Hallazgo histopatológico de Strongyloides stercoralis en enfermedad de Crohn: reporte de caso / Histopathologic finding of Strongyloides stercoralis in a patient with Crohn's disease: Case report

Resumen Caso clínico: Se describe un caso clínico poco frecuente en un paciente inmunocomprometido con hallazgo histopatológico de infestación parasitaria. Es un paciente masculino de edad media que habita en zona subtropical con diagnóstico de enfermedad de Crohn tratado con corticoide e inmunomoduladores, presentaba dolor abdominal y anemia crónica de 1 año de evolución, analítica negativa para parásitos, reactantes de fase aguda normales, gastroscopia y colonoscopia previas (6 meses) sin hallazgos relevantes. Por la persistencia del cuadro clínico se repitieron los estudios endoscópicos en los que se visualizaron hemorragias subepiteliales con resultados histopatológicos de Strongyloides stercoralis. Conclusión: En el contexto de un paciente inmunocomprometido, en zona endémica y con evolución tórpida, debe obligar a realizar un diagnóstico diferencial en el que se debe sospechar siempre de infestación parasitaria. Aunque la endoscopia no se necesita para el diagnóstico de estrongiloidiasis, su intervención puede ser oportuna.

Abstract Clinical case: The following is a rare clinical case in an immunocompromised patient with histopathological findings of parasitic infestation. The patient is a middle-aged male who lives in a subtropical area and has a diagnosis of Crohn's disease treated with corticosteroids and immunomodulators. The patient presented with abdominal pain and chronic anemia for 1 year, with negative laboratory tests for parasites and normal acute phase reactants. Gastroscopy and colonoscopy were performed before the consultation (6 months) without relevant findings. Due to the persistence of the symptoms, endoscopic studies were repeated, finding subepithelial bleeding with histopathological results of Strongyloides stercoralis. Conclusion: In the context of an immunocompromised patient living in an endemic area and with a torpid evolution, a differential diagnosis should be made always suspecting a parasitic infestation. Although endoscopy is not necessary to diagnose strongyloidiasis, its use may be convenient.

Hiponatremia asociada a hipopituitarismo en síndrome de silla turca vacía

RESUMEN Paciente femenino de 53 años de edad, que ingreso por cuadro clínico de 10 días de evolución caracterizado por mialgias y edema en extremidades inferiores. Al examen físico: facie abotagada, piel seca, cabello fino, disminución del vello axilar y púbico. En laboratorio se evidencia elevación de enzimas musculares (mioglobina 3000 U/L, CPK 2876 U/L), alteración del Na sérico 112 mEq/L, perfil tiroideo alterado (TSH normal a baja 1,14 UI/mL y FT4 baja 0,08 UI/ml), cortisol AM de 7,2 mcg/dL. Se solicito resonancia magnética con protocolo de silla turca se observa; hipófisis disminuida de tamaño en todos sus diámetros que confirma el hallazgo de un síndrome de silla turca parcialmente vacía. La hiponatremia asociada a hipopituitarismo es poco común.

ABSTRACT A 53-year-old female patient was admitted by a clinical case of 10 days of evolution characterized by myalgia and edema in the lower extremities. On physical examination: facial swelling, dry skin, fine hair, decreased axillary and pubic hair. In the laboratory there is evidence of elevation of muscle enzymes (myoglobin 3000 U/L, CPK 2876 U/L), alteration of serum Na 112 mEq/L, altered thyroid profile (normal to low TSH 1.14 IU/mL and FT4 low 0.08 IU/ml), AM cortisol 7.2 mcg/dL. Magnetic resonance imaging is requested with sella Turcica protocol. It is observed a decreased pituitary gland in all its diameters confirming the finding of a partially empty sella syndrome. Hyponatremia associated with hypopituitarism is uncommon.

Improving family satisfaction and participation in decision making in an intensive care unit.

