Plitidepsin as a successful rescue treatment for prolonged viral SARS-CoV-2 replication in a patient with previous anti-CD20 monoclonal antibody-mediated B cell depletion and chronic lymphocytic leukemia.

BACKGROUND: There is an urgent need for highly efficacious antiviral therapies in immunosuppressed hosts who develop coronavirus disease (COVID-19), with special concern for those affected by hematological malignancies. CASE PRESENTATION: Here, we report the case of a 75-year-old male with chronic lymphocytic leukemia who was deficient in CD19+CD20+ B-lymphocyte populations due to previous treatment with anti-CD20 monoclonal antibodies. The patient presented with severe COVID-19 pneumonia due to prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and was treated with two courses of the antiviral plitidepsin on a compassionate use basis. The patient subsequently achieved an undetectable viral load, and his pneumonia resolved. CONCLUSIONS: Treatment with plitidepsin was well-tolerated without any further hematological or cardiovascular toxicities. This case further supports plitidepsin as a potential antiviral drug in SARS-CoV-2 patients affected by immune deficiencies and hematological malignancies.

Safety and Efficacy of Prolonged Use of Dalbavancin in Bone and Joint Infections.

Dalbavancin is a lipoglycopeptide with potent activity against Gram-positive microorganisms, a long half-life, a favorable safety profile, and a high concentration in bone, which makes it an interesting alternative for treatment of osteoarticular infections. We performed a multicentric retrospective study of all patients with an osteoarticular infection (septic arthritis, spondylodiscitis, osteomyelitis, or orthopedic implant-related infection) treated with at least one dose of dalbavancin between 2016 and 2017 in 30 institutions in Spain. In order to evaluate the response, patients with or without an orthopedic implant were separated. A total of 64 patients were included. Staphylococcus epidermidis and Staphylococcus aureus were the most frequent microorganisms. The reasons for switching to dalbavancin were simplification (53.1%), adverse events (25%), or failure (21.9%). There were 7 adverse events, and no patient had to discontinue dalbavancin. In 45 cases, infection was related to an orthopedic implant. The implant material was retained in 23 cases, including that in 15 (65.2%) patients that were classified as cured and 8 (34.8%) that presented improvement. In 21 cases, the implants were removed, including those in 16 (76.2%) cases that were considered successes, 4 (19%) cases were considered improved, and 1 (4.8%) case that was considered a failure. Among the 19 cases without implants, 14 (73.7%) were considered cured, 3 (15.8%) were considered improved, and 2 (10.5%) were considered failures. The results show that dalbavancin is a well-tolerated antibiotic, even when >2 doses are administered, and is associated with a high cure rate. These are preliminary data with a short follow-up; therefore, it is necessary to gain more experience and, in the future, to establish the most appropriate dose and frequency.

Diabetes mellitus tipo 2 en el paciente anciano institucionalizado / Type 2 diabetes mellitus in elderly institutionalized patients

Una mujer de 93 años de edad ingresa en una planta de hospitalización convencional por una infección respiratoria aguda. La paciente tiene diabetes mellitus tipo 2 de unos 15 años de evolución y no presenta otras comorbilidades asociadas, salvo progresiva dependencia por senescencia y un ingreso hospitalario previo por neumonía hace 6 meses; actualmente vive en una residencia asistida. En un análisis reciente tenía una HbA1c de 7,8%, con una creatinina sérica de 1,3mg/dl (MDRD: 45ml/min). Su tratamiento habitual consistía en glibenclamida 5mg al día y metformina 850mg cada 12h. ¿Qué pauta debemos seguir una vez hospitalizada? ¿Precisa de alguna modificación de su tratamiento al alta? (AU)

A 93-year-old woman is admitted to a conventional hospital ward for an acute respiratory infection. The patient has type 2 diabetes mellitus of approximately 15 years evolution and has no other associated comorbidities, except for progressive dependence due to senescence and a previous hospitalization for pneumonia 6 months ago. She is currently in an assisted-living residence. A recent laboratory test revealed an HbA1c level of 7.8%, with a serum creatinine level of 1.3mg/dl (MDRD, 45ml/min). Her standard treatment consists of 5mg of glibenclamide a day and 850mg of metformin every 12hours. What regimen should we follow once she is hospitalized? Does she require any change in her treatment at discharge? (AU)

Type 2 diabetes mellitus in elderly institutionalized patients. / Diabetes mellitus tipo 2 en el paciente anciano institucionalizado.

