[The current clinical spectrum of pulmonary thromboembolism]. / El espectro clínico actual del tromboembolismo pulmonar.

BACKGROUND. Mortality in pulmonary thromboembolism (PTE) decreases considerable when it is diagnosed early. The suspicion based on clinical and complementary data is essential for an early diagnosis. METHODS. Retrospective review of the clinical features in patients diagnosed of PTE in an Internal Medicine department from January 1993 to December 1999. RESULTS. A total of 117 patients with PTE were identified. The median age was 68.8 years. Sixty-six patients (56.4%) had one or more risk factors for PTE. The most common risk factor was immobilization (37.6%). Dyspnea was the most common symptom (74.4%) and tachypnea the most common sign (66.7%). Fever/low grade fever and leukocytosis were present in 16.2% and 31.6% of patients, respectively. Respiratory failure, alkalosis and hypocapnia were present in 44.4%, 38.5% and 47% of patients, respectively. An alveolar-arterial oxygen gradient > 20 mmHg was demonstrated in 96.6% of patients. Chest radiographs and electrocardiograms were normal in 52.1% and 23.9% of patients, respectively. A vein echo-duplex of the lower limbs demonstrated deep vein thrombosis (DVT) in 52.1% of patients. The hospital mortality rate was 6.8%. CONCLUSIONS. PTE still affects older patients mainly and frequently known risk factors are not detected. The presence of fever/low grade fever and/or leukocytosis does not rule out PTE. Both chest radiographs and electrocardiograms may be normal. Not demonstrating DVT in the lower limbs by the vein echo-duplex does not rule out PTE. The hospital mortality rate has not decreased considerably in the last few years.

El espectro clínico actual del tromboembolismo pulmonar / The current clinical spectrum of pulmonary thromboembolism

Fundamento. La mortalidad del tromboembolismo pulmonar (TEP) disminuye de manera considerable cuando es diagnosticado precozmente. La sospecha basada en los datos clínicos y complementarios es fundamental en el diagnóstico precoz. Métodos. Revisión retrospectiva de las características de los pacientes diagnosticados de TEP en un servicio de Medicina Interna entre enero de 1993 y diciembre de 1999. Resultados. Identificamos 117 pacientes con TEP. La edad media fue 6 8 ,8 años. Sesenta y seis pacientes (5 6 ,4 %) tuvieron uno o varios factores de riesgo conocidos para TEP. El factor de riesgo más frecuente fue la inmovilización (3 7 ,6 %). La disnea (7 4 ,4 %) y la taquipnea (6 6 ,7 %) fueron, respectivamente, el síntoma y el signo más frecuente. Un 16,2% y un 31,6% de los casos presentó fiebre/ febrícula y leucocitosis. Un 44,4%, un 38,5% y un 47% de los pacientes presentaron insuficiencia respiratoria, alcalosis e hipocapnia, respectivamente. Un 9 6 ,6 % tuvo un gradiente alvéolo-arterial de oxígeno > 2 0 mmHg. La radiografía de tórax y el electrocardiograma fueron normales en el 52,1% y en el 23,9% de los casos, respectivamente. El eco-dúplex venoso de miembros inferiores demostró una trombosis venosa profunda (TVP) en el 5 2 ,5 % de los casos. La mortalidad intrahospitalaria fue del 6 ,8 %. Conclusiones. El TEP sigue afectando preferentemente a personas mayores, y con frecuencia no existe un factor de riesgo conocido. La presencia de fiebre/ febrícula y/ o leucocitosis no excluye un TEP. Un gradiente alvéolo-arterial de oxígeno normal es excepcional en el TEP. La radiografía de tórax y el electrocardiograma pueden ser normales. La no demostración de una TVP en miembros inferiores mediante eco-dúplex venoso no permite excluir un TEP. La mortalidad intrahospitalaria del TEP no ha disminuido considerablemente en los últimos años (AU)

Background. Mortality in pulmonary thromboembolism (PTE) decreases considerable when it is diagnosed early. The suspicion based on clinical and complementary data is essential for an early diagnosis. Methods. Retrospective review of the clinical features in patients diagnosed of PTE in an Internal Medicine department from January 1993 to December 1999. Results. A total of 117 patients with PTE were identified. The median age was 6 8 .8 years. Sixty- six patients (5 6 .4 %) had one or more risk factors for PTE. The most common risk factor was immobilization (37.6%). Dyspnea was the most common symptom (7 4 .4 %) and tachypnea the most common sign (6 6 .7 %). Fever/ low grade fever and leukocytosis were present in 1 6 .2 % and 3 1 .6 % of patients, respectively. Respiratory failure, alkalosis and hypocapnia were present in 4 4 .4 %, 3 8 .5 % and 4 7 % of patients, respectively. An alveolar-arterial oxygen gradient > 2 0 mmHg was demonstrated in 9 6 .6 % of patients. Chest radiographs and electrocardiograms were normal in 5 2 .1 % and 2 3 .9 % of patients, respectively. A vein echo-duplex of the lower limbs demonstrated deep vein thrombosis (DVT) in 5 2 .1 % of patients. The hospital mortality rate was 6 .8 %. Conclusions. PTE still affects older patients mainly and frequently known risk factors are not detected. The presence of fever/ low grade fever and/ or leukocytosis does not rule out PTE. Both chest radiographs and electrocardiograms may be normal. Not demonstrating DVT in the lower limbs by the vein echo-duplex does not rule out PTE. The hospital mortality rate has not decreased considerably in the last few years (AU)

Ischemic heart disease associated with vincristine and doxorubicin chemotherapy.

