Síndrome de Mazabraud. Asociación poco frecuente de mixoma intramuscular y displasia fibrosa / Mazabraud’s syndrome, an uncommon association of intramuscular myxoma with fibrous dysplasia

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Solución del caso 27. Gasoma intrapericárdico / Solution to case 27. Intrapericardial gossypiboma

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Solución del caso 22. Peritonitis tuberculosa / No disponible

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Plaquetopenia preoperatoria con diagnóstico postoperatorio de púrpura trombocitopénica trombótica / Preoperative plaquetopenia with a postoperative diagnosis of thrombotic thrombocytopenic purpura

Una paciente de 64 años acudió al servicio de urgencias con vómitos y dolor abdominal, y se le indicó cirugía por sospecha de apendicitis. En la analítica preoperatoria destacaba una importante plaquetopenia (39.000/µl), y ante la intervención prevista se le transfundieron 6 unidades de plaquetas. En la cirugía sólo se objetivó una ileítis y un divertículo de Meckel. Durante las primeras 48 h del postoperatorio persistió la trombopenia a pesar de una nueva transfusión de plaquetas, con deterioro del nivel de conciencia y fracaso renal agudo. Tras el diagnóstico de púrpura trombocitopénica trombótica (PTT), la paciente ingresó en una unidad de cuidados intensivos iniciándose el tratamiento con plasma fresco y corticoides. Dos semanas después, y tras una evolución compleja y 10 sesiones de plasmaféresis, pudo ser dada de alta a la planta de hematología. La PTT debe considerarse una urgencia médica y las transfusiones de plaquetas están contraindicadas ya que pueden causar un deterioro clínico importante. El hallazgo analítico de una plaquetopenia preoperatoria, debe llevar a realizar un diagnóstico diferencial de sus posibles causas, orientando sobre la necesidad o no de transfundir plaquetas. Algunos de los procesos etiológicos, como es el caso que presentamos, pueden suponer un riesgo vital para el paciente y es imprescindible instaurar de manera precoz un adecuado tratamiento médico, así como evitar la transfusión de plaquetas (AU)

[Preoperative thrombocytopenia with a postoperative diagnosis of thrombotic thrombocytopenic purpura]. / Plaquetopenia preoperatoria con diagnóstico postoperatorio de púrpura trombocitopénica trombótica.

A 64-year-old woman came to the emergency room complaining of vomiting and abdominal pain; appendicitis was suspected and surgery ordered. A blood work up showed a significantly low platelet count (39,000/microliter) and 6 units were transfused before surgery. The only observations during surgery were ileitis and Meckel's diverticulum. Thrombocytopenia persisted over the first 48 hours after surgery in spite of another transfusion of platelets, with worsening awareness and acute renal failure. After diagnosis of thrombotic thrombocytopenic purpura (TTP), the patient was admitted to the intensive care unit and treatment with fresh plasma and corticoids was started. Two weeks later, after complex evolution and ten sessions of plasmapheresis, the patient was transferred to the hematology ward. TTP must be considered a medical emergency. Platelet transfusions are contraindicated, as they can cause serious clinical deterioration. A low platelet count before surgery should lead to differential diagnosis to determine the cause, with the aim of judging whether platelet transfusion is warranted or not. In some etiological processes, such as in the case we report, platelet transfusion may be life-threatening; corrective measures must be taken early in the process and such transfusion avoided.

[The clinico-epidemiological characteristics of cholera patients in Mexico City]. / Características clínico-epidemiológicas de pacientes con cólera en la ciudad de México.

OBJECTIVE: To compare the clinical and epidemiological characteristics of cholera patients and patients with diarrhea of different etiology (controls), treated at Mexican Institute of Social Security medical units in northeast Mexico City, from 1995 to 1998. MATERIAL AND METHODS: Cross-sectional analytical study design. Data were collected using the official form "Immediate Notification of Cholera Cases" that each medical unit reports to the Coordination of Community Health. Statistical analysis consisted of comparisons of means and proportions between both groups. RESULTS: In 4,952 notifications, there were 588 cholera cases and 4,364 controls. The age range of cases was 39 to 51 years and 54% were females. During 1995 and 1997 (years with higher proportion of cases) patients with cholera had a greater frequency of watery evacuations than controls (97% vs. 73%), "rice water" appearance (31% vs. 13%), vomiting (72% vs. 63%), muscular spasms (49% vs. 26%), dehydration (83% vs. 71%), hypovolemic shock (10% vs. 1%) and death (0.85% vs. 0.25%). These differences were statistically significant. CONCLUSIONS: Cholera presents a biannual cyclic behavior; greater frequencies are associated with greater severity and complications. It is necessary to increase epidemiologic surveillance and medical efforts for opportune diagnosis and treatment.

[Silent pulmonary aspiration of barium after esophagogastroduodenography and subtotal gastrectomy]. / Aspiración pulmonar silente de bario tras esofagogastroduodenografía y gastrectomía subtotal.

