Varón con síndrome constitucional y atelectasia completa del lóbulo superior derecho / No disponible

Presentamos el caso de un paciente varón de 62 años que ingresa procedente del Servicio de Urgencias por síndrome constitucional. El hallazgo en la radiografía simple de tórax de una atelectasia completa del lóbulo superior derecho, junto con el antecedente de tabaquismo del paciente no es sino una “pista que despista”. De este caso hemos aprendido que, por claros que parezcan los síntomas y signos, siempre debemos establecer un amplio diagnóstico diferencial, tanto para nosotros los clínicos como para el estudio anatomopatológico (AU)

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Eficacia diagnóstica de los complejos trombina-antitrombina III y dímero D ELISA rápido en el embolismo pulmonar: efecto de la anticoagulación con heparina / Diagnostic and capacity of the thrombin-antithrombin III and rapid D dimer ELISA in pulmonary embolism: effect of anticoagulation with heparina

Hemos evaluado la eficacia de los complejos trombina-antitrombina III por ELISA (TAT) y dímero D ELISA rápido (DD-VIDAS) en el diagnóstico del embolismo pulmonar (EP). También se analizó el efecto que sobre la eficacia diagnóstica de TAT y DD-VIDAS puede tener el inicio del tratamiento con heparina previo a la toma de la muestra. El estudio incluye a 52 pacientes consecutivos con sospecha clínica de EP. El diagnóstico de confirmación de EP o exclusión de EP se realizó según la impresión clínica y resultados de la gammagrafía pulmonar, estudio de miembros inferiores y arteriografía pulmonar. En todos los pacientes, antes de transcurridas 24 horas desde la sospecha de EP, se obtuvo una muestra de plasma para determinar TAT y DD-VIDAS. En cada caso se registró el inicio o no del tratamiento anticoagulante con heparina previo a la toma de la muestra. En 24 pacientes se confirmó EP (46%) y en 28 se excluyó (54%). Con un punto de corte de 500 ng/ml el DD-VIDAS mostró una sensibilidad del 96%, especificidad del 53%, valor predictivo positivo del 63% y valor predictivo negativo del 93%, observándose un solo falso negativo. Para los TAT con un nivel de corte de 4 ng/ml la sensibilidad fue del 79%, la especificidad del 50%, el valor predictivo positivo del 57% y el valor predictivo negativo del 73%, presentando 5 falsos negativos. La anticoagulación previa a la toma de la muestra estaba presente en 4 de los 5 falsos negativos observados para los TAT y en el único caso falso negativo para el DD-VIDAS. En conclusión, de las dos técnicas estudiadas, DD-VIDAS y TAT, el DD-VIDAS con un punto de corte de 500 ng/ml parece potencialmente útil para excluir EP en nuestro medio, aunque es necesario ampliar la serie para confirmar estos resultados. Los TAT mostraron escasa utilidad en el diagnóstico de exclusión de EP. El inicio de la anticoagulación con heparina previo a la toma de la muestra parece un factor decisivo que puede afectar a los resultados obtenidos con los TAT (AU)

We have evaluated the efficacy of the thrombin-antithrombin III complexes by ELISA (TAT) and rapid D dimer (VIDASDD) in the diagnoses of pulmonary embolism (PD). The effect that the initiation of treatment with Heparin before the sample is obtained has on diagnostic efficacy of TAT and DD-VIDAS was also analyzed. The study includes 52 consecutive patients with clinical suspicion of PD. The confirmation diagnoses of PD or exclusion of PD was made according to a clinical impression and results on the pulmonary scintigraphy, study of the lower limbs and pulmonary arteriography. A sample of plasma was obtained in all of the patients within 24 hours from the suspicion of PD to determine TAT and VIDAS-DD. In every case, the initiation or not initiation of anticoagulant treatment with heparin prior to obtaining the sample was recorded. In 24 patients, PD (46%) was confirmed and it was excluded in 28 (54%). Using a cut off of 500 ng/ml, the VIDAS-DD showed a sensitivity of 96%, specificity of 53% and negative predictive value of 93%, only one false-negative being found. For the TAT with a cutoff of 4 ng/ml, sensitivity was 79%, specificity 50%, positive predictive value 57% and negative predictive value 73%, there being five false negatives. Anticoagulation prior to obtaining the sample was present in 4 of the 5 false negatives observed for TAT and in the only case of false-negative for VIDAS- DD. In conclusion, of the two techniques studied, VIDAS-DD and TAT, VIDAS-DD with a cutoff of 500 ng/ml seems to be potentially useful to exclude PD in our setting, although this series must be extended to confirm these results. The TAT showed little utility in the exclusion diagnosis of PD. Initiation of anticoagulation with heparin before the sample is obtained seems to be a decisive factor that may affect the results obtained with TAT (AU)

[Respiratory form of onset of motor neuron disease]. / Forma de comienzo respiratorio de la enfermedad de motoneurona.

OBJECTIVE: To present a case of respiratory failure as the form of onset of amyotrophic lateral sclerosis, to review the main clinical findings, data of the investigations done which suggest the presence of this disorder and describe its therapeutic management. CLINICAL CASE: A 68 year old man presented with a subacute illness characterized by a sleep disorder with sleep fragmentation, snoring of increasing intensity, without clear pauses of apnea, progressive diurnal hypersomnia accompanied by progressive dyspnea followed by respiratory failure with respiratory acidosis and difficulty in manipulating things with his hands. Diagnostic investigations showed a restrictive pattern without pulmonary fibrosis, due to paralysis of the diaphragm, and the presence of electromyographic signs compatible with motorneuron disease. The patient was treated with riluzole 100 mg/day and non-invasive mechanical ventilation and maintained an acceptable quality of life. CONCLUSIONS: Motorneuron disease may start with acute or progressive respiratory failure without a clear etiological cause and may appear to be similar to obstructive sleep apnea syndrome. The treatment of choice for this respiratory problem is non-invasive mechanical ventilation. Absence of symptoms of bulbar involvement is essential for a favourable prognosis.