A 93-year-old woman is admitted to a conventional hospital ward for an acute respiratory infection. The patient has type 2 diabetes mellitus of approximately 15 years evolution and has no other associated comorbidities, except for progressive dependence due to senescence and a previous hospitalization for pneumonia 6 months ago. She is currently in an assisted-living residence. A recent laboratory test revealed an HbA1c level of 7.8%, with a serum creatinine level of 1.3mg/dl (MDRD, 45ml/min). Her standard treatment consists of 5mg of glibenclamide a day and 850mg of metformin every 12hours. What regimen should we follow once she is hospitalized? Does she require any change in her treatment at discharge?

Aproximación al manejo diagnóstico y terapéutico del síndrome de Charles Bonnet en un servicio de urgencias: una serie de 10 casos / Diagnostic and therapeutic management of Charles Bonnet syndrome in an emergency department: a description of 10 cases

Se expone el manejo diagnóstico y terapéutico del síndrome de Charles Bonnet (SCB)en urgencias. Estudio de una serie de casos de todos los casos atendidos por alucinaciones visuales que cumplían los criterios diagnósticos de SCB (introspección preservada, baja agudeza visual y ausencia de otros diagnósticos alternativos), en un servicio de urgencias de un hospital terciario y universitario durante 2 años (2010-2011). Posteriormente se realizó un seguimiento telefónico a los 6 meses para conocer la evolución clínica. De los 140 pacientes atendidos por alucinaciones visuales, 14 tuvieron como juicio clínico al alta de probable SCB, de los cuales sólo 10 cumplían los criterios diagnósticos de SBC. La edad media fue de 80,4 (DE 4,90) años, y 6 (60%) fueron mujeres. La sintomatología alucinatoria de presentación fue generalmente compleja (7 pacientes con visión de personas), y en la mayoría de los casos tenía una persistencia de escasos días (9pacientes con una duración de 1 a 4 días). En 8 (80%) de los casos la agudeza visual fue menor de 0,05 y en 3 (30%) tenían amaurosis en uno o ambos ojos. La exploración neurológica, los estudios analíticos, la radiografía simple no mostraron alteraciones de interés, y en aquellos 8 (80%) pacientes en los que se disponía de TC craneal, los hallazgos observados fueron inespecíficos. Se recomendaron medidas no farmacológicas en todos los casos y quetiapina 25 mg/día en 4 casos. El SCB se resolvió en menos de 3 meses en 6 (60%) de los pacientes. El SCB es una entidad que hay que tener en cuenta en los pacientes ancianos con pobre agudeza visual que consultan en urgencias por alucinaciones visuales. Su conocimiento puede resultar de interés a los urgenciólogos de cara a poder tranquilizar al paciente y evitar pruebas complementarias o tratamientos innecesarios con potenciales efectos adversos (AU)

To describe the diagnosis and therapeutic management of Charles Bonnet syndrome in the emergency department based on a retrospective descriptive study of all patients with visual hallucinations who were diagnosed with Charles Bonnet syndrome in the emergency department of Hospital Universitario Ramón y Cajal in 2010 and 2011. The patients met all the diagnostic criteria for this syndrome: preserved insight, diminished vision, and absence of an alternative diagnosis. Follow-up interviews were carried out by telephone an average of 6 months after diagnosis. Of a total of 140patients with visual hallucinations, 14 were discharged with a diagnosis of Charles Bonnet syndrome but only 10 met allthe diagnostic criteria. The mean (SD) age was 80.4 (4.90) years, and 60% were women. Complex visual hallucinations(of persons in 70%) had developed within 1 to 4 days of consultation in 90%. Visual acuity was less than 0.05 (hand movements or lights) for 80%, and 3 had full loss of vision in one or both eyes. Neurologic examination, laboratory tests, and a simple radiograph yielded no findings of interest. Computed tomography images of the head (70%) yieldedonly nonspecific findings. Hygienic measures and quetiapine (25 mg/d) were recommended for 4 patients. The syndrome resolved in less than 3 months in 60% of the patients. Charles Bonnet syndrome is relatively common among elderly patients with visual hallucinations and poor visual acuity, but the short-term prognosis is good. An understanding this syndrome is of great importance in emergency medicine, in the interest of avoiding unnecessary tests or treatments that may be harmful (AU)

