Neumoencéfalo, coma y convulsiones después de una cirugía de descompresión lumbar / Pneumocephalus, coma and seizures following lumbar decompression surgery

Describimos un caso de neumoencéfalo en una paciente con estenosis de canal medular por espondilolistesis degenerativa tras cirugía de descompresión lumbar. El caso comienza en el momento del despertar de la anestesia, en el que la paciente presenta bajo nivel de consciencia, sin respuesta de apertura ocular, ninguna respuesta verbal y la respuesta motora sOlo retira en respuesta al dolor (Glasgow 7), que precisa ingreso en la unidad de cuidados intensivos para ventilación mecánica. Posteriormente la paciente experimentó una crisis convulsiva tónico-clónica generalizada, por lo que se realizó una tomografía computarizada (TC) donde se observa un neumoencéfalo voluminoso con un efecto ocupante de espacio en los lóbulos frontal y parietal, los ventrículos laterales y la cisterna.Se inició terapia antiepiléptica (diazepam y levetiracetam) y vigilancia neurológica. A las 12h postoperatorias, la TC repetida demostró que el neumoencéfalo había mejorado persistiendo una cantidad mínima que Solo se limitaba al lóbulo frontal. La consciencia persistía severamente disminuida. El electroencefalograma mostró actividad epileptiforme continua y la adicción de fenitoína continua intravenosa al tratamiento antiepiléptico previo consigue mejorar gradualmente el nivel de consciencia y las respuestas motoras y verbales. A las pocas horas, la paciente fue extubada y no presentó déficits neurológicos posteriores. El neumoencéfalo debe considerarse en el diagnóstico diferencial cuando se evalúa a un paciente con un estado mental alterado después de una cirugía lumbar.(AU)

We describe a patient with pneumocephalus following lumbar decompression surgery who presented altered mental status at time to awake of anesthesia and the patient was admitted in intesive care unit in mechanical ventilation. The patient has not eye-opening response, no verbal response and motor response only withdraw in response to pain (7 points on Glasgow coma scale). Then, the patient experienced a generalized tonic-clonic seizure. Immediate cranial computed tomography (CT) images were performed. Cerebral pneumocephalus was present in CT, imaging revealed a voluminous pneumocephalus responsible for a significantspace-occupying effect on the frontal and parietal lobes, lateral ventricles and quadrigeminal plate cistern.Anti-epileptic therapy (diazepam and levetiracetam) and neurological monitoring were initiated. At 12 postoperative hours repeat CT scanning showed pneumocephalus were completely improved to minimal quantity and only limited to frontal lobe. The consciousness is impaired, and a generalized tonic-clonic seizure was present. Electroencephalogram showed continuous epileptiform activity and phenytoin IV was administered in continuous infusión. Four hours later the level of consciousness gradually improved, and the patient was right in eye opening, verbal and motor responses. A few hours later the patient was extubated, and no neurological deficits were present. Pneumocephalus should be considered in the differential diagnosis when evaluating a patient with altered mental status following lumbar surgery.(AU)

Pneumocephalus, coma and seizures following lumbar decompression surgery.

We describe a patient with pneumocephalus following lumbar decompression surgery who presented altered mental status at time to awake of anaesthesia and the patient was admitted in intesive care unit in mechanical ventilation. The patient has not eye-opening response, no verbal response and motor response only withdraw in response to pain (7 points on Glasgow coma scale). Then, the patient experienced a generalized tonic-clonic seizure. Immediate cranial computed tomography (CT) images were performed. Cerebral pneumocephalus was present in CT, imaging revealed a voluminous pneumocephalus responsible for a significantspace-occupying effect on the frontal and parietal lobes, lateral ventricles and quadrigeminal plate cistern. Anti-epileptic therapy (Diazepam and levetiracetam) and neurological monitoring were initiated. At 12 postoperative hours repeat CT scanning showed pneumocephalus were completely improved to minimal quantity and only limited to frontal lobe. The consciousness is impaired, and a generalized tonic-clonic seizure was present. Electroencephalogram showed continuous epileptiform activity and phenytoin IV was administered in continuous infusión. Four hours later the level of consciousness gradually improved, and the patient was right in eye opening, verbal and motor responses. A few hours later the patient was extubated, and no neurological deficits were present. Pneumocephalus should be considered in the differential diagnosis when evaluating a patient with altered mental status following lumbar surgery.