Background Survey data revealed that families of patients in a surgical intensive care unit were not satisfied with their participation in decision making or with how well the multidisciplinary team worked together. Objectives To develop and implement an evidence-based communication algorithm and evaluate its effect in improving satisfaction among patients' families. Methods A multidisciplinary team developed an algorithm that included bundles of communication interventions at 24, 72, and 96 hours after admission to the unit. The algorithm included clinical triggers, which if present escalated the algorithm. A pre-post design using process improvement methods was used to compare families' satisfaction scores before and after implementation of the algorithm. Results Satisfaction scores for participation in decision making (45% vs 68%; z = -2.62, P = .009) and how well the health care team worked together (64% vs 83%; z = -2.10, P = .04) improved significantly after implementation. Conclusions Use of an evidence-based structured communication algorithm may be a way to improve satisfaction of families of intensive care patients with their participation in decision making and their perception of how well the unit's team works together.

A multicenter prospective study of interobserver agreement using the Full Outline of Unresponsiveness score coma scale in the intensive care unit.

OBJECTIVE: The classification of the comatose patient has been greatly improved with the use of coma scales. The Full Outline of Unresponsiveness score has emerged as an alternative to the Glasgow Coma Scale in that it incorporates essential information needed to assess the depth of coma. One set of patients for which the Full Outline of Unresponsiveness score could be particularly beneficial is those admitted to an intensive care unit, where approximately 30%-35% of all patients are intubated or ventilated. This manuscript reports on a study that examined the inter-rater reliability of the Full Outline of Unresponsiveness score in five intensive care units. SETTING: Seven intensive care units at five U.S. hospitals partici-pated. SUBJECTS: Patients admitted during parts of 2010 and 2011 had their Full Outline of Unresponsiveness score assessed independently by two nurses within 1 hr of admission. DESIGN: We evaluated the weighted kappa statistic of the Full Outline of Unresponsiveness score over all patients and stratified by mechanical ventilation status. Finally, we looked for evidence of heterogeneity in Full Outline of Unresponsiveness score agreement across hospitals. MEASUREMENTS AND MAIN RESULTS: A total of 907 adult critically ill patients had Full Outline of Unresponsiveness score assessments by two evaluators. The overall weighted kappa statistic was 0.92, and this did not differ by whether or not a patient was on a ventilator. Among hospitals there was modest heterogeneity for the weighted kappa; however, all of the values were >0.80. CONCLUSIONS: The Full Outline of Unresponsiveness score showed excellent inter-rater agreement overall and at each of the five hospitals. This demonstrates that the Full Outline of Unresponsiveness score can be utilized reliably in critically ill patients.

Patient characteristics associated with end-of-life decision making in critically ill surgical patients.

BACKGROUND: Palliative care is an important and necessary humanistic facet of ICU care. Wide variations exist in selection and implementation of palliative care decisions. Understanding patient factors associated with these decisions is crucial. STUDY DESIGN: Consecutive deaths (n = 151 patients) in a tertiary care surgical ICU during a 2-year period were reviewed. All data had been entered into the APACHE IV database. Patients were divided into groups: Withhold (WH), which included patients who had potentially lifesaving therapies withheld or withdrawn, and Full Care (FC), which included patients who had full resuscitative efforts before death. Patient factors including demographics, severity of illness, admission source, and history were compared between groups. RESULTS: Of 151 patients, 111 (74%) had potentially lifesaving therapy withheld or withdrawn (WH group). Forty patients (26%) had full treatment, including CPR, until time of death (FC group). Compared with WH, FC patients had a higher degree of illness at ICU admission (APACHE IV score 103.4 ± 36.6 vs 90.6 ± 29.3; p < 0.02) and were less likely to be male (35% vs 62%; p < 0.005). There were no differences between groups with regard to age, requirement for intubation on admission, medical history, admission source (emergency room vs operating room vs recovery room) or the number of patients admitted status post emergent vs elective surgery or admitted for nonsurgical diagnoses. In a multivariable regression model, male sex (odds ratio = 3.22; 95% CI, 1.45-7.19) and severity of illness (odds ratio = 0.98; 95% CI, 0.97-0.99) retained independent associations with decisions to limit care. CONCLUSIONS: Higher severity of illness and history play no role in the decision to limit care. Sex plays a strong and independent role. Factors influencing end-of-life care require additional study.