Extranodal nk/t-cell lymphoma, nasal type: case report

ABSTRACT Introduction: Extranodal NK/T-cell lymphoma, nasal type (ENKL), is a highly aggressive non-Hodgkin's lymphoma of unknown etiology. Clinical manifestations are usually nasal obstruction, epistaxis, and inflammatory signs. Diagnosis can be difficult to achieve and requires histo-pathology and immunohistochemistry studies. Radiotherapy and chemotherapy have been proposed as treatment, depending on the stage of the disease. Case presentation: A 44-year-old male patient, previously healthy, attended the outpatient service due to clinical nasal obstruction, secretion, edema, and facial erythema for 2 months. Facial cellulitis was initially diagnosed, but since there was no improvement with antibiotic treatment, the patient was referred to the emergency department of a higher complexity center, where complementary imaging showed a mass in the right nasal cavity. A histopathological analysis established that it was an ENKL, so radiotherapy was indicated; however, as a result of the advanced stage of this neoplasm, the patient died. Conclusion: Timely diagnosis of ENKL is crucial to improve life expectancy. Nevertheless, it may represent a clinical challenge due to its nonspecific presentation.

RESUMEN Introducción. El linfoma extranodal nasal de células T/natural killer (ENKL) es un linfoma no Hodgkin altamente agresivo y de etiología desconocida. Sus manifestaciones clínicas suelen ser obstrucción nasal, epistaxis y signos inflamatorios; sin embargo, el diagnóstico puede llegar a ser difícil, requiriendo histopatología e inmunohistoquímica para su detección. Como tratamiento se han propuesto radioterapia y quimioterapia, según el estadio de la enfermedad. Presentación del caso. Paciente masculino de 44 años de edad, previamente sano, quien asistió al servicio de consulta externa por cuadro clínico de 2 meses de evolución consistente en síntomas de obstrucción y secreción nasal, edema y eritema facial. Se realizó diagnóstico inicial de celulitis facial, pero dado que no hubo mejoría con el tratamiento antibiótico, el sujeto fue remitido al servicio de urgencias de una institución de mayor complejidad, donde se le practicaron imágenes complementarias que mostraron una masa en la cavidad nasal derecha; mediante análisis histopatológico se estableció que se trataba de un ENKL, por lo que se indicó radioterapia; sin embargo, a consecuencia del estadio avanzado de dicha patología, el paciente falleció. Conclusión. El diagnóstico oportuno de ENKL es crucial para mejorar la expectativa de vida de quienes lo padecen; sin embargo, puede representar un reto clínico debido a su presentación inespecífica.

Porcentaje de mamografías de tamizaje con resultado BIRADS 4 y 5 en las que se diagnosticó cancer por biopsia en el Instituto Salvadoreño del Seguro Social de enero 2013 a diciembre 2014 / Percentage of screening mammograms with BIRADS 4 and 5 results in which cancer was diagnosed by biopsy at the "Instituto Salvadoreño del Seguro Social" from January 2013 to December 2014

El cáncer de mama en las mujeres representa en frecuencia el primer lugar debido a que anualmente a nivel mundial se diagnostican un promedio de 1.67 millones de nuevos casos con una incidencia que va de 27 (en África) a 92 (en Norteamérica) por 100,000 mujeres. La mamografía es la primera herramienta de imagen para la detección precoz del cáncer de mama, debido a que ha probado ser un método que ha logrado disminuir la mortalidad por dicha neoplasia. Existen varios sistemas de clasificación para la interpretación de las imágenes en mamografía, de estas BI-RADS® (Breast Imaging Reporting and Data System: Sistema de informes y registro de datos de imagen de la Mama) es la más utilizada, siendo el resultado BI-RADS® 4 y 5 sugestivas de malignidad, y por tanto ameritan confirmación histológica. Con el presente estudio se determinó el porcentaje de lesiones sospechosas de malignidad por hallazgo en mamografía de tamizaje en las cuales se diagnosticó cáncer de mama en mujeres del Instituto Salvadoreño del Seguro Social de enero 2013 a diciembre de 2014, mediante un estudio descriptivo, transversal. Tomando como población a todas las mujeres tamizadas para cáncer de mama mediante mamografía entre los 40 y 69 años en periodo ya mencionado con resultado BI-RADS® 4 o BI-RADS® 5. Con los datos obtenidos se concluyó que la edad media de las pacientes con BI-RADS® 4 y 5 es de 51.17 años; en su mayoría beneficiarias, la composición de la mama en su mayor porcentaje fue de tipo B. Las biopsia negativa a malignidad fueron 74.23% que correspondió en su mayoría a cambios fibroquisticos. Las biopsias positivas a malignidad fueron de 25.77% de las cuales se diagnosticaron en un estadio 0= 12%, IA= 16%; IIA=12%; IIB= 16%; IIIA= 12%; siendo el Carcinoma Canalicular Infiltrante el más común. IIIB, IIIC y IV no se diagnosticaron. Con dicho estudio se reconoció la importancia de este método de tamizaje para la detección temprana de cáncer de mama