[The oncology patient in emergencies. Epidemiological data]. / Enfoque global del enfermo oncológico en urgencias. Datos epidemiológicos.

Oncology patients do not form a large proportion within the overall figures of an emergency service, but their clinical characteristics mean that attending to them is often complex. The elaboration of a complete clinical history, specifying the characteristics and stage of the tumoural disease, is a basic weapon for taking decisions when an emergency arises. According to the data from our centre, oncology patients account for 5% of the total of emergency cases. The most frequent type of tumour that we deal with is pulmonary, followed by breast and colon. It is often the case that these patients come to the emergency department several times in the same month and pain is the most frequent reason for consultation, although it is normal for them to mention several causes on each occasion. In a high percentage of cases the reason for the consultation is related to the disease itself, but on as many as 35% of occasions it is an intercurrent pathology. The index of admissions is high (around 50%), especially if the patient has come for a reason related to the disease. In global terms, they account for 14% of total admissions from emergencies.

Enfoque global del enfermo oncológico en urgencias. Datos epidemiológicos / The oncology patient in emergencies. Epidemiological data

Los pacientes oncológicos no representan un gran volumen dentro del global de un servicio de urgencias, pero sus características clínicas hacen que su atención sea a menudo compleja. La realización de una historia clínica completa, en la que se especifiquen las características y estadio de la enfermedad tumoral, es un arma fundamental para la toma de decisiones en el momento urgente. Según datos de nuestro centro, los enfermos oncológicos representan un 5% del total de las urgencias. El tipo de tumor que más frecuentemente atendemos es el pulmonar, seguido del de mama y colon. Es frecuente que estos enfermos acudan a urgencias varias veces en un mismo mes y el motivo de consulta más frecuente es el dolor, aunque es habitual que comenten varias causas en cada ocasión. En un alto porcentaje de casos la causa de su consulta está relacionada con la propia enfermedad pero hasta en un 35% de las ocasiones es una patología intercurrente. El índice de ingresos es elevado (alrededor del 50%) y especialmente si el paciente ha acudido por un motivo relacionado con la enfermedad. En global suponen un 14% del total de ingresos desde urgencias (AU)

Oncology patients do not form a large proportion within the overall figures of an emergency service, but their clinical characteristics mean that attending to them is often complex. The elaboration of a complete clinical history, specifying the characteristics and stage of the tumoural disease, is a basic weapon for taking decisions when an emergency arises. According to the data from our centre, oncology patients account for 5% of the total of emergency cases. The most frequent type of tumour that we deal with is pulmonary, followed by breast and colon. It is often the case that these patients come to the emergency department several times in the same month and pain is the most frequent reason for consultation, although it is normal for them to mention several causes on each occasion. In a high percentage of cases the reason for the consultation is related to the disease itself, but on as many as 35% of occasions it is an intercurrent pathology. The index of admissions is high (around 50%), especially if the patient has come for a reason related to the disease. In global terms, they account for 14% of total admissions from emergencies (AU)

[Cytomegalovirus retinitis after highly active antiretroviral therapy: a case report]. / Retinitis por citomegalovirus tras terapia antirretroviral altamente activa: a propósito de un caso.

CASE REPORT: An HIV infected patient with cytomegalovirus retinitis with a CD4 lymphocyte count of 498 cells/mm3 after a good response to highly active antiretroviral therapy is described. COMMENT: Some aspects of the immune system after highly active antiretroviral therapy remain unknown. CD4 T lymphocyte count might not be a good marker to identify some patients at risk of developing cytomegalovirus retinitis after this therapy.

Retinitis por citomegalovirus tras terapia antirretroviral altamente activa: a propósito de un caso / Cytomegalovirus retinitis after highly active antiretroviral therapy: a case report

Caso clínico: Se describe a un paciente HIV positivo que desarrolló retinitis por citomegalovirus con un recuento de linfocitos CD4 de 498 células/mm3 tras una buena respuesta a la terapia antirretroviral altamente activa. Discusión: Algunos aspectos del funcionamiento del sistema inmune tras la terapia antirretroviral altamente activa permanecen desconocidos. El recuento de linfocitos CD4 podría no ser un buen marcador para detectar algunos pacientes con riesgo de sufrir retinitis por citomegalovirus tras este tratamiento (AU)

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Value of limited necropsy in HIV-positive patients.