We describe a 66-year-old patient who underwent subtotal gastrectomy and omentectomy for gastric adenocarcinoma six days after esophago-gastro-duodenography with barium contrast medium. In the postoperative period a series of chest films showed bronchogram due to aspiration of the contrast medium from the stomach, and finally multiple cottony infiltrates bilaterally. The patient had no respiratory symptoms and 6 days after admission to the intensive care recovery unit, he was moved to the general surgery ward for observation. Follow-up later passed to the outpatient with satisfactory evolution. We conclude that pulmonary aspiration occurred after extubation in the operating theater, since during the operation the patient remained stable hemodynamically and respiratorily. This case corroborates the theory of the existence of silent aspiration without pulmonary complications and the need to adjust clinical treatment, which can be conservative when, once the process is diagnosed, no symptoms present.

Inhibition of the pituitary-gonadal axis by a single intramuscular administration of D-Trp-6-LH-RH (decapeptyl) in a sustained-release formulation in patients with prostatic carcinoma.

For the past 6 years we used daily injection of luteinizing hormone-releasing hormone (LH-RH) agonists to treat patients with advanced prostate carcinoma. In this study we determined the hormonal response of the pituitary-testicular axis over a 2-month period and evaluated the safety and tolerance of the single intramuscular administration of sustained-release formulations of D-Trp-6-LH-RH microcapsules designed to release 50, 100, or 200 micrograms/day for over 1 month. Serum levels of LH, testosterone, and D-Trp-6-LH-RH were measured by RIA for up to 60 days in 10 patients with advanced prostatic carcinoma who had not received any previous drug therapy. After the administration of the microcapsules there was a biphasic increase in D-Trp-6-LH-RH serum levels. The maximal peak was obtained between 1 and 3 hr, and a second peak occurred between weeks 4 and 6. LH levels increased initially, with a maximal peak at 60 min, and elevated serum LH values persisted for more than 24 hr. LH levels began to fall on the second day, reaching subnormal values after 1 week. Serum testosterone rose during the first week and fell subsequently to less than 100 ng/dl. A rebound in LH and testosterone was seen about the 50th day after the microcapsule administration. Following the first week of therapy, we observed in all patients a significant decrease in bone pain, improvement in urinary flow obstruction, and a reversal of the signs of prostatism. No side effects were observed, and acceptance of the microcapsules was very good. Our results show that a single dose of D-Trp-6-LH-RH microcapsules suppresses of the pituitary-testicular axis for at least 50 days. D-Trp-6-LH-RH microcapsules facilitate the treatment and should lead to an improvement in the therapeutic response.

Persistent blockade of the pituitary-gonadal axis in patients with prostatic carcinoma during chronic administration of D-Trp-6-LH-RH.

Forty patients with stage D2 prostatic carcinoma were treated for up to 30 months with D-Trp-6-LH-RH. The analog was given s.c. once daily at a dose of 1 mg/day for the first 7 days. Subsequently, the dose was reduced to 100 micrograms/day. In follow-up studies, 30 men continued this therapy for up to 24 months. Blood samples were taken before the injection of the analog and 1, 2, 4, and 6 hours later. Serum LH, FSH, and testosterone levels were measured by RIA every month for 2 years. The initial administration of 1 mg D-Trp-6-LH-RH caused a marked elevation of LH and FSH, which lasted more than 24 hours. However, 1 month later and throughout the therapy, the basal values of LH and FSH were below the normal range and no increase in serum gonadotropins levels was obtained after administration of the analog. Initial plasma testosterone was within normal limits, but during treatment with D-Trp-6-LH-RH it fell to castration levels, and no increases were seen during the 6 hours following the injection of the analog. These results show that chronic administration of D-Trp-6-LH-RH, at the doses used, blocks the pituitary-gonadal axis and that the escape phenomenon from the effects of the LH-RH agonists-induced blockade does not occur under our conditions in contrast to observations of Kerle et al with the I.C.I. Analog 118630 (8). The accumulated results reinforce the view that long-term therapy with agonists of LH-RH is the preferred alternative to surgical castration or therapy with estrogens in men with metastatic prostate cancer.

Treatment of advanced prostatic carcinoma with D-Trp-6-LH-RH.

Twenty patients with stage D2 prostatic carcinoma were treated for up to 18 months with D-Trp-6-LH-RH. Results of more than 3 months of treatment on these 20 patients are reported. The analog was given SC once daily at a dose of 1,000 micrograms/day. All patients had bone pain and high levels of acid and alkaline phosphatase. After the first week of D-Trp-6-LH-RH administration, major decreases in bone pain and reversal of the signs of prostatism were observed. Acid phosphatase gradually fell, achieving normal values after 12 weeks. Initial plasma testosterone was within normal limits, but during treatment with D-Trp-6-LH-RH it fell to castration levels. Resting values of PRL, GH, TSH, and cortisol did not show significant changes. After TRH, TSH increased in five patients, but five did not respond. However, at 2 and 4 months, all patients released TSH in response to TRH. Two patients died during the treatment with D-Trp-6-LH-RH despite initial subjective responses and decreases in testosterone levels. The rise in acid phosphatase levels in these two patients was accompanied by a general deterioration, suggesting that they had androgen-independent cancer. One patient who developed progressive hepatic, bone, and pulmonary metastases in spite of previous orchiectomy was also treated with the analog. Three months later his acid phosphatase levels were within normal values, and partial regression of metastases was observed. These results demonstrate that D-Trp-6-LH-RH and other LH-RH agonists can be used as an effective endocrine therapy for advanced prostate carcinoma, thereby avoiding the side effects of estrogens or the psychological impact of surgical castration.