Gammapatía biclonal transitoria posterior a infección por SARS-CoV-2. Reporte de un caso / Transient biclonal gammopathy after SARS-CoV-2 infection. A case report

Resumen Los pacientes infectados por SARS-CoV-2 presentan un curso clínico variable, desde asintomáticos o con síntomas respiratorios leves hasta una evolución grave con gran reacción inflamatoria e inmune. La aparición de un componente monoclonal como manifestación de este estado inflamatorio e inmune está poco descrito. Se presenta el caso de un paciente masculino de 74 años que inicia en 2020 con síndrome anémico, livedo reticularis y acrocianosis, gatillados por frío y aliviados por calor. El laboratorio evidencia anemia hemolítica por anticuerpos fríos y su estudio complementario es compatible con enfermedad por crioaglutininas. Se trata con rituximab sin respuesta, posteriormente recibe rituximab-bendamustina resolviendo síntomas, disminuyendo el título de crioaglutininas, mejorando la anemia y normalizando el perfil bioquímico. En febrero de 2022 presenta neumonía multifocal por SARS COV 2, requiriendo hospitalización por 19 días, con reactivación mínima de su enfermedad de base. En esta etapa se detecta en electroforesis e inmunofijación en suero dos componentes monoclonales IgG kappa e IgG lambda, sumados a su IgM kappa conocido por su enfermedad por crioaglutininas. El seguimiento muestra que dichos componentes persisten detectables por 4 meses, pero un control posterior evidencia la persistencia de sólo IgM kappa en inmunofijación, con desaparición de los nuevos componentes. La electroforesis es también negativa. Usualmente las infecciones virales generan hipergammaglobulinemias policlonales, en contraste mostramos como en este caso la infección por SARS-CoV-2 se asocia a gammapatía biclonal transitoria, la que planteamos como manifestación de la intensa reacción inmune generada por el virus.

Abstract Patients infected by SARS-CoV-2 present a variable clinical course, from asymptomatic or mild respiratory symptoms to a severe evolution with a major inflammatory and immune reaction. The appearance of a monoclonal component as a manifestation of this inflammatory and immune state is poorly described. We present the case of a 74-year-old male patient, who began in 2020 with anemic syndrome, livedo reticularis and acrocyanosis triggered by cold and relieved by heat. The laboratory showed hemolytic anemia due to cold antibodies and its complementary study was compatible with cold agglutinin disease. He was treated with rituximab without response, subsequently receiving rituximab-bendamustine, resolving symptoms, decreasing cold agglutinin titer, improving anemia and normalizing biochemical profile. In February 2022, he presented multifocal pneumonia due to SARS-CoV-2, requiring hospitalization for 19 days, with minimal reactivation of his underlying disease. At this stage, two monoclonal components IgG kappa and IgG lambda are detected in electrophoresis and immunofixation in serum, added to their IgM kappa known for cold agglutinin disease. The follow-up shows that these components remain detectable for 4 months, a subsequent control shows the persistence of only IgM kappa in immunofixation, with the disappearance of the new components. The electrophoresis is also negative. Usually viral infections generate polyclonal hypergammaglobulinemias, in contrast we show how in this case the SARS-CoV-2 infection is associated with transient biclonal gammopathy, which we propose as a manifestation of the intense immune reaction generated by the virus.

[Low-risk community-acquired pneumonia: implications of its outcome due to the determining factors for admission not contemplated by the scores]. / Neumonía adquirida en la comunidad de bajo riesgo: Consecuencias evolutivas de los determinantes de internación no contemplados por los scores.

OBJECTIVES: The decision to admit patients with community-acquired pneumonia (CAP) to hospital are based on stratification scales. This classification into risk groups is not perfect. In low-risk community-acquired pneumonia (LR-CAP), physicians often depend on their subjective impressions to decide the need for hospitalisation, which suggests the existence of conditions not considered by the scores. The aim of this article was to describe the determining factors for admission in LR-CAP, and to analyse the relationship between these causes and clinical outcome. MATERIAL AND METHODS: A descriptive, observational, retrospective study, based on the review of medical records during a 2 year-period. It included patients over 18 years, who were hospitalised in a third level hospital in Argentina due to LR-CAP. RESULTS: A total of 80 cases were identified. The causes that led to hospitalisation were: comorbidities not included in the scores, development of pleural effusion and sepsis, lack of response to ambulatory antibiotic treatment, oral intolerance, and social causes. HIV infection was associated with an unfavourable clinical progress during hospital admission (p=.03), as well as the lack of response to outpatient treatment (p=.03) and the development of pleural effusion (p=.03). Social causes were associated with a need for longer intravenous treatment. CONCLUSIONS: HIV infection, social causes, and lack of response to ambulatory treatment were related to unfavourable clinical progress.