We performed limited autopsy with histological examination of tissue cores obtained percutaneously using the Tru-Cut needle and the Jamshidi trocar in 150 adult HIV-positive patients. Data were compared retrospectively with the antemortem clinical diagnosis. Eighty-one percent of the patients were male, and 78% were intravenous drug users. Specimens were obtained from the brain, liver, lung, bone marrow, and kidney of most patients. The main findings included liver cirrhosis in 22 cases (associated with HCV infection in 81%), Pneumocystis carinii pneumonia in 21, Cytomegalovirus (CMV) infection in 19, Mycobacterium avium-intracellulaire (MAI) infection in 17, bacterial pneumonia in 14, tuberculosis in 12, and lymphoma in 13 cases. Forty-six (30.6%) patients had at least one clinical diagnosis that was confirmed by autopsy, i.e., there was 40.6% agreement between pre- and postmortem findings. Forty-six (30.6%) patients had at least one clinical diagnosis that was not confirmed at autopsy, whereas 41 (27.3%) had at least one AIDS-related or unrelated disease that was not suspected clinically. The results obtained by limited autopsy are principally comparable to those achieved by full necropsy, with the advantages of decreasing the contagious risk, saving cost and time, including a rapid final diagnosis, and easily obtaining the consent for postmortem examination so that necropsy studies may be performed on a larger number of patients, thus contributing to a better understanding of the spectrum of HIV infection in our environment.

Prospective application of risk scores in the interhospital transport of patients.

We carried out a prospective evaluation of 172 patients using our own risk score for patients transferred from the emergency department of a community hospital in Tudela, Spain, to main centres, during 1988. Although the data go back almost 10 years, this scoring has not been internationally published and is at present widely applied in Spain. Patients scoring less than 7 points were transferred under specialized nursing supervision (Group I), and those scoring equal to or over 7 points were transferred in a specially equipped intensive care unit surface ambulance and supervised by a physician and a nurse (Group II). There were 102 patients in Group I and 70 in Group II. Complications arising during transfer were defined as minor or serious. A low overall incidence of complications was recorded--a total of 29 cases (16.9% of all transfers). The incidence of complications was significantly higher in Group II patients (p < 0.005). One patient from Group II died during transport. All patients from Group II were admitted to the ICUs compared with only 20 (18.6%) from Group I (p < 0.001). Of a total of 23 deaths in hospital, nine were from Group I and 14 from Group II. During the first 24 hours after admission, six patients died from Group II and none from Group I. The application of risk scores has permitted to assign effectively technical and human resources for a safe interhospital transfer of critically ill patients.

[Tuberculin test in HIV infection]. / Prueba de la tuberculina en infección por HIV.

BACKGROUND: Intravenous infected-HIV drug abusers (IDAP/HIV+) are known to have a higher risk of tuberculosis (TB) than others. The effectiveness of tuberculin testing (Mantoux) in the detection of the TB infection in HIV(+) patients is probably lower than HIV(-) individuals. The aim of this paper is to assess tuberculin testing in the active search of cases of TB infection in IDAP individuals and their differences between HIV(+) and HIV(-) ones. METHODS: We studied 332 patients with intravenous drug use belonging to a therapeutic community and to in-patients. Tuberculin testing was performed on all of them. They were examinated if had been previously vaccinated with BCG and we carried out the counting of linfocites CD4 in HIV(+) ones. In the cases of negative tuberculin skin test a second test was administered after 7 days. The patients were grouped in HIV(+) and HIV(-) and the variables were statistically assessed by the chi 2 and a logistic regression model. RESULTS: Tuberculin testing resulted positive in 16.9% IDAP/HIV(+) in comparison with 39.9% of IDAP/HIV(-). The induration size was significantly smaller in HIV(+) than HIV(-) individuals. In both cases, we found that in BCG vaccinated patients positive tuberculin testing was significantly lower than negative tuberculin. The booster effect was detected in 8.9% of HIV(+), whereas in HIV(-) not BCG vaccinated it was of 21.4% and in HIV(-) BCG vaccinated it increased to 30.9%. When the level of the linfocites CD4 exceeds 500/mm3 in HIV(+) the percentage of Mantoux test (+) equals HIV(-) individuals. CONCLUSIONS: A decrease in sensitivity of tuberculin testing in the diagnosis of TB infection in IDAP/HIV(+) was detected. A high percentage of booster effect in IDAP was also demonstrated. We recommend the performance of tuberculin testing at the beginning of HIV infection.