In vitro Activity of Cefditoren against Middle Ear Fluid Isolates from Costa Rican Children with Otitis Media.

Otitis media (OM) is one of the most common infections in children, Streptococcus pneumoniae and nontypable Haemophilus influenzae being the two most common pathogens isolated in the middle ear fluid (MEF) of children with OM. Cefditoren is a third-generation cephalosporin with broad-spectrum antibacterial activity, including activity against those pathogens commonly causing OM, with enhanced stability against common ß-lactamases. The main objective of this study was to evaluate the in vitro activity of cefditoren against pathogens collected from the MEF of Costa Rican children with OM between 2006 and 2011. A total of 715 samples were analyzed. Among the 89 S. pneumoniae strains that were penicillin-nonsusceptible, only 7% were cefditoren-resistant according to Spanish Regulatory Agency criteria; among the H. influenza and M. catarrhalis isolates obtained, 100 and 90% of the isolates, respectively, were cefditoren-susceptible. MIC50/90 against the 207 PCV-13 S. pneumoniae serotyped strains and the 79 serotypes not covered by PCV-13 for cefditoren were 0.03/1 and 0.03/0.12 mg/l, respectively. For both amoxicillin-susceptible and resistant H. influenzae strains, the MIC range against cefditoren was from ≤0.015 to 0.06 mg/l as well. In conclusion, the confirmation of the wide spectrum of activity of cefditoren and its intrinsic strength against resistant strains allows us to suggest that cefditoren might be included as one of the best choices among antibiotics that are widely used in empiric therapy for OM in pediatric patients.

Functional significance of early-life iron deficiency: outcomes at 25 years.

OBJECTIVE: To evaluate adulthood function following chronic iron deficiency in infancy. STUDY DESIGN: At 25 years, we compared 33 subjects with chronic iron deficiency in infancy to 89 who were iron-sufficient before and/or after iron therapy. Outcomes included education, employment, marital status, and physical and mental health. RESULTS: Adjusting for sex and socioeconomic status, a higher proportion of the group with chronic iron deficiency did not complete secondary school (58.1% vs 19.8% in iron-sufficient group; Wald value = 8.74; P = .003), were not pursuing further education/training (76.1% vs 31.5%; Wald value = 3.01; P = .08; suggestive trend), and were single (83.9% vs 23.7%, Wald value = 4.49; P = .03). They reported poorer emotional health and more negative emotions and feelings of dissociation/detachment. Results were similar in secondary analyses comparing the chronic iron-deficient group with subjects in the iron-sufficient group who had been iron-deficient before treatment in infancy. Path analysis showed direct paths for chronic iron deficiency in infancy and being single and more detachment/dissociation at 25 years. There were indirect paths for chronic iron deficiency and not completing secondary school via poorer cognitive functioning in early adolescence and more negative emotions via behavior problems in adolescence, indicating a cascade of adverse outcomes. CONCLUSION: The observational nature of this study limits our ability to draw causal inference, even when controlling for background factors. Nonetheless, our results indicate substantial loss of human potential. There may be broader societal implications, considering that many adults worldwide had chronic iron deficiency in infancy. Iron deficiency can be prevented or treated before it becomes chronic or severe.

Streptococcus pneumoniae serotypes isolated from the middle ear fluid of Costa Rican children following introduction of the heptavalent pneumococcal conjugate vaccine into a limited population.

