and decaying polymorphonuclear (PMN) leukocytes surrounded by elastase-containing inclusions were found in the neighborhood of zones rich in elastic material. These findings suggest that immune complex deposition is a prominent feature of temporal arteritis and that the PMN elastase is probably involved in the destruction of elastic fibers. The combined immunohistochemical investigation appears to increase the diagnostic value of temporal artery biopsy.

Degradation in vivo of articular cartilage in rheumatoid arthritis by leucocyte elastase from polymorphonuclear leucocytes.

Using a specific substrate, no leucocyte elastase activity could be detected in 55 synovial fluids, including 29 from patients with rheumatoid arthritis (RA). However, a high percentage of samples contained phagocytic inclusions of elastase, alpha 1-proteinase inhibitor (alpha 1-PI) and alpha 2-macroglobulin (alpha 2-MG) in both the polymorphonuclear (PMN) and mononuclear phagocytes. Immunofluorescence and indirect peroxidase-antiperoxidase staining of articular cartilage (ACA) from 52% of 21 patients with RA and one with juvenile RA (JRA) showed presence of elastase in the superficial layer of microscopically intact but proteoglycan depleted pannus-free ACA. In histologically altered pannus-free RA-ACA superficial elastase deposits were found in 24% of the cases. Adjacent ACA sections contained IgG, C3, alpha 1-PI and rarely alpha 2-MG. RA-ACA below or surrounded by pannus showed close contact with intact and decaying PMN in 62% and 48% of the cases, respectively. ACA specimens from patients with degenerative disease and systemic lupus were negative. These findings strongly suggest that PMN leucocyte elastase is operative in the degradation of RA-ACA and JRA-ACA, and that this activity is largely dependent upon the presence of entrapped immune complexes in such cartilage.