Inhalación masiva de amoniaco: reporte de dos casos / Massive ammonia inhalation: report of two cases

Ammonia (NH3) is an irritant and corrosive gas whose inhalation at high concentrations mainly occurs during agricultural and industrial activities, as occupational accidents. The extent and severity of the damage depends on the concentration and time of exposure to the toxic, which can cause skin, eye, respiratory and life-threatening injuries. We present two cases of patients acutely exposed to high concentrations of NH3. Both patients survived to the acute phase of the respiratory injury, but developed chronic lung derangements.

El amoniaco (NH3) es un gas irritante y corrosivo cuya inhalación aguda en altas concentraciones se produce principalmente durante accidentes laborales en el sector agrícola e industrial. La extensión y severidad del daño depende de la concentración y tiempo de exposición al tóxico, el cual puede causar lesiones a nivel cutáneo, ocular, respiratorio y riesgo vital. Presentamos dos casos de pacientes expuestos en forma aguda a NH3 en altas concentraciones. Ambos pacientes sobrevivieron a la fase aguda y evolucionaron con lesiones respiratorias crónicas.

Factores sociodemográficos asociados al antecedente de aborto inducido en cuatro centros de salud de la ciudad de Lima - Perú / Sociodemographic factors associated with background of induced abortion in four health centers in the city of Lima - Peru

Se realizó un estudio descriptivo en 552 mujeres que se habían sometido al aborto inducido. El trabajo se hizo en los centros de salud de Chosica, el Agustino, el centro de Lima y el Hospital Cayetano Heredia durante los años 1999-2003. El objetivo era identificar factores sociodemográficos asociados al aborto inducido en algunos centros de salud de la ciudad de Lima, además de investigar complicaciones médicas según los autores que lo practicaron. La totalidad de mujeres estaban en la edad reproductiva; el 61 por ciento tenía instrucción secundaria completa o superior; el 66 por ciento en unión estable (casadas y convivientes). Habían iniciado su actividad sexual en la adolescencia un 74 por ciento y en esta misma etapa interrumpieron su embarazo un 23 por ciento. Hubieron en total 828 abortos inducidos, 59 por ciento fueron practicados pasado el mes de amenorrea y más de tres meses el 3.26 por ciento. De total de las 552 mujeres un 41 por ciento había interrumpido su primera gestación por medio del aborto inducido. De lo manifestado de este grupo de mujeres, médicos fueron quienes más practicaron esta intervención 84 por ciento, mientras que los empíricos tuvieron mayor proporción de complicaciones 63 por ciento. Las complicaciones se presentaban en mayor proporción mientras mayor fue el tiempo de embarazo y menor el conocimiento médico de quien lo practicó. Razones para tomar la determinación de abortar, fueron la situación económica difícil para las casadas y convivientes, mientras que para las solteras fue el no estar unidad. Una gran mayoría 96 por ciento estaba consciente de que el aborto inducido ponía en peligro su salud, en la misma proporción conocían o habían usado anticonceptivos y sin embargo no tomaron precauciones por descuido 83 por ciento. Sentimientos de culpa poco o nada manifestaron 64 por ciento. Gran proporción manifestó ser creyente a predomino de las católicas 92 por ciento.

It was done a descriptive research in 552 women, who have submitted to an induced abortion. Research was done in Chosica’s Health center, Agustino’s Health center, Lima’s Health center and Cayetano Heredia Hospital since 1999-2003. The propose of this research, was identify sociodemographic factors associated to induce abortion in some Heath Centers around Lima City, also this research was done in order to indicate the medical complications by the same doctors who has done it. All of women were in reproductive age; 61 per cent of them have studied secondary until they finished or in some cases they have continued; 66 per cent of them live together with a partner in a faithful way (married or not married). They have started their sexual activity during adolescence in a 74 per cent, and at this same stage the interrupted their pregnancy in 23 per cent. There were in total 828 cases of induced abortion, 59 per cent of them were done some time later the month of amenorrhea, and 3.25 per cent were done after months. From 552 women as a total, 41 per cent have interrupted their first pregnancy by means of induced abortion. This group of women declares that, doctors were the ones who did this intervention in most of the cases 84 per cent. On the hand, interventions that have been done by empirics result in a high percent of complication 63 per cent. Complications seem to appear in a high rate if the time of pregnancy was long or if the medical knowledge was not enough in them who did this intervention. Some reasons to abort was the hard economy situation for them who live with a partner (married or not married), the single ones considered that beings alone was the reason. A high percent 96 per cent knew that induced abortion included some risks which could be harmful for their health the same percent of women knew or have used contraceptives. Nevertheless they did not take precaution because of oversight 83 per cent. Women felt a bit fault or non fault...