BACKGROUND: The heptavalent pneumococcal conjugate vaccine (PCV-7) was introduced in high risk children and into the private market in Costa Rica in 2004 (<5% annual birth cohort). The aim of this study was to compare the Streptococcus pneumoniae serotype (ST) distribution, antibiotic resistance patterns and potential coverage before and after partial introduction of PCV-7. METHODS: A comparison between the S. pneumoniae isolates obtained and serotyped from the middle ear fluid (MEF) of Costa Rican children with otitis media between years 1999 and 2003 (before PCV-7 usage) and those isolates obtained from 2004 to 2008. RESULTS: A total of 145 and 218 MEF S. pneumoniae were serotyped between years 1999 and 2003 and 2004 and 2008, respectively. Considering a 19F outbreak observed between years 1999 and 2003, the following statistically significant changes in serotype distribution were detected between 1999 and 2003 and 2004 and 2008: ST 3: 4.8-12.8% (P=0.01); ST 11A: 0-4.1% (P=0.01); ST 14: 3.5-21.1% (P<0.001) and ST 19F: 52.4-18.3% (P<0.05). Comparison of the two study periods demonstrated that during 2004 and 2008 a statistically significant decrease in penicillin non-susceptible serotypes (36.2-20.4% [P=0.003]) and a statistically significant increase in trimethoprim-sulfametoxazole resistant serotypes (54.9-68.5%, respectively [P=0.03]) was observed. Potential pneumococcal vaccines coverage between 1999 and 2003 and between 2004 and 2008 were: for PCV-7: 77.2-60.5%, respectively (P=0.001); for the 10-valent conjugated vaccine (PCV-10): 78.6-61.4%, respectively (P=0.0008) and for the 13-valent conjugated vaccine (PCV-13): 84.8-79.3%, respectively (P=0.2). CONCLUSIONS: Changes in the serotype distribution and antimicrobial susceptibility of MEF S. pneumoniae have been observed in Costa Rican children with OM. Because of the limited use of PCV-7 during the study period, these changes probably cannot be attributed to PCV-7 use. Between 2004 and 2008, PCV-13 offered the highest potential vaccine coverage.

Streptococcus pneumoniae serotype 3 among Costa Rican children with otitis media: clinical, epidemiological characteristics and antimicrobial resistance patterns.

BACKGROUND: After the introduction of the seven valent-pneumococcal conjugated vaccine into our National Immunization Program, it is important to establish and track local serotype distribution in order to evaluate its impact specially because serotype replacement phenomena has been described.To describe the clinical, epidemiological and antimicrobial resistance patterns of Costa Rican children with otitis media caused by Streptococcus pneumoniae serotype 3. METHODS: Middle ear fluid samples were obtained from Costa Rican children with otitis media who participated in various antimicrobial clinical trials between 1992 and 2007. Streptococcus pneumoniae was identified according to laboratory standard procedures. Strains were serotyped and antimicrobial susceptibility to penicillin, amoxicillin, cefuroxime, ceftriaxone, azithromycin and levofloxacin was determined by E-test. RESULTS: Throughout 1992-2007 a total of 1919 tympanocentesis were performed in children with otitis media (median age: 19 months) and yielded a total of 1208 middle ear isolates. The most common pathogens were: Streptococcus pneumoniae, 511 isolates (49%); Non-Typable Haemophilus influenzae, 386 isolates (37%); Moraxella catarrahalis, 100 isolates (9.5%); and Streptococcus pyogenes, 54 isolates (5%). Streptococcus pneumoniae serotyping was performed in 346/511 isolates (68%) recovered during years 1999-2006. The most common serotypes were 19F (101/30.0%), 14 (46/13.7%), 3 (34/10.1%), 6B (30/8.9%) and 23F (23/6.8%). Analysis performed per years showed a higher prevalence of serotype 3 Streptococcus pneumoniae during the study period 2004 and 2005. During the entire study period (1999-2006) serotype 3 was most commonly isolated in children older than 24 months (61.2% vs 40.6%;P = 0.05) and showed a lower rate of penicillin non-susceptibility (4.0% vs 18%; P = 0.003). CONCLUSION: Streptococcus pneumoniae serotype 3 is an important pathogen in Costa Rican children with otitis media, especially in children older than 24 months of age (P = 0.05). Most serotype 3 isolates were susceptible to penicillin, cephalosporins, macrolides and quinolones.

Seasonal distribution of otitis media pathogens among Costa Rican children.