Úlceras estenosantes, múltiples, recurrentes y crónicas del intestino delgado: una entidad propia como causa de dolor abdominal, anemia ferropénica y enteropatía pierde proteínas / Cryptogenia multifocal ulcerous stenosing enteritis: An entity on its own as a cause of abdominal pain, iron deficiency anemia and protein-losing enteropathy

A propósito del estudio de un paciente con anasarca, enteropatía pierde proteínas y dolor abdominal recurrente secundario a episodios de suboclusión intestinal, al que se le diagnostica de enteritis ulcerosa criptogénica, estenosante y multifocal (CMUSE), se revisa esta enfermedad rara y poco conocida, probablemente causada por mutaciones en el gen de PLA2G4A, que se caracteriza por múltiples estenosis cortas del intestino delgado con ulceraciones que no sobrepasan la submucosa. La enfermedad inflamatoria intestinal (enfermedad de Crohn), la tuberculosis intestinal y las ulceraciones intestinales asociadas a la toma de antiinflamatorios no esteroides son los principales diagnósticos diferenciales. En conclusión, CMUSE debería ser incluida en el diagnóstico diferencial del dolor abdominal recurrente, anemia ferropénica con sangrado intestinal oculto, edemas y enteropatía pierde proteínas (AU)

We studied a patient with edema secondary to protein losing enteropathy, and recurrent bouts of bloating and abdominal pain secondary to intestinal subocclusion episodes. After the clinical study, the patient was diagnosed of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE), that is a rare disease, probably caused by mutations in the gene PLA2G4A, and characterized by multiple short stenosis of the small bowel with superficial ulcers, which do not exceed the submucosa layer. Inflammatory bowel disease (Chron's disease), intestinal tuberculosis and intestinal ulcers secondary to non-steroidal anti-inflammatory drugs are the main differential diagnosis. To sum up, physicians should included CMUSE in the differential diagnosis of recurrent abdominal pain, iron deficiency anaemia, occult intestinal bleeding, edema and protein losing enteropathy (AU)

Cryptogenia multifocal ulcerous stenosing enteritis: an entity on its own as a cause of abdominal pain, iron deficiency anemia and protein-losing enteropathy.

We studied a patient with edema secondary to protein losing enteropathy, and recurrent bouts of bloating and abdominal pain secondary to intestinal subocclusion episodes. After the clinical study, the patient was diagnosed of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE), that is a rare disease, probably caused by mutations in the gene PLA2G4A, and characterized by multiple short stenosis of the small bowel with superficial ulcers, which do not exceed the submucosa layer. Inflammatory bowel disease (Chron's disease), intestinal tuberculosis and intestinal ulcers secondary to non-steroidal anti-inflammatory drugs are the main differential diagnosis. To sum up, physicians should included CMUSE in the differential diagnosis of recurrent abdominal pain, iron deficiency anaemia, occult intestinal bleeding, edema and protein losing enteropathy.

Revisión de 862 pacientes portadores de drogas intrabdominales (body packers) ingresados en una unidad de vigilancia de urgencias. Protocolo de manejo / Retrospective review of 862 intraabdominal body packers carrying illicit drugs admitted to an emergency department observation unit: the management protocol

