Respuesta de los autores: Onicomadesis en paciente adulto inmunocompetente / Author's reply: Onychomadesis in an immunocompetent adult patient

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[Polyarthralgia as an initial symptom of sarcoidosis]. / Poliartralgia como primer síntoma de sarcoidosis.

A 39 year-old patient consulted his family doctor due to migratory polyarthralgia, with C-reactive protein 7.99mg/dl, ESR 89mm and normal anti-streptolysin O (ASO). A sample was taken for analysis in the Rheumatology Clinic: ACE 72 IU, with normal rheumatoid factor, C-reactive protein and ASO; HLA non-specific. Chest X-ray showed an increased pulmonary interstitial pattern, and his chest-CT showed multiple bilateral pulmonary nodules and mediastinal lymph nodes. A differential diagnosis of lymphoproliferative process was considered. A gallium scintigraphy was performed with no relevant findings. The patient was referred to Thoracic Surgery for a lymph node biopsy by mediastinoscopy, which showed a non-necrotizing granulomatous lymphadenitis consistent with a sarcoidosis. Treatment with prednisone and anti-osteoporosis drugs was started and the patient was evaluated at four months with a new chest X-ray. There was a clinical and radiological remission therefore it was decided to gradually reduce the corticosteroid therapy.

Poliartralgia como primer síntoma de sarcoidosis / Polyarthralgia as an initial symptom of sarcoidosis

Varón de 39 años que acude a la consulta de Atención Primaria por un cuadro de poliartralgia migratoria, con proteína C reactiva de 7,99 mg/dl, velocidad de sedimentación globular (VSG) de 89 mm y valores de antiestreptolisina O (ASTO) normales. En la consulta de reumatología se le realiza analítica: enzima conversora de la angiotensina (ECA), 72 U/I; factor reumatoide, proteína C reactiva y ASTO, normales, y HLA inespecífico. La radiografía de tórax muestra aumento de la trama intersticial pulmonar. En la TC torácica aparecen nódulos pulmonares bilaterales y adenopatías mediastínicas múltiples. Se plantea el diagnóstico diferencial de proceso linfoproliferativo mediastínico, realizándose gammagrafía con galio sin hallazgos. El paciente se deriva a Cirugía Torácica para realizar una biopsia de adenopatía por mediastinoscopia, con resultado de linfadenitis granulomatosa no necrosante compatible con sarcoidosis. Se comienza tratamiento con prednisona y terapia antiosteoporótica, evaluándose al paciente en 4 meses con nueva radiografía de tórax. Se observa remisión clínica y radiológica y se pauta la reducción progresiva de la corticoterapia (AU)

A 39 year-old patient consulted his family doctor due to migratory polyarthralgia, with C-reactive protein 7.99 mg/dl, ESR 89 mm and normal anti-streptolysin O (ASO). A sample was taken for analysis in the Rheumatology Clinic: ACE 72 IU, with normal rheumatoid factor, C-reactive protein and ASO; HLA non-specific. Chest X-ray showed an increased pulmonary interstitial pattern, and his chest-CT showed multiple bilateral pulmonary nodules and mediastinal lymph nodes. A differential diagnosis of lymphoproliferative process was considered. A gallium scintigraphy was performed with no relevant findings. The patient was referred to Thoracic Surgery for a lymph node biopsy by mediastinoscopy, which showed a non-necrotizing granulomatous lymphadenitis consistent with a sarcoidosis. Treatment with prednisone and anti-osteoporosis drugs was started and the patient was evaluated at four months with a new chest X-ray. There was a clinical and radiological remission therefore it was decided to gradually reduce the corticosteroid therapy (AU)

Alergias en salud laboral / Allergies in occupational health

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Una causa mortal de síncope / A mortal cause of syncope