BACKGROUND: Otitis media is an important cause of pediatric consultation, and knowledge of yearly pathogen distribution might improve antimicrobial selection. OBJECTIVES: To determine the seasonal pathogen and antimicrobial resistance distribution among Costa Rican children with otitis media. METHODS: Between 1999 and 2004, 952 children with otitis media, aged 3-144 months who participated in various clinical trials, were analyzed. Data obtained from this period were compared against historical data collected between 1992 and 1997. RESULTS: Five hundred sixteen (52%) children had a baseline middle ear fluid pathogen isolated. The most common pathogens were Streptococcus pneumoniae 252 (49%), Haemophilus influenzae 190 (37%), S. pyogenes 38 (7%), and Moraxella catarrhalis 36 (7%). The overall proportion of H. influenzae (24-37%; P = 0.01) and the production of beta-lactamase producing H. influenzae (2.6-7%; P = 0.02) increased from 1992-1997 to 1999-2004. There was a nonstatistically significant trend for a higher frequency of S. pneumoniae and H. influenzae isolates detected during the rainy season than during the dry season: S. pneumoniae 58% versus 42% but not significant (P = 0.1) and H. influenzae 68% versus 32% (P = 0.06), respectively. During the rainy season, penicillin-nonsusceptible S. pneumoniae was identified more frequently (38.5%) than during the dry season (18%) (P = 0.003; odds ratio: 2.94; 95% confidence interval: 1.4-6.45). Penicillin-nonsusceptible S. pneumoniae decreased from 46.5% (1999-2001) to 16% (2002-2003) and this was associated with a significant decline of a circulating 19F penicillin-resistant S. pneumoniae serotype (from 89% to 26%), respectively. CONCLUSIONS: S. pneumoniae and H. influenzae are the 2 most common pathogens producing otitis media in Costa Rican children. An increase in the number of H. influenzae and M. catarrhalis was observed in recent years. Penicillin-nonsusceptible S. pneumoniae isolates were more commonly observed during the rainy season, in which increased morbidity with respiratory pathogens is observed.

An open-label, double tympanocentesis, single-center study of trimethoprim sulfametoxasole in children with acute otitis media.

Trimethoprim sulfamethoxasole has been recommended for the treatment of acute otitis media. In this double tympanocentesis study, children aged 3 to 48 months with acute otitis media received trimethoprim sulfamethoxasole twice daily (40 mg/kg/d) for 10 days. All children had a baseline tympanocentesis and in culture-positive children, tympanocentesis was repeated at the on-therapy visit. Of 89 children enrolled, 51 (57%) were clinically and bacteriologically evaluable. Bacteriologic eradication was achieved in 80% (42 of 52) of children, and overall clinical response at the end of therapy was 78%. Clinical success was 69% for culture-positive children versus 91% for culture-negative children at baseline tympanocentesis (P = 0.03). In this study, trimethoprim sulfamethoxasole clinical response was unsatisfactory, especially among culture-'positive children.

Activity of trimethoprim-sulfamethoxazole against middle ear fluid pathogens obtained from Costa Rican children with otitis media.

For many years, trimethoprim-sulfamethoxazole (TMP-SMX) has been recommended as an alternative antimicrobial agent for the treatment of children with otitis media (OM). This study analyzed the in vitro activity of TMP-SMX against respiratory pathogens obtained from middle ear fluid of Costa Rican children 6-60 months of age with acute OM, recurrent OM, therapeutic failures and acute OM at risk for having a resistant pathogen. Between 2002 and 2003, a total of 124 middle ear fluid bacterial isolates were analyzed and compared with historic data from 1992 to 1997. A significant increase in the number of TMP-SMX Streptococcus pneumoniae (P = 0.00008)- and Haemophilus influenzae (P = 0.04)-resistant strains was observed during 2002-2003 when compared with strains from 1992-1997.

Middle ear fluid Streptococcus pneumoniae serotype distribution in Costa Rican children with otitis media.