Forma de comienzo respiratorio de la enfermedad de motoneurona / Respiratory form of onset of motorneuron disease

Objetivo. Presentar un caso de insuficiencia como forma de comienzo de la esclerosis lateral amiotrófica, así como revisar sus manifestaciones clínicas principales, los datos de pruebas diagnósticas sugestivos de esta enfermedad y su manejo terapéutico. Caso clínico. Varón de 68 años que presentó cuadro subagudo caracterizado por la aparición de trastorno del sueño con fragmentaciones del mismo y ronquidos crecientes en intensidad, sin claras pausa de apnea, junto con hipersomnia diurna progresiva, acompañado de disnea progresiva y posterior fallo respiratorio con acidosis respiratoria y de dificultad manipulatoria en manos. Los tests diagnósticos objetivaron un patrón restrictivo sin la presencia de fibrosis pulmonar debido a parálisis diafragmática y a la presencia de signos electromiográficos compatibles con enfermedad de motoneurona. El paciente recibió tratamiento con riluzole 100 mg/día y ventilación mecánica no invasiva manteniendo una calidad de vida aceptable. Conclusiones. La enfermedad de motoneurona puede comenzar como un cuadro de insuficiencia respiratoria aguda o progresiva sin una causa etiológica clara, pudiendo simular un síndrome de apnea obstructiva del sueño. El tratamiento de elección para su problema respiratorio sería la ventilación mecánica no invasiva, siendo fundamental para un pronóstico más favorable la ausencia de síntomas de afectación bulbar (AU)

[The spectrum of bronchiolitis]. / El espectro de las bronquiolitis.

Over the last years numerous entities affecting small airways of respiratory tract has been described. It has gone accompanied of a considerable degree of confusion, leading to gather together different diseases which only share the term bronchiolitis. Our aim is to report three patients, one bronchiolitis, noticing their characteristic features and analysing the origin of this situation.

[Castleman's disease: presentation of a case and review of the literature]. / Enfermedad de Castleman: presentación de un caso y revisión de la literatura.

The traditional Castleman's Disease is characterized by the presence of a single tumor constituted by hyperplasic lymphoid tissue. It is usually asymptomatic and has a good prognosis. More recently, another disease which is histologically undistinguishable has been described. However, it courses with polyadenopathic signs, consumptive syndrome, anemia, hypergammaglobulemia and fever and has been called multicentric Castleman's Disease. A comprehensive review of national and international literature is included.

[Diabetes insipidus and Langerhans-cell histiocytosis without changes in cerebral CAT and NMR]. / Diabetes insípida en histiocitosis de células de Langerhans, sin alteraciones en la TAC y RMN cerebral.

In LCH extended disease CNS involvement in is not infrequent. Diabetes insipidus, due to the affectation of hypothalamus-hypophysis axis, is its most frequent finding. The solitary affectation of hypothalamus-hypophysis axis is exceptional. At times, it's a difficult diagnosis and could precede the diagnosis of LCH several years. Usually, CAT and NMR show morphologic lesions. We report a patient who was diagnosed of idiopathic diabetes insipidus when he was 16 years old. Seven year later, he was diagnosed of LCH after underwent a bone marrow biopsy examination, just when the disease involved the bone and lung. Cerebral CAT and NMR didn't show morphologic lesions. In the presence of morphologic lesions in hypothalamus and/or hypophysis, proved by cerebral CAT and NMR, or a clinical setting of DI, the possibility of LCH must be considered.

[The role of BCG in the prevention of tuberculosis]. / El papel de la BCG en la prevención de la tuberculosis.

Tuberculosis is still a major international public health problem. The role of vaccination with BCG in the prophylaxis of the tuberculosis has been a source of controversy almost since ist introduction in the thirties, because of the disparity of the results regarding efficacy and protection of the several studies that have been done. Currently, everybody seems to agree that in countries with annual infection risk lower than 1%, a massive vaccination campaign with BGC is not profitable. On the other hand, BCG interferes the lecture of the Mantoux intra-dermo-reaction and, thus, it invalidates the most effective test that we have for the diagnosis of the tuberculosis infection. In our country, the battle against tuberculosis is currently focused on the identification and treatment of the tuberculous patient, chemoprophylaxis with contacts of these patients and avoidance of the development of the tuberculosis infection to tuberculosis disease.

[Current status of the antipneumococcal vaccine: a pending issue]. / Situación actual de la vacuna antineumocócica: una asignatura pendiente.

In spite of antibiotic treatment, mortality due to pneumonia caused by Streptococcus pneumoniae is still considerable and it is related to the presence of bacteremia. Prophylaxis with 23-polyvalent anti-pneumococcus vaccine would prevent severe processes in high risk populations. We present in this work the current status of our knowledge about this vaccine, regarding its efficacy in preventing bacteremia, economic cost, and secondary effects, we point out the indications of this vaccine according to IPAC (Immunization Practices Advisory Committee) and those special situations which modify prophylaxis (pregnancy, revaccination and massive immunizations) are discussed.

[Tuberculin test: usefulness of an old technique]. / Prueba tuberculínica: utilidad de una antigua técnica.

Tuberculin test was first used as a diagnostic test of tuberculous infection during the first decades of this century. From the up to date, no other method has proven to be more efficient for this task. In the present work we try to explain what the test consists of, what is its use, how it is interpreted, and which are the indications for the Mantoux intradermal reaction. We emphasize the importance of performing this technique correctly so as to not invalidate the results of this test which is essential both from a individual as from an epidemiological point of view.