OBJECTIVE: To report the ocurrence of ischemic heart disease (IHD) in a patient with multiple myeloma treated with vincristine and doxorubicin. CASE SUMMARY: A 46-year-old man developed a Q-wave inferior and right-ventricle myocardial infarction with postinfarction angina after receiving his third cycle of vincristine and doxorubicin for immunoglobulin A multiple myeloma. Angiography showed two small filling defects consistent with thrombi in the distal right coronary artery. DISCUSSION: IHD may be a serious but uncommon complication of treatment with several chemotherapeutic agents. It is likely that chemotherapy played a role in the development of IHD in our patient. Several putative mechanisms for vascular toxicity have been associated with chemotherapy. CONCLUSIONS: Chemotherapy with vincristine and doxorubicin may play a role in the ocurrence of IHD. Physicians should possess an awareness of this potentially serious complication of chemotherapy.

Anemia perniciosa y otras anemias megaloblásticas / Pernicious anemia and other megaloblastic anemias

Objetivo: Describir las características clínicas y biológicas de las anemias megaloblásticas (AM) en nuestro medio, y determinar posibles diferencias entre la anemia perniciosa (AP(+)) y el resto de las AM (AP(-)). Método: Estudio retrospectivo de los pacientes diagnosticados de AM en nuestro servicio entre 1993 y 1998. Resultados: Cincuenta pacientes fueron diagnosticados de AM. La edad media al diagnóstico fue 70,7 años. Las causas de AM fueron: déficit de cobalamina (DC) en 40 casos (80%), déficit de folato (DF) en 7 casos (14%) y déficit de ambos en 3 casos (6%). Una AP fue diagnosticada en 19 pacientes (38%). Todos los casos presentaron hipersegmentación de los neutrófilos y 41 casos (81%) macroovalocitosis. Veintidós pacientes (44%) tuvieron una hemoglobina <8 g/dl. El nivel medio de LDH sérica fue 2.059 ñ 1.739 U/l. Hubo una menor frecuencia del sexo femenino y un ADE mayor en el grupo AP(+). No encontramos otras diferencias significativas entre ambos grupos en el resto de características estudiadas, salvo la presencia de anticuerpos anti-células parietales y/o anticuerpos anti-factor intrínseco en el grupo AP(+). Conclusiones: La AM se debió fundamentalmente en nuestra serie a DC. La AP fue la causa más frecuente de DC. La mayor parte de los casos de AM correspondieron a una anemia macrocítica severa con hipersegmentación de los neutrófilos, macroovalocitosis y una LDH sérica considerablemente elevada. No identificamos ninguna característica clínica o biológica, salvo la presencia de anticuerpos anti-células parietales y/o anticuerpos anti-factor intrínseco y un ADE mayor en el grupo AP(+), que permita distinguir los grupos AP(+) y AP(-) (AU)

[Pernicious anemia and other megaloblastic anemias]. / Anemia perniciosa y otras anemias megaloblásticas.

OBJECTIVE: To describe the clinical and biological characteristics of a series of patients with megaloblastic anemia (MA) and to identify potential differences between patients with pernicious anemia (PA(+)) and patients with other MA (PA(-)). METHOD: Retrospective study of 50 patients with MA diagnosed in our service between 1993 and 1998. RESULTS: MA was diagnosed in 50 patients. The median age in the moment of diagnosis was 70.7 years. The causes of MA were: cobalamin deficiency (CD) in 40 cases (80%), folate deficiency (FD) in 7 cases (14%) and both deficiencies in 3 cases (6%). PA was diagnosed in 19 patients (38%). All cases showed hyper-segmented neutrophils and 41 cases (81%) macroovalocytosis. Hemoglobin level < 8 g/dl was present in 22 patients (44%). The median serum LDH level was 2.059 +/- 1.739 U/l. There was a lower frequency of female sex and a higher RDW in the group PA(+). There were no significant differences between both groups in the rest of studied features, except for the presence of antiparietal cell antibodies and anti-intrinsic factor antibodies in the group PA(+). CONCLUSIONS: CD was the most frequent cause of MA in our series. PA was the most frequent cause of CD. Most cases of MA corresponded to a severe macrocytic anemia with hyper-segmented neutrophils, macroovalocytosis and very high serum LDH level. We did not identify any clinical or biological characteristic, except for the presence of antiparietal cell antibodies and anti-intrinsic factor antibodies and a higher RDW in the group PA(+), to permit distinguish the groups PA(+) and PA(-).

[Hepatic granulomatosis caused by Q fever: a cause of erroneous tuberculosis diagnosis]. / Granulomatosis hepática por fiebre Q: una causa de falso diagnóstico de tuberculosis.

We present the case of a 31-year-old man hospitalized for the study of a fever syndrome. The patient developed acute respiratory failure, with anemia and hepatic affection. In the histological examination of the liver and bone marrow, the presence of granulomas suggesting a tuberculous etiology was demonstrated. Antibodies IgG anti-Coxiella burnetti were detected, using indirect immunofluorescence, at the level of 1/200, with latter seroconversion to 1/800. Therapy with doxycycline was administered (200 mg/day during 14 days). Fever subsided in 24 hours and the other clinico-biochemical disorders disappeared in the following days. After the literature review, we conclude that Q fever must be taken into account for the differential diagnosis of any granulomatous disease observed in the liver and/or bone marrow. We can confirm that any granuloma is specific of just one pathological entity. The diagnosis must be always supported by other clinical, supplementary and serological data.