OBJETIVO: Describir la experiencia en el manejo de body packers (personas que transportan drogas ilegales en el interior de su cuerpo) en el Hospital Universitario Ramón y Cajal de Madrid, centro de referencia del aeropuerto de Madrid-Barajas, y presentar su protocolo de tratamiento. MÉTODO: Se revisaron retrospectivamente las historias clínicas de los body packers ingresados desde julio de 2007 hasta marzo de 2012. En diciembre de 2011, se establecen diferencias en manejo según el tipo de envoltorio, por el mayor riesgo teórico de rotura de los envoltorios blandos y la posibilidad de contener drogas líquidas. RESULTADOS: Se obtuvieron los datos de 862 casos, en su mayoría varones, con una mediana de edad de 32 años (RIC 14). La mayoría no presentaban comorbilidades previas(78,1%) ni eran consumidores de drogas (67,8%). La vía más común de introducción de cápsulas en el organismo fue la oral (93,5%), y la cocaína fue la droga transportada con más frecuencia (83,2%). La media de cápsulas transportadas fue de 61 (DE 31)(duras en el 83,7%). El 0,8% presentó signos de intoxicación aguda por drogas. El98,5% fueron dados de alta tras tratamiento conservador. En 13 casos serealizó intervención quirúrgica. Las variables con relación estadística con la cirugía deurgencia fueron los síntomas de intoxicación aguda (p < 0,001), la frecuencia cardiaca(p < 0,001), la leucocitosis con desviación izquierda (p = 0,037), los días de ingreso (p < 0,001) y el número de deposiciones limpias consecutivas al alta (p = 0,002). No se registró ninguna muerte, y la mediana de días ingresados fue de 3 (RIC 3). Si se analizan las poblaciones separadamente, la tasa de éxito antes del cambio de protocolo fue del 98,7% y posteriormente del 96,3%. CONCLUSIONES: El protocolo descrito propone distinciones en el manejo de body packers según el tipo de envoltorio en que sea transportada la droga, con una elevada tasa de éxito global (98,5%) y sin fallecimientos

OBJECTIVE: To describe the management of illicit drug body packers in the emergency department of Hospital Universitario Ramón y Cajal in Madrid, the referral hospital for the Madrid-Barajas airport. METHOD: The case histories of body packers admitted from July 2007 to March 2012 were reviewed. In 2011, differences in management were established in relation to packaginga, reflecting greater theoretical risk of rupture with the use of soft materials or containers holding drugs in liquid form. RESULTS: A total of 862 cases were studied. Most body packers were men. The median age (interquartile range) was 32 (14) years. Most (78.1%) had no history of prior medical conditions, and 67.8% were not drug users. The body packers had typically swallowed the containers (in 93.5% of the cases). Cocaine was the drug being transported in most cases (83.2%). A mean (SD) of 61 (31) packages were being transported; 83.7% were made of a hard material. Signs of acute drug poisoning were present in 0.8%. It was possible to discharge 98.5% of the patients after conservative management. Surgery was performed in 13 cases. Statistically significant variables related to the need for emergency surgery were symptoms of acute poisoning (P<.001), heart rate (P<.001), white blood cell count with left shift (P=.037), duration of hospitalization (P<.001), and number of package-free bowel movements (P=.002). No deaths occurred; the median duration of hospitalization was 3 (3) days. Medical management was successful before and after the change in protocol (in 98.7% and 96.3% of the body packers, respectively). CONCLUSIONS: A high success rate (98.5%), with no deaths, was achieved with the proposed protocol for managing body packers according to type of material used to enclose the drug

Síndrome de hipergammaglobulinemia IgE con infecciones recurrentes: patogénesis, diagnóstico y aproximación terapéutica / Hyper-IgE recurrent infection syndrome: pathogenesis, diagnosis and therapeutic management

El síndrome de la hipergammaglobulinemia IgE con infecciones recurrentes es una inmunodeficiencia primaria poco frecuente, que se caracteriza por niveles elevados de IgE, dermatitis eccematoide, infecciones recurrentes de piel y pulmón por Staphylococcus aureus, y formación de abscesos con escasos signos inflamatorios. También produce alteraciones dentarias, esqueléticas y del tejido conjuntivo. La forma clásica (tipo 1) está causada por mutaciones dominantes del gen de la proteína transductora de señal y activadora de la transcripción 3. Se ha descrito una forma incompleta (tipo 2) solo con las manifestaciones de la inmunodeficiencia, pero sin manifestaciones mesenquimales. Esta forma incompleta se debe a la mutación recesiva del gen de la tirosin-cinasa 2. Ambas mutaciones condicionan un déficit en la generación de células Th17 a partir de células T CD4+. Estos avances en el conocimiento genético e inmunológico del síndrome de hipergammaglobulinemia IgE han permitido la mejor comprensión de los fenómenos clínicos de la enfermedad(AU)