La anafilaxia es una reacción generalizada debida a la liberación masiva de mediadores de mastocitos y otras células inflamatorias que se instaura rápidamente y puede causar la muerte. Su diagnóstico es clínico y en ocasiones los síntomas con que se presenta pueden simular enfermedades más leves como cuadros vasovagales, ansiedad o asma, por lo que a menudo resulta infradiagnosticada. Es necesario un alto índice de sospecha para su diagnóstico. Presentamos el caso de una mujer joven que acude por síncope al centro de atención primaria. A pesar de la ausencia de lesiones cutáneas, la hipotensión mantenida nos hizo sospechar una anafilaxia, permitiendo la administración precoz de tratamiento y derivación urgente al hospital. en urgencias, nuestra hipótesis se vio reforzada al hallar niveles elevados de triptasa en sangre. La ausencia de exposición a alérgenos comunes nos hizo pensar en una hidatidosis hepática complicada como causa del cuadro, lo que se confirmó mediante ecografía y tomografía computarizada (TC) (AU)

Anaphylaxis is a generalized reaction produced by the massive release of mediators from mast cells, is rapid in onset and may cause death. The diagnosis is clinical, and the initial symptoms often overlap with those of many other disorders such as, vasovagal reactions, anxiety or asthma, and is often underdiagnosed. A high index of suspicion is necessary for the diagnosis. We report the case of a young woman who presented with syncope in a Primary Care Centre. In spite of the absence of skin lesions, we suspected an anaphylaxis because of the refractory low blood pressure. Thus treatment was started she was transferred to the Hospital. In the Emergency Department, the elevated serum tryptase levels supported our diagnosis. The absence of a clear exposure to a known allergen lead us to suspect a hydatid cysts rupture. The abdominal ultrasound and CT scan confirmed this (AU)

[A mortal cause of syncope]. / Una causa mortal de síncope.

Anaphylaxis is a generalized reaction produced by the massive release of mediators from mast cells, is rapid in onset and may cause death. The diagnosis is clinical, and the initial symptoms often overlap with those of many other disorders such as, vasovagal reactions, anxiety or asthma, and is often underdiagnosed. A high index of suspicion is necessary for the diagnosis. We report the case of a young woman who presented with syncope in a Primary Care Centre. In spite of the absence of skin lesions, we suspected an anaphylaxis because of the refractory low blood pressure. Thus treatment was started she was transferred to the Hospital. In the Emergency Department, the elevated serum tryptase levels supported our diagnosis. The absence of a clear exposure to a known allergen lead us to suspect a hydatid cysts rupture. The abdominal ultrasound and CT scan confirmed this.

Dolor abdominal en paciente con bulimia nerviosa / Abdominal pain in bulimic patient

La incidencia de bulimia nerviosa ha cobrado importancia en los países occidentales en las últimas décadas. La dilatación gástrica aguda es un proceso muy grave e infrecuente en pacientes sin antecedentes de enfermedad digestiva. Sin embargo, se han descrito casos en pacientes con alteraciones de la conducta alimentaria, especialmente después de ingestas compulsivas. Las complicaciones de la dilatación gástrica aguda son la necrosis isquémica del órgano y la perforación que pueden conducir a una situación de shock irreversible. El diagnóstico precoz y la evacuación gástrica, incluso en fases incipientes de isquemia y necrosis pueden evitar la realización de una laparotomía. Se debería realizar una cuidadosa investigación de los hábitos alimentarios con objeto de ofertar un tratamiento precoz. Presentamos el caso de una mujer de 24 años que padecía bulimia nerviosa e ingresó por una dilatación gástrica aguda y revisamos las características más importantes de esta entidad (AU)

The incidence of bulimia nervosa has attained significance in the last decades in the Western countries. Massive gastric dilatation is a very serious condition that is extremely rare in patients with no background of gastrointestinal disease. However, several cases have been reported in patients with eating disorders, particularly after a compulsive ingestion. Complications of acute gastric dilatation are infarction and perforation with severe and irreversible shock. Prompt diagnosis of acute gastric dilatation and decompression of the stomach even when gastric ischemia and mucosal necrosis is present may avoid unnecessary laparotomy. Careful investigation of eating habits may result in therapeutic gastric emptying at an earlier stage. We present a case of a 24-year old woman who suffered bulimia nervosa and was admitted because of acute gastric dilatation. We review the most important features of this condition (AU)