BACKGROUND: Streptococcus pneumoniae conjugate vaccine became available in Costa Rica in 2004. Previous S. pneumoniae middle ear fluid (MEF) data obtained during the period 1999-2001 from Costa Rican children indicated that serotype 19F was the most common type (75%), but more recently other serotypes have become more prevalent. OBJECTIVES: To establish the most common S. pneumoniae serotypes present in the MEF of Costa Rican children with otitis media (OM) and to analyze serotype distribution by demographic factors, disease distribution and antimicrobial susceptibility patterns and assess the potential protection provided by the new conjugated heptavalent S. pneumoniae vaccine in Costa Rican children with OM. METHODS: During 2002 and 2003, 69 S. pneumoniae isolates were obtained from the MEF of Costa Rican children, ages 3-49 months, with OM. Serotyping was performed by the quellung reaction with antisera from Statens Serum Institute, Copenhagen, Denmark. RESULTS: The most common S. pneumoniae serotypes isolated were 19F (26.1%), 6B (14.5%), 9V (8.7%), 16F (8.7%), 14 (5.8%), 23F (5.8%), 3 (5.8%) and 6A (5.8%). Serotype distribution was similar among children younger than 24 months of age or 24 months of age or older and by disease distribution. There was a tendency towards more penicillin- and trimethoprim-sulfamethoxazole-nonsusceptible isolates among vaccine-type strains than among non-vaccine type strains. CONCLUSIONS: The serotype distribution of S. pneumoniae causing pediatric OM in Costa Rica is similar to those reported from developed countries. The current heptavalent pneumococcal conjugate vaccine covers 74% of OM episodes in Costa Rican children.

In vitro activities of levofloxacin and comparable agents against middle ear fluid, nasopharyngeal, and oropharyngeal pathogens obtained from Costa Rican children with recurrent otitis media or failing other antibiotic therapy.

This study analyzes the in vitro activities of levofloxacin and other commonly used antimicrobials against middle ear fluid, nasopharyngeal, and oropharyngeal pathogens obtained from children with otitis media at risk of having a resistant pathogen. Levofloxacin proved to be very active against these pathogens and had intermediate activity against Streptococcus pyogenes.

A randomized, multicenter, double blind, double dummy trial of single dose azithromycin versus high dose amoxicillin for treatment of uncomplicated acute otitis media.

BACKGROUND: High dose amoxicillin is recommended for the initial treatment of children with acute otitis media (AOM), particularly patients at risk for having drug-resistant Streptococcus pneumoniae. Single dose azithromycin (30 mg/kg) is considered an alternative agent for the treatment of AOM. OBJECTIVE: To compare the clinical efficacy and safety of single dose azithromycin with that of high dose amoxicillin among children with uncomplicated AOM. METHODS: This was a double blind, double dummy, multinational, clinical trial in which children (6-30 months of age) with AOM were randomized to treatment with single dose azithromycin (30 mg/kg) or high dose amoxicillin (90 mg/kg/d, in 2 divided doses) for 10 days. Tympanocentesis was performed at baseline and clinical responses were assessed at days 12-14 (end of therapy) and at days 25-28 (end of study). RESULTS: The study enrolled 313 patients, and 83% of the patients were < or =2 years of age. A total of 158 patients in the azithromycin group and 154 in the amoxicillin group were considered clinical modified intent-to-treat patients. A middle ear pathogen was detected for 212 patients (68%). Haemophilus influenzae was the most common pathogen (isolated for 96 patients), followed by S. pneumoniae (92 patients), Moraxella catarrhalis (23 patients) and Streptococcus pyogenes (23 patients). beta-Lactamase production was observed for 17% of H. influenzae isolates and 100% of M. catarrhalis isolates. Thirty-five (38%) S. pneumoniae isolates were penicillin-nonsusceptible and 24 (26%) isolates were macrolide-resistant. At the end of therapy, clinical success rates for azithromycin and amoxicillin were comparable for all patients (84 and 84%, respectively) and for children < or =2 years of age (82 and 82%, respectively). At the end of therapy and end of study, clinical efficacies among all microbiologic modified intent-to-treat evaluable subjects were comparable for patients treated with azithromycin (80%) and patients treated with amoxicillin (83%). The rates of treatment-related adverse events for azithromycin and amoxicillin were 20% and 29%, respectively (P = 0.064). Diarrhea was more common in the amoxicillin group than in the azithromycin group (17.5 and 8.2%, respectively) (P = 0.017). Compliance, defined as completion of > or =80% of the study medication, was higher in the azithromycin group (100%) than in the amoxicillin group (90%) (P = 0.001). CONCLUSIONS: In this study, single dose azithromycin was as effective as high dose amoxicillin for the treatment of children with AOM, whereas rates of adverse events were lower and compliance improved with the simplified single dose regimen.