Hyper-IgE recurrent infection syndrome is an uncommon primary immunodeficiency characterized by high serum levels of total IgE, eczema-like dermatitis, recurrent skin abscesses and staphylococci pneumonias, which can produce abscesses with mild inflammatory signs. It also causes dental, musculoskeletal and connective tissue abnormalities. The classical (type 1) variation is caused by autosomal-dominant mutations in signal transducer and activator of transcription 3. An incomplete form (type 2) has been described with only the immunological manifestations, but without the mesenchymal manifestations, has been described. This incomplete form is caused by recessive mutations in the tyrosine kinase 2 gene. Both kinds of mutations produce deficient formation of Th17-cells. These advances in the genetic and immunologic knowledge of hyper-IgE recurrent infection syndrome have allowed a better clinical comprehension of the clinical phenomena of the disease(AU)

[Hyper-IgE recurrent infection syndrome: pathogenesis, diagnosis and therapeutic management]. / Síndrome de hipergammaglobulinemia IgE con infecciones recurrentes: patogénesis, diagnóstico y aproximación terapéutica.

Hyper-IgE recurrent infection syndrome is an uncommon primary immunodeficiency characterized by high serum levels of total IgE, eczema-like dermatitis, recurrent skin abscesses and staphylococci pneumonias, which can produce abscesses with mild inflammatory signs. It also causes dental, musculoskeletal and connective tissue abnormalities. The classical (type 1) variation is caused by autosomal-dominant mutations in signal transducer and activator of transcription 3. An incomplete form (type 2) has been described with only the immunological manifestations, but without the mesenchymal manifestations, has been described. This incomplete form is caused by recessive mutations in the tyrosine kinase 2 gene. Both kinds of mutations produce deficient formation of Th17-cells. These advances in the genetic and immunologic knowledge of hyper-IgE recurrent infection syndrome have allowed a better clinical comprehension of the clinical phenomena of the disease.

Síndrome de la bolsa de orina púrpura (PUBS) / No disponible

El síndrome de la bolsa de orina púrpura (PUBS) es un trastorno infrecuente, en el que la bolsa y el catéter de la sonda vesical se vuelven de color púrpura tras el sondaje. Se ha descrito predominantemente en personas ancianas institucionalizadas, encamadas y con problemas de estreñimiento. Está relacionado con sondaje urinario de larga evolución y asociado a enfermedades crónicas o degenerativas avanzadas, como Alzheimer u otras demencias severas, e insuficiencia renal terminal. En su patogénesis, la teoría más aceptada es la que implica la degradación por algunas bacterias del indoxil sulfato urinario, procedente de aminoácidos de la dieta, en índigo (azul) e indirrubina (rojo). La mezcla de ambos produciría el típico color violeta o púrpura. En la mayoría de los casos se trata de un proceso inofensivo y raramente conduce a la sepsis, pero suele producir una intensa preocupación en el paciente y su familia y se acompaña de un intenso mal olor. En general, se recomiendan más las medidas de prevención que los tratamientos antibióticos específicos. Presentamos el caso de un paciente con leucemia mieloide aguda en tratamiento paliativo que desarrolló PUBS (AU)

Purple urine bag syndrome (PUBS) is a rare disorder in which the urinary catheter bag turns purple following urinary catheterization. It has been reported predominantly in bedridden, institutionalized and constipated elderly patients. It is associated with long-term urinary catheterization and chronic or degenerative advanced diseases, including Alzheimer's or severe dementia from other causes, and end-stage renal failure. In its pathogenesis, the most widely accepted theory involves a decomposition of urinary indoxyl sulfate, from amino acids in the diet, to indigo (blue) and indirubin (red) by bacteria. The mixture of both would produce the typical blue or purple color. lt rarely leads to sepsis, and in most cases the process is harmless but troubling to the patient and their families, and is accompanied by an intense odor. It is generally recommended that more preventive measures other than specific antibiotic treatment be used. We present a patient with acute myeloid leukemia and PUBS in palliative care (AU)